MODULE 2

PROBLEMS of ANXIETY

INTRODUCTION
Extraordinary People

David Beckham, Perfection On and Off the Field

Soccer star David Beckham’s extraordinary ability to curve shots
on corner kicks was immortalized in the movie Bend It Like Beckham.
Beckham’s perfectionism on the field is paralleled by his perfectionism
about order and symmetry: “I’ve got this obsessive-compulsive disorder
where I have to have everything in a straight line or everything has to be
in pairs” (quoted in Dolan, 2006). Beckham spends hours ordering the
furniture in his house in a particular way or lining up the clothes in his
closet by color. His wife, Victoria (the former Posh Spice), says, “If you
open our fridge, it’s all coordinated down either side. We’ve got three
fridges—food in one, salad in another and drinks in the third. In the
drinks one, everything is symmetrical. If there’s three cans he’ll throw
away one because it has to be an even number” (quoted in Frith, 2006).
Beckham has traveled around the world, playing for top teams
including Real Madrid, Manchester United, Los Angeles Galaxy, and AC
Milan. Each time he enters a new hotel room, he has to arrange
everything in order: “I’ll go into a hotel room. Before I can relax I have
to move all the leaflets and all the books and put them in a drawer.
Everything has to be perfect” (quoted in Frith, 2006). His teammates on
Manchester United knew of his obsessions and compulsions and would
deliberately rearrange his clothes or move the furniture around in his
hotel room to infuriate him. (Nolen-Hoeksema, S. 2011).

Anxiety is complex and mysterious, as

Sigmund Freud realized many years ago. In some
ways, the more we learn about it, the more
baffling it seems. “Anxiety” is a specific type of
disorder, but it is more than that. It is an emotion
implicated so heavily across the full range of
psychopathology that our discussion explores its

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general nature, both biological and psychological.

Next, we consider fear, a somewhat different but
clearly related emotion. Related to fear is a panic
attack, which we propose is fear that occurs when
there is nothing to be afraid of and, therefore, at
an inappropriate time. With these important ideas
clearly in mind, we focus on specific anxiety and
its related disorders.

Lesson 1 Brief description of Anxiety Disorders

Lesson 2 Types and Subtypes of Anxiety Disorders
Lesson 3 Obsessive-Compulsive and Related
Disorders
Lesson 4 Trauma and Stressor-Related Disorder
Brief Description
Lesson 5 Trauma and Stressor-Related Disorder
Types and Subtypes

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MODULE 2

PROBLEMS OF ANXIETY

 INTRODUCTION
Gretchen’s Case

I was 25 when I had my first attack. It was a few weeks after I’d come
home from the hospital. I had had my appendix out. The surgery had gone
well, and I wasn’t in any danger, which is why I don’t understand what
happened. But one night I went to sleep and I woke up a few hours later—
I’m not sure how long—but I woke up with this vague feeling of
apprehension. Mostly I remember how my heart started pounding. And my
chest hurt; it felt like I was dying—that I was having a heart attack. And I
felt kind of queer, as if I were detached from the experience. It seemed like
my bedroom was covered with a haze. I ran to my sister’s room, but I felt
like I was a puppet or a robot who was under the control of somebody else
while I was running. I think I scared her almost as much as I was frightened
myself. She called an ambulance .

Question: How will you describe Gretchen’s experience? Is she

suffering from a disorder?

Answers to the questions raised above will be provided in this

module. It is hoped that you will learn to correctly give diagnosis as we
progress in our discussion.

OBJECTIVES

After studying the module, you should be able to:

1. Understand the relationship between anxiety and anxiety

disorders.
2. Identify key vulnerabilities for developing anxiety and related
disorders.
3. Identify main diagnostic features of specific anxiety-related
disorders.
4. Differentiate between disordered and non-disordered functioning.

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DIRECTIONS/ MODULE ORGANIZER

There are five (5) lessons in the module outlined as follows:

1. Brief description of Anxiety Disorders
2. Types and subtypes of Anxiety Disorders
3. Brief description and type and subtype of Obsessive-Compulsive
disorders
4. Brief description of Trauma and Stressor-related disorders
5. Types and subtypes of Trauma and Stressor-related disorders

Read each lesson carefully then answer the exercises/activities to find out
how much you have benefited from it. Work on these exercises carefully and
submit your output to your tutor.

In case you encounter difficulty, discuss this with your tutor during
the face-to-face meeting. If not contact your tutor at the DOUS office.

Good luck and happy reading!!!

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Lesson 1

ANXIETY DISORDER
BRIEF
DESCRIPTION

The conditions discussed in this lesson are characterized by anxiety

and the behaviors by which people try to ward it off. Panic disorder, the
various phobias, and generalized anxiety disorder are collectively among the
most frequently encountered of all mental disorders listed in DSM-5. Yet, in
discussing them, we must also keep in mind three other facts about anxiety.
The first of these is that a certain amount of anxiety is not just
normal, but adaptive and perhaps vital for our well-being and normal
functioning. For example, when we are about to take an examination or
speak in public (or write a book), the fear of failure spurs us on to adequate
preparation. Similarly, normal fear lies behind our healthy regard for
excessive debt, violent criminals, and poison ivy.
Anxiety is also a symptom—one that’s encountered in many, perhaps
most, mental disorders. Because it is so dramatic, we sometimes focus our
attention on the anxiety to the exclusion of historical data and other
symptoms (depression, substance use, and problems with memory, to name
just a few) that are crucial to diagnosis. I’ve interviewed countless patients
whose anxiety symptoms have masked mood, somatic symptom, or other
disorders—conditions that are often not only highly treatable when they are
recognized, but deadly when they are not.
The third issue is that anxiety symptoms can sometimes indicate the
presence of a substance use problem, another medical condition, or even a
different mental disorder altogether (such as a mood, somatic symptom,
cognitive, or substance-related disorder). These conditions should be
considered for any patient who presents with anxiety or avoidance behavior
Anxiety can be defined as a negative mood state that is
accompanied by bodily symptoms such as increased heart rate, muscle
tension, a sense of unease, and apprehension about the future (APA, 2013;
Barlow, 2002).
Anxiety and closely related disorders emerge from “triple
vulnerabilities,”a combination of biological, psychological, and specific
factors that increase our risk for developing a disorder (Barlow, 2002;
Suárez, Bennett, Goldstein, & Barlow, 2009). Biological vulnerabilities
refer to specific genetic and neurobiological factors that might predispose
someone to develop anxiety disorders. No single gene directly causes
anxiety or panic, but our genes may make us more susceptible to anxiety

