Anxiety Phobias and OCD

Related Subjects: |Anxiety Phobias and OCD |Acute Appendicitis

😟 Anxiety disorders are common and treatable, but management should be tailored to the specific condition. In UK practice, NICE separates generalised anxiety disorder (GAD), panic disorder, social anxiety disorder (social phobia), and obsessive–compulsive disorder (OCD) because the recommended assessment and treatment pathways differ. 👉 Always assess severity, duration, functional impairment, comorbidity, substance misuse, and risk, including self-harm and suicide risk.

📖 About

• Generalised anxiety disorder (GAD): persistent, excessive worry about multiple areas of life, typically present on most days for months.
• Panic disorder: recurrent unexpected panic attacks with ongoing concern about further attacks and/or maladaptive behavioural change.
• Social anxiety disorder: marked fear of social situations involving possible scrutiny, embarrassment, or humiliation.
• Specific phobia: marked fear of a specific object or situation (for example, needles, heights, flying), usually leading to avoidance.
• OCD: distressing obsessions (intrusive thoughts, images, urges) and/or compulsions (repetitive behaviours or mental rituals) that are time-consuming or impairing.

🔍 Epidemiology

• Anxiety disorders are among the commonest mental health disorders seen in primary care and community services.
• They frequently begin in adolescence or early adulthood, though they can occur at any age.
• Women are affected more often by many anxiety disorders; OCD affects both sexes.
• Common comorbidities include depression, alcohol/substance misuse, and other anxiety disorders.

🧠 Pathophysiology

• Anxiety disorders reflect interaction between biological vulnerability, cognitive style, and environmental stressors.
• Fear circuitry involving the amygdala, prefrontal cortex, hippocampus, and autonomic nervous system becomes overactive or poorly regulated.
• Neurotransmitter systems implicated include serotonin, noradrenaline, and GABA.
• In OCD, dysfunction of cortico-striato-thalamo-cortical circuits is thought to underpin intrusive thoughts and ritualised behaviours.
• Psychologically, anxiety is maintained by avoidance, safety behaviours, catastrophic misinterpretation of symptoms, and reinforcement of threat beliefs.

📋 Clinical Features

• GAD: excessive worry, restlessness, feeling on edge, poor concentration, irritability, muscle tension, fatigue, and sleep disturbance.
• Panic disorder: sudden episodes of intense fear with palpitations, chest tightness, tremor, sweating, dizziness, breathlessness, derealisation, and fear of dying/losing control.
• Social anxiety disorder: fear of blushing, trembling, sweating, appearing foolish, being judged, or speaking in groups; often associated with anticipatory anxiety and post-event rumination.
• Specific phobia: immediate anxiety on exposure to the feared stimulus with marked avoidance.
• OCD:
  • Obsessions: contamination, checking, harm, sexual, religious, symmetry, or taboo intrusive thoughts.
  • Compulsions: washing, checking, repeating, counting, reassurance-seeking, arranging, or covert mental rituals.

🛠️ Risk Factors

• Family history of anxiety, OCD, or mood disorder.
• Adverse childhood experiences, trauma, bullying, chronic stress, or significant life events.
• Temperamental traits such as behavioural inhibition, perfectionism, or high neuroticism.
• Alcohol, stimulant drugs, excess caffeine, and some prescribed medicines may worsen symptoms.
• Physical illness can mimic or amplify anxiety symptoms, especially endocrine, respiratory, cardiac, and neurological disease.

🔎 Assessment

🩺 Diagnosis is clinical. A good assessment should define what type of anxiety problem is present, how long it has been present, how severe it is, and what effect it is having on work, relationships, sleep, study, and daily functioning. NICE recommends also checking for depression, substance misuse, self-harm/suicide risk, and relevant physical health differentials.

• Clarify the predominant syndrome: GAD, panic disorder, social anxiety disorder, specific phobia, or OCD.
• Ask about triggers, avoidance, safety behaviours, intrusive thoughts, compulsions, panic symptoms, and functional impairment.
• Screen for depression and suicide risk.
• Ask about alcohol, cannabis, stimulants, benzodiazepines, and OTC/herbal products.
• Review medication history and previous response to therapy.
• Consider validated tools where helpful:
  • GAD-7 for anxiety symptoms.
  • PHQ-9 if depression is suspected.
  • Mini-SPIN, SPIN, or LSAS for social anxiety where relevant.
  • Y-BOCS for OCD severity.

🧪 Investigations

Most people with anxiety disorders do not need extensive investigation. Investigations are used selectively to exclude physical causes suggested by the history or examination.

• Consider FBC, TFTs, glucose/HbA1c, U&E, and ECG only if clinically indicated.
• Think about hyperthyroidism, arrhythmia, asthma, anaemia, hypoglycaemia, medication adverse effects, and substance-related causes.
• Do not over-medicalise clear primary anxiety disorders with indiscriminate testing.

