Obsessive Compulsive Disorders

“OCD is a mental disorder which is characterized by the presence of obsessions and/or

compulsions.” (APA, 2013). The DSM-5 (Diagnostic and statistical manual of Mental Disorders-
5) has listed nine disorders under Obsessive-Compulsive and related disorders include
obsessive-compulsive disorder (OCD), body dysmorphic disorder, hoarding disorder, tricho-
tillo-mania (hair pulling disorder), Excoriation (skin-picking) disorder, Substance/Medication-
Induced obsessive- compulsive and related disorder, obsessive-compulsive and related disorder
due to Another Medical Condition; Other specified obsessive-compulsive and related disorder;
and Unspecified obsessive-compulsive and related disorder (e.g., body-focused repetitive
behavior disorder, obsessional jealousy).
The ICD-10 (International Classification of Diseases-10) has listed five disorders related
to OCD under the Neurotic, stress-related and somatoform disorders (F40-F48), where
F42 is devoted to Obsessive-compulsive disorder, and the disorders that fall under this are,
F42.0 Predominantly obsessional thoughts or ruminations, F42.1 Predominantly compulsive acts
[obsessional rituals], F42.2 Mixed obsessional thoughts and acts, F42.8 Other obsessive-
compulsive disorders, F42.9 Obsessive-
compulsive disorder, unspecified.
Case Study for OCD
Manasa, aged 32 years, married, and
graduated in political science, belonging to
middle
socioeconomic family and mother of two
children was brought to hospital by her husband
(lawyer) and her brother with the complaints of
excessive hand washing, thinking that she or any
of her family members may catch up some disease with the duration of 15 years and was
deteriorating for the last 5 years. She would wash hands when she touches door handles, taps,
gas stove, or when her children or her husband or any other person comes home. The patient
would make love to her husband only in bathroom and this was very disturbing to her husband.
Her behavior was scaring family members as she would believe that houseflies would
contaminate her home and thus would clean each and every place where she feels housefly might
have contaminated. She started keeping all the doors and windows shut in summers to stop
houseflies from coming inside. The patient had never visited any psychiatrist or psychologist for
any pharmacotherapy or psychotherapy in the past. She was put on clomipramine and fluoxetine;
and after 3 weeks of medications, she was taken up for psychotherapy and the dosage of
medicines was kept constant during psychotherapy sessions. (Source:
https://pdfs.semanticscholar.org/d440/71cac9ff6db0c545301d9408e92e277cd1c9.pdf)

Clinical Picture: Obsessive Compulsive Disorder

Obsessions can be defined as recurrent and persistent thoughts, urges, or images that are
experienced as intrusive and unwanted, which are disturbing, inappropriate and uncontrollable.
Whereas, compulsions are the repetitive behaviors or mental acts that an individual feels
driven to perform in response to the obsessions, to avoid some dreadful situation or must do so,
according to the rules that must be applied rigidly.
I am sure most of us have experienced minor obsessive thoughts, such as whether we’ve
locked the door or not, turned the stove off or turned all the switches off or not, and also, most of
us sometime tend to have some repetitive behaviors, such as checking the stove or the checking
the lock on the door. However, with OCD, these obsessions and repetitive behaviours are much
more persistent and distressing, which profusely interfere with everyday activities, making the
person’s life worse to live.
What do obsessions involve?
Many obsessive thoughts involve contamination fears, fears of harming oneself or others
(e.g. a daughter might fear that she would harm her mother in some way, but in reality won’t),
and pathological doubt. Other fairly common themes are concerns about or need for symmetry
(e.g., having magazines on a table arranged in a way that is “exactly right”), sexual obsessions,
and obsessions concerning religion, violence or aggression.
Now let us see what are these compulsive behaviours that are performed so ritualistically by
these persons. These rituals
can be of two types, i.e.
Firstly, Washing or cleaning
rituals can range from mild to
extreme (From spending 15 to
20 minutes washing one’s hands after going to the bathroom, to washing hands with disinfectants
until the point where the hands bleed)

Secondly, checking rituals can also range from mild to severe (such as checking all the lights,
appliances, and locks two or three times before leaving
the house, to going back to an intersection where one
thinks one may have accidentally killed somebody
without their knowing and spending hours checking for
any sign of the imagined incident). And these rituals
are often performed for a specific number of times and
thus also involve repetitive counting.
The performance of the compulsive acts brings
a feeling of reduced tension and satisfaction, as well as
a sense of control, although this anxiety relief is very fleeting as the individual is stuck in these
cycles of obsessive thoughts and compulsive behaviours.
Thus we know that Obsessive Compulsive Disorder is one of the most disabling mental
disorders which lead to a lower quality of life and a great deal of functional impairment and it
co-occurs with mood disorders, anxiety disorders, and in some cases with social phobia, panic
disorder, GAD, and PTSD.

