5.2 Anxiety Disorders, OCD, and Phobias

5.2 Anxiety Disorders, OCD, and Phobias

Quick Answer: Anxiety disorders involve excessive, debilitating fear, anxiety, and behavioral disturbances. Generalized Anxiety Disorder requires uncontrollable worry across multiple domains for at least 6 months with somatic tension. Panic Disorder is defined by unexpected panic attacks and at least 1 month of anticipatory worry or avoidance, while Agoraphobia requires fear in at least 2 public or escape-restricted settings. Specific phobias feature disproportionate cue-elicited fear; the Blood-Injection-Injury subtype uniquely produces a biphasic vasovagal response treated with Applied Tension. Obsessive-Compulsive Disorder (OCD) involves intrusive obsessions and neutralizing compulsions, treated with Exposure and Response Prevention (ERP).

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Anxiety Disorders in DSM-5-TR

Fear is the emotional response to real or perceived imminent threat, activating the autonomic "fight-or-flight" surge. Anxiety is the anticipatory state associated with future threat, characterized by muscle tension, vigilance, and cautious or avoidant behaviors. Pathological anxiety is distinguished by being excessive, persistent (typically lasting 6 months or longer), and causing clinically significant impairment.

Generalized Anxiety Disorder (GAD)

Generalized Anxiety Disorder is characterized by excessive anxiety and worry (apprehensive expectation) occurring more days than not for at least 6 months, about a number of events or activities (e.g., work performance, finances, health of family members, minor household matters).

Core Diagnostic Criteria:

1. The individual finds it difficult to control the worry.
2. The anxiety and worry are associated with at least three of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months). Note: Only one item is required in children.
   • Restlessness or feeling keyed up or on edge.
   • Being easily fatigued.
   • Difficulty concentrating or mind going blank.
   • Irritability.
   • Muscle tension (the most distinct somatic marker differentiating GAD from major depression).
   • Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
3. Cognitive Characteristics: Individuals with GAD exhibit high intolerance of uncertainty. Worry functions as a maladaptive cognitive avoidance strategy: by incessantly worrying verbally about potential catastrophes, clients avoid deeper somatic processing of core emotional distress.

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Panic Disorder

Panic Disorder is characterized by recurrent, unexpected panic attacks.

Panic Attack Criteria:

A panic attack is an abrupt surge of intense fear or intense discomfort that peaks within minutes, during which at least four of the following 13 symptoms occur:

1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feelings of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light-headed, or faint
9. Chills or heat sensations
10. Paresthesias (numbness or tingling sensations)
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself)
12. Fear of losing control or "going crazy"
13. Fear of dying

Diagnostic Requirements:

At least one of the attacks must be followed by 1 month (or more) of one or both of the following:

• Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, "going crazy").
• A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar locations).
• Unexpected vs. Expected Attacks: Diagnostic criteria mandate unexpected attacks (occurring out of the blue with no obvious cue). Expected panic attacks (attacks with an obvious trigger, such as seeing a snake) occur across all anxiety disorders.

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Agoraphobia

In DSM-IV, Agoraphobia was coded as a secondary specifier to Panic Disorder. In DSM-5 and DSM-5-TR, Agoraphobia is an independent, separate diagnosis.

Diagnostic Criteria:

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 spaces (e.g., shops, theaters, cinemas).
4. Standing in line or being in a crowd.
5. Being outside of the home alone.

Core Cognitive Mechanism:

The individual fears or avoids these situations because 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).

• The agoraphobic situations almost always provoke fear or anxiety, are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.
• The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

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Social Anxiety Disorder (Social Phobia)

Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others (e.g., social interactions, being observed eating or drinking, performing in front of others).

• Core Fear: The individual fears that they 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 will offend others).
• The social situations almost always provoke fear or anxiety, are actively avoided or endured with intense fear, and persist for 6 months or more.
• Performance Only Specifier: Assigned if the fear is restricted to speaking or performing in public (e.g., public speakers, musicians, athletes).

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Specific Phobia Subtypes and the BII Vasovagal Paradox

Specific Phobia involves marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood), lasting for 6 months or more.

DSM-5-TR Subtypes:

1. Animal: Spiders, insects, dogs, snakes.
2. Natural Environment: Heights, storms, water.
3. Blood-Injection-Injury (BII): Needles, medical procedures, blood draws.
4. Situational: Airplanes, elevators, enclosed spaces.
5. Other: Choking, vomiting, loud sounds.

The Blood-Injection-Injury (BII) Phobia Paradox

Specific phobias typically trigger an acute sympathetic nervous system surge (elevated heart rate, elevated blood pressure, pupil dilation). However, Blood-Injection-Injury (BII) phobia features a unique, biphasic autonomic vasovagal response:

• Phase 1: An initial, brief acceleration of heart rate and elevation of blood pressure.
• Phase 2: A rapid, profound parasympathetic (vagal) rebound, causing severe bradycardia (slowed heart rate), widespread peripheral vasodilation, and systemic hypotension, resulting in vasovagal syncope (fainting).
• Treatment Implication (High-Yield NCE Topic): Standard relaxation techniques (e.g., progressive muscle relaxation, diaphragmatic breathing) lower blood pressure and are therefore contraindicated in BII phobia, as they accelerate fainting. The gold-standard treatment is the Applied Tension Technique (developed by Lars-Göran Öst), where clients repeatedly tense large skeletal muscle groups (arms, chest, legs) to elevate blood pressure and prevent syncope during exposure to medical cues.

