Anxiety disorders

DSM-V
 Anxiety disorders
• -include disorders that share features of excessive
fear and anxiety and related behavior
disturbances

-individuals typically overestimate the danger in

situations they fear or avoid, the primary
determination of whether the fear or anxiety is
excessive or out of proportion is made by the
clinician, taking cultural contextual factors into
account
 Anxiety disorders
• Develop during childhood and tend to persist if
not treated

• Most occur more frequently in females

• Each anxiety disorder is diagnosed only when the

symptoms are not attributable to the
physiological effects of a substance/medication
or to another medical condition or are not better
explained by another mental disorder
 Anxiety disorder
• The disturbance causes clinically significant
distress or impairment in social, academic,
occupational, or other important areas of
functioning.
 Causes of Anxiety disorders
1. Biological Contributions
- inherit a tendency to be tense, uptight and
anxious
- Depleted levels of GABA

2. Psychological Contributions

3. Social Contributions
 Panic attack specifier
• Two types:
- Expected – obvious cues or trigger
- Unexpected – no obvious cue or trigger

- Within minutes
• Comorbidity – co-occurrence of two or
more disorders in a single individual

p. 128
 Anxiety disorders
Generalized Anxiety disorder
Panic disorder
Agoraphobia
Specific phobia
Social anxiety disorder
Separation Anxiety disorder
Selective Mutism
 General anxiety disorder
• Diagnostic Criteria: p 130

GAD in children: only one physical symptom

- worry about competence in academics,
athletic or social performance as well as family
issues
 PANIC DISORDER
• Refers to recurrent unexpected panic attacks
Example: nocturnal panic attack

• Panic attack is an abrupt surge of intense fear

or intense discomfort that reaches a peak
within minutes, and during which time four or
more of a list of 13 physical and cognitive
symptoms occur. p.124
 Panic disorder
• Culture – p.137

- Susto (Latin America)

- Ataques de Nervios (Caribbean)
- Kyol Goeu or “wind overload” (Cambodia and
Vietnamese)
 agoraphobia
Fear and avoidance of situations in which a
person feels unsafe or unable to escape to get
home or to a hospital in the event of a
developing panic symptoms or other physical
symptoms.

Agora = marketplace
 Agoraphobia
• An individual who has not had a panic attack for
years may still have strong agoraphobic
avoidance

• Cope: alcohol/drugs

• Do not avoid agoraphobic situations but endure

them with “intense dread”

• Interoceptive avoidance p.136

 agoraphobia
Diagnostic Criteria: p.137

Note: if an individual’s presentation meets

criteria for panic disorder and agoraphobia,
both diagnoses should be assigned
 SPECIFIC PHOBIA
Is an irrational fear of a specific object or
situation that markedly interferes with an
individual’s ability to function.

Diagnostic Criteria: p 143

 Specific phobia
• An individual who becomes anxious only occasionally
upon being confronted with the situation or object
(e.g., becomes anxious when flying only on one out of
every five airplane flights) would not be diagnosed
with specific phobia

• Sociocultural context: fear of the dark may be

reasonable in a context of ongoing violence

• It is common for individuals to have multiple specific

phobias
 Specific phobia
• Types:

1. Blood-Injection-Injury Phobia
2. Situational Phobia
3. Natural Environment Phobia
4. Animal Phobia
 Specific phobia
• Culture-Bound syndrome:
Pa-leng (China)

Causes:
1. Direct Experience
2. Experiencing a false alarm in a specific situation
3. Vicarious Experience
4. Information transmission
 Separation Anxiety Disorder
• - “Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence” (DSM-IV)
 Separation anxiety disorder
• Diagnostic Criteria:
A. Developmentally inappropriate and excessive
fear or anxiety concerning separation from
those to whom the individual is attached, as
evidenced by at least three of the following:
1. Recurrent excessive distress when anticipating or
experiencing separating from home or from major
attachment figures.
2. Persistent and excessive worry about losing
major attachment figures or about possible harm to
them, such as illness, disasters, or death
3. Persistent and excessive worry about
experiencing an untoward event (getting lost,
being kidnapped, having an accident,
becoming ill) that causes separation from a
major attachment figure

4. Persistent reluctance or refusal to go out,

away from home, to school, to work, or
elsewhere because of fear of separation

5. Persistent and excessive fear of or

reluctance about being alone or without
major attachment figures at home or in other
settings
6. Persistent reluctance or refusal to sleep
away from home or to go to sleep without
being near a major attachment figure.

7. Repeated nightmares involving the

theme of separation.