OBSESSIONS

Temporary
releif OCD ANXIETY

COMPULSIONS

Fig.1 Vicious Cycle of Obsessive-Compulsive Disorder

 Diagnostic Criteria for Obsessive Compulsive Disorder
A. Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as
intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some
other thought or action (i.e., by performing a compulsion).
Compulsions are defined by (1) and (2):
1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating
words silently) that the individual feels driven to perform in response to an obsession or according to rules that must
be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded
event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are
designed to neutralize or prevent, or are clearly excessive.
Note: Young children may not be able to articulate the aims of these behaviors or mental acts.
B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically
significant distress or impairment in social, occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in
generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding
or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin
picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized
eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and
addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as
in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in
major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other
psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).
Source: Diagnostic and Statistical Manuel of Mental Disorders, Fifth Edition, American Psychiatric Association, (2013).

Etiology: Obsessive Compulsive Disorder

Biological Causal Factors

Genetic Factors: Twin studies reveal that monozygotic twins are at a slightly higher risk
of developing OCD than do dizygotic twins. Moreover, research also suggests that OCD begins
in the childhood and is usually characterized by chronic motor tics and is later manifested into a
full-blown obsessive compulsive disorder (Lochner & Stein, 2003).
Neurological basis of OCD: abnormalities in the basal ganglia and the amygdala, which
control the emotional behaviors can lead to OCD.
Neurotransmitter Abnormalities: suggest that increased serotonin activity and increased
sensitivity of some brain structures to serotonin are involved in OCD symptoms.

Psychological Causal Factors

Mowrer’s two-process theory of avoidance learning (1947) explain OCD stating that
neutral stimuli becomes associated with frightening thoughts or experiences through classical
conditioning and elicit anxiety.
For instance, when touching a doorknob or shaking hands with someone, are associated
with the “scary” idea of contamination. Once this association is made, the person may discover
that the anxiety produced by shaking hands or touching a doorknob can be reduced by hand
washing. Washing his or her hands extensively reduces the anxiety, and so this washing response
is reinforced, which makes it more likely to occur again in the future even in other situations
where the person feels anxious about contamination (Rachman & Shafran, 1998). Once learned,
such avoidance responses are extremely resistant to extinction (Mineka, 2004; Mineka &
Zinbarg, 1996, 2006).
Cognitive Causal Factors: If we observe, when we try to suppress some unwanted
thoughts, we do experience a paradoxical increase in those thoughts later (Abramowitz et al.,
2001; Wegner, 1994). The difference between the people with normal and abnormal obsessions
is primarily the degree to which they resist their own thoughts and find them unacceptable. Thus,
when people with OCD attempt to suppress them, this could contribute to the frequency of
obsessive thoughts, and the negative moods with which they are often associated.
Appraisals of Responsibility for Intrusive Thoughts: People with OCD often seem to
have an inflated sense of responsibility and in turn, in some vulnerable people, this inflated sense
of responsibility can be associated with beliefs that simply having a thought, of doing something
(e.g., attacking one’s own mother) is morally equivalent to actually having done that act (e.g.,
having attacked his/her mother). This is called thought–action fusion (Berle & Starcevic, 2005;
Rachman et al., 2006; Shafran & Rachman, 2004, for reviews). And it is these thoughts that also
force the person to perform the compulsive behaviors to reduce or stop the consequences from
happening.
Treatments: Obsessive Compulsive Disorder
A behavioral treatment that combines exposure and response prevention has been proved
effective to treat obsessive-compulsive disorders (e.g., Franklin & Foa, 2002, 2007; Stein et al.,
2009).
In this treatment clients with OCD develop a hierarchy of upsetting stimuli and rate them
on a 0 to 100 scale according to the stimuli’s capacity to evoke anxiety, distress, or disgust. Then
the clients are asked to expose themselves repeatedly (either through guided fantasy or directly)
to the stimuli that will provoke their obsession (such as, for someone with compulsive washing
rituals, touching the bottom of their shoe or a toilet seat in a public bathroom). Following each
exposure, they are asked to not engage in the rituals that they ordinarily would engage in to
reduce the anxiety or distress provoked by their obsession. Preventing the rituals is essential so
that they can see that if they allow enough time to pass, the anxiety created by the obsession
would come down naturally to at least 40 to 50 points on the 100-point scale. And in addition to
the exposures conducted during therapy sessions, “homework” is assigned to the clients.
Some people refuse such treatment or even drop out early. But if one continues, it does
help up to 50-70% of the symptoms to reduce and have an improved quality of life.
Medications: To date, medications that affect the neurotransmitter serotonin seem to be
the primary class of medication to treat persons with OCD. But a major disadvantage of
medication treatment for OCD, as for other anxiety disorders, is that when the medication is
discontinued relapse rates are generally very high.

