# 01 - Chapter 5 Anxiety, Obsessive Compulsive, Trau

# Chapter 5 Anxiety, Obsessive-Compulsive, Trauma, and Stressor-Related Disorders

Anxiety Disorders......................................................................................................................48
Treatment Guidelines................................................................................................................49
Pharmacotherapy.....................................................................................................................49
Psychotherapy..........................................................................................................................49
Panic Attacks.......................................................................................................................49
Panic Disorder......................................................................................................................50
Agoraphobia........................................................................................................................51
Specific Phobias...................................................................................................................51
Social Anxiety Disorder (Social Phobia)................................................................................52
Selective Mutism.................................................................................................................52
Separation Anxiety Disorder................................................................................................53
Generalized Anxiety Disorder (GAD).....................................................................................54
Obsessive-Compulsive and Related Disorders...........................................................................55
Obsessive-Compulsive Disorder (OCD).................................................................................55
Body Dysmorphic Disorder...................................................................................................56
Hoarding Disorder...............................................................................................................56
Trichotillomania (Hair-Pulling Disorder)..............................................................................57
Excoriation (Skin-Picking) Disorder......................................................................................58
Posttraumatic Stress Disorder (PTSD) and Acute Stress Disorder..........................................58
Adjustment Disorders..........................................................................................................60
STRESSOR-RELATED DISORDERS
A N X I E T Y, OBSES S IV E - CO M P U L S I V E, T R AU MA, A ND 
CHAPTER 5

48
ANXIETY, OBSESSIVE-COMPULSIVE, TRAUMA, AND STRESSOR-RELATED DISORDERS
Anxiety Disorders
WARDS TIP
Assess for psychopathology if an 
individual’s symptoms are causing 
Social and/or Occupational Dysfunction (use mnemonic SOD).
WARDS TIP
Late-onset anxiety symptoms 
without a prior history or family 
psychiatric history should increase 
suspicion of anxiety caused by 
another medical condition or 
substance use.
TABLE 5-1. Signs and Symptoms of Anxiety
WARDS 
QUESTION
Constitutional
Fatigue, diaphoresis, shivering
Q: In a patient with comorbid 
anxiety and depression, would 
treatment with a benzodiazepine 
be a first-line treatment?
A: No. Avoid use of benzodiazepines because they may worsen 
depression.
TABLE 5-3. Medical Conditions That Cause Anxiety
Anxiety disorders are characterized by excessive or inappropriate fear or anxiety. Fear is manifested by a transient increase in sympathetic activity (“fight 
or flight” physiologic response, thoughts, feelings, behaviors) in a situation 
perceived as dangerous or threatening. By contrast, anxiety involves apprehension regarding the possibility of a negative future event. The criteria for most 
anxiety disorders involve symptoms that cause clinically significant distress 
or impairment in social and/or occupational functioning (see Table 5-1). 
DSM-5 anxiety disorders include generalized anxiety disorder, panic disorder, 
agoraphobia, social anxiety disorder, selective mutism, and specific phobias.
 ■ Anxiety disorders are caused by a combination of genetic, biological,
environmental, and psychosocial factors.
 ■ Primary anxiety disorders are diagnosed after determining that symptoms
are NOT due to the physiological effects of a substance, medication (see 
Table 5-2), or another medical condition (see Table 5-3).
 ■ Major neurotransmitter systems implicated: norepinephrine (NE), serotonin
(5-HT), and gamma-aminobutyric acid (GABA).
Cardiac
Chest pain, palpitations, tachycardia, hypertension
Pulmonary
Shortness of breath, hyperventilation
Neurologic/ 
musculoskeletal
Vertigo, light-headedness, paresthesias, tremors, insomnia, muscle 
tension
Gastrointestinal
Abdominal discomfort, anorexia, nausea, emesis, diarrhea, 
constipation
TABLE 5-2. Medications and Substances That Cause Anxiety
Alcohol
Intoxication/withdrawal
Sedatives, hypnotics, or anxiolytics
Withdrawal
Cannabis
Intoxication
Hallucinogens (PCP, LSD, MDMA)
Intoxication
Stimulants (amphetamines, cocaine)
Intoxication/withdrawal
Caffeine
Intoxication/withdrawal
Tobacco
Intoxication/withdrawal
Opioids
Withdrawal
LSD, lysergic acid diethylamide; MDMA, 3,4-methylenedioxy methamphetamine; PCP, phencyclidine.
Neurologic
Epilepsy, migraines, brain tumors, multiple sclerosis, Huntington 
disease
Endocrine
Hyperthyroidism, hypoglycemia, pheochromocytoma, carcinoid 
syndrome
Metabolic
Vitamin B12 deficiency, electrolyte abnormalities, porphyria
Respiratory
Asthma, chronic obstructive pulmonary disease (COPD), hypoxia, 
pulmonary embolism (PE), pneumonia, pneumothorax
Cardiovascular
Congestive heart failure (CHF), angina, arrhythmia, myocardial 
infarction (MI)

