Anxiety Disorders

Obsessive- Compulsions and Related Disorders

Trauma- and Stress or-Related Disorders

LIYEW. A
Jimma University

1
 Outline of the session

• Definition of anxiety
• Anxiety versus fear
• Type of anxiety disorder
• Obsessive- Compulsions and Related Disorders

2
Anxiety

What is Anxiety?
• A normal experience with a readily identifiable trigger
• Anxiety can be useful in increasing performance and as an
appropriate way of adapting to specific situations in life (e.g.
fight or flight)

• Presents in thinking, feeling (e.g. emotions and physiological)

and behaviour

3
 When does anxiety become a disorder

• It is of greater severity and duration than would be generally be

expected
• Developmentally inappropriate.
• Can lead to impairment of functioning in social life, work and
relationships
• Can result in unexplained medical symptoms and / or unwanted
thoughts can be present (i.e. Intrusions )
• People with anxiety disorders share a preoccupation with or
persistent avoidance of thoughts and situations that provoke fear
or anxiety

4
Anxiety disorders…

• Highly treatable .

• Often begins early in life

• Reported more by women than men

• Often co morbid both with other anxiety disorders and with

other disorder groups (e.g. Mood disorders, psychoses)

5
 Anxiety versus fear

• ANXIETY • FEAR
-anxious apprehension and -Experienced when a person
worry that is a more general
faced with real and immediate
reaction that is out of
danger.
proportion to threats in
environment
-future oriented -Present-oriented
-can be adaptive if not -Can be adaptive
excessive

6
 4. More considered
response based on
1. Thalamus receives cortical processing
stimulus and sends to
both amygdala and
cortex

Sensory Input 2. Amygdala

registers
danger

3. Amygdala
triggers fast
response

• Parts of the brain involved in fear response = thalamus, amygdala,

hypothalamus, which then instruct the endocrine glands and autonomic
nerv.sys.
• Evolved fear module (pink) versus considered response (green) = “fight
or flight” versus “feel the fear and do it anyway (or do it differently)”!7
 Type of anxiety disorder

1. Separation anxiety disorder

2. Selective mutism
3. Specific phobia
4. Social anxiety disorder (social phobia)
5. Panic disorder
6. Agoraphobia
7. Generalized anxiety disorder
8. Substance/medication-induced anxiety disorder
9. Anxiety disorder due to another medical condition

8
 Separation anxiety disorder

 Fearful or anxious about separation from attachment figures to

a degree that is developmentally inappropriate.
 Fear or anxiety about harm coming to attachment figures and
events that could lead to loss of or separation from attachment
figures and reluctance to go away from attachment figures, as
well as nightmares and physical symptoms of distress.
Lasting at least 4 weeks in children and adolescents and
typically 6 months or more in adults.

9
 Selective mutism

 Consistent failure to speak in social situations in which there is

an expectation to speak (e.g., school) because of social anxiety
even though the individual speaks in other situations.
 Has significant consequences on achievement in academic or
occupational settings or otherwise interferes with normal
social communication.
 The duration of the disturbance is at least 1 month (not limited
to the first month of school)
 The onset of selective mutism is usually before age 5 years.

10
 Specific phobias
 Marked fear or anxiety about a specific objects or situations.
 The phobic object or situation almost always provokes
immediate fear or anxiety.
 The phobic object or situation is actively avoided or endured
with intense fear or anxiety.
 The fear or anxiety is out of proportion to the actual danger
posed by the specific object or situation and to the sociocultural
context.
 The fear, anxiety, or avoidance is persistent, typically lasting for
6 months or more.
 many individuals with specific phobia are unable to recall the
specific reason for the onset of their phobias but Persons with
specific phobias may anticipate harm.
 majority of cases developing prior to age 10 years. 11
 Specify type:

Animal type(e.g., spiders, insects, dogs).

Natural environment type (e.g., heights, storms, water)

Blood-injection-injury type(e.g., needles, invasive medical

procedures)

Situational type (e.g., airplanes, elevators, enclosed places)

Other type (e.g., fear of choking, vomiting, or contracting an

illness; in children, fear of loud sounds or costumed characters)

12
 e.g. of specific phobias
• Heights Acrophobia
• Water Hydrophobia
• Enclosed places claustrophobia
• Animals Zoophobia
• Death Thanatophobia
• Pain Algophobia

13
 Social Anxiety Disorder (Social Phobia)
A. Marked fear or anxiety about one or more social situations in
which the individual is exposed to possible scrutiny by others.
Examples include social interactions (e.g., having a conversation,
meeting unfamiliar people), being observed (e.g., eating or
drinking), and performing in front of others (e.g., giving a
speech).
B. The individual fears that he or she will act in a way or show
anxiety symptoms that will be negatively evaluated (i.e., will be
humiliating or embarrassing: will lead to rejection or offend
others).
C. The social situations almost always provoke fear or anxiety.
D. The social situations are avoided or endured with intense fear or
anxiety.
E.The fear, anxiety, or avoidance is persistent, typically lasting for 6
14
months or more.
 Conti.....
• Specify if: Performance only:
have performance fears that are typically most impairing in their
professional lives (e.g., musicians, dancers, performers,
athletes) or in roles that require regular public speaking.
• Distinguishing feature is the fear of doing something in front of
others
• Fear of one’s own behaviour causing negative attention from
others, judged as anxious, weak, crazy, stupid, boring,
intimidating, dirty, or unlikable.
• 30% = remission of symptoms within 1 year
• 50%= remission within a few years.