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Separation Anxiety Disorder & Selective Mutism

• Separation Anxiety Disorder: Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, evidenced by at least 3 symptoms (distress anticipating separation, worry about harm to attachment figures, reluctance to go out, fear of being alone, reluctance to sleep away, nightmares of separation, physical complaints). Duration must be at least 4 weeks in children and adolescents and typically 6 months or more in adults (can be diagnosed in adulthood).
• Selective Mutism: Consistent failure to speak in specific social situations in which there is an expectation to speak (e.g., at school), despite speaking in other situations (e.g., at home with immediate family). The disturbance interferes with educational or occupational achievement or with social communication. Duration must be at least 1 month (and cannot be limited to the first month of school). Not due to lack of knowledge of spoken language or a communication disorder.

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Anxiety Spectrum Comparison Table

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Obsessive-Compulsive and Related Disorders (OCRDs)

In DSM-5, OCD was removed from the anxiety disorders category and established as the anchor for an independent diagnostic chapter: Obsessive-Compulsive and Related Disorders.

Obsessive-Compulsive Disorder (OCD)

OCD is characterized by the presence of obsessions, compulsions, or both.

Obsessions Defined:

1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

• Common Themes: Contamination (germs, dirt, bodily fluids), pathological doubt/harm (leaving stove on, door unlocked), symmetry/order, aggressive/violent urges, sexual obsessions, religious/blasphemous scrupulosity.

Compulsions Defined:

1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

Diagnostic Criteria:

• The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or functional impairment.
• Insight Specifiers: With good or fair insight (recognizes beliefs are definitely or probably not true); with poor insight (thinks beliefs are probably true); with absent insight / delusional beliefs (completely convinced that beliefs are true).
• Tic-Related Specifier: Assigned if the individual has a current or past history of a tic disorder (comorbidity present in up to 30% of cases).

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Body Dysmorphic Disorder (BDD)

• Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
• At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing appearance with that of others) in response to appearance concerns.
• Specifier: With muscle dysmorphia (preoccupation that body build is too small or insufficiently muscular; occurs almost exclusively in males).
• High clinical severity: High rates of suicidal ideation and attempts. Dermatological or plastic surgery procedures rarely alleviate symptoms and often exacerbate distress.

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Hoarding Disorder

• Persistent difficulty discarding or parting with possessions, regardless of their actual value.
• This difficulty is due to a perceived need to save the items and to the distress associated with discarding them.
• Results in the accumulation of possessions that congest and clutter active living areas and substantially compromise their intended use.
• Specifier: With excessive acquisition (if difficulty discarding is accompanied by excessive buying or gathering of free items).
• Differential Distinction: In OCD, hoarding behaviors are secondary to intrusive obsessions (e.g., fear of harm if an item is thrown away). In Hoarding Disorder, clutter accumulation is driven by emotional attachment to possessions and distress when discarding, without intrusive obsessional themes.

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Evidence-Based Interventions for Anxiety and OCRDs

1. Exposure and Response Prevention (ERP)

Developed by Victor Meyer and refined by Edna Foa, Exposure and Response Prevention (ERP) is the empirical gold standard behavioral treatment for Obsessive-Compulsive Disorder.

• Components:
  • Exposure: Systematic, hierarchical confrontation with feared stimuli, thoughts, or situations that trigger obsessional anxiety (both in vivo exposure and imaginal exposure).
  • Response Prevention: Strict, prolonged refraining from executing the neutralizing compulsive rituals, avoidance behaviors, or reassurance seeking.
• Mechanisms: Historically explained through habituation (reduction in physiological arousal over time). Contemporary cognitive science emphasizes the Inhibitory Learning Model (Michelle Craske): exposure does not erase fear associations; rather, it creates new, competing non-threat associations that inhibit the retrieval of original threat expectations.
• Subjective Units of Distress Scale (SUDS): Clients rate distress from 0 to 100 to guide hierarchical exposure progression.

2. Interoceptive Exposure

Pioneered by David Barlow in Panic Control Treatment (PCT), interoceptive exposure is the primary intervention for Panic Disorder.

• Mechanism: Targets catastrophic misinterpretations of benign physiological sensations ("My heart is racing, so I must be having a heart attack").
• Technique: Clients deliberately induce feared internal bodily sensations in session through exercises:
  • Hyperventilation for 60 seconds (induces dizziness and lightheadedness)
  • Spinning in a swivel chair for 60 seconds (induces vertigo and disorientation)
  • Breathing through a narrow straw for 2 minutes (induces airway resistance and choking sensations)
  • Running in place or stair stepping (induces tachycardia and sweating)
• By repeatedly confronting somatic cues without catastrophic consequences, clients extinguish the conditioned fear of autonomic sensations.

3. Cognitive Restructuring

• Probability Overestimation: Correcting the cognitive error that a catastrophe is virtually guaranteed to occur.
• Catastrophic Thinking: Decatastrophizing by examining the realistic consequences and coping capacities ("If that happens, what would you do to manage it?").
• Thought-Action Fusion (TAF): Common in OCD; the cognitive distortion that thinking an unacceptable thought is morally equivalent to performing the action (Moral TAF), or that thinking about an event increases the objective likelihood of it happening (Likelihood TAF).