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CHAPTER 6 ANXIETY• 0 BSESSIVE-COMPULSJVE, AND TRAUMA-RELATED DISORDERS :1S7.

ll
OGY
PSYCHOPATHOL
UNDERSTANDING
DSM-5 ICD-10
stress disorder(PT s0) �m anxi COf d" ocder (in the
Posttraumatic di cder M-5 ha
Presence o f one (or more) of the following intrusion ► A state of autonomic

. "'
um•tic str 1h C O symptom s associated with _th e traumatic event(s)
on uf p l)Sttra en' chapter of hyper a rousal and
' or-c elated di ord
0
The ,h;ft in I cati uma and "'5 PTSD entails m
ultipl e beginning after the tr a mat1c ev�nt(s) occurred: • hypervigila nc e (enhanced
the n w 'tra of trau ma. �
DSM-IV) lot o the d efiniti 0n ) h nee ( 1} Recurrent 1nvolu ary, d intrusive distr essing �tartle reaction and insomnia).
• on tightening & orth 2017

-
nt em ph asis (Pai, uri s. , ai:'
pi ced significa r/anxieO{ p tru
m gnostic memories of the traumat1c event( s) • Aruoety and depression ar e

•
fall out St·d < 0f th C fea indu 50 i n of mo<e di
em 0Uons that >Ocders. Thi
has r ulted in the tom that r auh f,om
Not e · In ch"l1 dren older than 6 years, repet 1!1ve commo�ly associ ated with the
anxi Of di ral sym p play m ay occur in whlch the mes or aspects of
m the ation of 1h t b h
e aviou bove s1_gns and symptoms, and
it rem (val fro .
well , , elflan upp 0rtiv eof th ete : .

-
ifiers, SD are gen erally th e traumatic e vent(s) e expressed u 1C1dal ideation is not infrequent.
criteria and pec in the treaunent 0f PT clude ver< ming ;;
o. • l, wh s
P $)'eh 0lo gil
0 pec iaU se
Un C with thera
py goal • Th in
• (2) Recurrent distressin s In which the • O nset fo llows the trauma with a

'
P'f m 0re In ati C ev nt,
elf, and cont ent and/or affec� of �:dream are related to
uch ut th e trau m lat ency period that m aY range
chang CS• th ey,,. now m live belie! abo • and
CS- ham from a t�w weeks to months.
'
vely n of gui lt, the tr aumatic event(s).
tructuring cxce,si em otion
avoidance; r but• 5luclc PTSO Course is fluctuating, but
g th· t comm 0n Note: In children, ther e _may be frightening •

•
s a r lvin

•
well
symptom 5; a s. llinv 0lve s d rea ms without � nisable content.
•
017). rec ?very can be e xpected in the
Mon on, & Chard, 2 ymptom pattem :���
anger (R CSick, v ral pos Ible in (3) Dissociative rea c 9- fla_shbacks) in which m aionty of c ases.
ays and re ult in , which culminate �
PT O present
In varie d,
eatening exp erie nc th e individual feels or � as if the �a umatic • In a small proportion of cases
an intensely thr . Type-1 trauma
•
t or tun �
ver a e of
atic C ven p rio d C event(s) were recurring. ( uch reactions m ay
1>um the condition may follow a
expOSU1' to a tr of the trauma o where complex
'
ab rrant fear re
pon to reminders
'
r one igni ficantly tr ful
Cril rion A ev ent.
m as Co( I itre, Cou rto l, et II.,
occur on a cont·1nuum • with the most ext rem e
expression being a lete loss of awaren ess
c?ronic course over many y ears
with e_ventual tr ansition to an
,
develop aft we call Type-II tnu
PT O typi caUy int, Crpu $0nul, of present surround�n� )
:

'
0 p a fter wh et , ofte n enduring per sonality change.
may devel ted or pr ()longed
tTauma
PT D (C-1'1"S0) ide red re pea chi ldh 0od exual
or Note : In children, such tra um a -spec1fic
r typ<' con victim of
2 0II). Thi i latte dudin 8 b CIng a
not po ible, in
reenactment m ay cur in play..
h e cap wa e trad e, for instance. :; sycholog1cal d stress
and �m whic g, or lav (4) Intense or prolon
dome tic viol
•n cc, · traffickin �
i
phy icnl abuse, and ICD-10 at exposur e to in�m ernal cu es that
lrom tne DSM-5 �� :
stress diSO(der symbol ise or re se mb� pect of the
lic ciite<ia for posttraurnatlc traumatic event(s)
gnos
Table &.e, Qia
(S) Mark ed physiol ic a1 r �t1ons to interna l or
: hse or resemble
extern al cues th� sym an
as a delayed
• QisOrde r aris es aspect of_the tr aum atic event(s).
ctu a l or thr ea t ened dea
th, serious
Of protr ed response o a I
C. Pers·st
I ant avoidance of stimuli,
.
associated with the
Exposure to a
more) of the situatiOn
violence n one (or s ressful event or traumatic event(s) , begi nning after the traumatic
injury, or sexual duratiOn) ol
ways : ). ( f or long n event(s) occurred , as evidenced by one or both of the
follo wlng matic ev e nt(s lernng
riencing the trau n exceptionally thr83 following:
(1) ()irectly expe n, the event(s) as
it occurred
catastr ephi c nature, 1l\<81Y .
in pe rso or (1) Avoidance of or efforts to 1d d1stress1ng
(2) Witnessing, distress In f
to others. to cause pervasiVe mem�nes, tho ughts, or e:;�gs about or closely
occurr ed to
ng th a t th e tra umatic event s) \ almOSl anyone. associated with the tr aurnatlc ev ent(s).
(3) Learni ose fnend. In ca
ses
features include:
a close fa
mily member or cl emb er • Typical ted relM09
(2) Avoidance of or ffiarts to av oid external I
th re aten ed
eat of a I ily m ► EpisodeS of repea reminders (pea :
• p ' places, conve rsations,
of a ctual or viol ent or intnJSIVe
, vent(s) mus ha of he 1(8U(OB (In activities ts, �rtua tions) that arouse
or friend the e oacl<S'
memorleS, 'flash distressi�;�ec o es , t oughts, or feefings about
accidental. at the traum atic nightmares). �
, l e arni ng th dreamS , or or closely �_ a ;ed wit� th e traumatJc event(s).
Note : In children caregiving figur e . ckgroundS
U:
I
ed to a parent or • PersiSl1n9 t,a D. Negative alterations
even (s) OCCl.lrr h in cognitions and mood
g rep eat ed or extreme e xpos
ure to
sense
o1 of 'numbness' 8SSOclated with l uma�c event(s). beginning or
(4) E,(perlencln event(s) (e.g. untin9
of the traumatic and emotional bl �ng after ;ra
raumatic event(s) occur ed as
avetsiVe details an remains; polic
e ot
nd e rs coll ecting hum (de tachment from hel'ess to evidenced b two (or more) of the fol
y lowing.• r
'
first respo of child siven (1) Inablhly
edly exposed t o d etails people, unrespon .
to remember
officers re pe at he(lofll8} as m
� portan
t a spect of the
surroundings, an iVltieS traumatic event(s) (typicafly due to dissociative
abuse).
4 doe s not app ly to exposure well as avoida1'C8 of act 01 amne sia and not Io oth er factors such as head
Not e : Crit erion A a , t elevisio
n, rnovies, or at lonS reminisC
en1
nic me di and s1tu inJury, alcohol• or drugs)
through electro k-rela t ed.
exposure is wor the trauma . __
pictures, unless this
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CHAPTER 6 ANXIETY, OBSESSIVE-COMPULSIV

