Ch. 6 (pgs: 184-217)

Compulsive hoarding occurs in approximately 10-40% of people diagnosed with OCD.

People with hoarding disorder both acquire and fail to discard many possessions that seem useless or of very limited value, in part because of the emotional attachment they develop to their possessions. Their living spaces are extremely cluttered and disorganized to the point of interfering with normal activities that would otherwise occur in those spaces, such as cleaning, cooking, and walking through the house. People have literally been buried alive in their own home by their hoarded possessions.

These frightening thoughts may cause many more physical symptoms of anxiety, which further fuel the catastrophic thoughts, leading to a vicious circle culminating in a panic attack.

The person is not necessarily aware of making these catastrophic interpretations; rather, the thoughts are often just barely out of the realm of awareness.

Approximately 3% of the population suffers from GAD in any 1-year period and 5.7% at some point in their lives.

...It also tends to be chronic.

A study of individuals with BDD found that:

56-68% reported a history of emotional neglect or emotional abuse, and approximately 30% reported a history of physical or sexual abuse or physical neglect.

most symptoms of a panic attack are physical

85% of people having panic attacks may show up repeatedly at ER or doctors' offices for what they are convinced is a medical problem.

The dominant behavioral or learning view or obsessive-compulsive disorder is derived from Mowrer's two-process theory of avoidance learning (1947).

According to this theory, neural stimuli become associated with frightening thoughts or experiences through classical conditioning and come to elicit anxiety. For example, touching a doorknob or shaking hands might become associated with the "scary" idea of contamination. Once having made this association, the person might discover that the anxiety produced by shaking hands or touching a doorknob can be reduced by hand washing.

GAD is approximately twice as common in women as in men.

Although GAD is quite common, most people with this disorder manage to function in spite of their high levels of worry and low perceived well-being.

Although panic attacks themselves appear to come out of the blue, the first one frequently occurs following feelings of distress or some highly stressful life circumstances such as loss of a loved one, loss of an important relationship, loss of a job, or criminal victimization.

Although not all studies have found this, some have estimated that approximately 80-90% of people report that their first panic attack occurred after one or more negative life events.

Sufferers of BDD commonly go to the dermatologist or plastic surgeon.

An astute doctor will not do the requested procedures and may instead make a referral to a psychologist or psychiatrist. Usually, the patient gets what they want, and unfortunately is almost never satisfied with the outcome.

A newer medication called buspirone is also effective...

And it is neither sedating nor does it lead to physiological dependence.

This conditioning of anxiety to the internal or external cues associated with panic thus sets the stage for the development of two of the three components of panic disorder:

Anticipatory anxiety and, sometimes, agoraphobic fears.

The other category of medication that is useful in the treatment of panic disorder and agoraphobia is the...

Antidepressants (including primarily the tricyclics, the SSRI's, and most recently the serotonin-norepinephrine reuptake inhibitors).

Not only do people with GAD have frequent frightening thoughts, they also process threatening information in a biased way, perhaps because they have prominent danger schemas.

Anxious people tend to preferentially allocate their attention toward threatening cues when both threat and nonthreat cues are present in the environment.

Obsessions

Are persistent and recurrent intrusive thoughts, images, or impulses that are experienced as disturbing, inappropriate, and uncontrollable. People who have such obsessions actively try to resist or suppress them or to neutralize them with some other thought or action.

There is now considerable evidence that...

Attempts to control thoughts and worry may paradoxically lead to increased experience of intrusive thoughts and enhanced perception of being unable to control them.

A recent twin study found that overconcern with a perceived or slight defect in physical appearance is a moderately heritable trait.

BDD seems to be occurring in a sociocultural context that places great value on attractiveness and beauty, and people who develop BDD often hold attractiveness as their primary value.

Treatment for OCD includes:

Behavioral and cognitive-behavioral approaches as well as medication.

Evidence for genetic factors in GAD is mixed...

But there does seem to be a modest heritability, although perhaps smaller than that for most other anxiety disorder except phobias.

