DONE BY:

Al-Yaqdhan Al-Atbi

Senior Medical Student at Sultan Qaboos University;

Sultanate of Oman

ANXIETY DISORDERS AND OCD

Definition of anxiety disorders"Normal" Anxiety vs. Generalized Anxiety

Disorder (GAD) Classification of anxiety disorders

Generalized Anxiety DisorderPhobic disordersPanic disordersObsessive-compulsive disorder

OUTLINE

anxiety is a universal human characteristic which serves as an adaptive mechanism to warn about an external threat by activating the sympathetic nervous system (fight or flight)

3Anxiety disorder

Definition

4Anxiety disorder

"Normal" Anxiety vs. Anxiety Disorder

“Normal” Worry: Anxiety Disorder Your worrying doesn’t get in the way

of your daily activities and responsibilities.

You’re able to control your worrying.

Your worries, while unpleasant, don’t cause significant distress.

Your worries are limited to a specific, small number of realistic concerns.

Your bouts of anxiety last for only a short time period.

Your anxiety significantly disrupts your job, activities, or social life.

Your anxiety is uncontrollable.

Your worries are extremely upsetting and stressful.

You worry about all sorts of things, and tend to expect the worst.

You’ve been worrying almost every day for long peroid

The difference between “normal” anxiety and generalized anxiety disorder (GAD) is that the anxiety involved in GAD is: excessive , intrusive , persistent , debilitating

5

Classification of anxiety disorders

Episodic anxiety

Anxiety disorders

Mixed patternPanic disorder

Panic with agoraphobia in DSMAgoraphobia with panic in ICD10

Phobic anxiety disorder

agoraphobiaSocial phobiaSimple phobia

Generalized anxiety disorder

Generalized Anxiety Disorder

Diagnosis excessive anxiety and worry for at least 6

months (chronic) about a number of events and activities (e.g. money, job security, marriage, health)

difficult to control the worry

GENERALIZED ANXIETY DISORDER (GAD)

Three or more of the following six symptoms (only one for children) mnemonic - BE SKIM

Blank mind, difficulty concentrating Easy fatigability Sleep disturbance Keyed up, on edge or restless feeling Irritability Muscle tension

Not due to GMC/substance use

GENERALIZED ANXIETY DISORDER (GAD)

GAD occur in 3% of populationWomen > MenThe prevalence is estimated to be between 5

and 8 percent in the primary care setting

Epidemiology

Aetiology

GENETICS

CHILDHOOD UPBRINGING

PERSONALITY TYPE

Generalized Anxiety Disorder

•pallor

tens posture

sweating

Appearance

•Fearful anticipation

Irritability

poor conc.

•Sensitivity

restlessness

psychological

•Dry mouth

dysphagia

Epigastric discomfort

•Loose motions

GI

•Constriction in chest

•Overbreathing

RS

•Palpitation

missed beats

•Discomfort in chest

CVS

•Tremor

prickling sensation

dizziness

•headache

Neuromuscular

•Insomnia

night terors

Sleep disturbance

•Depression

obsession

depersonlization

Other symptoms

Differential diagnosis Depressive disorder. Schizophrenia. Dementia. Withdrawal from drugs ,alcohol or

excessive use of caffeine. Physical illness

Phobic Anxiety Disorders

A phobia is defined as an irrational fear that produces a conscious avoidance of the feared subject, activity, or situation.

The affected person usually recognizes that the reaction is excessive

The symptoms of phobic disorders are same as anxiety disorders except in three:Anxiety in particular circumstanceAvoidance of circumstance that provoke anxietyAnticipatory anxiety

Phobic Anxiety Disorders

Phobic disorders can be divided into 3 types: Specific (simple)phobiasSocial phobia (now called social

anxiety disorder)Agoraphobia.

• Marked and persistent fear caused by presence or anticipation of a specific object or situation

• Types: • Natural environment—heights, water, lightening• Situation—flying, tunnels, crowds, social gathering• Injury—needles, blood, dentist, doctor• Animals or insects—insects, snakes, bats, dogs

Simple (specific) phobia

Afraid of it

Bothers slightly

Not at all afraid of it

Beingclosed in,

in a smallplace

Being alone

ina houseat night

Percentageof peoplesurveyed

10

0

90

80

70

60

50

40

30

20

10

0

Snakes Beingin high,exposedplaces

Mice Flyingon an

airplane

Spidersand

insects

Thunderand

lightning

Dogs Driving

a car

Being in

a crowdof people

Cats

Study of normal anxieties

Social Phobia• marked and persistent fear of social or

performance situations in which person is exposed to unfamiliar people or to possible scrutiny by others

• They avoid doing activities in public such as eating or speaking, as well as using public bathrooms

• Most commonly, social phobia develops between early adolescence and age 25 (Schneier et al., 1992).

