CHAPTER 5 TWO
Social Anxiety Disorder (Social Phobia)
Social Anxiety Disorder (SAD), also known as social phobia, is an extreme, enduring, irrational fear and avoidance of social or performance situations. It is significantly more severe than typical shyness, which affects 20–50% of college students. For example, Siyabonga, a 13-year-old, exhibited severe anxiety, avoiding social activities and hiding during breaks, driven by fear of embarrassment or humiliation.
Clinical Description
SAD involves anxiety severe enough to negatively impact performance, even for talented individuals, due to intense focus on potential embarrassment or failure. It can also manifest as worry about noticeable and uncontrollable physical reactions in social settings, such as blushing or sweating palms.
Performance anxiety is a subtype of SAD where individuals have no difficulty with general social interaction but experience intense anxiety when performing specific tasks in front of others. Common situations include public speaking, eating in a restaurant, or signing documents. This is often referred to as stage fright in performing artists. Anxiety-provoking physical reactions include:
Blushing
Sweating
Trembling
Paruresis (bashful bladder) in males
These anxieties are present only when others are watching and potentially evaluating behavior, not when the activities are performed in private.
Epidemiology
Lifetime Prevalence: Approximately 12.1% of the general population. In a given one-year period, prevalence is 6.8%. 8.2% in adolescents.
Global Impact: Second only to specific phobia among anxiety disorders, affecting over 35 million people in the USA.
South Africa: Lifetime prevalence of 2.8% in adults (Stein et al., 2008), peaking at 3.5% between ages 35 and 39. Studies indicate higher rates of childhood trauma, especially emotional abuse, in South African SAD patients compared to those with panic disorder (Lochner et al., 2010).
Sex Ratio: Almost 50:50, unlike other anxiety disorders where females often predominate.
Professional Help: 45.6% of individuals with SAD seek professional help within a 12-month period.
Age of Onset: Usually begins in adolescence, with a peak age around 13 years.
Demographics: More prevalent in young adults (18–29 years), undereducated, single individuals, and those of low socioeconomic status. It is less than half as prevalent in individuals over 60.
Cultural Differences:
White Americans are more commonly diagnosed with SAD than African Americans, Hispanic Americans, and Asian Americans.
Asian cultures show the lowest rates, while Russian and US samples show the highest.
In Japan,
taijin kyofushoresembles SAD but often focuses on the fear of offending or embarrassing others (e.g., body odor, blushing, stuttering) rather than oneself. Japanese males outnumber females in this specific manifestation.
DSM-5 Diagnostic Criteria for Social Anxiety Disorder
A. Marked fear or anxiety about one or more social situations in which the person is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), or performing in front of others (e.g., giving a speech).
* Note: In children, the anxiety must occur in peer settings and not just in interactions with adults.
B. The individual fears that he or she will act in a way, or show anxiety symptoms, that will be negatively evaluated (i.e., will be humiliating, embarrassing, lead to rejection, or offend others).
C. The social situations almost always provoke fear or anxiety.
* Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
D. The social situations are avoided, or endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed by the social situation, and to the sociocultural context.
F. The fear, anxiety or avoidance is persistent, typically lasting for ext{six months or more}.
G. The fear, anxiety or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The fear, anxiety or avoidance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
I. The fear, anxiety or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety or avoidance is clearly unrelated or is excessive.
Specify if: Performance only: If the fear is restricted to speaking or performing in public.
Causes
SAD development is complex, involving biological, psychological, and social factors.
Evolutionary Biases: Humans may be evolutionarily predisposed to fear angry, critical, or rejecting people, as avoiding hostile individuals could have increased survival. Studies show quicker learning and slower diminishment of fear responses to angry faces compared to other expressions (Öhman and colleagues, Mogg et al.). Socially anxious individuals show greater amygdala activation and less cortical control in response to angry faces (Goldin et al., Stein et al.).
Temperamental/Biological Vulnerability:
Some infants are born with behavioral inhibition or shyness, evident as early as ext{four months} of age (Jerome Kagan). Excessive behavioral inhibition increases the risk for phobic behavior.
