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Anxiety, Obsessive-Compulsive, and Trauma- T Related Disorders 5 C Angelina / What Do You Think? Speci...

Anxiety, Obsessive-Compulsive, and Trauma- T Related Disorders 5 C Angelina / What Do You Think? Special Features Worry, Anxiety, Fear, and Anxiety; Obsessive-Compulsive; and Trauma-Related Disorders: What Are They? CONTINUUM FIGURE 5.1 Worry, Anxiety, and Fear Along Anxiety, Obsessive-Compulsive, and Trauma-Related a Continuum 102 Disorders: Features and Epidemiology C Jonathan CONTINUUM FIGURE 5.2 Continuum of Emotions, Cognitions, and Behaviors Regarding Anxiety-Related C Marcus Disorders 102 Stigma Associated with Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders 5.1 FOCUS ON COLLEGE STUDENTS: Trauma and PTSD 116 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Causes and Prevention Anxiety, Obsessive-Compulsive, and Trauma-Related 5.2 FOCUS ON GENDER: Are There True Gender Differences in Anxiety-Related Disorders? 116 Disorders: Assessment and Treatment FINAL COMMENTS 5.3 FOCUS ON DIVERSITY: Anxiety-Related Disorders and Sociocultural Factors 117 THOUGHT QUESTIONS KEY TERMS V THE CONTINUUM VIDEO PROJECT Darwin / PTSD 125 Personal Narrative 5.1 Anonymous 128–129 5.4 FOCUS ON LAW AND ETHICS: The Ethics of Encouragement in Exposure-Based Practices 138 99 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203 100 CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders C / Angelina case Angelina was 25 years old when she was referred was also reluctant to date because she might to a specialized outpatient clinic for people with “seize up” and look foolish. Her greater con- anxiety-related disorders. She came to the clinic cern, however, was that she might have to after a scary episode in which she nearly had drop out of college even though she was near gyn9037/Shutterstock.com a car accident. Angelina said she was driving graduation. This belief arose from the fact that across a high bridge when she suddenly felt her on her way to her first day of class, Angelina heart start to race, her breath become short, and had driven across the bridge that led to her her vision become blurry. These feelings were so worst anxiety attack. The two other attacks intense she thought she might wreck the car and that followed also caused her to miss so many hurt herself or others. She was able to pull the something bad might happen. Angelina said she classes, she felt she had to drop all of them. car off to the shoulder of the bridge as she strug- was most concerned about the professor look- Angelina was thus sad and tearful, feeling gled with her symptoms. The symptoms seemed ing at her or being asked a question for which she would not be able to return to college and to ease a bit after a few minutes. Angelina then she did not have an answer. She was also con- finish her degree. waited another 20 minutes, still shaken from cerned other people would notice her physical Angelina now spent her days at home, and the experience, before driving straight home to symptoms of anxiety. her mother had driven her to the therapist’s where she felt safe. Angelina’s nervousness escalated a year office. She had trouble going to the supermar- The therapist who spoke to Angelina asked earlier when she began to experience specific ket or restaurants and preferred to avoid them if such an episode had happened before. episodes of intense anxiety. Angelina said her altogether. Even speaking to the therapist now Angelina said the experience had occurred first “anxiety attack” happened as she walked led Angelina to report an anxiety rating of 8 on several times, usually when she was driving or into class to take a midterm examination. a 0 to 10 scale. The therapist asked her what surrounded by many people. Angelina gener- Her heart began racing, and she was short she would like to see different in her life, and ally felt she could handle her symptoms during of breath. When the professor handed her Angelina said she wanted to be like her old these episodes. This last episode, though, and the test, she was shaking and having much self—someone who went to school, saw her two more that followed, were much more intense trouble concentrating. Angelina said she felt friends, dated, and enjoyed life. The therapist than what she had felt before. She recently she “wasn’t even there” and that “everything asked her if she could commit to a full-scale saw an emergency room doctor and a car- was moving in slow motion.” Worse, she felt assessment and treatment program, and Angelina diologist to determine any potential medical she could not concentrate well enough to take agreed to do so. causes for her symptoms, but none were found. the test. She did complete the test, however, Angelina was then referred for outpatient psy- and received a “B-minus” (she was normally What Do You Think? chological treatment. an “A/B” student). Other “anxiety attacks” 1. Which of Angelina’s symptoms seem The therapist asked more about Angelina’s after that point tended to occur when she was typical of someone in college, and which history with these symptoms. Angelina said going to school or about to enter a classroom. seem very different? she had always been “the nervous and worried These attacks happened about once a week 2. What external events and internal factors might be responsible for Angelina’s type” and that her anxiety worsened as she but not typically on weekends or when she was feelings? attended college. She had particular trouble not in school. 3. What are you curious about regarding driving to school and walking into class where Over the past few months, Angelina’s Angelina? other people were sitting and possibly looking “attacks” became more frequent and affected 4. Does Angelina remind you in any way of at her. Angelina usually sat in the back of the other, similar situations. Angelina would some- yourself or someone you know? How so? class in case she had to exit quickly to calm her- times have trouble driving to a local mall and 5. How might Angelina’s anxiety affect her life self. The therapist asked Angelina if she worried shopping among hundreds of people. She in the future? Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203  Worry, Anxiety, Fear, and Anxiety; Obsessive-Compulsive; and Trauma-Related Disorders: What Are They? 101 sense of dread and develop a study schedule to prevent failure. Worry is thus normal and even adaptive. Worry is often a grad- ual process that starts slowly for a distant event (oh, yeah, that test is coming) but becomes more intense as the event draws closer (uh-oh, better get studying). If the event draws closer and seems even more threatening, as when a test draws nearer and one is still not prepared, then anxiety may occur. Anxiety is an emotional state that occurs as a threaten- ing event draws close. Worry is more cognitive in nature, but anxiety has three key parts: physical feelings, thoughts, and be- haviors. Physical feelings may include heart racing, sweating, dry mouth, shaking, dizziness, and other unpleasant symptoms. Thoughts may include beliefs that one will be harmed or will lose control of a situation. Behaviors may include avoiding cer- tain situations or constantly asking others if everything will be OK (Davies, Niles, Pittig, Arch, & Craske, 2015; Sharp, Miller, & Heller, 2015). If you have a test tomorrow, and have not studied, then you may feel muscle tension (physical feeling), believe you will not do well (thought), and skip the test (behavior). Anxiety, like worry, is a normal human emotion that tells us something is wrong or needs to change. The three parts of anxiety often occur in a sequence. Think Image Source/Jupiterimages about a blind date. You might feel physically nervous as you are about to meet the other person for the first time—perhaps you will sweat, tremble a bit, or feel your heart race. You may then start to think the other person will notice your symptoms and that you will look foolish and be judged negatively. You may Anxiety involves a sense of apprehension that something bad might also be apprehensive about awkward pauses in the conversa- happen. tion or what the other person will say or look like. You may even decide to shorten the date or cancel it because of these feelings and beliefs. Many people with anxiety have a combina- tion of troublesome physical feelings, thoughts, and behaviors. Worry, Anxiety, Fear, and Anxiety; Think about Angelina—what were her major physical feelings, thoughts, and behaviors? Obsessive-Compulsive; and Trauma- Fear is an intense emotional state that occurs as a threat is Related Disorders: What Are They? imminent or actually occurring. Fear is a specific reaction that is clear and immediate: fright, increased arousal, and an over- H ave you ever been concerned that something bad will hap- whelming urge to get away (Beckers, Krypotos, Boddez, Effting, Bruce Laurance/The Image Bank/ pen? Have you ever been nervous about an upcoming & Kindt, 2013). A fear reaction is usually toward something well event? Have you ever been afraid of something, like Angelina defined. If you take a quiz you have not was? Some people worry a lot about what could happen in the studied for, you may experience se- future. Other people become nervous or anxious at the thought vere physical arousal and dread and Getty Images of going on a date, speaking in public, or taking a test. For oth- leave the situation quickly. Many ers, the sight of a snake or an airplane causes intense and im- people are afraid of snakes. If some- mediate fear. For people like Angelina, worry, anxiety, and fear one places a cobra nearby, you may can spiral into an uncontrollable state that makes them want to immediately become frightful and avoid many things such as school. But what are worry, anxiety, physically aroused, and run away and fear, and what are the differences among them? as quickly as possible. Fear is an Worry is a largely cognitive or “thinking” concept that re- ancient human feeling that fers to concerns about possible future threat. People who worry tells us we are in danger tend to think about the future and about what painful things and that we may have might happen. A person might worry about failing to pay bills to fight whatever on time or a future terrorist attack. Worry is not necessarily a bad thing because it helps people prepare for future events and solve problems (Deschênes, Dugas, & Gouin, 2016). If you have People often worry about daily events, such as school- or job-related a test next week and have not prepared for it, you may feel a tasks or finances. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203  102 CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders as a test comes closer in time and distance. Worry also tends CONTINUUM 5.1 Worry, Anxiety, and Fear to be a general and slow reaction that is cautionary, whereas FIGURE Along a Continuum moderate anxiety or apprehensiveness is more specific and often spurs a person into action (start studying!). Fear involves an im- WORRY ANXIETY FEAR mediate and focused reaction so a person can confront or flee a Potential threat Approaching threat Imminent threat certain situation. Worry, anxiety, and fear can also be viewed along a dimen- sion of severity. Worry, anxiety, and fear are normal human Little arousal Moderate arousal Severe arousal emotions, so all of us experience them to some extent. We worry (physical feelings) about the safety of our children, become anxious when about to perform or interview before others, and are frightened when Heavily cognitive Moderately cognitive Scarcely cognitive airplanes experience severe turbulence. These experiences are a common part of life, and many people learn to cope with them Little avoidance Moderate avoidance Severe avoidance successfully. Many people go on blind dates even when ner- vous, and they eventually relax and have a good time. Worry, © Cengage Learning ® anxiety, or fear may become more intense, however, to the point General and slow More focused and Very focused and fast reaction (caution) quicker reaction reaction (fight or flight) where a person finds it difficult to concentrate, finish a task, or (apprehensiveness) relax (see Figure 5.2). Worry, anxiety, and fear may even become severe and cre- ate enormous trouble for a person—this could be an anxiety, obsessive-compulsive, or trauma-related disorder (we sometimes is before us or flee the situation as quickly as possible (fight or refer to these collectively as anxiety-related disorders in this flight). Fear is thus normal and protects us from potential harm, chapter). People like Angelina with these kind of disorders have like when we jump away from a snake. Fear that is intense and persistent episodes of severe worry, anxiety, or fear that keep severe is panic. them from doing things they would normally like to do, such