Unit 2

Anxiety Based Disorders

Anxiety based disorders:

Panic Disorder,

Phobia,

Generalized Anxiety disorder,

Obsessive-Compulsive disorder,

Post Traumatic Stress Disorder.

Anxiety Based Disorder: Anxiety involves a general feeling of apprehension about possible
future danger, and fear is an alarm reaction that occurs in response to immediate danger.
Individuals may experience anxiety in many different forms. Generalized anxiety disorder,
the most common of the anxiety disorders, is characterized by a global and persistent feeling
of anxiety. A specific phobia is observed when an individual experiences anxiety related to a
specific object or subject. Similarly, an individual may experience agoraphobia when they
feel fear specific to leaving their home and traveling to public places. Social anxiety disorder
occurs when an individual experiences anxiety related to social or performance situations,
where there is the possibility of being evaluated negatively. And finally, there is panic
disorder, where an individual experiences recurrent panic attacks consisting of physical and
cognitive symptoms.

Panic Disorder

panic disorder, the individual experiences recurrent unexpected panic attacks and is
persistently concerned or worried about having more panic attacks or changes his or
her behavior in maladaptive ways because of the panic attacks (e.g., avoidance of
exercise or of unfamiliar locations). Panic attacks are abrupt surges of intense fear or
intense discomfort that reach a peak within minutes, accompanied by physical and/or
cognitive symptoms. Panic attacks may be expected, such as in response to a typically
feared object or situation, or unexpected, meaning that the panic attack occurs for no
apparent reason.
Comorbidity

The prevalence of panic disorder is elevated in individuals with other disorders,

particularly other anxiety disorders (and especially agoraphobia), major depressive
disorder, bipolar I and bipolar II disorder, and possibly mild alcohol use disorder. A
subset of individuals with panic disorder develop a substance-related disorder, which
for some represents an attempt to treat their anxiety with alcohol or medications.
Comorbidity with other anxiety disorders and illness anxiety disorder is also common.
Panic disorder is significantly comorbid with numerous general medical symptoms
and conditions, including, but not limited to, dizziness, cardiac arrhythmias,
hyperthyroidism, asthma, COPD, and irritable bowel syndrome. Although mitral valve
prolapse and thyroid disease are more common among individuals with panic disorder
than in the general population, the increases in prevalence are not consistent.

Causes

Biological – Neurobiological structures

One relatively early prominent theory about the neurobiology of panic attacks
implicated the locus coeruleus in the brain stem (see below figure) and a particular
neurotransmitter—norepinephrine—that is centrally involved in brain activity in this
area. However, today it is recognized that it is increased activity in the amygdala that
plays a more central role in panic attacks than does activity in the locus coeruleus.
First, the amygdala triggers the hypothalamic-pituitary-adrenal (HPA) axis to prepare
for immediate action— either to fight or flight. The second pathway is activated by
the feared stimulus itself, by sending a sensory signal to the hippocampus and
prefrontal cortex, for determination if threat is real or imagined. If it is determined that
no threat is present, the amygdala sends a calming response to the HPA axis, thus
reducing the level of fear.

Biochemical Abnormalities

At present, two primary neurotransmitter systems are most implicated in panic attacks
—the noradrenergic and the serotonergic systems. Noradrenergic activity in certain
brain areas can stimulate cardiovascular symptoms associated with panic. Increased
serotonergic activity also decreases noradrenergic activity. This fits with results
showing that the medications most widely used to treat panic disorder today (the
selective serotonin reuptake inhibitors—SSRIs) seem to increase serotonergic activity
in the brain but also to decrease noradrenergic activity. By decreasing noradrenergic
activity, these medications decrease many of the cardiovascular symptoms associated
with panic that are ordinarily stimulated by noradrenergic activity. The inhibitory
neurotransmitter GABA has also been implicated in the anticipatory anxiety that many
people with panic disorder have about experiencing another attack.

Psychological causal factors

Comprehensive Learning Theory of Panic Disorder

The Comprehensive Learning Theory of Panic Disorder suggests that panic attacks
and the subsequent development of panic disorder are influenced by both classical and
operant conditioning processes. Traumatic experiences or false alarms can lead to the
association of bodily sensations with fear, resulting in the development and
maintenance of panic disorder symptoms.