■ Most common form of psychopathology.
 ■ More frequently seen in women compared to men, approximately 2:1 ratio.
Treatment Guidelines
 ■ Determine treatment course based on the severity of symptoms.
 ■ Initiate psychotherapy for mild anxiety.
 ■ Consider a combination of therapy and medication for moderate to severe
anxiety.
Pharmacotherapy
 ■ Selective serotonin reuptake inhibitors (SSRIs) (e.g., sertraline) and
serotonin-norepinephrine reuptake inhibitors (SNRIs) (e.g., venlafaxine) 
are first-line medications.
 ■ Benzodiazepines can be used as an adjunctive short-term treatment to
achieve acute reduction of severe anxiety symptoms (e.g., while getting 
stabilized on an SSRI), but regular use can result in dependence. Therefore, 
minimize the use, duration, and dose, and avoid in patients with a history of 
substance use disorders, particularly alcohol.
 ■ Mechanism of action: Enhance activity of GABA at GABA-A receptor.
 ■ In patients with comorbid substance use consider nonaddictive anxiolytic
alternatives for PRN use, such as gabapentin and antihistamines with 
anxiolytic properties (e.g., diphenhydramine or hydroxyzine).
 ■ Buspirone is a non-benzodiazepine anxiolytic which has partial agonist
activity at the 5-HT1A receptor. Due to minimal efficacy as monotherapy, 
buspirone is typically prescribed only as augmentation.
 ■ Beta-blockers (e.g., propranolol) may be used to help control autonomic
symptoms (e.g., palpitations, tachycardia, sweating) of panic attacks or 
performance anxiety.
 ■ Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors
(MAOIs) may be considered if first-line agents are not effective. Their sideeffect profile, especially cardiovascular effects, makes them less tolerable and 
more dangerous.
Psychotherapy
 ■ Many modalities of psychotherapy are helpful for patients suffering from
anxiety disorders.
 ●Cognitive-behavioral therapy (CBT) has proven effective for anxiety disorders. CBT examines the relationship between anxiety-driven
­cognitions (thoughts), emotions, and behavior.
 ●Psychodynamic psychotherapy facilitates insight into the development of anxiety symptoms, leading to more adaptive coping styles and
­subsequent improvement over time.
PANIC ATTACKS
A panic attack is a fear response involving a sudden onset of intense anxiety 
which may either be triggered or occur spontaneously. Panic attacks peak 
ANXIETY, OBSESSIVE-COMPULSIVE, TRAUMA, AND STRESSOR-RELATED DISORDERS
WARDS TIP
Use benzodiazepines to temporarily bridge patients until long-term 
medication becomes effective.
WARDS 
QUESTION
Q: How long does it take for SSRIs 
to typically become fully effective?
A: About 4–6 weeks.
WARDS TIP
The goal of medication treatment 
is to achieve symptomatic relief 
and continue treatment for at least 
6 months before attempting to 
titrate off medications.
WARDS TIP
Medications can reduce symptoms 
sufficiently so that a patient can 
participate and learn the skills 
offered in therapy. Therapy can additionally be used as maintenance 
treatment to prevent relapse.