• Symptoms are similar to those of other anxiety disorders although blushing and trembling are particulary frequent

Is an anxiety disorder characterized by anxiety in situations where the sufferer perceives the environment to be difficult or embarrassing to escape

Fears commonly involve clusters of situations like being out alone, being in a crowd, standing in a line, or travelling on a bus

Situations are avoided, endured with anxiety or panic, or require companion

Agoraphobia can account for approximately 60% of phobias

Onset is usually between ages 20 and 40 years and more common in women.

Agoraphobia

Panic Disorders

Panic Disorder is recurrent unexplained panic attacks with anxiety about these attacks (or future attacks).

It is sometimes accompanied by agoraphobia – a fear of being in public places.

Panic attack: a period of intense fear in which 4 of 13 defined symptoms develop abruptly and peak rapidly less than 10 minutes from symptom onset

Panic Disorders

With several physical or cognitive symptoms For example:

Panic attack

PhysiologicalPalpitations or racing heartSweatingTrembling or shakingFeeling a shortness of breathFeeling of chokingChest pain or discomfortNausea and abdominal distressDizziness/faintnessChills or hot flushesNumbness or tingling

CognitiveFeeling of derealization ordepersonalizationFear of losing controlFear of going crazyFear of dying

VEDIO

Criteria for panic disorder without agoraphobia

A. Both (1) and (2)1. Recurrent unexpected Panic Attacks

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

(a) Persistent concern about having additional attacks (b) Worry about the implications of the attack or its consequences (eg, losing

control, having a heart attack, "going crazy") (c) A significant change in behavior related to the attacks

B. Absence of Agoraphobia

C. The Panic Attacks are not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition (eg, hyperthyroidism).

D. The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia ,Specific Phobia, Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder, or Separation Anxiety Disorder.

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Obsessive-Compulsive Disorder (OCD)

DSM-IV classify OCD as a type of anxiety disorders, while in ICD-10 considered OCD as a separate

disorder

recurrent and persistent thoughts, impulses, or images that are intrusive, inappropriate, and cause marked anxiety and distress.

the thoughts, impulses, or images are not simply excessive worries about real-life problems.

attempts made to ignore/ neutralize/ suppress obsession with other thoughts or actions (resistance).

patient aware obsessions originate from own mind.

Obsession

Types:Obsessional thoughts:

Repeated intrusive words or phrases which take many forms including obscenities, blasphemies and thoughts about distressing occurrences

e.g. contaminated handObsessional doubt:

Recurrent uncertainties about a pervious actione.g. switch of an electrical appliance

Obsessional impulses:Are urges to carry out actions that are usually aggressive,

dangerous, or socially embarrassingE.g. using knife to stab someone, jump in front moving train

Obsessional ruminations:Repeated sequences of such thoughtse.g. the end of the world

Obsession

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

the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation

these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

compulsion

Different themes:Checking rituals:

often concerned with safetyE.g. repeatedly checking gas tap

Cleaning rituals:E.g. hand washing

Counting rituals:E.g. counting particular number or counting in

threeDressing rituals:

Cloths are always set out or put on in a particular way

Compulsion

Obsessive-Compulsive Disorder (OCD)

• DSM IV Obsessive Compulsive Disorder (OCD) diagnostic criteria :

a) Either Obsession or compulsion or both

b) recognition that obsessions or compulsions are excessive or unreasonable

c) obsessions or compulsions cause distress, are time-consuming, or interfere with normal functioning

d) not due to GMC/substance use

Clinical features:Obsession: thoughts, image, ruminations,

doubt, impulseCompulsionPhobiaSlowness in performing everyday activities.AnxietyDepressiondepersonalization

Obsessive-Compulsive Disorder (OCD)

Epidemiology:Men and women affected equallyOCD occurs in 2 to 3 percent of the United

States population. bimodal distribution of the age of onset: (10 years and 21 years old)

Obsessive-Compulsive Disorder (OCD)

The cause of obsessive-compulsive disorder isn't fully understood. Main theories include: Biology

OCD may be a result of changes in your body's own natural chemistry or brain functions. OCD also may have a genetic component, but specific genes have yet to be identified.