Panic Circle

The Panic Circle refers to a self-perpetuating cycle in panic disorder. It involves the
interplay between bodily sensations, catastrophic interpretations of those sensations,
and subsequent anxiety. Physical sensations trigger fear, which leads to further
physical symptoms and heightened anxiety, reinforcing the cycle of panic and anxiety.
Learning and Cognitive Explanations of Results from Panic Provocation Studies:

These studies often involve exposing individuals to stimuli or situations that elicit
panic-like symptoms. From a learning perspective, the findings suggest that
individuals with panic disorder may have learned to associate certain cues or bodily
sensations with fear and danger, leading to heightened sensitivity and exaggerated
responses. On the other hand, cognitive explanations emphasize the role of
catastrophic interpretations and negative beliefs about bodily sensations.

Safety Behaviors and the Persistence of Panic:

These are actions or strategies that individuals engage in to cope with or avoid the
feared outcomes of a panic attack. While they may provide temporary relief and a
sense of control, safety behaviors actually contribute to the maintenance of panic. By
relying on these behaviors, individuals prevent themselves from fully experiencing
and learning that the feared outcomes are unlikely or manageable. Consequently,
safety behaviors reinforce the belief that the feared situations are dangerous,
perpetuating the cycle of anxiety and panic. Addressing and reducing safety behaviors
is a key component of effective treatments for panic disorder.

Treatment
Medications

Many people with panic disorder (with or without agoraphobia) are prescribed
anxiolytics (antianxiety 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 minutes) and so can be useful in acute situations of
intense panic or anxiety. However, these anxiolytic medications can also have quite
undesirable side effects such as drowsiness and sedation, which can lead to impaired
cognitive and motor performance. The other category of medication that is useful in
the treatment of panic disorder and agoraphobia is the antidepressants (including
primarily the tricyclics, the SSRIs, and most recently the serotonin-norepinephrine
reuptake inhibitors—SNRIs). One major advantage is that they do not create
physiological dependence in the way benzodiazepines can, and they also can alleviate
any comorbid depressive symptoms or disorders.

Cognitive Behavioural therapy

CBT is the most effective treatment option for individuals with panic disorder as the
focus is on correcting misinterpretations of bodily sensations. Nearly 80 percent of
people with panic disorder report complete remission of symptoms after mastering the
following five components of CBT for panic disorder

Psychoeducation. Treatment begins by educating the patient on the nature of panic

disorder, the underlying causes of panic disorder, as well as the mechanisms that
maintain the disorder such as the physical, cognitive, and behavioral response
systems. This part of treatment is fundamental in correcting any myths or
misconceptions about panic symptoms, as they often contribute to the exacerbation of
panic symptoms.

Self-monitoring. Self-monitoring, or the awareness of self-observation, is essential to

the CBT treatment process for panic disorder. In this part of treatment, the individual
is taught to identify the physiological cues immediately leading up to and during a
panic attack. Then, the patient is encouraged to recognize and document the thoughts
and behaviors associated with these physiological symptoms. By bringing awareness
to the symptoms, as well as the relationship between physical arousal and cognitive-
behavioral responses, the patient learns the fundamental processes with which they
can manage their panic symptoms.

Relaxation training. Similar to that in exposure-based treatment for phobias, prior to

engaging in exposure training, the individual must learn relaxation techniques to apply
during onset of panic attacks. While breathing training was once included as the
relaxation training technique of choice for panic disorder due to the high report of
hyperventilation during panic attacks, more recent research has failed to support this
technique as effective in the use of panic disorder.

Progressive muscle relaxation. To replace the breathing retraining, with progressive

muscle relaxation (PMR). In PMR, the patient learns to tense and relax various large
muscle groups throughout the body. Generally speaking, the patient is encouraged to
start at either the head or the feet, and gradually work their way through the entire
body, holding the tension for roughly 10 seconds before relaxing. The theory behind
PMR is that in tensing the muscles for a prolonged period, the individual exhausts
those muscles, forcing them (and eventually) the entire body to engage in relaxation.