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ANXIETY, OBSESSIVE-COMPULSIVE, TRAUMA, AND STRESSOR-RELATED DISORDERS
KEY FACT
Symptoms of panic attacks
Da PANICS
Dizziness, disconnectedness, 
derealization (unreality), depersonalization (detached from self)
Palpitations, paresthesias
Abdominal distress
Numbness, nausea
Intense fear of dying, losing 
­control or “going crazy”
Chills, chest pain
Sweating, shaking, shortness of 
breath
PANIC DISORDER
Diagnosis and DSM-5 Criteria
WARDS TIP
Use the Bs to Block the Ps:
Beta-Blockers for Panic attacks and 
Performance anxiety.
Etiology
WARDS TIP
Epidemiology
Smoking is a risk factor for panic 
attacks.
 ■ Lifetime prevalence: 4%.
 ■ Median age of onset: 20–24 years old.
WARDS 
QUESTION
Course and Prognosis
Q: When a patient presents with 
the new onset of a panic attack, 
what potentially life-threatening 
medical conditions should be 
ruled out?
A: Heart attack, cardiac arrhythmia, electrolyte dysfunction, 
hypoglycemia, thyrotoxicosis, and 
pulmonary embolism.
within minutes and usually resolve within half an hour. Patients may continue 
to feel anxious for hours afterwards and believe they are experiencing a prolonged panic attack. Although classically associated with panic disorder, panic 
attacks can also be experienced with other psychiatric disorders and medical 
conditions.
Panic disorder is diagnosed in patients who experience spontaneous, recurrent 
panic attacks and who are fearful of reoccurring attacks. These attacks most 
often occur suddenly, out of the blue, although they may sometimes have a clear 
trigger. The frequency of attacks ranges from multiple times per day to a few 
times per month. The keystone feature of panic disorder is that patients develop debilitating anticipatory anxiety about having future attacks—“fear of the 
fear.”
 ■ Recurrent, unexpected panic attacks without an identifiable trigger.
 ■ One or more of panic attacks followed by ≥1 month of continuous worry
about experiencing subsequent attacks or their consequences, and/or a 
maladaptive change in behaviors (e.g., avoidance of possible triggers).
 ■ Not due to the physiological effects of a substance, another medical or
neurological condition (e.g., traumatic brain injury), or another mental 
disorder.
 ■ Genetic factors: Greater risk of panic disorder if a first-degree relative is
affected.
 ■ Psychosocial factors: Increased incidence of stressors (especially loss) prior
to onset of disorder; history of childhood physical or sexual abuse.
 ■ Higher rates in woman compared to men, approximately 2:1.
 ■ Panic disorder has a chronic course with waxing and waning symptoms.
 ■ Relapses are common with discontinuation of medication.
 ■ Only a minority of patients have full remission of symptoms.
 ■ Up to 65% of patients with panic disorder also have major depression.
 ■ Additional comorbid syndromes include other anxiety disorders
(e.g., agoraphobia), bipolar disorder, and alcohol use disorder.
Treatment
Combination of CBT and Pharmacotherapy = most effective.
 ■ First-line: SSRIs (e.g., sertraline, citalopram, escitalopram).
 ■ SNRIs (e.g., venlafaxine, desvenlafaxine, duloxetine) are also efficacious.
 ■ If the above options are not effective, can consider TCAs
(e.g., clomipramine, imipramine).
 ■ Can use benzodiazepines (e.g., clonazepam, lorazepam) as scheduled or
PRN, until other medications reach therapeutic efficacy.

AGORAPHOBIA
Agoraphobia is an intense fear of being in public places where escape or obtaining help may be difficult. It often develops with panic disorder. The course 
of the disorder is usually chronic. Avoidance behaviors may become as extreme 
as complete confinement to the home.
Diagnosis and DSM-5 Criteria
 ■ Intense fear/anxiety about at least two situations due to concerns of
difficulty escaping or obtaining help in case of panic or other humiliating 
symptoms:
 ●Outside of the home alone.
 ●Open spaces (e.g., bridges).
 ●Enclosed places (e.g., stores).
 ●Public transportation (e.g., trains).
 ●Crowds/lines.
 ■ The triggering situations cause fear/anxiety that is out of proportion to the
potential danger posed, leading to endurance of intense anxiety, avoidance, 
or need for a companion. This holds true even if the patient suffers from 
another medical condition such as inflammatory bowel disease (IBS), which 
may lead to embarrassing public scenarios.
 ■ Symptoms cause significant social or occupational dysfunction.
 ■ Symptoms last ≥6 months.
 ■ Symptoms not better explained by another mental disorder.
Etiology
 ■ Strong genetic factor: Heritability about 60%.
 ■ Psychosocial factor: Onset frequently follows a traumatic event.
Course/Prognosis
 ■ More than 50% of patients experience a panic attack prior to developing
agoraphobia.
 ■ Onset is usually before age 35.
 ■ Course is persistent and chronic, with rare full remission.
 ■ Comorbid diagnoses include other anxiety disorders, depressive disorders,
and substance use disorders.
Treatment
 ■ CBT and SSRIs
SPECIFIC PHOBIAS
A phobia is defined as an irrational fear that leads to endurance of the anxiety and/or avoidance of the feared object or situation. A specific phobia is an 
intense fear of a specific object or situation (i.e., the phobic stimulus).
Diagnosis and DSM-5 Criteria
 ■ Persistent, excessive fear elicited by a specific situation or object which is out
of proportion to any actual danger/threat.
 ■ Exposure to the situation triggers an immediate fear response.
 ■ Situation or object is avoided when possible or tolerated with intense anxiety.
ANXIETY, OBSESSIVE-COMPULSIVE, TRAUMA, AND STRESSOR-RELATED DISORDERS
WARDS TIP
A classic panic disorder case 
involves a woman who repeatedly 
visits the ER because she is afraid 
of dying when she experiences 
episodes of palpitations, diaphoresis, and shortness of breath. 
The patient has no prior medical 
history and the medical workup is 
negative.
WARDS TIP
Carefully screen patients with 
panic attacks for suicidality. They 
are at an increased risk for suicide 
attempts.
WARDS TIP
Start SSRIs or SNRIs at low doses 
and ↑ slowly because side effects 
may initially worsen anxiety, 
­especially in panic disorder.
KEY FACT
Characteristic situations avoided 
in agoraphobia include bridges, 
crowds, buses, trains, or any open 
areas outside the home.
KEY FACT
Common Domains of Social 
­Anxiety Disorder (Social Phobia):
• Speaking in public.
• Eating in public.
• Using public restrooms.