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and influence how our brains react to stress. Psychological vulnerabilities

refer to the influences that our early experiences have on how we view the
world. If we were confronted with unpredictable stressors or traumatic
experiences at younger ages, we may come to view the world as
unpredictable and uncontrollable, even dangerous. Specific vulnerabilities
refer to how our experiences lead us to focus and channel our anxiety . If
we learned that physical illness is dangerous, maybe through witnessing our
family’s reaction whenever anyone got sick, we may focus our anxiety on
physical sensations. If we learned that disapproval from others has negative,
even dangerous consequences, such as being yelled at or severely punished
for even the slightest offense, we might focus our anxiety on social
evaluation. If we learn that the “other shoe might drop” at any moment, we
may focus our anxiety on worries about the future. None of these
vulnerabilities directly causes anxiety disorders on its own—instead, when
all of these vulnerabilities are present, and we experience some triggering
life stress, an anxiety disorder may be the result.
Anxiety disorders can cause people into try to avoid situations that
trigger or worsen their symptoms. Job performance, school work and
personal relationships can be affected.
In general, for a person to be diagnosed with an anxiety disorder, the fear
or anxiety must:
• Be out of proportion to the situation or age inappropriate
• Hinder your ability to function normally

In the next lesson, we will briefly explore each of the major anxiety
based disorders, found in the fifth edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-5) (APA, 2013).

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CASE ANALYSIS

Read carefully the information provided in the case to be

able to:
a) give the proper diagnosis; and,
b) link the specific facts of the case to the different
symptoms of the disorder

The first time Celia had a panic attack, two days

before her twentieth birthday, she was working at
McDonald’s. As she was handing a customer a Big Mac, the
earth seemed to open up beneath her. Her heart began to
pound, she felt she was smothering, she broke into a sweat,
and she was sure she was going to have a heart attack and
die. After about 20 minutes of terror, the panic subsided.
Trembling, she got in her car, raced home, and barely left
the house for the next 3 months.
Since that time, Celia has had about three attacks a
month. She does not know when they are coming. During
them she feels dread, searing chest pain, smothering and
choking, dizziness, and shakiness. She sometimes thinks this
is all not real and she is going crazy. She also thinks she is
going to die.

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LESSON 2

ANXIETY DISORDERS
TYPES AND SUBTYPES

There are several types of anxiety disorders, including generalized

anxiety disorder, panic disorder, specific phobias, agoraphobia, social
anxiety disorder and separation anxiety disorder.
1. Panic Disorder and Agoraphobia. Have you ever gotten into a near-
accident or been taken by surprise in some way? You may have felt a flood
of physical sensations, such as a racing heart, shortness of breath, or
tingling sensations. This alarm reaction is called the “fight or flight”
response (Cannon, 1929) and is your body’s natural reaction to fear,
preparing you to either fight or escape in response to threat or danger. It’s
likely you weren’t too concerned with these sensations, because you knew
what was causing them. But imagine if this alarm reaction came “out of the
blue,” for no apparent reason, or in a situation in which you didn’t expect
to be anxious or fearful. This is called an “unexpected” panic attack or a
false alarm. Because there is no apparent reason or cue for the alarm
reaction, you might react to the sensations with intense fear, maybe
thinking you are having a heart attack, or going crazy, or even dying. You
might begin to associate the physical sensations you felt during this attack
with this fear and may start to go out of your way to avoid having those
sensations again.
Unexpected panic attacks such as these are at the heart of panic
disorder (PD). However, to receive a diagnosis of PD, the person must not
only have unexpected panic attacks but also must experience continued
intense anxiety and avoidance related to the attack for at least one month,
causing significant distress or interference in their lives. People with panic
disorder tend to interpret even normal physical sensations in a catastrophic
way, which triggers more anxiety and, ironically, more physical sensations,
creating a vicious cycle of panic . The person may begin to avoid a number
of situations or activities that produce the same physiological arousal that
was present during the beginnings of a panic attack. For example, someone
who experienced a racing heart during a panic attack might avoid exercise
or caffeine. Someone who experienced choking sensations might avoid

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wearing high-necked sweaters or necklaces. Avoidance of these internal

bodily or somatic cues for panic has been termed interoceptive avoidance.

The individual may also have experienced an overwhelming urge to

escape during the unexpected panic attack. This can lead to a sense that
certain places or situations—particularly situations where escape might not
be possible—are not “safe.” These situations become external cues for
panic. If the person begins to avoid several places or situations, or still
endures these situations but does so with a significant amount of
apprehension and anxiety, then the person also has agoraphobia.
Agoraphobia can cause significant disruption to a person’s life, causing
them to go out of their way to avoid situations, such as adding hours to a
commute to avoid taking the train or only ordering take-out to avoid having
to enter a grocery store. In one tragic case, a woman suffering from
agoraphobia had not left her apartment for 20 years and had spent the past
10 years confined to one small area of her apartment, away from the view
of the outside. In some cases, agoraphobia develops in the absence of panic
attacks and therefore is a separate disorder in DSM-5. But agoraphobia often
accompanies panic disorder.
About 4.7% of the population has met criteria for PD or agoraphobia
over their lifetime. In all of these cases of panic disorder, what was once an
adaptive natural alarm reaction now becomes a learned, and much feared,
false alarm.
2. Specific Phobia. The majority of us might have certain things we fear,
such as bees, or needles, or heights (Myers et al., 1984). But what if this
fear is so consuming that you can’t go out on a summer’s day, or get
vaccines needed to go on a special trip, or visit your doctor in her new
office on the 26th floor? To meet criteria for a diagnosis of specific phobia,
there must be an irrational fear of a specific object or situation that
substantially interferes with the person’s ability to function. For example, a
patient at our clinic turned down a prestigious and coveted artist residency
because it required spending time near a wooded area, bound to have
insects. Another patient purposely left her house two hours early each
morning so she could walk past her neighbor’s fenced yard before they let
their dog out in the morning.
The list of possible phobias is staggering, subtypes of this disorder are
the following:
1. Animal type (such as snakes, spiders, dogs)
2. Natural environment type (such as heights)
3. Blood-injection-injury type (such as blood, wounds, hypodermic needles
or medical procedures)
4. Situational type (such as driving, flying, bridges, and a child's fear of
school)
5. Other type (such as contracting an illness, loud sounds).
These irrational fears and reactions must result in interference with
social and work life to meet the DSM-5 criteria:
• Persistent and irrational fear for the situation or object, cued by its
presence or anticipation.
• The fear is persistent and lasts at least 6 months.

