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Abnormal Psychology Unit 4: Anxiety, Obsessive-Compulsive and Trauma-Related Disorders

Fear and anxiety are normal alarms, but in these disorders they become excessive, persistent and disabling. The DSM-5-TR places anxiety disorders, obsessive-compulsive and related disorders, and trauma- and stressor-related disorders in three separate chapters, which share causes and respond to similar treatments.

Covers: Generalized anxiety disorder, Specific phobia, social anxiety disorder and agoraphobia, Panic attacks and panic disorder, Obsessive-compulsive and related disorders, PTSD, acute stress disorder and adjustment disorder, Biological and psychological causes of anxiety, Exposure-based and medication treatments

Study guide

Fear is a response to an immediate threat, while anxiety is a future-oriented sense of apprehension. Generalized anxiety disorder (GAD) involves excessive, hard-to-control worry about many everyday matters, occurring more days than not for at least six months, with at least three of six symptoms in adults: restlessness, fatigue, poor concentration, irritability, muscle tension and sleep disturbance. Specific phobia is marked fear of a particular object or situation, such as animals, heights, blood or flying, that is out of proportion to the danger and leads to avoidance, usually for six months or more. People with blood-injection-injury phobia may faint because of a sudden drop in heart rate and blood pressure. Social anxiety disorder is intense fear of situations in which a person might be scrutinized or negatively evaluated by others.

A panic attack is an abrupt surge of intense fear that peaks within minutes and includes at least four symptoms, such as a pounding heart, sweating, shortness of breath, chest pain, dizziness, fear of losing control or fear of dying. Panic attacks occur in many disorders, so they can be listed as a specifier. Panic disorder requires recurrent unexpected attacks followed by at least one month of persistent worry about more attacks or a maladaptive change in behavior to avoid them. Agoraphobia, a separate diagnosis in the DSM-5-TR, is fear and avoidance of at least two kinds of situations, such as public transportation, open spaces, enclosed places, crowds or being outside the home alone, because escape might be difficult or help unavailable. The anxiety disorders chapter also includes separation anxiety disorder and selective mutism.

Obsessive-compulsive disorder (OCD) involves obsessions, which are intrusive, unwanted thoughts, urges or images that cause anxiety, and compulsions, which are repetitive behaviors or mental acts, such as washing, checking, counting or praying, performed to reduce that anxiety or prevent a feared event. Symptoms are time-consuming (often more than an hour a day) or cause significant distress or impairment. Clinicians specify insight as good or fair, poor, or absent with delusional beliefs. Related disorders include body dysmorphic disorder (preoccupation with perceived flaws in appearance), hoarding disorder (persistent difficulty discarding possessions), trichotillomania (hair pulling) and excoriation disorder (skin picking). Brain research links OCD to overactivity in a circuit involving the orbitofrontal cortex, the caudate nucleus and the thalamus, and to serotonin.

Trauma- and stressor-related disorders require exposure to a stressor. Posttraumatic stress disorder (PTSD) follows exposure to actual or threatened death, serious injury or sexual violence, whether experienced, witnessed, learned about from a close person or encountered repeatedly at work. It has four symptom clusters: intrusion (memories, nightmares, flashbacks), avoidance of reminders, negative changes in thoughts and mood (such as self-blame or detachment), and changes in arousal and reactivity (such as hypervigilance, irritability or an exaggerated startle). Symptoms must last more than a month. Acute stress disorder covers similar symptoms lasting from three days to one month after the trauma. Adjustment disorder involves emotional or behavioral symptoms that develop within three months of any stressor, such as a breakup, and cause distress out of proportion to it or significant impairment. Prolonged grief disorder also appears in this chapter.

Causes span every model. Genes contribute modest risk, and anxiety is linked to an overreactive amygdala and to low activity of the inhibitory neurotransmitter GABA. Mowrer's two-factor theory says fears are acquired by classical conditioning and maintained by operant conditioning, since avoidance brings relief. Seligman's preparedness theory explains why fears of snakes and heights are more common than fears of cars. Cognitive theories point to anxiety sensitivity and, in panic disorder, catastrophic misinterpretation of bodily sensations, as described by David Clark. In OCD, thought-action fusion is the belief that thinking about an act is like doing it. Exposure therapy, which gradually confronts feared situations without escape, is the leading treatment; for OCD it is exposure and response prevention (ERP). SSRIs help many disorders, while benzodiazepines act quickly but carry risks of tolerance and dependence. PTSD treatments include prolonged exposure and cognitive processing therapy.