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ANXIETY, OBSESSIVE-COMPULSIVE, TRAUMA, AND STRESSOR-RELATED DISORDERS
KEY FACT
 ■ Duration ≥6 months.
Common Specific Phobias:
Animal—spiders, insects, dogs, 
snakes, and mice.
Natural environment—heights, 
storms, and water.
Situational—elevators, airplanes, 
buses, and enclosed spaces.
Blood-injection-injury—needles, 
injections, blood, injuries, and 
invasive medical procedures.
Epidemiology
Treatment
 ■ Treatment of choice: CBT with exposure.
WARDS TIP
Patients with blood-injury- injection-specific phobia (fear of 
needles, etc.) may experience 
­bradycardia and hypotension 
­leading to vasovagal syncope.
KEY FACT
Substance use and depressive 
disorders frequently co-occur 
with phobias.
Epidemiology
WARDS 
QUESTION
Treatment
 ■ Treatment of choice: CBT.
Q: What medication often successfully treats performance anxiety?
A: Beta-blockers.
SELECTIVE MUTISM
 ■ Symptoms cause significant social or occupational dysfunction.
 ■ Not due to the physiological effects of a substance, another medical or
neurological condition (e.g., traumatic brain injury), or another mental 
disorder.
 ■ Phobias are the most common psychiatric disorder in women and second
most common in men (substance-related is first).
 ■ Lifetime prevalence of specific phobia: >10%.
 ■ Mean age of onset for specific phobia is 10 years.
 ■ Specific phobia rates are higher in women compared to men (2:1) but vary
depending on the type of stimulus.
SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)
Social anxiety disorder (social phobia) is the fear of scrutiny by others or fear 
of acting in a humiliating or embarrassing way. The phobia may develop in 
the wake of negative or traumatic encounters with the stimulus. Social situations causing significant anxiety may be avoided altogether, resulting in social 
and academic/occupational impairment.
The diagnostic criteria for social anxiety disorder (social phobia) are similar 
to specific phobia except the phobic stimulus is related to social scrutiny and 
negative evaluation. The patients fear embarrassment, humiliation, and rejection. This fear may be limited to performance or public speaking, which may 
be routinely encountered in the patient’s occupation or academic pursuit.
 ■ Median age of onset for social anxiety disorder is 13 years.
 ■ Social anxiety disorder occurs equally across genders.
 ■ First-line medication, if needed: SSRIs (e.g., sertraline, fluoxetine) or SNRIs
(e.g., venlafaxine) for debilitating symptoms.
 ■ Benzodiazepines (e.g., clonazepam, lorazepam) can be used as scheduled or
PRN.
 ■ Beta-blockers (e.g., atenolol, propranolol) PRN for performance anxiety/
public speaking.
Selective mutism is a rare condition characterized by a failure to speak in 
specific situations for at least 1 month, despite the intact ability to comprehend and use language. Symptom onset typically starts during childhood. The 
majority of these patients suffer from anxiety, particularly social anxiety, as the

mutism manifests in social settings. The patients may remain completely silent 
or just whisper. They may use nonverbal means of communication, such as 
writing or gesturing.
Diagnosis and DSM-5 Criteria
 ■ Consistent failure to speak in select social situations (e.g., school) despite
speech ability in other scenarios.
 ■ Mutism is not due to a language difficulty or a communication disorder.
 ■ Symptoms cause significant impairment in academic, occupational, or social
functioning.
 ■ Symptoms last >1 month (extending beyond first month of school).
Treatment
 ■ Psychotherapy: CBT, family therapy.
 ■ Medications: SSRIs (especially with comorbid social anxiety disorder).
SEPARATION ANXIETY DISORDER
As part of normal human development, infants become distressed when they 
are separated from their primary caregiver. Stranger anxiety begins around 
6 months and peaks around 9 months, while separation anxiety typically 
emerges by 1 year of age and peaks by 18 months. However, when the anxiety 
due to separation becomes extreme or developmentally inappropriate, it is 
considered pathologic. Separation anxiety disorder may be preceded by a 
stressful life event.
Diagnosis and DSM-5 Criteria
Excessive and developmentally inappropriate fear/anxiety regarding separation from attachment figures, with at least three of the following:
 ■ Separation from attachment figures leads to extreme distress.
 ■ Excessive worry about loss of or harm to attachment figures.
 ■ Excessive worry about experiencing an event that leads to separation from
attachment figures.
 ■ Reluctance to leave home or attend school or work.
 ■ Reluctance to be alone.
 ■ Reluctance to sleep alone or away from home.
 ■ Complaints of physical symptoms when separated from major attachment
figures.
 ■ Nightmares of separation and refusal to sleep without proximity to
attachment figure.
 ■ Lasts for ≥4 weeks in children/adolescents and ≥6 months in adults.
 ■ Symptoms cause significant social, academic, or occupational dysfunction.
 ■ Symptoms not due to another mental disorder.
Treatment
 ■ Psychotherapy: CBT, family therapy.
 ■ Medications: SSRIs can be effective as an adjunct to therapy.
ANXIETY, OBSESSIVE-COMPULSIVE, TRAUMA, AND STRESSOR-RELATED DISORDERS
WARDS TIP
Separation anxiety may lead to 
complaints of somatic symptoms 
to avoid school/work.

