Anxiety Disorder

Anxiety Disorder – Introduction

Everyone experiences anxiety at some point of their lives and this is because anxiety is a normal human emotion. Anxiety is the body’s natural way of responding to stress. Anxiety is not always negative, and can have life-saving qualities. However, it can also be negative and debilitating. Anxiety has played a key role in psychodynamic theory, neuroscience focused research and cognitive behavioural principles.

Anxiety disorders also make up common groups of psychiatric disorders. This article will focus on anxiety disorders by discussing the difference between fear and anxiety, and thereafter looking at the different types of anxiety disorders. The specific types of anxiety disorders that will be discussed are generalized anxiety disorder, panic disorder, phobias with specific focus on agoraphobia, and lastly, obsessive-compulsive disorder.

Anxiety – South Africa

One in four people meet the diagnostic criteria for at least one anxiety disorder (Sadock, Sadock & Ruiz, 2015). South Africa is no different, a study conducted by Williams, Herman, Stein, Heeringa, Jackson, Moomal and Kessler (2008) revealed that anxiety disorders are very common amongst South Africans. Anxiety disorders include disorders that share features of excessive fear and anxiety and related behavioural disturbances.

Panic attacks feature prominently within the anxiety disorders, but are not limited to anxiety disorders and can also be seen in other mental disorders. There is often a relationship between stress and anxiety, as anxiety is one of the responses that people may have in relation to stress. If the ego is not functioning well with response to stress, and imbalance continues for a long time, the person may experience chronic anxiety, which is anxiety over one’s lifetime (Sadock, Sadock & Ruiz, 2015).

Anxiety disorders differ from one another in the types of objects or situations that induce fear, anxiety, or avoidance behaviours, and the associated cognitive ideation. Thus, while the anxiety disorders tend to be highly comorbid with each other, they can be differentiated by close examination of the types of situations that are feared or avoided and the content of the associated thoughts or beliefs. (APA, 2013, p. 189).

Anxiety can also have positive effects in our lives, for example, anxiety might assist someone who needs to prepare for an exam by helping them study under stressful situations in order to pass that exam. One might avoid a ball that was thrown at their head to prevent an injury that would have otherwise occurred, or running to catch the last bus might prevent one from missing the last transport available for them to get home.

Anxiety – Obsessive-Compulsive

Obsessive-compulsive and related disorders include obsessive-compulsive disorder (OCD), body dysmorphic disorder, hoarding disorder, trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, substance/medication-induced obsessive-compulsive and related disorder, obsessive-compulsive and related disorder due to another medical condition, and other specified obsessive-compulsive and related disorder and unspecified obsessive-compulsive and related disorder (e.g. body-focused repetitive behaviour disorder, obsessional jealousy).

OCD is characterized by the presence of obsessions and/or compulsions. Obsessions are recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, whereas compulsions are repetitive behaviours or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly (Stein, 2002).

Some other obsessive-compulsive and related disorders are also characterized by preoccupations and by repetitive behaviours or mental acts in response to the preoccupations. Other obsessive-compulsive and related disorders are characterized primarily by recurrent body-focused repetitive behaviours (e.g. hair pulling, skin picking) and repeated attempts to decrease or stop the behaviours. (APA, 2013, p. 235).

Olfactory reference syndrome is a belief that one has foul body odour that is not perceived by other people, the repetitive behaviour would be bathing or changing clothes repeatedly (Sadock, Sadock & Ruiz, 2015). It needs to be noted that OCD is different from obsessive-compulsive personality disorder. The obsessive-compulsive personality disorder relates to the preoccupation with details, perfectionism, neatness and similar personality traits (Sadock, Sadock & Ruiz, 2015).

Fear versus Anxiety

Although there are many similarities between fear and anxiety, these are two very different concepts (Ohman, 1993; Ohman, 2008). These two states overlap but also differ, with fear more associated with surges of autonomic arousal necessary for fight or flight, thoughts of immediate danger, and escape behaviours; and anxiety more often associated with muscle tension and vigilance in preparation for future danger and cautious or avoidant behaviours (APA, 2013).