PHOBIAS
Specific Phobia
The DSM-5 (Diagnostic and statistical manual of Mental Disorders-5) lists Specific
Phobia under Anxiety Disorders and the diagnosis needs to be specified if it is phobia toward
Animals, Natural environment, Blood-injection-injury (Fear of blood, Fear of injections and
transfusions, Fear of other medical care, Fear of injury), Situational or Other.
The ICD-10 (International Classification of Diseases-10) has listed Specific (isolated)
Phobias under the Neurotic, stress-related and somatoform disorders (F40-F48), where
F40 is devoted to Phobic Anxiety Disorder, and the code for Specific (isolated) Phobias is
F40.2

Case Study
Jacob is 12 and is really afraid of getting injections. When he was eight years old, he
passed out at the doctor's office during a blood test. Since then, Jacob avoids watching or
thinking about anything that has to do with blood, needles, or medical procedures. He says they
make him feel like “my body is out of control” and that “my mind goes blank”, and he worries
he will either "freak out" or "faint again". On the days leading up to a doctor's visit, Jacob
repeatedly asks for reassurance and promises from his parents that he will not need to get a shot
or have blood drawn, and becomes explosive if they cannot provide that certainty. Although the
family has been mildly successful at avoiding shots and blood/medical procedures for Jacob over
the past few years, Jacob now has an abscessed tooth that needs extracting and will require
several injections. When the dentist told Jacob about this, Jacob got very upset and started to
breathe heavily and shake. He also began sobbing loudly and insisted they leave. Jacob's mom
was surprised by her son's physical reaction, and thinks he may have had a panic attack. She is
worried that Jacob will be unable to have this dental procedure, which is critical to prevent
further infection. (Source: https://www.anxietycanada.com/parenting/specific-phobia#slideshow-
1)
Clinical Picture: Specific Phobia
A person is diagnosed as having a specific phobia if they show strong and persistent fear
toward that particular object or situation. It is important to know that when individuals with
specific phobias encounter a phobic stimulus, they often show an immediate fear response that
often resembles a panic attack except for the existence of a clear external trigger (APA, 2013).

The DSM-5 has recognized five subtypes of

specific phobias, they are,
Animal type: Snakes, spiders, dogs, insects, birds
Natural Environment Type: Storms, heights, water
Blood-Injection-Injury Type: Seeing blood or an injury, receiving an injection, seeing a person
in a wheelchair
Situational Type: Public transportation, tunnels, bridges, elevators, flying, driving, enclosed
spaces
Other: Choking, vomiting (Emetophobia), “space phobia” (fear of falling down if away from
walls or other support)

The fear or anxiety that people with specific phobia experience when they encounter a
phobic stimuli (an object or situation), may range from mild feelings of apprehension and
distress (usually while still at some distance) to full-fledged activation of the fight-or-flight
response. Regardless of its intensity, phobic behavior tends to be reinforced because every time
the person with a phobia avoids a feared situation his or her anxiety decreases. Also the
secondary benefits of being disabled, are increased attention, sympathy, and some control over
the behavior of others, may also reinforce a phobia. The time of onset of these different types of
phobias differ, according to the age, gender and ethnicity of individuals. While some tend to
begin early in life, some begin late.