LOGY
DING PSYCHOPATHO
UNDERSTAN
Acute stress disorder
Acute stress disorder is marked by the development of characteristic symptoms following
exposure to one or more traumatic event(s). The symptoms last for a period of between
l fs three days and one month following traumatic exposure, and they do not extend beyond a
e :; ese , led negative be ie
(2) pe(Sistent � xa n lf others,
or the period of four weeks. Thus, acute stress disorder symptoms occur in the early post-trauma
s
or expectauon 8 , • one can be tNSled • period and could potentially result in a later presentation of PTSD. However, this is not
bad , Noc:i gerou ' , •My whole
wor1d le.g. 'I am an s always the case because, in many instances, Lhe traumatic symptoms remit naturally. Acute
·Toe world is comple ely ely ruined' . stress disorder typically presents as an anxiety response that includes some foon of re­
f'l8l'VOUS sySleffi IS com'7t cog i ions al:)OUl lh8
nt experiencing of, or reactivity to, the traumatic event(s) (American Psychiatric Association,
e aggera ed s)
(3) Persisten and xuence or the traumatie event(
cause or con seq hlmself/h8Csell 201 3). Th e clinical presentation may also vary, a in the case of PTSD.
dual to bla me
\ha lead the nc!M I Acu te stress disorder was introduced in the DSM-IV to describe people who were
or others. ein o tion al st ate (e.g. fear, exposed to a traumatic event and presented with symptoms consistent with PTSD but had
i.�4) Persistent negatllle shame). not yet fulfilled the criteria for duration of disturbance. This diagnostic category was meant
or
hOfl'Of, anger, uilt ·nt or participation \n to identify individuals who were at risk of developing PTSD. This sparked much discussion
M arked lY dim 9ni� , erest
l5) les. and debate, as questions related to whether it is a reliable predictor of PTSD arose, as well
significant actiV\l angement from
detachment or estr as whether it pathologises what is considered to be a normal stress reaction. In the DSM-IV,
(6) Feehfl9S of I the diagnostic criteria for acute stress disorder were the same as those for PTSD, except a
others. •ence pos1tiVe
ity to expe!1 shorter duration of time was specified for acute stress disorder. The diagnostic criteria for
(7) Persistent loabl. inabi ity to expenence hal)piness,
uons le,g acute stress disorder have changed significantly with the publication of the DSM-5.
emo .
saus1acoon, °' lovin9 feellnQS).
sal and reactiVitY or
E. MarKed alt h the trau
er�tk>ns �tic event(s) , beginning
assooiated w, tie e'-lent(s) occurred as Adjustment disorders
worsen'lf'l9 after lh8 trauma following:
o �or rno little Adju tm nt disord rs r ult from a malad ptiv r pon e to tr ful life vents. They o cur
evidenced 'r:1-J tw a: ;:; outbUrsts (with in respon to an identifiabl lre sor, and are experienc d a disrre ing and have a negativ
1 1mtabl8 b e h a v�
() \ typlcally expressed as verb8I
or no provocatiOf\ . toward peoPle or obJeets. impact on a n individual' daily functioning. Adjustment di orde occur within three
or physical aggressiOO ive t)ehaVioor. months of the onset of the stressor and do not rep re-Sent bereavement. Once the stressor bas
self-destnJci I
(2) Reckless or been resolved, the symptoms do not persist beyond a period of six months.
H yperv\9 "ance. The tr or may b an individual event or it may be r current, a in the ea of ong ing
(3) startle response,
(4) Exaggerated 0
with concen ratlOfl, falling or sta," ,,.nn
.,, dome tic abu e \ •ith increasing inten ity. The level ofdistres exp riencedi out of proportion
. difficulty to the •erity and inten ity of the tr or. For the fir t time, th e di orders form part
SleeP�
(a) PrOOI
{5) dlStUrbanC8 (e.g ,
asteeP or restless sleep,. . . of the trauma and tr or-related di orders chapt r of the DSM-5, and they continue to
e B , c o and E) Is
Duration of the dlsturbaOC8 (Co na b recognl ed in th ICD- 10. In prevlou ver i n of the DSM, adju tment di order wer
F. h·
more u,an 1 moncaus . . ,... 5' ricant distress po. itioncd between the V-code (problem lev I condition ) and Axis 1 di orders. The D M-5
UQJnro
. _.._,., es cl1rn 1'1 ,m,.,,,.11,
l-"'' -,nt·
G. Toe dtStUr occ uP 11ona1. other diagno tic criteria for adjuslm nt di ord ar Ii t d in Table 6.9.
or impairmen'""" t \n soc!al
areas of 1unction1:� ltl'ibUt ble to \he Table 6.9: Diagnostic criteria for adjustment disorders from the DSM-5 and ICD-1 0
ot a \
H. The dlst1.lf\)81'\C8 a
f a subStanc& (e .g.
pt,yslOI09\cal effects O ef medica l condition, -. L---
-�
or anoth - - DSM-5 ICD- 1 0
medication, atcohol) I
-- rtcal nval of Menta/ 0rs0rdetS• l
\- and s1a11s a Ma The development of emotional or behavioural ■ States of subjective distress and
trom the o;agr,ostie
source·• RePrlnted with � AsSOCi&\lon (APA). 2013, P· 2n . no tt1e ,co-10 c,assif,<;SIJO(I
Qrganil&I\Ol'l ('M-IOJ '°
symptoms response to an Identifiable emotional disturbance, usually interfering
. for ReSearch wor1d Heallh

__ ____,
AmefiC8ll pgychaalr1C
sorcJerS' 0ragnosuc en,ena
. s tessor(s) occurring W1I • three months of with social functioning and performance ,
edition {OSM-5\,
(3ehaVIOUTai Di he ons of the stressor(s). arising in the period of adaptation
Mental and
Geneva, 2007 ·
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PDFelement
CHAPTER 6 ANXIETY, OBSESSIVE-COMPULSI

Y
OPATHOLOG
DING P SY CH
UNDERSTAN
Unfortunately, insufficie nt attention has been given to examining the impact ofsociocultural
factors on the manifestation of anxiety disorders in particular societies and cultures. This

_
=
8 or a stressful is especially relevant in South Africa, where there has been a paucity of research aimed at
to a signif . icant life chafl9 Y have exploring the culture-related clinical patterns of anxiety disorders. Cross-cultural studies of
nica lly ma
ha'JIOUIS are cli of life event Toe �
5 l's \
iheS!:l symptom
s both \ attected \he lntegn ty an indiV\dua anxiety provide critical information about the presentation and manifestation of the disorders
avid� n� by one or n\, separatlOO across different culture . This is essential as it sheds light on the interplay of biological,

I
sigrnfica nt. as eme
social netwOrk (b8l'88"' wider system of psychological, and social factors that impact on the expression of anxiety disorders. While
the f=:d\ ss that \s OU of propor\lOO -'�)
expe,..,. ,- Ol' th8 and values lm19ra\l00,
stre anxiety has been identified across different cultures on a global scale, the context in which it is
(1 ) to the severity or 1ntensitY of t: ei<t81'nal social supports 18 tee! a major
, or experienced shapes how it is interpreted and the responses given to it.
into aceount retugee status) cnsiS (going \
stressor, taI<,ng ltural factors t,at l ra�
developmenta m,ng a parent , f iure Cultural beliefs tend to influence how an individual processes and interprets anxiety­
SI
cu
context and the and beCO
symptom �•IY �..""'1
to __ heel personal goal, provoking stimuli in the environment. In the Middle East, for instance, panic disorder usually
might influence
ivv,, •

to attain a ual pred\SpOSIUo the \

n or involves the fear of the afterlife, rather than of dying, as people fear possible punishment and
presentati�. . ant in social , reuremen cnen
t). 1nd � In
l2) Sign r�t 1rn or1r�
pa i p o rtant ar eas of 8 ·mportant role torture after death, if their wrongdoings on earth outweigh their good deeds (Mosotho, Louw,
o her m vu\nerabifrtv tp,u the
shaping. of the
occupational. \ ...,..,... p1a
,rr enysce �� & Calitz, 20 1 lb). Pe rceptions about mental illness, coping styles and support from family,
nsK oI """"'." a<fiostrnent d1SOI'ders.
functioning. not me,et Of \ friends, and the community may influence an individual's help-seeking behaviours. The
d\sturbance d08S er and is manl{estatior\S ss assumed • that the
. T he st,ess-related men= •-' dis ord bi.rt it 1s neverth ele withOUt clinician's own culture and beliefs may also influence the clinician's approach to treatment.
c . for a not her . . g ha ve an sen
the cntena of a preex1st1n ld r,o\
condltiOn wou manitestauons vary 1he DSM has identified certain culture-bound syndromes (see Chapter 10) that are
exacerbatlon
not merely an u,e stresSOI'· The mood, anxiety or ' specific to a particular culture and are recognised as an illness within the context of that
\ orde r. l
mental dis sent norma and include
ressed
e), a teelll'\Q of
\
ms do not repre �xtIJre of thes
culture. The brain fag syndrome has been described in the DSM as a cluster of somatic
D. Toe symptont.
bereaveme
stresSOI'
E. Once the the or :ns clO not persist
. oonseQuences have
for
worrY lor a m1
inability to COP8: pi�;
\n \he �\ 51\1)8:n u,a pertorrnance
head 01' continue
as �ell as some
complaints (consisting of pains and burning sensations around the head and neck), cognitive
impairments (including inability to grasp the meaning of written and sometimes spoken
ter min a ted nth s. bi words, inability to concentrate, and poor retention), sleep-related complaints (consisting of
�ional six mo degree of diSa ders may
more than an 8 'dY nduct dlsoc
. Co fatigue and sleepiness despite adequate rest), and other somatic impairments (e.g. blurring,
of da!IY routine eat .,....",iCUlarlY 1n
ure """'
•at ed t eye pain, and excessive tearing) (A merican Psychiatric Association, 2013). This psychiatric
be an asSOot oant feature
ad(>leSCE!O\S. The Predon'i \onQed depresslve condition was first studied among African students in the 1960s, and it represents a highly
a b rief pro
may be ors utbanee o other researched aspect of anxiety disorders.
,
,eact1on, 01' a Although anxiety is a universal phenomenon, and the manifestation of different anxiety
a nd conduct.
emotiortS disorders is se en across different cultures, there are significant cross-cultural differences in
- - --
tal Disorders, the description and experience of anxiety (Guarnaccia et al., 2005). For example, the word
St troal Ma I �f Men lntematjo(llll 'anxiety' is not used in many African cultures and languages.
. o;agnosuc srid ;: \ tCD-1 o
inted with per 2()13, p. �� n1'1A\k>O ('NHO).
(3eneV0, 2016, Traditionally, African people view personhood from a systemic, communal, and socio­
SOUrce•• RePr Health Vl\P' - centric perspective, in which the individual is part of a bigger whole. An individual's social
5), Am8f.c,an
iltt'I ed'1Uon ll)SM- /ofl C)isea
of

icat and cultu ral context plays a significant role in how the individual interprets and copes with
Stafisucar crassf
traumatic events that could potentially result in the onset of PTSD. Toe African perspective