They are both associated with intense negative feelings and strong bodily manifestations (Ohman, 2008). Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of a future threat. Fear is a response to a known external, definite threat, whereas anxiety is an alerting signal, which warns of a future threat or danger (Sadock, Sadock & Ruiz, 2015). This particular threat may be real or unreal. Anxiety assists the person by encouraging them to act in a way that may prevent or postpone this future threat or danger (Ohman, 1993; Ohman, 2008).

Ohman (2008) theorised that anxiety is unresolved fear. He further said that fear is a focused response to external stimuli (e.g. phobias). If this fear is not processed or dealt with, it is likely to result in anxiety, which is unfocused, the result of which would be a panic attack relating to those phobias. This is how fear is related to panic attacks.

Although a panic attack forms part of anxiety disorders, it is related to fear, as it is unresolved fear from the past. Another alternative is that the unresolved fear may cause constant mental preoccupations, which would result in generalized anxiety disorder. This example demonstrates how fear penetrates and relates to different anxiety disorders.

Clinical Features of Anxiety Disorders

Generalized Anxiety Disorder

People who seem anxious about almost everything in their lives are classified as having generalized anxiety disorder (Sadock, Sadock & Ruiz, 2015). This worry is often difficult to control or stop. People diagnosed with GAD often say that they have been anxious for as long as they can remember, this is the reason why GAD is considered a chronic illness (Tyrer & Baldwin, 2006).

Some studies have reported that there is a relationship between GAD and stress, which means that the more chronically stressed an individual is, the more likely they are to develop GAD (Sramek, Zarotsky & Cutler, 2002). Women are twice as likely to be diagnosed with GAD than men are (Tyrer & Baldwin, 2006).

Diagnostic Criteria

  1. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

  2. The individual finds it difficult to control the worry

  3. 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 (difficulty falling or staying asleep, or restless, unsatisfying sleep)

  1. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  2. The disturbance is not attributable to the physiological affects of a substance (e.g. a drug of abuse, medication) or another medical condition (e.g. hyperthyroidism)

  3. The disturbance is not better explained by another mental disorder (e.g. anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder (social phobia), contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder) (APA, 2013, p. 222)


Diagnostic Features

The essential feature of generalized anxiety disorder is excessive anxiety and worry (apprehensive expectation) about a number of events or activities. The intensity, duration, or frequency of the anxiety and worry is out of proportion to the actual likelihood or impact of the anticipated events. The individual finds it difficult to control the worry and to keep worrisome thoughts from interfering with attention to tasks at hand. Adults with generalized anxiety disorder often worry about everyday, routine life circumstances, such as possible job responsibilities, health and finances, the health of family members, misfortune to their children, or minor matters (e.g. doing household chores or being late for appointments).” (APA, 2013, p. 222)

Children with generalized anxiety disorder tend to worry excessively about their competence or the quality of their performance. During the course of the disorder, the focus of worry may shift from one concern to another. Several features distinguish generalized anxiety disorder from nonpathological anxiety. First, the worries associated with GAD are excessive and typically interfere significantly with psychosocial functioning, whereas the worries of everyday life are not excessive and are perceived as more manageable and may be put off when more pressing matters arise.” (APA, 2013, p. 222)

Second, the worries associated with generalized anxiety disorder are more pervasive, pronounced, and distressing; have longer duration; and frequently occur without precipitants. The greater the range of life circumstances about which a person worries (e.g. finances, children’s safety, job performance), the more likely his or her symptoms are to meet criteria for GAD. Third, everyday worries are much less likely to be accompanied by physical symptoms (e.g. restlessness or feeling keyed up or on edge). Individuals with GAD report subjective distress due to constant worry and related impairment in social, occupational, or other important areas of functioning. (APA, 2013)


Individuals whose presentation meets the criteria for GAD are likely to have met, or currently meet, criteria for other anxiety and unipolar depressive disorders. The neuroticism or emotional liability that underpins this pattern of comorbidity is associated with temperamental antecedents and genetic and environmental risk factors shared between these disorders, although independent pathways are also possible. Comorbidity with substance use, conduct, psychotic, neurodevelopmental, and neurocognitive disorders is less common. (APA, 2013)

Panic Disorder

A panic attack is defined as an acute intense attack of anxiety accompanied by feelings of impending doom (Sadock, Sadock & Ruiz, 2015); it can also be described as an intense state of fear (Reiss, 1991). Patients with panic disorder have an increased likelihood of having experienced stressful life events at some point of their lives that they struggled to process.

