3.4 Anxiety Disorders, OCD, and Trauma-Related Disorders

Anxiety Disorders, OCD, and Trauma-Related Disorders

Exam Tip: Distinguish between normal fear (a response to a known, external, definite threat) and pathological anxiety (anticipatory, out of proportion, and functionally impairing).

1. Anxiety Disorders

Generalized Anxiety Disorder (GAD)

• Criteria: Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events or activities.
• Symptoms: At least 3 of the following (only 1 required for children): Restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance.
• Differential: vs. Adjustment Disorder with anxious mood (GAD requires 6 months and is not tied to a single stressor).
• Treatment: SSRIs/SNRIs are first-line (Escitalopram, Venlafaxine XR, Duloxetine). Buspirone (5-HT1A partial agonist) is an alternative without addiction potential but requires 2-4 weeks for onset and is less effective for severe anxiety. CBT is the therapy of choice.

Panic Disorder

• Criteria: Recurrent, unexpected panic attacks (abrupt surge of intense fear peaking within minutes) with at least 4 of 13 somatic/cognitive symptoms (palpitations, sweating, trembling, dyspnea, choking, chest pain, nausea, dizziness, chills/heat, paresthesias, derealization/depersonalization, fear of losing control, fear of dying).
• Post-attack: At least one of the attacks has been followed by 1 month (or more) of persistent concern about having another attack or a significant maladaptive change in behavior (avoidance).
• Note: Panic attacks can occur in the context of any psychiatric disorder (e.g., PTSD, Phobia); Panic Disorder requires unexpected attacks.
• Treatment: SSRIs (first-line), CBT with interoceptive exposure. Short-term benzodiazepines may bridge the 4-6 week delay in SSRI efficacy but should be avoided in patients with substance use history.

Specific Phobia & Social Anxiety Disorder

• Specific Phobia: Marked fear about a specific object or situation (e.g., flying, heights, blood-injection-injury) lasting ≥ 6 months. The blood-injection-injury subtype is unique — it produces a vasovagal bradycardia and syncope rather than tachycardia; apply tension-to-syncope technique during exposure. Treatment: Exposure therapy (systematic desensitization).
• Social Anxiety Disorder: Marked fear of social situations where the individual is exposed to possible scrutiny by others, lasting ≥ 6 months. Treatment: SSRIs, CBT. For performance-only type (e.g., public speaking), beta-blockers (Propranolol) can be used PRN.

Agoraphobia

• Criteria: Marked fear or anxiety in ≥ 2 of 5 situations: public transportation, open spaces, enclosed places, standing in line/being in a crowd, being outside the home alone. The situations are avoided or endured with intense fear, requiring a companion.
• Differential from Specific Phobia: Agoraphobia involves multiple situations; specific phobia is single situation-bound.
• Treatment: CBT with in-vivo exposure; SSRIs.

2. Obsessive-Compulsive and Related Disorders

Obsessive-Compulsive Disorder (OCD)

• Obsessions: Recurrent, persistent, intrusive, and unwanted thoughts, urges, or images that cause marked anxiety.
• Compulsions: Repetitive behaviors (e.g., hand washing, checking) or mental acts (e.g., counting) the individual feels driven to perform in response to an obsession, aimed at reducing distress.
• Criteria: The obsessions/compulsions are time-consuming (e.g., > 1 hour per day) or cause significant impairment. The patient typically has insight (knows the obsessions are a product of their own mind), specified as good/fair, poor, or absent (delusional beliefs — still OCD, not psychosis).
• Treatment: First-line pharmacotherapy often requires higher doses of SSRIs than depression (e.g., Fluvoxamine up to 300 mg/day, Sertraline up to 200 mg/day, Paroxetine, Fluoxetine). Clomipramine (TCA) is highly effective but has more side effects. An adequate trial is 8-12 weeks at maximum tolerated dose. Psychotherapy of choice is Exposure and Response Prevention (ERP).