-C U LT U R AL
A o AF R\ C A
N of trauma is based on the view that trauma is based on one's interaction with society and
culture over a period of time (Motsi & Masango, 2012).
C RO SS
S
E CT \V E o be of
p ERS P n hown t
- mrou m . ti
• and have b ha ve b n
esp r ll co e di orders The Ugan dan psychiatrist Seggane Musisi has written, 'It behoves all African scholars,
ty ers are w i d ili g b
;;!;� :use of d' ab ty � :! t:nd to mak ttq : e f ue
n,c.ie disord arict health workers in particular, to research and publicise the causes, effects, and sequels
. pre'Valene an d a c t • a peo ple "'th urvey co ndu
of mass tra uma on our peoples and to find appropriate solutions both for prevention and
'Ih:
increaslng ·a1 h ea\thcar
co
r\d Me ntal H
ealth S
und
iO at
h u
as ociat d wit � ��o ta e Uva, 1998_) . t Hfet\me diagnosi "' . : ted tb I ::t rnent. These are the areas In need of extensive research by researchers possessing
er dtcat e h (2007) in
u e of health � al., 2009) in on, t in et al. othd' s-cultu ral and transdisciplinary competence' (2004, p. 82) .
04� e \er et . In ad�iti th l Su99e t
ft m 2002-�0 th A fric an r p ondent . ty di order compared ""1· s Why Musisi calls for a focus on 'mass trauma'.
of ou c of all)CI
1 3 t on -thlrd
e
. hest pr v le n
as the \JCth hig
outh Africa h
cou ntries.
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PDFelement

CHAPTER 6 A NXIETY, OBSESSIVE-COMPULSIVE, AND TRAUMA-RELATED DISORDERS

ATHOLOGY
UN DERSTA NDIN G PSY CHOP

fe ar_ and anxiety involve behavio ural, au ton omic• and endocnne .
. eh anges auned at
. • al (Sbiromani et ,!., 2009 )
increas ing an organi s m's chances of su_rvrv rough our enses,
Y
E PI DE MI O LO G
. c .
we take in information from . the env1ronme nt, an d certa1·n iniormation Th is
· subsequently
airment in
function ing aero . s our behaviour:. Several s ecific hob'ias h ave
i and re ult
in ign ificant imp y y ears, althou
gh the sel ected for further processmg
.
, wh ic· h guide p p
a, e fo ·
been identified as or1g·m ating as nat ura1 survival mechan is ms ratl1er th an p athological
diS rders ulli r
n man
An,iety W order
h r
d to
pe p , I th a nxiety mtl ty di order i oi
ntext . Man y o le of a e
condition s (Bandelow et al·• 20 16 ) .
multiple co ge. Th lifetune pr valence p p , it h an aniciety
es in ; th r out o fou
er a o le
pr valence dec re
old r
te rn count rie e ( \ch<el,
Zet he,
% and 29% in We d r I n their Iii tim Neurochem istry
va,y between \ th me nra l di or gge to b th mo t .
ce '1 \east on bia are s u
o r s ted
disorder experien r and pecific pho with comorbid Multipl e neurotran smitters h ave bee n found to play a role in fear and aruoety behaviour.
cial an,dcty Ws rde com m nly pre enl .
Margr.>f, 2007 ). o • a b oth di rders az, Ledermann, N eur o t ran s mitters implicated i n ama e ty di �r de ni inclu de serotonin
k • g l ut a mate, GABA
di o rd r rders (Rud
nd
ti e ,nxi ety e
anxi ty o (gam m•••mino butyric acid )• and norep me.phrin ( also nown as norad ren a1·me),
common UC.
di
m and other e
g m d di orders . .
me nt al disoc
de< • in ludin
, and they Seroton in enhances fear and .aruc1ety . . • and ,s ·t ,ruuogenic (anxi e ·cou g! effects respond to
sk , 20 l 7). w m n than men . � sm
argraf, B cker, Cra
aid to b mor
pr lenumon g i burden h
as been selectwe serotorun reu ptake mh 1b 1to rs (SSRI ), selective seroton m-norepme .
· re uptake
Ph rme
nxi ty are g y. To N N
Oepre ion and a urden inhibitors (S R I) • and oth er cflasses Of Ph armacological drugs• orepmephr'me neurons are
e loba ll
t cau o f di ea e b ty W ord r r
uh
lgn ilic n t at anxi
account for
the mo t a
cient evldence to
ugg h
anxi< projected to different areas o the bnu• n by a structure called th e Iocus coeruleus . These
. Th i uffi d th people with ..
ove r tb, y<a<
e at
recogn iS d
a\ been n te
neurons regul,te moo d • c ognition, and sl eep.
rtality globally. 11 ha rmo u finan
cial i mpUcations
in increa ed
m rbidity and mo re ervi c , wh ich has en
alt hca
i,nd to make grea
ter u e f he
Brain structure and f unct1oning
act on pr0ductivity. . .
and a negative iinp Several neural circuits h ave b ee n found. t o �ork differen tly i n people with an xiety d isorders.
The amygdala an d ins ula h ave been i dentified " two s tructur • t hal s eem to b e overly
responsi ve In the brains of _people with high level s o f anxiety ,;, ::"ygd,la is a complex
AETI OLO GY
; i:
gene ty structure whose functi;;,: oorly known. It has been a oc , e with the storage of
l ain the c m
pl ,oty and heter emotional memories, p ig fear a nd oth er a pects of emot1. ona l and soaa . I b eh,viour.
e «d t exp of biological
ical cau se have be e n of! e nile . central in i nstigating a nxiety es onse
A nu mber of a tiolo
g models mph• i
h
pri Stud ies sugge t that the amygdala JS . Th is structu re
Earll" theoretical y theories oom . : p
plays a critical role i n med,·at'. n� emot ions, such as anxiety• Functional neuro-1m
of a n>d ty
di rden.
iety diSorde r .
whUe contemporar nvi ron m nt,I
. a ging has
f anx ic, a . . ,v,'d uals. Function,!
uoil asp et .>I, ge nd
gnitive, b havi ur
n
a nd beh avio
shown elevated amygd aI a activity m · the brains o f healthy aruo.ous md·
t include co burl n in advandng
bi psycho
ocial model tha els ha e m ade
ignlficanl oont ri and anatomical c hanges . the a mygdala also occur following t and cJuoruc stress.
o rder To e m od che s. m .
pects of nxi ety d i .
e
u pp The limbic system i to a group of interrel,ted suu,.::;:, :h,t he on both sides of
er fr m ari
a o r
of aruc.iety di ord the thala,nus, beneat:":i."; rebrum. This system comprises a Ioop of cortical s tructures
our u nd rst nding

B iologic al proc
esses
ignificant observati
n tbat there are co
m-
rurrounding the corpus ea:oswn and thafamus, and iS m,de
parahippocampal ""' lupp t of the angu l,te gyms.
�pus. amygd,la, and hyp oth • amus . The hypo th,l,mus
medi,tes the t, s�esp�nse, while the hippocam pu s is res onsibl
l . Ani mal re ea«h . p e for enc
. oding memori
olo i t C in human an
,nJ (Hmson Modiba 20 17). Other struct u res of the bram are at r'"'": considered al o to form
d m a
Th b!olog;c,\ ' ,
sight into the .
cha in the provided so me in fe tu res of p
cifir pan of the 1un
· b1c system . A cnt,c,I
. !unction of the limbi; s stem ." �ediatin g aut ono mi c
c t all <motional, and behav\;�ra! r�sponses to threat, ,nd it ,!so p \�ys a s g nificant f nction in th e
they do not rep\l
a
on
ondlng a a e
u ll in "" u
,ti u tun i
I anxiety c rtain "'"'"' of emotion,! mor 1es . Some of these limbic
o
In le re pon se to
n
u nds ond _ · structures are suggested to be hyper-
me r . Toe e o .
r pon ive in a11Xl.ety-pron
a nx\e
er . AO
. d a nd d
ours of their p redato e individuals ( Han son & Modiba, 201 7).

environ ment
, for In ta n the an i mal. aren and rea
odour naturally
licit a
r, ll re ull
in heighte ned a,
lutiona rily
d
ni natu nl,
When an orga
e
b en d crib d as
m
t o c i an d auton mi
the aver lve
eve n t or h
pecific en d r n
d it inv l ed w ith fea
r
r p nse to envirO
nm , .
e autono mic
change as odat
th v\t n enral
the fac, of an e
m
tecti ng o n o
a im d at pro
e
e to et in a
parti ular way in ur such a fighti
n
organ ism to prepar ated, a ocia ted defe n i e behavio
fear resp o n e I act iv 20 9).
the
ro ma ni, Kean
e. LeDoux,
freezing o cur (Shi
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CHAPTER 6 ANXIETY, OBSESSIVE-COMPULSI
■ PDFelement

G pSYC HOPATHOLOGY
UNDERSTAN DIN
threats faced by children are usually related to abandonment or the loss of an object, lo s
of the object's affection, castration anxiety, and superego anxiety (guilt) (Wolitzky & Eagle,
1997).