EnvironmentOCD may stem from behavior-related habits that you learned

over time.(hygiene)

Insufficient serotoninPatients who takes medications that improves serotonin

action have fewer symptoms.

Aetiology of OCD

Management of Anxiety Disorders & OCD

Initial treatmentDetect and treat any co-morbid depressive disorderAgree a clear planExplain the nature and cause of symptoms,

reassure about specific concernsIdentify and reduce or avoid any stressorsAdvice about self help methods (time organizing,

taking time off to relax)Limit the use of anxiolytic drugs:

For severe disorders or cases in which immediate relief is essential

Should not be prescribed for more than 3 weeks because of the risk of dependency

Management of Anxiety Disorders

Further treatment:Relaxation training (yoga)Respiratory control if hyperventilation

To terminate Acute episodeTo prevent further episodes

Medication if anxiety still severeUse of antidepressants:

Have anxiolytic effect and do not produce dependence (good for long-term treatment)

Different medications for different types of Anxiety disorders

Refer to cognitive behavior therapyProvided by a psychiatristTechnique vary according to the type of disorder

Management of Anxiety Disorders

General measures

Self-help methods: Ask patient to write down the worrying thoughts. Consider for each problem anything can be done to resolve

the worrying problems

Anxiolytic medication: Use of benzodiazepine for short-term

Antidepressant medication: tricyclics(amitriptyline), SSRI, MAOIs

Cognitive behaviour therapy

Treatment of GAD

Cognitive-behavioral therapy (CBT) is very useful in treating anxiety disorders.

The cognitive part helps people change the thinking patterns that support their fears, and the behavioral part helps people change the way they react to anxiety-provoking situations.

Cognitive behaviour therapy

Simple phobia:General measures: all measures applied except

no need to prescribe antidepressantSelf-help methods: patient should strive to

enter repeatedly the situation that make him anxious.

Medications: benzodiazepine in severe phobiaCognitive behaviour therapy: best treatment is

exposure

Treatment of Phobic anxiety

Social phobia:General measures: all are appliedSelf-help method: exposure to social situationAntidepressant medications:

Usual choice is SSRI (fluvoxamine, sertraline) for short termMAOI also good for short termWhile taking medications, patient should practice exposure to

social situationAnxiolytic drugs: good for immediate short-term reliefBeta antagonists: control tremor and palpitationCognitive-behaviour therapy:

Combine exposure to feared situation with procedures to reduce the patient’s anxiety-provoking thoughts

Treatment of Phobic anxiety

Agoraphobia:General measuresSelf-help methods:

Exposure to situation that they avoidedShould use relaxation and destruction to control

anxiety in phobic situationPatient should stay in situation until the symptoms

subsided, otherwise the phobic will not decline and may increase

AntidepressantCognitive-behaviour therapy

Treatment of Phobic anxiety

General measuresInformation: explain to the patient about the process of

developing panic attackSelf-help method

Writing down thoughts during panic attack Carrying a card on which is written the rational explanation

for the panic attackAntidepressant:

Imipramine: most studied drug as a treatment for panic disorders

SSRI also have anti-panic effectAnxiolytic drugs:

Alprazolm can be used for long treatmentCognitive therapy

Treatment of Panic Disorders

General measures

Information: most pateint think that they are “going mad” explain that OCD doesn’t progress to this level

Reducing and voiding stressors

Self-help methods: Try to encourage to resist the rituals

Medications SSRI (first choice) and clomipramine suppress OCD These drug slow to act (6 week to peak) Continue for 6 months Anxiolytic only used for short term Cognitive-behaviour therapy: “exposure”

Treatment for OCD

http://www.helpguide.org/mental/generalized_anxiety_disorder.htm

http://emedicine.medscape.com/article/288016-overview http://www.biologicalunhappiness.com/DSM-OCD.htm Karno M, Golding JM, Sorenson SB, Burnam MA. The

epidemiology of obsessive-compulsive disorder in five US communities. Arch Gen Psychiatry 1988; 45:1094.

Rasmussen SA, Eisen JL. The epidemiology and differential diagnosis of obsessive compulsive disorder. J Clin Psychiatry 1992; 53 Suppl:4.

http://www.nimh.nih.gov/health/publications/anxiety-disorders/treatment-of-anxiety-disorders.shtml

•Generalized Anxiety Disorder,Psychiatr Ann. 2011 February;41(2):54-56 By Michael E. Portman, DPhil, LISW-S

•Psychiatry, 3rd edition by M.Glder; R. Mayou; J. Geddes

Reference:

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