Chapter 27: Anxiety, OCD,

Dissociative Disorders
STRESS

Alarm stage: mobilization of bodys defensive forces; activation of potential

for fight or flight
o +1 or +2 anxiety
o Increased level of alertness and anxiety
Resistance stage: optimal adaptation to stress within the persons
capabilities
o +2 to +3 anxiety
o Increased use of coping mechanisms
Exhaustion stage: loss of ability to resist stress because of depletion of
body resources; fight or flight or immobilization occurs
o +3 to +4 anxiety
o Disorganization of thinking and personality
o If exposure continues, stupor or violence may occur

LAZARUS INTERACTIONAL MODEL

Anxiety is the response to threat.

Primary appraisal: the judgment that individuals make about a particular
event
Secondary appraisal: the persons evaluation of the way to respond to an
event
Reappraisal: further appraisal that is made after new info is received

ANXIETY

Subjective experience that can be detected only by objective behaviors;

emotional pain; apprehension, fearfulness, or a sense of powerlessness from
a perceived threat
Most common mental disorder

GENERALIZED ANXIETY DISORDER

Excessive or unreasonable worry or apprehension

Intensity of worry is out of proportion to actual likelihood of the event
Chronic, excessive, or unreasonable worry that may concern everyday events
Decreased concentration and memory problems
Difficulty sleeping, fatigue, and muscle tension
High genetic correlation between GAD and major depression

Increased activity of the amygdala

Usual onset 30 years
More common in women

MANAGEMENT

Calm and quiet environment

Ask patient to identify their
feelings and identify possible
causes

Listen for helplessness or

hopelessness
Ask if they feel suicidal or have
a plan to harm themselves
Involve patients in activities

PSYCHOPHARMACOLOGY

Antidepressants most effective; better than benzodiazepines due to

possibility of dependency and tolerance with long-term use

MILIEU MANAGEMENT

Cognitive therapy
Recreational activities
Relaxation exercises

PANIC DISORDER

Recurrent panic attacks

Worried about having more
attacks
Abrupt surge of intense fear or
discomfort

Peaks within 10 minutes

Unexpected; occur out of the
blue
Situationally bound
Women more prone

MANAGEMENT

Stay with patient and

acknowledge discomfort
Maintain calm style and
demeanor
Speak in short simple sentences
Give one direction at a time
Treat hyperventilation

Allow to cry and pace

Tell patient you are in control
and wont let anything happen
to them
Tell them they are safe
Move or direct them to a quieter
environment
Encourage talking about fears

PSYCHOPHARMACOLOGY

SSRIs and SNRIs used for long term treatment

Benzodiazepines used for immediate effect

AGORAPHOBIA

Fear or anxiety triggered by real

or anticipated exposure to
certain situations
Public transportation

Being
Being
Being
Being

in open spaces
in enclosed spaces
in a crowd
outside of the home alone

SPECIFIC PHOBIAS

Phobias: marked fear or anxiety in the presence of a specific object or

situation
Provokes immediate fear, which is avoided or endured with intense anxiety
Specific phobias typically develop after a traumatic event

SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)

Marked fear or anxiety of being scrutinized in social situations

Fear of being humiliated or embarrassed by a negative evaluation
Afraid they will be judges as weak, stupid, boring, crazy, unlikeable, or
intimidating
Trembling, sweating, or stumbling over their words
Thinking about upcoming events cause anticipatory anxiety and dread

MANAGEMENT

Accept patients with a noncritical attitude

Provide and involve patients in activities that dont increase anxiety
Help patients with physical safety and comfort
Help patients recognize their behavior is a method of avoiding anxiety
Help enhance social interaction and decrease avoidance

PSYCHOPHARMACOLOGY

CBT: most successful treatment for phobias

Systematic desensitization
Exposure therapy
Clonidine and propranolol: taken as needed before social engagements to
ease symptoms of social phobia
SSRIs: used to reduce anxiety and depression if present

OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

Includes OCD, body dysmorphic disorder, hoarding, trichotillomania, and

excoriation

OBSESSIVE-COMPULSIVE DISORDER

Presence of obsessions or compulsions, or both

Obsessions: recurrent and persistent thoughts, ideas, impulses, or images
that are experienced as intrusive and unwanted
Compulsions: the persons attempt to neutralize obsessions with another
thought or action
o Repetitive behaviors or mental acts the person feels driven to perform
to reduce anxiety triggered by the obsession
o Typically not connected realistically to the feared thoughts
Origin: genetic transmission; might run in families
o Increased brain activity in the frontal lobe and basal ganglia
o Serotonin dysregulation may be involved
Obsessions or compulsions can be so severe that they significantly interfere
with the patients normal routine and so time-consuming they interfere with
jobs or social functioning