Differences among worry, anxiety, and fear can be illus- as shop, drive, attend school, or get a new job (Figure 5.2). An trated along a continuum or dimension (see Figure 5.1). Worry anxiety-related disorder can be less severe, as when a person occurs in reaction to potential threat, anxiety occurs in reaction worries so much about getting into a car accident that driving to approaching threat, and fear occurs in reaction to imminent is difficult. Or an anxiety-related disorder can be more severe, as threat. Worry is a largely cognitive concept that involves fewer when a person is so fearful of germs that she never leaves the physical feelings and less avoidance than anxiety or fear. A per- house. People with anxiety-related disorders generally experi- son may experience more physical feelings (arousal) and greater ence worry, anxiety, or fear that is severe, that lasts for long pe- desire to avoid or escape, however, as a threatening event such riods of time, and that interferes with daily living. We next cover CONTINUUM FIGURE 5.2 Continuum of Emotions, Cognitions, and Behaviors Regarding Anxiety-Related Disorders NORMAL MILD Emotions Slight physical arousal but good alertness. Mild physical arousal, perhaps feeling a bit tingly, but with good alertness. Cognitions “I’m going on a job interview today. I hope they like me. I’m “I’m going on a job interview today. I wonder if they will think going to show them what I’ve got!” badly of me. I hope my voice doesn’t shake.” Behaviors Going to the job interview and performing well. Going to the job interview but fidgeting a bit. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203  Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Features and Epidemiology 103 the major anxiety-related disorders that cause many people like Angelina so much distress. Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Features and Epidemiology T he following sections summarize the major features and characteristics of the most commonly diagnosed anxiety- related disorders. Many of the disorders in this chapter have anxiety as a key component and were historically studied as one diagnostic group. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the disorders were separated into smaller diagnostic groups labeled anxiety, obsessive-compulsive, and trauma- and stressor-related disorders (we shorten this latter label in this chapter). We first discuss the concept of a panic attack, which serves as a key part of several anxiety-related disorders. Panic Attack Have you ever felt scared for no reason? Perhaps you were just Marmaduke St. John/Alamy Stock Photo sitting or standing and suddenly felt intense fear out of the blue. If so, you may have experienced a panic attack similar to the ones Angelina reported. A panic attack involves a period of time, usually several minutes, in which a person experiences intense feelings of fear, apprehension that something terrible will happen, and physical symptoms. A panic attack is not a diagnosis but an event that commonly occurs in people with anxiety disorders. Features of a panic attack are listed in Fear is an intense emotional state that occurs when some threat is Table 5.1 (APA, 2013). imminent. ANXIETY-RELATED DISORDER—LESS ANXIETY-RELATED DISORDER—MORE MODERATE SEVERE SEVERE Moderate physical arousal, including shaking Intense physical arousal, including shaking, Extreme physical arousal with dizziness, heart and trembling, with a little more difficulty dizziness, and restlessness, with trouble palpitations, shaking, and sweating with great concentrating. concentrating. trouble concentrating. “Wow, I feel so nervous about “Oh, no that interview is today. I feel sick. I just don’t “No way can I do this. I‘m a total loser. I can’t get the interview today. I bet I think I can do this. They will think I’m an idiot!” that job. Why even bother? I don’t want to look don’t get the job. I wonder if I foolish!” should just forget about it?” Drafting two e-mails to Postponing the interview twice before finally going. Canceling the interview and staying home all day. cancel the interview but Appearing quite agitated during the interview and Inspirestock/Corbis not sending them. Going to unable to maintain eye contact. the interview but appearing physically nervous. © Cengage Learning ® Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203 104 CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders TABLE 5.1 DSM-5 TABLE 5.2 DSM-5 Panic Attack Panic Disorder Note: Symptoms are presented for the purpose of identifying a panic A. Recurrent unexpected panic attacks. A panic attack is an abrupt attack; however, panic attack is not a mental disorder and cannot be surge of intense fear or intense discomfort that reaches a peak coded. Panic attacks can occur in the context of any anxiety disorder within minutes, and during which time four (or more) of the as well as other mental disorders (e.g., depressive disorders, post- following symptoms occur: traumatic stress disorder, substance use disorders) and some medical Note: The abrupt surge can occur from a calm state or an anxious state. conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal). When 1. Palpitations, pounding heart, or accelerated heart rate. the presence of a panic attack is identified, it should be noted as a 2. Sweating. specifier (e.g., “posttraumatic stress disorder with panic attacks”). For 3. Trembling or shaking. panic disorder, the presence of panic attack is contained within the 4. Sensations of shortness of breath or smothering. criteria for the disorder and panic attack is not used as a specifier. 5. Feelings or choking. An abrupt surge of intense fear or intense discomfort that 6. Chest pain or discomfort. reaches a peak within minutes, and during which time four (or more) 7. Nausea or abdominal distress. of the following symptoms occur: 8. Feeling dizzy, unsteady, light-headed, or faint. Note: The abrupt surge can occur from a calm state or an anxious 9. Chills or heat sensations. state. 10. Paresthesias (numbness or tingling sensations). 1. Palpitations, pounding heart, or accelerated heart rate. 11. Derealization (feelings of unreality) or depersonalization 2. Sweating. (being detached from oneself). 3. Trembling or shaking. 12. Fear of losing control or “going crazy.” 4. Sensations of shortness of breath or smothering. 13. Fear of dying. 