Diagnostic Criteria

  1. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:

Note: The abrupt surge can occur from a calm state or an anxious state.

  1. Palpitations, pounding heart, or accelerated heart rate

  2. Sweating

  3. Trembling or shaking

  4. Sensations of shortness of breath or smothering

  5. Feelings of choking

  6. Chest pain or discomfort

  7. Nausea or abdominal distress

  8. Feeling dizzy, unsteady, light headed or faint

  9. Chills or heat sensations

  10. Paresthesias (numbness, or tingling sensations)

  11. Derealization (feelings of unreality) or depersonalization (being detached from one-self)

  12. Fear of losing control or “going crazy”

  13. Fear of dying

Note: Culture-specific symptoms (e.g. tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

  1. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:

  1. Persistent concern or worry about additional panic attacks or their consequences (e.g. losing control, having a heart attack, “going crazy”).

  2. A significant maladaptive change in behaviour related to the attacks (e.g. Behaviours designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).

  1. The disturbance is not attributable to the physiological effects of a substance (e.g. a drug of abuse, medication) or another medical condition (e.g. hyperthyroidism, cardiopulmonary disorders).

  2. The disturbance is not better explained by another mental disorder (e.g. the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder). (APA, 2013, p. 208-209)


Diagnostic Features

Panic disorder refers to recurrent unexpected panic attacks (Criterion A). A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four or more of a list of 13 physical and cognitive symptoms occur. The term recurrent literally means more than one unexpected panic attack. The term unexpected refers to a panic attack for which there is no obvious cue or trigger at the time of occurrence- that is, the attack appears to occur from out of the blue, such as when the individual is relaxing or emerging from sleep (nocturnal panic attack).

In contrast, expected panic attacks are attacks for which there is an obvious cue or trigger, such as a situation in which panic attacks typically occur. The determination of whether panic attacks are expected or unexpected is made by the clinician, who makes this judgement based on a combination of careful questioning as to the sequence of events preceding or leading up to the attack and the individual’s own judgement of whether or not the attack seemed to occur for no apparent reason. Cultural interpretations may influence the assignment of panic attacks as expected or unexpected.” (APA, 2013, p. 208-209)

The frequency and severity of panic attacks vary widely. In terms of frequency, there may be moderately frequent attacks (e.g. one per week) for months at a time, or short bursts of more frequent attacks (e.g. daily) separated by weeks or months without any attacks or with less frequents attacks (e.g. two per month) over many years. Persons who have infrequent panic attacks resemble persons with more frequent panic attacks in terms of panic attack symptoms, demographic characteristics, comorbidity with other disorders, family history, and biological data.

In terms of severity, individuals with panic disorder may have both full-symptom (four or more symptoms) and limited-symptom (fewer than four symptoms) attacks, and the number and type of panic attack symptoms frequently differ from one panic attack to the next. However, more than one unexpected full-symptom panic attack is required for the diagnosis of panic disorder.” (APA, 2013, p. 208-209)

The worries about panic attacks or their consequences usually pertain to physical concerns, such as worry that panic attacks reflect the presence of life-threatening illnesses (e.g. cardiac disease, seizure disorder); social concerns, such as embarrassment or fear of being judged negatively by others because of visible panic symptoms’ and concerns about mental functioning, such as “going crazy” or losing control (Criterion B).

The maladaptive changes in behaviour represent attempts to minimize or avoid panic attacks or their consequences. Examples include avoiding physical exertion, reorganising daily life to ensure that help is available in the event of a panic attack, restricting usual daily activities, and avoiding agoraphobia-type situations, such as leaving home, using public transportation, or shopping. (APA, 2013)


Panic disorder infrequently occurs in clinical settings in the absence of other psychopathology. The prevalence of panic disorder is elevated in individuals with other disorders, particularly other anxiety disorders (and especially agoraphobia), major depression, bipolar disorder, and possibly mild alcohol use disorder. While panic disorder often has an earlier age onset than the comorbid disorder(s), onset sometimes occurs after comorbid disorder and may be seen as a severity marker of the comorbid illness.

