Chapter 6: Anxiety, Obsessions, and Compulsions

Raskin examines anxiety disorders and obsessive-compulsive conditions, emphasizing how they are defined, diagnosed, explained, and treated across multiple perspectives. The chapter opens with case studies of the Steadman family, illustrating generalized anxiety, separation anxiety, and obsessive-compulsive behaviors. Anxiety is distinguished from fear, obsessions from compulsions, and the DSM-5-TR and ICD-11 criteria are carefully reviewed for specific phobia, social anxiety disorder, panic disorder, agoraphobia, generalized anxiety disorder (GAD), separation anxiety disorder, selective mutism, obsessive-compulsive disorder (OCD), and related conditions such as body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder. Diagnostic controversies include poor reliability in distinguishing GAD and comorbidity issues, debates about whether OCD and PTSD belong outside anxiety categories, and alternative frameworks such as the PDM-2, HiTOP, and Power Threat Meaning Framework (PTMF), which critique pathologizing normal responses. Historical perspectives trace anxiety explanations from humoral imbalances in Ancient Greece and religious fears in the Middle Ages, through Esquirol’s 19th-century accounts of OCD, Westphal’s identification of agoraphobia, and DSM’s categorical separation of neuroses into discrete disorders in the 20th century. Biological perspectives detail neurotransmitters (GABA, serotonin, norepinephrine, glutamate), anxiolytic drugs like benzodiazepines, SSRIs, and buspirone, brain structures such as the amygdala, insula, and cortico-striatal-thalamo-cortical loop implicated in OCD, genetic heritability evidence, evolutionary mechanisms such as prepared conditioning and group selection theory of OCD, and new research on inflammation, cortisol, and the gut–brain axis. Psychological perspectives include Freud’s cases of Little Hans and the Rat Man, psychodynamic accounts of insecure attachment, the Unified Psychodynamic Protocol (UPP-ANXIETY), CBT models such as conditioning, catastrophic misinterpretation, intolerance of uncertainty, and faulty thinking, alongside core interventions like exposure plus response prevention, systematic desensitization, modeling, thought stopping, mindfulness-based therapies, MBCT, ACT, and transdiagnostic CBT. Humanistic and existential therapies explain anxiety as arising from incongruence, existential givens such as death and freedom, and logotherapy’s focus on meaning-making, while Emotion-Focused Therapy (EFT) addresses unresolved emotional conflicts. Sociocultural perspectives highlight cultural syndromes like taijin kyofusho, ataques de nervios, and khyâl attacks; global prevalence patterns; economic inequality; and gender differences, with feminist and social justice critiques pointing to structural oppression and over-medicalization of women’s distress. Service user narratives emphasize stigma, lived experience of OCD, and the role of art and expression in coping. Systems perspectives stress the impact of expressed emotion, accommodation, and family therapy approaches such as structural family therapy. Closing reflections by neuroscientist Joseph LeDoux argue that anxiety and fear are uniquely human emotions, requiring integrated biological, psychological, and sociocultural explanations.