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Chapter 9 Anxiety Disorders and Obsessive-­Compulsive and Related Disorders...

Chapter 9 Anxiety Disorders and Obsessive-­Compulsive and Related Disorders Shari A. Steinman, Amber L. Billingsley, Cierra B. Edwards, Mira D. Snider, and Lauren S. Hallion Chapter contents Introduction156 Theoretical Models of Anxiety and OCRDs 156 Diagnostic Criteria 159 Assessment162 Treatment164 Conclusion and Call for Future Research 167 References168 Copyright © 2019. Taylor & Francis Group. All rights reserved. Maddux, J. E., & Winstead, B. A. (Eds.). (2019). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from vuw on 2024-09-26 08:31:05.  156 | Shari A. Steinman et al. Introduction Anxiety refers to an emotional state one experiences in response to a threat, and is characterized by physiological arousal (e.g., increased heart rate), negative cognitions, and avoidance behaviors (American Psychiatric Association, 2013). In the evolution of the human species, anxiety originated as an adaptive response to alert individuals that a threat was present and to encourage them to act in ways that were self-­preserving (Ohman & Mineka, 2001). In prehistoric times, it was helpful for people who encountered threat (e.g., in the form of a saber-­toothed tiger) to experience a rush of physiological arousal (e.g., sweating, rapid heartbeat) and negative thoughts (e.g., “the tiger is going to eat me!”). These experiences led to a strong desire to avoid the tiger (e.g., run away), which generally improved their chances for survival. Despite the advantages of anxiety, it can become maladaptive. If Marc, a man living in present day Chicago, had a similar reac- tion every time he saw anything that reminded him of a tiger (such as a picture of a tiger, or a small housecat), it would probably cause problems in his life. He might avoid visiting friends or family members that own cats, or refuse to see movies that may have tigers or even cats in them. If his fear and avoidance of tiger-­related stimuli got to the point where it was causing significant distress or impairment, it would most likely meet the diagnostic criteria for an anxiety disorder. Anxiety disorders are prevalent, impairing, and costly to treat. They are the most common mental illness in the United States, affecting up to 33.7% of the United States population at some point in their lifetimes (Bandelow & Michaelis, 2015), and cause significant impairment and disability (Bokma, Batelaan, van Balkom, & Penninx, 2017). For example, decreased work productivity and absenteeism related to anxiety disorders costs the United States approximately $4.1 billion every year (Greenberg et al., 1999). Additionally, increased primary care use related to anxiety disorders costs the economy of the United States approximately $23 bil- lion per year (Katon et al., 1990; Manning & Wells, 1992). In the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-­5 (American Psychiatric Asso- ciation, 2013), anxiety disorders include separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder (social phobia), panic disorder, agoraphobia, generalized anxiety disorder, and several categories designed to capture clinically significant anxiety-­related impairment that does not meet criteria for another anxiety disorder. Specific anxiety disorders are reviewed in more detail later. A closely related class of disorders called obsessive-­compulsive and related disorders (OCRDs) was created for DSM-­5. OCRDs include obsessive-­compulsive disorder (OCD), body dysmorphic disorder (BDD), hoarding disorder, trichotillomania (hair pulling disorder), excoriation (skin picking) disorder, and residual categories for clinically significant obsessive-­compulsive-­related symp- toms that do not meet criteria for a formal OCRD diagnosis. Relative to anxiety disorders, OCRDs are less prevalent; OCD affects 2.3% of the United States population during their lives (Ruscio, Stein, Chiu, & Kessler, 2010). However, these disorders are no less significant in terms of their detrimental effect on role functioning; OCD and related disorders (e.g., hoarding disorder; BDD) are major sources of distress, impairment, and disability (Jacoby, Leonard, Riemann, & Abramowitz, 2014; Phillips, Menard, Fay, & Weisberg, 2005; Ruscio et al., 2010; Tolin, Frost, Steketee, Gray, & Fitch, 2008). In this chapter, we present theoretical models of pathological anxiety, brief descriptions of each anxiety disorder and OCRD, and an introduction to the evidence-­based assessments and treatments for these disorders. Theoretical Models of Anxiety and OCRDs In the text that follows, we review different theoretical models of anxiety disorders and OCRDs. Importantly, these models are not mutually exclusive, but can be thought of as different complementary lenses through which to view the development and mainte- nance of anxiety disorders and OCRDs. The Cognitive Model Copyright © 2019. Taylor & Francis Group. All rights reserved. The subjective, internal experiences of anxiety, OCD, and related disorders are central to their diagnosis (American Psychiatric Asso- ciation, 2013). Cognitive symptoms of these disorders can include preoccupation with a potentially disastrous event, predicting terrible outcomes if a certain behavior is (or isn’t) performed, feeling unable to control distressing or unwanted thoughts, or threatening thoughts related to certain kinds of experiences, objects, or situations. While anticipating the unknown and formulating judgments is a fundamental part of being human, the thought patterns above often deviate from reality and can cause substantial distress. Cognitive theories of anxiety and OCD posit that distress-­inducing stimuli are accompanied by automatic (involuntary) thoughts and images that persons with these disorders interpret as meaningful or important (Beck & Clark, 1997; Rachman, 1998). These patterns of deviation from logical reasoning and processing are known as cognitive biases. Common categories of cognitive biases in anxiety and OCD include attentional biases, judgmental (or interpretation) biases, and memory biases (Mathews & MacLeod, 2005). For example, a 30-­year-­old woman named Juliana may demonstrate a judgmental bias by overestimating the likelihood that she will be embarrassed if she goes out with her friends. She also demonstrates a memory bias by selectively recalling times she felt embarrassed in front of her friends and being unable to remember the times she has gone out and had lots of fun. While she is out, Juliana may show attentional bias by focusing most of her attention on her friends while they are looking at their phones, and ignoring the times that they are smiling up at her. Maddux, J. E., & Winstead, B. A. (Eds.). (2019). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from vuw on 2024-09-26 08:31:05.  