8. Repeated complaints of physical

symptoms when separation from major
attachment figures occurs or is
anticipated.
• B. at least 4 weeks in children and
adolescents and 6 months or more in
adults

• C. Causes clinically significant distress or

impairment in social, academic,
occupational, or other important areas
of functioning

• D. The disturbance is not better

explained another mental disorder
 Separation Anxiety Disorder
• Consider the culture

• Gender

• Causes: after stress, parental overprotection

and intrusiveness
 SOCIAL ANXIETY DISORDER (Social
phobia)
• Characterized by marked fear or anxiety about
one or more social situations in which the
individual is exposed to possible scrutiny by
others

• Examples: social interactions (having a

conversation, meeting unfamiliar people), being
observed (eating or drinking) performing in front
of others(giving speech)

• Diagnostic Criteria: p. 151

 Social anxiety disorder
• Causes: stressful and humiliating experiences

• Culture: socially anxious may be considered

appropriate in social situations (sign of respect)

• Last for 6 months or more. No longer over age 18.

• The social situations almost always provoke fear

or anxiety
 Social anxiety disorder
• Blushing is a hallmark physical response

• Specifier: Performance only: if the fear is

restricted to speaking or performing in public

• Culture: taijin kyofusho – characterized by social-

evaluative concerns

• Shyness – social reticence – personality trait

 Social anxiety disorder
• An individual who is afraid to speak in public
would not receive a diagnosis of social anxiety
disorder if this activity is not routinely
encountered on the job or in classroom work,
and if the individual is not significantly
distressed about it.
 Selective mutism
Diagnostic Criteria:
A. Is characterized by a consistent failure to speak in social situations in
which there is an expectation to speak even though the individual
speaks in other situations

* Do not initiate speech or reciprocally respond when spoken to by

others
• Onset is usually before age 5

B. Interferes with educational or occupational achievement or with

social communication.

C. At least one month (but not limited to the first month of school)
 Selective mutism
D. The failure to speak is not attributable to a
lack of knowledge of, or comfort with, the
spoken language required in the social situation.

E. The disturbance is not better explained by a

communication disorder and does not occur
exclusively during the course of autism
spectrum disorder, schizophrenia, or another
psychotic disorder
 Selective mutism
• Causes: parental modeling, overprotective, or
controlling

• Culture: immigrated to a country

ANXIETY DISORDERS DSM IV
ANXIETY-is a negative mood state characterized
by bodily symptoms of physical tension and
by apprehension about the future

3 Basic Components of Anxiety

1. Subjective reports
2. Behavioral responses
3. Physiological responses
• Fear
– Immediate, present-oriented
– Sympathetic nervous system activation

• Anxiety
– Apprehensive, future-oriented
– Somatic symptoms = tension
* It no longer function as a signal of danger or a
motivation for needed change but becomes
chronic and permeates major portions of the
person’s life, resulting in maladaptive behavior
and emotional disability.
• Anxiety Disorders do not destroy reality
contact.

> may misinterpret or overreact to certain

stimuli related to their psychological problems
COMORBIDITY – co – occurrence of two or more
disorders in a single individual

p. 128
 ANXIETY DISORDERS:
Generalized Anxiety Disorder
Panic Disorder with and without Agoraphobia
Specific Phobias
Social Phobia
Posttraumatic Stress Disorder
Obsessive-Compulsive Disorder
 PANIC ATTACK
- An abrupt experience of intense fear or acute
discomfort, accompanied by physical
symptoms that usually include heart
palpitations, chest pain, shortness of breath,
and dizziness

- p. 124
THREE KINDS OF PANIC ATTACKS:
A. Unexpected or uncued attacks

B. Situationally bound or cued attacks –

common in specific and social phobias

C. Situationally predisposed panic attacks

 PANIC ATTACK
DIAGNOSTIC CRITERIA:
A discrete period of intense fear or discomfort, in which four (or more) of the
following symptoms developed abruptly and reached a peak within 10 minutes:
1. palpitations, pounding heart, or accelerated heart
2. Sweating
3. Trembling
4. Sensations of shortness of breath or smothering
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, lightheaded, or faint
9. Derealization or depersonalization
10. Fear of losing control or going crazy
11. Fear of dying
12. Paresthesias (numbness or tingling sensations)
13. Chills or hot flushes
I. GENERALIZED ANXIETY DISORDER

