Anxiety, Obsessive Compulsive Disorder & Anxiolytics

ANXIETY, OBSESSIVE COMPULSIVE DISORDER & ANXIOLYTICS

Dr. Asma Perveen
GSP 508 Psychopharmacology

FUNCTION OF EMOTIONS

  • Joy: Promotes social bonding and encourages exploration of the environment.

  • Sadness: Signals loss and can foster social support but may lead to withdrawal if prolonged.

  • Anger: Can motivate protection and change, but may lead to conflict if expressed maladaptively.

  • Disgust: Helps in avoiding harmful substances, and can foster social cohesion by rejecting undesirable behaviors.

  • Fear: Triggers fight-or-flight responses, promotes survival by avoiding danger.

DIFFERENTIAL DIAGNOSIS

Symptoms of Anxiety

  • Physical Symptoms:

    • Trembling or feeling shaky.

    • Restlessness and muscle tension.

    • Shortness of breath and smothering sensation.

    • Tachycardia (rapid heartbeat).

    • Sweating, cold hands, and feet.

    • Light-headedness and dizziness.

    • Paresthesia (tingling of the skin).

    • Diarrhea, frequent urination, or both.

    • Feelings of unreality (derealization).

    • Initial insomnia (difficulty falling asleep).

    • Impaired attention and concentration.

    • Nervousness, edginess, or tension.

Anxiety versus Panic Attacks

  • Anxiety:

    • Onset: Can be gradual

    • Duration: Prolonged

    • Intensity: Mild to moderate, usually precipitated by stressors.

  • Panic Attacks:

    • Onset: Very sudden

    • Duration: One to thirty minutes

    • Intensity: Severe, often without identifiable triggers.

Anxiety Syndromes

  1. Generalized Anxiety Disorder (GAD)

  2. Adjustment Disorder with Anxiety

  3. Specific Phobias

  4. Social Phobias/Social Anxiety Disorder

  5. Agoraphobia without Panic

  6. Anxiety Symptoms Secondary to General Medical Conditions

  7. Substance-Induced Anxiety Disorder

  8. “Neurotic” Anxiety

  9. Panic Disorder

Generalized Anxiety Disorder (GAD)

  • Chronic, low-level anxiety without specific stressors.

  • Excessive worry about multiple aspects of life.

Adjustment Disorder with Anxiety

  • Symptoms arise after identifiable stressors.

  • Acute onset following stressor exposure.

Specific Phobias

  • Intense fear of specific objects or situations.

  • Symptoms manifest only in phobic situations.

  • Complete avoidance of phobic triggers.

Social Anxiety Disorder

  • Anxiety only in social/interpersonal contexts, fear of judgment and rejection.

  • Avoidance impacts work and personal functioning.

Agoraphobia Without Panic

  • Intense fear of situations where escape is difficult or embarrassing.

  • Commonly develops during Panic Disorder, but no previous panic attacks experienced.

Anxiety Related to Medical Conditions/Substance Use

  • Anxiety symptoms secondary to other medical conditions or substance abuse.

Neurotic Anxiety

  • Conflicts exist at unconscious or conscious levels.

  • Symptoms manifest overtly as generalized anxiety.

Panic Disorder

  • Characterized by recurring unprovoked panic attacks, anticipatory anxiety develops over time, commonly associates with agoraphobia.

Etiology of Anxiety Disorders

Psychogenic Origins

  • Psychoanalytic Theory (Freud):

    • Anxieties arise from unconscious danger perception—realistic, moral, and id anxiety.

    • Defensive operations trigger symptoms when defenses fail.

  • Cognitive Models (Beck, 1976):

    • Misjudging dangers; distorted perceptions lead to inappropriate fight-or-flight responses.

Biological Factors

  • Involves complex neural pathways, hormonal responses, and neurotransmitter networks.

  • The body mobilizes resources to cope with perceived danger; hyperarousal states develop.

Neural Pathways

  • Fight-or-Flight Response:

    • Triggered by stressful events involving the amygdala, hypothalamus, and sympathetic nervous system leading to adrenaline and cortisol release.

  • Neuroendocrine Pathways: High arousal leads to increased respiration, alertness, and control of physiological states via CRF and TRH feedback loops.

Treatment Approaches for Anxiety Disorders

General Anxiety Treatments

  • Psychotherapy: Typically first-line treatment.

  • Medications: Can be indicated for severe cases.

    • Benzodiazepines: Quick-acting but carry risks of addiction and tolerance.

    • Buspirone: Non-addictive, slower onset but effective.

    • SSRIs/SNRIs: Increasingly used for chronic anxiety.

    • Gabapentin: Non-habit forming, often used for bipolar anxiety.

Specific Treatment Recommendations
Panic Disorder

  • Combined pharmacological and psychological interventions are most effective.

  • Medications aimed at reducing panic attacks include benzodiazepines and antidepressants.

Agoraphobia Without Panic

  • Treated with behavioral therapy, relaxation training, and possible acute medications.

Social Phobias

  • Primarily treated through cognitive behavioral therapy; medications used if symptoms are pervasive.

OBSESSIVE-COMPULSIVE DISORDER (OCD)

Definitions

  • Obsessions: Persistent, intrusive thoughts recognized as senseless—often concerning contamination, aggression, religion, or symmetry.

  • Compulsions: Repetitive behaviors or rituals responding to obsessions (e.g., checking behaviors, cleaning, counting).

DSM-5 OCD Disorders

  • Body Dysmorphic Disorder, Hoarding Disorder, Trichotillomania, and others.

  • Increased risk of co-occurring Major Depression and substance use disorders.

Etiology of OCD

  • Traditional theories related to early strict parenting but biological processes show a stronger correlation.

  • Genetic factors shown to be present; higher incidence in first-degree relatives.

  • Neuroimaging reveals increased metabolic activity in relevant brain regions for symptomatic patients.

Treatment for OCD

Psychotherapy

  • Behavioral techniques such as exposure and response prevention show high success rates.

Medication Treatment

  • SSRIs are most effective, typically requiring higher doses than for depression.

  • Nesting rituals reflect instincts similar to primitive behaviors, reinforcing compulsiveness.

Summary of Medication Classifications

  • Benzodiazepines: alprazolam, diazepam used for anxiety and panic disorders.

  • Azapirones: buspirone for generalized anxiety.

  • SSRIs: fluoxetine, paroxetine for OCD and anxiety.

  • Beta Blockers: propranolol for performance anxiety symptoms.

  • Anti-histamines: hyroxyzine used for anxiety.

ANXIOLYTICS

Mechanisms and Risks

  • Benzodiazepines work mainly by enhancing GABA functions within the CNS.

  • Side Effects: Sedation, dependency, overdose risks especially in individuals with prior substance use issues.

Withdrawal Management

  • Gradual tapering advised to minimize withdrawal symptoms; rapid discontinuation can lead to severe effects.

Patient Education

  • Importance of discussing risks, benefits, and treatment duration to avoid dependence.

Summary of Treatment Recommendations

  • For Depression: SSRIs/SNRIs.

  • For Anxiety Disorders: Benzodiazepines for short-term; SSRIs/SNRIs for long-term.

  • For OCD: High-dose SSRIs or tricyclics.

  • For PTSD: SSRIs used effectively.

  • For Performance Anxiety: Beta-blockers recommended.

  • Chronic Conditions: Medications with long-term management strategies are needed.