Some studies have suggested that this heritability is at least partly specific for panic disorder...

But twin studies suggest that there is overlap in the genetic vulnerability factors for panic disorder and both phobias and separation anxiety.

The cognitive theory of panic disorder proposes that people with panic disorder are hypersensitive to their bodily sensations and are very prone to giving them the most dire interpretation possible.

Clark referred to this as a tendency to catastrophize about the meaning of their bodily sensations.

Five primary types of compulsive rituals:

Cleaning (hand washing and showering), checking, repeating, ordering or arranging, and counting, and many people exhibit multiple kinds of rituals.

Not all people who have a panic attack following a stressful event go on to develop full-blown panic disorder.

Estimates are that nearly 23% of adults have experienced at least one panic attack in their lifetimes, but most do not go on to develop full-blown panic disorder.

The exact nature of the dysfunction in serotonergic systems in OCD is unclear.

Evidence suggests that increases serotonin activity and increased sensitivity on some brain structure to serotonin are involved in OCD symptoms. Long term administration of clomipramine causes a downregulation of certain serotonin receptors, further causing a functional decrease in the availability of serotonin. Although the immediate short term effects of clomipramine or fluoxetine may be to increase serotonin levels, the long term effects are quite different. These drugs must be taken for at least 6-12 weeks before significant improvement in OCD symptoms occur.

People with GAD have...

Far less tolerance for uncertainty than nonanxious controls and even people with panic disorder. This low tolerance for uncertainty in people with GAD suggests that they are especially disturbed by not being able to predict the future. Moreover, the greater the intolerance of uncertainty, the more severe the GAD. A similar intolerance for uncertainty also seems to be elevated in people with obsessive-compulsive disorder.

Pharmacological studies of causal factors in OCD intensified with the discovery in the 1970's that a tricyclic drug called clomipramine (Anafranil) is often effective in the treatment of OCD even though other tricyclic antidepressants are generally not very effective.

Research shows that this is because clomipramine has greater effects on the neurotransmitter serotonin, which is now strongly implicated in OCD. Several other antidepressant drugs from the SSRI category that also have relatively selective effects in serotonin, such as fluoxetine (Prozac), have also been shown to be about equally effective in the treatment of OCD.

Although worry can be reinforcing, some of its effects are clearly negative...

For example, worrying itself is not an enjoyable activity and can actually lead to a greater sense of danger and anxiety because of all the possible catastrophic outcomes that the worrier envisions.

Cognitive-behavioral treatment...

For generalized anxiety disorder has become increasingly effective as clinical researchers have refined the techniques used. It usually involves a combination of behavioral techniques, such as training in applied muscle relaxation, and cognitive restructuring techniques aimed at reducing distorted cognitions and information-processing biases associated with GAD as well as reducing catastrophizing about minor events.

Koro is another culture related syndrome that occurs in China and other southeast Asian countries.

For men it involves intense, acute fear that the penis is retracting into the body and that when this process is complete the sufferer will die. Koro occurs less frequently in women, for whom the fear is that their nipples are retracting and their breasts shrinking. Koro tends to occur in epidemics— especially in cultural minority groups when their survival is threatened— and it is often attributed to either malicious spirits or contaminated food.

According to the psychoanalytic viewpoint, generalized or free-floating anxiety results from an unconscious conflict between ego and id impulses that is not adequately dealt with because the person's defense mechanisms have either broken down or have never developed.

Freud believed that it was primarily sexual and aggressive impulses that had been either blocked from expression or punished upon expression that led to free-floating anxiety.

The inhibitory neurotransmitter GABA has also been implicated in the anticipatory anxiety that many people with panic disorder have about experiencing another attack.

GABA is known to inhibit anxiety and has been shown to be abnormally low in certain parts of the cortex in people with panic disorder.

The biological causal factors of panic disorder include...

Genetics, brain activity, and biochemical abnormalities.

Biological factors involved in GAD can be attributed to...

Genetics, neurotransmitter abnormalities, and neurobiological differences.