5. Feelings of choking. Note: Culture-specific symptoms should not count as one of the 6. Chest pain or discomfort. four required symptoms. 7. Nausea or abdominal distress. 8. Feeling dizzy, unsteady, light-headed, or faint. B. At least one of the attacks has been followed by 1 month (or more) 9. Chills or heat sensations. of one or both of the following: 10. Paresthesias (numbness or tingling sensations). 1. Persistent concern or worry about additional panic attacks or 11. Derealization (feelings of unreality) or depersonalization (being their consequences. detached from oneself). 2. A significant maladaptive change in behavior related to the 12. Fear of losing control or “going crazy.” attacks. 13. Fear of dying. C. The disturbance is not attributable to the physiological effects of a Note: Culture specific symptoms should not count as one of the four substance or another medical condition. required symptoms. D. The disturbance is not better explained by another mental disorder. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. Common physical symptoms include accelerated heart rate, thus involve many troubling physical symptoms and thoughts, shortness of breath, chest pain or discomfort, dizziness, and feel- two components of anxiety described earlier. ings of choking. People having a panic attack also often worry about dying, going “crazy,” or losing control and doing some- thing terrible. Angelina’s panic attack in her car led her to think Panic Disorder she might crash. Panic attacks may also involve feelings that sur- People who regularly experience unexpected panic attacks rounding events are not real (derealization) or that a person is have panic disorder, a diagnosis involving the DSM-5 criteria watching himself go through the situation (depersonalization). in Table 5.2 (APA, 2013). At least one of these attacks must Recall Angelina’s feeling of detachment when taking her test. be followed by a month or more of concern about having an- Panic attacks that occur out of the blue, or without warning other attack, worry about what the panic attack might mean, or predictability, are unexpected panic attacks. This can make or a change in behavior. Angelina did indeed worry about hav- panic attacks pretty scary. Some people even have panic attacks ing more attacks and wondered if she might have to drop out during sleep (Boland & Ross, 2015). Over time, a person with of school because of her attacks. Her driving behavior also panic attacks may be able to predict when these attacks are more changed drastically. Panic attacks and panic disorder must likely to occur. Angelina said her panic attacks tended to occur not be a result of substance use or a medical condition. Panic when she was driving or among crowds. An expected panic at- disorder is different from other anxiety disorders (see following tack has a specific trigger; for example, a person may experience sections) in which panic attacks are more closely linked to spe- severe panic symptoms when speaking in public. Panic attacks cific (or expected) situations such as public speaking. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203  Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Features and Epidemiology 105 Panic disorder is a frightening condition for several reasons. TABLE 5.3 DSM-5 First, a person often has little idea when a panic attack might happen. Panic attacks can occur frequently during the day or be Agoraphobia spaced out across several days. Imagine going places and always wondering if a panic attack might strike. Second, panic attacks A. Marked fear or anxiety about two (or more) of the following five are not harmful, but many people with panic disorder become situations: terrified of their own internal sensations of dizziness, heart pal- 1. Using public transportation. pitations, or other panic attack symptoms. Some people with 2. Being in open spaces. panic disorder may believe their symptoms indicate something 3. Being in enclosed places. serious such as a terminal heart condition or illness. People with 4. Standing in line or being in a crowd. 5. Being outside of the home alone. panic disorder thus fear the onset of more panic attacks. People with panic disorder, like Angelina or Professor Smith B. The individual fears or avoids these situations because of thoughts from Chapter 4, might avoid situations in which they may have that escape might be difficult or help might not be available in the panic symptoms. Some people with panic disorder may thus event of developing panic-like symptoms or other incapacitating or be diagnosed with agoraphobia. Agoraphobia refers to anxiety embarrassing symptoms. about being in places where panic symptoms may occur, espe- C. The agoraphobic situations almost always provoke fear or anxiety. cially places where escape might be difficult. Agoraphobia also D. The agoraphobic situations are actively avoided, require the pres- refers to avoiding those places or enduring them with great anxi- ence of a companion, or are endured with intense fear or anxiety. ety or dread (see Table 5.3; APA, 2013). About half of those with panic disorder develop agoraphobia, though agoraphobia appears E. The fear or anxiety is out of proportion to the actual danger posed more common among people with severe or chronic panic disor- by the agoraphobic situations and to the sociocultural context. der (Greene & Eaton, 2016; Nay, Brown, & Roberson-Nay, 2013). F. The fear, anxiety, or avoidance is persistent, typically lasting for Recall that behavioral avoidance is a main component of 6 months or more. anxiety. Angelina did not want to go to a restaurant because she G. The fear, anxiety, or avoidance causes clinically significant distress might have a panic attack and look foolish. Many people with or impairment in social, occupational, or other important areas of panic disorder stay close to exits or avoid potentially embarrass- functioning. ing situations. Some also develop agoraphobia so severe they cannot leave home. This can obviously lead to severe marital, H. If another medical condition is present, the fear, anxiety, or avoid- occupational, academic, and other problems. Angelina was cer- ance is clearly excessive. tainly on that path. I. The fear, anxiety, or avoidance is not better explained by the symp- toms of another mental disorder—for example, the symptoms are not confined to specific phobia, situational type; do not involve only social Social Phobia situations (as in social anxiety disorder); and are not