1. Anxiety Disorders And Obsessive-Compulsive Disorders
Med 2017

2. Objectives:
Appreciating the prevalence and the burden of various of anxiety disorders
Describing the key features of various anxiety disorders
Understanding how to differentiate between different anxiety disorders.
Recognizing comorbidities of different anxiety disorders
Planning psychopharmacologic and psychotherapeutic approaches to different anxiety disorders

3. ANXIETY AND FEAR ARE NORMAL
ANXIETY AND FEAR ARE NORMAL!! SERVES IMPORTANT ROLES: ADAPTATION, INITIATION, MOTIVATION ANXIETY PREPARES US TO TAKE ACTION AND IS NORMAL IN MODERATE AMOUNTS

4. Benefits of anxiety Yerkes-Dodson law:
Performance improves as a function of anxiety up to a threshold beyond which there is a fall off in performance

5. The Continuum Between Normal and Abnormal Anxiety
Anxiety is an expectable part of everyday life
Pathological anxiety is on the extreme end of the continuum for
Trait anxiety: how anxious a person
feels in general (as in generalized
anxiety disorder) and/or
State anxiety: how anxious a person
feels in response to specific events
(as in phobias)

6. WHAT ARE ANXIETY DISORDERS?
A group of 7 diagnosable disorders
some shared features
some distinct
The most prevalent group of psychiatric conditions

7. DIAGNOSING ANXIETY DISORDERS
DSM 5
PANIC DISORDER
AGORAPHOBIA
GENERALIZED ANXIETY DISORDER
SOCIAL PHOBIA
SPECIFIC PHOBIA
SEPERATION ANXIETY
SELECTIVE MUTISM

8. SHARED CLINICAL FEATURES
Triggered by innocuous stimuli
Maladaptive thinking patterns: tend to catastrophize, misjudge probability
Prominent physical symptoms: autonomic arousal
Typical behavioral responses: escape, avoidance, help-seeking

9. WHY ARE ANXIETY DISORDERS IMPORTANT?
THE MOST PREVALENT PSYCHIATRIC DISORDERS IN ADULTS
NATIONAL COMORBIDITY STUDY
Kessler et al Arch Gen Psychiatry Jan 1994

10. ANXIETY DISORDERS CAUSE IMPAIRMENT
Daily life effects
Physical functioning
Social functioning
Pain
Fatigue
General health
Sense of well being
Increased risk of
Less Income
Fewer than 16 years of education

11. INCREASED RISK OF SUICIDE
Overall Anxiety Disorders associated with 3 fold risk for suicide attempts
PTSD: 6 fold risk
Panic Disorder and GAD: 5.6 fold risk
Social Phobia: 2.1 fold risk
Kessler et al. Arch Gen Psychiatry. 1999;56:617.

12. Other Anxiety Disorders Substance Use Disorders
COMORBIDITY
Anxiety Disorders co-occur with many mental and physical disorders, esp.
Major Depression
Bipolar Disorder
Other Anxiety Disorders
Substance Use Disorders

13. Comer, Ronald J., Fundamentals of Abnormal Psychology, Seventh Edition Copyright © 2014 by Worth Publishers

14. ANXIETY DISORDERS ARE ASSOCIATED WITH BIOLOGICAL CHANGES
Brain Imaging Abnormalities
Autonomic Activation
Neuroendocrine Changes
Early Bio-behavioral Changes

15. Amygdala Lateral Nucleus
Creates link between conditioned and unconditioned stimulus
Exposure to subsequent relevant stimulus, activates
Central Nucleus: (coordinates fear response)
periaqueductal gray region - freezing or immobility
lateral hypothalamus - autonomic responses
paraventricular hypothalamus – neuroendocrine

16. Shift From Passive Fear to Active Coping in the Brain
LeDoux J and Gorman J Am J Psychiatry 158: , December 2001

17. Generalized Anxiety Disorder (GAD)
Characterized by excessive “free floating” anxiety under most circumstances and worry about practically anything
Symptoms: feeling restless, keyed up, or on edge; fatigue; difficulty concentrating; muscle tension, and/or sleep problems
Must last at least 6 months

18. Specific Phobia
Marked or persistent fear (>6 months) that is excessive or unreasonable cued by the presence or anticipation of a specific object or situation
Anxiety must be out of proportion to the actual danger or situation
It interferes significantly with the persons routine or function

19. Specific Phobia Epidemiology Up to 15% of general population
Onset early in life
Female: Male 2:1
Etiology
Learning, contextual conditioning
Treatment
Behavioural,Systematic desensitization