Individuals may inherit a generalized biological vulnerability to anxiety or a biological tendency to be socially inhibited, or both.
Specific Psychological Vulnerability:
A belief that social evaluation, in particular, is dangerous is a key factor. Parental influence plays a role, as children with SAD often have socially fearful parents concerned with others' opinions (Bruch and Heimberg, Rapee and Melville).
Generalized Psychological Vulnerability: A belief that events, especially stressful ones, are uncontrollable can augment overall vulnerability to anxiety.
Stress-Diathesis Model: Genetic factors predispose individuals to be easily stressed and anxious, making traumatic experiences more likely to result in SAD.
Social Trauma: Experiencing real social trauma, like severe teasing and bullying in childhood (92% of adults with social phobia in one study reported this, McCabe et al., 2003), can lead to anxiety through classical conditioning.
Unexpected Panic Attacks: An unexpected panic attack in a social situation can become conditioned to social cues, leading to anxiety about future attacks in similar contexts.
Management (Treatment)
Effective treatments have been developed for SAD, combining psychological and, at times, pharmacological approaches.
Psychological Treatments:
Cognitive Therapy (CT): Emphasizes real-life experiences during therapy to challenge and disprove automatic perceptions of danger. This approach has shown substantial benefits, with 84% of individuals improving and maintaining results at one-year follow-up (Clark et al., 2006). It proved superior to interpersonal psychotherapy (IPT).
Social Mishap Exposures: A specific approach targeting avoidance and safety behaviors that maintain SAD. Patients are confronted with actual consequences of social mishaps (e.g., spilling a drink during a conversation). This group intervention had an 82% completion rate and a 73% response rate, maintained at six months (Hofmann et al., 2013).
Cognitive Behavioral Therapy (CBT): Effective for adolescents, leading to relatively normal functioning in school and social settings. Family-based CBT can outperform individual treatment when parents also have an anxiety disorder and may prevent anxiety disorder onset in children of anxious parents.
Pharmacological Treatments:
SSRIs (Selective Serotonin Reuptake Inhibitors): Paroxetine and fluoxetine are FDA-approved and commonly used.
SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors): Venlafaxine is also FDA-approved.
Beta-antagonists (e.g., propranolol): Evidence for their effectiveness is mixed and not conclusively supported.
d-cycloserine: When added to CBT, it significantly enhances treatment effects and may hasten therapeutic outcomes, though it doesn't necessarily augment a full course of CBT (Hofmann, Sawyer and Asnaani, 2012).
Treatment Comparisons:
A study comparing Clark's CT, fluoxetine plus self-exposure (SE), and placebo plus SE found CT to be substantially better at all times, with gains maintained after five years (Clark et al., 2003).
CombiningSSRIs with psychological treatments has mixed evidence; some studies found them comparable in efficacy but no additional benefit from combination (Davidson, Foa and Huppert, 2004).
Selective Mutism
Selective Mutism (SM) is a rare childhood disorder, now grouped with anxiety disorders in DSM-5. It is characterized by a consistent failure to speak in specific social situations where speaking is expected, despite speaking in other settings (e.g., at home but not at school).
Characteristics: Not due to lack of speech knowledge, physical difficulties, or other disorders like autism spectrum disorder. The lack of speech must occur for more than one month and not be limited to the first month of school.
Relation to Social Anxiety: Strongly driven by social anxiety, with high comorbidity rates with SAD (nearly 100% in some studies, Dummit et al., 1997).
Prevalence: Averages about 0.5% of children, with girls more affected than boys.
Possible Causes: Well-meaning parents may inadvertently enable this behavior by speaking for the child.
Treatment: Employs cognitive-behavioral principles similar to SAD treatment for children, with a greater emphasis on speech.
Trauma- and Stressor-Related Disorders
DSM-5 groups disorders that stem from a stressful or traumatic life event. These include:
Attachment disorders: In childhood, due to inadequate or abusive child-rearing.
Adjustment disorders: Persistent anxiety and depression following a life stressor.