Behavioural models
us
- Cinqulale gyi B ehavioural/learning models were the prominent empirical theoretical framework
of anxiety disorders .from the 1920s until the 1970s (Mineka & Zinbarg 2006) . Fear
conditioning theories have shaped our understanding of the acquisition and persistence
of phobic behaviours through a process of associated lea rning. These models desc ribe
Thalamus how pathological anxiety and phobias are acquired through traumatic exposure and
aversive classical conditioning. Through the process of Pavlovian fear conditioning, a non­
t-\\ppocampus threatening object or environmental stimulus (conditional stimulus) is paired with a fear­
m
eorpusca11osu pro ducing (dangerous and threatening) stimulus, resulting in a phobic reaction.
As a result of this exposure, the non-threatening object/stimulus elicits a new set
of responses aimed at increasing the organism's chances of survival. Once an individual
experience an anxiety episode, it result in increased vigilant fear of future anxiety attacks.
This anticipatory state can cause physiological arousal for the vulnerable individual, who
becomes sensitive and hypervigilant to environmental stimuli . In this way, future anxiety
attacks may be triggered by a wide variety of events.
Through a process of operant conditioning, pathological fears are maintained. Operant
tem conditioning involves a process of reinforcement, in which the phobic person actively
. the limbic sys
brain io rm.1n9 undertakes to avoid the feared object. This avoidance results in a reduction in anxiety
t agram of th e areas of the
Schematic. di
(negative reinforcement), which serves to maintain the fear.
fi. gure 6 •9·· an x1e y. Behavioural models also provide a useful frame for understanding the development
olv ed In
that are inv of PTSD, using the learning theory principles of classical conditioning. Although many
neti< individuals are exposed to traumatic events, not all go on to devdop PTSD. Keane and Barlow
clty of t he
r, h pecifi (2002) proposed a triple vulnerability model, aimed at explaining how PTSD develops. This
Genetics h n"'bility e 11
m a te of onJU"Y
model is based on the theoretical descriptions of fear and anxiety (Keane, Marshall, & Ta ft,
play fam ily (Shlmad>·
G neti c facto" ttall , \t hin 2006). Based on this model, an individual's vulnerability towards PTSD is determined by
i uncl rin""
pre<fispo iti on temperamen
t 1h l lat
pre-existing psychological variables (i.e. pre-existing psychological factors related to the
am e tthato
oDou
di orders ugg
e
ug g
o, ow a, ity e limab individual), factors related to the traumatic event (e.g. one's immediate response to the
ug i m oto,
lopin trauma), and events that occur following the trauma. These factors may not be considered
ne' risk of dev causative, but rather as risk factors that predispose an individual to PiSD.
• di or
traits and anide The authors also explain that exposure to a traumatic event triggers intense basic emotions,
which serve as true alarms. Such basic emotions include rage, disgust, and distress, as well
al p
P sy ch ol o gic
as other emotio ns that are brought about by the overwhelming effect of the traumatic event.

t
Expo ure to events that resemble or trigger an aspect of the traumatic event tend to evoke
the0r1SI
o dy n a 111 ic 111 d Isk. F nd n tem porar p� ho d narni
� ptua li a11on
lhe true alarm response, and from this a learned alarm develops. Learned alarms include
P yc h � of r ud
co � c c nc e
anniversaries of the traumatic event, memories, and other cues related to the trauma This
Toe traditional P ych ;�::�0:��e nature of the . �\p �:��n�ip with pare nt a� f\g�
oa .
lllay esult in persistent avoidance of stimuli related to the trauma, as in the case of a phobic
range inS,
ity, m1�r� tilt �
has provided a :\ 'Cf tern from an impoven tional proxim lta�tton. Anxiety disorders may result
cc o/: mo y in an individual living a progressively restricted life,

:
p syc�opa �b
th
that tale in th � et'f fo lio� 1th li mits their
posi void-\ike a state oftanid rooS opportunities to master their fears.
�:�t�
hildren ven ;::;,\1�
relational figu . �: o:;�� �: an attemp to pre t t Ailbough useful, early behavioural/learning
re s g

and cont:un y y
ar tnoo . h
models did not account for why, after
'[he e de ences \ ulford & Hi\ enr • . . and• ure to the same aversive or distressing stimulus, ome people develop phobias while
c tivation
of a defence. raumatic ( aVtn-_ an. i
. s,·t uation [rom becoming t th1 res ults in traumatic 'Oet)'0I rs do not. or do they explain why some go on to develop anxiety in the absence of
c\1
lntrapsychtc _ adequate de r,e � 1he pri mary an J<.ieti or p y
ce
abl t a c tiv ate
anxiety t at lS un ety.
o
. de cri.bed a anx.t
e

te n _ton that l
tat of internal
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■ PDFelement
CHAPTER 6 ANXIETY, OBSESSIVE-COMPULSIV

ATHOLO GY
DING PSYCHOP
UNDERSTAN

o me
Humanistic and existential models
. in contact , .,th on ) and , hy . Hum anistic and existential theories posit that people have a need to survive and to live
ake wi th ul b , ng ot er . Vicario
(e.g. a � r o f n
fear compare d wit h h
uch umu\u t r en e of , h bic-\ike as fully as possible. These approaches place emphasis on the individual's subjective
likely to elicit g� tho e p eople who acqui:e tronf P .
experience, self awareness, and positive growth. Humanistic approaches view human
l'un uli were mo re can a c u nt tO r
a v a n g fean1.1-,1Y·
in h b", o
a trau ma r b h
beh aviour as fundamentally good, and the approach is based on the assumption that people
conditioning p vati. n of other e.-q,erie ncing 0
o o
e
C e pe ple d velop
a vule nerability V

reacti ns after ob er e nc :a al O accou s n t for ' hy om have the potential to maintain healthy relaUonships and to act in their own and others' best
• ay I m ay be ffected
by
g
individual.. li_fs e exp
� on .
bi s· 'Ihe pr• oces
e n �, of con h lll di in terests.
Uirv ·, to e cape 0
nt (e.g. the ab I
•
I i t certain ph
nerab'l'ty ver a traum uc ve Anxiety results when people fail to win the approval of others and/or do not meet their
or an lnv ul div idu l C o diti d fear over
of the co
h
h at an i n 0
a on
f co n ol t e re g n
own i nternal harsh standards for an ideal self. An existential approach views psychological
act on th
th
t h \eve\
n
ce of nother
tr t
), while othes r ve
nt can imp
rei n forced follo
wing the experient difficulties as stemming from anxiety over existential i sues oflife such as the meaninglessness
t he itu alion 0 hat beco me
a fe a t 6) ·
(e .g. . vent) (M jn 0 ka a& Zinbar, 200
r
a peri d of tun of li fe (experienced as isolation, lonelines , and despair) and the finality of death.
relat d o r un relat
ed troum attc 0 a t •
C 0 s Family systems theory
eh a anxiety and
• ode Is
•
iod
Cog nitive m I r a ective d t �ne �e way "e elect, Genera l systems theory is based on the premise thal systems $ are made up of interrelated