Reported lifetime rates of comorbidity between major depressive disorder and panic disorder vary widely, ranging from 10% to 65% in individuals with panic disorder. In approximately one third of individuals with both disorders, the depression precedes the onset of panic disorder. In the remaining two thirds, depression occurs coincident with or following the onset of panic disorder (APA, 2013). This has often sparked debate as to whether the depression is the reason for the onset of panic disorder, or whether the panic disorder leads to one being diagnosed with depression.” (APA, 2013, p. 208-209)

A subset of individuals with panic disorder develop a substance-related disorder, which for some represents an attempt to treat their anxiety with alcohol or medications. Comorbidity with other anxiety disorders and illness anxiety disorder is also common. Panic disorder is significantly comorbid with numerous general medical symptoms and conditions, including, but not limited to, dizziness, cardiac arrhythmias, hyperthyroidism, asthma, COPD, and irritable bowel syndrome.

However, the nature of the association (e.g. cause and effect) between panic disorder and these conditions remains unclear. Although mitral valve prolapse and thyroid disease are more common among individuals with panic disorder than in the general population, the differences in prevalence are not consistent.” (APA, 2013, p. 208-209)

Panic attacks and a diagnosis of panic disorder in the past twelve months are related to a higher rate of suicide attempts and suicidal ideation in the past twelve months even when comorbidity and a history of childhood abuse and other suicide risk factors are taken into account. (APA, 2013)


The term phobia refers to an excessive fear of a specific object, circumstance or situation” (Sadock, Sadock & Ruiz, 2015, p. 400). There are different types of phobias, depending on what the person fears the most. Specific phobia refers to a fear of a particular object or situation (e.g. intense fear of being bitten by a dog or fear of going up an escalator). Social anxiety disorder, also known as social phobia, is the fear of social situations, including situations that involve strangers (e.g. oral presentations or meeting new people).

The difference between specific phobia and social phobia is that people diagnosed with social phobia fear embarrassing themselves in particular situations, whereas those with a specific phobia fear the particular situation (Sadock, Sadock & Ruiz, 2015). Agoraphobia on the other hand, is the fear or anxiety regarding places from which escape might be difficult, this is the most disabling of phobias as it affects the person’s ability to function at work or being in public spaces.

Diagnostic Criteria

  1. Marked fear or anxiety about two (or more) of the following five situations:

  1. Using public transport (e.g. automobiles, buses, trains, ships, planes)

  2. Being in open spaces (e.g. parking lots, marketplaces, bridges)

  3. Being in enclosed places (e.g. shops, theatres, cinemas)

  4. Standing in line or being in a crowd

  5. Being outside of the home alone

  1. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g. fear of falling in the elderly; fear of incontinence)

  2. The agoraphobic situations almost always provoke fear or anxiety

  3. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety

  4. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.

  5. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more

  6. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  7. If another medical condition (e.g. inflammatory bowel disease, Parkinson’s disease) is present, the fear, anxiety, or avoidance is clearly excessive

  8. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder-for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in obsessive-compulsive disorder), perceived defects or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation (as in separation anxiety disorder).

Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual’s presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned. (APA, 2013, p. 217-218)

Diagnostic Features

The essential feature of agoraphobia is marked, or intense, fear or anxiety triggered by the real or anticipated exposure to a wide range of situations (Criterion A). The diagnosis requires endorsement of symptoms occurring in at least two of the above-mentioned five situations. The examples for each situation are not exhaustive; other situations may be feared. When experiencing fear and anxiety cued by such situations, individuals typically experience thoughts that something terrible might happen (Criterion B).” (APA, 2013, p. 217-218)

Individuals frequently believe that escape from such situations might be difficult (e.g. “cant get out of here”) or that help might be unavailable (e.g. “there’s nobody to help me”) when panic-like symptoms or other incapacitating or embarrassing symptoms occur. “Panic-like symptoms” refer to any of the 13 symptoms included in the criteria for panic attack, such as dizziness, faintness or fear of dying.