Highly anxious people...

Have a kind of functional deficiency in GABA, which ordinarily plays an important role in the way our brains inhibits anxiety in stressful situations.

Most people with BDD...

Have compulsive checking behaviors (such as checking their appearance in the mirror excessively or hiding or repairing a perceived flaw).

Age of onset is often difficult to determine because 60-80% of people with GAD remember having been anxious nearly all their lives, and many others report a slow and insidious onset.

However, research has also documented that GAD often develops in older adults, for whom it is the most common anxiety disorder.

The same neurotransmitter (serotonin) and the same sets of brain structures are...

Implicated in the two disorders (OCD and BDD).

Historically, agoraphobia was thought to involve a fear of the agora, the Greek word for "open gathering place".

In agoraphobia, the most commonly feared and avoided situations include streets and crowded places such as shopping malls, movie theaters, and stores. Married women typically get agoraphobia.

People with OCD often seem to have an inflated sense of responsibility.

In turn, in some vulnerable people, this inflated sense of responsibility can be associated with beliefs that simply having a thought about doing something is morally equivalent to actually having done it, or that thinking about the behavior increases the chances of actually doing so. This is known as Thought-action Fusion.

Obsessive thoughts

Involve contamination fears, fears of harming oneself or others, and pathological doubt. Other common ones are concerns about or need for symmetry, sexual obsessions, and obsessions concerning religion or aggression. Even though such obsessive thoughts are very rarely acted on, they remain a source of often excruciating torment to a person plagued with them.

Compulsions

Involve overt repetitive behaviors that are performed as lengthy rituals (such as hand washing, checking, putting things in order over and over again). Compulsions may also involve more covert mental rituals (such as counting, praying, or saying certain words silently over and over again).

Although people often think of suicide as being especially associated with depression, a major study in the 1980s reported that panic disorder...

Is a strong predictor of suicidal behavior. Subsequent research suggested that the link between panic and suicidal behavior is largely explained by the presence of comorbid disorders such as depression and substance abuse, leading researchers to conclude that panic itself doesn't increase the risk of suicidal behavior. However, two large epidemiological studies have found that panic disorder is indeed associated with increased risk for suicidal ideation and attempts independent of its relationship with comorbid disorders.

Panic disorder...

Is about twice as prevalent in women as in men

A major disadvantage of medication treatment for OCD...

Is that when the medication is discontinued relapse rates are generally very high (50-90%).

BDD's existence:

Its prevalence may have increased in recent years as contemporary western culture has become increasingly focused on "looks as everything".

Troublesome side effects (such as dry mouth, constipation, and blurred vision with the tricyclics, and interference with sexual arousal with the SSRI's) mean that...

Large numbers of people refuse to take the medications or discontinue their use. Moreover, relapse rates when the drugs are discontinued are quite high.

Cultural perspectives

Lifetime risk for social phobia, generalized anxiety disorder, and panic disorder is somewhat lower among ethnic minority groups than among the non-Hispanic whites.

People with BDD may focus on almost any body part.

Many sufferers have perceived defects in more than one body part. Some researchers estimate that about half the people with BDD have concerns about their appearance that are of delusional intensity.

In severe cases, people with BDD...

May become so isolated that they lock themselves up in their houses and never go out, even to work, with the average employment rate estimated at only about 50%.

Biological causal factors...

May play a stronger causal role for OCD relative to the other disorders discussed.

The prevalence of BDD seems to be approximately equal in men and women although the primary body parts that are focused on tend to differ in men and women.

Men are more likely to obsess about their genitals, body build, and balding, whereas women tend to obsess more about their skin, stomach, breasts, buttocks, hips, and legs. The age of onset is usually in adolescents, when many people start to become preoccupied with their appearance. People with BDD commonly have a depressive diagnosis (with most estimates being over 50%), and it can even lead to suicide attempts or death. Nearly 200 patients with BDD, found that 80% reported a history of suicidal ideation, and 28% had a history of suicide attempt. Rates of comorbid social phobia and obsessive-compulsive disorder are also quite substantial, although not as high as for depression. Not surprisingly, BDD, like OCD, is often associated with a poor quality of life.