15
 Panic Disorder
• Panic disorder is the presence of:

a) recurrent, unexpected panic attacks,(4 symptom from 13)

b) at least one of the attacks has been followed by 1 month (or

more) of one or both of the following

1. persistent concern or worry about additional panic attacks or

their consequences

2. A significant maladaptive change in behavior related to the

attacks.

16
 Panic Attack
• Panic attack: abrupt experience of intense fear or acute
discomfort , accompanied by physical symptoms (e.g., heart
palpitations, chest pain, shortness of breath, dizziness).

• Symptoms develop suddenly and reach a peak within minutes

• Four of the following symptoms develop abruptly and reach a
peak within minutes
STUDENTS FEAR THE 3 C’S

Sweating

Trembling/shaking
17
Cont..

• Unsteadiness

• Depersonalization ,Derealization

• Excessive heart rate

• Nausea

• Tingling/ paresthesia

• Shortness of breath

• Fear of dying, of losing control or going crazy

• Chest pain,chills,choking
18
 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.

19
 Cont…

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 fear, anxiety, or avoidance is persistent, typically lasting for 6

months or more.

20
 Generalised Anxiety Disorder

• Characterised by persistent and global worry: worry about

“everything”, “worry about worry”

• Distinguished from normal worry by severity, interference,

irrationality

• Common problem but little is known

• Resistant to change

21
Generalised Anxiety Disorder

A. Excessive worry (apprehensive

expectation), occurring more days
than not for at least 6 months, about a
number of events or activities (such as
work or school performance).
B. The person finds it difficult to control

22
C. The anxiety and worry are associated with three (or more) of the
following six symptoms (with at least some symptoms present for
more days than not for the past 6 months).

(1) restlessness or feeling keyed up

(2) being easily fatigued

(3) difficulty concentrating or mind going blank

(4) irritability

(5) muscle tension

(6) sleep disturbance (difficulty falling or staying asleep, or restless

unsatisfying sleep) 23
 Cont..
BESKIM

 Blank mind, difficulty concentrating

 Easy fatigability

 Sleep disturbance

 Keyed up on edge or restlessness

 Irritability

 Muscle tension
24
 Substance/Medication-Induced Anxiety Disorder

• Substance-induced disorder is the direct result of a toxic

substance, including drugs of abuse, medication, poison, and
alcohol, among others.

• Substance-induced anxiety disorder is common, both as the

result of the ingestion of so-called recreational drugs and as the
result of prescription drug use.

25
 Anxiety Disorder due to a Another Medical Condition

• Many medical disorders are associated with anxiety. Symptoms

can include panic attacks, generalized anxiety and other signs
of distress.

• In all cases, the signs and symptoms will be due to the direct
physiological effects of the medical condition.

26
Other Specified Anxiety Disorder

1. Limited-symptom attacks.
2. Generalized anxiety not occurring more days than not.

Unspecified Anxiety Disorder

There is insufficient information to make a more specific diagnosis

(e.g., in emergency room settings).

27
 Obsessive- Compulsions and Related Disorders
•Obsessive-compulsive disorder (OCD)
• Body dysmorphic disorder
• Hoarding disorder(Persistent difficulty discarding or parting with
possessions, regardless of their actual value).
• Trichotillomania (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
•Unspecified obsessive-compulsive and related disorder
28
 Obsessive Compulsive Disorder

• Characterized by the presence of obsessions and/or

compulsions
• Obsessions are recurrent and persistent thoughts, urges, or
images that are experienced as intrusive and unwanted.
• compulsions are repetitive behaviors or mental acts that an
individual feels driven to perform in response to an obsession
or according to rules that must be applied rigidly.
• 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.

29
 Common Examples of OCD
Common
Common Obsessions:
Compulsions:
Contamination fears of germs, dirt, etc. Washing
Imagining having harmed self or others Repeating
Imagining losing control of aggressive
Checking
urges
Intrusive sexual thoughts or urges Touching
Excessive religious or moral doubt Counting
Forbidden thoughts Ordering/arranging
A need to have things "just so" Hoarding or saving
A need to tell, ask, confess Praying
30
Specify if:

• With good or fair insight: The individual recognizes that

obsessive-compulsive disorder beliefs are definitely or
probably not true or that they may or may not be true.
• With poor insight: The individual thinks obsessive-
compulsive disorder beliefs are probably true.
• With absent insight/delusional beliefs: The individual is
completely convinced that obsessive-compulsive disorder
beliefs are true.