INTERVENTIONS

Ensure basic needs are met

Provide time to perform rituals
Explain expectations, routines,
and changes
Convey acceptance and
understanding

Assist patient to connect

behavior and feelings
Structure simple achievable
activities
Reinforce non-ritual behaviors
to increase self-esteem and selfworth

PSYCHOPHARMACOLOGY

SSRIs are effective in treating OCD

Usually started with a higher treatment dosage of SSRIs than patients with
depression
Response usually occur at 10-12 weeks

MILIEU MANAGEMENT

Relaxation
Exercises

CBT: thought stopping when an intrusive thought occurs, patient says

stop and snaps a rubber band on the wrist or substitutes an adaptive
behavior for the ritual

Stress management
Recreational skills

BODY DYSMORPHIC DISORDER

Preoccupation with perceived flaws in ones physical appearance that arent

noticeable by others

Leads to the person feeling ugly, abnormal, or deformed

Focuses on outward appearance
Perform repeated behaviors in response (mirror checking; excessive surgery)

HOARDING DISORDER

Persistent difficulties parting with possessions regardless of their actual value

Distress associated with discarding, selling, recycling, or throwing them away
Results in accumulation of possessions
Main motivation: perceived value of the items or strong sentimental
attachment

TRICHOTILLOMANIA

Recurrent pulling out of ones hair, resulting in hair loss in various regions of
the body
Repeated attempts to quit are unsuccessful
Feeling a loss of control, embarrassment, and shame
May attempt to conceal the hair loss

EXCORIATION

Recurrent picking at ones own

skin, resulting in lesions
Commonly on face, arms, and
hands

Pick with fingernails, tweezers,

or pins
Preceded by feelings of anxiety
or boredom and results in relief
or pleasure

TRAUMA AND STRESSOR-RELATED DISORDERS

Disorders that develop after exposure to a clearly identifiable traumatic event

POSTTRAUMATIC STRESS DISORDER

AND ACUTE STRESS DISORDER

Intense emotional reactions after exposure to a traumatic event
Denial, repression, suppression are common in both disorders
Avoidance of situations, activities, or people who might evoke memories of
the trauma
Re-experiencing the traumatic event in some way
Intrusive, unwanted memories
Dreams or nightmares
Illusions; flashbacks
Increased arousal, anxiety, restlessness, irritability, sleep disturbance
ASD: diagnosis is made when a person has dissociative symptoms during or
immediately after the distressing event (3 days to 1 month)
o

Amnesia

Depersonalization

o
o
o
o

Derealization
Decreased awareness of
surroundings
Numbing
Detachment

o
o

Lack of emotional
response
Preexisting psychiatric
disorders at increased
risk

PTSD: symptoms that occur 1 month or more after the trauma

o
o
o
o

Same characteristic
symptoms of ASD
Occasional outbursts of
anger or rage
Survival guilt
Increased risk to attempt
suicide

Preexisting psychiatric
disorders at increased
risk
History of previous
traumas at increased risk

MANAGEMENT

Be nonjudgmental and honest

Offer empathy and support
Assure patient that feelings and behaviors are normal
Help patient see connection between trauma and current feelings
Help evaluate past behaviors in context of trauma to reduce guilt and selfjudgment
Provide safe verbalization of feelings
Encourage adaptive coping strategies
Facilitate progressive review of trauma to reduce re-experiencing it
Encourage patient to establish or reestablish relationships
Recreation and exercise programs can help reduce tension and promote
relaxation

PSYCHOPHARMACOLOGY

SSRIs first line treatment for PTSD

TCAs and MAOIs are second line
Trazodone: helps with insomnia and reduces nightmares
Benzodiazepines: reduce anxiety; risk for dependence
Clonidine and propranolol: diminish response associated with fear,
anxiety, and nightmares
Atypical antipsychotics: used for severe PTSD or with comorbid diagnosis
of psychosis or bipolar

ADJUSTMENT DISORDER

Marked emotional distress resulting from an identifiable stressful life event

Develops within 3 months
Reaction not severe enough to be PTSD

Symptoms out of proportion

Acute reaction interferes with functioning but lasts no longer than 6 months
after the stressor
Major treatment goals: recognize relationship between stressful situation
and current problems
o Review and integrate the feelings and memories of the original
situation