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•Exposure to phobic object/situation provokes an acute anxiety

response (sometimes a panic attack).
•The fear or anxiety is out of proportion to the actual danger posed
by the object/situation.
•The fear or anxiety is not a typical response in the person’s social or
cultural context.
•Phobic situations/objects are avoided or else are endured with
intense anxiety or distress.
•The avoidance, distress and fear interferes significantly with
someone’s daily routine.
•The fear, distress or avoidance cannot be explained by another
mental disorder
3. Social Anxiety Disorder (Social Phobia). For social anxiety disorder, the
anxiety is directed toward the fear of social situations, particularly those in
which an individual can be evaluated by others. More specifically, the
individual is worried that they will be judged negatively and viewed as
stupid, anxious, crazy, boring, unlikeable, or boring to name a few. Some
individuals report feeling concerned that their anxiety symptoms will be
obvious to others via blushing, stuttering, sweating, trembling, etc. These
fears severely limit an individual’s behavior in social settings. For example,
and individual may avoid holding drinks or plates if they know they will
tremble in fear of dropping or spilling food/water. Additionally, if one is
known to sweat a lot in social situations, they may limit physical contact
with others, refusing to shake hands.
Unfortunately, for those with social anxiety disorder, all or nearly all
social situations provoke this intense fear. Some individuals even report
significant anticipatory fear days or weeks before a social event is to occur.
This anticipatory fear often leads to avoidance of social events in some
individuals; others will attend social events with a marked fear of possible
threats. Because of these fears, there is a significant impact in one’s social
and occupational functioning.
It is important to note that the cognitive interpretation of these
social events is often excessive and out of proportion to the actual risk of
being negatively evaluated. There are instances where one may experience
anxiety toward a real threat such as bullying or ostracizing. In this instance,
social anxiety disorder would not be diagnosed as the negative evaluation
and threat are real.
4. Selective Mutism. Selective mutism is a rare childhood anxiety disorder
in which a child is unable to speak in certain situations or to certain people.
It is not a form of shyness, though it may be thought of as extreme timidity.
Nor is it an intentional refusal to speak, though it may be perceived that
way. Symptoms and co-existing conditions can vary from individual to
individual, as can treatment options.
The onset of selective mutism is usually between the ages of 3 and 6.
Most children who develop selective mutism also suffer from social anxiety,
or social phobia. Temperamentally, they are timid and cautious in new
situations, even as young infants. They may experience separation anxiety.
Many show physical signs, such as awkward body language, stiffness, and
lack of facial expressions. Those who are comfortable in a situation may be
mute but have more relaxed physical characteristics. A child with selective

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mutism may speak in some select situations but not in others, or with select
people but not with others. For instance, the child may speak normally at
home or with close friends, but not at school or other social settings, where
there is the expectation or pressure to communicate. Some children with
selective mutism can use nonverbal communication, such as nodding their
head or moving their hands, while others may appear frozen. Others may
experience so much pressure for their selective mutism that they become
mute in all situations, with all people. To be labeled selectively mute, the
symptoms must continue for at least a month, not including a child’s first
month of school.
Symptoms include:
 Consistent failure to speak in specific social situations (in which there
is an expectation for speaking, e.g., at school) despite speaking in
other situations.
 The disturbance interferes with educational or occupational
achievement or with social communication.
 The duration of the disturbance is at least 1 month (not limited to
the first month of school).
 The failure to speak is not due to a lack of knowledge of, or comfort
with, the spoken language required in the social situation.
 The disturbance is not better accounted for by a Communication
Disorder (e.g., Stuttering) and does not occur exclusively during the
course of a Pervasive Developmental Disorder,Schizophrenia, or other
Psychotic Disorder.
5. Generalized Anxiety Disorder. Most of us worry some of the time, and
this worry can actually be useful in helping us to plan for the future or make
sure we remember to do something important. Most of us can set aside our
worries when we need to focus on other things or stop worrying altogether
whenever a problem has passed. However, for someone with generalized
anxiety disorder (GAD), these worries become difficult, or even impossible,
to turn off. They may find themselves worrying excessively about a number
of different things, both minor and catastrophic. The DSM-5 criteria specify
that at least six months of excessive anxiety and worry of this type must be
ongoing, happening more days than not for a good proportion of the day, to
receive a diagnosis of GAD.
The anxiety and worry is associated with at least 3 of the following
physical or cognitive symptoms (In children, only 1 symptom is necessary for
a diagnosis of GAD.):
•Edginess or restlessness.
•Tiring easily; more fatigued than usual.
•Impaired concentration or feeling as though the mind goes blank.
•Irritability (which may or may not be observable to others).
•Increased muscle aches or soreness.
•Difficulty sleeping (due to trouble falling asleep or staying asleep,
restlessness at night, or unsatisfying sleep).
Many individuals with GAD also experience symptoms such as
sweating, nausea or diarrhea.

