Chapter 4

Chapter 11: Strategic Leadership
Chapter 4Chapter 4
ANXIETY, OBSESSIVE-
COMPULSIVE AND TRAUMA
RELATED DISORDERS

Chapter outline
• Introduction
• Fear, anxiety and stress
• History of anxiety and panic disorders
• Clinical picture
• Section 1: Anxiety Disorders
• Section 2: Obsessive-Compulsive and related
disorders
• Section 3: Trauma and stressor related disorders
• Cross cultural and African perspectives

Introduction
• Most common category of mental disorders;
• Prescription drugs and general health care for
those with anxiety problems is costly.
• 74% have co-morbid mental disorder.
• Sex bias: Women at greater risk.
• Anxiety results from interplay of phenomena:
• cognitive
• perceptual
• psychological
• physical

Introduction, cont.
Understanding the difference between problematic
anxiety and worry that is still ‘within normal limits’ is
important in psychology.

Introduction, cont.
• Anxiety that is not excessive is a normal state that
aids functioning.
• Anxiety is dysfunctional when it causes significant
distress and impairment.
• Worry, or anxious apprehension, very common in
people with anxiety disorders.
• Albert Ellis described ‘meta-worry’, or worry about
worry, which could complicate treatment.

Introduction, cont.
Fear
• Present-oriented mood state.
• Marked negative affect.
• Immediate fight or flight response to danger or
threat.
• Strong avoidance/escapist tendencies.
• Abrupt activation of the sympathetic nervous
system.

Introduction, cont.
Anxiety
• Future-oriented mood state.
• Marked negative affect.
• Somatic symptoms of tension.
• Apprehension about future danger or
misfortune.
• Anxiety and fear are normal emotional states in
response to threat.
• Most people have experienced some physical
symptoms of anxiety.

Introduction, cont.
Anxious and depressed mood frequently share a
similar presentation.

Introduction, cont.

Introduction, cont.
Stress
• Medical field focuses on negative stressful life
demands.
• Selye distinguished ‘distress’ and ‘eustress’.
• General Adaptation Syndrome (GAS):
• Phase 1: Fear and ‘alarm response’
• Phase 2: ‘Resistance’
• Phase 3: ‘Exhaustion’ (chronic stress and
damage)
• Ongoing or unmanageable stress 
• negative effect on immune system
• causation or maintenance of physical disorders

History of anxiety & panic disorders
• Until recently, anxiety seen as expression of
emotions (e.g. fear).
• Theorising now shifted to cognitive processes.
• Phobia = specific intense fear  avoidance
behaviours; phobias documented since Greek
mythology.
• Hippocrates: First clinical description of phobia.
• Accounts of phobia found throughout writing of
philosophers, religious writers, playwrights.
• Term ‘phobia’ entered psych lit late 1800s.
• ‘Panic’ used since 1603; derived from the
mythological Greek deity, Panikos (Pan).
• DSM-III (1980) recognised both Panic Disorder With
and Without Agoraphobia.

Clinical picture
DSM-5
Anxiety Disorders
Obsessive-Compulsive
and Related Disorders
Disorders
Trauma- and Stressor -
Related Disorders
Separation Anxiety
Disorder
Selective Mutism
Specific Phobias
Social Anxiety Disorder
Panic Disorder
Agoraphobia
Generalized Anxiety
Disorder
Obsessive- Compulsive
Disorder
Body Dysmorphic
Disorder
Hoarding Disorder
Trichotillomania
Excoriation
Reactive Attachment
Disorder
Disinhibited Social
Engagement Disorder
Posttraumatic Stress
Disorder
Acute Stress Disorder
Adjustment Disorder

ANXIETY DISORDERS
Section 1

Introduction
• In previous editions of the DSM, the anxiety
disorders (e.g. Generalized Anxiety Disorder, Panic
Disorder and Phobias), obsessive-compulsive
disorders and stress related disorders were all
grouped together in one category, Anxiety
Disorders.
• In the DSM-5, these disorders are now split into
three distinct categories, however, the sequential
order of these chapters in DSM-5 reflects the close
relationships (the presence of anxiety) among them.
• The anxiety and stress related disorders make up
the most common categories of mental disorders.