Cognitive restructuring. Cognitive restructuring, or the ability to recognize cognitive

errors and replace them with alternate, more appropriate thoughts, is likely the most
powerful part of CBT treatment for panic disorder, aside from the exposure part. The
clinician encourages the patient to view these thoughts as “hypotheses” as opposed to
fact, which allows the beliefs to be questioned and challenged. This is where the
detailed recordings in the self-monitoring section of treatment are helpful.

Exposure. Exposure techniques such as in vivo exposure and interoceptive exposure,

while also incorporating the cognitive restructuring and relaxation techniques
previously learned to reduce and eliminate ongoing distress. Interoceptive exposure
involves inducing panic-specific symptoms to the individual repeatedly for a
prolonged period, so that maladaptive thoughts about the sensations can be
disconfirmed and conditional anxiety responses are extinguished. In vivo exposure is a
therapeutic technique that involves gradually and systematically facing feared
situations or stimuli in real-life settings, helping individuals reduce anxiety and
overcome avoidance behaviors.

Specific Phobia

Specific phobia is distinguished by fear or anxiety specific to an object or a situation.

While the amount of fear or anxiety related to the specific object or situation varies
among individuals, it also varies related to the proximity of the object/situation. When
individuals are face-to-face with their specific phobia, immediate fear is present. It
should also be noted that these fears are excessive and irrational, often severely
impacting one’s daily functioning
Psychological Causal Factors

Psychoanalytic view point

From a psychoanalytic viewpoint, specific phobias are seen as a manifestation of

unresolved unconscious conflicts and repressed desires. Freudian psychoanalysis
suggests that specific phobias may be symbolic representations of deeper, hidden fears
and anxieties. Psychoanalytic therapy aims to explore and resolve these unconscious
conflicts through techniques such as free association and interpretation, bringing
awareness to the repressed content and facilitating the integration of unconscious
material into conscious awareness to alleviate the symptoms of specific phobias.
Phobias as Learned Behavior

Phobias can be understood from a behavioral perspective as learned behaviors.

According to classical conditioning, phobias develop through the association of a
neutral stimulus with a traumatic or fear-inducing event. Operant conditioning also
plays a role, as individuals learn to avoid or escape the feared stimulus to alleviate
anxiety. Vicarious learning, where phobias are acquired through observing others' fear
responses, can also contribute to the development of phobias. Behavioral therapies,
such as exposure therapy, focus on unlearning these fear responses through systematic
desensitization and gradual exposure to the feared stimuli to promote new learning
and reduce phobic reactions.

Individual differences in learning

Individual differences in learning play a significant role in the development and

maintenance of phobias. Some individuals may be more prone to developing phobias
due to their genetic predispositions, temperament, or specific cognitive processing
styles. Additionally, differences in learning experiences and environmental factors,
such as exposure to traumatic events or vicarious learning, can contribute to the
formation of specific phobias. Understanding these individual differences can help
tailor treatment approaches, considering factors such as cognitive processing styles
and learning histories, to effectively address and alleviate phobic symptoms.

Evolutionary preparedness in learning certain fears and phobia

Evolutionary preparedness suggests humans are predisposed to acquire fears of

survival threats, like snakes or heights, due to our evolutionary history. This inherent
readiness reflects a biological basis for certain phobias shaped by our ancestral
experiences.

Biological causal factors

Behavior genetic studies suggest a genetic contribution to specific phobias, with

identical twins more likely to share phobias compared to nonidentical twins.
Nonshared environmental factors also play a significant role, supporting the idea that
phobias are learned behaviors. Heritability varies between animal phobias and
complex phobias like social phobia and agoraphobia.

Treatment

Exposure treatments. Seeing as the behavioral theory suggests phobias develop via
classical conditioning, the treatment approach revolves around breaking the
maladaptive association between the object and fear. This is generally accomplished
through exposure treatments. As the name implies, the individual is exposed to their
feared stimuli. This can be done in several different approaches: systematic
desensitization, flooding, and modeling.

Systematic desensitization is a therapeutic technique used to treat phobias and anxiety

disorders. It involves gradually exposing individuals to feared stimuli or situations
while teaching relaxation techniques. This process helps individuals reduce their
anxiety response and develop new, adaptive associations with previously feared
stimuli, leading to symptom relief.