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•The anxiety, worry, or associated symptoms make it hard to carry

out day-to-day activities and responsibilities. They may cause
problems in relationships, at work, or in other important areas.
•These symptoms are unrelated to any other medical conditions and
cannot be explained by the effect of substances including a
prescription medication, alcohol or recreational drugs.
•These symptoms are not better explained by a different mental
disorder.
6. Separation Anxiety. In some children, separation anxiety is a sign of a
more serious condition known as separation anxiety disorder, starting as
early as preschool age.
If the child's separation anxiety seems intense or prolonged —
especially if it interferes with school or other daily activities or includes
panic attacks or other problems — he or she may have separation anxiety
disorder. Most frequently this relates to the child's anxiety about his or her
parents, but it could relate to another close caregiver.
Separation anxiety disorder is diagnosed when symptoms are
excessive for the developmental age and cause significant distress in daily
functioning. Symptoms may include:
 Recurrent and excessive distress about anticipating or being away
from home or loved ones
 Constant, excessive worry about losing a parent or other loved one to
an illness or a disaster
 Constant worry that something bad will happen, such as being lost or
kidnapped, causing separation from parents or other loved ones
 Refusing to be away from home because of fear of separation
 Not wanting to be home alone and without a parent or other loved
one in the house
 Reluctance or refusing to sleep away from home without a parent or
other loved one nearby
 Repeated nightmares about separation
 Frequent complaints of headaches, stomach aches or other symptoms
when separation from a parent or other loved one is anticipated
Separation anxiety disorder may be associated with panic disorder and
panic attacks ― repeated episodes of sudden feelings of intense anxiety and
fear or terror that reach a peak within minutes.

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THINK IT THROUGH!

1. Name and describe the three main vulnerabilities

contributing to the development of anxiety and related
disorders. Do you think these disorders could develop out of
biological factors alone? Could these disorders develop out of
learning experiences alone?

2. Many of the symptoms in anxiety and related disorders

overlap with experiences most people have. What features
differentiate someone with a disorder versus someone
without?

3. Many people are shy. What differentiates someone who is

shy from someone with social anxiety disorder? Do you think
shyness should be considered an anxiety disorder?
Is anxiety ever helpful? What about worry?

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LESSON 3

OBSESSIVE- COMPULSIVE
and RELATED DISORDERS
DISORDERS

I. BRIEF DESCRIPTION

Obsessive-compulsive and related disorders are a group of

overlapping disorders that generally involve intrusive, unpleasant thoughts
and repetitive behaviors. Many of us experience unwanted thoughts from
time to time (e.g., craving double cheeseburgers when dieting), and many
of us engage in repetitive behaviors on occasion (e.g., pacing when
nervous). However, obsessive-compulsive and related disorders elevate the
unwanted thoughts and repetitive behaviors to a status so intense that these
cognitions and activities disrupt daily life. Included in this category are
obsessive-compulsive disorder (OCD), body dysmorphic disorder, and
hoarding disorder.

Watch this psychology video to learn about the accurate definitions of

OCD and not the colloquial uses that people sometimes throw around
when they say things like, “You’re room is so clean, you must have
OCD!”.

Video Source:
https://www.youtube.com/watch?v=epDVMBNXsXY

II. TYPES AND SUBTYPES

1. Obsessive-Compulsive Disorder (OCD). Obsessive compulsive disorder
(OCD), more commonly known as OCD, requires the presence of obsessions,
compulsions, or both obsessions and compulsions together (the most
common presentation of the disorder).
Obsessions are defined as repetitive and persistent thoughts, urges, or
images. These obsessions are intrusive, time consuming, and unwanted,
often causing significant distress in an individual’s daily functioning.

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Common obsessions are contamination (dirt on self or objects), errors of

uncertainty regarding daily behaviors (locking door, turning off appliances),
thoughts of physical harm or violence, and orderliness, to name a few).
Often the individual will try to ignore these thoughts, urges, or images.
When they are unable to ignore them, the individual will engage in
compulsatory behaviors to alleviate the anxiety.
Compulsions are defined as repetitive behaviors or mental acts that an
individual performs in response to an obsession. Common examples of
compulsions are checking (i.e. repeatedly checking if the stove is turned off
even though the first four times they checked it was), counting (i.e. flicking
the lights off and on for 5 times), hand washing, symmetry, or repeating
specific words. These compulsive behaviors essentially alleviate the anxiety
associated with the obsessive thoughts. For example, an individual may feel
as though their hands are dirty after using utensils at a restaurant. They
may obsess over this thought for a period of time, impacting their ability to
interact with others or complete a specific task. This obsession will
ultimately lead to the individual performing a compulsion where they will
wash their hands with extremely hot water to rid all the germs, or even
wash their hands a specified number of times if they also have a counting
compulsion. At this point, the individual’s anxiety should be temporarily
relieved.
These obsessions and compulsions are more excessive than the typical
“cleanliness” as they consume a large part of the individual’s day.
Additionally, they cause significant impairment in one’s daily functioning.
Given the example above, an individual with a fear of contamination may
refuse to eat out at restaurants, or maybe bring their own utensils with
them and insist on using them when they are not eating at home.
OCD was previously categorized as an Anxiety Disorder, but in the most
recent version of the DSM (DSM-5; APA, 2013) it has been reclassified under
the more specific category of Obsessive-Compulsive and Related Disorders.
2. Body Dysmorphic Disorder. An individual with body dysmorphic disorder
is preoccupied with a perceived flaw in her physical appearance that is
either nonexistent or barely noticeable to other people (APA, 2013). These
perceived physical defects cause the person to think she is unattractive,
ugly, hideous, or deformed. These preoccupations can focus on any bodily
area, but they typically involve the skin, face, or hair. The preoccupation
with imagined physical flaws drives the person to engage in repetitive and
ritualistic behavioral and mental acts, such as constantly looking in the
mirror, trying to hide the offending body part, comparisons with others,
and, in some extreme cases, cosmetic surgery (Phillips, 2005). An estimated
2.4% of the adults in the United States meet the criteria for body
dysmorphic disorder, with slightly higher rates in women than in men (APA,
2013).
Specifiers include:
With muscle dysmorphia: The individual is preoccupied with the idea that
his or her body build is too small or insufficiently muscular. This specifier is
used even if the individual is preoccupied with other body areas, which is
often the case.