- a chronic state of diffuse anxiety

- “free-floating anxiety”
- crisis to crisis

- onset: gradual
- symptoms: hyperarousal of the CNS
Diagnostic Criteria:
a. Excessive anxiety and worry: more days than not for at least 6 months
b. The person finds it difficulty to control the worry
c. The anxiety and worry are associated with three or more of the
following six symptoms
1. restlessness or feeling keyed up or on edge
2. being easily fatigued
3. difficulty concentrating or mind going blank
4. irritability
5. muscle tension
6. sleep disturbance
d. The focus of the anxiety and worry is not confined to features of an Axis
1 Disorder
e. Cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
f. Not due to the direct physiological effects of a substance
 Diagnostic Criteria:
d. The focus of the anxiety and worry is not confined to features of an Axis I
Disorder; that is, the anxiety or worry is not about having a panic attack
(as in panic disorder), being embarrassed in public (as in social phobia),
being contaminated (as in OC disorder)….

e. Cause clinically significant distress or impairment in social, occupational,

or other important areas of functioning.

f. Not due to the direct physiological effects of a substance

 I. GENERALIZED ANXIETY DISORDER
• GAD in Children
– Need only one physical symptom
– Worry = academic, social, athletic performance
• GAD in the Elderly
– Worry about failing health, loss
• Sleep problems
• Falls
• Cognitive impairments
 II. PANIC DISORDER with and without
Agoraphobia

• Clinical Description
– Unexpected panic attacks
– Anxiety, worry, or fear of another attack
– Persists for 1 month or more
– Agoraphobia
• Fear or avoidance of situations/events
 AG0RAPHOBIA
A. Anxiety about being in places or situations
from which escape might be difficult (or
embarrassing) or in which help may not be
available in the event of having an
unexpected or situationally predisposed
Panic Attack or panic-like symptoms
 AGORAPHOBIA
Agoraphobia fears typically involve
characteristics clusters of situations that include:
a. Being outside the home alone
b. Being in a crowd or standing in a line
c. Being on a bridge
d. Traveling in a bus, train, or automobile
 AGORAPHOBIA
B. The situations are avoided (e.g. travel is
restricted) or else are endured with marked
distress or with anxiety about having a Panic
Attack or panic-like symptoms, or require the
presence of a companion.
 AGORAPHOBIA
C. The anxiety or phobic avoidance is not better
accounted for by another mental disorder, such
as Social Phobia, Specific phobia, Separation
Anxiety Disorder and others

*not a codable disorder

– Avoidance can be persistent
– Use and abuse of drugs and alcohol
– Interoceptive avoidance – avoidance of internal
physical sensations
 Panic Disorder with Agoraphobia
Diagnostic Criteria

A. Both 1 and 2
1. Recurrent unexpected panic attacks are
present

2. At least one of the attacks has been followed

by 1 month or more of one or more of the
following:
• a. persisitent concern about having additional
attacks
• b. worry about the implications of the attack
or its consequences (e.g. losing control, having
a heart attack)
• c. a significant change in behavior related to
the attacks
B. The presence of agoraphobia

C. The panic attacks are not due to the direct

physiological effects of a substance or general
medical condition

D. The panic attacks are not better accounted

for by another mental disorder, such as social
phobia
Panic Disorder without Agoraphobia
 III. SPECIFIC PHOBIA
• Clinical Description
– Extreme and irrational fear of a specific object or
situation
– Significant impairment
– Recognizes fears as unreasonable
– Avoidance
 Diagnostic Criteria:
A. Marked and persistent fear that is excessive
or unreasonable, cued by the presence or
anticipation of a specific object or situation.

B. Exposure to the phobic stimulus almost

invariably provokes an immediate anxiety
response, which may take the form of a
situationally bound or situationally
predisposed panic attack.
C. The person recognizes that the fear is
excessive or unreasonable.
D. The phobic situation is avoided or else is
endured with intense anxiety or distress.
E. The avoidance, anxious anticipation, or
distress in the feared situations interferes
significantly with the person’s normal routine,
occupational functioning, or social activities or
relationships.
F. In individuals under age 18, the duration is at
least 6 months.

G. Not better accounted for by another mental

disorder
 III. SPECIFIC PHOBIA
• Blood-Injection-Injury Phobia
– Decreased heart rate and blood pressure
– Fainting
– Inherited vasovagal response
– Onset = ~ 9
 III. SPECIFIC PHOBIA
• Situational Phobia
– Fear of specific situations
• Transportation, small places
– No uncued panic attacks
– Onset = early to mid 20s
 III. SPECIFIC PHOBIA
• Natural Environment Phobia
– Heights, storms, water
– May cluster together
– Associated with real dangers
– Onset = ~7
 III. SPECIFIC PHOBIA
• Animal Phobia
– Dogs, snakes, mice
– May be associated with real dangers
– Onset = ~7
 OTHER PHOBIAS
• Illness

• Choking

• Separation Anxiety Disorder

– School phobia
 IV. SOCIAL PHOBIA
Clinical Description
– Extreme and irrational fear/shyness
– Social/performance situations
– Significant impairment
– Avoidance or distressed endurance
 Diagnostic Criteria
A. A marked and persistent fear of one or more
social or performance situations in which the
person is exposed to unfamiliar people or to
possible scrutiny by others.

