Anxiety disorders and obsessive compulsive Disease

1. DONE BY:
Al-Yaqdhan Al-Atbi
Senior Medical Student at Sultan Qaboos University;
Sultanate of Oman

2.  Definition of anxiety disorders
 "Normal" Anxiety vs. Generalized Anxiety Disorder
(GAD)
 Classification of anxiety disorders
 Generalized Anxiety Disorder
 Phobic disorders
 Panic disorders
 Obsessive-compulsive disorder

3.  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

4. 4Anxiety 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. 5
Episodic anxiety
Anxiety disorders
Mixed pattern
Panic disorder
Panic with agoraphobia in DSM
Agoraphobia with panic in ICD10
Phobic anxiety disorder
agoraphobiaSocial phobiaSimple phobia
Generalized anxiety disorder

7.  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

8.  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

9.  GAD occur in 3% of population
 Women > Men
 The prevalence is estimated to be between 5 and 8
percent in the primary care setting

10. GENETICS
CHILDHOOD
UPBRINGING
PERSONALI
TY TYPE

11. • pallor tens posture sweatingAppearance
• Fearful anticipation Irritability poor conc.
• Sensitivity restlessnesspsychological
• Dry mouth dysphagia Epigastric discomfort
• Loose motionsGI
• Constriction in chest
• OverbreathingRS
• Palpitation missed beats
• Discomfort in chestCVS
• Tremor prickling sensation dizziness
• headacheNeuromuscular
• Insomnia night terors
Sleep
disturbance
• Depression obsession depersonlizationOther symptoms

12.  Differential diagnosis
 Depressive disorder.
 Schizophrenia.
 Dementia.
 Withdrawal from drugs ,alcohol or excessive
use of caffeine.
 Physical illness

14.  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 circumstance
 Avoidance of circumstance that provoke anxiety
 Anticipatory anxiety

15. Phobic disorders can be divided into 3 types:
 Specific (simple)phobias
Social phobia (now called social anxiety
disorder)
Agoraphobia.

16. • 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

17. Afraid
of it
Bothers
slightly
Not at all
afraid of it
Being
closed in,
in a
small
place
Being
alone
in
a house
at night
Percentag
e
of people
surveyed
10
0
90
80
70
60
50
40
30
20
10
0
Snakes Being
in high,
exposed
places
Mice Flying
on an
airplane
Spiders
and
insects
Thunder
and
lightning
Dogs Drivin
g
a car
Being
in
a crowd
of people
Cats

18. • 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

19.  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.

21.  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

22.  With several physical or cognitive symptoms For
example:
Physiological
Palpitations or racing heart
Sweating
Trembling or shaking
Feeling a shortness of
breath
Feeling of choking
Chest pain or discomfort
Nausea and abdominal
distress
Dizziness/faintness
Chills or hot flushes
Numbness or tingling
Cognitive
Feeling of derealization or
depersonalization
Fear of losing control
Fear of going crazy
Fear of dying

24. 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.
©2012 UpToDate®

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

26.  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.

27.  Types:
 Obsessional thoughts:
 Repeated intrusive words or phrases which take many forms
including obscenities, blasphemies and thoughts about distressing
occurrences
 e.g. contaminated hand
 Obsessional doubt:
 Recurrent uncertainties about a pervious action
 e.g. switch of an electrical appliance
 Obsessional impulses:
 Are urges to carry out actions that are usually aggressive, dangerous,
or socially embarrassing
 E.g. using knife to stab someone, jump in front moving train
 Obsessional ruminations:
 Repeated sequences of such thoughts
 e.g. the end of the world

28.  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

29.  Different themes:
 Checking rituals:
 often concerned with safety
 E.g. repeatedly checking gas tap
 Cleaning rituals:
 E.g. hand washing
 Counting rituals:
 E.g. counting particular number or counting in three
 Dressing rituals:
 Cloths are always set out or put on in a particular way

30. • 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
a) obsessions or compulsions cause distress, are
time-consuming, or interfere with normal
functioning
a) not due to GMC/substance use

31.  Clinical features:
 Obsession: thoughts, image, ruminations, doubt,
impulse
 Compulsion
 Phobia
 Slowness in performing everyday activities.
 Anxiety
 Depression
 depersonalization

32.  Epidemiology:
 Men and women affected equally
 OCD occurs in 2 to 3 percent of the United States
population. bimodal distribution of the age of onset: (10
years and 21 years old)

33.  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.
 Environment
 OCD may stem from behavior-related habits that you learned over
time.(hygiene)
 Insufficient serotonin
 Patients who takes medications that improves serotonin action have
fewer symptoms.

35.  Initial treatment
 Detect and treat any co-morbid depressive disorder
 Agree a clear plan
 Explain the nature and cause of symptoms, reassure
about specific concerns
 Identify and reduce or avoid any stressors
 Advice 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

36.  Further treatment:
 Relaxation training (yoga)
 Respiratory control if hyperventilation
 To terminate Acute episode
 To prevent further episodes
 Medication if anxiety still severe
 Use 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 therapy
 Provided by a psychiatrist
 Technique vary according to the type of disorder

37.  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

38.  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.

39.  Simple phobia:
 General measures: all measures applied except no need
to prescribe antidepressant
 Self-help methods: patient should strive to enter
repeatedly the situation that make him anxious.
 Medications: benzodiazepine in severe phobia
 Cognitive behaviour therapy: best treatment is exposure

40.  Social phobia:
 General measures: all are applied
 Self-help method: exposure to social situation
 Antidepressant medications:
 Usual choice is SSRI (fluvoxamine, sertraline) for short term
 MAOI also good for short term
 While taking medications, patient should practice exposure to
social situation
 Anxiolytic drugs: good for immediate short-term relief
 Beta antagonists: control tremor and palpitation
 Cognitive-behaviour therapy:
 Combine exposure to feared situation with procedures to reduce the
patient’s anxiety-provoking thoughts

41.  Agoraphobia:
 General measures
 Self-help methods:
 Exposure to situation that they avoided
 Should use relaxation and destruction to control anxiety in
phobic situation
 Patient should stay in situation until the symptoms subsided,
otherwise the phobic will not decline and may increase
 Antidepressant
 Cognitive-behaviour therapy

42.  General measures
 Information: explain to the patient about the process of
developing panic attack
 Self-help method
 Writing down thoughts during panic attack
 Carrying a card on which is written the rational explanation for the
panic attack
 Antidepressant:
 Imipramine: most studied drug as a treatment for panic disorders
 SSRI also have anti-panic effect
 Anxiolytic drugs:
 Alprazolm can be used for long treatment
 Cognitive therapy

43.  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”

44.  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