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ANXIETY, OBSESSIVE-COMPULSIVE, TRAUMA, AND STRESSOR-RELATED DISORDERS
WARDS TIP
GAD Mnemonic
Worry WARTS
Wound up, worn-out
Absent-minded
Restless
Tense
Sleepless
GENERALIZED ANXIETY DISORDER (GAD)
WARDS TIP
For patients with anxiety, 
­evaluate for caffeine use and 
­recommend significant reduction 
or ­elimination.
Diagnosis and DSM-5 Criteria
 ■ Difficulty controlling worry.
WARDS TIP
Exercise can significantly reduce 
anxiety.
Epidemiology/Etiology
 ■ Lifetime prevalence: 5–9%.
WARDS TIP
Course/Prognosis
 ■ Symptoms of worry begin in childhood.
The worries associated with GAD 
are free-floating across various 
areas, as opposed to being fixed 
on a specific trigger.
 ■ Median age of onset of GAD: 30 years.
 ■ Rates of full remission are low.
 A 24-year-old law student presents to an outpatient psychiatry clinic with a 
chief complaint that she is “so stressed out, worrying about everything.” She 
is overwhelmed with her academic workload and upcoming exams. She has 
had trouble falling asleep and feels chronically fatigued. The patient also suffers from frequent headaches and muscle tightness in her neck and shoulders.
The patient’s husband describes her as “a worrier. She’s always concerned 
about me getting into an accident, her flunking out of school, not finding a 
job—the list goes on.”
The patient reports that she has always had some degree of anxiety, but 
previously found it motivating. Over the last year since law school began, her 
symptoms have become debilitating.
What is the most likely diagnosis?
With the patient’s history of excessive worrying about everything, the most 
likely diagnosis is generalized anxiety disorder (GAD). Like many patients 
with GAD, she is described as a worrier. She reports typical associated symptoms: insomnia, fatigue, and impaired concentration. Her symptoms have 
been present for over 6 months.
What is the next step?
A complete physical exam and medical workup should be performed to rule 
out other medical conditions or substance use contributing to or causing her 
anxiety symptoms.
What are treatment options?
Treatment options for GAD include psychotherapy (usually CBT) and pharmacotherapy (typically SSRIs). A combination of both modalities may achieve 
better remission rates than either treatment alone.
Patients with GAD have persistent, excessive anxiety about many aspects of 
their daily lives. Commonly associated physical symptoms include fatigue and 
muscle tension, which often lead to an initial presentation to primary care.
 ■ Excessive anxiety/worry about various daily events/activities ≥6 months.
 ■ Associated ≥3 symptoms: restlessness, fatigue, impaired concentration,
irritability, muscle tension, insomnia.
 ■ Not due to the physiological effects of a substance, another medical or
neurological condition (e.g., traumatic brain injury), or another mental disorder.
 ■ Symptoms cause significant social or occupational dysfunction.
 ■ GAD rates higher in women compared to men (2:1).
 ■ One-third of risk for developing GAD is genetic.
 ■ Course is chronic, with waxing and waning symptoms.
 ■ GAD is highly comorbid with other anxiety and depressive disorders.