B. Exposure to the feared social situation almost

invariably provokes anxiety
C. The person recognizes that the fear is
excessive or unreasonable.

D. The feared social or performance situations

are avoided or are endured with intense anxiety
or distress

E. Interferes significantly with the person’s

normal routine
F. If under age 18, duration is at least 6 months.

G. Not due to the direct physiological effects of a

substance.

Specify: Generalized
 V. POST-TRAUMATIC STRESS DISORDER
- characterized by the re-experiencing of an extremely traumatic
event

- Trauma exposure
– Extreme fear, helplessness, or horror
– Continued re-experiencing
• (e.g., memories, nightmares, flashbacks)
– Avoidance
– Emotional numbing
– Interpersonal problems
– Dysfunction
 V. POST-TRAUMATIC STRESS DISORDER

Most Common Traumas

– Sexual assault
– Accidents
– Combat
Subtypes:
acute ptsd:
chronic ptsd:
delayed onset:
 V. POST-TRAUMATIC STRESS DISORDER

PTSD cannot be diagnosed within the month

ACUTE STRESS DISORDER – occurs within the

first month after the trauma
Diagnostic Criteria: The disturbance lasts for a
minimum of 2 days and a maximum of 4
weeks and occurs within 4 weeks of the
traumatic event
 Diagnostic Criteria
A. The person has been exposed to a traumatic event in which
both of the following were present:
1. The person experienced, witnessed, or was confronted with
an event/s that is involve actual or threatened death or
serious injury or a threat to the physical integrity of self or
others

2. The person’s response involved intense fear, helplessness, or

horror
B. The traumatic event is persistently re-experienced in
one or more of the ff ways:

1. Recurrent and intrusive distressing recollections of

the event
2. Recurrent distressing dreams of the event
3. Acting or feeling as if the traumatic event were
recurring
4. Intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
5. Physiologic activity
• C. Persistent avoidance of stimuli associated with the trauma
and numbing of general responsiveness (not present before
the trauma), as indicated by three or more of the ff:
1. Efforts to avoid thoughts, feelings, or people that arouse
recollections of the trauma
2. Efforts to avoid activities, places, or people that arouse
recollections of the trauma
3. Inability to recall an important aspect of the trauma
4. Markedly diminished interest or participation in significant
activities
5. Feeling of detachment or estrangement from others
6. Restricted range of affect
7. Sense of a foreshortened future
D. Persistent symptoms of increased arousal (not
present before trauma), as indicated by two or more of
the ff:
1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Hypervigilance
5. Exaggerated startle response
E. Duration of disturbance (B,C,D is more than one
month
• F. The disturbance causes significant distress
or impairment in social, occupational or other
important areas of functioning.

• Specify:
Acute
Chronic
Delayed onset
VI. OBSESSIVE-COMPULSIVE DISORDER
- ego dystonic
Clinical Description
– Obsessions
• Intrusive and nonsensical
• Thoughts, images, or urges
• Attempts to resist or eliminate

– Compulsions
• Thoughts or actions
• Suppress obsessions
• Provide relief
 VI. OBSESSIVE-COMPULSIVE DISORDER

Obsession
– Contamination
– Aggressive impulses
– Sexual content
– Somatic concerns
– Need for symmetry

Compulsion:

– Checking
– Ordering
– Arranging
– Washing/cleaning
 Diagnostic Criteria
A. Either obsessions or compulsions
Obsessions are defined by 1,2,3 and 4
1. Recurrent and persistent thoughts, impulses, or images that are
experienced, at some time during the disturbance, as intrusive and
inappropriate and cause marked anxiety or distress
2. The thoughts, impulses, or images are not simply excessive worries about
real-life problems
3. The person attempts to ignore or suppress such thoughts, impulses or
images or to neutralize them with some other thought or action
4. The person recognizes that the obsessional thoughts, impulses or images
are a product of his or her own mind
• Compulsions as defined by 1 and 2:
1. Repetitive behaviors or mental acts that the person 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 distress or preventing some dreaded event or
situation

B. At some point, the person recognized that the

obsessions or compulsions are excessive or
unreasonable
C. Causes marked distress, are time consuming
(more than 1 hour)

D. If another Axis I disorder is present, the

content of the obsessions or compulsions is not
restricted to it

E. Not due to direct effects of a substance

• hoarding
DISSOCIATIVE DISORDERS
-Severe alterations or detachments
-Significant impairments
– Identity
– Memory
– Consciousness

- The disturbance may be sudden or gradual,

transient or chronic.
• During a severe trauma, a person may
dissociate the “observing self” from the
“experiencing self”.