related exclu- Do you feel nervous when doing something in front of others? sively to obsessions (as in obsessive-compulsive disorder), perceived Do you cringe when asked to speak in public or meet someone defects or flaws in physical appearance (as in body dysmorphic for the first time? Many people feel nervous in these situations, disorder), reminders of traumatic events (as in posttraumatic stress which is normal. We are concerned about what other people disorder), or fear or separation (as in separation anxiety disorder). think of us and what the consequences might be if they respond Note: Agoraphobia is diagnosed irrespective of the presence of negatively to us. Most of us, however, can control or disregard panic disorder. If an individual’s presentation meets criteria for panic our anxiety in these situations and function well. For other peo- disorder and agoraphobia, both diagnoses should be assigned. ple, social anxiety is a crippling phenomenon that makes casual American Psychiatric Association. (2013). Diagnostic and statistical manual of conversations or other interactions extremely difficult. mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. Social phobia, also called social anxiety disorder, is marked by intense and ongoing fear of potentially embarrassing social or performance situations. A diagnosis of social phobia involves had trouble dating, answering questions in class, and shopping the DSM-5 criteria in Table 5.4 (APA, 2013). Social situations and eating in front of others. These are all situations where she include interactions with others, such as dating, having con- could be negatively evaluated. Social avoidance can obviously versations, or attending parties. Performance situations include interfere with one’s ability to live a normal life. People with some evaluation from others, such as taking a test, giving an social phobia find it difficult to attend school, take high-profile oral presentation, or playing a musical instrument at a recital. jobs, and make and keep friends. People with social phobia are extremely fearful they will act in Many people with social phobia believe they will do some- a way that causes great personal embarrassment or humiliation thing “dumb” or “crazy” to make them appear foolish before in these situations. others. They may fear stuttering, fainting, freezing, or shaking People with social phobia may have expected panic attacks around other people. They know their fear is excessive and un- in social and performance settings and avoid these settings. Or reasonable, but they still have trouble doing what they must, such they endure the settings with great anxiety or dread. Angelina as chatting during a job interview (Morrison & Heimberg, 2013). Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203 106 CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders TABLE 5.4 DSM-5 TABLE 5.5 DSM-5 Social Anxiety Disorder (Social Phobia) Specific Phobia A. Marked fear or anxiety about one or more social situations in which A. Marked fear or anxiety about a specific object or situation. the individual is exposed to possible scrutiny by others. Note: In children, the fear or anxiety may be expressed by crying, Note: In children, the anxiety must occur in peer settings and not tantrums, freezing, or clinging. just during interactions with adults. B. The phobic object or situation almost always provokes immediate B. The individual fears that he or she will act in a way or show anxiety fear or anxiety. symptoms that will be negatively evaluated (i.e., will be humiliating C. The phobic object or situation is actively avoided or endured with or embarrassing; will lead to rejection or offend others). intense fear or anxiety. C. The social situations almost always provoke fear or anxiety. D. The fear or anxiety is out of proportion to the actual danger posed Note: In children, the fear or anxiety may be expressed by crying, by the specific object or situation and to the sociocultural context. tantrums, freezing, clinging, shrinking, or failing to speak in social situations. E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. D. The social situations are avoided or endured with intense fear or anxiety. F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of E. The fear or anxiety is out of proportion to the actual threat posed functioning. by the social situation and to the sociocultural context. G. The disturbance is not better explained by the symptoms of F. The fear, anxiety, or avoidance is persistent, typically lasting for another mental disorder. 6 months or more. American Psychiatric Association. (2013). Diagnostic and statistical manual of G. The fear, anxiety, or avoidance causes clinically significant distress mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. or impairment in social, occupational, or other important areas of functioning. H. The fear, anxiety, or avoidance is not attributable to the physiological encounter a dog, airplane, clown, or whatever they fear. Specific effects of a substance or another medical condition. phobias are arranged into five types: I. The fear, anxiety, or avoidance is not better explained by the symp- Animal phobias involve fears of—you guessed it, animals— toms of another mental disorder, such as panic disorder, body especially dogs, rodents, insects, and snakes or other reptiles. dysmorphic disorder, or autism spectrum disorder. Natural environment phobias involve fears of surrounding J. If another medical condition is present, the fear, anxiety, or avoid- phenomena such as heights, water, and weather events ance is clearly unrelated or is excessive. such as thunderstorms. American Psychiatric Association. (2013). Diagnostic and statistical manual of Blood-injection-injury phobias involve fears of needles, mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. medical procedures, and harm to self. Situational phobias involve fears of specific areas such as enclosed spaces in airplanes and elevators. People with social phobia may even have trouble with simple things like using a debit card in a store, using a public restroom, Other phobias involve any other intense fear of a specif- ic object. Examples include more common ones such as or getting together with friends at a mall. If someone with social iophobia (fear of poison) but also unusual ones such as phobia fears only speaking or performing in public, then the dis- levophobia (fear of things to one’s