Treatment
The most effective treatment approach combines psychotherapy and 
­pharmacotherapy:
 ■ CBT.
 ■ SSRIs (e.g., sertraline, citalopram) or SNRIs (e.g., venlafaxine, duloxetine).
 ■ Can also consider a short-term course of benzodiazepines or augmentation
with buspirone.
 ■ Much less commonly used medications are TCAs and MAOIs.
Obsessive-Compulsive and Related Disorders
OBSESSIVE-COMPULSIVE DISORDER (OCD)
OCD is characterized by obsessions and/or compulsions that are time-consuming, distressing, and impairing. Obsessions are recurrent, intrusive, and undesired thoughts that increase anxiety. Patients may attempt to relieve the anxiety 
by performing compulsions, which are repetitive behaviors or mental rituals. 
Anxiety may increase when a patient resists acting out a ­compulsion. Patients 
with OCD have varying degrees of insight.
Diagnosis and DSM-5 Criteria
 ■ Experiencing obsessions and/or compulsions that are time-consuming (e.g.,
>1 hr/day) and cause significant distress or dysfunction.
 ●Obsessions: Recurrent, intrusive, anxiety-provoking thoughts, images, or
urges that the patient attempts to suppress, ignore, or neutralize by some
other thought or action (i.e., by performing a compulsion).
 ●Compulsions: Repetitive behaviors or mental acts the patient feels driven
to perform in response to an obsession, or a rule aimed at stress reduction
or disaster prevention. The behaviors are excessive and/or not realistically
connected to what they are meant to prevent.
 ■ Not due to the physiological effects of a substance, another medical or
neurological condition (e.g., traumatic brain injury), or another mental 
disorder.
Epidemiology
 ■ Lifetime prevalence: 2–3%.
 ■ No gender difference in prevalence overall.
Etiology
 ■ Significant genetic component: Higher rates of OCD in first-degree relatives
and monozygotic twins than in the general population. Higher rate of OCD 
in first-degree relatives with Tourette’s disorder.
Course/Prognosis
 ■ Chronic, with waxing and waning symptoms.
 ■ Less than 20% remission rate without treatment.
 ■ Suicidal ideation in 50% and suicide attempts in 25% of patients with OCD.
 ■ High comorbidity with other anxiety disorders, depressive or bipolar
disorder, obsessive-compulsive personality disorder, and tic disorder.
Treatment
Utilize a combination of psychopharmacology and CBT.
ANXIETY, OBSESSIVE-COMPULSIVE, TRAUMA, AND STRESSOR-RELATED DISORDERS
KEY FACT
Compulsions can often take the 
form of repeated checking or 
counting.
KEY FACT
Patients with OCD often initially 
seek help from primary care and 
other nonpsychiatric providers 
for help with the consequences 
of compulsions (e.g., excessive 
washing).
KEY FACT
The triad of “uncontrollable 
urges”—OCD, ADHD, and tic 
disorder—are usually first seen in 
children or adolescents.
KEY FACTS
Common Patterns of Obsessions 
and Compulsions
Obsessions
Compulsions
Contamination
Cleaning or avoidance of contaminant
Doubt or 
harm
Checking multiple 
times to avoid potential danger
Symmetry
Ordering or counting
Intrusive, 
taboo 
thoughts
With or without 
related compulsion

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ANXIETY, OBSESSIVE-COMPULSIVE, TRAUMA, AND STRESSOR-RELATED DISORDERS
KEY FACT
Differentiating OCD and obsessive-compulsive personality 
disorder (OCPD):
• Individuals with OCPD are
­obsessed with details, control, 
and perfectionism without 
­experiencing unwanted preoccupations or compulsions.
• OCD patients are distressed by
their symptoms (ego-dystonic).
BODY DYSMORPHIC DISORDER
Diagnosis and DSM-5 Criteria
Epidemiology
 ■ Mean age of onset: 15 years.
Course/Prognosis
 ■ High rate of suicidal ideation and attempts.
Treatment
HOARDING DISORDER
Diagnosis and DSM-5 Criteria
CBT focuses on exposure and response prevention: prolonged, graded exposure 
to ritual-eliciting stimulus and prevention of the relieving compulsion.
 ■ First-line medication: SSRIs (e.g., sertraline, fluoxetine), typically at higher doses.
 ■ Second-line agents: SNRIs (e.g., venlafaxine) or the most serotonin selective
TCA, clomipramine.
 ■ Can augment with atypical antipsychotics in severe cases.
 ■ In debilitating, treatment-resistant cases, consider psychosurgery
(cingulotomy) or electroconvulsive therapy (ECT).
 ■ Patients with body dysmorphic disorder are preoccupied with nonexistent or
minor physical defects that they regard as severe, grotesque, and repulsive.
 ■ These individuals spend significant time trying to correct perceived flaws
with makeup, dermatological procedures, or plastic surgery.
 ■ Preoccupation with one or more perceived defects or flaws in physical
appearance that are not observable by or appear slight to others.
 ■ In response to the appearance concerns, repetitive behaviors (e.g., skin
picking, excessive grooming) or mental acts (e.g., comparing appearance to 
others) are performed.
 ■ Preoccupation causes significant distress or impairment in functioning.
 ■ Appearance preoccupation is not better accounted for by concerns with
body fat/weight in an eating disorder.
 ■ Slightly more common in women than men.
 ■ Prevalence elevated in those with high rates of childhood abuse and neglect.
 ■ Increased risk in first-degree relatives of patients with OCD.
 ■ Higher prevalence in dermatologic and cosmetic surgery patients.
 ■ The onset is usually gradual, beginning in early adolescence. Symptoms tend
to be chronic.
 ■ Surgical or dermatological procedures are routinely unsuccessful in
satisfying the patient.
 ■ Comorbidity with major depression, social anxiety disorder (social phobia),
and OCD.
 ■ SSRIs and/or CBT may reduce the obsessive and compulsive symptoms in
many patients.
 ■ Persistent difficulty discarding possessions, regardless of value.
 ■ Difficulty is due to need to save the items and distress associated with
discarding them.