• Observing self- may not experience fear,

horror, or pain.
I. DISSOCIATIVE AMNESIA
-client cannot remember
important personal information
-is often selective
- are less disturbed over their
condition
- events forgotten can often be
recovered under hypnosis
II. DISSOCIATIVE FUGUE
- a person not only forgets all or most of
his or her past but also takes a sudden,
unexpected trip away from home
- are completely amnesic for the events
that occurred during the fugue
- “wake up”
- seek professional help
III. DISSOCIATIVE IDENTITY DISORDER
- also known as Multiple Personality
disorder
-each personalities are well integrated and
well developed
-each personalities take turns
-amnesia is present
Case of “Miss Beauchamp” – 17 personalities
(1901)

Case of Chris Sizemore – “The Three Faces of

Eve” – 22 personalities (1957)

Case of Sybil – 16 personalities (1974)

Forms:

a. Alternating Personality
b. One or more dominant personalities and one
or more subordinate ones
IV. DEPERSONALIZATION DISORDER
- has a persistent or recurrent feeling being
detached from his or her mental processes or
body.
- depersonalization and derealization
- déjà vu and jamais vu
- do not lose their touch with reality
- may also occur in “near-death experience”
DISSOCIATIVE DISORDERS

DSM V
 DISSOCIATIVE DISORDERS
• Characterized by a disruption of and or
discontinuity in the normal integration of
consciousness, memory, identity, emotion,
perception, body representation, motor
control and behavior
 Dissociative disorders
• DISSOCIATIVE IDENTITY DISORDER
• DISSOCIATIVE AMNESIA
• DEPERSONALIZATION/DEREALIZATION
DISORDER
 DISSOCIATIVE AMNESIA
• PLEASE REFER TO PREVIOUS POWERPOINT –
DSM IV

• IN DSM V changes include:

Specify if:
With Dissociative fugue: Apparently purposeful
travel or bewildered wandering that is
associated with amnesia for identity or for
other important autobiographical information
 Dissociative amnesia
• More likely to occur with:
a. A greater number of adverse childhood
experience, particularly physical and /or sexual
abuse

b. Interpersonal violence

c. Increased severity, frequency, and violence of

the trauma
 Depersonalization/derealization disorder
• Persistent of recurrent episodes of depersonalization, derealization or
both

• Depersonalization: e.g. “I have no self”, “I am no one”, “I know I have

feelings but I don’t feel them” , “My thoughts don’t feel like my own”,
feeling robotic
The individual may feel as if he or she were in a fog, dream or bubble or as
if there were a veil or a glass wall between the individual and world
around.

• Derealization: e.g. Accompanied by visual distortions, such blurriness,

macropsia, micropsia, voices or sounds are muted or heightened.

• Without amnesia, reality testing remains intact

 Dissociative identity disorder
• Disruption of identity characterized by two or
more distinct personality states, which may be
described in some cultures as an experience
of possession.

• Recurrent gaps in the recall of everyday

events, important personal information, and
or traumatic events that are inconsistent with
ordinary forgetting
 Dissociative identity disorder
• Causes clinically significant distress or impairment

• The disturbance is not a normal part of a broadly

accepted cultural or religious practice

• Not attributable to the physiological effects of a

substance or another medical condition

• In children, the symptoms are not better explained by

imaginary playmates or other fantasy play
 Dissociative identity disorder
• The dissociative amnesia of individuals with
dissociative identity disorder manifests in three
primary ways:
1. Gaps in remote memory of personal life events
(e.g. Periods of childhood or adolescence; some
important life events such as the death of a
grandparent, getting married, giving birht)
2. Lapses in dependable memory (e.g. What
happened today, of well-learned skills such as
how to do their job, use a computer, read, drive)
 Dissociative identity disorder
3. Discovery of evidence of their everyday
actions and tasks that they do not recollect
doing (e.g. Finding unexplained objects in
their shopping bags or among their
possessions; finding perplexing writings or
drawings that they must have created;
discovering injuries
 Dissociative identity disorder
• Dissociative fugue in DID:
Individual discovers dissociated travels
FACTITIOUS DISORDERS
- Are characterized by physical or
psychological symptoms that are
intentionally produced or feigned in
order to assume the sick role.