“Other incapacitating or embarrassing symptoms” include symptoms such as vomiting and inflammatory bowel symptoms, as well as, in older adults, a fear of falling or, in children, a sense of disorientation and getting lost. The amount of fear experienced may vary with proximity to the feared situation and may occur in anticipation of or in the actual presence of the agoraphobic situation.” (APA, 2013, p. 217-218)

Also, the fear or anxiety may take the form of a full or limited-symptom panic attack (i.e. an expected panic attack). Fear or anxiety is evoked nearly every time the individual comes into contact with the feared situation (Criterion C). Thus, an individual who becomes anxious only occasionally in an agoraphobic situation (e.g. becomes anxious when standing in line on only one out of every five occasions) would not be diagnosed with agoraphobia. The individual actively avoids the situation or, if he or she either is unable or decides not to avoid it, the situation evokes intense fear or anxiety (Criterion D).” (APA, 2013, p. 217-218)

Active avoidance means the individual is currently behaving in ways that are intentionally designed to prevent or minimize contact with agoraphobic situations. Avoidance can be behavioural (e.g. changing daily routines, choosing a job nearby to avoid using public transportation, arranging for food delivery to avoid entering shops and supermarkets) as well as cognitive (e.g. using distraction to get through agoraphobic situations) in nature. The avoidance can become so severe that the person is completely homebound.

Often, an individual is better able to confront a feared situation when accompanied by a companion, such as a partner, friend, or health professional. However, this can sometimes negatively impact relationships as the partner/family/friend might feel drained by the constant need to assist and might not fully understand the phobia, particularly because the avoidance may seem out of proportion to the actual danger posed by the situation. This might in turn lead to the person losing the relationships due to the phobia.” (APA, 2013, p. 217-218)

Differentiating clinically significant agoraphobic fears from reasonable fears (e.g. leaving the house during a bad storm) or from situations that are deemed dangerous (e.g. walking in a parking lot or using public transportation in a high-crime area) is important for a number of reasons. First, what constitutes avoidance may be difficult to judge across cultures and sociocultural contexts (e.g. it is socioculturaly appropriate for orthodox Muslim women in certain parts of the world to avoid leaving the house alone, and thus such avoidance would not be considered indicative of agoraphobia. Another example would be a South African woman who might be afraid to walk alone in the street at night, due to the high crime rates in South Africa, this too would not be considered as indicative of agoraphobia).” (APA, 2013, p. 217-218)

Second, older adults are likely to overattribute their fears to age-related constraints and are less likely to judge their fears as being out of proportion to the actual risk. Third, individuals with agoraphobia are likely to overestimate danger in relation to panic-like or other bodily symptoms. Agoraphobia should be diagnosed only if the fear, anxiety or avoidance persists (Criterion F) and if it causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion G). The duration of “typically lasting for 6 months or more” is meant to exclude individuals with short-lived, transient problems. However, the duration criterion should be used as a general guide, with allowance for some degree of flexibility. (APA, 2013)


The majority of individuals with agoraphobia also have other mental disorders. The most frequent additional diagnoses are other anxiety disorders (e.g. specific phobias, panic disorder, social anxiety disorder), depressive disorders (major depressive disorder), PTSD, and alcohol use disorder. Whereas other anxiety disorders (e.g. separation anxiety disorder, specific phobias, panic disorder) frequently precede onset of agoraphobia, depressive disorders and substance use disorders typically occur secondary to agoraphobia. (APA, 2013)

Obsessive-Compulsive Disorder

Obsessive-compulsive disorder is represented by a diverse group of symptoms that include intrusive thoughts, rituals, preoccupations, and compulsions” (Sadock, Sadock & Ruiz, 2015, p. 418). The obsessions or compulsions are time-consuming and often interfere with a person’s daily routine, work and relationships. A person diagnosed with OCD may have an obsession, a compulsion, or both. An obsession is defined as “a recurrent and intrusive thought, feeling, idea or sensation…which is a mental event” (Sadock, Sadock & Ruiz, 2015, p. 418). Whereas a compulsion is normally a response to the obsession, and is characterized by a particular behaviour.

OCD is associated with reduced quality of life as well as high levels of social and occupational impairment. Impairment occurs across many different domains of life and is associated with symptom severity. Impairment can be caused by the time spent obsessing and doing compulsions. Avoidance of situations that can trigger obsessions or compulsions can also severely restrict functioning.