Diagnostic Criteria for Specific Phobia

A. A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an
injection, seeing blood).
Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging.
B. The phobic object or situation almost always provokes immediate fear or anxiety.
C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.
D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the
sociocultural context.
E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
G. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and
avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia):
objects or situations related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in
posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or
social situations (as in social anxiety disorder).
Source: Diagnostic and Statistical Manuel of Mental Disorders, Fifth Edition, American Psychiatric Association, (2013).
Etiology: Specific Phobias
The Psychoanalytic Viewpoint suggests that phobias represent a defense, against anxiety,
that stems from repressed impulses of the id. According to Freud, because it is too dangerous to
“know” the repressed id impulse, the anxiety is displaced onto some external object or situation
that has some symbolic relationship to the real object of the anxiety (Freud, 1909). However, this
theory has its vast number of speculations too.
Some behaviorists state that Phobias are Learnt Behavior. Phobic behavior is learnt
through classical conditioning, where the fear response is conditioned to previously neutral
stimuli when these stimuli are paired with traumatic or painful events. Also, once acquired,
phobic fears would be generalized to other, similar objects or situations. Try and remember the
“Little Albert Experiment”?
Vicarious Conditioning: Direct traumatic conditioning as we have seen is not the only
way that people can learn irrational, phobic fears. Simply watching a phobic person behaving
fearfully with his or her phobic object can be distressing to the observer and can result in fear
being transmitted from one person to another through vicarious or observational classical
conditioning. However, watching a non-fearful person undergoing a frightening experience can
also lead to vicarious conditioning. For example, one man, as a boy, had witnessed his
grandfather vomit while dying. Shortly after this traumatic event (his grandfather’s distress while
dying) the boy had developed a strong and persistent vomiting phobia (Mineka & Zinbarg,
2006).
Evolutionary Preparedness for Learning Certain Fears and Phobias: Primates and
humans seem to be evolutionarily prepared to rapidly associate certain objects—such as snakes,
spiders, water, and enclosed spaces—with frightening or unpleasant events which we might have
carried forward through evolution.
Treatments: Specific Phobias
A form of behavior therapy called exposure therapy—which is the best treatment for
specific phobias. It involves controlled exposure to the stimuli or situations that elicit phobic
fear. Clients are gradually placed—symbolically or under “real-life” conditions— in those
situations that frighten them and are encouraged to expose themselves (either alone or with the
aid of a therapist or friend) for long enough periods of time till their fear begins to subside.
 For certain phobias such as small-animal phobias, flying phobia, claustrophobia, and
blood-injury phobia, exposure therapy is often highly effective when administered in a single
long session (of up to 3 hours). Another variant of this procedure, known as participant
modeling has also proved to be effective.
A combination of cognitive restructuring techniques or medications with exposure-based
techniques has also been tired. But, the addition or the sole use of any of these therapeutic or
medical techniques did not have any better results when compared with the effectiveness of
exposure-based techniques.
Agoraphobia

Case Study
Richa first began to experience a great deal of difficulty in her early twenties and she
reported to feel nervous. She spoke about an "unreal feeling," and became too anxious to shop
alone, travel by herself, or even standing in a crowded grocery store. She was afraid that she
would become nervous while alone and without help,
and that she would fall apart or wouldn’t be able to
handle herself if "trapped" in a long line. The thought
of traveling by bus or train, where she could not easily
"get out" if something went wrong, terrified her. These
fears started simply as a reluctance to shop or drive,
but soon became so severe that she could not even
travel a few blocks unaccompanied, and just leaving
the house produced considerable anxiety. She could
not work or do anything much as much of it would
involve her stepping out of the house. She also reported to have these sudden attacks of panic
during which her heart would pound, making her believe that she might die, she would sweat
profusely, feel short of breath, and tingling sensations. After these attacks, she felt feeling shaken
and more fearful than before. And these attacks occurred at least two to three times weekly. At
this point, Richa had typical symptoms for agoraphobia with panic attacks.
Clinical Picture
 Agoraphobia (from the Greek agora, meaning “marketplace”) People with agoraphobia
are afraid of being in public places or situations where escape might be difficult or help,
unavailable, should they experience panic or become incapacitated (APA, 2013).
The DSM-5 (Diagnostic and statistical manual of Mental Disorders-5) lists Agoraphobia
under Anxiety Disorders, and the ICD-10 (International Classification of Diseases-10) lists
Agoraphobia under the Neurotic, stress-related and somatoform disorders (F40-F48), and
sub-categorized under Phobic Anxiety Disorder (F40), under which the code for Agoraphobia
is F40.0. The ICD-10 has classified Agoraphobia as Agoraphobia without Panic Disorder and
Agoraphobia with Panic Disorder, coded .00 and .01 respectively. Likewise, DSM-5 has also
changed its former classification of Agoraphobia as a subtype of panic disorder in DSM-4-TR, to
a separate disorder in DSM-5.
As we have already seen that people with agoraphobia are afraid of being in public
places where they fear they cannot get any help, in case of any emergency, this fear leads them to
avoid situations including going out into streets, crowded places etc.
Many people with agoraphobia are virtually unable to leave their house, and even those who can
do so only with great distress.