- Involves fabrication of subjective

complaints
- Engages in some form of lying

- Deny any suggestion that symptoms are

self-induced or exaggerated and upon
confirmation usually discharge
themselves
- factitious disorder by proxy or Munchausen’s
syndrome by proxy:

> When an individual deliberately makes

someone sick
> possible instance of child abuse and should
be reported to appropriate authorities
 MALINGERING
- Is the intentional production of false or
grossly exaggerated physical or psychological
symptoms solely to gain external incentives.

- lack of cooperation in the evaluation process

and poor compliance with recommended
treatment are common

- Not a mental disorder

SOMATOFORM FACTITIOUS MALINGERING
Motivated by inner, Motivated by Motivated by
psychic gain assumption of the external gain
sick role
Symptoms are Symptoms are Symptoms are
unintentional, fabricated and or intentionally caused
involuntary injury self-inflicted or feigned
May be result of past History vague and
or current, traumatic confusing, often
stressor chronic

Doctor shopping Doctor shopping Poor cooperation in

evaluation and
treatment
Obsessive-compulsive and
related disorders
DSM -V
 Ocd AND RELATED DISORDERS
OBSESSIVE –COMPULSIVE DISORDER
BODY DYSMORPHIC DISORDER
HOARDING DISORDER
TRICHOTILLOMANIA DISORDER
EXCORIATION (skin-picking) DISORDER
 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.
 Obsessive-compulsive disorder
• Compulsions are typically performed in response
to an obsession (e.g. Thoughts of contamination
leading to washing rituals or that something is
incorrect leading to repeating rituals until it feels
“just right”)

• Obsessions and compulsions must be time-

consuming (e.g more than 1 hour per day) of
cause clinically significant distress or impairment
to warrant a diagnosis of OCD
 OBSESSIVE-COMPULSIVE DISORDER
Absent insight/delusional beliefs
The individual is convinced that the house will
burn down if the stove is not checked 30
times.
 OBSESSIVE-COMPULSIVE DISORDER
• Types:

1. Symmetry/exactness/just right
2. Forbidden thoughts or actions
3. Cleaning/Contamination
4. Hoarding
 OBSESSIVE-COMPULSIVE DISORDER
Causes:
 thought-action fusion
 Physical and sexual abuse in childhood
 Environmental factors
 Genetics: greater internalizing symptoms, higher negative
emotionality and behavioral inhibition in childhood

Treatment:
 Exposure and ritual prevention

Culture:
 Body-dysmorphic disorder
• -formerly known as dysmorphophobia

• Characterized by preoccupation with one or more

perceived defects or flaws in their physical
appearance, which they believe look ugly,
unattractive, abnormal, or deformed

• The preoccupations are intrusive, unwanted,

time-consuming (3-8 hours per day) and usually
difficult to resist or control
 Body-dysmorphic disorder
• Performs repetitive behaviors (mirror
checking, excessive grooming, comparing his
or her appearance with that of others

• Causes clinically significant distress or

impairment

• The appearance preoccupation is not better

explained by concerns with body fat or weight
 Body-dysmorphic disorder
• Body Dysmorphic disorder by proxy – a form
of body dysmorphic disorder in which
individuals are preoccupied with defects they
perceive in another person’s appearance
 Body-dysmorphic disorder
• Ideas of reference
• Delusions of reference

- Believe that other people take special notice of

them or mock them because of how they look.

Cause:
 Body-dysmorphic disorder
• Culture:
Shubo-kyofu – phobia of a deformed body
(Japan)

Korea, Burma

Gender: both males and females

Muscle dysmorphia
 hoarding
Diagnostic Criteria:
A. Persistent difficulty discarding or parting with
possessions, regardless of their actual value

B. Difficulty is due to a perceived need to save the items

and to distress associated with discarding them.

C. Difficulty discarding possessions results in the

accumulation of possessions that congest and clutter
active living areas and substantially compromises their
intended use. If living areas are uncluttered, it is only
because of the interventions of third parties.
 hoarding
D. Causes clinically significant distress or impairment
E. The hoarding is not attributable to another medical
condition (brain injury, cerebrovascular disease)
F. The hoarding is not better explained by the symptoms
of another mental disorder.

• Specify if:
With excessive acquisition: If difficulty discarding
possessions is accompanied by excessive acquisition of
items that are not needed or for which there is no
available space.
 hoarding
Specify if:
With good or fair insight: The individual recognizes that
hoarding – related beliefs and behaviors (pertaining to
difficulty discarding items, clutter, or excessive
acquisition) are problematic.