Anxiet y Disorders and Obsessive-­C ompulsive and Related Disorders | 157 Behavioral Models Another way of understanding how the symptoms of anxiety, OCD, and related disorders develop is through the principles of behav- ioral learning. The two-­factor theory (Mowrer, 1951), proposes that two types of incidental learning – classical and operant conditioning – can be used to explain how fears develop in individuals who suffer from phobias and how problematic fear-­related behaviors such as avoidance and escape are maintained after the fear has developed. In the classical conditioning model, fear is learned when a normal fear response to a threatening stimulus becomes associated or paired with a non-­threatening stimulus. When this association occurs, the unconditioned fear that an individual experiences in response to the threatening stimulus becomes associated with the non-­threatening stimulus, such that both stimuli evoke a fear response in the individual. For example, a 24-­year-­old man named Tom is fearful of coming into contact with germs after contract- ing an illness while visiting his friend’s house. Since his friend allowed his outdoor dog to come inside for the duration of Tom’s visit, Tom develops an association between the dog and the illness that he experienced. If this association persists, he may eventually refuse to go near any dog that could possibly be “contaminated” by germs. He may even feel fearful of touching another person who has recently come into contact with dogs. In the operant conditioning model, fear-­related behaviors such as avoidance or rituals are learned when the behavior removes an unpleasant stimulus and results in a decrease of uncomfortable emotions and physiological sensations. This type of learning, also known as negative reinforcement, can make the avoidance or escape behavior more likely to occur in future scenarios because it allows an individual to feel better in the short term. However, these behaviors can adversely affect quality of life by limiting pleas- urable activities and one’s ability to maintain personal responsibilities. For example, Tom’s fear of dogs may lead him to wash his hands repeatedly after coming into contact with objects that the dog may have touched. This washing ritual makes Tom feel as though he is no longer “contaminated” by the dog, making him more comfortable in the short term. However, Tom has now learned that washing rituals are effective strategies to remove this discomfort (i.e., the behavior is negatively reinforced), and over time he may become dependent on these strategies, potentially to the detriment of important work or social relationships. Behavioral theories are most helpful for explaining scenarios where there is a clear, learning event preceding a fear response. The two-­factory theory does not sufficiently explain why conditioned fears may persist when there has not been continued rein- forcement by means of exposure to the fear-­inducing stimulus. Additionally, the two-­factor theory does not sufficiently explain how avoidance may occur in the absence of fear or a specific signaling stimulus, a phenomenon that has been documented in both rat and human studies (Hassoulas, McHugh, & Reed, 2014; Rachman & Hodgson, 1974; Sidman, 1953). The Cognitive-­Behavioral Model The Cognitive-­Behavioral Model incorporates elements of both cognitive and behavioral theories. It expands upon cognitive theo- ries by proposing that there are reciprocal relationships between thoughts, fear-­related behaviors, and fear-­related feelings (Butler, Chapman, Forman, & Beck, 2006). In other words, consistently biased perceptions of events can lead to the distressing emotions, uncomfortable bodily sensations, and detrimental behaviors like avoidance, checking, and rumination that characterize these disor- ders. These three components (i.e., thoughts, feelings, and behaviors) can be visually represented in a triangle with bidirectional arrows connecting each component. The cognitive-­behavioral framework illustrates how changes in one area of the triangle can have an effect on the other areas. For example (see Figure 9.1), Juliana frequently experiences panic attacks when she is out in public. She has automatic associations between social situations and discomfort or embarrassment and often thinks that social situations will inevitably end with a panic attack. This desire to avoid the possibility of a panic attack leads Juliana to avoid going out with friends and stay home at night instead. While she may experience sadness or guilt as a result of missing these events, staying home is effective in that she does not experience a panic attack. Consequently, the belief that staying home is the safer choice is reinforced and becomes stronger. Alter- natively, Juliana may decide to go out with friends. While she is out, she is likely to feel nervous about having a panic attack, which Copyright © 2019. Taylor & Francis Group. All rights reserved. in turn causes her heart to beat faster. Because Juliana is fearful of having a panic attack, she is paying close attention (hypervigilant) to her bodily sensations and therefore notices her heart rate increasing. She incorrectly assumes that an increase in heart rate is a signal of an impending panic attack. However, this misinterpretation generates more anxiety and perpetuates a self-­fulfilling proph- ecy; the vicious cycle ultimately results in a full-­fledged panic attack. This experience in turn reinforces her fearful associations and belief that going out with friends will lead to a panic attack. Psychosocial Models Research on social systems and other environmental factors that occur across individuals are also important for understanding how learning occurs in anxiety, OCD, and related disorders. Social cognitive theory (Bandura, 1986) proposes that new information can be learned as a result of reciprocal interactions between individuals, behaviors, and social environments. In other words, fear is something that may be acquired when a fear response is witnessed within a social interaction (e.g., observing someone reacting fearfully toward snakes may result in one becoming fearful of snakes; hearing caregivers talk negatively about dirt might predispose one to developing hygiene-­related obsessions). Cultural factors such as religion and social hierarchies can also influence how stimuli Maddux, J. E., & Winstead, B. A. (Eds.). (2019). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from vuw on 2024-09-26 08:31:05.  158 | Shari A. Steinman et al. Thoughts "If I leave the house, I will have a panic a ack" Feelings Behaviors Fear of panic a ack, heart racing Avoids going out Figure 9.1 The Cognitive-­Behavioral Triangle. are perceived and shape the course of social learning events, leading to fears or obsessions related to those topics (Mineka & Zinbarg, 2006). This theory can be used to understand why some individuals develop fears that are not classically or operantly conditioned in one’s own life experiences. However, social learning theory does not fully account for situations in which an individual observes another person’s fear without adopting the fear themselves. Research in child development has indicated that an individual’s formative years can serve as a critical window for developing fear responses. For example, children who are subjected to stressful experiences or trauma without the option to escape the stressful stimulus may form a lack of perceived control during stressful events later on in life (Chorpita & Barlow, 1998). This lack of per- ceived control over one’s surroundings may lead to patterns of thinking where one consistently overestimates their vulnerability to harm or illness (Gallagher, Bentley, & Barlow, 2014). Biological Models Several symptoms