Separation Anxiety Disorder
• In previous editions of the DSM disorders that are common in children
were classified in the section ‘Disorders Usually First Diagnosed in
Infancy, Childhood, or Adolescence’, however, in the DSM-5 many of
the disorders that were in this category were moved to other sections.
• Although this disorder is primarily diagnosed in children, the criteria do
allow for this diagnosis to be made in adults as well. The core feature of
this disorder is extreme distress when an individual is separated from
other people to whom she / he are attached.
• The distress is not necessarily limited to a real, physical separation, but
may also be related to anticipated separation or persistent worry about
losing a major attachment figure (APA, 2013).
• The disorder also manifests in a number of behavioural and physical
symptoms.
• A person suffering from this disorder may be reluctant, or refuse, to go
away from home or being alone without a major attachment figure.
• They may experience recurrent nightmares (related to separation) and
physical symptoms (e.g. headaches, stomach aches, etc.,), the latter
being evident when separation occurs or is anticipated (APA, 2013).

Specific Phobias
• Formerly called ‘simple phobias’, the Specific Phobias typically refer to a
clearly recognisable situation or object (often inanimate) that the person
fears (unlike Agoraphobia with its many feared situations).
• Craske (2003) defines Specific Phobias as the marked and persistent
fear of clearly discernable and circumscribed objects or situations.
• When a person with a Specific Phobia encounters the feared situation or
object, they may experience intense and immediate anxiety that could
reach the levels of a full-blown Panic Attack.
• For example, someone who never goes to the doctor for fear of being
close to needles, or someone who refuses to walk on the beach for fear
of encountering a crab, may have a Specific Phobia. Such a person is
likely to become anxious and apprehensive at the mere suspicion that
they will come across the specific situation or object, and will often make
a concerted effort to avoid any contact with it.
• It is not unheard of for a person with a severe phobia of snakes, for
instance, to avoid paging through wildlife magazines for fear of seeing a
photograph of a snake on its pages.

Specific Phobias cont.
• Beck (2005a) contends that many fears are innate and that they
played an important protective function in the early years of human
development.
• Certainly, the fear of some situations or objects has held survival
value for human beings and has been selected during evolution
(Barlow, 2004).
• It is, for instance, adaptive to fear and avoid jumping into a rough
sea alone (especially if you are a non-swimmer) or picking up
brightly coloured snakes (which are likely to be poisonous).
• However, with repeated exposure to many dangers, an adaptive
mechanism may develop.
• Firefighters who have trained to fight fires, for example, may
experience less anxiety than would other people, even in ‘high risk’
situations.
• This may be linked to the heavy reliance on behavioural and
cognitive-behavioural treatments favoured for anxiety (Craske &
Barlow, 2007).

• The maladaptive fears characteristic of phobias are typically
unreasonable or excessive (Beck, 2005b).
• Adults are able to recognise that their phobic fears are out of
proportion to the potential threat of the situation or object, or that they
are simply illogical, while children will not necessarily have insight into
this.
• However, this ‘danger value’ tends to dominate a phobic person’s
appraisal of a situation (not objectivity) and they are likely to estimate
greater harm from the situation or object as they approach it.
• Common examples of feared objects or situations are:
• Animal type: dogs, mice, snakes, spiders, moths, worms
• Situational type: driving in a car, flying in an airplane, elevators,
tunnels, bridges, enclosed spaces
• Natural environment type: heights, water, thunder, lightning
• Blood-injection-injury type: blood, injection needles, medical
practitioners, hospitals, someone else’s injury.

• People with a Specific Phobia typically experience sympathetic
nervous system arousal that causes an alarm response and
resultant physiological changes such as increased heart rate,
blood pressure, respiration, and perspiration as described above.
• They react to the phobic situation (e.g. airplane) or object (e.g.
mouse) as if it were a truly life-threatening danger that they have to
be prepared to either fight or flee.
• People with a blood-injection-injury type phobia, however, exhibit
different and unusual physiological reactions.
• They typically experience marked decreases in heart rate and
blood pressure when encountering their feared situation or object
and very often faint as a result.
• This does seem counterproductive if the fear or anxiety component
of these disorders is a false alarm of preparation for better survival
responses.