With poor insight: The individual is mostly convinced that

hoarding-related beliefs and behaviors (pertaining to
difficulty discarding items, clutter, or excessive
acquisition) are not problematic despite evidence to
the contrary.
 hoarding
• Specify if:
With absent insight/delusional beliefs: The
individual is completely convinced that
hoarding-related beliefs and behaviors
(pertaining to difficulty discarding items,
clutter, or excessive acquisition) are not
problematic despite evidence to the contrary
 hoarding

With excessive acquisition. Approximately 80%-

90% of individuals with hoarding disorder
excessive acquisition.

The most frequent form of acquisition is

excessive buying, followed by acquisition of
free items (e.g. Leaflets, items discarded by
others)
 hoarding
• Causes: genetics: indecisiveness

• Culture: Asian countries

Trichotillomania (hair-pulling disorder)
Diagnostic criteria:
A. Recurrent pulling out of one’s hair, resulting in hair loss.

B. Repeated attempts to decrease or stop hair pulling.

C. Causes clinically significant distress or impairment

D. The hair pulling or hair loss is not attributable to another

medical condition (e.g. a dermatological condition)

E. The hair pulling is not better explained by the symptoms of

another mental disorder (e.g. attempts to improve a
perceived defect or flaw in appearance in body dysmorphic
disorder)
Trichotillomania (hair-pulling disorder)
• Hair pulling may be accompanied by a range of
behaviors or rituals involving hair
 Particular kind of hair to pull
 Pull out hair in a specific way
 Visually examine or tactilely or orally manipulate
the hair

“itch-like” or tingling sensation

No pain
Trichotillomania (hair-pulling disorder)
• Some individuals may pull hairs from pets,
dolls, and other fibrous materials

• Have one or more other body-focused

repetitive behaviors, including skin picking,
nail biting, and lip chewing
 Excoriation (skin-picking) disorder
Diagnostic Criteria:
1. Recurrent skin picking resulting in skin lesions.
2. Repeated attempts to decrease or stop skin
picking.
3. Causes clinically significant distress or
impairment
4. The skin picking is not attributable to the
physiological effects of a substance
5. The skin picking is not better explained by
symptoms of another mental disorder
 Excoriation (skin-picking) disorder
• The most commonly picked sites are the face, arms, and hands, but
many individuals pick from multiple body sites

• Most individuals pick with their fingernails, although many use

tweezers, pins or other objects.

• Spend significant amounts of time on their picking behavior,

sometimes several hours per day

• Skin picking lead to skin lesions

• Triggered by anxiety or boredom that may lead to gratification and

pleasure
Somatic symptom and related
disorders
DSM - V
 SOMATIC SYMPTOM AND RELATED
DISORDERS
• Share a common feature: the prominence of
somatic symptoms associated with significant
distress and impairment

• Individuals with disorders with prominent

somatic symptoms are commonly encountered in
primary care and other medical settings but are
less commonly encountered in psychiatric and
other mental health settings.
 SOMATIC SYMPTOM AND RELATED
DISORDERS
SOMATIC SYMPTOM DISORDER
ILLNESS ANXIETY DISORDER
CONVERSION DISORDER (FUNCTIONAL
NEUROLOGICAL SYMPTOM DISORDER)
PSYCHOLOGICAL FACTORS AFFECTING OTHER
MEDICAL CONDITIONS
FACTITIOUS DISORDER
 SOMATIC SYMPTOM DISORDER
• Formerly somatization disorder

• Have multiple, current, somatic symptoms that

are distressing or result in significant disruption
of daily life

• Specify if:
With predominant pain (previously pain disorder):
This specifier is for individuals whose somatic
symptoms predominantly involve pain
 Somatic symptom disorder
• Specify if:
Persistent: A persistent course is characterized
by severe symptoms, marked impairment, and
long duration (more than 6 months)
 Somatic symptom disorder
• The individual’s suffering is authentic, whether
or not it is medically explained.
 Illness anxiety disorder
• Formerly Hypochondriasis

• Preoccupation with having or acquiring a serious

illness

• Preoccupation has been present for at least 6

months

• With high level of anxiety

 Illness anxiety disorder
• Individual performs excessive health-related
behaviors (e.g. Repeatedly checks his or her body
for signs of illness) or exhibit maladaptive
avoidance (e.g. Avoids doctor appointments and
hospitals

• Specify whether:
Care – seeking type: Medical care, including
physician visits or undergoing tests and
procedures, is frequently used
Care-avoidant type: medical care is rarely used
Conversion disorder (functional neurological symptom
disorder

• One or more symptoms of altered voluntary

motor or sensory function

• Clinical findings provide evidence of

incompatibility between the symptom and
recognized neurological or medical conditions
 Conversion disorder (functional neurological
symptom disorder
Specify if:
Acute episode: Symptoms present for less than 6
months
Persistent: Symptoms occurring for 6 months or
more

Specify if:
With psychological stressor
Without psychological stressor
 Conversion disorder (functional neurological
symptom disorder
• Conversion disorder is often associated with
dissocative symptoms such as depersonalization,
derealization, and dissociative amnesia

• La belle indifference is not specific for conversion

disorder and should not be used to make the
diagnosis.