of anxiety and related disorders are physiological. Increased heart rate, shortness of breath, and digestive problems are commonly experienced during a fear response (Berle et al., 2016). Neuroimaging research has identified several brain regions and networks of regions that become especially metabolically active when the individual is exposed to threat, fear, or anxiety (Gross & Canteras, 2012; Tovote, Fadok, & Lüthi, 2015). The best known of these locations is the amygdala, which is a small almond-­ shaped structure located in the temporal lobe. The amygdala has long been believed to play a major role in threat detection and the acquisition of fear in mammals by operating as part of a “fear circuit” with other areas of the subcortical brain (Rauch, Shin, & Wright, 2003; Shekhar, Truitt, Rainnie, & Sajdyk, 2005), and some research has shown that the amygdala may become overactivated in individuals who present with anxiety disorders (Brühl, Delsignore, Komossa, & Weidt, 2014; Etkin & Wager, 2007). However, more recent neurobiological research has indicated that not all responses to a perceived threat are tied to the amygdala or the same neural pathways. One neural circuit, known as the “defensive survival circuit” is thought to underlie behavioral and physiological responses to a perceived threat (e.g., freezing, avoidance, increased heart rate) and primarily includes subcortical regions of the brain that operate unconsciously (e.g., regions of the amygdala, nucleus accumbens) (LeDoux & Pine, 2016). This defensive circuit is associated with activation of the autonomic nervous system, which controls involuntary bodily functions such as breathing and heartbeat. The autonomic nervous system contains the sympathetic nervous system and the parasympathetic nervous system, which produce opposing physiological responses. When a fear-­inducing stimulus is encountered, the sympathetic nervous system becomes acti- vated and the parasympathetic system is inhibited, engaging the “fight or flight” response. This response accelerates heart rate, quickens breathing, and slows digestive functioning so the body is more prepared to confront or escape the perceived threat (Pow- Copyright © 2019. Taylor & Francis Group. All rights reserved. ley, 2013). A separate circuit, known as the cognitive circuit, is thought to underlie the cognitive and emotional experience of fear. This circuit primarily includes cortical regions of the brain such as the prefrontal cortex that regulate other conscious processes such as attention and working memory (LeDoux & Pine, 2016). Evolutionary Models Some models posit that there are variations across individuals in their genetic vulnerability to experience anxiety and fear. In other words, susceptibility to excessive fear might be a hereditary trait, and certain individuals with this trait might be more likely to experience symptoms of anxiety/­OCD when confronted by a fear-­inducing stimulus. This is known as the vulnerability-­stress model (Barlow, 2000). From an evolutionary psychology perspective, a genetic susceptibility to fear could have evolved to facilitate adaptive responses to dangerous stimuli in the past, including physical threats such as predators (remember Marc and the tiger from the introduction), Maddux, J. E., & Winstead, B. A. (Eds.). (2019). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from vuw on 2024-09-26 08:31:05.  Anxiet y Disorders and Obsessive-­C ompulsive and Related Disorders | 159 but also other threats to survival and reproduction, such as social exclusion (Ohman & Mineka, 2001). This model suggests that humans may be born with the genetic potential to develop certain fears more easily than others. Individuals are particularly likely to develop fears of animals, objects, or situations that would be likely to reduce their chances of passing on their genes to the next generation. Fear of snakes and spiders are a common example of this. From an evolutionary perspective, Juliana’s fears of not being accepted in social situations could be related to the fact that rejection from social groups could be fatal in pre-­historic times. Simi- larly, Tom’s fear of germs and contamination could be considered adaptive in the sense that they prevent contact with life-­threatening diseases. Although these evolutionarily relevant threats may be easy to detect, additional research has indicated that the detection of more modern, evolutionarily non-­relevant threats (such as guns, knives, and syringes) may also be easily learned (Fox, Griggs, & Mouchlianitis, 2007; LoBue, 2010). Diagnostic Criteria The diagnostic criteria described in the text that follows are from the Diagnostic and Statistical Manual of Mental Disorders (DSM-­5) (American Psychiatric Association, 2013), which is the primary psychiatric classification system in the United States. Symptoms described in the 11th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-­11) (World Health Organization, 2018) are in line with DSM-­5 diagnostic criteria for all disorders described in this chapter except where oth- erwise noted. For each of the following disorders, except where otherwise noted, the symptoms must: (1) cause significant distress and/­or functional impairment; (2) be persistent (e.g., lasting for at least six months); (3) not be due to another psychological or medical disorder; and (4) not be due to the use of a substance. Anxiety Disorders Separation Anxiety Disorder Separation anxiety disorder is characterized by a developmentally inappropriate fear of being separated from important individuals (e.g., a parent or spouse). Usually the fear relates to concerns that harm will befall the attachment figure, or that the attachment figure will not return. This can be evidenced by distress when separated or anticipating separation; worry about losing (e.g., illness, death) or being separated from (e.g., getting lost, kidnapped) a major attachment figure; unwillingness to be alone, sleep away, or go to school or work; and somatic symptoms related to anticipated or actual separation (e.g., an upset stomach). The ICD-­11 adds that the focus on separation anxiety is different for children and adults: children tend to focus on their caregivers (e.g., parents, family members), while adults tend to focus on their children or partners (e.g., spouse, boyfriend, girlfriend). The estimated 12-­ month prevalence in the United States is 1.2% (Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012), though estimated prev- alence rates vary across countries (Silove et al., 2015). Separation anxiety disorder is more common in children than adults, although approximately 57% of adults with the disorder report that it began during childhood (Silove et al., 2015). Separation anxiety disorder occurs more frequently in women than men (Silove et al., 2015). An example of a child with separation anxiety disorder would be a 9-­year-­old boy who refuses to go to school or spend time at a friend’s house because he worries his mother might be involved in a car accident while they are separated. Selective Mutism Individuals with selective mutism fail to speak in specific situations. To be diagnosed with selective mutism, an individual must fail to speak in situations where they would be expected to do so, despite having adequate knowledge and comfort with