Social Anxiety Disorder (Social
Phobia)
• Social Anxiety Disorder is not the fear of a specific situation or
object, but rather the fear of scrutiny and evaluation by others or
being embarrassed in front of others.
• It is defined as an excessive fear of social performance situations in
which embarrassment is feared (Craske, 2003).
• For most people, being judged or embarrassed in social situations
(especially in front of important others) is an unpleasant experience.
• Having to speak in public or perform an activity while being closely
watched or evaluated is also not a favoured activity for most.
• However, those who have this disorder exhibit more than moderate
nervousness and may experience a full-blown Panic Attack in a
social performance situation.
• They have also been found to believe that everyone judges and
criticises the performance skills of others (Turk, Heimberg, & Magee
2007).

Social Anxiety Disorder
(Social Phobia) cont.
• The socially phobic individual strongly wishes to avoid being
observed or judged by others but, if this should occur, they
are likely to experience anxiety, increased perspiration,
heart palpitations, trembling and shaking, dizziness, and
confusion.
• People with Social Anxiety Disorder may avoid doing simple
things such as eating or drinking with others, writing in front
of others, or even using public toilets.
• The more complex the social task at hand, however, the
more likely it is for the phobia to impair performance.
• Socially anxious people often believe that others will be able
to notice the signs of their anxiety (although these are
mostly more subjective than observable) and will judge them
for it.

Panic disorders
• Frequent Panic Attacks (PA) = Panic Disorder.
• PA can occur independently or as part of another
anxiety disorder.
• Single episode Panic Attacks are not a disorder.
• Ancient alarm system (fight/flight) + inappropriate
and dysfunctional learning.
• ‘True alarm’ is functional; ‘false alarm’ is
disordered.

An open setting such as a shopping mall can be a
trigger for Agoraphobia.

Panic disorders, cont.
• Recurrent panic attacks, with anxiety and
fear of having more attacks.
• Irregular and unpredictable attacks.
• Onset: Late adolescence to mid-thirties.
• Often mistaken for a medical condition
(e.g. heart attack).
• DSM-5 subtypes of Panic Attacks
• Cued: Situationally bound PA
• Uncued: Unexpected PA
• Situationally predisposed PA

Panic disorders, cont.
As the symptoms of
Panic Attach are
often mistaken for
medical conditions
such as heart attack,
medical teams often
identify patients with
Panic Disorder.

Agoraphobia
• Fear of public places, or a place that cannot easily
be escaped from.
• Acquired fear of bodily sensations resembling a
PA.
• Extreme cases limit sufferer to home.
• Role of cognition and expectations important to
treatment.
• Women twice as likely as men to develop
disorder.
• High co-morbidity.

Phobias, cont.

Generalised Anxiety Disorder
(GAD)
• Chronic anxiety, unfocused, excessive, with
uncontrollable worry, and bodily symptoms.
• Worry about minor and major life issues.
• Symptoms: Restlessness, irritability, chronic muscle
tension, difficulty concentrating, disturbed sleep, and
possible physical problems.
• Common, chronic course, affects more women.
• High co-morbidity (NB with mood disorders).
• Early onset (childhood/adolescence).
• Disagreement over excessive worry as necessary
symptom.
• Diagnostic criteria for Overanxious Disorder of
Childhood are similar to GAD.

OBSESSIVE-COMPULSIVE DISORDER
AND RELATED DISORDERS
Section 2

Introduction
• As has been mentioned before, Obsessive-Compulsive Disorder was
categorized as an Anxiety Disorder in the previous DSM’s.
• This disorder was characterised by the presence of both obsessions
and compulsions, however, this approach was restrictive as there are
a number of disorders that are characterised by only obsessions or
compulsions.
• A new category, i.e. Obsessive-Compulsive and Related Disorders,
was created in the DSM-5 and all disorder with obsessions,
compulsions or both, were included in this category.
• The disorders in this category are related to one another in terms of a
range of diagnostic validators, as well as the clinical utility of grouping
these disorders.
• Obsessive-Compulsive Disorder has been moved from Anxiety
Disorders to this category, and a number of new disorders have been
introduced in this category, for example hoarding disorder and
excoriation (skin-picking) disorder, and other disorders such as
trichotillomania and Body Dysmorphic Disorder has been moved from
other DSM-IV categories to this category.

Obsessive-Compulsive Disorder
• OCD classified as an anxiety disorder because
people with OCD suffer anxiety due to their
obsessions and compulsions.
• DSM-5 diagnostic criteria require either
obsessions, compulsions, or both.
• Obsessions:
• Intrusive, persistent, and anxiety-provoking
thoughts, images, or impulses
• that person is unable to control
• but recognise to be irrational.