A study found that...

More than 25% of people in the United States report experiencing obsessions or compulsions at some time in their lives.

OCD frequently co-occurs with other anxiety disorders, most commonly social phobia, panic disorder, GAD, and PTSD.

Moreover, approximately 25-50% of people with OCD experience major depression at some time in their lives and as many as 80% experience significant depressive symptoms, often at least partly in response to having OCD.

Latin Americans from the Caribbean (especially those from Puerto Rico) and other people from the Caribbean, do show higher rates of a variant of panic disorder called ataque de nervios than do other groups.

Most of the symptoms of ataque de nervios are the same as in a panic attack, but they may also include bursting into tears, anger, and uncontrollable shouting. Other symptoms include shakiness, verbal or physical aggression, dissociative experiences, and seizure-like or fainting episodes.

The vast majority of people with panic disorder (83%) have at least one comorbid disorder...

Most often generalized anxiety disorder, social phobia, specific phobia, PTSD, depression, and substance-use disorder.

According to family and twin studies...

Panic disorder has a moderate heritable component.

Obsessive-compulsive disorder

Occurrence of both obsessive thoughts and compulsive behaviors performed in an attempt to neutralize such thoughts.

Approximately 4.7% of the adult population has had panic disorder with or without agoraphobia at some time in their lives, with panic disorder without agoraphobia being more common. Panic disorder with or without agoraphobia typically begins in the 20s to the 40s, but sometimes begins in the late teen years.

Once panic disorder develops, it has a chronic and disabling course. Less than 50% of patients with panic disorder with agoraphobia had recovered in 12 years, and 58% of those who had recovered at some point had had a recurrence.

The second set of techniques that were developed is cognitive restructuring techniques, in recognition that catastrophic automatic thoughts may help maintain panic attacks.

One kind of integrative cognitive-behavioral treatment for panic disorder—panic control treatment (PCT)— targets both agoraphobic avoidance and panic attacks.

Many people with panic disorder are prescribed anxiolytics (anti anxiety medications) from the benzodiazepine category such as alprazolam (Xanax) or clonazepam (klonopin).

One major advantage of these drugs is that they act very quickly (30-60 mins) and so can be useful in acute situations of intense panic or anxiety. However, these anxiolytic medications can have side effects such as drowsiness and sedation, which can lead to impaired cognitive and motor performance. Also with prolonged use, most people using moderate to high doses develop physiological dependence on the drug, which results in withdrawal symptoms when the drug is discontinued.

Approximately 2-3% of people meet criteria for OCD at some point in their lifetime, and approximately 1% meet criteria in a given year.

Over 90% of treatment-seeking people with OCD experience both obsessions and compulsions.

Neuroimaging research has found that:

People diagnosed with OCD who have compulsive hoarding symptoms also show patterns of activation in certain brain areas when their symptoms are provoked.

Generalized anxiety disorder (GAD)

People suffering from GAD live in a relatively constant, future-oriented mood state of anxious apprehension, chronic tension, worry, and diffuse uneasiness that they cannot control. They also show marked vigilance for possible signs of threat in the environment and frequently engage in subtle avoidance activities such as procrastination, checking, or calling a loved one frequently to see if he or she is safe.

Orbital frontal cortex

Primitive urges regarding sex, aggression, hygiene, and danger.

Because OCD in its most severe form is such a crippling and disabling disorder...

Psychiatrists have begun to examine the usefulness of certain neurosurgical techniques for the treatment of severe, intractable OCD.

This genetic vulnerability is manifested at a psychological level at least in part by the important personality trait called neuroticism.

Several studies have begun to identify which specific genetic polymorphisms are responsible for this moderate heritability, either alone or in interaction with certain types of stressful life events.

The original behavioral treatment for agoraphobia from the early 1970s involves prolonged exposure to feared situations, often with the help of a therapist or family member.