OCD vs. Obsessive-Compulsive Personality Disorder (OCPD)

OCD is ego-dystonic (the patient recognizes the obsessions as irrational); OCPD is ego-syntonic (the patient views perfectionism, control, and rigidity as correct). OCPD lacks true obsessions and compulsions; instead it features preoccupation with rules, orderliness, and workaholism at the expense of leisure.

Related Disorders

• Body Dysmorphic Disorder: Preoccupation with a perceived defect in appearance that is either slight or unobservable to others. Common behaviors include mirror checking, excessive grooming, and seeking cosmetic procedures. Treat with SSRIs and CBT.
• Hoarding Disorder: Persistent difficulty discarding possessions regardless of value, due to perceived need to save them. Causes cluttered, unlivable spaces. Treat with CBT tailored to hoarding; SSRIs have mixed evidence.
• Trichotillomania (Hair-Pulling Disorder): Recurrent pulling out of one's hair causing hair loss; preceded by tension and followed by relief. Treat with habit reversal training (CBT). Clomipramine and N-acetylcysteine have shown benefit.
• Excoriation Disorder (Skin-Picking): Recurrent picking causing skin lesions. Treat with habit reversal training and SSRIs.

3. Trauma- and Stressor-Related Disorders

Posttraumatic Stress Disorder (PTSD)

• Criterion A (Trauma): Exposure to actual or threatened death, serious injury, or sexual violence (direct experience, witnessing, learning it happened to a close family member, or repeated exposure to aversive details — e.g., first responders).
• Symptom Clusters (B, C, D, E):
  • Intrusion (B): Memories, nightmares, flashbacks, psychological and physiological reactivity to cues.
  • Avoidance (C): Avoiding trauma-related thoughts, feelings, or external reminders.
  • Negative Cognitions/Mood (D): Dissociative amnesia, negative beliefs ("I am bad"), distorted blame, detachment, anhedonia, inability to experience positive emotions.
  • Arousal/Reactivity (E): Hypervigilance, exaggerated startle, irritability, sleep disturbance, reckless behavior, concentration problems.
• Duration (F): Symptoms must last for more than 1 month.
• Specifier: With dissociative symptoms (depersonalization or derealization).

Acute Stress Disorder

• Similar symptom presentation to PTSD following a trauma.
• Duration constraint: Symptoms begin immediately after the trauma but persist for at least 3 days and up to 1 month.
• If symptoms persist past 1 month, the diagnosis changes to PTSD.

PTSD vs. Adjustment Disorder

Adjustment disorder occurs within 3 months of a stressor and involves emotional symptoms that are out of proportion to the stressor's severity. The stressor in adjustment disorder is typically not life-threatening, whereas PTSD Criterion A requires exposure to actual/threatened death, serious injury, or sexual violence. If the stressor does not meet Criterion A, the diagnosis is adjustment disorder, not PTSD.

Treatment for PTSD

• Pharmacotherapy: SSRIs (Sertraline, Paroxetine are FDA-approved) or SNRIs (Venlafaxine).
• Nightmares: Prazosin (Alpha-1 antagonist) is frequently tested for PTSD-related nightmares; off-label but evidence-supported.
• Avoid: Benzodiazepines are not recommended for PTSD — they may interfere with fear extinction and carry addiction risk.
• Psychotherapy (first-line): Trauma-focused CBT, Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), Eye Movement Desensitization and Reprocessing (EMDR).

Clinical Vignette: A 21-year-old college student was involved in a severe car accident 3 weeks ago. Since then, she has been having vivid nightmares of the crash, refuses to get into a car, feels detached from her friends, and is easily startled by loud noises. Diagnosis: Acute Stress Disorder (the time since the trauma is < 1 month).

Worked Example — PTSD vs. Adjustment Disorder: A 35-year-old loses his job and develops depressed mood, insomnia, and anxiety within 2 weeks of the layoff. He has no intrusive memories, no avoidance, and the event involved no threat of death. Diagnosis: Adjustment Disorder with mixed anxiety and depressed mood — not PTSD, because Criterion A is not met.