Flooding is another exposure technique in which the clinician does not utilize a fear
hierarchy, but rather repeatedly exposes the individual to their most feared object or
situation. Similar to systematic desensitization, flooding can be done in either in vivo
or imaginal exposure. Clearly, this technique is more intensive than systematic or
gradual exposure to feared objects. Because of this, patients are at a greater likelihood
of dropping out of treatment, thus not successfully overcoming their phobias.

Modeling is another common technique used to treat phobia disorders. In this

technique, the clinician approaches the feared object/subject while the patient
observes. As the name implies, the clinician models appropriate behaviors when
exposed to the feared stimulus, showing that the phobia is irrational. After modeling
several times, the clinician encourages the patient to confront the feared stimulus with
the clinician, and then ultimately, without the clinician.

Agrophobia
Agoraphobia is defined as an intense fear triggered by a wide range of situations;
however, unlike GAD, the fears are related to situations in which the individual is in
public situations where escape may be difficult. In order to receive a diagnosis of
agoraphobia, there must be a presence of fear in at least two of the following
circumstances: using public transportation such as planes, trains, ships, buses; being in
large, open spaces such as parking lots or on bridges; being in enclosed spaces like
stores or movie theaters; being in a large crowd similar to those at a concert; or being
outside of the home in general
Comorbidity

Similar to the other anxiety disorders, comorbid diagnoses include additional anxiety
disorders, depressive disorders, and substance use disorders, all of which typically
occurs after the onset of agoraphobia. Also, there is high comorbidity between
agoraphobia and PTSD. While agoraphobia can be a symptom of PTSD, an additional
diagnosis of agoraphobia is made when all symptoms of agoraphobia are met in
addition to the PTSD symptoms.

Treatment

Similar to the treatment approaches for specific phobias, exposure-based techniques

are among the most effective treatment options for individuals with agoraphobia.
However, unlike the high success rate in specific phobias, exposure treatment for
agoraphobia has been less effective in providing complete relief of the disorder. The
success rate may be impacted by the high comorbidity rate of agoraphobia and panic
disorder. Because of the additional presentation of panic symptoms, exposure
treatments alone are not the most effective in eliminating symptoms as residual panic
symptoms often remain.

Therefore, the best treatment approach for those with agoraphobia and panic disorder
is a combination of exposure and CBT techniques. For individuals with agoraphobia
without panic symptoms, the use of group therapy in combination with individual
exposure therapy has been identified as a successful treatment option. The group
therapy format allows the individual to engage in exposure-based field trips to various
community locations, while also maintaining a sense of support and security from a
group of individuals whom they know.

Social Phobia/ Social Anxiety Disorder

social anxiety disorder, the anxiety or fear relates to social situations, particularly
those in which an individual can be evaluated by others. More specifically, the
individual is worried that they will be judged negatively and viewed as stupid,
anxious, crazy, boring, or unlikeable, to name a few. Some individuals report feeling
concerned that their anxiety symptoms will be obvious to others via blushing,
stuttering, sweating, rembling, etc. These fears severely limit an individual’s behavior
in social settings.
Psychological Causes

Social Phobia as a Learned Behaviour: Social phobias can be understood as learned

behaviors. They often develop through the process of social conditioning, where
individuals associate social situations with fear and negative experiences. Avoidance
and safety behaviors reinforce the phobia, perpetuating the cycle of anxiety and
avoidance in social interactions.

Social Fears and Phobias in an Evolutionary Context : Social fears and phobias in an
evolutionary context can be seen as a result of our ancestral need for social belonging
and acceptance. Fears of social rejection or humiliation may have served as adaptive
mechanisms to ensure survival within social groups, leading to the development of
social anxiety and phobias in modern society.

Perceptions of Uncontrollability and Unpredictability: Perceptions of uncontrollability

and unpredictability play a significant role in the development and maintenance of
social phobia. The belief that one has little control over social situations and the
anticipation of unpredictable outcomes can heighten anxiety and contribute to
avoidance behaviors, reinforcing the phobia.