■ Results in accumulation of possessions that congest/clutter living areas and
compromise use.
 ■ Hoarding causes clinically significant distress or impairment in social,
occupational, or other areas of functioning.
 ■ Hoarding is not attributable to another medical condition or another mental
disorder.
Epidemiology/Etiology
 ■ Point prevalence of significant hoarding is 2–6%.
 ■ Hoarding is three times more prevalent in the elderly population.
 ■ Onset often preceded by stressful and traumatic events.
 ■ 50% of individuals with hoarding have at least one hoarding relative.
Course/Prognosis
 ■ Hoarding behavior begins in early teens and tends to worsen over time.
 ■ Usually chronic course.
 ■ 75% of individuals have comorbid mood (MDD) or anxiety disorder (social
anxiety disorder).
 ■ 20% of individuals have comorbid OCD.
Treatment
 ■ Very difficult to treat.
 ■ Specialized CBT for hoarding.
 ■ SSRIs can be used.
TRICHOTILLOMANIA (HAIR-PULLING DISORDER)
Diagnosis and DSM-5 Criteria
 ■ Recurrent pulling out of one’s hair, resulting in hair loss.
 ■ Repeated attempts to decrease or stop hair pulling.
 ■ Causes significant distress or impairment in daily functioning.
 ■ Hair pulling or hair loss is not due to another medical condition or
psychiatric disorder.
 ■ Usually involves the scalp, eyebrows, or eyelashes. May include facial,
axillary, or pubic hair.
Epidemiology/Etiology
 ■ Lifetime prevalence: 1–2% of the adult population.
 ■ More common in women than in men (10:1 ratio).
 ■ Onset usually at puberty and frequently associated with a stressful event.
 ■ Etiology may involve biological, genetic, and environmental factors.
 ■ Increased incidence of comorbid OCD, major depressive disorder, and
excoriation (skin-picking) disorder.
 ■ Course may be chronic with waxing and waning periods. Adult onset is
generally more difficult to treat.
Treatment
 ■ Recommended: Specialized types of cognitive-behavior therapy (e.g., habit
reversal training).
 ■ Pharmacologic treatment includes SSRIs, second-generation antipsychotics,
lithium, or N-acetylcysteine (NAC).
ANXIETY, OBSESSIVE-COMPULSIVE, TRAUMA, AND STRESSOR-RELATED DISORDERS

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ANXIETY, OBSESSIVE-COMPULSIVE, TRAUMA, AND STRESSOR-RELATED DISORDERS
EXCORIATION (SKIN-PICKING) DISORDER
Diagnosis and DSM-5 Criteria
 ■ Recurrent skin picking resulting in lesions.
Epidemiology/Etiology
 ■ More than 75% of cases are women.
Course/Prognosis
 ■ Skin picking begins in adolescence.
Treatment
 ■ SSRIs have shown some benefit.
Trauma and Stressor-Related Disorders
 ■ Repeated attempts to decrease or stop skin picking.
 ■ Causes significant distress or impairment in daily functioning.
 ■ Not due to the physiological effects of a substance, another medical or
neurological condition (e.g., traumatic brain injury), or another mental 
disorder.
 ■ Lifetime prevalence: 1.4% of the adult population.
 ■ More common in individuals with OCD and first-degree family members.
 ■ Course is chronic with waxing and waning periods if untreated.
 ■ Comorbidity with OCD, trichotillomania, and MDD.
 ■ Specialized types of cognitive-behavior therapy (e.g., habit reversal training).
A 19-year-old freshman is brought to the ER by her college roommate due 
to her concerns that she “really needs to get some help—she hasn’t been 
herself since a party we went to together.” The freshman has been hypervigilant, tearful, and crying out so loudly in her sleep that she wakes up her 
peers. The roommate discloses concern that a traumatic incident occurred at 
a party last month. The patient is guarded and reluctant to talk about details. 
She reports that since the party, she has experienced intrusive thoughts and 
nightmares. The patient is afraid to leave her room, and feels on edge most of 
the time.
What is the most likely diagnosis?
The patient has been suffering from symptoms of posttraumatic stress disorder (PTSD) for the last month after a traumatic incident with associated low 
mood, avoidance, hypervigilance, intrusive thoughts, and nightmares.
POSTTRAUMATIC STRESS DISORDER (PTSD) AND ACUTE STRESS DISORDER
PTSD is characterized by the development of multiple symptoms after exposure 
to one or more traumatic events: intrusive symptoms (e.g., nightmares, flashbacks), avoidance, negative alterations in thoughts and mood, and increased 
arousal. The symptoms last for at least a month and may occur immediately 
after the trauma or with delayed ­expression.
Acute stress disorder is diagnosed in patients who experience a major traumatic event and suffer from similar symptoms as PTSD (see Table 5-4) but for a 
shorter duration. The onset of symptoms occurs within 1 month of the trauma 
and symptoms last for less than 1 month.