Obsessive-Compulsive Disorder,
cont.
• Compulsions:
• Repetitive mental acts or behaviours
• that individual feels compelled to do
• to relieve obsessions and the anxiety they
produce.
• People do not usually carry out their obsessive
impulses, but feel anxiety and guilt over them.
• Compulsions can become extreme and
debilitating, or dangerous.
• Compulsions only temporarily calm anxiety.
• Childhood onset.
• Runs chronic course if not treated.

Body Dysmorphic Disorder
• Body Dysmorphic Disorder primarily concerns the
preoccupation with a perceived bodily abnormality.
• Facial features are the most common focus of concern, but
more than one body region can elicit attention.
• Concerns can be specific or vague.
• Mirror checking or avoidance, repetitive grooming, and
attempts to hide deformities are common compulsive
features.
• Concerns about a perceived bodily deformity can reach
delusional intensity. It is interesting to note than men and
women share many of the clinical features such as disliked
body areas, types of repetitive behaviours, etc., however
men are more likely to have genital preoccupations and
women more likely to have a comorbid eating disorder (APA,
2013).

Body Dysmorphic Disorder
• Depression and anxiety are common in the history
and mental state examination, and psychosocial
dysfunction can be severe.
• Suicide attempts are not uncommon. Common co-
morbid conditions are major depression and anxiety
disorders.
• Perfectionist, schizoid and narcissistic personality
traits are also found.
• An insidious onset is characteristic and it runs a
chronic course with fluctuating symptoms (Hales,
2008; Sadock & Sadock, 2000).

Hoarding Disorder
• In the DSM-IV hoarding was listed as one of the possible symptoms of
obsessive-compulsive personality disorder and it was noted that extreme
hoarding may occur in obsessive-compulsive disorder.
• However, reviewing available data seemed to indicate that there are
sufficient symptoms to warrant a separate disorder and not just a variant
of obsessive-compulsive disorder or another mental disorder.
• The core feature of this disorder is a persistent difficulty dis-carding or
parting with possessions due to a perceived need to save the items and
distress associated with discarding them (APA, 2013).
• The hoarding is excessive to such an extent that that the resulting clutter
“…impairs basic activities such as: moving through the house, cooking,
cleaning, personal hygiene, and even sleeping” (APA, 2013, p.250).
• Hoarding disorder may have unique neurobiological correlates, but is not
diagnosed if the disorder is the direct consequence of a degenerative
disorder (e.g. frontotemporal lobar degeneration or Alzheimer’s disease)
(APA, 2013).
• People with this disorder often have comorbid disorders such as major
depressive disorder, social anxiety disorder, generalized anxiety disorder
or OCD.

Trichotillomania (Hair-Pulling Disorder)
• Trichotillomania was included in DSM-IV, although “hair-pulling
disorder” has been added parentheti-cally to the disorder’s name
in DSM-5.
• The essential feature of this disorder is the recurrent pulling out
of one’s hair, which may be from any area of the body where hair
grows.
• These sites may vary over time and typically occurs in brief
episodes during the day.
• The disorder may endure for months and years and is associated
with both distress and social and occupational impairment (APA,
2013).
• Not only could the disorder lead to irreversible hair growth, but
also associated physical problems (e.g. carpal tunnel syndrome,
shoulder, back and neck pain, and trichophagia) (APA, 2013).
• The disorder seems to have a genetic vulnerability to this
disorder and it is commonly associated with OCD.

Excoriation (Skin-Picking) Disorder
• Excoriation (skin-picking) disorder is newly added to DSM-
5, with the essential feature of this disorder being picking at
one’s own skin.
• The skin picking is not limited to a particular body site and
people with this disorder may pick at healthy skin or at
minor skin irregularities (e.g. pimples, calluses, scabs,
etc.).
• It often involves rituals (e.g. searching for particular kind of
scab, pulling, examining, playing or swallowing the skin
after it has been pulled) and is often triggered by an
emotional state (e.g. anxiety, boredom, etc.)
• There seems to be a genetic vulnerability to this disorder
and it is often associated with OCD and OCD-related
disorders (APA, 2013).

TRAUMA- AND STRESSOR-
RELATED DISORDERS
Section 3

Stress disorders
• Caused by stressful/traumatic life event/s.