Cognitive Biases: Cognitive biases, such as attentional bias and interpretation bias, are
prevalent in social phobia. Individuals with social phobia tend to selectively focus on
and interpret social stimuli in a negative and self-threatening manner, perpetuating
feelings of anxiety and contributing to the maintenance of the disorder.

Treatment

Exposure. A hallmark treatment approach for all anxiety disorders is exposure.

Specific to social anxiety disorder, the individual is encouraged to engage in social
situations where they are likely to experience increased anxiety.

Social skills training. This treatment is specific to social anxiety disorder as it

focuses on the patient’s skill deficits or inadequate social interactions that contribute
to their negative social experiences and anxiety. During a session, the clinician may
use a combination of skills such as modeling, corrective feedback, and positive
reinforcement to provide feedback and encouragement to the patient regarding their
behavioral interactions.

Cognitive restructuring. While exposure and social skills training are suitable
treatment options, research routinely supports the need to incorporate cognitive
restructuring as an additive component in treatment to provide substantial symptom
reduction.

Generalised Anxiety Disorder

Generalized anxiety disorder, commonly referred to as GAD, is a disorder

characterized by an underlying excessive worry related to a wide range of events or
activities. While many individuals experience some levels of worry throughout the
day, individuals with GAD experience worry of greater intensity and for longer
periods than the average person. Additionally, they are often unable to control their
worry through various coping strategies, which directly interferes with their ability to
engage in daily social and occupational tasks. Individuals with GAD will also
experience somatic symptoms during intensive periods of anxiety. These somatic
symptoms may include sweating, dizziness, shortness of breath, insomnia,
restlessness, or muscle aches.

Psychological Causal Factors

The Psychoanalytic Viewpoint: The psychoanalytic viewpoint suggests that
Generalized Anxiety Disorder (GAD) stems from unconscious conflicts and
unresolved issues related to early childhood experiences. Anxiety is seen as a
manifestation of repressed desires and unresolved conflicts, and therapy aims to
uncover and resolve these underlying conflicts to alleviate symptoms of GAD.

Perceptions of Uncontrollability and Unpredictability: Perceptions of uncontrollability

and unpredictability are central in Generalized Anxiety Disorder (GAD). Individuals
with GAD tend to perceive events and situations as beyond their control and
unpredictable, leading to persistent worry and anxiety. This cognitive bias reinforces
the sense of threat and contributes to the maintenance of GAD symptoms.

Biological causal Factors

Genetic Factors: The evidence is increasingly strong that GAD and major depressive
disorder have a common underlying genetic. What determines whether individuals
with a genetic risk for GAD and/or major depression develop one or the other disorder
seems to depend entirely on the specific environmental experiences they have
(nonshared environment). At least part of this common genetic predisposition for
GAD and major depression is best conceptualized as the basic personality trait
commonly known as neuroticism

Neurotransmitter and Neurohormonal Abnormalities

A Functional Deficiency in GABA: It appears that highly anxious people have a kind
of functional deficiency in GABA, which ordinarily plays an important role in the way
our brain inhibits anxiety in stressful situations. The benzodiazepine drugs appear to
reduce anxiety by increasing GABA activity in certain parts of the brain implicated in
anxiety, such as the limbic system, and by suppressing the stress hormone cortisol.

The Corticotropin-Releasing Hormone System and Anxiety: An anxiety-producing

hormone called corticotropin releasing hormone (CRH) has also been strongly
implicated as playing an important role in generalized anxiety (and depression). When
activated by stress or perceived threat, CRH stimulates the release of ACTH
(adrenocorticotropic hormone) from the pituitary gland, which in turn causes release
of the stress hormone cortisol from the adrenal gland cortisol helps the body deal with
stress. The CRH hormone may play an important role in generalized anxiety through
its effects on the bed nucleus of the stria terminalis (an extension of the amygdala),
which is now believed to be an important brain area mediating generalized.

Treatment

Psychopharmacology. selective serotonin-reuptake inhibitors (SSRIs) and serotonin-

norepinephrine reuptake inhibitors (SNRIs) are generally considered to be first-line
medication options for those with GAD.