• Secondary gain is also not specific to conversion

disorder
 Factitious disorder
1. Factitious Disorder Imposed on Self
2. Factitious Disorder Imposed on Another
(Previously Factitious Disorder by Proxy)
Psychological factors affecting other medical conditions

• The essential feature of psychological factors

affecting other medical conditions is the presence
of one or more clinically significant psychological
or behavioral factors

• Psychological or behavioral factors include

psychological distress, patterns of interpersonal
interaction, coping styles, and maladaptive health
behaviors, such as denial of symptoms or poor
adherence to medical recommendations
SOMATOFORM DISORDERS
Sigmund Freud observed that people with
hysteria improved with hypnosis and
experience relief from their physical
symptoms when they recalled memories and
expressed emotions.
• Feature: presence of physical symptoms that
suggest a general medical condition

• Soma = Body
– Preoccupation with health or appearance
– Physical complaints
– No identifiable medical condition
 Somatoform Disorders
– Hypochondriasis
– Somatization disorder
– Conversion disorder
– Pain disorder
– Body dysmorphic disorder
 HYPOCHONDRIASIS
Clinical Description
– Anxiety or fear of having a disease
– High comorbidity with anxiety/mood disorders
– Focus on bodily symptoms
– At least 6 months
 HYPOCHONDRIASIS
Little benefit from medical reassurance
- tends to engage in “doctor shopping”
- Strong disease conviction
Misperceptions of symptoms
Checking behaviors
High trait anxiety
- Does not reach delusional proportions
 HYPOCHONDRIASIS
• Culture-Specific Syndromes
– China – koro - genitals are retracting into the
abdomen
– India – dhat – losing semen
– Africa – crawling in the head
– Pakistan /Indian – sensation of burning in the
hands and feet
 Hypochondriasis
• Causes
– Disorder of cognition or perception
– Familial history of illness
• Genetics
• Modeling/learning
– Other factors
• Stressful life events
• High family disease incidence
• “Benefits” of illness
 SOMATIZATION DISORDER
• Clinical Description
– Long history of physical complaints
-characterized by multiple physical
symptoms
- before age 30 years old that occur
over a period of several years
– Significant impairment
– Concern about symptoms, not meaning
 SOMATIZATION DISORDER
- combination of:
: 4 pain symptoms
2 gastrointestinal symptoms
1 sexual symptom
1 pseudoneurological symptom
- formerly known as Briquet’s syndrome or
hysteria
- tends to engage in “doctor shopping”
 SOMATIZATION DISORDER
• History of family illness or injury
• Gender roles
 PAIN DISORDER
• Clinical Description
– Pain in one or more areas
– Significant impairment
– Etiology may be physical
– Maintained by psychological factors
 PAIN DISORDER
• An important feature:
Pain is real and it hurts regardless of the causes

If medical treatments for existing physical conditions

are in place and pain remains, or if the pain seems
clearly related to psychological factors, psychological
interventions are appropriate
 CONVERSION DISORDER
• Clinical Description
– Physical malfunctioning
• sensory-motor areas
• common: blindness, deafness, paralysis
– Lack physical or organic pathology
– Lack awareness
– “La belle indifference”
– Intact functioning
 CONVERSION DISORDER
Causes
• Freudian psychodynamic view
– Trauma, conflict experience
– Repression
– “Conversion” to physical symptoms
• Primary gain
– Attention and support
• Secondary gain
 CONVERSION DISORDER
Causes
• Behavioral
– Traumatic event must be escaped
– Avoidance is not an option
– Social acceptability of illness
– Negative reinforcement
 Differential diagnosis
• Malingering

• Factitious Disorder/Munchausen’s
 BODY DYSMORPHIC DISORDER

- preoccupation with an imagined or

exaggerated defect in physical appearance.
 BODY DYSMORPHIC DISORDER
Clinical Description
– Fixation or avoidance of mirrors
– Suicidal ideation and behavior
– Unusual behaviors
• Ideas of reference
• Checking/compensating rituals
 BODY DYSMORPHIC DISORDER
Causes:
• Little scientific knowledge

• Cultural imperatives
– Body size
– Skin color

• Similarities with OCD

– Intrusive thoughts
– Rituals
– Age of onset and course
 BODY DYSMORPHIC DISORDER
• Plastic surgery is often unhelpful