Key ideas

• Fear responds to present danger; anxiety anticipates future threat.
• GAD involves broad, uncontrollable worry for at least six months, whereas phobias target specific objects or situations.
• Panic disorder requires unexpected attacks plus at least a month of worry or avoidance; agoraphobia is diagnosed separately.
• Compulsions are performed to reduce the anxiety caused by obsessions, which is why preventing them is key in treatment.
• PTSD lasts more than a month and has four clusters: intrusion, avoidance, negative mood and cognition, and arousal.
• Avoidance maintains anxiety through negative reinforcement, so exposure without escape is the core treatment.
• SSRIs are first-line medications; benzodiazepines work fast but can cause dependence.

Formulas and rules

Common mistakes

• Diagnosing panic disorder from a single panic attack or from attacks that only occur during a phobic situation.
• Calling any tidy or careful person 'OCD'; the disorder requires distressing obsessions or compulsions that take time or impair life.
• Saying PTSD can be diagnosed one week after a trauma; that would be acute stress disorder.
• Believing that exposure therapy works best when clients are allowed to leave as soon as anxiety rises.
• Forgetting that agoraphobia is a separate diagnosis from panic disorder in the DSM-5-TR.

Before the test, make sure you can

• Distinguish fear from anxiety, and GAD from specific phobia and social anxiety disorder.
• Identify the criteria for a panic attack, panic disorder and agoraphobia.
• Explain the relationship between obsessions and compulsions and name the OCD-related disorders.
• List the four PTSD symptom clusters and the time rules that separate acute stress disorder, PTSD and adjustment disorder.
• Apply the two-factor theory, preparedness and catastrophic misinterpretation to explain a case.
• Describe how exposure therapy and ERP work and why avoidance must be blocked.
• Compare SSRIs and benzodiazepines in speed, use and risks.

Words to know

Generalized anxiety disorder

Excessive, hard-to-control worry about many matters more days than not for at least six months, with physical symptoms.

Specific phobia

Marked, out-of-proportion fear of a specific object or situation that is actively avoided.

Social anxiety disorder

Intense fear of social or performance situations in which one might be evaluated negatively.

Panic attack

An abrupt surge of intense fear peaking within minutes, with at least four physical or cognitive symptoms.

Panic disorder

Recurrent unexpected panic attacks followed by at least a month of worry about attacks or avoidance behavior.

Agoraphobia

Fear and avoidance of two or more situations where escape may be difficult or help unavailable.

Obsession

A persistent, intrusive and unwanted thought, urge or image that causes marked anxiety.

Compulsion

A repetitive behavior or mental act performed to reduce anxiety or prevent a feared outcome.

Body dysmorphic disorder

Preoccupation with perceived flaws in appearance that others see as slight or absent, with repetitive behaviors such as mirror checking.

Hoarding disorder

Persistent difficulty discarding possessions, leading to clutter that compromises living areas.

PTSD

A disorder lasting more than a month after trauma, with intrusion, avoidance, negative mood and cognition, and arousal symptoms.

Acute stress disorder

Trauma-related symptoms lasting from three days to one month after the traumatic event.

Adjustment disorder

Marked distress out of proportion to a stressor, or significant impairment, beginning within three months of it.

GABA

The brain's main inhibitory neurotransmitter; low GABA activity is linked to anxiety, and benzodiazepines enhance it.

Preparedness

Seligman's idea that humans are biologically primed to fear threats that endangered our ancestors, such as snakes.

Anxiety sensitivity

A tendency to interpret anxiety-related bodily sensations as harmful.

Thought-action fusion

The belief that having a thought is morally equal to doing the act or makes it more likely to happen.

Exposure and response prevention

OCD treatment in which clients face obsessional triggers while refraining from compulsions.

Benzodiazepines

Fast-acting anti-anxiety drugs, such as alprazolam, that enhance GABA but can cause tolerance and dependence.

Sample practice questions

30 more questions like these, from level 1 to 5, are in the practice set.