Rational-Emotive therapy. Albert Ellis developed rational emotive therapy in the mid-
1950s as one of the first forms of cognitive-behavioral therapy. Ellis proposed that
individuals were not aware of the effect their negative thoughts had on their behaviors
and various relationships, and thus, established a treatment to address these thoughts
and provide relief to those suffering from anxiety and depression. The goal of rational
emotive therapy is to identify irrational, self-defeating assumptions, challenge the
rationality of those assumptions, and to replace them with new, more productive
thoughts and feelings. By identifying and replacing these assumptions, one will
experience relief of GAD symptoms

Cognitive Behavioral Therapy (CBT). CBT is discussed in great detail in the Mood
Disorder Module; however, it is also among the most effective treatment options for a
variety of anxiety disorders, including GAD. The fundamental goal of CBT is a
combination of cognitive and behavioral strategies aimed to identify and restructure
maladaptive thoughts while also providing opportunities to utilize these more effective
thought patterns through exposure-based experiences.

Biofeedback. Biofeedback is a technique that provides real-time feedback on a

patient's physiological arousal. It involves connecting the patient to a computer that
continuously monitors and displays information about their physiological states.
Common methods of biofeedback include electromyography (EMG) to measure
muscle activity, electroencephalography (EEG) to measure brain activity, heart rate
variability (HRV) to measure heart rate and blood pressure, and galvanic skin
response (GSR) to measure sweat. These measurements help patients gain awareness
and control over their bodily responses, aiding in the management of various
conditions, including anxiety and stress-related disorders.

OCD

Obsessive-compulsive disorder, more commonly known as OCD, requires the

presence of both obsessions and compulsions. Obsessions are defined as repetitive and
persistent thoughts, urges, or images. These obsessions are intrusive, time-consuming,
and unwanted, often causing significant distress in an individual’s daily functioning.
Common obsessions are contamination (dirt on self or objects), errors of uncertainty
regarding daily behaviors (locking the door, turning off appliances), thoughts of
physical harm or violence, and orderliness, to name a few. Often the individual will
try to ignore these thoughts, urges, or images. When they are unable to ignore them,
the individual will engage in compulsatory behaviors to alleviate the anxiety.
Compulsions are repetitive behaviors or mental acts that an individual performs in
response to an obsession. Common examples of compulsions are checking (e.g.,
repeatedly checking if the stove is turned off even though the first four-times they
checked it was), counting (e.g., flicking the lights off and on exactly five times), hand
washing, symmetry, or repeating specific words.
Comorbidity

There is a high comorbidity rate between OCD and other anxiety disorders. Nearly
76% of individuals with OCD will be diagnosed with another anxiety disorder, most
commonly panic disorder, social anxiety disorder, generalized anxiety disorder, or a
specific phobia. There is a high comorbidity rate between OCD and tic disorder,
particularly in males with an onset of OCD in childhood. Children presenting with
early-onset OCD typically have a different presentation of symptoms than traditional
OCD. Research has also indicated a strong triad of OCD, Tic disorder, and attention-
deficit/hyperactivity disorder in children. Due to this psychological disorder triad, it is
believed there is a neurobiological mechanism at fault for the development and
maintenance of the disorders. It should be noted that there are several disorders
schizophrenia, bipolar disorder, eating disorders, and Tourette’ where there is a higher
incidence of OCD than the general public. Therefore, clinicians who have a patient
diagnosed with one of the disorders above should also routinely assess patients for
OCD.

Psychological Causal Factors

OCD as Learned Behavior: OCD (Obsessive-Compulsive Disorder) can be

conceptualized as a learned behavior. The repetitive and ritualistic behaviors
characteristic of OCD develop as individuals learn that performing these actions
temporarily reduces anxiety and distress associated with intrusive thoughts or
obsessions, reinforcing the cycle of compulsions.

OCD and Preparedness: OCD (Obsessive-Compulsive Disorder) and preparedness

theory suggest that certain obsessions and compulsions may be more likely to develop
due to evolutionary factors. Individuals may be predisposed to develop specific OCD
symptoms as a result of our ancestors' need to detect and respond to threats or
potential dangers in their environment.