20. How Are Specific Phobias Treated?
Systematic desensitization
Teach relaxation skills
Create fear hierarchy
Pair relaxation with feared objects or situations
Since relaxation is incompatible with fear, relaxation response is thought to substitute for fear response
Several types:
In vivo desensitization (live)
Covert desensitization (imaginal)

21. Panic Disorder

22. PANIC ATTACK
Sudden escalation and rapid crescendo peak of 4 or more symptoms (physical symptoms prominent
Panic can be
Spontaneous
situation predisposed
situation bound
Can occur with any anxiety disorder and many other physical and mental disorders

23. Panic Disorder
Recurrent unexpected panic attacks and for a one month period or more of:
Persistent worry about having additional attacks
Worry about the implications of the attacks
Significant change in behavior because of the attacks

24. A Panic Attack is: Palpitations or rapid heart rate Sweating
A discrete period of intense fear in which 4 of the following
Symptoms abruptly develop and peak within 10 minutes:
Palpitations or rapid heart rate
Sweating
Trembling or shaking
Shortness of breath
Feeling of choking
Chest pain or discomfort
Nausea
Chills or heat sensations
Paresthesias
Feeling dizzy or faint
Derealization or depersonalization
Fear of losing control or going crazy
Fear of dying

25. Panic disorder epidemiology
2-3% of general population; 5-10% of primary care patients ---Onset in teens or early 20’s
Female: male 2-3:1

26. Things to keep in mind A panic attack ≠ panic disorder
Panic disorder often has a waxing and waning course

27. Panic Disorder Comorbidity
50-60% have lifetime major depression
One third have current depression
20-25% have history substance dependence

28. Agoraphobia

29. Agoraphobia
Marked fear or anxiety for more than 6 months about two or more of the following 5 situations:
Using public transportation
Being in open spaces
Being in enclosed spaces
Standing in line or being in a crowd
Being outside of the home alone

30. Agoraphobia
The individual fears or avoids these situations because escape might be difficult or help might not be available
The agoraphobic situations almost always provoke anxiety
Anxiety is out of proportion to the actual threat posed by the situation
The agoraphobic situations are avoided or endured with intense anxiety
The avoidance, fear or anxiety significantly interferes with their routine or function

31. Social Anxiety Disorder

32. Social Anxiety Disorder (SAD)
Marked fear of one or more social or performance situations in which the person is exposed to the possible scrutiny of others and fears he will act in a way that will be humiliating
Exposure to the feared situation almost invariably provokes anxiety
The anxiety lasts more than 6 months
The feared situation is avoided or endured with distress
The avoidance, fear or distress significantly interferes with their routine or function
Initial remembered traumatic event in 58%
Genetic/familial (heritability about 30%)
Behavioral inhibition in childhood (increased reactivity to novelty, shyness)
Cognitive factors

33. SAD epidemiology 7% of general population
Age of onset teens; more common in women. Stein found half of SAD patients had onset of sx by age 13 and 90% by age 23.
Causes significant disability
Increased depressive disorders
Incidence of social anxiety disorders and the consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry 2007 Mar(4):

34. Social Anxiety Disorder treatment
Social skills training, CBT
Medication – SSRIs, SNRIs, MAOIs, benzodiazepines, gabapentin

35. TREATMENT OF ANXIETY DISORDERS
Promote active coping
MEDICATION: Provide information, directly moderate neurobiology
COGNITIVE BEHAVIORAL TREATMENT: Provide information, Change neural circuitry through exposure, Teach specific coping techniques

36. PATIENTS AND FAMILY NEED INFORMATION
About the illness: symptoms and course
Biological aspects of anxiety
Psychological components of symptoms
Simple principles of conditioned responses
Role of thoughts and behaviors in affecting emotions
Relationship between physiology, psychology and treatment

37. PHARMACOLOGIC TREATMENT OF ANXIETY DISORDERS: EARLY GENERATION
Typical Antidepressants, for example,
imipramine,
clomipramine,
nortriptyline,
monoamine oxidase Inhibitors (like phenelzine)
Benzodiazepines (alprazolam, clonazepam)
Most worked for some, but not all of the anxiety disorders

38. PHARMACOLOGIC TREATMENT OF ANXIETY DISORDERS: NEWER MEDICATIONS
SSRIs and SNRIs
citalopram
fluoxetine
fluvoxamine
paroxetine
sertraline
Escitalopram
Venlafaxine
Doluxetine
Act as “broad spectrum” antianxiety agents

39. Preferred by many patients
COGNITIVE BEHAVIORAL TREATMENTS ARE EQUALLY EFFICACIOUS AS MEDICATION FOR ANXIETY DISORDERS
Preferred by many patients
Associated with improvement in biological as well as psychological abnormalities

