Anxiety Disorders, Part V

(Chapter 5)

March 3, 2014

PSYC 2340: Abnormal Psychology

Brett Deacon, Ph.D.

From Last Class

• Specific phobias

• Social phobia

• OCD

• Obsessions

Exam Review• Disorders Covered

• Nature of emotions of anxiety and panic

• Panic disorder and agoraphobia

• Specific Phobia

• Social Phobia

• Obsessive-Compulsive Disorder

• Generalized Anxiety Disorder

• Post-Traumatic Stress Disorder

• Hypochondriasis

• Body Dysmorphic Disorder

Exam Review

• For each disorder….

• Symptoms/diagnostic criteria

• Associated features: basic demographics, feared stimuli, maladaptive beliefs and behaviors, contributing factors

• Nature and effectiveness of treatment options

Compulsions

• Compulsions – thoughts or actions used to neutralize obsessions and reduce anxiety

• Compulsions reduce anxiety and/or prevent feared catastrophes

Compulsions

• Not compulsions• Any action that is not performed to neutralize

obsessions and/or reduce anxiety• E.g., “compulsive” gambling, shopping, etc.

Compulsions

• Common types of compulsions• Checking• Cleaning/washing• Ordering/arranging• Mental rituals• Repeating• Counting• Hoarding

Compulsions

• Not compulsions• Actions that do not reduce anxiety caused by

an obsession• “Compulsive” shopping, eating, drinking,

gambling, watching porn, etc.• Compulsive cleanliness, orderliness;

perfectionistic studying

Common Manifestations of OCD

• Obsessions and compulsions often go together according to a central theme• Harming• Contamination• Hoarding• Unacceptable thoughts• Symmetry

Obsessive-Compulsive Disorder

• DSM-IV criteria:

• Either obsessions or compulsions

• Obsessions:• Recurrent obsessions• Obsessions are not just excessive worries• Attempts to ignore, suppress, or neutralize

obsessions• Recognizes obsessions are product of own

mind (i.e., person is not psychotic)

Obsessive-Compulsive Disorder

• Compulsions:• Repetitive compulsions done in response to

obsessions or according to rigid rules• Compulsions are misguided attempts to

reduce distress or prevent feared catastrophe

• Recognize that symptoms are excessive or unreasonable

• Causes distress, interference, or time consuming

Obsessive-Compulsive Disorder

• Facts and statistics• 2.6% lifetime prevalence• 55%-60% women• Age of onset = early adolescence to mid-20s• Chronic course without treatment

Maladaptive Beliefs in OCD

• Thought-action fusion: thought = action• Likelihood• Morality

• Does the act of thinking about something happening make it more likely to happen?• Harm befalling others?• Acts of violence toward self or others?

• Does the act of thinking about something immoral mean that you are immoral?

Maladaptive Beliefs in OCD

• Inflated sense of responsibility for preventing harm to others• Even when the possibility of harm is remote• Even when your actions have no logical

connection with reducing the possibility that others will be harmed

• Case example: fear of hitting pedestrian with car

“Backing out of a parking space I wonder if I might run over

anything or anyone without seeing it or them. So, as I drive away I

need to look back at the area to make sure no one is lying on the

ground injured. Then I feel stupid because I would hate to get into

an accident because I was driving forward but looking backward.

If I drive through a crosswalk and delay a pedestrian from entering

the crosswalk, I feel responsible for that person until they make it

to the other side of the street. Consequently, I keep checking the

crosswalk in my rearview mirror as I drive away to make sure the

person makes it to the other side.”

A Case Example

Treating OCD

• Medications

• Clomipramine (older antidepressant) and other SSRIs – benefit about 60%

• Psychosurgery (cingulotomy) – used in extreme cases

• Relapse is common with medication discontinuation

• Symptom reduction is less than with CBT

Treating OCD

• Psychological treatment

• Exposure-based cognitive-behavioral therapy is the most effective treatment for OCD

• Involves exposure and response prevention (elimination of safety behaviors)

• Adding medication not more effective than CBT alone

Treating OCD: Exposure Therapy vs. Antidepressant Medication

Foa et al., 2005

Hypochondriasis and Body

Dysmorphic Disorder

(Chapter 6, these disorders ONLY)

NOTE: Special thanks to Steve Taylor, Ph.D.,

for permission to use his slides in this lecture.

“Every morning in the bathroom I check my body for unusual moles and lesions. Today I found a bump on my skin that I hadn’t noticed before. I couldn’t stop worrying that it might be cancer. As I prodded and squeezed the bump to check it out, it got bigger, redder, and angrier. That really frightened me, to the point that I had to snip it off with nail clippers.”