Cognit1
. . :e m 0 d \s have b n a promi en t
m de) prop e th
n frame fo
•
at cogn iuv
. . �roce
• d e ter m
and that c gniti
ve proce parts that each perform a specific fu nction in maintaining
.
the whole. A change in one part
depre ,on . C To es . I'. rmation fr m the environment, ' . P•"OC ing infor mat.ion of the system impacts on the system as a whole Murray Bowen, an American psychiatrist,
1010 10,
interpret, and pr.
ce p on e . Thi y tero ff developed a family systems theory that views the family as an emotional unit in which
•
$S
onaI �nd b e
ha ioural r de' tore, and r tneve
a w elec t, e nco
mediat all emou
•
members are able to impact each other's thoughts, feelings, and behaviours in significant
fr m the env�on m 0 C , d�:0:::�
ent for« ou r urvival
eck & Clark, ways. This refers to the family' level of interdependence, which varies from family to family.
der to c . s otential dangedeve(B a c gni�� _ /}fu
ry 0 of anxie
utformatlon in or
'
l ped Toe degree of family cohesion, emotional support, and warmth serves as a protective factor
B eck 0 b ed on the
CS ew rk for s.
0 i ar n ety. lt i
•
c h iatr an:a
Th Amer ican P a cone pV tual fram n c ry or urvi·vat' t against anxiety disorders.
vid at is
and dep_r i nC th� to gnitivie appraisal of environm:t�I :real and they underestimate
th Conversely, negative experiences in one's family of origin (such as family abuse or violence)
0
wnpl1on _t� t l
e degre� I'S may result in an individual having poor emotion regulation, and difficulty balancing
" .mco_rrectl v e r tim ate th
eived ph
s
0 ysical . and cholo tO
gical danget ty
a,ru<.iou individu, al d' t or ersSl inv AIv 0the perc p I�ain tha t we
process individuality and togetherness in relationships, which may manifest as anxiety (Priest,
pe. A n • e� (198 )_ x
their abllity tot co
e
x
DaCvid Clark (I
on iste nt with
2015). While a child may have a genetic predisposition towards anxiety, the environment
n P y ehOl gi t re c
•
dt uh
Beck. and the Ca0 em · tim th
n a
. th rough eh . are di r garded in which that child is raised often play an additional role in exacerbating their anxiety. A
the en ,r runent th t are in ons• tent
information from d d sto red, w hile th
! hem d minate the child may also have a learned fear response as a rcsull of witnessing such responses in other
. are ncode an t ve c a
exi ti ng sehema opathod logic . al 0 taC te ' malad le. hen an family members.
and lar , gottetl ·
information-proce
H w e-ve
,
. n g
r, i n p eh
t and they re0 n
·
• • · , 1· m
th mal
perm ea
d
bl
p
e,
ti
an d on cre
. ve chema are t rigs red.
Developmental perspectives
y. rn
a a
cu,lar, (Invi ron ment, I t
•
ers a Pa � C
individual. e ncount • e h s 'II relevant liCe Developmental theories emphasise the role of personality and tempe rament, the family
re ulting lD an anx.1·
ety ep1
t
ou..1.
ch s pro_p. an i n
.
e .
y teractional roodeod \ that e• a. m r in
phobic er on to
context, and parenting styles in the development of anxiety. For example, chilc!Ien of parents
Cognit i e approa. m els ass1 t lhe s-
•
vul ner abill . Th wis th healthy and who display a controlling and overprotective style of parenting are prone to developing
with c n1 t e
rep th e
tr sors i ntera · ct l_.1 t t rn f in ki ng an d lac .
fu ctional anxiety di order . In additio n, when parent reinforce an avoidant tyle of i nteraction in
a nd s tor tru pa e th
redby dy n
emofLOn are tngge
'
d their children, this may al o lead to the children d veloplng anxiety di orders. Cbildr n
r adjust m ala op o ed that sr. 0 perso11
functional ogl'uu aton
liefs ,
I B .
_
e ck(
d l9 6)
ttl de C and that th
l o pr
e b lief lead to � �
cse g auv
·
1 dan t b e
-;
evaluated or cr
h avio u I
utini p whose paren arc indiffe rent, or sbo, rejection towards their chilc!Ien, aJ o how a
gr ater rulnerability to anxiety di order . A childs temp rament (inherited emotional a nd
b b the
•
• an
he or he will
may e ie.:C that .
ne
though ieh may cau ln
e
�\ /
n d ear, . wh t beh�vioura) responslve
i th ciaes l ph b1a rehension ,
•
$
• ty app ro ainta ne ) may a l so attrac t a particular tyle of parenting. For ins tance,
rnay restult in � v
al i ntera ction er
xie to
e child who i hy may clicit v rprotectivenes . This i nterplt ay between temperam
by other ' which A�oidance f ci /I $ n t and
cial int ract1on . s • s I
par nting styles influences the child' ulne rability to anxiety di order through its negative
•
idu al o avoid
in di
• CS
v t
iety. s se IInpact on the child's independence and se nse of agency.
the in dividual'str anx
w a
• •
I)
so
S S
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PDFelement

CHAPTER 6 ANXIETY, OBSESSIVE-COMPULSIVE AND TRAUMA-RELATE

' O DISORDERS

PSY CHOPATHOLOGY
UNO ERSTANOING

esso rs
Psych os ocial str glcal facto
tulat d � ACTIVITY
and tre ors ha b en p
rplay between uch as tra um•ti< exp erience
An i nt rder , P ych
o oci anxiety 201 1 , South African researcher L. I. Zungu and N. G. Malun u ,.,
ficant con10butor to '. n � odu ced a draft report:
to for m the basl of er ,n the South African Min ing91 � sl
a
an i nd ividu al'
Ii ever t tawn•lic Post Traumatic Stress Dis hen stu yi ng
the c re , <><d
cc urring during d
r mo ry
to be related to
ne
o the the claims submitted b '· W
ers for PTSO, they found tha� 't�e maj�
di
D is un
requir nt for the path genest w l �.:;; •�;- •rk rity (87.8%) of
e of fact are s) wtU devel p PTS0 claimants i nes � traumatic mine accidents corn ared to a monority (12.2%)
rang aumati c venl(
o
er, a
e who ha been e xp i Uowing who were reported to be th v,ct,ms of such accidents' (p . 75/ . How does this observation
not everyone ely t develop PTSD
dis
ng upp rt ne tw
rk plays an relate to the extract above :Y Karunakara et al.?
h o have a st,o and co nun unlly me mbers
PT from family, frie ds.
nL c ial upport
n
g m echani m , suc
h as active
y cop
set of PT 0, Health
in
a
imp n preventi ng the on tin PTSD. Integrated perspectives
also signincan i n preven g ty
probl , a ho\ gical factor with nxie .
have linked ocial and psyc
with partner ituati �urrent research suggests that anx.iety disorders should be viewed from an i ntegrated,
con ten tedn b1opsychosocial perspective, whic �equ i res an understanding ofth e complex i n teractton ·
eh a livi ng alone, di life have b Th � of
and p or quality brain, body, and environm en:t . 1s mtegrated approach advances euorts
t work, and loneline tb m e n an d wo m
en (FI . a to d eveJ op • moce
or
i o rder for b ring ch ildhood comprehensive understan dmg o f anxiety di sorders. Anxiety disordm usu,tly res ult from a
ignific tor of anxi v life ., nt that ccur du
n, & •'" 20 1 2). egati e
order , combi nation of the factors bdow ·
Tols ru rab lity t o anxi•ly di . . .
a ch ild's w\n • B.ologi<al facto,s (e.g. ge·netic
i
ina nt ca usal
e
reel may in vulnerability, an overs ens 1t1ve fear n etwork,
(e.g. par tte or i the predom
acut e tte rder and PT D, the b re gard d as
m al daptlve neurochemistry)·
In th tr s di ord tS m y e . .
h e dis<>t 1h e
tr rs, the conditio, ■ PsyclioTogical factors ( e.g. maladaptive cogmtive appraisaJs• cogm. tov .
. e distortions, , nd
t e of tb
factor r t re • and i n the ab
en
Jack of perceived control ov:r stressful life events).
re pon vere r c<>ntin fu
• Socialfacto,s ( e.g. dys nct1onal lea rned respons es or conditioning).
woul d n ot exist.
.
1:1e biopsychosoci al model of anxiety recog n i ses th a t biolo . ,nd/or psychologi cal
..
� ACTIVITY erience war and fn
rc,d (1.e. temperamental) vul =b,hly pfays • role in influencing tt"'I extent to which '"' eve nt
ps of people who ex ;
is v�wed o, experienc as traumatic. In addition, environm.' tal st essors sensitise the
experienced t,y grou ;oumal Africsn flea/lh r
PTSD is commonly of Africa, In 20 04, the
indi,idua\ who is biol:gi. caJly pred1spo
_ o
· a I arm respons
case In rnanY parts est-traumatic stress _ s ed to an overactive e. An in tegr,led
migration , as is the ents and symp orns of p model of anxiety cons1ders th e c�nvergence between the ove n;enstti ,_ .
article 'Traumatk: ev in the west Nile'. Tnis sed b1ologi cal system
Sciences published the gees and Uga nda ns .
psychologic,J vulnerability, I earn mg processes ' and disrupted attachment and ,
anese na11ona1s refu m n psychoth
erap;s, separation
dis(>roet amongst Sud ma ra and t he Ger a
en by India n doc tor Unni Krishn n Kan Sc auer, Kavl ta Sing h , Kennelh
was writt -rete h
g with co-authors extract below and ex
plain wt,ich d
Frank Neuner, alon
Elbe rt, and G tbert B rnha. Read the CON CLU SIO N
Hill, Thomas by their findings. -
was not corrobol'ated In the prece<fi"!I
their expectations
'Regression analy ses shO W t,,., trau
a�c events experienced
ents ever ex perienced · Contrail'
to "" """''Y
The paradoxical function o f . has bee
-- n- exte
pon , it is es n t · 1 . preparing ,n organism
-� o sivel d .
• m t
li er,t u re. A, '"' ,d,ptive
redictive tha raumattc
ev
ant In predicting sy
mpt°"" to :,;� future thre,ts; however,
year were more p to ba mo re s ignific ue • W '"•ss ive, it m: "
m
ssed events turned out could be that the refug
ees contin various forms of psycho:.i:::1;• gy. Ch,nges rn the DSM
expectations, wi ne ents . An explanation e,1pec
"' oris,lion of �':'; tsorders .
!� '° h ave advanced our und an ng of these disorders
ed ev the ta

maY
a d
of PTSD than experienc eases anxiety levels
n
and that wltn eSSill!I incr
""" °'" ••me. Culture infl e the epidemiology, phenomeool: ,n! treatment outcome of
v otent act
be in an insecure state n to the m- Wt,erea s, having survived a d, i could pie who su ffe, r
fo ; : � .'
e y e signific,nce of certain allXlety-related
coul d happe On the ott,er han do .u t . 1h symptoms and
':°"text
that the sa me me of the surv lVors -
Jevets ol arndely In so a wo.st 1YP' ;,,m :-ning assigned to these, is also influenced b .
socmcultur al
a \lmlting effect on mit being a v\Ctim of ICllln. Theret"; . . of the tre;ting
that resp ond ents were unwilling to ad may 1nac our ately ,epert "" ,g ""lely diso,:
,t " essential to develop a mole:�at assumes an mtegrated framework
elso be rvivors
peri ence l ike sexual violence. Toes• su rs.
:••
trau matic ex the traumatic event.'
n experienced.
witnessed, rather tha
et al.. 200 .
Source: Karunal<.ara
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PDFelement