Severe reactions to trauma: Such as Post-Traumatic Stress Disorder (PTSD) and Acute Stress Disorder.
These disorders are characterized by a proximal instigating stressful event followed by intense emotional responses, including rage, horror, guilt, and shame, in addition to fear and anxiety.
South African Context: Trauma- and stressor-related disorders are common, with over \frac{1}{3} of the population exposed to extreme violence (Kaminer et al., 2009).
Post-Traumatic Stress Disorder (PTSD)
An enduring, distressing emotional disorder that follows exposure to severe helplessness or a fear-inducing threat. The victim relives the trauma, avoids associated stimuli, develops emotional numbing, increased vigilance, and arousal. Common traumatic events in South Africa include crime, violence, and car accidents.
Clinical Description
Setting Event (DSM-5 Criterion A): Exposure to an event involving actual or threatened death, serious injury, or sexual violation. This can be:
Directly experiencing the event.
Witnessing the event as it occurred to others.
Learning the event occurred to a close family member or friend (violent or accidental death).
Enduring repeated or extreme exposure to aversive details of traumatic events (e.g., first responders).
Note: Criterion A4 excludes exposure through electronic media unless work-related.
Re-experiencing: Victims re-experience the event through disturbing memories and nightmares. Flashbacks are vivid, autonomous memories accompanied by strong emotion, as if reliving the event.
Avoidance: Victims often avoid cues reminding them of the trauma.
Numbing of Responsiveness: Characteristic restriction or numbing of emotional responsiveness, potentially disrupting relationships. May be unable to remember aspects of the event (dissociative amnesia).
Increased Arousal/Reactivity: Victims are typically chronically overaroused, easily startled, irritable, easily provoked, and quick to anger. DSM-5 added 'reckless or self-destructive behaviour' as an indicator.
Dissociative Subtype: New addition to DSM-5 describing victims with less arousal, experiencing dissociative feelings of unreality, detachment, depersonalization, and derealization. They may respond differently to treatment.
Historical Context: Descriptions date back centuries (e.g., Samuel Pepys after the Great Fire of London, 1666), known as 'war fatigue,' 'shell shock,' or 'bossies' among South African soldiers.
Diagnosis Timeline: Cannot be made until at least one month after the traumatic event, requiring symptoms to be enduring for at least a month.
Delayed Onset: In some individuals, full-blown PTSD develops at least six months, or even years, after the trauma, despite few or no immediate symptoms.
Acute Stress Disorder
Definition: Severe reaction immediately following a terrifying event, often including amnesia, emotional numbing, and derealization.
Relation to PTSD: Emphasizes the continuum of symptoms. If symptoms persist beyond one month, it may evolve into PTSD. Dissociative symptoms are usually more pronounced than in PTSD. Approximately 50% of individuals with acute stress disorder develop PTSD.
Epidemiology
Overall Lifetime Prevalence: 6.8\% in the general population in the USA (Kessler, Berglund et al., 2005).
US Military Personnel: 4.3\% overall, with 7.6\% among those experiencing combat (Smith et al., 2008).
Adolescents: 3.9\% (Kessler et al., 2012).
South Africa: Lifetime prevalence of only 2.3\% in an adult sample, despite high-risk factors (Stein et al., 2008; Atwoli et al., 2013). Most common traumatic events were unexpected death of a loved one and witnessing trauma.
High-Risk Traumas (USA): Highest rates associated with rape (49.0\%), being held captive/tortured/kidnapped (53.8\%), and being badly assaulted (31.9\%) (Breslau, 2012).
Gender Differences: In South Africa, rape and intimate partner violence had the strongest association with PTSD among women; political detention, criminal assault, and childhood abuse for men (Kaminer et al., 2009).
HIV-Related PTSD: 46\% of HIV-positive patients in a South African sample met criteria for HIV-related PTSD (Martin and Kagee, 2011).
South African Children/Adolescents: Main traumatic events were witnessing the death of a close relative (30\% children, 34.5\% adolescents) and sexual assault/rape (20\% children, 31\% rape in adolescents) (Calitz et al., 2014). Loss of parent is a significant risk factor.