Similar to what is done with specific and social phobias, the idea was to make people gradually face the situations they feared and learn that there was nothing to fear. Such exposure-based treatments were quite effective and helped about 60-75% of people with agoraphobia show clinically significant improvement. These effects were generally well maintained at 2 to 4 year follow-up. But this left approximately 25-40% not improved to a clinically significant degree.

Researchers have noted similarities between BDD and eating disorders, especially anorexia nervosa.

Similarities between these disorders are the excessive concern and preoccupation about physical appearance, dissatisfaction with ones body, and a distorted image of certain features of ones body. People with anorexia are emaciated and generally satisfied with this aspect of their appearance.

Divorced (or separated) and unemployed people are somewhat overrepresented among people with OCD, which is not surprising given the great difficulties this disorder creates for interpersonal and occupational functioning.

Some studies showed little or no gender difference in adults, which would make OCD quite different from most of the rest of the anxiety disorders. However, one British epidemiological study found a gender ratio of 1.4 to 1 (women to men). OCD typically begins in late adolescence or early adulthood, but also can occur in children, where its symptoms are strikingly similar to those of adults.

Several of the benefits that people with GAD most commonly think derive from worrying are:

Superstitious avoidance of catastrophe ("worrying makes it less likely that the feared event will occur"). Avoidance of deeper emotional topics ("worrying about most of the things I worry about is a way to distract myself from worrying about even more emotional things, things that I don't want to think about"). Coping and preparation ("worrying about a predicted negative event helps me to prepare for its occurrence").

Trichotillomania (compulsive hair pulling):

Symptom is the urge to pull out ones hair from anywhere on the body (most often the scalp, eyebrows, or arms). Hair pulling is usually preceded by an increasing sense of tension, followed by pleasure, gratification, or relief when the hair is pulled out.

The model also predicts...

That changing their cognitions about their bodily symptoms should reduce or prevent panic.

Abnormalities occur primarily in certain cortical and subcortical structures such as the basal ganglia.

The basal ganglia are in turn linked at the amygdala to the limbic system, which controls emotional behaviors. People with OCD have abnormally high levels of activity in two parts of the frontal cortex (the orbital frontal cortex and the cingulate cortex/gyrus), which are also linked to the limbic area. People with OCD also have abnormally high levels of activity in the subcortical caudate nucleus, which is part of the basal ganglia. These primitive brain circuits are involved in executing primitive patterns of behavior such as those involved in sex, aggression, and hygiene concerns.

In the 1950's,...

The benzodiazepine category of medications was found to reduce anxiety.

A person with OCD usually feels driven to perform this compulsive, ritualistic behavior in response to an obsession, and there are often very rigid rules regarding exactly how the compulsive behavior should be performed.

The compulsive behaviors are performed with the goal of preventing or reducing distress or preventing some dreaded event or situation. OCD is often one of the most disabling mental disorders in that it leads to a lower quality of life and a great deal of functional impairment.

The most effective treatment for OCD is a behavioral treatment called exposure and response prevention.

The exposure component involves having individuals with OCD repeatedly expose themselves (either in guided fantasy or directly) to stimuli that provoke their obsessions. The response prevention component requires that they then refrain from engaging in the rituals that they ordinarily would perform to reduce their anxiety or distress. Although some people refuse such treatment or drop out early, most who stick with it show a 50-70% reduction in symptoms.

One technique involves the variant on exposure known as interoceptive exposure, meaning deliberate exposure to feared internal sensations.

The idea was that fear of these internal sensations should be treated in the same way that fear of external agoraphobic situations is treated— namely through prolonged exposure to those internal sensations so that the fear may extinguish.

The nearly constant worries of people with generalized anxiety disorder leave them continually upset and discouraged.

The most common areas of worry tend to be family, work, finances, and personal illness.

Medications from the benzodiazepine (anxiolytic) category such as Xanax or klonopin are used—and misused— for tension relief, reduction of other somatic symptoms, and relaxation.