In addition, specific symptoms can create specific obstacles. For example, obsessions about harm can make relationships with family and friends feel hazardous; the result can be avoidance of these relationships. Obsessions about symmetry can derail the timely completion of school or work projects because the project never feels “just right”, potentially resulting in school failure or job loss. (APA, 2013)

Health consequences can also occur. For example, individuals with contamination concerns may avoid doctors’ offices and hospitals (e.g. because of fears of exposure to germs) or develop dermatological problems (e.g. skin lesions due to excessive washing). Sometimes the symptoms of the disorder interfere with its own treatment (e.g. when medications are considered contaminated).

When the disorder starts in childhood or adolescence, individuals may experience developmental difficulties. For example, adolescents may avoid socializing with peers; young adults may struggle when they leave home to live independently. The result can be few significant relationships outside the family and a lack of autonomy and financial independence from their family of origin, in addition, some individuals with OCD try to impose rules and prohibitions on family members because of their disorder (e.g. no one in the family can have visitors to the house for fear of contamination), and this can lead to family dysfunction. (APA, 2013)

Diagnostic Criteria

  1. Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):

  1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.

  2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e. by performing a compulsion).

Compulsions are defined by (1) and (2):

  1. Repetitive behaviours (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

  2. The behaviours or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviours 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 behaviours or mental acts.

  1. The obsessions or compulsions are time-consuming (e.g. take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  2. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g. drug of abuse, medication) or another medical condition.

  3. The disturbance is not better explained by the symptoms of another mental disorder (e.g. excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania (hair pulling disorder); skin picking, as in excoriation (skin-picking) disorder; stereotypes, as in stereotypic movement disorder; ritualized eating behaviour, as in eating disorders; preoccupation with substance or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behaviour, as in autism spectrum disorder) (APA, 2013, p. 237)


Diagnostic Features

The characteristic symptoms of OCD are the presence of obsessions and compulsions (Criterion A). Obsessions are repetitive and persistent thoughts (e.g. of contamination), images (e.g. of violent or horrific scenes), or urges (e.g. to stab someone). Importantly, obsessions are not pleasurable or experienced as voluntary: they are intrusive and unwanted and cause marked distress or anxiety in most individuals.

The individual attempts to ignore or suppress these obsessions (e.g. avoiding triggers or using thoughts suppression) or to neutralize them with another thought or action (e.g. performing a compulsion). Compulsions (or rituals) are repetitive behaviours (e.g. washing, checking) or mental acts (e.g. counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

Most individuals with OCD have both obsessions and compulsions. Compulsions are typically performed in response to an obsession (e.g. thoughts of contamination leading to washing rituals or that something is incorrect leading to repeating rituals until it feels “just right”).” (APA, 2013, p. 238)

The aim is to reduce the distress triggered by obsessions or to prevent a feared event (e.g. arranging items symmetrically to prevent harm to a loved one) or are clearly excessive (e.g. showering for hours each day). Compulsions are not done for pleasure, although some individuals experience relief from anxiety or distress. Criterion B emphasizes that obsessions and compulsions must be time-consuming (e.g. more than 1 hour per day) or cause clinically significant distress or impairment to warrant a diagnosis of OCD.

This criterion helps to distinguish the disorder from the occasional intrusive thoughts or repetitive behaviours that are common in the general population (e.g. double-checking that a door is locked). The frequent and severity of obsessions and compulsions vary across individuals with OCD (e.g. some have mild to moderate symptoms, spending 1-3 hours per day obsessing or doing compulsions, whereas others have nearly constant intrusive thoughts or compulsions that can be incapacitating).” (APA, 2013, p. 238)


Individuals with OCD often have other psychopathology. Many adults with the disorder have a lifetime diagnosis of an anxiety disorder (e.g. panic disorder, social anxiety disorder, generalized anxiety disorder, specific phobia) or a depressive or bipolar disorder (for any depressive or bipolar disorder, with the most common being major depressive disorder). Onset of OCD is usually later than for most comorbid anxiety disorders (with the exception of separation anxiety disorder) and PTSD but often precedes that of depressive disorders. Comorbid obsessive-compulsive personality disorder is also common in individuals with OCD (e.g. ranging from).