DSM-5 Diagnostic Criteria for Post-Traumatic Stress Disorder
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
Directly experiencing the traumatic event(s).
Witnessing, in person, the event(s) as they occurred to others.
Learning that the event(s) occurred to a close relative or close friend. In cases of actual or threatened death, the event(s) must have been violent or accidental.
Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders).
Note: Criterion A4 does not apply to exposure through electronic media, TV, movies, or pictures, unless work-related.
B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
Recurrent, involuntary and intrusive distressing memories of the traumatic event(s). (In young children, repetitive play may occur).
Recurrent distressing dreams related to the traumatic event(s). (In children, frightening dreams without recognizable content).
Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (In young children, trauma-specific re-enactment in play).
Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble the traumatic event(s).
Marked physiological reactions to internal or external cues that symbolize or resemble the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
Avoidance of or efforts to avoid distressing memories, thoughts, feelings, or conversations about or closely associated with the traumatic event(s).
Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
Inability to remember an important aspect of the traumatic event(s) (dissociative amnesia).
Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world.
Persistent distorted cognitions about the cause or consequences of the traumatic event(s) that lead to self or other blame.
Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
Markedly diminished interest or participation in significant activities.
Feelings of detachment or estrangement from others.
Persistent inability to experience positive emotions.
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
Irritable behavior and angry outbursts (verbal or physical aggression).
Reckless or self-destructive behavior.
Hypervigilance.
Exaggerated startle response.
Problems with concentration.
Sleep disturbance.
F. Duration of the disturbance (Criteria B, C, D, and E) is more than one month.
G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a substance or another medical condition.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder.
J. If another medical condition is present, the fear, anxiety, or avoidance is clearly unrelated or excessive.
Specify if: Performance only (fear restricted to speaking or performing in public).
Specify if: With dissociative symptoms (depersonalization or derealization).
Specify if: With delayed expression (full criteria not met until at least 6 months after the event).
Causes
PTSD development is complex, involving biological, psychological, and social factors.
Intensity of Traumatic Event: Correlates with likelihood of developing PTSD. Man-made calamities are more prone to cause PTSD than natural disasters. For example, 67\% of Vietnam prisoners of war developed PTSD, but 33\% did not.
Generalized Biological Vulnerability: Family history of anxiety, genetic factors predisposing to stress and anxiety (stress-diathesis model). Concordance for PTSD is higher in monozygotic twins (0.28–0.41) than dizygotic twins (0.11–0.24).
Presence of the short allele of the serotonin transporter gene correlates with increased risk of major depression and acute stress symptoms.
Certain biomarkers, like emotional reactivity to 35\% carbon dioxide-enriched air, can predict higher stress perception in war zones and greater PTSD risk.
Generalized Psychological Vulnerability: Early experiences with unpredictable or uncontrollable events (e.g., family instability) can instil a sense that the world is dangerous, increasing PTSD risk.
Social Factors: Strong social support reduces the likelihood of developing PTSD after trauma, affecting biological and psychological responses to stress (e.g., reduced cortisol secretion and HPA-axis activity).
Neurobiological Systems: Involves altered corticotropin-releasing factor (CRF) responses and heightened HPA-axis reactivity. Chronic arousal may lead to changes in brain function and structure (e.g., decreased hippocampal volume, correlating with increased arousal and memory deficiencies).
Conditioned Alarm Reaction: A true initial alarm (real danger) can lead to a conditioned or learned alarm reaction to trauma-に関連する stimuli (e.g., Mandy's reaction to being alone).
Dissociation: May cause functional lesions of neural networks, producing flashbacks, overt dissociative symptoms, and affective restriction.
Management (Treatment)
Psychological Treatments:
Facing the Trauma: Clinicians agree victims should face the original trauma, process emotions, and develop coping procedures.
Catharsis: Reliving emotional trauma to relieve suffering, common in psychoanalytic therapy.
Imaginal Exposure: Systematically working through the content and emotions of trauma, often by developing a narrative of the experience.