left), arachibutyrophobia order is specified as performance only. (fear of peanut butter sticking to the roof of the mouth), and hippopotomonstrosesquippedaliophobia (you guessed Specific Phobia it—fear of long words). We mentioned that most people are leery of snakes, so this kind of fear is normal. For other people, though, fear is so Generalized Anxiety Disorder strong and pervasive that it interferes with daily functioning. Do you ever get concerned about many things, large and small? Think about a fear of snakes so strong a person cannot walk If you do, welcome to the human race, especially if you are a in his yard or go to the park. Such is the case for some people student. Many people worry about what could happen, espe- with specific phobia. cially in this day and age with threats everywhere. We seem to A specific phobia is an excessive, unreasonable fear of a read every day about terrible events such as terrorist attacks and particular object or situation. A diagnosis of specific phobia devastating weather. Knowing about these things and wonder- involves the DSM-5 criteria in Table 5.5 (APA, 2013). People ing if they might happen to us naturally makes us uptight and with specific phobia may have expected panic attacks when they worried. Such worry is normal. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203  Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Features and Epidemiology 107 TABLE 5.6 DSM-5 Generalized Anxiety Disorder A. Excessive anxiety and worry (apprehensive expectation), occur- ring more days than not for at least 6 months, about a number of events or activities. B. The individual finds it difficult to control the worry. C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Note: Only one item is required in children. 1. Restlessness or feeling keyed up or on edge. 2. Being easily fatigued. 3. Difficulty concentrating or mind going blank. 4. Irritability. 5. Muscle tension. 6. Sleep disturbance. D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Dennis Jacobsen/Shutterstock.com E. The disturbance is not attributable to the physiological effects of a substance or another medical condition (e.g., hyperthyroidism). F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder). American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. Many people are afraid of spiders, but a phobia of spiders, known as arachnophobia, involves a more intense and irrational fear. We mentioned that worry is an adaptive phenomenon that concentrating. Generalized anxiety disorder and worry are helps us prepare for and solve problems. Worry is also some- largely cognitive concepts, so physical and behavioral symp- thing most of us can control and put aside when we have to toms are less prominent than what is seen in panic disorder concentrate. Many people can put aside their worries about and social and specific phobias. People with generalized anxi- the upcoming weekend as they prepare a Wednesday dinner. ety disorder do not focus on internal symptoms of panic but Worry is thus usually normal and controllable. For other people, more on potential external threats (Chen et al., 2013). They though, worry is so strong and persistent it interferes with their also believe these threats to be dangerous or full of dire con- ability to work, make decisions, and relax. sequences. One might worry excessively that not paying a bill Generalized anxiety disorder involves extreme levels of 15 days early will result in a damaged credit rating and inability worry about various events or activities. A diagnosis of gener- to buy a new car. alized anxiety disorder involves the DSM-5 criteria in Table 5.6 The key aspect of generalized anxiety disorder, worry, is re- (APA, 2013). People with generalized anxiety disorder have trou- ported by many people to be a lifelong problem. Generalized ble controlling their worry and thus often have trouble concentrat- anxiety disorder is often the first of several anxiety and other ing, sleeping, or resting. Those with generalized anxiety disorder mental disorders a person may have (Newman, Llera, Erickson, often worry excessively about minor things such as paying bills or Przeworski, & Castonguay, 2013). Recall Angelina said she was picking up their children on time. Such worry is not in proportion always the “nervous and worried type.” Generalized anxiety dis- to actual risk or problems. Many people worry about paying bills order that develops early in life is not associated with a specific when their homes are near foreclosure, but people with gener- life event, or trigger, but later-onset generalized anxiety disor- alized anxiety disorder might worry about paying bills when no der often is related to a particular stressor such as bankruptcy. financial problems exist. Other common worries of those with Generalized anxiety disorder is perhaps the least reliably diag- generalized anxiety disorder include health issues, chores, being nosed of the major anxiety disorders. Uncontrollable and exces- on time, work-related tasks, and competence in different activities. sive worry, muscle tension, and scanning the environment for You may have noticed from Table 5.6 that people with threats, however, are key symptoms that separate generalized generalized anxiety disorder do not usually experience panic anxiety disorder from other anxiety disorders (Prater, Hosanagar, attacks but rather have muscle tension or trouble sleeping and Klumpp, Angstadt, & Phan, 2013; Rutter & Brown, 2015). Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203 108 CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders C / Jonathan case TABLE 5.7 DSM-5 Jonathan was a 33-year-old man in therapy for behaviors that recently cost Obsessive-Compulsive Disorder him his job and that were threatening his marriage. Jonathan said he had A. Presence of obsessions, compulsions, or both: overwhelming urges to check things to see if they were in place and to order Obsessions are defined by (1) and (2): things if they were not. Jonathan said he would go to work and spend the first 1. Recurrent and persistent thoughts, urges, or images that are 3 hours organizing his desk, office, e-mail messages, and computer files. He experienced, at some time during the disturbance, as intrusive would also check other offices to see if things were grossly out of place, such and unwanted, and that in most individuals cause marked as plants, wastebaskets, and keyboards. He did this so often his coworkers anxiety or distress. complained that Jonathan spent more time with them than in his own office. 