41. CBT MODEL OF PANIC DISORDER
Catastrophic
misinterpretation
Conditioned
response
Bodily Sensation
Fear
Physiological
arousal 14

42. Behavioral Anxiety Management
Decrease Physiological Arousal
Slow Abdominal Breathing
Progressive Muscle Relaxation
Re-Instate Normal Activities
Exposure to Anxiety Provoking Situations

43. Target Negative Thinking and Logical Errors
Cognitive Therapy
Target Negative Thinking and Logical Errors
Overestimation of Probability of Negative Consequences
Catastrophizing
Techniques
Identify and Challenge Negative Thoughts
Provide Alternative Explanations

44. WHAT TO REMEMBER ABOUT ANXIETY DISORDERS
Common and debilitating conditions
Often co-occur with other medical and psychiatric conditions
Characterized by
prominent somatic symptoms
catastrophic misinterpretations
escape and avoidance behaviors

45. WHAT TO REMEMBER ABOUT ANXIETY DISORDERS
Avoidance
Can prevent help-seeking
Inhibits reporting of symptoms
Highly treatable
Medication, especially serotonin active antidepressants
Cognitive behavioral treatment

46. Obsessive-Compulsive Disorders
body dysmorphic disorder,
hoarding disorder,
Trichotillomania
excoriation disorder

47. OCD OBSESSIONS: Recurrent and persistent thoughts COMPULSIONS:
Repetitive behaviors or mental acts
Distress/Dysfunction

48. OCD Contamination concerns  hand-washing
Possible harm concerns  checking
Symmetry concerns  symmetry behaviours

49. Obsessive-Compulsive Disorder
Diagnosis is called for when symptoms:
Feel excessive or unreasonable
Cause great distress
Take up much time
Interfere with daily functions

50. NOT OCD Obsessive-compulsive personality disorder
Pathological or problem gambling, compulsive sexual disorder, problematic internet use
Hoarding concerns  hoarding behaviors
Being a meticulous professional or student

51. OCD 4th most common psychiatric disorder in one USA study
10th most disabling of all medical disorders in WHO BoD study
Subclinical washing, checking, symmetry, symptoms are common
(Ruscio et al, 2008)

52. OCD Spectrum
Range of disorders with intrusive thoughts and repetitive behaviors
- Tourette’s syndrome
- Body Dysmorphic Disorder
- Hypochondriasis
- Hoarding Disorder
- Trichotillomania
- Skin Picking Disorder

53. Epidemiology
The lifetime prevalence of OCD is between 2 and 3%. Child/adolescent prevalence is 1-2.3%.
There is similar epidemiology among diverse cultures (studies in Europe, Asia and Africa have confirmed rates).
In adults, male and female prevalence is the same. In children and adolescents, males are more likely than females to be affected.

54. Epidemiology II
Mean age of onset is approximately 20 years old (males with mean around 19 and females around 22).
Two-thirds of affected people have onset before age 25. Less than 15% have onset after age 35.

56. Biological Serotonin Hypothesis Clomipramine, SSRI’s, mCPP
Neuroimmunology
PANDAS, autoimmune
Genetics
1st degree relatives 35%, Monozygotes 80-87%
Neuroimaging
Orbital Frontal Cortex, Basal Ganglia, Anterior Cingulate Gyrus

58. Screening Questions Why Screen?
Lag time from onset to diagnosis, shame
Do you have repetitive thoughts that make you anxious and that you can’t get rid of no matter how hard you try?
Do you keep things extremely clean or wash your hands frequently?
Do you check things to excess?
Check for comorbidity
Lifetime MDD in adults is 2/3. OCD often precedes MDD in kids and adults

59. Treatment Pharmacotherapy Cognitive-Behavioral Therapy Psychosurgery
Deep Brain Stimulation

60. OCD: Biological Perspective
Serotonin-based antidepressants (sertraline; Paroxetine,clomipraine)
Bring improvement to 50–80% of those with OCD
Relapse occurs if medication is stopped
Research suggests that combination therapy (medication + cognitive behavioral therapy approaches) may be most effective

61. OCD: Behavioral Perspective
In fearful situation, perform a particular act (washing hands)
When threat lifts, associate improvement with random act
After repeated associations, believe compulsion is changing situation
Act becomes method to avoiding or reducing anxiety

62. OCD: Behavioral Perspective
Behavioral therapy
Exposure and response prevention (ERP)
Clients are repeatedly exposed to anxiety-provoking stimuli and told to resist performing compulsions
Therapists often model behavior while client watches

63. BE HAPPY DON’T WORRY BE HAPPY BE HAPPY BE HAPPY BE HAPPY BE HAPPY