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Indicate degree of insight regarding body dysmorphic disorder beliefs (e.g.,

“I look ugly” or “I look deformed”).
With good or fair insight: The individual recognizes that the body
dysmorphic disorder beliefs are definitely or probably not true or that they
may or may not be true.
With poor insight: The individual thinks that the body dysmorphic beliefs
are probably true.
With absent insight/delusional beliefs: The individual is completely
convinced that the body dysmorphic beliefs are true.
3. Hoarding Disorder. Although hoarding was traditionally considered to be
a symptom of OCD, considerable evidence suggests that hoarding represents
an entirely different disorder. People with hoarding disorder cannot bear to
part with personal possessions, regardless of how valueless or useless these
possessions are. As a result, these individuals accumulate excessive amounts
of usually worthless items that clutter their living areas (Figure 2). Often,
the quantity of cluttered items is so excessive that the person is unable use
his kitchen, or sleep in his bed. People who suffer from this disorder have
great difficulty parting with items because they believe the items might be
of some later use, or because they form a sentimental attachment to the
items (APA, 2013). Importantly, a diagnosis of hoarding disorder is made
only if the hoarding is not caused by another medical condition and if the
hoarding is not a symptom of another disorder (e.g., schizophrenia) (APA,
2013).
4. Trichotillomania (Hair Pulling Disorder). Trichotillomania is a DSM-5
(Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) diagnosis
assigned to individuals who recurrently pull out their own hair. Individuals
with trichotillomania feel compelled to pull hairs, either from their head or
elsewhere, resulting in hair loss and other forms of impairment.
An individual with trichotillomania experiences an irresistible urge to
pull out hair from the scalp or other places, such as the eyelashes or
eyebrows. People with trichotillomania tend to feel rising tension until they
pull out a hair, at which point they experience relief. Some sufferers of
trichotillomania pull hairs out as a response to stress; others do it
subconsciously.
The condition most commonly presents at or following the onset of
puberty and is more prevalent among females than males at a ratio of 10:1.
In any given year, between one and two per cent of the American
population will be affected by trichotillomania. (American Psychiatric
Association 2013)
If someone is suffering from trichotillomania, they will usually display
various symptoms, including:
 Constant pulling or twisting hair
 Bald patches or hair loss
 Uneven hair appearance
 Denial of the hair pulling
 Obstructed bowels if the hair is consumed
 Tension before hair is pulled and relief or gratification after
 Other self-injury behaviors
 Poor self-image

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 Feeling sad, depressed or anxious

Symptoms of trichotillomania usually begin before the age of 17 and
many are commonly seen in children and young people. The majority of
people with trichotillomania pull hair from their scalps but others may pull
out hair from their eyebrows, eyelashes, genital area, beard or moustache.
5. Excoriation Disorder (Dermatillomania/Skin-Picking). Excoriation
disorder, also known as dermatillomania, skin-picking disorder and neurotic
or psychogenic excoriation, is a new entry in the Diagnostic and Statistical
Manual of Mental Disorders (American Psychiatric Association, 2013). It is a
disorder of impulse control characterized by the urge to pick at the skin,
even to the extent that damage is caused. It is analogous to trichitillomania,
the urge to pull one’s own hair, that was in the DSM-4 (American Psychiatric
Association, 2000) but has now been anglicized to hair-pulling disorder. Both
are classified with the obsessive-compulsive disorders, but some analogies
have been suggested to substance use disorders.
The cardinal symptom is a compulsive urge to pick, squeeze or
scratch an area of skin, often a perceived skin defect, when under stress or
experiencing anxiety. The face is predominantly involved, followed by the
extremities and scalp. Picking is usually done for brief periods at a time but
may be engaged in incessantly, particularly by developmentally disabled
patients. The fingers are usually used to pick, but some patients excoriate
the skin with tools such as needles or tweezers, and are apt to do this in
response to feeling anxious or depressed or after examining the skin and
finding perceived irregularities.
Skin-picking has been analogized to the compulsive hair pulling of
trichotillomania because both are obsessive ritualistic behaviors but are not
preceded by obsessive thoughts, both are triggered by anxiety or
depression, both actions reduce the patient’s arousal level and both
conditions have their onset in childhood. Both hair-pulling and skin-picking
have been categorized in the obsessive-compulsive disorders because they
involve repetitive behaviors with diminished control that reduce patient
anxiety.

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THINK IT OVER!

The symptoms of OCD have been theorized to be learned

responses, acquired and sustained as the result of a combination of
two forms of learning: classical conditioning and operant
conditioning (Mowrer, 1960; Steinmetz, Tracy, & Green, 2001).
Specifically, the acquisition of OCD may occur first as the result of
classical conditioning, whereby a neutral stimulus becomes
associated with an unconditioned stimulus that provokes anxiety or
distress. When an individual has acquired this association,
subsequent encounters with the neutral stimulus trigger anxiety,
including obsessive thoughts; the anxiety and obsessive thoughts
(which are now a conditioned response) may persist until she
identifies some strategy to relieve it. Relief may take the form of a
ritualistic behavior or mental activity that, when enacted
repeatedly, reduces the anxiety. Such efforts to relieve anxiety
constitute an example of negative reinforcement (a form of
operant conditioning). Recall from the chapter on learning that
negative reinforcement involves the strengthening of behavior
through its ability to remove something unpleasant or aversive.
Hence, compulsive acts observed in OCD may be sustained because
they are negatively reinforcing, in the sense that they reduce
anxiety triggered by a conditioned stimulus.

Suppose an individual with OCD experiences obsessive thoughts

about germs, contamination, and disease whenever she encounters
a doorknob. What might have constituted a viable unconditioned
stimulus? Also, what would constitute the conditioned stimulus,
unconditioned response, and conditioned response? What kinds of
compulsive behaviors might we expect, and how do they reinforce
themselves? What is decreased? Additionally, and from the
standpoint of learning theory, how might the symptoms of OCD be
treated successfully?