2. The individual attempts to ignore or suppress such thoughts, Jonathan did get some work done, but he usually could not concentrate for urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion). more than 3 hours per day. He was fired for his lack of productivity. Jonathan said he often had troubling thoughts about things being out of Compulsions are defined by (1) and (2): order. He told his therapist he worried that disorganization would lead him to 1. Repetitive behaviors (e.g., hand washing) or mental acts (e.g., repeating words silently) that the individual feels driven to forget important pieces of information such as what bills needed to be paid perform in response to an obsession or according to rules that and what reports were due. He spent so much time organizing items at work must be applied rigidly. and home, however, that he could accomplish little else. His wife recently 2. The behaviors or mental acts are aimed at preventing or threatened to leave if Jonathan did not seek professional help. Jonathan also reducing anxiety or distress, or preventing some dreaded event said he felt depressed and wished he “could think like a normal person.” or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Note: Young children may not be able to articulate the aims of these behaviors or mental acts. Obsessive-Compulsive Disorder B. The obsessions or compulsions are time-consuming or cause Many of us have little rituals or habits, or compulsions, we do clinically significant distress or impairment in social, occupational, every day to keep order or check on things, but not to the ex- or other important areas of functioning. tent Jonathan does. Keeping things in place has its advantages in a competitive workplace or if you want to find something C. The obsessive-compulsive symptoms are not attributable to the at home. Checking the windows and doors at night before go- physiological effects of a substance or another medical condition. ing to bed can also protect against disaster. For other people, D. The disturbance is not better explained by the symptoms of rituals or compulsions are associated with painful thoughts, or another mental disorder (e.g., excessive worries, as in generalized obsessions, and become overly time-consuming, distressing, anxiety disorder). and destructive. Obsessions can also come in the form of con- American Psychiatric Association. (2013). Diagnostic and statistical manual of stant ideas, impulses, or even images. mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. Obsessive-compulsive disorder involves (1) obsessions, or troublesome thoughts, impulses, or images, and/or (2) compul- sions, or ritualistic acts done repeatedly to reduce anxiety from a row that the person misses school or work that day. Com- the obsessions. A diagnosis of obsessive-compulsive disorder in- pulsions other than checking include hand washing, ordering, volves the DSM-5 criteria in Table 5.7 (APA, 2013). Obsessions counting, silently repeating words or phrases, and seeking reas- occur spontaneously, frequently, and intrusively, meaning they surance from others. Hand washing usually occurs in response are unwanted by the person but uncontrollable. Obsessions may to a contamination obsession—a person may obsess about mas- also be quite strange—one might have images or thoughts of sive bacteria on her hand and then wash vigorously and often massive bacteria on doorknobs or coins. This is a contamina- to compensate. Obsessions and compulsions occur nearly every tion obsession. Other common obsessions include the following: day and interfere with a person’s ability to concentrate or work. Doubt, such as concern about leaving the front door open Compulsions may take place at least 1 hour per day, but often last much longer. Counting your change when you get home from Need for order, such as need to have shoes organized by size school might be normal, but counting the change so many times and type or food organized by expiration date you take hours doing so might indicate obsessive-compulsive dis- Impulses toward aggression, such as intolerable thoughts order. Many people with little rituals are not disturbed by their be- about harming an infant havior, but people with obsessive-compulsive disorder find their Sexual imagery, such as recurrent mental pictures of pornography obsessions and compulsions to be extremely distressing. Compulsions are motor behaviors or mental acts performed in response to an obsession. Someone who obsesses about the Obsessive-Compulsive-Related Disorders front door being open will keep checking the door to make sure DSM-5 includes disorders that are related to obsessive-compulsive it is closed and locked. This may continue so many times in disorder. Hoarding disorder refers to people who have persistent Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203  Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Features and Epidemiology 109 TABLE 5.8 DSM-5 Body Dysmorphic Disorder A. Preoccupation with one or more perceived defects or flaws in physi- cal appearance that are not observable or appear slight to others. B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns. C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. breasts will shrink into one’s body and cause death (Promodu, Nair, & Pushparajan, 2012). The disorder may also be similar to shubo-kyofu, a phobia among some Japanese who fear a deformed face or body (Hofmann & Hinton, 2014). wollertz/Fotolia LLC Posttraumatic Stress Disorder and Acute Stress Disorder Many people with obsessive-compulsive disorder will perform certain The disorders discussed so far are often linked to regularly occur- rituals more often than usual, such as this woman, who trims her grass ring events like public speaking. Other disorders—posttraumatic with a pair of scissors several hours every day. stress and acute stress disorder—follow a specific traumatic event. DSM-5 lists these as trauma- and stressor-related disorders. difficulty parting with possessions, who feel they need to save items, and who experience cluttered living areas. Other related disorders include people who continually pull out their own hair C / Marcus case (trichotillomania) or pick their skin (excoriation excoriation disorder disorder). Marcus was a 27-year-old man in therapy for symptoms following