Obsessive-Compulsive Disorder

Found in 3% of the population. Less than half those with OCD come for treatment. The World Health Organization – states, ‘One of the most handicapping disorders of humans.’

Obsessions are intrusive ideas or impulses which the patient considers to be inappropriate and therefore cause anxiety or distress. These are frequently about contamination or doubts about having left doors unlocked or stoves switch on.

The most common obsessions are repeated thoughts about contamination (e.g., becoming contaminated by shaking hands), repeated doubts (e.g., worrying about having left a door unlocked, or a stove switched on), a need to have things in a particular order (e.g., intense distress when objects are out of order), aggressive or horrific impulses (e.g., to hurt one’s child or shout an obscenity in church), and sexual imagery.

Compulsions are repetitive physical acts (such as hand washing) or mental acts (such as checking, counting) - designed to prevent or reduce the distress which accompanies obsessions. The individual feels driven to these compulsions.

In OCD, anxiety may exist at several levels – the patient is aware that the symptoms are illogical/silly, experiences a loss of autonomy and suffers the universal fear of mental illness.

Treatment includes various psychological therapies including Exposure and response prevention (ERP) and thought stopping. Pharmacotherapy includes the SSRIs, which may be supplemented by antipsychotics. Psychosurgery including “Gamma knife capsulotomy is being offered in specialized units. Deep transcranial magnetic stimulation has recently been approved by the FDA in the USA as a treatment of OCD.

Anxiety Disorders

Anxiety disorders are common and can be very disabling. They have their roots in normal responses.

Fear is a response to a real imminent threat. Normal fear is adaptive. If an intruder comes into the house, most healthy persons will be fearful.

Anxiety is the anticipation of future threat. Normal anxiety is adaptive, it signals that action needs to be taken. The healthy person who has lost her/his pay packet will be anxious and keen to do something about the outstanding bills. 

Pathological anxiety is diagnosed when the individual responds as if there is great danger when there is little or no danger. 

One view is that normal anxiety is a normal response to an abnormal situation (anxiety at being threatened by a mugger) and pathological anxiety is an abnormal response to a normal situation (anxiety about leaving the home). 

Anxiety Disorder Classification

Anxiety can take various forms – some people may suffer continuous anxiety (Generalized anxiety disorder) others may suffer anxiety only when they are troubled by a particular thought (such as spider phobia). The following ‘types’ of anxiety disorder have been described by the American Psychiatric Association.  

Generalized Anxiety Disorder (GAD)

The prominent feature is “Excessive anxiety…about a number of events or activities” – which might occur in the future. GAD symptoms have also been described as “unspecified or free-floating”, and often, the patient cannot identify what “is making” them anxious. This cannot be controlled by the patient. GAD is common (about 4% of the population) and can be disabling, impairing social and occupational functioning.

Patients often feel restless or ‘on edge’, easily fatigued, suffer muscle tension (which causes aches and pains) and sleep problems. Interestingly, they may be irritable.

Panic Disorder

The prominent feature is panic attacks which reach a peak in 3-4 minutes – and involve palpitations, sweating, chills or hot flushes, shortness of breath or the sensation of smothering and trembling. There may be chest pain, nausea or abdominal distress. Patients may fear they are losing control, going crazy or about to die.

Agoraphobia

Agoraphobia is a common disorder which features anxiety about, or avoidance of, places from which escape might be difficult. There may be anxiety about open spaces (the marketplace, the ‘agora’) or closed spaces. It may prevent patients leaving home, using public transport or standing in lines. Agoraphobia is often associated with panic disorder.

Social Anxiety Disorder (Phobia)

A phobia is a fear which is persistent and intense, there is a compelling desire to flee or avoid the phobic place/object - the fear is irrational. 

Social phobia is very common - the experience of intense fear of being negatively evaluated by others or of being publicly embarrassed because of impulsive acts. The disability is high, causing people to discontinue education early and avoid interacting with others.

Specific Phobia

In addition to social contact - people experience phobias about a range of objects (spiders) and actions (injections) which may disrupt their ability to live freely.

Treatments

Anxiety disorders take many forms, and thus, treatments may differ greatly. Psychological treatments include cognitive behaviour therapy (CBT) Acceptance and Commitment Therapy (ACT) and others. Pharmacological treatments include the selective serotonin reuptake inhibitors (SSRIs). The benzodiazepines were once the mainstay, but concern has been raised that they may lead to dependency. Interestingly, anxiety disorders are the leading justification for the supply of medicinal cannabis in Canada.