Cognitive Therapy (CT): Correcting negative assumptions (e.g., self-blame, guilt) about the trauma.
Timing with Sleep: Exposure treatment effects may be strengthened by strategically timing it with sleep, as extinction learning occurs during slow-wave sleep and sleep quality reduces anxiety.
Early Interventions: Structured interventions delivered soon after trauma are useful in preventing PTSD. For example, 12 sessions of CT reduced PTSD development to 11\% compared to 61\% in a self-help group.
Avoid Single Debriefing Sessions: Forcing expression of feelings shortly after trauma can be harmful.
Pharmacological Treatments:
Antidepressants: SSRIs (e.g., fluoxetine, sertraline) are effective as they relieve severe anxiety, panic attacks, and depressive symptoms.
Anticonvulsant Mood Stabilizing Agents: Carbamazepine, sodium valproate, lamotrigine may reduce flashbacks, irritability, and alleviate depression.
Benzodiazepines: Limited use for acute symptomatic relief.
Beta-antagonists (e.g., propranolol): Early use may diminish risk or reduce symptom severity.
Treatment Comparisons: Combining SSRIs with psychological treatments has mixed evidence; some studies found no additional benefit. ERP (Exposure and Ritual Prevention) has shown superior results to medication alone, with lower relapse rates.
Prolonged Grief Disorder (PGD)
A disorder where acute grief is prolonged and intensifies over time rather than diminishing, occurring in 9.8\% to 11\% of all grieving adults. The experience includes intense longing for and preoccupation with the deceased, with other symptoms making it difficult to move on after a year or more (six months for children).
DSM-5 Diagnostic Criteria for Prolonged Grief Disorder (Extracted from Text)
A. The death, at least 12 months ago, of a person who was close to the bereaved individual (for children and adolescents, at least 6 months ago).
B. Since the death, the development of a persistent grief response characterized by one or both of the following symptoms, which have been present most days to a clinically significant degree. In addition, the symptom(s) have occurred nearly every day for at least the last month:
Intense yearning/longing for the deceased person.
Preoccupation with thoughts or memories of the deceased person (in children and adolescents, preoccupation may focus on the circumstances of the death).
C. Since the death, at least three of the following symptoms have been present most days to a clinically significant degree. In addition, the symptoms have occurred nearly every day for at least the last month:
Identity disruption (e.g., feeling as though part of oneself has died) since the death.
Marked sense of disbelief about the death.
Avoidance of reminders that the person is dead (in children and adolescents, may be characterized by efforts to avoid reminders).
Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death.
Difficulty reintegrating into one’s relationships and activities after the death.
Emotional numbness (absence or marked reduction of emotional experience) as a result of the death.
Feeling that life is meaningless as a result of the death.
Intense loneliness as a result of the death.
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The duration and severity of the bereavement reaction clearly exceed expected social, cultural, or religious norms for the individual’s culture and context.
F. The symptoms are not better explained by major depressive disorder, posttraumatic stress disorder, or another mental disorder or attributable to the physiological effects of a substance or another medical condition.
COVID-19 Pandemic: Contributed to a 'grief pandemic' due to unexpected deaths and restrictions on grieving rituals, potentially increasing PGD likelihood.
Management: New treatments resembling effective PTSD treatments, but adapted for prolonged grief, have been developed.
Adjustment Disorders
Definition: Anxious or depressive reactions to life stress that are generally milder than acute stress disorder or PTSD but still impair work, academic performance, and quality of life.
Characteristics: Stressful events are not considered traumatic. Individual is unable to cope with demands. If symptoms persist for more than 6 months after stress removal, it's considered 'chronic'. Often a residual diagnostic category for anxiety/depression linked to identifiable life stress not meeting criteria for other disorders.
Attachment Disorders
Disturbed and developmentally inappropriate behaviors in children (before 5 years of age) due to inadequate or abusive child-rearing practices, resulting in a failure to form normal attachment relationships.
Reactive Attachment Disorder (RAD): Child seldom seeks or responds to caregiver comfort, showing lack of responsiveness, limited positive affect, and heightened emotionality (fearfulness, sadness).