Diagnostic Criteria for Agoraphobia

A. Marked fear or anxiety about two (or more) of the following five situations:
1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).
2. Being in open spaces (e.g., parking lots, marketplaces, bridges).
3. Being in enclosed places (e.g., shops, theaters, cinemas).
4. Standing in line or being in a crowd.
5. Being outside of the home alone.
B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might
not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms
(e.g., fear of falling in the elderly; fear of incontinence).
C. The agoraphobic situations almost always provoke fear or anxiety.
D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense
fear or anxiety.
E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the
sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease) is present, the fear, anxiety,
or avoidance is clearly excessive.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder—for example,
the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in social
anxiety disorder): and are not related exclusively to obsessions (as in obsessive-compulsive disorder), perceived
defects or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in
posttraumatic stress disorder), or fear of separation (as in separation anxiety disorder).
Source: Diagnostic and Statistical Manuel of Mental Disorders, Fifth Edition, American Psychiatric Association, (2013).

Treatments: Agoraphobia
Research shows that through years there has been little impact made in the treatment of
agoraphobia, (the fear of leaving one’s home and entering public places). However, more
recently, new approaches developed by Behaviorists i.e. a variety of exposure approaches for
agoraphobia has been beneficial (Gloster et al., 2014, 2011). In these interventions, therapists
typically help clients to venture farther and farther from their homes and to gradually enter
outside places, one step at a time. Sometimes the therapists use support, reasoning, and coaxing
to get clients to confront the outside world. They also use more systematic exposure methods.
Exposure therapy for people with agoraphobia often includes additional features—
particularly the use of support groups and home-based self-help programs— to motivate clients
to work hard at their treatment.
In the support group approach, a small number of people with agoraphobia go out
together for exposure sessions that last for several hours. The group members support and
encourage one another, and eventually coax one another to move away from the safety of the
group and perform exposure tasks on their own. In the home-based self-help programs, clinicians
give clients and their families detailed instructions for carrying out exposure treatments
themselves.
Unfortunately, these improvements are often partial rather than complete, due to major
problem of relapses in this disorder.
Social Anxiety Disorder (Social Phobia)
Case Study
“I started to observe that I got really anxious if I had to
do a presentation in the class. I’d worry about it for days
and the night before I couldn't sleep. When it came to the presentation, I’d be sweating, blushing,
my mouth would go dry…it was like torture. It felt like everyone in the class was laughing at me.
Other social situations were really difficult too. Going to parties, chatting with the opposite
gender, I just couldn't do it. I’d stick close to one or two friends, let them do the talking, and
just tag along. I've been pretty much the same ever since. When I was doing my tech training in
the air force, I’d sit at the back of the class hoping no-one would notice me. If there was any
chance I’d have to talk in front of the class, I’d call in sick or make some lame excuse. I was OK
if it was only a couple of mates, but with people I didn't know or large groups, I could never
converse. I knew it was stupid and irrational, but that just made it worse. Why couldn't I just pull
myself together and be confident like my friends?” (Source: https://at-
ease.dva.gov.au/veterans/resource-library/case-studies/case-study-social-anxiety-disorder)
Clinical Picture
Social phobia (or social anxiety disorder), is characterized by disabling fears of one or
more specific social situations (such as public speaking, urinating in a public bathroom, or eating
or writing in public).
The DSM-5 (Diagnostic and statistical manual of Mental Disorders-5) lists Social
Anxiety Disorder under Anxiety Disorders and the diagnosis needs to be specified if it
“performance only”.
The ICD-10 (International Classification of Diseases-10) lists Social Phobia under the
Neurotic, stress-related and somatoform disorders (F40-F48), and sub-categorized under
Phobic Anxiety Disorder (F40), under which the code for Social Phobia is F40.1
Although this disorder is labeled social phobia in the DSM-IV-TR, the term social
anxiety disorder was proposed in the DSM-5 because the problems caused by it tend to be much
more pervasive and to interfere much more with normal activities than the problems caused by
other phobias (Liebowitz, Heimberg, Fresco, et al.,
2000).
In these situations, a person fears that he or she
may be exposed to the scrutiny and potential negative
evaluation of others or that he or she may act in an
embarrassing or humiliating manner. Because of their
fears, people with social phobias either avoid these
situations or endure them with great distress. Intense fear of public speaking is the single most
common type of social phobia. DSM-5 also identifies two subtypes of social phobia, i.e. firstly,
fear of performance situations such as public speaking and secondly, that which is more general
and includes nonperformance situations (such as eating in public). Indeed, the people with the
‘more general subtype’ of social phobia are the ones affected badly.
Diagnostic Criteria for Social Anxiety Disorder
A. Marked fear or anxiety about two (or more) of the following five situations:
1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).
2. Being in open spaces (e.g., parking lots, marketplaces, bridges).
3. Being in enclosed places (e.g., shops, theaters, cinemas).
4. Standing in line or being in a crowd.
5. Being outside of the home alone.
B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might
not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms
(e.g., fear of falling in the elderly; fear of incontinence).
C. The agoraphobic situations almost always provoke fear or anxiety.
D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense
fear or anxiety.
E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the
sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease) is present, the fear, anxiety,
or avoidance is clearly excessive.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder—for example,
the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in social
anxiety disorder): and are not related exclusively to obsessions (as in obsessive-compulsive disorder), perceived
defects or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in
posttraumatic stress disorder), or fear of separation (as in separation anxiety disorder).
Source: Diagnostic and Statistical Manuel of Mental Disorders, Fifth Edition, American Psychiatric Association, (2013).