the language and being able to speak fluidly in other circumstances. The lack of speech must cause significant functional interference, and must Copyright © 2019. Taylor & Francis Group. All rights reserved. last at least one month (not including the first month of school). Selective mutism is rare; point prevalence (proportion of a popu- lation that has the disorder) is estimated to be less than 1% across countries, though this statistic varies based on ages of children and setting (Muris & Ollendick, 2015). Age of onset is usually between two and five years old (often when children first begin school), and occurs more commonly in females than males (Muris & Ollendick, 2015). For example, a 5-­year-­old girl might speak freely at home with family and friends, but refuse to speak at school. Specific Phobia Individuals with specific phobia fear a specific situation or object (e.g., spiders, storms, heights). The feared stimuli must almost always cause fear and be avoided or endured with high anxiety. The fear must be excessive (e.g., not in line with actual danger of situation). The 12-­month prevalence of specific phobias in the US is 12.1% (Kessler et al., 2012). The most common specific pho- bias include animals (e.g., spiders, snakes) and heights (Eaton, Bienvenu, & Miloyan, 2018). Specific phobia tends to begin at a young age (mean age of onset is seven years old), and occurs more frequently in women than men (Wardenaar et al., 2017). For example, a 33-­year-­old male might avoid entering his basement because he saw a spider in the basement once several years ago. Maddux, J. E., & Winstead, B. A. (Eds.). (2019). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from vuw on 2024-09-26 08:31:05.  160 | Shari A. Steinman et al. Social Anxiety Disorder The defining feature of social anxiety disorder is fear and avoidance of social situations, specifically because the individual fears negative evaluation or social humiliation (Clark & Wells, 1995). Individuals with social anxiety disorder consistently experience intense fear in social situations and concern that he/­she will be negatively evaluated. They either avoid the social situations or endure them with high anxiety. Social anxiety disorder has a 12-­month prevalence rate of approximately 7.4% in the United States, with higher rates occurring in women (Kessler, 2003; Kessler et al., 2012). Social anxiety disorder often begins during childhood or adolescence, with an average age of onset between ages 11 and 13 (Kessler, 2003). For example, an intelligent and capable 58-­year-­old woman might be afraid of sounding stupid and blushing while speaking in public and therefore avoids opportunities for promotion at work that involve speeches or presentations. Panic Disorder A panic attack is a rush of physiological symptoms (e.g., rapid heartbeat, shortness of breath, derealization, fear of dying, etc.) that peaks within minutes. Individuals with and without anxiety disorders can experience panic attacks. Approximately 28% of individ- uals report experiencing one or more panic attacks during their lifetime; however, most of these individuals do not meet diagnostic criteria for panic disorder (Kessler et al., 2006). A diagnosis of panic disorder is warranted if panic attacks are recurrent and followed by at least one month of significant fear of future panic attacks, fear of potential consequences of panic attacks, and/­or a change in behavior related to the panic attacks (e.g., avoiding places where panic attacks have occurred in the past). The ICD-­11 specifies that within panic disorder, panic attacks should occur in multiple situations. The estimated 12-­month prevalence of panic disorder for adults in the US is 2.4% (Kessler et al., 2012). Panic disorder is more common among women than among men (de Jonge et al., 2016). It is also more commonly diagnosed among adults than among children, with an average age of onset of 23 (Kessler et al., 2006). For example, a 30-­year-­old fitness instructor might avoid going to his job at the gym because he has experienced panic attacks while exercising and fears future attacks. Agoraphobia The defining feature of agoraphobia is a fear of situations in which a person may not be able to escape or get help if they experience embarrassing (e.g., vomiting) or panic-­like (e.g., shortness of breath) physiological symptoms. Situations that are often feared by individuals with agoraphobia include crowds, lines, enclosed places (e.g., movie theaters), open places (e.g., parking lot), public transportation, or being alone while out of the house. To meet diagnostic criteria, the feared situations must almost always cause fear and must be avoided (or only attended with a friend or family member) or endured with high anxiety. The ICD-­11 highlights that agoraphobic fear is due to a fear of negative outcomes (e.g., panic attacks, embarrassing bodily symptoms). The estimated 12-­ month prevalence of agoraphobia in the United States is 1.7%, with typical onset occurring in young adults (i.e., early 20s; Kessler et al., 2012). Agoraphobia is more common in women than among men (Bekker, 1996). For example, a 22-­year-­old resident of New York City might avoid taking the subway or other forms of transportation, even though public transportation is the only way for her to get to work and to visit with friends, because she worries she may faint. Generalized Anxiety Disorder Generalized anxiety disorder (GAD) is characterized by excessive worry and anxiety about multiple topics (e.g., relationships, work, health). To be diagnosed with GAD, an individual must experience uncontrollable and excessive worry about multiple topics for more days than not over a period of six months, and must experience at least three related physical symptoms (e.g., muscle tension, difficulty concentrating, being easily fatigued). Unlike the DSM-­5, the ICD-­11 states that individuals must have either excessive worry about multiple topics or general apprehension (“free-­floating anxiety”). The lifetime prevalence of GAD is 3.7% worldwide, with higher rates present in higher-­income countries (Ruscio et al., 2017). GAD typically begins in adulthood, and is more common among women than among men. For example, a 42-­year-­old women cannot stop worrying about her health, her relationship with Copyright © 2019. Taylor & Francis Group. All rights reserved. her wife, and the safety of her children. As a result, she often feels tired and has trouble staying focused on her work assignments to the point that her job is now in jeopardy. Obsessive-­Compulsive and Related Disorders Obsessive Compulsive Disorder Obsessive-­compulsive disorder (OCD) is characterized by obsessions and compulsions. Obsessions are repetitive, intrusive thoughts, doubts, ideas, or images that cause significant anxiety or distress. Common obsessions include unwanted thoughts related to vio- lence, sex, religion, contamination or germs, and thoughts that one will be responsible for future disasters (Bloch, Landeros-­ Weisenberger, Rosario, Pittenger, & Leckman, 2008). Compulsions are repetitive and ritualistic behaviors (including mental acts) that reduce the anxiety caused by the obsessions. Examples include checking the stove, praying, handwashing, or repeating a phrase Maddux, J. E., & Winstead, B. A. (Eds.). (2019). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from vuw on 2024-09-26 08:31:05.  Anxiet y Disorders and Obsessive-­C ompulsive and Related Disorders | 161 silently in one’s head (Bloch et al., 2008). To be diagnosed with OCD, individuals must experience obsessions and/­or compulsions, and the obsessions and compulsions must take up at least one hour per day. The estimated 12-­month prevalence in the US is 1.2% (Kessler et al., 2012). OCD can onset in childhood or adulthood, though average age of onset is slightly earlier in men (average age of onset is 21 years old) compared to women (average age of onset is 22–24 years old; Rasmussen & Eisen, 1992b). OCD is slightly more prevalent among adult women than among adult men, with an earlier age of onset for boys than for girls (Rasmussen & Eisen, 1992a). For example, a 31-­year-­old new mother with intrusive thoughts about stabbing her baby experiences extreme distress about her thoughts, repeatedly asks her spouse if their child is okay, and refuses to hold sharp objects (e.g., knives, scissors) while in the home. Body Dysmorphic Disorder In body dysmorphic disorder (BDD), individuals are preoccupied with perceived physical flaws that are minor or not visible to others. The preoccupation must be associated with repetitive behaviors (e.g., checking mirrors, mental acts), and cannot be better explained by an eating disorder (e.g., cannot solely be related to weight in an individual diagnosed with anorexia nervosa). The point prevalence in the United States is 1.7–2.4%, and the mean age of onset is 16 (Fang, Matheny, & Wilhelm, 2014). Although there is no difference in prevalence between men and women, body areas of concern tend to vary by gender: women are more likely to be concerned with their skin, breasts, thighs, and body hair, while men are more likely to be concerned with genitals, balding, and muscular build (labeled “muscle dysmorphia”; Fang et al., 2014). For example, a 45-­year-­old woman who is convinced her nose is too large might repeatedly look at her nose in the mirror, compare the size of her nose to other people’s noses in pictures online for hours each week, and regularly consult with plastic surgeons to determine if she should have surgery. Hoarding Disorder Hoarding disorder is characterized by difficulty discarding items resulting in significant accumulation of clutter. The difficulty dis- carding must be due to a need to save the items or to avoid distress associated with discarding, and the resulting clutter must impair the use of living areas. According to the ICD-­11, hoarding can either be characterized by excessive acquisition or difficulty discarding (as opposed to DSM-­5, which requires difficulty discarding for a hoarding diagnosis). The point prevalence is estimated to be 2–6% (Iervolino et al., 2009; Mueller, Mitchell, Crosby, Glaesmer, & de Zwaan, 2009; Samuels et al., 2008). Hoarding disorder is more common among older adults than younger adults (Cath, Nizar, Boomsma, & Mathews, 2017). Epidemiological studies of hoarding disorder are lacking, but preliminary studies suggest no difference in prevalence between men and women (Nordsletten et al., 2013). For example, a 62-­year-­old man cannot cook in his kitchen because he filled his counters and stove with important docu- ments and books, which he says he has no place else to store. Body-­Focused Repetitive Behavior Body-­focused repetitive behavior is a category of related disorders characterized by compulsive urges to pick, pull, or bite skin, hair, or nails. Two examples include excoriation (skin-­picking) disorder and trichotillomania. To meet criteria for either disorder, the behavior must result in visible problems (e.g., hair loss, skin lesions), and the individual must make repeated attempts to stop or reduce the behavior. Both excoriation and trichotillomania (along with other habitual or compulsive body-­focused behaviors, such as lip-­biting, cheek-­chewing, and nail biting) fall under the more general category of “body focused repetitive behavior disorder” in the ICD-­11. Estimates of the lifetime prevalence in the United States is 0.6% for trichotillomania (Grant & Chamberlain, 2016) and 1.4% for excoriation (Grant et al., 2012). Typical age of onset for trichotillomania is between 10 and 13 years of age (Grant & Chamberlain, 2016), while there is a wide variation in age of onset for excoriation (Grant et al., 2012). For example, an 18-­year-­old college student is worried about an exam and plucks out all her natural eyebrows to relieve stress while studying. Copyright © 2019. Taylor & Francis Group. All rights reserved. Hypochondriasis Hypochondriasis (or illness anxiety disorder) is categorized as an OCRD in the ICD-­11, but is classified as a Somatic Symptom or Related Disorder in DSM-­5. Individuals with hypochondriasis have a preoccupation with developing or having a significant illness or disease. Diagnostic criteria for hypochondriasis include anxiety that is out of proportion with any actual physical symptoms, high anxiety related to health, and repetitive health-­related behaviors (e.g., checking body for signs of disease, seeking reassurance from doctors). Unlike OCRDs, symptoms do not need to cause significant distress and/­or impairment according to DSM-­5 (though dis- tress or impairment is required in the ICD-­11). The ICD-­11 adds that the anxiety tends to be associated with “catastrophic misinter- pretations of bodily signs or symptoms.” Individuals with hypochondriasis tend to utilize medical care more than individuals without the disorder (Fink, Ørnbøl, & Christensen, 2010). Prevalence in the general population is estimated to be 0.4%, (Weck, Richtberg, & Neng, 2014), with higher rates among women than among men (El-­Gabalawy, Mackenzie, Thibodeau, Asmundson, & Sareen, 2013). Rates of hypochondriasis increase as age increases with an average age of diagnosis of 57. (El-­Gabalawy et al., 2013). For example, a 63-­year-­old man is convinced he has cancer and repeatedly visits his doctors despite taking numerous medical tests and repeatedly being given a clean bill of health. Maddux, J. E., & Winstead, B. A. (Eds.). (2019). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from vuw on 2024-09-26 08:31:05.  