SOMATIC SYMPTOM AND RELATED DISORDERS

Includes somatic symptom disorder, illness anxiety disorder, conversion

disorder, and factitious disorder
Patients have physical symptoms with no known organic cause
Primary gain: the individuals desire to relieve anxiety to feel better and
more secure
Secondary gain: the attention or support the person derives from others
because of illness

SOMATIC SYMPTOM DISORDER

Multiple recurrent, significant somatic symptoms with no evidence of medical

explanation
Patients are not in control of their symptoms
They dont deal with their anxiety but displace the anxiety into bodily
symptoms
Medical interventions rarely alleviate the individuals concern

ILLNESS ANXIETY DISORDER

Excessively preoccupied with having or acquiring a serious undiagnosed

illness
Substantial anxiety over various types of bodily discomfort
Preoccupation with undiagnosed illness results in the person researching the
disease excessively and making it the prominent topic in social interactions

CONVERSION DISORDER

A deficit or alteration in voluntary motor or sensory function that mimics a

neurologic or medical condition
Associated with psychological or physical stress or trauma
Spontaneous attacks of severe physical disability despite lack of medical
evidence
Paralysis, tremors, gait abnormalities, abnormal limb posturing, altered or
absent skin sensation, blindness, inability to hear, non-epileptic seizures
Generalized limb shaking, dysphonia, dysarthria, globus, diplopia

FICTITIOUS DISORDER

Falsification of medical or psychological signs and symptoms in oneself or

others
Impose harm on themselves or others by representing, exaggerating,
fabricating, inducing, simulating, or causes signs or symptoms of illness or
injury
Can lead to excessive medical intervention; adding blood to urine, injecting
insulin, etc.

MANAGEMENT

Use a matter-of-fact approach

Encourage description of
feelings
Assist patient to verbalize
feelings
Offer positive reinforcement
when they focus on topics

unrelated to illness or
symptoms
Be consistent
Teach to distinguish between
actual sensation and those with
no source
Encourage diversional activities
Dont push insight into
problems

DISSOCIATIVE DISORDERS

Disruption in consciousness, memory, identity, emotion, perception, body

representation, motor control, and behavior
Depersonalization, derealization, amnesia, numbing, and flashbacks
In the aftermath of trauma
Dissociation: removal from conscious awareness of painful feelings,
memories, thoughts, or aspects of identify
o An unconscious defense mechanism that protects a person from the
emotion pain of experiences
o Helps them endure and survive intense emotional events
Derealization: feelings of detachment or unfamiliarity with ones
surroundings
o Blurriness, altered distant objects, heightened acuity, or muted sounds

DISSOCIATIVE AMNESIA

Inability to recall important personal information, usually of traumatic nature

Localized: when the person cant remember what occurred during a specific
period of time
Selective: ability to recall only a specific aspect of an event
Generalized: complete loss of memory related to ones life history; very rare

DEPERSONALIZATION/DEREALIZATION DISORDER

Persistent or recurrent episodes of depersonalization or derealization or both

in response to overwhelming stress
Blurriness, altered distant objects, heightened acuity, or muted sounds
Feel as if they are in a fog, dream, or bubble

DISSOCIATIVE IDENTITY DISORDER

Existence of two or more distinct identities or personality states

Recurrent episodes of amnesia
Alternative personalities typically manifest as if another person is taking
control
Alters have distinct attitudes, emotions, and behaviors; each personality is
different; has its own name, behavior traits, memories, emotional
characteristics, social relations
May be aware or unaware of the alters
Can have memory problems, depersonalization, time loss, voices talking to
each other, and somatic symptoms
A defense against extreme anxiety that is aroused in highly painful and
emotionally traumatic events; usually childhood sexual abuse

Dissociative fugue: person reports suddenly found themselves in a location

with no memory how they got there
Often have comorbid disorders: depression, bipolar, PTSD, borderline
personality disorder
Some cultures may call it a possession
Sexual abuse is a strong risk indicator
Best predicted by disorganized attachment and absence of familial and social
support in combo with abuse

MANAGEMENT

Help patient gain control of overwhelming feelings and impulses through brief
verbal interactions
Help patient build on coping strategies that helped in the past
Encourage patient to contact support people who will provide comfort
Teach patient to avoid anxiety situation that provoke the behaviors
Offer meds and other therapeutic strategies to alleviate symptoms