ANXIETY DISORDERS

AND OBSESSIVE
COMPULSIVE
DISORDER

Ai Ying, Dharmini
Anxiety: a universal human characteristic involving
tension, apprehension, or fear which serves as an
adaptive mechanism to warn about an external
threat. The feelings of apprehension are
accompanied by a physiological “fight or flight”
response.

Fear: State of the brain presented with external

stimuli that is dangerous to the person.
Anxiety becomes pathological when:
■ fear is greatly out of proportion to risk/severity
of threat
■ response continues beyond existence of threat or
becomes generalized to other similar or dissimilar
situations
■ social or occupational functioning is impaired
■ often comorbid with substance use and
depression
The current slide and following three slides were taken from https://www.slideshare.net/SayantiSau/screening-of-
anxiolytics
GENERALIZED ANXIETY
DISORDER
 DSM-5 CRITERIA
A. 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).
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 of 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)
A. The anxiety, worry or physical symptoms cause clinically
significant distress or impairment in social, occupational or
other important areas of functioning.
B. The disturbance is not attributable to the physiological
effects of a substance (e.g., drug of abuse, a medication) or
another medical condition (e.g., hyperthyroidism)
C. 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 SAD [social phobia],
contamination or other obsessions in obsessive-compulsive
disorder, separation from attachment figures in separation
anxiety disorder, reminders of traumatic events in PTSD,
gaining weight in anorexia nervosa, physical complaints in
somatic symptom disorder, perceived appearance flaws in
body dysmorphic disorder, having a severe illness in illness
anxiety disorder, or the content of delusional beliefs in
schizophrenia or delusional disorder.
 EPIDEMIOLOGY
• Incidence: 5%
• Female more prone than male
• Age of onset: early 20s
• One of the most common psychiatric disorders that coexist
with other psychiatric disorders.
Management
• Psychotherapy
Cognitive Behaviour Therapy (CBT)

• Pharmacotherapy
- To be considered:
Age, previous treatment response, risk of deliberate self-harm,
cost, patient preference
- Medications:
SSRIs (first line)
Benzodiazepines for acute management (short term only)
 The overall aims of treatment are 4-fold:

(1) to reduce the core symptoms of GAD (both the

psychic and somatic), including restoration of sleep;
(2) To improve patient function and quality of life;
(3) To treat comorbid disorders—present at the time of
diagnosis and those that appear over the long term;
and
(4) To continue treatment for long enough to produce
remission and, where possible, prevent relapse.
 PANIC DISORDER
Panic attack –
Period of intense fear characterized by a cluster of symptoms that
develop rapidly, reach a peak of intensity in about 10 mins , and
generally do not last longer than 20–30 mins. Fears that some kind of
disaster will occur.