Their effects on worry and other psychological symptoms are not as great. Moreover, they can create physiological and psychological dependence and withdrawal and are therefore difficult to taper.

OCD seems to respond best to medications that affect the serotonin system.

These medications, such as clomipramine (Anafranil) and fluoxetine (Prozac) reduce the intensity of OCD symptoms. About 30-50% of clients do not show any clinical significant improvement.

A substantial body of evidence now implicates biological causal factors in OCD.

This evidence comes from genetic studies, from studies of abnormalities in brain function, and from studies of neurotransmitter abnormalities.

Obsessive-compulsive and related disorders used to be classified in the DSM as anxiety disorders; however, as of DSM-5 they have been classified separately as their own type of disorder.

This new category includes not only OCD but also body dysmorphic disorder, hoarding disorder, excoriation (skin-picking) disorder, and trichotillomania (compulsive hair pulling).

One theory about the neurobiology of panic attacks implicated the locus coeruleus in the brain stem and a particular neurotransmitter—norepinephrine—that is centrally involved in brain activity in this area.

Today, it is recognized that it is increased activity in the amygdala that plays a more central role in panic attack's than does activity in the locus coeruleus. The amygdala is a collection of nuclei in front of the hippocampus in the limbic system of the brain that is critically involved in the emotion of fear.

Although the medications typically used to treat OCD are generally not effective in treating people with compulsive hoarding symptoms, some studies have suggested that one antidepressant can be somewhat effective.

Traditional behavioral therapy using exposure and response prevention is also less effective than for traditional OCD.

Treatment of body dysmorphic disorder

Treatment effective for BDD are closely related to those used in the effective treatment of OCD. It is possible that inadequate doses of the medication were used, thus leading to an underestimation of their true potential effects. In general, it seems that higher doses of these medications are needed to effectively treat BDD relative to OCD. Additionally, a form of cognitive-behavioral treatment emphasizing exposure and response prevention has been shown to produce improvement in 50-80% of treated patients.

Anxiety disorders were the most common category of disorder reported in all but one country:

Ukraine

In human children, experiences with control and mastery often also occur in the context of the parent-child relationship and so parents responsiveness to their children's needs directly influences their children's developing sense of mastery.

Unfortunately, parents of anxious children often have an intrusive, overcontrolling parenting style, which may serve only to promote their children's anxious behaviors by making them think of the world as an unsafe place in which they require protection and have little control themselves.

Body dysmorphic disorder (BDD)

Was classified as a somatoform disorder in DSM-IV-TR because it involves preoccupation with certain aspects of the body. Because of its very strong similarities with OCD, it was moved out of the somatoform category and into the OCD and related disorders category in DSM-5. People with BDD are obsessed with some perceived or imagined flaw or flaws in their appearance to the point they firmly believe they are disfigured or ugly.

The effects of attempting to suppress obsessive thoughts:

When most people attempt to suppress unwanted thoughts they sometimes experience a paradoxical increase in those thoughts later.

A comprehensive learning theory of panic disorder developed during the past few decades suggests that initial panic attacks become associated with initially neural internal and external cues through an interoceptive conditioning or exteroceptive conditioning process...

Which leads anxiety to become conditioned to these C's, and the more intense the panic attack, the more robust the conditioning that will occur.

Agoraphobia occurs much more frequently in...

Women than men, and the percentage of women increases as the extent of agoraphobic avoidance increases. Among people with severe agoraphobia, approximately 80-90% are female.

People with GAD...

do frequently show up in physicians offices with medical complaints (such as muscle tension or gastrointestinal and/or cardiac symptoms) and are known to be overusers of health care resources.

correct diagnosis is often not made for years due to the normal results on numerous costly medical tests.

patients with cardiac problems are at a nearly twofold elevated risk for developing panic disorder. diagnosis and treatment are also important because panic disorder causes approximately as much impairment in social and occupational functioning as that caused by major depressive disorder. panic disorder can contribute to development or worsening of medical problems.

The person must recognize that...

the obsession is the product of his or her own mind rather than being imposed from without.