CHAPTER 7 MOOD DISORDERS

OGY
G PSYCHOPATHOL
UNDERSTANDIN
.
al_so expe ience cognitiv e, ph si cal (s�matic), beh avioural, and ercept a changes, as well as
entlal IO e >
iablish hether r sl p i u l
pr e ive pi o
de is made. it is ess al di order- Mo
disturbances in neuro-vegeta!ve. functions (e.g. appetite and eep d sturban<"'), F diagnos . °'
i s,
of maj ther men .
rder OT ano these symptoms must have pernsted fu,a duration of two week, but th � also la.st long«.
d

When a diagnosis re �ve diso s i an e

ential
de t
p thi
or
ajor e ther fore . . • .
pa<t of a sses, and . depressive diso,der a lifelong, episo di c dis o,de
Maio, t h multipl e recurre nces'
ey
the episode is with medical illn e ive di order
d

this, major dcpre

m
comorbid � r
co mm 0nly dditi on t 0 e reav<ment, averaging one episode in e �ery ve-yea r period (Fa va & Kendler,WJ.2 000) · It also h a.s a vruciable
di ord tr are ma d . 1n a

..
ag • are on ext fb . .
er w hen di reave ment. In the course (in terms ofchromc1ty and rem,•s�,on), with a hig h pmbabilityofrecur,ence(Thom a.s
I

a peel to co I\ id al adn or be bey ond a

OS l t 0
ymptoms pe i
n c

tiat<d £tom n orm .

mu I b differen o r i only made if the & Seedac 2018). The ada t<d D S diagnosti<criteria £ or depressive disorder are
P' iv i hiatric Association ' 2013�' ;:aJ
is of majo, dep list«! in Table 73
. (A m .P an PsycM-5 omas & Seedat, 2018):
rde
a diagnos
d
n
e
e c

of time.
c ertain perio d .
. for major d epressrve disorder from the DSM-5 and major
Table 7.3: Diagnostic en·t ena
.

..
depressive episode from the ICD-10
DISORDERS
DEPRESSIVE adne t ome point in th
eir lives,
of\ mo d oT a p artlcula.- t
h p eri t <
identifi able e •
DSM-5
gon throug
ICD-10

Mo t people have in re p o,e to an di r dei

d n o

nd it is ometime group of clin ical

Major depressive disorder Major depressive

'Ibis I 1nmsient a teS tve di order are a gnttiv,

p with omalic or c
episode
the o ther ba d mo od.
tan . O or i, it abl
of c i,cu ms
de

< of ad, emp y, ave a significanl

n

mp tom h
F'iv� (or more) or the followi ng s- mptoms h ave been prese nt
:i� • In �pic a! depressive
et n e
p e en y
c r
by th 3)- '!he e
characterised ociatlon, 201 unc tions . lt may be
difficult 1a dunng the same two-week � and represent a ch ange episodes of all
r

an Psychiatric
e

eh nge ( mcric to perfo<m

his or her daily f f'?m previous functio ning· t one o_f the symptoms is three varieties ( mild
n ivid uar abill d fri n .
impact on an age vith family an , depression I c on
i der«I 1a either (1) depr essed mood or (2) loss of interest or pleasure moderate, and sev�re)
tu dy, a nd eng
d d

', d the wodd (1) Depressed mood m t the day, nearly every day, as·
leep, eat , ork, on ,.; llions of p
ople arou n
a n\ ta\lon (W
\-10) rec 0gnise the individual usually
Owing to its un pact alth Org indicated by subject�::port (e.g. feels sad, empty or suffers from:
1'.bc World \-le ated 4.4% ofth,
old of men llI Iii a ... IJ,o,dUt - one that affect ane>tnn hopeless) or observat'on made by others (e.g. ap�ars ► Depressed mood.
be 'thecomm on c ost pr ev ,Jent sa bil \dw"1c (Wbitefool tearfuQ. (Note: In chlld1ran or adolescents, can be Irritable Lo:35 of interest and
flh to
J
a s on I•� t conrributo
,.. .,,
de pres sion
lty
mood.)
e m

and i the inglc enJoyment.

e o r di
· ·
of su,o
w0M population associated witb an ln.:n,Hed ri k bil e othe requi• (2) Markedly diminished I te est in pleasure i n all, or almost > Reduced energy
o �
t al., 2013). lt is
al
e ttea d in pri mary
urden in the
world all, activities mos t of t �e �y, near1y every day (as leading to increased
h di o rder ar
Many peopl e with ur th leading
ea
te
b
indicated by either sub'Ject1ve account . . or observation). fatigabllity and
on is th fo
t l I J
ajor epr< i al 200 2).
hospit>II ation. M yea R (Co Stell o et uch of the
dat• i (3) s·,gni'fi,cant weight loss whe n not d1et1ng or weight gain diminished activity.
between IS and 44 ii Umited, m
d

(e.g. a change of more th f body weight in a ► Marked tiredness

in pe0pie aged 1hc prtM1lenu 1111e< (To mli ns on, Grimsrud, «in month), or decrease or i n��e ?in_ appetite nearly every �fter only slight effort
I n outh Afr iea,
cy of
c who do not
cuni
ich 1nlJ'O(luce a l!()!
th• cnU.! bi

collec ted in
dln ic ,ruin wh account for h day. (Note: In children ' cons Id er failure to m ake expected is co m mon.
use 1h $ d weight gai n.) ■ ?ther symptoms
Wil\lam , Meytt,
th. i s is beca et.
nl in d111'•1 l pi>
);
(4) Insomnia h
1009
nia nearly every day include:
treatment, or tho>t
wtio-k tteiUITie nclude : (5) Psychom�;or :;:t�; retardat10n nearly every d ay
1<\M'S ea1,go ry ► Reduced
1n the DsM�S, u,e (observable by others · ;�, e:ly subjective feeli ngs or
r<>• vc di
concentration and
dep
being �low: own.)
• major deprets
\ve disorder 6 restlessness or attention.
per ·ste nt depressive
disorder ( ) Fatigue or loss of e y nearly wery day ► Reduced self­
• 51 (7) Feelings Of worth! nerg s or excessive or inappropriate
m str ual phorlc di ordec esteem and self­
■ pr ,.,rder
dys
guilt (which may b=s,� nal) near1y every day ( not confidence.
en

• di rupuve mood
e
dyvegulation ii disorder
c e/m e ind" td de prusiv• ondition . ":erely self-reproach or° . guilt about being sick) • Ideas of guilt and
• ub tan m edical c (8) Diminished abTity to thi nk or concentrate, or
ioo·
r
dlcal
u t unworthiness.
order d ft ·
■ depressive di ed more bri
s
o ano 1hc
indecisivenes;, nearly every daY (either .
e
e mention by subjective ► Bleak and
ed below, ,vhil
e th other twO a, account or observed b others). pessimistic views of
e are des crib (9) Recurrent thoughts of �eath_ (not Just .
Toe fir t [our ofthe fear of dying} , the future.
recurre nt suicidal Id eatlon without a s ·ric pla a ► Ideas or acts of self­
(MOD) suicide attempt, or a specific PIa n forpee, com m1tt1ngn, suicide . harm or suicide.
sive disorderguished from a state il"1 syrnpto'."11s cause cllnicall s.gn cant distress or
Major depresder OD ) is distin
transient mood
Pal � i ifi ► Disturbed sleep.
(M Ill fTl1ent ,n socia l , occupational, or other important areas of
r is a di
Major depre ive "'
di or
y p eople at ome stage in
thcir iiv<S . Major depr
I
essive di sorde
.....-�· llCbon,ng. Diminished appetite.
d by man mo od 0 r los of or pleasure in lisO
experienc
esl
ess d
nter
eri d by a pr th is c
yndro me ch aract ly every day. People
C wi th
he day, near
de

prC, ent fi r
m0 st Q f t
which is
a tivitle ,
 �
--

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1 PDFelement

OLO GY
DING PSYCHOPATH
UNDERSTAN

ICD-10 to longing for the deceased (American Psychiatric Association, 20 13). On the other hand, in
Major depre
ssive th e case of a major depressive episode, such thoughts are often focused on ending one's own
DSM-5
disorder episode life (American Psychiatric Association, 20 13).
Major depressive