Panic disorder –
A condition where a person experiences recurrent unexpected panic
attack that are not associated with substance abuse, medical condition
or another psychiatric disorder. Frequency of occurrence may vary from
many attacks a day to only a few a year.
PATHOPHYSIOLOGY OF A PANIC
ATTACK
 DSM-5 CRITERIA
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.
Palpitations
Sweating
Trembling or shaking Note:
Sensations of shortness of breath or smothering Culture-specific
Feelings of choking symptoms may be
Chest pain or discomfort seen but do not
count as one of the
Nausea or abdominal discomfort.
four required
Feeling dizzy, unsteady, light-headed or faint. symptoms.
Chills or heat sensations.
Paresthesis (numbness or tingling sensations)
Derealiization (feelings of unreality) or depersonalization (being detached from
oneself)
Fear f losing control or ‘going crazy’
Fear of dying
A. At least one of the attacks has been followed by 1 month
(or more) of one or both of the following:
2. Persistent concern or worry about additional panic attacks
or their consequences (e.g., losing control, having a heart
attack or ‘going crazy’.
3. A significant maladaptive chance in behavior related to the
attacks (e.g., behaviors designed to avoid having panic
attacks such as avoidance of exercise or unfamiliar
situations.).
D. The disturbance is not attributed to the physiologic effects
of a substance (e.g., a drug of abuse, a medication) or
another medical condition (such as hyperthyroidism or
cardiopulmonary disorders)
E. The disturbance is not better explained by another mental
disorder (e.g., panic attacks do not occur only in response to
feared social situations as in social anxiety disorder, in
response to circumscribed phobic object or situations as in
specific phobia, in response to obsessions as in OCD, in
response to reminders of traumatic events like PTSD or like
DIFFERENTIALS
• Other anxiety disorder ( Phobias, Social Anxiety, Agoraphobia,
Generalized Anxiety Disorder )
• Depression
• Post Traumatic Stress Disorder (PTSD)
• Obsessive Compulsive Disorder (OCD)
• Hyperventilation syndrome
• Hypoparathyroidism
• Phaeochromocytoma
• Chronic obstructive pulmonary disease
• Asthma
• Mitral valve prolapse
• Diabetes mellitus
• Hypoglycemia
• Thyrotoxicosis
• Anaemia
 Management
Similar to that of panic disorder:
1. Pharmacological:
SSRIs
High potency agents like alprazolam and clonazepam are
effective in providing rapid relief . The patients should be
monitored when discontinuing the medication as the rates of
relapse are high.
After improvement with medication, antidepressant treatment for
panic disorders should be continued for at least 6 months.
2. Psychosocial
CBT is the best option.
Others: exposure to symptoms or situations, cognitive
restructuring, breathing exercise and monitoring for panic
attacks.
 PHOBIAS

1. Agoraphobia
2. Social Phobia
3. Specific Phobia
 AGORAPHOBIA
Fear and avoidance of situations in which a person feels unsafe
or unable to escape to get home or to a hospital in the event of
developing panic symptoms.
Fear of being in public or open spaces.
From the Greek word “agora” which means fear of the
marketplace.

Lifetime risk 1-2%

Female twice as likely
as males to experience
agoraphobia.
DSM-5 CRITERIA
A. The fear, anxiety or avoidance is persistent , typically
lasting for 6 months or more.
B. The fear, anxiety or avoidance causes clinically significant
distress or impairment in social, occupational or other
important areas of functioning.
C. If other medical condition (e.g., IBD, Parkinson’s) is
present, the fear, anxiety or avoidance is clearly excessive.
D. The fear, anxiety or avoidance is not better explained by
thee symptoms of another mental disorder

NOTE: Agoraphobia is diagnosed irrespective of the presence of

panic disorder.
 SOCIAL PHOBIA
Social phobia is characterized by marked fear brought about by social situations (e.g..
being the focus of attention or fear of behaving in a manner that will be
embarrassing), leading to avoidance of being the focus of attention.
Management
• Pharmacology
SSRI antidepressants are recommended first line of treatment.
(Paroxetine)
• Psychosocial
Cognitive behavioural therapy
Exposure to feared situations is a crucial component
SPECIFIC PHOBIA
 There must be:
1. Significant anxiety about a particular object or situation.
2. Encounters with the object or situation always causes
marked anxiety
3. The specified object or situation is avoided.
4. The anxieties and worries are excessively out of proportion
in consideration of the actual threat posed.