31
 Body dysmorphic disorder (dysmorpho -phobia)
•Preoccupation with imagined or exaggerated defects or flaws in
physical appearance that are not observable or appear slight to others.
•The individual has performed repetitive behaviors (e.g., mirror
checking, excessive grooming, skin picking, reassurance seeking) or
mental acts (e.g., comparing his or her appearance with that of others)
in response to the appearance concerns.
•Causes clinically significant impairment in social or occupational
function…
 person may undergo repeated plastic surgeries for nose repair or to
change face etc.
 Common complaints focus on facial, jaws, hair, breast, genitals,
nose
 Slight physical abnormality exists, the person displays excessive
concern.
 attempts to hide the presumed deformity (with makeup or clothing

32
 …Body Dysmorphic

• Belives that there is a problem with

appearance
• Obsessive
• M/F=1
• Frequent cosmetic surgery

33
Trauma- and Stressor-Related Disorders

• Reactive attachment disorder

• Disinhibited social engagement disorder
• Posttraumatic stress disorder(PTSD)
• Acute stress disorder
• Adjustment disorders
• Other Specified Trauma- and Stressor-Related Disorder
• Unspecified Trauma- and Stressor-Related Disorder

34
 Posttraumatic Stress disorder (PTSD)
Symptoms of PTSD fall into 5 major categories. Symptoms in each
must occur longer than 1 month.

• Exposure/ experiencing traumatic life event.

• Reexperiencing the traumatic event/ intrusion symptoms

• Avoidance of stimuli associated with the event or numbing of

responsiveness.

• Negative alterations in cognitions and mood associated with the

traumatic event(s)

• Symptoms of increased arousal

35
Diagnostic criteria
A. Exposure to actual or threatened death, serious injury, or sexual
violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3.Learning that the traumatic event(s) occurred to a close family
member or close friend. In cases of actual or threatened death of a
family member or friend, the event(s) must have been violent or
accidental.
4. Experiencing repeated or extreme exposure to aversive details of
the traumatic event(s) (e.g., first responders collecting human
remains: police officers repeatedly exposed to details of child
abuse).

36
B. Presence of one (or more) of the following intrusion symptoms
associated with the traumatic event(s), beginning after the traumatic
event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the
traumatic event(s).
2. Recurrent distressing dreams in which the content and/or affect of
the dream are related to the traumatic event(s).
3. Dissociative reactions (e.g., flashbacks) in which the individual
feels or acts as if the traumatic event(s) were recurring. (Such
reactions may occur on a continuum, with the most extreme
expression being a complete loss of awareness of present
surroundings.)
4. Intense or prolonged psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect of the
traumatic event(s).
37
5. Marked physiological reactions to internal or external cues that
symbolize or resemble an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic
event(s), beginning after the traumatic event(s) occurred, as
evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories,
thoughts, or feelings about or closely associated with the
traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people,
places, conversations, activities, objects, situations) that arouse
distressing memories, thoughts, or feelings about or closely
associated with the traumatic event(s).

38
 D. Negative alterations in cognitions and mood associated with the
traumatic event(s),beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or more) of the
following:
1. Inability to remember an important aspect of the traumatic
event(s) (typically due to dissociative amnesia and not to other
factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about
oneself, others, or the world (e.g., “I am bad,” “No one can be
trusted,” ‘The world is completely dangerous,” “My whole
nervous system is permanently ruined”).
.

39
3. Persistent, distorted cognitions about the cause or consequences
of the traumatic event(s) that lead the individual to blame
himself/herself or others
4. Persistent negative emotional state (e.g., fear, horror, anger,
guilt, or shame).
5. Markedly diminished interest or participation in significant
activities.
6. Feelings of detachment or estrangement from others.
7.Persistent inability to experience positive emotions (e.g.,
inability to experience happiness, satisfaction, or loving
feelings).

40
E. Marked alterations in arousal and reactivity associated with the
traumatic event(s), beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or more) of the
following:
1.Irritable behavior and angry outbursts (with little or no
provocation) typically expressed as verbal or physical
aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hyper vigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6.Sleep disturbance (e.g., difficulty falling or staying asleep or
restless sleep).

41
F. Duration of the disturbance (Criteria B, C, D, and E) is more
than 1 month.
G. The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
H. The disturbance is not attributable to the physiological effects
of a substance (e.g., medication, alcohol) or another medical
condition.

42
• Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more
Specify if:
With delayed expression: if onset of symptoms is at least 6
months after the stressor

43
Acute Stress Disorder

• Presence of nine (or more) of symptoms from any of the five

categories of intrusion, negative mood, dissociation, avoidance,
and arousal, beginning or worsening after the traumatic event(s)
occurred:

• Duration of the disturbance is 3 days to 1 month after trauma

exposure.

44