Lesson 4

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TRAUMA
AND
STRESSOR-RELATED DISORDERS

I. BRIEF DESCRIPTION
Trauma- and stressor-related disorders are a group of psychiatric
disorders that arise following a stressful or traumatic event. The English
word trauma derives from the Greek word traumatikos, meaning wound. So
in the broadest sense, when we discuss trauma we are simply talking about
a human wound, be it physical or emotional. Before we can launch into the
specific diagnostic considerations, it might be helpful to review some
general definitions of the terminology that we will be discussing in this
lesson.
The definition of trauma used by the American Psychological
Association is as follows:
"Trauma is an emotional response to a terrible event like an accident,
rape, or natural disaster. Immediately after the event, shock and denial are
typical. Longer term reactions include unpredictable emotions, flashbacks,
strained relationships and even physical symptoms like headaches or nausea.
While these feelings are normal, some people have difficulty moving on with
their lives."
It is important to note that this definition includes not only people
who directly experienced such events, but also those who may have directly
witnessed such an event. For instance, directly witnessing a horrific
accident can meet the criteria for trauma, while indirect experiencing or
witnessing, such as watching an accident on TV, does not.
But trauma, by definition is unbearable and intolerable. Most rape
victims, combat soldiers, and children who have been molested become so
upset when they think about what they experience that they try to push it
out of their minds, trying to act as if nothing happened, and move on. It
takes a tremendous amount of energy to keep functioning while carrying the
memory of terror, and the shame of utter weakness and vulnerability.
The following are the symptoms that characterize the group (or class)
of disorders called Trauma and Stressor-Related Disorders:
Intrusive symptoms were previously called re-experiencing symptoms
in older editions of the Diagnostic and Statistical Manual of Mental Disorders
(DSM). People experiencing these intrusive symptoms describe it as though
they are right back there, reliving (re-experiencing) the trauma all over
again. These are called intrusive symptoms because they are unwanted,
unbidden, and therefore, involuntary. Intrusive symptoms may be indicated
in several ways:
1. Involuntary, distressing images, thoughts, or memories;

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2. Flashbacks or dissociative reactions where it seems as if the

trauma is reoccurring;
3. Distressing dreams and/or nightmares related in content or
emotion to the trauma;
4. Intense psychological distress at reminders of the trauma,
5. Intense physiological distress, often referred to as body memory or
body cues.
Avoidance symptoms represent an effort to withdraw from certain
situations that bring about body-level distress of trauma-related symptoms.
We can also view these symptoms as the activities that people engage in to
limit other types of distressing experiences. For instance, using alcohol or
other drugs can be an activity someone engages in self-medicate anxious
feelings.
Our moods are affected by our thoughts, feelings, and beliefs about
ourselves and the world around us. In a circular fashion, our thoughts,
feelings, and beliefs are affected by our mood. Since unhealed wounds can
affect our mood states, it make sense to pay attention to unhelpful thinking
patterns, and to explore our feelings about ourselves and the world around
us thus cognition and mood symptoms. Listed below:
 Blocking out/not remembering important aspects of trauma;
 Negative beliefs about oneself, others, or the world (i.e., "I'm not
good enough," "The world isn't safe," "No one can be trusted," "I have
no future");
 Distorted sense of who is to blame (either of self or of others) related
to trauma;
 Persistent display of negative emotions (e.g., fear, horror, anger,
guilt, or shame);
 Diminished interest or participation in previously enjoyable activities;
 Feeling detached or estranged from others; and,
 Persistent inability to experience positive emotions (e.g. happiness,
pleasure in life activities, joy).
This category of symptoms has also been called heightened arousal in
previous editions of the DSM, it now called arousal and reactivity
symptoms, as follow:
 Jumpiness, exaggerated startle response, hypervigilance
 Sleep disturbance
 Irritability and/or aggressive behavior
 Problems with concentration
 Reckless or self-destructive behaviors
A stress disorder, on the other hand, occurs when an individual has
difficulty coping with or adjusting to a recent stressor. Stressors can be any
event- either witnessed firsthand, experienced personally or experienced by
a close family member- that increases physical or psychological demands on
an individual. These events are significant enough that they pose a threat,
whether real or imagined, to the individual. While many people experience
similar stressors throughout their lives, only a small percentage of
individuals experience significant maladjustment to the event that
psychological intervention is warranted.
Post-traumatic stress disorder (PTSD) was first introduced in 1980 and

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was included in the group of disorders known as Anxiety Disorders. Among

the most commonly studied triggers for trauma related disorders are combat
and physical/sexual assault. Symptoms of combat related trauma date back
to World War I, when soldiers would return home with “shell shock” (Figley,
1978). Unfortunately, it wasn’t until after the Vietnam War that significant
progress was made in both identifying and treating war-related
psychological difficulties (Roy-Byrne et al., 2004). With the more recent
wars in Iraq and Afghanistan, attention was again brought to posttraumatic
stress disorder (PTSD) symptoms due to the large number of service
members returning from deployments and reporting significant trauma
symptoms.
Physical assault, more specifically sexual assault, is another
commonly studied traumatic event. Rape, or forced sexual intercourse or
other sexual act committed without an individual’s consent, occurs in one
out of every five women and one in every 71 men (Black et al., 2011).
Unfortunately, this statistic is likely an underestimate of the actual number
of cases that occur due to the reluctance of many individuals to report their
sexual assault. Of the reported cases, it is estimated that nearly 81% of
female and 35% of male rape victims report both acute stress disorder and
posttraumatic stress disorder symptoms (Black et al., 2011).
One of the major changes in the newest edition, (DSM-5, 2013) was
the inclusion of a new group of disorders called Trauma and Stressor-
Related Disorders. The new chapter of Trauma and Stressor-Related
Disorders contains the following diagnoses/types:
 Reactive Attachment Disorder
 Disinhibited Social Engagement Disorder
 Acute Stress Disorder
 Posttraumatic Stress Disorder
 Adjustment Disorders

THINK IT THROUGH

What are the marked symptoms of

someone exposed to trauma? Explain.