A time duration of at least 6 months is necessary to make a

diagnosis of specific phobia and there must be significant
impairments in terms of functioning.
Management
Beta blockers are effective for specific and circumscribed
anxiety, especially for patients with prominent sympathetic
hyperarousal such as palpitations and tremor.
- Propranolol (10-40mg) taken 45-60 minutes before
performance is sufficient for most patients.
OBSESSIVE
COMPULSIVE
DISORDER
Lifetime prevalence: 0.8%
Gender: F:M=1.5:1
Mean age of onset: 20 years
 Definition:
According to DSM V:
1. Obsession:
• Recurrent and persistent thoughts, urges, or images that are
experienced as intrusive and unwanted and that in most of the
individuals cause marked distress or anxiety.
• The individual tries to suppress or ignore such thoughts, urges, or
images or to neutralise them with some other thoughts or action
(eg: by performing a compulsion)
Forms of obsession:
• Thoughts: words, ideas or beliefs (words or phrases)
• Ruminations: repetitive worrying themes of more complex
thoughts (eg: worrying about the end of the world)
• Impulses/images: repetitive urges to carry out actions that
are usually embarrassing or undesirable (eg: shout
obscenities in church, mentally seeing disturbing images
such as stabbing onself)
• Rituals: repetitive but senseless mental activities or
behaviours in a certain sequence or number of times (eg:
repeating a certain form of words, excessive hand washing
28 times in a day), followed by doubts whether it has been
completed in the right way. If interrupted, it has to be
repeated from the beginning.
• Doubts: uncertainty about previous actions that might not be
completed adequately (eg: turning off the gas tap)
• People can spend several hours in a day with their minds
occupied with obsessions
• Because obsessions are unwanted and distressing, people will
try to resist, or get rid of them or reduce their distress in other
ways: avoidance, compulsion or distraction
2. Compulsions:
• Repetitive behaviours or mental acts that the individuals feel
driven to perform in response to obsessions or according to
rules that must be applied rigidly.
• The behaviours or mental acts are aimed at preventing or
reducing anxiety or distress or preventing some dreaded
event/situation, however these are not connected in a
realistic way with what they are designed to neutralise or
prevent or are clearly excessive.
• Short term relief for obsession
• For long term, it keeps the OCD going
Examples:
• Cleaning or washing
• Checking
• Counting
• Ordering or arranging
• Repeating actions
• Touching
• Mental acts
When is it OCD?
• How frequent are the symptoms?
• Do the symptoms cause the person distress?
• Do the symptoms interfere with daily activities (school, work,
relationship, quality of life)?
Examples:
• A college student who must taps on doorframe of every
classroom 14x before entering because she fears something
might happens to her family if she doesn’t
• A man who washes his hands 100x until his hands turn red and
dry and cracks
• A woman who locks and unlocks and relocks her door for half
an hour before going to work every day so she is late to work
every day
How OCD works:

Trigger

Obsessions
Temporary
relief
Anxiety/distress

Compulsion (urge to neutralise distress)

How compulsion fuels obsession:
Anxiety level
 Treatment:
• Inpatient treatment is indicated if patient poses a severe risk to
self or others, demonstrate severe self-neglect (poor hygiene or
eating), extreme distress or functional impairment, or respond
poorly to treatment requiring compliance monitoring.

Pharmacotherapy
• First line: Selective serotonin reuptake inhibitor (eg: sertraline,
fluoxetine, paroxetine)
• Second line: tricyclic antidepressants (clomipramine)
-used when there is an adequate trial of at least one SSRI found to
be ineffective, SSRI is poorly tolerated, patient prefers
clomipramine or there has been a previous good response to
clomipramine.
Non-pharmacological
• Cognitive behavioural therapy: GOLD STANDARD
1. Challenge the meaning of the intrusive thoughts:
-overimportance of thoughts: challenge the meaning of thoughts and
thought action fusion (TAF), behavioural experiments about neutral
outcome and increasing to bad outcome
-overestimation of danger: estimate the probability of negative
outcome, determine all the events that can happen and lead to negative
outcome, calculate the combined probability
2. Exposure and response prevention (ERP) therapy: first exposure to
the OCD trigger, then you sit with the anxiety without doing anything
(do not engage with the compulsion) , then repeat and gradually
increase the difficulty

3. keeping a diary, anxiety management, coping strategies

 Example on overestimation of danger:

House burning down:

OCD prediction: 40% probability
Left the kettle plugged in: 50%
short circuit happened: 10%
Fire started from the short circuit: 10%
Sprinkler system did not work: 1%
None of the neighbours notice until too late: 5%
Fire fighters did not arrive in time: 30%
Combined probability: 0.000075%
Overestimation: 533333 times

This will helps them to evaluate what is the actual probability of what
their fear is going to be a reality, which make them think: do I really
need to go back and check even though the probability that my house is
going to burn down? (helps to prevent compulsive response)