162 | Shari A. Steinman et al. Olfactory Reference Disorder Olfactory reference disorder does not appear in the DSM-­5 and is categorized under OCRDs in the ICD-­11. The defining feature of olfactory reference disorder is a preoccupation with the erroneous belief that one gives off a foul odor (e.g., unpleasant body odor). Individuals with olfactory reference disorder are self-­conscious about the perceived smell, and conduct repetitive behaviors (e.g., checking for the odor, seeking reassurance) or avoid situations that lead to distress related to the perceived smell (e.g., social situa- tions). Individuals with olfactory reference disorder have varying levels of insight into their erroneous odor-­related belief, with some expressing delusional conviction (Stein et al., 2016). Although some individuals with olfactory reference disorder experience olfactory hallucinations, 59% of individuals with the disorder report not being able to smell the odor they believe they are emitting (Begum & McKenna, 2010). There are no published epidemiological studies on olfactory reference disorder, but community prev- alence estimates range from 0.5–2.1% and onset is typically reported in the mid-­20s (Thomas, Plessis, Chiliza, Lochner, & Stein, 2015). For example, a 22-­year-­old woman is convinced that she has terrible breath and brushes her teeth ten times a day and avoids social situations. Assessment Depending on the setting, common anxiety assessments may include interviews, self-­reports, behavioral assessments, or psycho- physiological assessments. Broadly, these assessments are designed to elicit information about a patient’s symptoms (e.g., the specific nature or severity of symptoms or their change during treatment). Depending on the setting, the patient’s history (e.g., medical, social, family) may also be assessed. Interview and self-­report assessments are often used in clinical settings to track patients’ pro- gress. These and other assessment techniques are also used for research purposes to better understand factors that contribute to anxiety and OCDs and their successful treatment. Interviews Diagnostic interviews are an important tool for detecting the presence of an anxiety disorder or OCRD and for determining clinical severity. Interviews vary in terms of their level of structure (i.e., the extent to which specific interview questions are scripted versus left to the clinician’s judgment). There are pros and cons of each of these approaches. Unstructured interviews do not follow a predetermined format and typically consist of open-­ended questions that are asked at the clinician’s discretion. Despite the absence of an explicit script, unstructured interviews typically include questions related to the patient’s presenting symptoms, psychiatric history, medical history, developmental history, family history, and social history. When assessing for anxiety and OCRDs, specific information should be gathered regarding avoidance behaviors, negative future-­oriented cognitions, and physiological arousal (e.g.,fast pulse, sweating). Unstructured interviews have the advantage of allowing the clinician freedom to probe deeply into spe- cific problems, but a disadvantage is that important information may be missed if it is not assessed systematically. Structured and semi-­structured clinical interviews help clinicians determine whether an individual meets diagnostic criteria for a disorder. Both types of interviews include a specific set of questions and follow a predetermined format. The major difference is that semi-­structured interviews explicitly allow the clinician to “go off script” and ask for more elaboration or follow-­up ques- tions, while structured interviews are fully scripted. An advantage of a fully structured interview is that it requires less training to administer and is usually shorter in duration. A semi-­structured interview relies more heavily on the clinician’s training, knowledge, and judgment. Both types of interviews have the advantage of including diagnostic criteria and other important information (such as suicidality or alcohol use) that the clinician might otherwise forget to assess. Structured and semi-­structured interviews are gen- erally considered to be more reliable and valid ways to make diagnostic decisions (Kashner et al., 2003; Ramirez Basco et al., 2000). Examples of widely used structured and semi-­structured interviews for anxiety and OCRDs are described below. (See Chapter 7 in this volume for additional information about assessment interviews.) Copyright © 2019. Taylor & Francis Group. All rights reserved. Anxiety Disorder Interview Schedule for DSM-­5 (ADIS-­5) (Brown & Barlow, 2013) The ADIS-­5 is a structured clinical interview that focuses on gathering detailed information about anxiety and a wide range of related disorders, including OCD, trauma, mood, substance use, somatic symptom disorders, and others. Although this interview provides detailed information about anxiety, the ADIS-­5 does not assess for multiple OCRDs, such as trichotillo- mania, hoarding, or excoriation disorder. Diagnostic Interview for Anxiety, Mood, and Obsessive-­Compulsive and Related Neuropsychiatric Disorders (DIA- MOND) (Tolin et al., 2016) The DIAMOND is a semi-­structured interview that focuses primarily on OCRDs, including those not assessed by the ADIS-­5. The DIAMOND also includes modules for anxiety, mood, substance use, psychotic and certain neurodevelopmental disor- ders (e.g., ADHD), among others. The DIAMOND also includes an optional screening tool that allows for a shorter admin- istration time. World Health Organization Mental Health Survey Composite International Diagnostic Interview (WHO WMH-­CIDI) (Kessler & Ustun, 2004) Maddux, J. E., & Winstead, B. A. (Eds.). (2019). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from vuw on 2024-09-26 08:31:05.  Anxiet y Disorders and Obsessive-­C ompulsive and Related Disorders | 163 The WHO WMH-­CIDI is a structured diagnostic interview that is used to assess for disorders according to both ICD-­10 and DSM-­IV criteria. As of writing, the WHO WMH-­CIDI has not been updated for ICD-­11 or DSM-­5 criteria. Mini-­International Neuropsychiatric Interview for DSM-­5 (MINI) (Sheehan, 2015) The MINI is a structured clinical interview that is briefer than most of the other structured interviews. Due to its brevity, this interview does not cover all anxiety disorders, omitting some such as specific phobia. An advantage of the MINI is its rel- atively short administration time. Because it is fully structured, it also requires less training than many other interviews. Structured Clinical Interview for DSM-­5 (SCID-­5) (First, Williams, Karg, & Spitzer, 2015) The SCID-­5 is a semi-­structured clinical interview that includes most major DSM-­5 diagnoses. It is widely used, but a disadvantage is that it can take several hours to complete. Disorder-­Specific Interviews Disorder-­specific interviews are clinician-­administered interviews that provide detailed information about a particular diagnosis. These often take the form of a structured or semi-­structured interview and often require specialized training to complete. For example, the Yale-­Brown Obsessive-­Compulsive Scale (Y-­BOCS) (Goodman et al., 1989) is a clinician-­rated interview that measures the severity of obsessions and compulsions in OCD and is not influenced by the type or quantity of OCD symptoms. The Y-­BOCS demonstrates excel- lent interrater reliability (Goodman et al., 1989) and excellent one-­week test-­retest reliability (Kim, Dysken, & Kuskowski, 1990). The Hoarding Rating Scale-­Interview (HRS-­I) (Tolin, Frost, & Steketee, 2010) is another example of a disorder-­specific inter- view that demonstrates excellent internal consistency and test-­retest reliability. This measure provides an overall severity rating of hoarding disorder and includes questions pertaining to the core symptoms of the disorder. Self-­Report Measures Self-­report measures for anxiety or obsessive-­compulsive disorders include validated questionnaires that assess specific anxiety symptoms. They often ask an individual to rate the frequency and/­or severity of different types of anxiety and related symptoms. This type of assess- ment can be useful when making differential diagnoses, assessing progress over the course of treatment, and for research purposes. Self-­Report