Lesson 5

TRAUMA AND
STRESSOR-RELATED DISORDERS
Module 2
TYPES AND SUBTYPES
 22

Various types of stress and trauma are responsible for the disorders
we’ll consider in this lesson, as follows:
1. Reactive Adjustment Disorder. Reactive attachment disorder occurs in
children who have experienced severe social neglect or deprivation during
their first years of life. It can occur when children lack the basic emotional
needs for comfort, stimulation and affection, or when repeated changes in
caregivers (such as frequent foster care changes) prevent them from
forming stable attachments.
Children with reactive attachment disorder are emotionally
withdrawn from their adult caregivers. They rarely turn to caregivers for
comfort, support or protection or do not respond to comforting when they
are distressed. During routine interactions with caregivers, they show little
positive emotion and may show unexplained fear or sadness. The problems
appear before age 5. Developmental delays, especially cognitive and
language delays, often occur along with the disorder.
Reactive attachment disorder is uncommon, even in severely
neglected children. Treatment involves the child and family working with a
therapist to strengthen their relationship.
2. Disinhibited social engagement disorder. Disinhibited social
engagement disorder occurs in children who have experienced severe social
neglect or deprivation before the age of 2. Similar to reactive attachment
disorder, it can occur when children lack the basic emotional needs for
comfort, stimulation and affection, or when repeated changes in caregivers
(such as frequent foster care changes) prevent them from forming stable
attachments.
Disinhibited social engagement disorder involves a child engaging in
overly familiar or culturally inappropriate behavior with unfamiliar adults.
For example, the child may be willing to go off with an unfamiliar adult with
minimal or no hesitation. These behaviors cause problems in the child’s
ability to relate to adults and peers. Moving the child to a normal caregiving
environment improves the symptoms. However, even after placement in a
positive environment, some children continue to have symptoms through
adolescence. Developmental delays, especially cognitive and language
delays, may co-occur along with the disorder.
The prevalence of disinhibited social engagement disorder is
unknown, but it is thought to be rare. Most severely neglected children do
not develop the disorder. Treatment involves the child and family working
with a therapist to strengthen their relationship.
3. Posttraumatic stress disorder. Posttraumatic stress disorder (PTSD) is a
psychiatric disorder that can occur in people who have experienced or

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witnessed a traumatic event such as a natural disaster, a serious accident, a

terrorist act, war/combat, rape or other violent personal assault.
PTSD has been known by many names in the past, such as “shell
shock” during the years of World War I and “combat fatigue” after World
War II. But PTSD does not just happen to combat veterans. PTSD can occur
in all people, in people of any ethnicity, nationality or culture, and any age.
PTSD affects approximately 3.5 percent of U.S. adults, and an estimated
one in 11 people will be diagnosed PTSD in their lifetime. Women are twice
as likely as men to have PTSD.
People with PTSD have intense, disturbing thoughts and feelings
related to their experience that last long after the traumatic event has
ended. They may relive the event through flashbacks or nightmares; they
may feel sadness, fear or anger; and they may feel detached or estranged
from other people. People with PTSD may avoid situations or people that
remind them of the traumatic event, and they may have strong negative
reactions to something as ordinary as a loud noise or an accidental touch.
A diagnosis of PTSD requires exposure to an upsetting traumatic
event. However, exposure could be indirect rather than first hand. For
example, PTSD could occur in an individual learning about the violent death
of a close family. It can also occur as a result of repeated exposure to
horrible details of trauma such as police officers exposed to details of child
abuse cases.
Symptoms of PTSD fall into four categories. Specific symptoms can
vary in severity.
 Intrusive thoughts such as repeated, involuntary memories;
distressing dreams; or flashbacks of the traumatic event. Flashbacks
may be so vivid that people feel they are re-living the traumatic
experience or seeing it before their eyes.
 Avoiding reminders of the traumatic event may include avoiding
people, places, activities, objects and situations that bring on
distressing memories. People may try to avoid remembering or
thinking about the traumatic event. They may resist talking about
what happened or how they feel about it.
 Negative thoughts and feelings may include ongoing and distorted
beliefs about oneself or others (e.g., “I am bad,” “No one can be
trusted”); ongoing fear, horror, anger, guilt or shame; much less
interest in activities previously enjoyed; or feeling detached or
estranged from others.
 Arousal and reactive symptoms may include being irritable and having
angry outbursts; behaving recklessly or in a self-destructive way;
being easily startled; or having problems concentrating or sleeping.
Many people who are exposed to a traumatic event experience symptoms
like those described above in the days following the event. For a person to
be diagnosed with PTSD, however, symptoms last for more than a month
and often persist for months and sometimes years. Many individuals develop
symptoms within three months of the trauma, but symptoms may appear
later. For people with PTSD the symptoms cause significant distress or
problems functioning. PTSD often occurs with other related conditions, such

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as depression, substance use, memory problems and other physical and

mental health problems.
4. Acute stress disorder. Acute stress disorder occurs in reaction to a
traumatic event, just as PTSD does, and the symptoms are similar. However,
the symptoms occur between three days and one month after the event.
People with acute stress disorder may relive the trauma, have flashbacks or
nightmares and may feel numb or detached from themselves. These
symptoms cause major distress and cause problems in their daily lives.
About half of people with acute stress disorder go on to have PTSD.
An estimated 13 to 21 percent of survivors of car accidents develop
acute stress disorder and between 20 and 50 percent of survivors of assault,
rape or mass shootings develop it.
Psychotherapy, including cognitive behavior therapy can help control
symptoms and help prevent them from getting worse and developing into
PTSD. Medication, such as SSRI antidepressants can help ease the
symptoms.
5. Adjustment disorder. Adjustment disorder occurs in response to a
stressful life event (or events). The emotional or behavioral symptoms a
person experiences in response to the stressor are generally more severe or
more intense than what would be reasonably expected for the type of event
that occurred.
Symptoms can include feeling tense, sad or hopeless; withdrawing
from other people; acting defiantly or showing impulsive behavior; or
physical manifestations like tremors, palpitations, and headaches. The
symptoms cause significant distress or problems functioning in important
areas of someone’s life, for example, at work, school or in social
interactions. Symptoms of adjustment disorders begin within three months
of a stressful event and last no longer than six months after the stressor or
its consequences have ended.
The stressor may be a single event (such as a romantic breakup), or
there may be more than one event with a cumulative effect. Stressors may
be recurring or continuous (such as an ongoing painful illness with increasing
disability). Stressors may affect a single individual, an entire family, or a
larger group or community (for example, in the case of a natural disaster).
An estimated 5% to 20% of individuals in outpatient mental health
treatment have a principal diagnosis of adjustment disorder. A recent study
found that more than 15% of adults with cancer had adjustment disorder. It
is typically treated with psychotherapy.