Cognitive Causal Factors

The Effects of Attempting to Suppress Obsessive Thoughts: Attempting to suppress

obsessive thoughts in OCD can lead to the rebound effect, where the thoughts become
more persistent and intense. This phenomenon occurs because efforts to suppress
thoughts increase their salience and cognitive accessibility, making them more
difficult to control and contributing to increased distress and preoccupation with the
unwanted thoughts.

Appraisals of Responsibility for Intrusive Thoughts: Individuals with OCD often have
distorted appraisals of responsibility for intrusive thoughts. They tend to overestimate
their personal responsibility and believe that having such thoughts is morally wrong or
reflects their true character. These distorted appraisals contribute to increased anxiety
and the need to engage in compulsive behaviors to alleviate guilt and uncertainty.

Cognitive Biases and Distortions: Cognitive biases and distortions play a significant
role in OCD. Common cognitive biases include selective attention towards perceived
threats, overestimation of threat likelihood, and catastrophic thinking. Cognitive
distortions, such as perfectionism and intolerance of uncertainty, contribute to the
persistence of obsessions and the need for compulsive behaviors to reduce anxiety and
uncertainty.

Biological Causal Factors

Neuroimaging studies suggest that brain structures and circuits, particularly the
orbitofrontal cortex, play a role in the development of obsessive-compulsive
behaviors. The orbitofrontal cortex receives sensory/emotional information and
converts it into behavioral responses. It transmits impulses to the caudate nuclei,
which filter and pass along the strongest impulses to the thalamus. The thalamus then
reassesses the emotional response and determines whether to initiate a behavioral
response. These findings highlight the involvement of brain structures and
neurotransmitters in the manifestation of OCD symptoms.

Treatment

Exposure and Response Prevention (ERP). Treatment of OCD has come a long way in
recent years. Among the most effective treatment options is exposure and response
prevention. Individuals are repeatedly exposed to their obsession, thus causing
anxiety/fears, while simultaneously prevented from engaging in their compulsive
behaviors. Exposure sessions are often done in vivo (in real life), via videos, or even
imaginary, depending on the type of obsession. For example, a fear that one’s house
would burn down if their compulsion was not carried out would obviously be done via
imaginary exposure, as it would not be ethical to have a person burn their house down.

Psychopharmacology. There has been minimal support for the treatment of OCD with
medication alone. This is likely due to the temporary resolution of symptoms during
medication use. Among the most effective medications are those that inhibit the
reuptake of serotonin, clomipramine and SSRIs. While there has been some promise
in a combined treatment option of exposure and response prevention and SSRIs, these
findings were not superior to exposure and response prevention alone, suggesting that
the inclusion of medication in treatment does not provide an added benefit

PTSD

Posttraumatic stress disorder, or more commonly known as PTSD, is identified by the

development of physiological, psychological, and emotional symptoms following
exposure to a traumatic event. Individuals must have been exposed to a situation
where actual or threatened death occurred. The first category involves recurrent
experiences of the traumatic event, which can occur via flashbacks, distinct memories
(which may be voluntary or involuntary), or even distressing dreams. These recurrent
experiences must be specific to the traumatic event or the moments immediately
following to meet the criteria for PTSD. Regardless of the method, the recurrent
experiences can last several seconds or extend for several days.

The second category involves avoidance of stimuli related to the traumatic event.
Individuals with PTSD may be observed trying to avoid the distressing thoughts
and/or feelings related to the memories of the traumatic event.

The third category experienced by individuals with PTSD is negative alterations in

cognition or mood. This is often reported as difficulty remembering an important
aspect of the traumatic event. It should be noted that this amnesia is not due to a head
injury, loss of consciousness, or substances, but rather, due to the traumatic nature of
the event.
The fourth and final category is alterations in arousal and reactivity. Because of the
negative mood and increased irritability, individuals with PTSD may be quick-
tempered and act out aggressively, both verbally and physically. While these
aggressive responses may be provoked, they are also sometimes unprovoked.
Comorbidity
Given the traumatic nature of the disorder, it should not be surprising that there is a
high comorbidity rate between PTSD and other psychological disorders. Individuals
with PTSD are 80% more likely than those without PTSD to report clinically
significant levels of depressive, bipolar, anxiety, or substance abuse-related symptoms