a trau- Another disorder in this section, body dysmorphic dis- order, was once grouped with somatic symptom disorders matic event. Marcus was about to enter a shopping mall at night two months (Chapter 6) but is now thought to be more closely related to ago when two men threatened him with a gun and demanded his wallet. obsessive-compulsive behavior. A diagnosis of body dysmorphic Marcus was initially shocked the event was occurring and thus hesitated, disorder involves the DSM-5 criteria in Table 5.8 (APA, 2013). which prompted one of the men to strike him in the face. Marcus then gave People with body dysmorphic disorder are preoccupied with an his wallet to the men, who fled. A shaken Marcus called police to report the imaginary or slight “defect” in their appearance. Many people incident and was taken to the hospital for treatment. The two assailants had with this disorder worry excessively about minor alterations in not yet been caught at the time of Marcus’s therapy. facial features, hair, wrinkles, skin spots, and size of body parts Marcus said he had been having trouble sleeping at home and concentrat- like noses or ears. Many of us are concerned with our appearance, ing at work. The latter was especially problematic because he was an accoun- but people with body dysmorphic disorder are so preoccupied tant. He also felt he was living his life in a “slow motion fog” and that people they may spend hours per day checking and grooming themselves seemed very distant from him. He increasingly spent time at home and avoided or they may visit cosmetic surgeons and undergo several surgeries major shopping areas and large parking lots, especially at night. Marcus also to correct imagined or minor flaws (Phillips, 2015). People with body dysmorphic disorder may be unable to date or work because feared the gunmen would find and rob him again because they had his driv- of deep embarrassment about some perceived body flaw. er’s license. Most distressing, however, were Marcus’s recurring images of the Body dysmorphic disorder has some similarities to koro, a event; he said, “I just can’t get the whole scene out of my mind.” He thus tried syndrome among people in West Africa and Southeast Asia who to block thoughts about the trauma as much as possible, with little success. fear that external genitalia and body parts such as nipples or Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203  110 CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders Have you ever been in a situation where you felt terrified, helpless, or extremely vulnerable? Some people experience traumatic events in their life, events so disturbing they produce changes in behavior and personality. Think about people victim- ized by the 9/11 terrorist attacks, Hurricane Katrina, the tsunami Thierry Chesnot/Getty Images News/Getty Images in Japan, recent earthquakes, or soldiers who faced constant danger in Iraq or Afghanistan. Some people can eventually deal with these stressors as they fade in memory over time. Other people like Marcus, however, find recovery from trauma to be a long and painful process. Posttraumatic stress disorder is marked by frequent re- experiencing of a traumatic event through images, memories, nightmares, flashbacks, or other ways. A diagnosis of post- traumatic stress disorder (PTSD) involves the DSM-5 criteria in People react in the aftermath of the Paris attacks. Trauma from events Table 5.9 (APA, 2013). Marcus’s images of his trauma con- such as terrorism can cause posttraumatic stress disorder in some stantly entered his mind. He also became upset at reminders people. of the trauma, such as walking through a large parking lot at TABLE 5.9 DSM-5 Posttraumatic Stress Disorder Note: The following criteria apply to adults, adolescents, and children older than 6 years. For children 6 years and younger, see corresponding criteria below. A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content. 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play. 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: 1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203  Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Features and Epidemiology 111 TABLE 5.9 DSM-5 Posttraumatic Stress Disorder—cont’d 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”). 3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 5. Markedly diminished interest or participation in significant activities. 6. Feelings of detachment or estrangement from others. 7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. 2. Reckless or self-destructive behavior. 3. Hypervigilance. 4. Exaggerated startle response. 5. Problems with concentration. 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Specify whether: With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following: 1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly). 2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures). Specify if: With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate). Posttraumatic Stress Disorder for Children 6 Years and Younger A. In children 6 years and younger, exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic events(s). 2. Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers. Note: Witnessing does not include events that are witnesses only in electronic media, television, movies, or pictures. 3. Learning that the traumatic event(s) occurred to a parent or caregiving figure. B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: Spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment. 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: It may not be possible to ascertain that the frightening content is related to the traumatic event. 3. Dissociative reactions (e.g., flashbacks) in which the child feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Such trauma-specific reenactment may occur in play. 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to reminders of the traumatic event(s). continued Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203 112 CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders TABLE 5.9 DSM-5 Posttraumatic Stress Disorder—cont’d C. One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s), or negative altera- tions in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s): Persistent Avoidance of Stimuli 1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s). 2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the t