Measures for Anxiety Disorders Beck Anxiety Inventory (BAI) (Beck, Epstein, Brown, & Steer, 1988) The BAI is a 21-­item measure of general anxiety severity, including how much a client is bothered by specific anxiety symp- toms (e.g., the feeling of choking, hands trembling). The BAI is a commonly used measure that demonstrates excellent internal consistency and adequate one-­week test-­retest reliability (Beck et al., 1988). Panic Disorder Severity Scale (PDSS) (Shear et al., 1997) The PDSS is a seven-­item scale that assesses the severity of panic disorder symptoms and is typically given to patients with panic disorder with or without comorbid agoraphobia. This scale demonstrates good reliability and is sensitive to change (Shear et al., 1997). Penn State Worry Questionnaire (PSWQ) (Meyer, Miller, Metzger, & Borkovec, 1990) The PSWQ is a 16-­item measure that assesses an individual’s tendency to worry excessively. Given that uncontrollable worry is a key symptom of generalized anxiety disorder (Hallion & Ruscio, 2013), this scale is often given to GAD patients to assess the severity of their worry. This scale demonstrates good to very good internal consistency and ad- equate to good test-­retest reliability (Molina & Borkovec, 1994). Copyright © 2019. Taylor & Francis Group. All rights reserved. Self-­Report Measures for OCRDs Obsessive-­Compulsive Inventory-­Revised (OCI-­R) (Foa et al., 2002) The OCI-­R is an 18-­item scale that assesses both the frequency and distress associated with symptoms of OCD. This measure has excellent psychometric properties, including good to excellent internal consistency and test-­retest reliability (Foa et al., 2002). Body Dysmorphic Disorder Symptom Scale (BDD-­SS) (Wilhelm, Greenberg, Rosenfield, Kasarskis, & Blashill, 2016) The BDD-­SS is a 54-­item scale that assesses the severity of multiple different BDD symptom groups (e.g., ritualistic behaviors, negative cognitions). This scale demonstrates good reliability and convergent validity (Wilhelm et al., 2016). Massachusetts General Hospital Hairpulling Scale (MGH Hairpulling Scale) (Keuthen et al., 1995) The MGH Hairpulling Scale is a seven-­item self-­report measure that assesses the severity of trichotillomania symptoms, including questions about attempts to stop pulling and perceived ability to control urges to pull hairs. This scale demonstrates good internal consistency and test-­retest reliability (O’Sullivan et al., 1995). Maddux, J. E., & Winstead, B. A. (Eds.). (2019). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from vuw on 2024-09-26 08:31:05.  164 | Shari A. Steinman et al. Behavioral Assessments Broadly, behavioral assessment is a clinician-­administered procedure used to obtain information about an individual’s observable behaviors. Behavioral assessment is typically more objective than subjective self-­report measures. When used to assess an anxiety or OCD, behavioral assessments provide information about disorder severity and the degree of avoidance that an individual exhibits. A commonly used method to assess behavior in anxiety and OCDs is Behavioral avoidance tasks (BATs). In BATs, an individual is asked to approach their feared object or situation until they wish to stop. For example, an individual with a phobia of spiders may be asked to go into a room with a caged spider, walk towards the cage, and finally touch the spider. How close (in distance or the number of steps completed) an individual gets to their feared stimulus before choosing to stop provides a measurement of the individual’s behavioral avoidance. BATs can provide a baseline assessment of avoidance, as well as act as a marker of progress throughout treatment or a measure of treatment outcome (Anderson, Rothbaum, & Hodges, 2003; Steketee, Chambless, Tran, Worden, & Gillis, 1996). BATs are commonly used in research settings as a way to assess the severity of social anxiety (Beidel, Turner, Jacob, & Cooley, 1989), OCD (Steketee et al., 1996), specific phobia (Garcia-­Palacios, Hoffman, Carlin, Furness, & Botella, 2002), and other anxiety-­related symptoms. Psychophysiological Assessments Psychophysiological assessments refer to the collection of physiological data (e.g., heart rate; skin conductance) that is related to psychological processes. Psychophysiological data is often used in research settings as a more objective measurement of fear responding (Lang, 1985). Psychophysiological data can also be used as a clinical tool, as a way to measure therapy outcome (Kozak, Foa, & Steketee, 1988), and as a target for intervention itself. For example, in biofeedback, individuals are trained to regulate their bodily processes (e.g., respiration, heart rate) to improve the severity of their psychological symptoms (Tolin, McGrath, Hale, Weiner, & Gueorguieva, 2017). Psychophysiological assessments for individuals with anxiety or OCRDs often focus on symptoms common to anxiety. Some examples of physiological constructs that one may assess in anxiety or OCRDs are electrodermal activity (i.e., skin conductance or sweat), end-­tidal CO2 (i.e., respiration), and heart rate variability. Electrodermal activity (EDA) refers to variations in skin conductance from electrical activity due to sweat secretions on the skin. Individuals who are experiencing autonomic arousal due to anxiety may show increased skin conductance compared to individuals who are not in an anxious or stressed state (Lader, 1967). Given this, EDA is often used as an objective measure of the fear response and of fear extinction (Dunsmoor, Campese, Ceceli, LeDoux, & Phelps, 2015). End-­tidal CO2 is a measure of the carbon dioxide present in exhaled breath; lower levels of end-­tidal CO2 (“hypocapnic”) often result from hyperventilation. Importantly, evidence of low end-­tidal CO2 can be seen across a variety of anxiety disorders and has been shown to predict treatment-­dropout in patients with anxiety and related disorders (Davies & Craske, 2014; Tolin, Billing- sley, Hallion, & Diefenbach, 2017). Heart rate variability (HRV) refers to the slight oscillations in beat-­to-­beat intervals in an individual’s heart rate, and results from the communication between the branches of the autonomic nervous system as it responds to stressors. Healthy hearts display high HRV, which indicates that the cardiac system is reactive and flexible in response to stressors (Thayer, Yamamoto, & Brosschot, 2010). Anxiety has been shown to be associated with decreased HRV (Chalmers, Quintana, Abbott, & Kemp, 2014). Treatment Evidence-­based cognitive-­behavioral interventions for anxiety and OCRDs are discussed in the following text. We focus primarily on treatments with strong empirical support, meaning that multiple well-­designed studies conducted by independent research teams support the intervention’s efficacy (Chambless & Hollon, 1998). Self-­guided and pharmacological treatment options are Copyright © 2019. Taylor & Francis Group. All rights reserved. briefly considered. Cognitive-­Behavioral Therapy Cognitive-­behavioral therapy (CBT) is a directive, problem-­focused, and time-­limited approach to treating anxiety. CBT is rooted in the idea that cognition, emotion, and behavior are interrelated and affect one another and that modifying any or all of these three factors may improve feelings of anxiety and avoidance behavior (Craske, 2010). Manualized versions of CBT usually consist of 12 to 16 sessions depending on the problem, although treatment often does not fall within this range in real-­world clinical settings. CBT has strong research support for most anxiety disorders and OCRDs (Chambless & Hollon, 1998; Society of Clinical Psychology, 2016). In addition, CBT is effective with adults, adolescents, and children (Higa-­McMillan, Francis, Rith-­Najarian, & Chorpita, 2016). Common components of CBT for anxiety include psychoeducation, cognitive restructuring, relaxation techniques, eliminating safety behaviors that provide temporary relief from anxiety, behavioral experiments and exposure, and relapse prevention (Leahy, Maddux, J. E., & Winstead, B. A. (Eds.). (2019). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from vuw on 2024-09-26 08:31:05.  Anxiet y Disorders and Obsessive-­C ompulsive and Related Disorders | 165 2018; Norton & Price, 2007). Cognitive restructuring entails changing negative patterns of thinking known as cognitive distortions. Probability overestimation (thinking an event is much more likely to occur than it actually is) and catastrophizing (the tendency to think the worst possible outcome will occur) are two of the more common cognitive distortions targeted in CBT for anxiety. Behav- ioral experiments involve testing a thought in a real-­life way to disconfirm anxiety-­congruent beliefs (McManus, Van Doorn, & Yiend, 2012). Exposure involves successively confronting an anxiety-­provoking stimulus with the two-­fold goal of learning that the feared outcome will likely not occur and that fear sensations in these situations are tolerable (Deacon & Abramowitz, 2004). Expo- sure differs from a behavioral experiment in that it may not be explicitly set up to testing the validity of a cognition (McMillan & Lee, 2010). CBT can be modified for certain problem behaviors in anxiety, OCD, and related disorders. In hoarding disorder for example, CBT may involve practice sorting, decision-­making, discarding items, and decluttering (Gail Steketee, Frost, Tolin, Rasmus- sen, & Brown, 2010). Specific variations of cognitive-­behavioral therapies include exposure therapy, exposure and response preven- tion, and acceptance and commitment therapy. Exposure Therapy Most forms of CBT involve exposure in some form; however, exposure treatment alone is effective for specific phobias (Society of Clinical Psychology, 2016). In exposure therapy, a client typically comes into contact with a feared stimulus in a gradual way. For example, consider Taylor who has a specific phobia of heights (acrophobia). In exposure therapy, Taylor would encounter progres- sively higher heights with the clinician’s assistance, such as buildings with several stories, elevators, bridges, ladders, and skyscrap- ers. In order to do exposure in a stepped approach (i.e., as opposed to rapid exposure to a feared situation, known as flooding), the client and clinician work together to build an exposure hierarchy ranking feared situations in order of anticipated anxiety and fear (Mathews et al., 1976). Then, exposures are conducted in session and through home-­practice in a systematic way toward the pro- gressively more feared situations. Exposures may be in vivo (in real-­life settings), imaginal (vividly pictured, imagined, and described), or through virtual reality (immersion with feared stimuli in virtual environments) depending on the needs of the individual client; each of these are effective (Hofmann & Smits, 2008; Parsons & Rizzo, 2008). Clinicians obtain ratings of client anxiety throughout therapy and during exposures to monitor progress and determine when to progress up the hierarchy (Katerelos, Hawley, Antony, & McCabe, 2008). Exposure therapy can be completed in as few as one to five sessions, and treatment effects can persist for a year or longer (Choy, Fyer, & Lipsitz, 2007). Exposure and Response Prevention Another variation on traditional CBT, exposure and response prevention (abbreviated to ERP or ExRP), has been shown to be par- ticularly effective for OCD (Gava et al., 2007; Rosa-­Alcázar, Sánchez-­Meca, Gómez-­Conesa, & Marín-­Martínez, 2008). In ERP, indi- viduals gradually and repeatedly confront the obsessive thoughts and anxiety-­provoking stimuli while not performing the compulsive behaviors normally used to alleviate anxiety in the short term (Abramowitz, 1996). Response prevention can be implemented gradually or all at once. For example, Jerry has obsessions related to contamination and safety. He ritualistically washes his hands up to a hundred times a day, especially when he is in public or interacting with people, and cleans household items and surfaces exces- sively. One component of response prevention for Jerry might be to have him touch a surface he felt was unclean and then go without washing his hands for a certain period of time. At the onset of therapy, that time frame the client and clinician arrive at together may be short, perhaps only five or ten minutes, but over the course of therapy, the time before he washes his hands can be gradually lengthened (e.g., one hour, three hours) and then eliminated completely. The goal for this client might be that at the end of therapy he is only washing his hands when it would normally be appropriate to do so rather than in a compulsive way. Some clients may be willing to eliminate some or all of their compulsions immediately. This stricter approach to eliminating compulsions may be more effective for OCD symptom reduction by increasing the intensity of exposures (Foa, Steketee, Grayson, Turner, & Latimer, 1984), although it comes with the drawback of temporarily increased distress. ERP typically lasts for approximately 10 to 12 weeks with sessions occurring once or twice per week (Friedman et al., 2003). Copyright © 2019. Taylor & Francis Group. All rights reserved. Acceptance and Commitment Therapy Acceptance and Commitment Therapy (ACT) and mindfulness-­based interventions are a more recent variation of traditional CBT (Arch & Craske, 2008), sometimes referred to as “third wave” CBT (the first and second wave being behavioral and cognitive inter- ventions, respectively). ACT and mindfulness-­based interventions for anxiety and OCD involve learning to live in the present moment, living a values-­based lifestyle, and nonjudgmentally accepting all of one’s emotions and experiences, even the distressing ones (Eifert & Forsyth, 2005). ACT includes a focus on cognitive defusion (detaching meaning from anxiety-­provoking, negative thoughts) and reducing experiential avoidance of private experiences (Masuda, Hayes, Sackett, & Twohig, 2004). While evidence for the effectiveness of ACT in treating anxiety and OCRDs is modest, it can be an effective adjunct to other treatment modalities or for mixed presentations of anxiety and depression (Society of Clinical Psychology, 2016). ACT can also be a helpful approach to complement other behavioral treatments. For example, habit reversal training and ACT appear to be an effective treatment for body-­ focused repetitive behaviors such as trichotillomania and excoriation disorder (Woods & Twohig, 2008). In habit reversal, repetitive, Maddux, J. E., & Winstead, B. A. (Eds.). (2019). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group