-Patient with Hypochondriasis

The Experience of Hypochondriasis

Diagnostic criteria for Hypochondriasis (HC)

• A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms

• Examples• Headache = brain tumor• stomach pain = liver disease

• B. The preoccupation persists despite appropriate medical evaluation and reassurance

• Viewed by some as “health anxiety”

Bodily Sensations/Symptoms Feared by those with Hypochondriasis

• Physical symptoms that do not seem to have an organic basis (vague and ambiguous)• Musculoskeletal and stomach pain• GI symptoms (vomiting/rumination syndrome)• Ear, nose, and throat symptoms• Fatigue• Dizziness and vertigo• Any sensation associated with the anxiety/fight-or-

flight response• Are these symptoms real, or “all in one’s head?”

Meaning Links “Symptoms” with Health Anxiety

• Headaches = brain tumors

• Scratchy or painful throat = throat cancer

• Tingling or cold extremities = neurological disease such as Lou Gehrig’s Disease (ALS)

• Dizziness = brain disease or inner ear (vestibular) illness

• Occasional forgetfulness = Alzheimer’s or Pick’s disease

• Constipation or diarrhea = Crohn’s disease

• Rash = Lyme disease

Prevalence of HC

• 5% lifetime prevalence

• 50%-50% gender distribution

• Between 30% and 80% of patients who consult physicians present with symptoms for which there is no physical basis

Common Beliefs in Health Anxiety

• “Good health is associated with few or no symptoms” (bodily sensations or changes)

• “Serious diseases are lurking everywhere”

• “It is possible to be absolutely certain about one’s health”

• “Doctors should be able to explain all of my symptoms”

• “If a doctor refers me for a test, it means that she/he thinks there’s something wrong”

• “Medical exams aren’t accurate if you don’t have symptoms at the time of the tests”

• “Medical evaluations are unreliable if you don’t give your doctor a complete and detailed description of your symptoms”

• “If the doctor simply listens to you and says ‘Your health is fine’ then the assessment can’t be trusted; a reliable evaluation requires a detailed interview and lab tests”

Environmental Factors

• Media reports of health risks increase

perceived threat

• H1N1

• Other examples from recent years?

Safety Behaviors in Hypochondriasis

• Reassurance seeking

• Doctor shopping

• Body checking

• Avoidance (sources of disease, doctors/tests with potential to yield “bad news”)

• Checking medical texts and the internet (“cyberchondria”)

Treatment of Hypochondriasis

• Medications (SSRIs)

• Cognitive-behavioral therapy• Education• Modifying mistaken beliefs• Exposure• Response prevention (eliminating safety

behaviors)

Andrea’s Fear Hierarchy

Exposure Situation Estimated SUDS

1. Thinking about having a deadly disease 95

2. Reading articles/watching TV about deadly diseases 90

3. Touching objects in public restrooms 85

4. Riding crowded elevators with medical patients 75

5. Touching objects in emergency room waiting area 70

6. Smoking a cigarette 60

7. Handling pets 55

8. Running 50

9. Hyperventilation 50

Andrea’s Safety Behavior List

• Avoidance: hospital waiting rooms, news/TV shows, reading paper, going outside, mall, movie theaters, exercise, elevators

• Body monitoring and checking: freckles, lumps, heart rate

• Reassurance seeking: unnecessary doctor visits, seeking reassurance from husband and mother

• Medical information: reading websites and medical books

• Washing/cleaning: excessive handwashing and sanitizing

• Safety aids: carrying antibacterial hand sanitizer

Andrea’s Safety Behavior Rules

• Body checking: none allowed

• Seeking medical information: none allowed

• Reassurance seeking: none allowed

• Doctor visits: none for previously evaluated symptoms, discuss handling new symptoms with therapist

• Cleaning/washing: no hand sanitizer, one 10-minute shower per day, hand washing only before meals, after using bathroom, and when visibly dirty

Body Dysmorphic Disorder

• Defining features• Excessive preoccupation with imagined

defect in appearance (“imagined ugliness”)• Lots of body checking• Most remain single, and many seek out

plastic surgeons

• Statistics• Little is known about prevalence• Gender distribution about equal

Body Dysmorphic Disorder

• Location of imagined defects• 1. Hair 2. Nose

• 3. Skin 4. Eyes

• 5. Head/face 6. overall build

• 7. Lips 8. Chin

• 9. Stomach/waist 10. Teeth

Body Dysmorphic Disorder

Causes and Treatment of BDD

• Causes• Little is known• Shares similarities with OCD• Social or cultural factors to look a certain

way

Causes and Treatment of BDD

• Treatment• Parallels that for OCD (exposure and

response prevention) and social phobia • Medications (i.e., SSRIs) provide some relief• Plastic surgery is often unhelpful