Disinhibited Social Engagement Disorder (DSED): Child shows no inhibitions in approaching adults, engaging in inappropriately intimate behavior (e.g., willing to accompany unfamiliar adults without checking with caregiver).
Obsessive-Compulsive and Related Disorders
A new class in DSM-5, consolidating disorders sharing characteristics like driven repetitive behaviors, similar course, and treatment response. This category includes OCD, hoarding disorder, body dysmorphic disorder, trichotillillomania, and excoriation (skin picking) disorder.
Obsessive-Compulsive Disorder (OCD)
A severe, debilitating, and chronic disorder involving unwanted, persistent, intrusive thoughts and impulses (obsessions), and repetitive actions intended to suppress them (compulsions). Anxiety in OCD is a symptom of underlying psychopathological processes, not a primary feature.
Clinical Description
Obsessions: Intrusive, recurrent, persistent, and mostly nonsensical thoughts, images, or urges that the individual attempts to resist or eliminate. They cause marked anxiety or distress.
Compulsions: Repetitive, ritualistic, time-consuming behaviors (e.g., hand washing, checking) or mental acts (e.g., counting, praying) that a person feels driven to perform in response to an obsession or rigid rules. They are aimed at preventing or reducing distress or a dreaded event, but are often 'magical' or not logically connected to the obsession.
Comorbidity: Often co-occurs with severe generalized anxiety, recurrent panic attacks, debilitating avoidance, and major depression.
Types of Obsessions and Compulsions
Symmetry/Exactness/“Just Right”: Needs things to be symmetrical or in perfect order. Compulsions include repeating rituals or putting things in a certain order.
Forbidden Thoughts or Actions (Aggressive/Sexual/Religious): Fears/urges to harm self or others, or offending God. Compulsions involve checking, avoidance, or seeking reassurance.
Cleaning/Contamination: Fears of germs or contaminants. Compulsions include repetitive or excessive washing, or using gloves/masks.
Hoarding: Fears of throwing anything away. Compulsions involve collecting/saving objects with little actual or sentimental value.
Tic Disorder and OCD
Tics: Semi-purposeful muscular behaviors (jerks, grimaces) or vocalizations, often pronounced during stress.
Comorbidity: Tic disorder is not uncommon in OCD patients (especially children) or their families. Obsessions in tic-related OCD are almost always related to symmetry.
PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection): In some children, OCD and tics emerge after Group A Streptococcus infection. Antibodies cross-react with neural tissue in the basal ganglia causing symptoms. PANDAS patients are more likely male, have dramatic onset with fever/sore throat, full remissions, and evidence of past strep infections. This concept has been broadened to PANS (Pediatric Autoimmune Neuropsychiatric Syndrome).
Epidemiology
Lifetime Prevalence: 1.6\% to 2.3\%. One-year prevalence is 1\%. Less severe cases are more common.
Sex Ratio: Nearly 1:1. Boys may develop OCD earlier, but by mid-adolescence, the ratio is equal.
Age of Onset: Ranges from childhood through the 30s, median age 19. Peaks earlier in males (13-15) than females (20-24).
Course: Tends to be chronic once it develops.
Cultural Similarities: OCD looks remarkably similar across cultures in terms of types and proportions of obsessions and compulsions. However, religious practices may influence themes (e.g., cleanliness in Muslim cultures). Rare among Sesotho-speaking participants in South Africa, warranting further investigation.
DSM-5 Diagnostic Criteria for Obsessive-Compulsive Disorder
A. Presence of obsessions, compulsions, or both:
Obsessions are defined by 1 and 2:
Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that in most individuals cause marked anxiety or distress.
The individual attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action.
Compulsions are defined by 1 and 2:
Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
B. The obsessions or compulsions are time-consuming (e.g., take more than one hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder.
Specify if: With good or fair insight, With poor insight, or With absent insight/delusional (regarding OCD beliefs).
Specify if: Tic-related (current or past history of a tic disorder).