Up to 30% of individuals with OCD also have a lifetime tic disorder. A comorbid tic disorder is most common in males with onset of OCD in childhood. These individuals tend to differ from those without a history of tic disorders in the themes of their OCD symptoms, comorbidity, course, and pattern of familial transmission. A triad of OCD, tic disorder, and attention-deficit/hyperactivity disorder can also be seen in children.” (APA, 2013, p. 238)

Disorders that occur more frequently in individuals with OCD than in those without the disorder include several obsessive-compulsive and related disorders such as body dysmorphic disorder, trichotillomania (hair-pulling disorder), and excoriation (skin-picking disorder). Finally, an association between OCD and some disorders characterized by impulsivity, such as oppositional defiant disorder, has been reported.

OCD is also much more common in individuals with certain other disorders than would be expected based on its prevalence in the general population; when one of those other disorders is diagnosed, the individual should be assessed for OCD as well. For example, in individuals with schizophrenia or schizoaffective disorder, the prevalence of OCD is approximately 12%. Rates of OCD are also elevated in bipolar disorder; eating disorders, such as anorexia nervosa and bulimia nervosa; and Tourette’s disorder. (APA, 2013)

Aetiology: Bio-Psycho-Social Model


The two major schools of thought about psychosocial factors contributing to anxiety disorders are the psychoanalytic school of thought and cognitive-behavioural school of thought. The psychoanalytic school hypothesises that anxiety is a symptom of unresolved, unconscious conflict. Whereas the cognitive-behavioural school theorises that anxiety disorder patients respond to incorrectly and inaccurately perceived dangers and that the patient often views themselves negatively and believes that they are unable to cope in the event of these negative occurrences (Sadock, Sadock & Ruiz, 2015).

Freud originally believed that anxiety stemmed from a physiological build up of libido, he ultimately redefined anxiety as a signal of the presence of danger in the unconscious” (Sadock, Sadock & Ruiz, 2015, p. 389). Freud theorised that anxiety is the result of tension between the unconscious sexual/aggression wishes and the superego. This tension would result in the person being in distress due to this conflict.

Freud later corrected himself by saying: “It was anxiety which produced repression and not, as I formerly believed, repression which produced anxiety” (Sadock, Sadock & Ruiz, p. 389). Repression is a state where individuals repress feelings/emotions that they don’t want coming to the fore. The tension between the two states (unconscious and superego) would cause anxiety, which would in turn cause repression of the unwanted feelings/emotions.

According to learning theorists, obsessions are conditioned stimuli. A certain stimulus will become associated with fear or anxiety, depending on an event that was anxiety provoking that occurred involving that particular stimulus. The person then learns to associate that stimulus with anxiety or fear. Compulsions come about when the person realises that certain actions reduce the anxiety associated with that stimuli, therefore these actions/behaviours become rituals to reduce the anxiety.

Physical and sexual abuse in childhood and other stressful or traumatic events have been associated with an increased risk for developing OCD. Some children may develop the sudden onset of obsessive-compulsive symptoms, which has been associated with different environmental factors, including various infections agents and a post-infectious autoimmune syndrome.



Cognitive and behaviour therapies are effective treatments for most anxiety disorders. Some therapists subscribe to and utilise psychoanalytic therapeutic interventions, although the usefulness of the intervention in some anxiety disorders is still widely debated. Cognitive therapy challenges the patient about false beliefs and fears, and challenges them to think about these beliefs or fears in a different way.

In behaviour therapy, the basic assumption is that change can occur without the development of psychological insight into underlying issues. Techniques include positive and negative reinforcements, systematic desensitization, response prevention, stop thought, relaxation techniques, panic control therapy, self-monitoring and hypnosis (Sadock, Sadock & Ruiz, 2015). The key aspects of successful treatment are: the patient’s commitment to treatment, clearly identified problems and objectives, and available alternative strategies for coping with the feelings (Wolpe & Rowan, 1988).

Cognitive therapy is based on the premise that maladaptive behaviour is secondary to distortions in how people perceive themselves and in how others perceive them. Treatment is short term and interactive, with assigned homework and tasks to be performed between sessions that focus on correcting distorted assumptions and cognitions (Sadock, Sadock & Ruiz, 2015). It has been recommended that the best treatment for anxiety disorders is a combination of cognitive/behaviour therapy and pharmacotherapy, and that clinicians should utilise both where possible.