TABLE 5-4. Posttraumatic Stress Disorder and Acute Stress Disorder
Posttraumatic Stress Disorder
Acute Stress Disorder
Trauma occurred at any time in past
Trauma occurred <1 month ago
Symptoms last >1 month
Symptoms last <1 month
Diagnosis and DSM-5 Criteria
 ■ Exposure to actual or threatened death, serious injury, or sexual violence by
directly experiencing or witnessing the trauma.
 ■ Recurrent intrusions of reexperiencing the event via memories, nightmares,
or dissociative reactions (e.g., flashbacks); intense distress at exposure to cues 
relating to the trauma; or physiological reactions to cues relating to the trauma.
 ■ Active avoidance of triggering stimuli (e.g., memories, feelings, people,
places, objects) associated with the trauma.
 ■ At least two of the following negative cognitions/mood: dissociative
amnesia, negative feelings of self/others/world, self-blame, negative 
emotions (e.g., fear, horror, anger, guilt), anhedonia, feelings of detachment/
estrangement, inability to experience positive emotions.
 ■ At least two of the following symptoms of increased arousal/reactivity:
hypervigilance, exaggerated startle response, irritability, angry outbursts, 
impaired concentration, insomnia.
 ■ Symptoms not caused by the direct effects of a substance or another medical
condition.
 ■ Symptoms result in significant impairment in social or occupational
functioning.
 ■ The presentation differs in children <7 years of age.
Epidemiology/Etiology
 ■ Lifetime prevalence of PTSD: >8%.
 ■ Higher prevalence in women, most likely due to greater risk of exposure
to traumatic events, particularly rape and other forms of interpersonal 
violence.
 ■ Exposure to prior trauma, especially during childhood, is a risk factor for
developing PTSD.
Course/Prognosis
 ■ PTSD usually begins within 3 months after the trauma.
 ■ Symptoms may manifest after a delayed expression.
 ■ Fifty percent of patients with PTSD have complete recovery within
3 months.
 ■ Symptoms tend to diminish with older age.
 ■ Eighty percent of patients with PTSD have a comorbid mental disorder
(e.g., MDD, bipolar disorder, anxiety disorder, substance use disorder).
Treatment
 ■ Pharmacological
 ●First-line antidepressants: SSRIs (e.g., sertraline) or SNRIs (e.g., venlafaxine).
 ●Prazosin, a1-receptor antagonist, targets nightmares and hypervigilance.
 ●Consider augmentation with a second-generation antipsychotic in severe
or treatment-resistant cases.
ANXIETY, OBSESSIVE-COMPULSIVE, TRAUMA, AND STRESSOR-RELATED DISORDERS
WARDS TIP
Q: What medication has shown 
some efficacy as an adjunct treatment for nightmares in patients 
with PTSD?
A: Prazosin.
WARDS TIP
Criteria of PTSD: TRAUMA
Traumatic event
Reexperience
Avoidance
Unable to function
Month or more of symptoms
Arousal increased

60
 ■ Psychotherapy
ANXIETY, OBSESSIVE-COMPULSIVE, TRAUMA, AND STRESSOR-RELATED DISORDERS
WARDS TIP
Cognitive processing therapy is 
a modified form of CBT in which 
thoughts, feelings, and meanings 
of the event are revisited and 
questioned.
 ●Couples/family therapy.
ADJUSTMENT DISORDERS
WARDS TIP
Addictive medications such as 
benzodiazepines should be avoided in the treatment of PTSD because of the high rate of ­comorbid 
substance use disorders and the 
lack of efficacy.
Epidemiology
KEY FACT
 ■ May occur at any age.
PTSD stressor = life threatening.
Etiology
Adjustment disorder stressor ≠ 
life threatening.
 ■ Triggered by psychosocial factors.
Treatment
 ■ Supportive psychotherapy.
 ■ Group therapy.
 ●Specialized forms of CBT (e.g., exposure therapy, cognitive processing
therapy).
 ●Supportive and psychodynamic therapy.
Adjustment disorders occur when behavioral or emotional symptoms develop 
after a non-life-threatening, stressful life event (e.g., divorce, death of a loved 
one, or loss of a job).
Diagnosis and DSM-5 Criteria
 1. Development of emotional or behavioral symptoms within 3 months in response to an identifiable stressful life event. These symptoms produce either:
• Excessive distress in relation to the event.
• Significant impairment in daily functioning.
 2. The symptoms are not those of normal bereavement.
 3. Symptoms resolve within 6 months after the stressor has terminated.
 4. The stress-related disturbance does not meet criteria for another mental
disorder.
Subtypes: Based on a predominance of either depressed mood, anxiety, mixed 
anxiety and depression, disturbance of conduct (such as aggression), or mixed 
disturbance of emotions and conduct.
 ■ 5–20% of patients in outpatient mental health clinics have an adjustment
disorder.
Prognosis
May be chronic if the stressor is chronic or recurrent.
 ■ If clinically indicated, pharmacotherapy can target associated impairing
symptoms (insomnia, anxiety, or depression).