Causes
Biological Vulnerability: Relates to subcortical neural networks involving the basal ganglia (striatum and frontal cortex connections). OCD Release of thoughts and associated behaviors is similar to movement disorders.
Specific Psychological Vulnerability: Early experiences conditioning that some thoughts are dangerous and unacceptable (e.g., 'thought-action fusion' – equating thoughts with actions, often due to excessive responsibility/guilt from childhood). Believing thoughts are unacceptable and must be suppressed increases risk.
Childhood trauma, especially emotional abuse and neglect, significantly increases the odds of OCD (Hemmings et al., 2013, in White South Africans).
Generalized Biological and Psychological Vulnerabilities: Must be present for the disorder to develop.
Management (Treatment)
Pharmacological Treatments:
Serotonin Reuptake Inhibitors: Most effective. Tricyclic antidepressant clomipramine (Anafranil) or SSRIs (fluoxetine, sertraline) benefit up to 60\% of patients. Relapse is common upon discontinuation. No single SRI offers a distinct advantage.
Antipsychotic Agents: May be beneficial in refractory cases with poor insight, especially selective D2-receptor antagonists (e.g., amisulpride).
Psychological Treatments (Often better efficacy, but less available):
Exposure and Ritual Prevention (ERP): Most effective approach. Patients are systematically and gradually exposed to feared thoughts/situations, while rituals are actively prevented. Facilitates 'reality testing'.
Cognitive Treatments: Focus on correcting overestimation of threat, inflated responsibility, and need for perfectionism/certainty. Initial results indicate effectiveness comparable to ERP.
Combined Treatments: ERP with or without clomipramine generally produces superior results to clomipramine alone. Combining treatments often offers no additional advantage, and relapse rates are high for medication-only groups upon withdrawal.
Psychosurgery: Radical treatment for very severe, refractory OCD (e.g., cingulotomy or capsulotomy). About 30-35\% of patients show substantial improvement, but with potential serious adverse effects. Deep-brain stimulation is a reversible alternative.
Body Dysmorphic Disorder (BDD)
A disorder featuring a disruptive preoccupation with one or more imagined defects or flaws in physical appearance that are not observable or appear slight to others ('imagined ugliness'). Now classified under obsessive-compulsive and related disorders in DSM-5 (formerly somatoform disorders).
Clinical Description
Preoccupation: With imagined physical defects (e.g., nose size, skin, hair, body build). Average focus on five to seven body areas.
Compulsive Behaviors: Engage in repetitive behaviors or mental acts in response to appearance concerns (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking, comparing appearance to others).
Fixation/Avoidance of Mirrors: Many become fixated on mirrors, checking defects, while others avoid them due to phobic extent.
Suicidal Ideation: Suicidal ideation, attempts, and suicide are common consequences.
Ideas of Reference: Thinking everything in their world relates to their imagined defect.
Impact: Can cause considerable disruption, leading to patients becoming housebound. Severity of distress and impairment can be worse than in depression, diabetes, or myocardial infarction.
Previous Classification ('Dysmorphobia'): Was thought to be a psychotic delusional state due to inability to realize ideas were irrational.
Insight: DSM-5 allows specifying insight (good/fair, poor, absent/delusional). Delusional subtype is generally more severe but responds to BDD treatments, not psychotic disorder treatments.
Course: Tends to run a lifelong course without treatment.
Epidemiology
Prevalence: Hard to estimate due to secrecy. Higher than previously thought. 1-2\% in community samples, 2-13\% in student samples. In a South African student sample, 5.1\% (Dlagnikova and Van Niekerk, 2015).
Sex Differences: Seen equally in men and women, but focus of concern differs. Men often focus on body build, genitals, thinning hair, and tend to have more severe BDD. Women focus on more varied body areas and are more likely to have an eating disorder.
Age of Onset: Early adolescence through the 20s, peaking at 16 or 17 years.
Treatment Seeking: Patients are reluctant; often driven by relatives. Many seek cosmetic surgery or dermatology rather than mental health services.