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TEST YOURSELF

A. Choose the correct preliminary diagnosis with

the cases below:(a) posttraumatic stress disorder,
(b) acute stress disorder, and (c) adjustment
disorder. B. Justify your choice.

1. Judy witnessed a horrific tornado level her farm 3

weeks ago. Since then, she’s had many flashbacks of
the incident, trouble sleeping, and a fear of going
outside in storms.

2. Jack was involved in a car accident 6 weeks ago

in which the driver of the other car was killed. Since
then, Jack has been unable to get into a car because
it brings back the horrible scene he witnessed.
Nightmares of the incident haunt him and interfere
with his sleep. He is irritable and has lost interest in
his work and hobbies.

3. Patricia was raped at the age of 17, 30 years ago.

Just recently, she has been having flashbacks of the
event, difficulty sleeping, and fear of sexual contact
with her husband.

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LEARNING ACTIVITY

Reflective Blog
Students will watch “Diagnosed with PTSD and MDD, and managing to
get a Ph.D.: Helen Abdali Soosan Fagan at TEDxLincoln”
(https://www.youtube.com/watch?v=JCrZimA5bKs)

The purpose of the blog is for them to reflect about – write about –
and discuss the new knowledge you and your fellow students actually
learned in the module readings and discussions, and how your thoughts,
feelings, and actions will be impacted by this new learning.

For this topic:

1. provide an overview of the topic and what you learned about it
2. describe how what you learned will impact the way you think,
feel, and behave in the future.

The minimum blog requirement is 500 original words

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 27

MODULE SUMMARY

In this module we covered disorders primarily caused by anxiety and

stress. These include Anxiety Disorders, Obsessive-compulsive and related
disorders and Trauma and stressor-related disorders. Additionally, types and
subtypes for each of these group of disorders were also discussed.

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SUMMATIVE TEST

CASE
ANALYSIS
Read carefully the information provided in the case to be able to:
a) give the proper diagnosis; and,
b) link the specific facts of the case to the different symptoms of the
disorder

1. Billy was the model boy at home. He did his homework, stayed out
of trouble, obeyed his parents, and was generally so quiet and
reserved he didn’t attract much attention. When he got to junior high
school, however, something his parents had noticed earlier became
painfully evident. Billy had no friends. He was unwilling to attend
social or sporting activities connected with school, even though most
of the other kids in his class went to these events. When his parents
decided to check with the guidance counselor, they found that she
had been about to call them. She reported that Billy did not socialize
or speak up in class and was sick to his stomach all day if he knew he
was going to be called on. His teachers had difficulty getting anything
more than a yes or no answer from him. More troublesome was that he
had been found hiding in a stall in the boy’s restroom during lunch,
which he said he had been doing for several months instead of eating.

2. Mrs. Betty Jones and her four children arrived at a farm to visit a
friend. (Mr. Jones was at work.) Jeff, the oldest child, was 8 years
old. Marcie, Cathy, and Susan were 6, 4, and 2 years of age. Mrs.
Jones parked the car in the driveway, and they all started across the
yard to the front door. Suddenly Jeff heard growling somewhere near
the house. Before he could warn the others, a large German shepherd
charged and leapt at Marcie, the 6-year-old, knocking her to the
ground and tearing viciously at her face. The family, too stunned to
move, watched the attack helplessly. After what seemed like an
eternity, Jeff lunged at the dog and it moved away. The owner of the
dog, in a state of panic, ran to a nearby house to get help. Mrs. Jones
immediately put pressure on Marcie’s facial wounds in an attempt to
stop the bleeding. The owner had neglected to retrieve the dog, and
it stood a short distance away, growling and barking at the frightened
family. Eventually, the dog was restrained and Marcie was rushed to
the hospital. Marcie, who was hysterical, had to be restrained on a
padded board so that emergency room physicians could stitch her
wounds

Required Textbooks & Materials:

Module 2
 29

American Psychiatric Association. (2013). Diagnostic and statistical

manual of mental disorders. (5th ed.). Arlington, VA: American
Psychiatric Publishing.
David H Barlow, Durand. Abnormal psychology : an integrative approach,
Boston, MA : Cengage Learning, [2018].
Ronald Comer, Abnormal Psychology, 9th ed. Worth Publishers, Inc.
Published: 2015.
James Morrison. DSM5 Made Easy:The Clinician,s Guide to Diagnosis 1st
ed. THE GUILFORD PRESS: New York.

References:
Blank, Donald W. and Jon E. Grant. DSM 5 Guidebook. American
Psychiatric Publishing:Washington (2014).
Bowie, M.J. and Schaffer, R. Understanding ICD-10: A worktext. Cengage
Learning, [2010]
Davey, G. (2014): Psychopathology . Wiley/BPS Textbooks
Davison, G., Neale, J. Study Guide: Abnormal Psychology. John Wiley &
Sons, Inc. (2000)
Comer, R. & E.E.Gorenstein (2014) Case studies in abnormal
psychology,2nd edition. Worth.
Byron, T. The Skeleton Cupboard: The making of a Clinical Psychologist.
MacMillan, 2015.
Davies, J. Cracked: Why Psychiatry is doing more Harm than Good. Icon
Books, 2013.
Hooley, J.M., Butcher, J.N., Nock, M.K. & Mineka, S. Abnormal
Psychology, Global Edition (2016).
Kring, A., Johnson, S. Abnormal Psychology, 12th ed. Wiley and Sons
(2016)
Loewenthal, K.M. Religion, Culture and Mental Health. Cambridge
University Press, 2009.
Nevid, J., Rathus, and Greene. Abnormal Psychology in the Changing
World, Pearson (2014)
Osborne, R.A. et al. Case Analyses for Abnormal Psychology. Routlidge,
New York (21016)

Module 2