Self-help treatment is popular amongst some patients who believe that they don’t require the assistance of a therapist or medication to treat their anxiety disorders (Tyrer & Baldwin, 2006). Activities such as exercise, relaxation techniques and a healthy diet are employed to curb the symptoms associated with the particular disorder they might be diagnosed with. Therapists and clinicians don’t often recommend self-help treatment as the validity and reliability of this treatment have not been scientifically proven.

Anxiety Disorders – South African Context

A survey conducted in 2008 revealed that South Africans have high levels of psychiatric disorders, with anxiety disorders at the forefront of this prevalence (Herman, Stein, Seedat, Heeringa, Moomal & Williams, 2009). This survey also revealed that most people diagnosed with these psychiatric disorders did not receive treatment (Williams et al., 2008). Williams et al. (2008) attributed these high levels of anxiety disorders to South Africa’s history of racial oppression and inequality. Apartheid affected black people in many traumatic ways. However, the focus is often on the economical disparities which led to the poverty we often see in townships and rural villages, and on the racial discrimination that was a pivotal aspect of apartheid.

There is seldom a focus or discussion on the emotional and psychological effects that apartheid had on black South Africans. The second reason for these high levels of anxiety disorders might be because of the high rate of crime in South Africa (StatsSA). South Africans live in constant fear due to these high rates of crime. This crime often does not discriminate between race or class. The media might focus on and report crime that occurs in suburban areas and cities, but this is not to say that there is no crime in townships or rural areas. People in the township also get mugged and hijacked; and there have also been reported cases of grandmothers being raped in their own homes, which would contribute to anxiety levels.

This study also revealed that of those diagnosed with psychiatric disorders, the majority of them (from rural areas/townships) did not have access to medication or therapeutic interventions to treat these psychiatric illnesses (Williams et al., 2008; Herman et al., 2009). The study reported that the reason for this was because most people from rural areas do not have access to medical facilities that have a psychiatric unit. Most clinics in villages do not have psychiatrists, and in instances where people can go to public hospitals, there is often a long queue with one psychiatrist/psychologist on call and people often lose hope as they have no means of continuously coming back to the hospital to be attended to.

Muris, Loxton, Neumann, du Plessis, King and Ollendick (2006) conducted a study amongst South African youth to assess perceived parental rearing behaviours. Studies in the past have reported that parental anxious rearing, overprotection and rejection contribute to anxiety symptoms in youth and children (Muris et al., 2006). After surveys were distributed to the youth, it emerged that the black youth had more anxiety symptoms than their white counterparts.

According to the survey, this meant that the black parents had directly or indirectly contributed to their children’s anxiety. However, there were criticisms regarding this survey and its results. The first critique was regarding the survey utilised. The screen for child anxiety related emotional disorders is a survey tool often used to screen youth for anxiety symptoms. However, this tool was developed in the United States for white children and youth. The critique was on the validity and reliability of the test being used on black South African youth. Language and standardization challenges cannot be ignored when conducting surveys.

Similar studies were conducted among children in South Africa and Nigeria. Muris, Schmidt, Engelbrecht and Perold (2002) conducted a study that assessed anxiety amongst South African children; whereas Ignmana, Ollendicka and Akandeb (1999) assessed fear amongst Nigerian and Kenyan children. In both studies, the anxiety levels and fear levels were higher in the black children than white children. This further proved that these surveys were created for white children and that more research is needed to create surveys better normed for black children.

The second critique was in relation to the parents being held responsible for their children’s anxiety symptoms. Muris et al. (2006) theorised that one cannot ignore aspects such as poverty, deprivation and violence as contributing factors to the emotional well-being of the youth. Therefore the results would have to be interpreted by incorporating all these factors that could potentially play a pivotal role in causing anxiety amongst youth. Further research would have to be conducted to understand the different correllations and what they mean.

In conclusion, anxiety disorders are some of the more common psychiatric disorders, and they have also been found to be prevalent in South Africa. Therapists, clinicians and doctors in South Africa need to find creative and culturally relevant ways to diagnose and treat South Africans diagnosed with anxiety disorders. Interventions need to be created to reach and treat people who are from previously disadvantaged backgrounds and who might not have access to medication, or psychiatric hospitals.


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