🪜 NICE-Stepped Care Principles

• GAD: NICE recommends a stepped-care approach:
  • Step 1: identification, education, active monitoring.
  • Step 2: low-intensity psychological interventions for persistent subthreshold symptoms or mild-to-moderate GAD.
  • Step 3: high-intensity CBT or drug treatment for marked functional impairment or inadequate response.
  • Step 4: complex, treatment-refractory, or high-risk cases need specialist input.
• Panic disorder: CBT is the main evidence-based psychological treatment; antidepressants can be used where indicated.
• Social anxiety disorder: offer individual CBT specifically developed for social anxiety disorder as first-line in adults.
• OCD: treatment intensity depends on severity and functional impairment, ranging from guided self-help / CBT with ERP to combined SSRI + CBT/ERP and specialist referral.

🧠 Psychological Therapies

• GAD: CBT or applied relaxation are evidence-based options; low-intensity interventions may be appropriate in milder disease.
• Panic disorder: CBT is first-line psychological treatment.
• Social anxiety disorder: individual CBT specifically for social anxiety is preferred in adults.
• Specific phobia: graded exposure / exposure therapy is the key treatment.
• OCD: CBT with ERP (exposure and response prevention) is the core psychological treatment.
• For OCD, merely discussing symptoms is usually not enough; treatment needs active work on exposure and prevention of rituals/reassurance-seeking.

💊 Pharmacological Management

💡 Drug treatment depends on the specific diagnosis. A major correction to the original draft is that it is not quite right to say “sertraline, fluoxetine, citalopram are first-line for anxiety, phobias and OCD” as a blanket rule. NICE recommendations vary by condition.

• GAD:
  • If choosing medication, NICE says to offer an SSRI; sertraline is commonly used as the first choice.
  • If ineffective, consider another SSRI or an SNRI.
  • If SSRIs/SNRIs are not suitable, pregabalin may be considered.
• Panic disorder:
  • If medication is used, offer an antidepressant licensed for panic disorder (typically an SSRI; some SNRIs or TCAs may also be used depending on the individual drug and context).
  • Warn that initial activation/anxiety can temporarily worsen symptoms early in treatment.
• Social anxiety disorder:
  • Adults who decline CBT or need medication may be offered an SSRI such as escitalopram or sertraline.
  • Adults should not routinely be offered anticonvulsants, tricyclics, benzodiazepines, or antipsychotics for social anxiety disorder.
• OCD:
  • SSRIs are the main pharmacological treatment.
  • For more severe OCD, combined SSRI + CBT with ERP is often appropriate.
  • Response may be slower than in depression, and adequate dose/duration is important before judging failure.

⚠️ Important Prescribing Points

• Discuss side effects, discontinuation symptoms, sexual dysfunction, adherence, and time to benefit before starting medication.
• When starting SSRIs/SNRIs, review early for agitation, worsening anxiety, or suicidal thinking, especially in younger adults.
• Benzodiazepines should not be offered routinely for GAD or panic disorder; in GAD they should usually only be used short-term during crises.
• Do not use antipsychotics to treat GAD in primary care.
• For panic disorder, NICE advises not to prescribe benzodiazepines, sedating antihistamines, or antipsychotics as routine treatment.

👥 Social & Functional Management

• Provide psychoeducation and normalise the treatment process without trivialising symptoms.
• Address sleep, caffeine, alcohol, exercise, work/study issues, and social isolation.
• Encourage gradual reduction of avoidance behaviours where safe to do so.
• Involve family or carers appropriately, especially when OCD rituals or reassurance cycles are maintaining symptoms.
• Signpost to NHS Talking Therapies / local psychological therapy services where appropriate.

🚨 Red Flags / When to Escalate

• Active suicidal ideation, self-harm, or inability to maintain personal safety.
• Severe self-neglect, marked weight loss, dehydration, exhaustion, or inability to function.
• Psychotic symptoms, mania, severe depression, or diagnostic uncertainty.
• Very severe OCD, housebound agoraphobia, inability to work/attend education, or severe family accommodation.
• Failure of appropriate first-line treatment or need for complex/risk-based management → refer to secondary care mental health services.

📊 Differential Diagnoses

• Depression with prominent anxiety symptoms.
• PTSD or trauma-related disorder.
• Health anxiety.
• Autism spectrum condition or ADHD (where social/behavioural symptoms overlap).
• Substance intoxication or withdrawal.
• Hyperthyroidism, arrhythmia, asthma, vestibular syndromes, anaemia, medication adverse effects.
• Psychosis, bipolar disorder, or personality disorder where clinically relevant.

📚 Exam Pearls

• GAD: think chronic, free-floating worry across multiple domains + somatic tension symptoms.
• Panic disorder: recurrent unexpected panic attacks + fear of further attacks.
• Social anxiety disorder: fear of scrutiny/embarrassment; NICE favours individual CBT tailored to social anxiety.
• Specific phobia: best treated with exposure-based therapy.
• OCD: intrusive thoughts are usually ego-dystonic; treatment cornerstone = ERP.
• Always assess depression, suicide risk, substance use, and physical differentials.
• Do not rely on benzodiazepines as ongoing treatment for anxiety disorders.