Treatment

Psychological Debriefing. Psychological debriefing is considered a type of crisis

intervention that requires individuals who have recently experienced a traumatic event
to discuss or process their thoughts and feelings related to the traumatic event,
typically within 72 hours of the event. While there are a few different methods to a
psychological debriefing, they all follow the same general format:

1. Identifying the facts (what happened?)

2. Evaluating the individual’s thoughts and emotional reaction to the events leading up
to the event, during the event, and then immediately following

3. Normalizing the individual’s reaction to the event

4. Discussing how to cope with these thoughts and feelings, as well as creating a
designated social support system

Exposure Therapy While exposure therapy is predominately used in anxiety disorders,

it has also shown great success in treating PTSD-related symptoms as it helps
individuals extinguish fears associated with the traumatic event. There are several
different types of exposure techniques— imaginal, in vivo, and flooding are among
the most common types

Trauma-focused cognitive-behavioral therapy (TF-CBT) is an adaptation of CBT that

utilizes both CBT techniques and trauma-sensitive principles to address the trauma-
related symptoms. According to the Child Welfare Information Gateway (CWIG;
2012), TF-CBT can be summarized via the acronym PRACTICE:

P: Psycho-education about the traumatic event. This includes discussion about the
event itself, as well as typical emotional and/or behavioral responses to the event.
R: Relaxation Training. Teaching the patient how to engage in various types of
relaxation techniques such as deep breathing and progressive muscle relaxation.

A: Affect. Discussing ways for the patient to effectively express their emotions/fears
related to the traumatic event.

C: Correcting negative or maladaptive thoughts.

T: Trauma Narrative. This involves having the patient relive the traumatic event
(verbally or written), including as many specific details as possible.

I: In vivo exposure (see above).

C: Co-joint family session. This provides the patient with strong social support and a
sense of security. It also allows family members to learn about the treatment so that
they are able to assist the patient if necessary.

E: Enhancing Security. Patients are encouraged to practice the coping strategies they
learn in TF-CBT to prepare for when they experience these triggers out in the real
world, as well as any future challenges that may come their way.

Eye Movement Desensitization and Reprocessing (EMDR). the basic components of

EMDR consist of lateral eye movement induced by the therapist moving their index
finger back and forth, approximately 35 cm from the client’s face, as well as
components of cognitive-behavioral therapy and exposure therapy. The following 8-
step approach is the standard treatment approach of EMDR

1. Patient History and Treatment Planning - Identify trauma symptoms and potential
barriers to treatment.

2. Preparation - Psychoeducation of trauma and treatment.

3. Assessment- Careful and detailed evaluation of the traumatic event. Patient

identifies images, cognitions, and emotions related to the traumatic event, as well as
trauma-related physiological symptoms.

4. Desensitization and Reprocessing - Holding the trauma image, cognition, and

emotion in mind, while simultaneously assessing their physiological symptoms, the
patient must track the clinician’s finger movement for approximately 20 seconds. At
this time, the patient must “blank it out” and let go of the memory.

5. Installation of Positive Cognitions - Once the negative image, cognition, and

emotions are reduced, the patient must hold onto a positive image or thought while
again tracking the clinician’s finger movement for approximately 20 seconds.

6. Body Scan - Patient must identify any lingering bodily sensations while again
tracking the clinician’s fingers for a third time to discard any remaining trauma
symptoms.

7. Closure - Patient is provided with positive coping strategies and relaxation

techniques to assist with any recurrent cognitions or emotions related to the traumatic
experience.

8. Reevaluation - Clinician assesses if treatment goals were met. If not, schedules

another treatment session and identifies remaining symptoms.

Psychopharmacological Treatment. clinicians agree that psychopharmacology

interventions are an effective second line of treatment, particularly when
psychotherapy alone does not produce relief from symptoms. Among the most
common types of medications used to treat PTSD symptoms are selective serotonin
reuptake inhibitors (SSRIs). SSRIs work by increasing the amount of serotonin
available to neurotransmitters. Tricyclic antidepressants (TCAs) and monoamine
oxidase inhibitors (MAOIs) are also recommended as second-line treatments.