DSM-5 Diagnostic Criteria for Body Dysmorphic Disorder
A. Preoccupation with one or more defects or flaws in physical appearance that are not observable or appear slight to others.
B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.
C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.
Specify if: With muscle dysmorphia (preoccupation with body build being too small/insufficiently muscular).
Specify if: Indicate degree of insight regarding body dysmorphic beliefs: With good or fair insight, With poor insight, or With absent insight/delusional beliefs.
Causes
Limited Information: Little is known about the etiology, genetic contributions, or biological/psychological predisposing factors.
Comorbidity with OCD: BDD often co-occurs with OCD and is found in family members, suggesting a shared pathogenesis.
Social Anxiety Link: Suggests a fundamental relationship between BDD and social anxiety, where perceived negative evaluation by others is crucial. Social anxiety disorder is commonly comorbid with BDD.
Management (Treatment)
Pharmacological Treatments:
Serotonin Reuptake Inhibitors: Provide relief to some individuals (e.g., clomipramine, fluoxetine), showing similar effectiveness as in OCD treatment.
Psychological Treatments:
Exposure and Response Prevention (ERP): A type of CBT effective in OCD, also successful with BDD. Tends to produce better and longer-lasting outcomes than medication alone.
Plastic Surgery and Other Medical Treatments: Generally ineffective and often lead to dissatisfaction, additional surgeries, or even legal action. It is crucial for surgeons to screen for BDD.
Other Obsessive-Compulsive and Related Disorders
Hoarding Disorder
Definition: Compulsive hoarding of things due to a fear of discarding items, leading to excessive clutter and gross disorganization. Individuals often experience pleasure from acquiring items.
Characteristics: Excessive acquisition, difficulty discarding, living with excessive clutter. Most begin acquiring in teenage years. Strong anxiety and distress about throwing anything away, believing everything has potential value or is an extension of identity.
Prevalence: 2\% - 5\% of the population, twice as high as OCD. Nearly equal numbers of men and women, found worldwide.
Course: Can begin early and worsen with each decade. Average age for treatment is around 50.
Complications: Can lead to unsafe living conditions, fire hazards, and public health concerns.
Animal Hoarding: A special group characterized by owning unusually large numbers of animals, failure to care for them, unsanitary conditions, and often little insight into the problem. May attribute human characteristics to animals and have dysfunctional relationships with people.
Management: CBT (teaches assigning different values to objects and reducing anxiety about discarding). Preliminary results are promising but more modest than with OCD.
Trichotillomania (Hair Pulling Disorder)
Definition: The urge to pull out one's own hair from anywhere on the body, resulting in noticeable hair loss, distress, and significant social impairment.
Prevalence: Observed in 1\% - 5\% of college students, with females reporting it more.
Overlap: Considerable overlap with skin-picking disorder. Higher dissociation and a trend towards avoidant personality disorder were noted in trichotillomania in one South African study.
Causes: May have some genetic influence. Tension relief was previously part of diagnostic criteria but removed in DSM-5.
Management: Habit Reversal Training (HRT) – patients learn to be aware of the behavior and substitute a different, harmless behavior. SSRI antidepressants (e.g., fluoxetine) have proven effective.
Excoriation (Skin Picking Disorder)
Definition: Repetitive and compulsive picking of the skin, leading to tissue damage, distress, embarrassment, and functional impairment.
Prevalence: 1\% - 5\% of the population experience noticeable skin damage, sometimes requiring medical attention. Largely observed in women.
Relation to OCD/BDD: Often co-occurs with OCD, BDD, and trichotillomania, hence its grouping in this category in DSM-5.
Causes: Also thought to relieve stress or tension, but this criterion was removed from DSM-5.
Management: Habit Reversal Training (HRT) is the most evidenced psychological treatment. Efficacy of SSRIs is less obvious than for trichotillomania.
DSM Controversies in Classifying Anxiety and Related Disorders
Shift from Categorical to Dimensional Approaches: Emerging conceptions of psychopathology favor considering larger dimensions or spectra of disorders (e.g., emotional disorders spectrum including anxiety and depression) rather than distinct