Reactive Attachment Disorder
• This disorder is one that is limited to infancy (at least 9 months old) or
early childhood (evident before the age of 5 years).
• The disorder is the result of extremes of insufficient care such as social
neglect or deprivation, repeated changes of primary care givers or
contexts where there are limited opportunities to form stable
attachments.
• This results in a consistent pattern of inhibited, emotionally withdrawn
behaviour toward adult caregivers such as not seeking comfort when
distressed or not responding to comfort when provided.
• The child also exhibits persistent social and emotional disturbances
such as limited responsiveness, limited positive affect and periods of
unexplained irritability, sadness or fearfulness (APA, 2013).
• It is generally accepted that children with this disorder have the capacity
to form attachments; however, due to their environments they have not
been given the opportunity to do so (APA, 2013).
• The main cause of this disorder is serious neglect, however, what is of
note is that not all children that are exposed to extreme neglect, develop
this disorder (APA, 2013).

Disinhibited Social Engagement Disorder
• In this case a child actively approaches and interacts with unfamiliar
adults in an impulsive, incautious, and overfamiliar way.
• As was the case with the previous disorder, this disorder also
seems to be the result of extreme neglect before the age of 2 years
(APA, 2013).
• This disorder, which is also limited to children, can almost be
described as the inverse of Reactive Attachment Disorder (RAD).As
opposed to RAD, children with this disorder readily approach
strangers without fear and with excessive familiarity.
• This familiarity includes a readiness to hug and accept comfort, food
or toys from an unknown person (APA, 2013).
• As is the case with RAD, serious social neglect is a diagnostic
requirement for this disorder, but again, not all seriously neglected
children develop this disorder.
• Although unconfirmed, it seems as if children who develop this
disorder may have a neurobiological vulnerability to this disorder
(APA, 2013).

Posttraumatic Stress Disorder (PTSD)
• The diagnosis of PTSD requires that a person
presents with a set of symptoms following exposure
to a traumatic event.
• The person would have to meet a certain minimum
number of each of the following three categories of
symptoms:
• Re-experiencing the traumatic event
• Avoiding associated stimuli, or emotional numbing and
detachment
• Hypervigilance and chronic arousal.

Stress disorders, cont.

Stress disorders, cont.
Posttraumatic Stress Disorder (PTSD), cont.
• Three key groups of symptoms:
• re-experiencing traumatic event
• avoiding associated stimuli; emotional numbing
and detachment
• hypervigilance and chronic arousal
• Guilt, shame, grief, distorted cognitions.
• Resilience: Most people exposed to traumatic events
will not develop PTSD.
• Research focus on harmful effects of trauma
exposure obscures possibility of Posttraumatic
Growth (PTG) (e.g. research with veteran
populations).

Acute Stress Disorder
• Same symptoms as PTSD.
• Experienced for a shorter time period following the
trauma:
• symptoms occur within one month
• symptoms last no longer than four weeks

Adjustment Disorders
• Adjustment disorders were previously a separate category in the DSM-
IV-TR, but it has now been reconceptualised in the DSM-5 as a stress-
response syndrome, and therefore fits into the category of Trauma- and
Stressor-Related Disorders.
• Previously these disorders were almost seen as residual disorders, i.e.
where a person did not meet the clinical threshold for other disorders
such Major Depression, Generalized Anxiety Disorders and the likes.
• In essence these disorders are seen to be emotional or behavioural
responses to an identifiable stressor (APA, 2013).
• The response may be due to a single (e.g. divorce) or multiple stressors
(cumulative stressful life events).
• Furthermore, these stressors may be recurrent or continuous, and may
affect only the individual or groups such as families or communities
(APA, 2013).
• The stressor can take on any form such as interpersonal difficulties,
natural disasters, health, financial, family or work problems.
• Typically the disorder develops within three months of the onset of the
stressor and lasts no longer than six months after the stressor has
ceased (APA, 2013).