Etiology: Social Anxiety Disorder (Social Phobia)

Cognitive theorists and researchers contend that people with this disorder hold a group of social
beliefs and expectations that consistently work against them. Some of these beliefs include:
 • Holding unrealistically high social standards and believe that they must perform perfectly
in social situations.
• Viewing themselves as unattractive social beings.
• Viewing themselves as socially unskilled and inadequate.
• They believe they are always in danger of behaving incompetently in social situations.
• They also believe that their inept behaviors in social situations will inevitably lead to
terrible consequences.
• Believing that they have no control over feelings of anxiety that emerge in social
situations.
Beset by such beliefs and expectations, people with social anxiety disorder find that their
anxiety levels increase as soon as they enter into a social situation. Later, after the social event
has taken place, the individuals repeatedly review the details of the event. They overestimate
how poorly things went and what negative results may take place, reinforcing their fears.
This suggests why they repeatedly perform “avoidance” and “safety” behaviors to help
prevent or reduce such disasters (Moscovitch et al., 2013).
Some of the other causal factors for this disorder were identified to be biological factors
such as genetic predispositions, trait tendencies, biological abnormalities, traumatic childhood
experiences, and overprotective parent-child interactions during childhood.
Treatments: Social Anxiety Disorder
Over the years therapists understood that Social Anxiety Disorder has two distinct features:
(1) Sufferers have overwhelming irrational social fears, and
(2) They often lack skill at starting conversations, communicating their needs, or meeting
the needs of others (Beck, 2010).
This insight has helped clinicians treat social anxiety disorder by trying to reduce social
fears, by providing training in social skills.
Another behavioral intervention is exposure therapy. Exposure therapists encourage
clients with social fears to expose themselves to the dreaded social situations and to remain until
their fears subside. Usually the exposure is gradual, and it often includes homework assignments
that are carried out in the social situations. In addition, group therapy offers great help by
allowing people to face fearful social situations in an atmosphere of support and care (McEvoy,
2007).
 A combination of several behavioural techniques is the Social skills training. Here, the
therapist usually models appropriate social behaviors to the clients and encourages them to try
out the same. The clients then role-play with the therapists, rehearsing their new behaviors until
they become more effective. Throughout the process, therapists provide frank feedback and
reinforce (praise) the clients for effective performances. Reinforcement from other people with
similar social difficulties is often more powerful than reinforcement from a therapist alone.
In social skills training groups and assertiveness training groups, members try out and
rehearse new social behaviors with other group members. Research suggests that social skills
training, both individual and group formats, has helped many people perform better in social
situations.
Yet other Cognitive therapies, such as the Albert Ellis’s Rational-Emotive Behavioural
Therapy (REBT) has also yielded good results, but usually when used in combination with
behavioural techniques.