cltn\catly Si9· niflcant distress r areas of

o Persistent depressive disorder (dysthymia)
The symp oms causeoccupationat or Ou,..,..,. .... mportant Persistent depressive disorder (dysthymia) is a syndrome characterised by a chronically
In __ ,.;..,t
::;u,.,=,
Impair. ment
'"""lcal effects ol a
. depressed mood lasting for at least two years. It differs from major depressive disorder in
functK>nin9• Wrv'l
p,....'Y-"""'
. no a tribUtable to the th at it is a chronic illness with generally less severe depressive symptoms.
c . The episode is another rned1cal condition.
substance or to a major depr essive episode. TI1e essential feature is a depressed mood that occurs for most of the day, for more days
Note: Criteria A-C represen t loss (e.g . bereavement , . than not, as indicated by either subjective reports or observation by others, for a period of
......n� to a Slgnl ,can . s medical
Note: �..,..,.-- from a na ural disaster, a � $8dn8SS, at least two years. In children and adolescents, the mood can be irritable, and the duration
nnanciat nm. the fee ngs of ,ntense
te, and "! ht
� incl ude must be at least one year.
1ness or disa ity) nsomnia, poor appetidepressN8 Other symptoms of the disorder include changes in appetite, sleeping patterns, low
rumination abOUt the m3>/\osS. , . resemble a
IOSS noted in Criterion A. wh'ct;oC:Ymay be understandable energy, low self-esteem, poor concentration or difficulty making decisions, and feelings of
such
_,..i.,,nrie. AlthOUQh ,..,;,,.,sym toss, the presence ponse
of a hopelessness. Any symptom-free period does not last longer than two months at a time.
ro.,.-8 topthe
or considered apP
�
e dd \ion to t e normal res During or preceding this time, the criteria for major depressive disorder may be continuously
major dePressive episOd ;��ful\y C()l'lSldered. This present.
t
to the s1gnmcant losS shOU the exei:cise ot clinical judgemen e Because of the persistent nature of this disorder, people who experience these symptoms
deCision Inevitably requ�� and the cuttural norms for t1,
may consider them as 'normal: and therefore not report them unless they are directly
dual 5 story
baSed on the indM In the context 01 toss.
expression of distress e Is not prompted.
ess11/8 episOd
of the maior

l
, .... occurrence $Chiz08ffect111
D. -n.... d'sorder' schizoph renia,
ctepr e lh"'
""
better explained by usi0f181 d]s()rder. or o
!LU}," ,,_ .
sch,.-if onn .
dis0l'd8f, del
-'rum or
ren1a -->tJ""' other Premenstrual dysphoric disorder
1 ed scn12opt,
specified or unspec'fl Premenstrual symptoms commonly affect women of reproductive age, resulting in mild
disor der. an\C
psyc hOtic c sode or a hypom to moderate psychological symptoms, including cognitive and behavioural changes. These
e,t81' t:ieen a mani. epi
\ E. There has n symptoms usually resolve by the end of menstruation and are followed by a symptom -free
•hke
episode- . doeS not applY 11 all of the manic e interval after menstruation and before ovulation (Walsh, Ishmaili, abeed, & O'Brien, 20 I 5) .
No e: ihls ��on .
e a re subStanee-induced or ar Premen truaJ dy phoric di order (PMDD) repre ents a new category in the D 1-5
or hypomanic-hk episOdeS of anothe< med
pt,yslolo9ical effects although premen trual change bad been identified in literature long before this addition.
attrlbUtable to the _J-----
cond rt.ion. In 193 1 , premenstrual change \ as termed 'pr men trual ten ion' (PMT) and later renamed
--�- o,cJsr$
MaflU8I of Men tal o;s 'pr men trual yndrom ' (PM ), which wa then included In the DSM-IV.
tic and Sta ,stical and \he tntematiOll81 Women with premenstrual dysphoric disorder experience fluctuations in mood, as well as
· p. 1 60 •
source:
AePMted th
pefT1ll
{.APA), 2013, � tlC0- 10). orld
Heantl
irritability, dysphoria, anxiety, and somatic (physical) symptoms that are
h th edttiOn {DSM
-5), nP h Pt'c)bl8n1S, \en.lh present during the
flOn of o;seases ma· rity of their menstrual cycles. The symptoms usually peak and
Stalisr,cal etassifiea then remit around the
O), Geneva. 2007. t of the menses, and resolve shortly thereafter (American Psychiatric Association, 2013).
Organl:lSlioO (WH
OE), •
ive epis<>d• (M
a major depr
on the urlace. app< r imlla< to ,n lo , with oeca,iontl · isruptive mood dysregulation disorder
While g,ief can,
d
ng i f em to a,
predomi..nt fecU moo d and inability ruptive mood dysregulation disorder is characterised by a series of severe, recurrent
the cae of g,ief tb This differ from
th de ivc episode (A
our. r d ep per outbursts that occur at least three time per week. These include verbal rages
m tion and hum
re
d with ia that
th•l I as ociate eriod f dysphor or Phys ically aggressive behaviours toward people or property that are grossly out of
happiness 2013). Duri ng gri
ef, the ece as ed,' h
atri • der of the d rtJon in intensity or duration to the situation, and are inconsistent with the individual's
ght o and P
s dated with thou e i m re p .,..,;vc 0Prnen tal level (American Psychiatric Association, 20 13), This diagnosis is reserved for
ity ssi
· h • m,jor depre en and youth aged 6- 1 8 years (although the typical age of onset is before the age of
scd tlon, 2013). ive eplSO
in a major d pr ). who display chronic, severe, persistent, non-episodic irritability, accompanied by
i frequently pre ent of d ath are usu.UY
ling thou ghts
d during grief, and
t
 Remove Wate m •
r ark ■ Wondershare
PDFelement
UNDERSTANDING PSYCHOPATHOLOGY
CHAPTER 12 SUBSTANCE-R
ELATED AND ADDICTIVE DISO
RDERS

Source: Rep led with pemJlsslon from

Table 12.4: Diagnostic criteria for substance/medication-Induced mental disorders (DSM-5)
and substance-induced psychotic disorder (ICD-10)
DSM-5 .
.
Substance/medication-induced
mental disorders
A. The disorder represents a clinically
significant symptomatic presentation
of a relevant mental disorder.
B. There is evidence from the history,
physical examination, or laboratory
findings of both of the following:
(1) The disorder developed
during or within one month
of a substance Intoxication
or withdrawal or taking a
medication; and
(2) The involved substance/
medication can produce the
mental disorder.
The disorder is not better explained
by an Independent mental disorder
0.e. one that is not substance� or
medication-induced). Such evidence
of an independent mental disorder
could include the following:
(1) The disorder preced � t�e
onset of severe intoXJcation or
withdrawal or exposure to the
medication, or
(2) Toe full mental disorder
persisted for a substantial
period (e.g. at least one
month) after the cessation of
acute withdrawal or severe
1 ICD-10
Substance-induced psychotic disorder
I SUBSTANCE USE DISORDERS
■ A cluster of psychotic phenomena th�t occur
during or immediately after psychoactive
. .
substance use and are characterised by V1v1d
_ daptiv patt rn continu for a
hallucinations {typically auditory, but often in more
_ one r more of rh following:
than one sensory modality), misidentifications,
delusions and/or ideas of reference (often of a
paranoid or persecutory nature), psychomotor
disturbances (excitement or stupo�, an� an
abnormal affect, which may range from intense
fear to ecstasy. The sensorium is usu�ly clear
but some degree of clouding of consciousness,
though not severe confusion, may be pre�nt.
Toe disorder typically resolves at least partially
within one month and fully within six mont�s.
■ Psychoactive substance-induced psychotic
disorders may present with varying patterns of
symptoms. These variations will be influenced
by the type of substance involved and the
personality of the user. For stimulant drugs such
as cocaine and amphetamines, drug-induced
psychotic disorders are generally closely related
to high dose levels and/or prolonged use of the
substance.
• A diagnosis of psychotic disorder sh?uld �ot be
made merely based on perceptual distortions
or hallucinatory experiences when substances
. intoxication or the desired effi
having primary hallucinogenic effects {e.g. �rg1c
acid dlethylamide (LSD), mescaline, cannabis at
high doses) have been taken. In such cases, and
Iha Diagnostic and Stntisticel
Manual of Mental D,sor<J, rs,
fifh edition (DSM-5). American Psychiatnc
Association (APA), 2013, p 488, 8lld
Mental Dnd Behaviouml Di Orders: Diagnos IC0-10 Classiticat,or, of
tic Cnteria for Researr:h, World Healt
Geneva, 2016 h C}rgaoizat10n (WHO),
The patter_n of ub tance u e in the e disor
der i malad.1ptive, leading to dlni
or di r as de cribed belo\ . The mala caJ impairment
mond1 or more, and re demon trated by period of twelv
■ Ongoing u that result in a failure
to meet important role obligation
home, w rk, or eh oL Thi can inclu a requir d by
de being repeat dly ab ent from
po r w rk performance, su pension work or chool,
, expulsion from chool, and n
hou ehold, all of which are directly attribu glect of childr n or
table to the ubstance u e.
■ Recurrent u of ub tance in plac ,
here lhi couJd be hazardous. Thi
driving a car while under the influence would include
or operating hea mad1inery, for
• Leg aJ pr blcms that m y arf vy exampl
be au e of ub tance u e. Th
for di orderly conduct or for criminal can includ b ing arr ted
b baviours, for example, p tty
ub ranee u e. theft du to
• Continued use of the substance, desp
ite experiencing problems in inter
vocational situations that are eithe personal or
r caused, or made worse, by using
problems may include arguments substances. These
and phy kal fights with a spouse
of intoxication (American Psychiatr about consequences
ic A ociation, 2000).
Furthermore, ub tance u e encompa
sse a group ofbehavioural, cogn
phenomena that occur after a perio itiv , and physiological
d of r petiti e and prolonged ubst
a difficulry in controlling the u e ance u e. ft inv lv
of a ub ta.nee and an a iated de ir to continue it u e.
There are a numb r of ymptom
that would indicate dep ndence:
■ ' olerance' d crib the
need for ever-increasing .1mounts
of a ubstance t produce
ct U e of increased amount
metjm cau e tolerance to lev of Lhe sub tance can
I that would b lethal to a non-u
• ·, ithdrnwal' i the deve er.
lopment of a ub lance- pecilic
yndrome due to lh t rmination