Cross-cultural and African
perspectives
• People interpret psychological events from within
their cultural framework.
• Cultural variation of anxiety symptoms worldwide.
• Western values may limit cross-cultural research.
• Psychology historically emphasised empirical,
positivist understandings of people – need to also
draw on qualitative research.
• Collectivist as well as individualist cultural
perspectives need to be considered.
• Need to take note of cultural context rather than
assume Western understanding of symptoms is
universal.

perspectives, cont.
Imagine that the young women are American psychology
students visiting South Africa and consider the amount
of cultural knowledge they would need to gain to be
able to work here.

perspectives, cont.
• In SA, important to acknowledge multicultural
influences.
• Unique presentation of culture-bound syndromes.
• Anxiety disorders common in SA but data needed on
prevalence and incidence across cultural groups.
• Linked to high crime rate; exposure to trauma in SA.
• Sexualised violence (rape/sexual abuse) is NB
problem in SA.
• Rape Trauma Syndrome (RTS) - similar to PTSD.
• High incidence of motor vehicle accidents; may 
Acute Stress Disorder.
• Repeated trauma can either  resilience or
compounded vulnerability.

Aetiology
• Factors (e.g. genetic) predispose person to anxiety
disorders, but they only develop if stressor occurs.
• Diathesis-stress model: Vulnerability + Stressor
• Stressor precipitates disorder.
• Other factors maintain/perpetuate the disorder.
• Factors:
• biological (e.g. neurochemical)
• psychological (e.g. temperament)
• social (e.g. poverty)

Aetiology, cont.
Biological perspectives
Genetics
• NB for Panic Disorder and phobias.
• Inherited tendency towards anxiety (temperament).
• In SA, found COMT gene to contribute to OCD.
Brain structure and functioning
• Stress causes permanently altered brain function,
especially in HPA axis and CRF neurons .

Aetiology, cont.
Biological perspectives, cont.
Neurochemistry
• Norepinephrine, serotonin, GABA, and
cholecystokinin (CKK) believed to play a role in
Panic Disorder.
• Serotonin system functioning related to OCD.
• Limbic system involved in the physiological and
emotional responses to threat.
• In Panic Disorder, person may have over-
reactive autonomic nervous system.
• Those with GAD, also thought to have insufficient
neurotransmitter GABA.

Aetiology, cont.
Psychological perspectives
Psychodynamic
• Unconscious anxiety displaced into object or
symbol.
• GAD a result of inadequate defence mechanisms.
Humanistic
• People grow up with conditional positive regard.
• Existentialists perceive GAD as a result of not
dealing with existential issues in life.

Aetiology, cont.
Behavioural
• Classical and operant conditioning.
• Evolutionary response explains certain phobias.
• Can occur through:
• direct association
• vicarious learning
• or information transmission
• Historically, exposure-based psychological
interventions considered most effective for anxiety.
• ‘Mindfulness’ and ‘Acceptance-based’
approaches also show promise with certain anxiety
disorders.

Aetiology, cont.
Cognitive
• Social phobia develops from negative beliefs and
cognitive biases (NB in post-event processing).
• GAD develops from cognitions related to threat.
• Panic Disorder involves cognitions related to:
• physical sensations
• negative misinterpretation of sensations
• catastrophic thinking (exaggerations)
• Heightened awareness of body cues can increase
anxiety and exacerbate panic.
• OCD obsessions develop through:
• rigid, moralistic thinking
• difficulty tolerating uncertainty

Aetiology, cont.
Personality and temperament
• Shy or timid; more prone to anxiety.
• Negative affectivity and threat-based styles of
emotion explain vulnerability to disorder.

Aetiology, cont.
Psychosocial stressors
• Stress disorders arise in direct response to stressor.
• Individual vulnerability and coping capacity play a
role in occurrence and severity of maladaptive stress
reactions.
• Individual proximity directly related to risk of
developing PTSD.
Familial perspectives
• Through observational learning (e.g. of their
parents), children may learn to respond with
fear/anxiety.

Aetiology, cont.
Socio-cultural perspectives
• Environmental demands on people influence
predisposition to disorder.
• Social and cultural norms (and gender) influence
presenting with and/or admitting to symptoms.
• Sex-role socialisation  men and women respond
differently to distress.

Aetiology, cont.
Integrated perspectives
• All factors are likely to interact.
• ‘Triple vulnerability theory’: Vulnerability factors
interact to cause disorder:
• genetic
• psychological
• early learning experiences

Conclusion
• Limited consensus over classification of anxiety
disorders.
• Further changes in classification and prevalence to
be expected.
• Multiple influences of gender, culture, ethnicity,
etc. on symptom presentation.
• Aetiological knowledge still growing.
• Need broader explanatory models,
acknowledging risk (or vulnerability) factors, as well
as resilience (or protective) factors.

Chapter 4

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