I•
intoxication or taking the
medication. This criterion does
not apply to substance-induced
neurocognitive disorders
or hallucinogen persisting
perception disorder, which
persist beyond the cessation of
acute intoxication or withdrawal.
D. The disorder does not occur
exclusively during the course of a
delirium.
E. The disorder causes clinically
also for confused states, a possible diagnosis of of, or reduction in, ub ta
nce u that h been heavy and
acute Intoxication should be considered. behavioural change that prolong, d. It i a maJ daptive
Particular care should also be taken to avo1� ccurs in the blo d and cell
. dependence i termina , hen u e of sub tance of
mistakenly diagnosing a more serio�s condition ted. The e chang can be eith r
phy ical or cognitive, or both, a
are cut and un plea nd
(e g schizophrenia) when a d1agnos1s of ant.
P�;hoactive substance-Induced psychosis is Dep nding on the ub t
ance b ing removed,
difficulty Jeeping, they can include convul ions,
appropriate. Many psychoactive substanc and perceptual dHficulrie halting,
�.: . Delirium, confu i n, and hallu
induced psychotic states are of short dura , m may al o occur. ln
alcohol withdrawal, delir cinations
provided that no further amounts of th� drug 10 1 he period ium trem en may ccur. Tuer i a time limit
of withdrawa l. and thi is relat
are taken (as in the case of amphetam,� being u ed .11 ed to the type and th amount
: th time of removal. Th pe of ub tance
and cocaine psychoses). False dlagnos, In �eliev or redu e the ymptom on Is likely to resum using the
cos tly ub tanc to
such cases may have d1stress1ng
• · and • .
ornpul Jv use'

L
significant distress or impairment implications for the patient and for the healtl1 a I nger per describes the patte rn of taking the substance in larger a
in social, occupational, or other services. iod than was originally inten mounts or over
or two drin ded, for example, if a person deci
important areas of functioning. ks when socialising but des to have one
instea d ends up drinking until
they are intoxicated
 UNDERSTANDING PSYCHOPATHOLOGY
CHAP TER 12 SUBSTANC

• There are often num erous and un�uccessful attempts to decrease or disco ntinue use. The
person continues to express a desire to stop or cut down on the use of the substance. Henry is a 45-year-old psychologist in
• There is a time compone nt, where the perso_n,s J'f � e i s taken over by sub stance -related private practice. He started smoking
at university. He can't really say why, exce cigarettes
pt that the rest of his classmates were
activities. There wo uld b e, for example, excess ive t1me spent on. it, and he felt it made him look cool. He stopped doing
wife was pregnant with each of their two
► acquiring the substance smoking in the house twice. while
children. He reports that he doe his
> u s ing the substance any health issues related to his smoking, but s not have
does tell an amusing story about
• recovering from its effects. passing out and having to be carried
down a flight of stairs when there was
almost
• A p erson may, for example, take leave from work on days when he or she has a hangover at his practice. He is unable to walk quickl a fire drill
. y, or to exercise. He has tried num
from excessive alcohoI consumption the night b efore. medications to stop, but feels that his 'head
needs to be in the right place' befor
erous
• The person's life begin to revolve aroun d th e u se of the substance. There is a corresponding will really get it right. He has stopped smok
ing on occasion, but not for longe
e he
. . .. three months. He has used a patch, chewed r than
reduction in other activitie .. s of da,·ty life for example vocational activities, sport , and nicotine gum, and used sprays, but
soc ialising. embarrassed when he uses them in front of feels
. . colleagues.
• Psychologi cal and p ys olo g:ic� tom s that can be directly attributed to use of the He has changed to a llghter cigarette with less
nicotine. because this is healthier, but
s ubst ance, fo_r
�
amp e e � srr;;i
�:: : l mnot contributel to a desire or attempts to stop. This
s 10
admits that he has started smoking more.
He puts this down to stress at work.
Sffting
i
occu rs even if:e cause o b e is directly re ated to substance u s e, for example, down and having a relaxing cigarette makes
him feel good. and he feels happy
he smokes. His favourite times to smoke are when
damage to organs due to alco ol use (American Psychiatri c Association, 2000; World When he has a beer, and after dinner.
He is not permitted to smoke in the
He alth Organization, 2016). house or in the car when his wife is
she says that she can feel the difference in her with hun, as
breathing when she is in close cont
with smokers. She Is a non-smoker. She has act
Table 1 2.5: Summary of general symptoms of substance dependence (ICD-1 O) suggested that he vape, but he says
he may get addicted to it, as he has heard that that
there are sometimes illegal substanc
mixed into the I/quids. The couple has not es
ICD- 1 0 been out for a romantic night out to
or dinner for some time, as he cannot go movies
without a cigarette for longer than
• A definite diagnosis of dependence should usuallY be made only If three or more of the minutes. His wife has tried to get him 30
.
following have been present together at some time during the previous year..
to go for hypnotherapy and cognitive
therapy. but he insists that ft Is a wast behaviour
. e of money as he is a professional
► A strong desire or �nse of compulsion to take the substance. that he will stop when he Is ready. She himself, and
feels that it Is affecting theh' intimate
► Difficulties In controlling substance-tak.ing behaviour in terms of its onset, termination, or does not enjoy kissing him, his breath fife - she
is bad and he sme/Js of smoke.
levels of use. Hfs doctor has Indicated that he
► A physiological withdrawal state when substance u se has ceased or been reduced, as
needs to stop smoking as he has
emphysema, a Chronic lung disease. eatfy•onset
evidenced by: the characteristic withdra sy f ubstance or use of the While he is aware that stopping will
signlficanlly
same (or a closely related) substance w;�he � , ::;n � :�:,ing or avoiding withdrawal
reduce his risk of death, he is reluctant
to stop smoking, say,ng that he knows
should, and will stop after the Chris that he
symptoms. tmas holidays, or his birthday. or a
difficult client at
work. or sometime soon.
► Evidence of tolerance, such t��t lncreased doses f the psychoactive substances are
required to achieve effec�s onginally p uc
r� e<:: �,:wer doses (clear examples of this are
found in alcohol- and op1ate-dependent ,nd IVldu s who may take dally doses sufficient to
Incapacitate or kill Intolerant users). � ACTIVJTY
► Progressive neglect of alternative pleasures or interests bec�use s h ctive
substance use; Increased amount of time necessary to obtain or ��e r�e ��bstance or to There am many memes
recover from its effects.
on social media that show desperate
laugh at these, and people craving coffee. We
Persisting with substance use despite cl�ar ev!dence of o rtl h f I consequences, sometimes even identify with the dozy
:S[ person who needs his or her
e :::� states consequent
lllOming coffee fix. Kyle
such as harm to the liver through excessJVe dnn:� · de� coffee to st
feels that he Is one of those people.
to periods of heavy substance use , or drug- relat mpa rme t of cognitive functioning. art his day, and then another 12 If he does not have a cup of
1 � be xpec t t be. aware to 14 during the day, he feels dysf
Efforts should be made to determine that the user was. or co ld e ed o
He reports that unctional.
he cannot wake up, cannot be crea
tive (he works in an advertising agen
of the nature and extent of the harm.
and is not able cy)
to function socially before he
-- �ffeine ls Used in combination with
has had h is caffeine hit.
n incre
ased doses it is
paink illers for treating both mild pain and
Source: ICD-1 o Classification of Mental and Behavioural Disorders:
. o·,agnosI'ic Criteria for Research, considered a banned substance in migraines.
World Health Organization (WHO), Geneva, 2016. :n crearns , and is sport. Caffeine is used In some
_ Used In the treatment of acute med
he is se
for �irn.
ical conditions. Kyle does not feel
that. as coffee makes him a nicer
lf-medicating. He feels
Is Kyle a subs person, it has value
tance abuser?