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Anxiety Disorders
Obsessive Compulsive Disorder
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Psychopathology >> Clinical Features of Anxiety Disorders - Obsessive Compulsive Disorder >> Contents
Contents
1. Introduction to Anxiety Disorders
2. Obsessive Compulsive Disorder
3. Case Study
4. Aetiology (Causes)
5. Treatment
10

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Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Introduction to Anxiety Disorders
1. Introduction to Anxiety Disorders (1/2)
11
Anxiety is normal…
• Anxiety is a common reaction to stress. It prevents
humans from being careless.
• Examples:
• Anxiety about your examination makes you study.
• Anxiety over her baby’s health makes a mother
care for her baby.
…however, in same situations anxiety can be abnormal
• If anxiety crosses a reasonable limit, it might become a disorder
• Examples:
• when one is so anxious that he/she has a breakdown in the
exam hall, forgetting everything
• when a mother is so anxious about her baby’s health, that she
spends day and night praying to God
Nature of Anxiety
Fear
• Fear is a basic emotion of human beings associated with
the perception of a real threatening situation and involves
the ‘fight or flight’ response activated by the sympathetic
nervous system.
• Example: If a street thug attacks you, you would feel intense
fear. Then, you would either run for dear life, or hit him back.
• Thus fear involves:
• cognition of the threatening object,
• subjective cognition of being in danger,
• physiological components like increased heart rate,
• behavioural components like running or hitting.
Anxiety
• Anxiety also involves subjective perception of threat,
physiological changes and some behavioural reaction.
• However, there is no immediate threat - you are
projecting the threatening situation in future and
reacting to it as if it is imminent. If you cannot go out of
your home because of apprehensions of an attack by a
hoodlum, it is anxiety.
• Anxiety serves an adaptive function - it prepares a person
for fight or flight if the danger really comes. But if the
person avoids the situation that in her perception may
cause the danger, and if such imagined situations are
unrealistic, then the effect becomes debilitating.

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One may distinguish between adaptive
anxiety and pathological anxiety by
assessing the realistic probability of the
occurrence of the object of anxiety and
by assessing how dysfunctional it makes
the person.

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Focus of this document
Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Introduction to Anxiety Disorders
1. Introduction to Anxiety Disorders (2/2)
13
Common Characteristics/Nature of Anxiety Disorders
• Cognition or subjective perception of danger – may be accompanied by
vivid, occasionally morbid, images of the difficulties encountered.
• Physiological Responses - through activation of sympathetic nervous
system. Usually includes dilated pupils, increased heart rate, trembling,
breathing discomfort, nausea etc.
• Behavioural Responses - usually a tendency to avoid the dreaded situation.
Except in OCD and sometimes PTSD, where repetitive behaviour is observed.
Anxiety
Disorder
Anxiety Disorder is a blanket term that covers a group of disorders characterized by
irrational fear of some thing or situation. The person is usually aware of the irrationality.
1
Panic Disorder
(with or without
agoraphobia)
2
Phobic Disorders
(specific or social)
3
Generalised
Anxiety Disorder
(GAD)
4
Obsessive
Compulsive
Disorder
(OCD)
5
Post Traumatic
Stress Disorder
(PTSD)
Types of Anxiety Disorders
(DSM IV TR)

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Psychopathology >> Clinical Features of Anxiety Disorders - Obsessive Compulsive Disorder >> Contents
Contents
1. Introduction to Anxiety Disorders
2. Obsessive Compulsive Disorder
3. Case Study
4. Aetiology (Causes)
5. Treatment
14

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Obsession
• Obsession refers to intrusive thoughts, images and impulses often of a negative or
unacceptable kind, despite one’s desire to get rid of it.
• According to DSM IV- TR, obsessions are recurrent and persistent thoughts, impulses
or images that are experienced as intrusive and generate considerable anxiety.
• These thoughts do not concern current real life problems, and are often irrelevant to
present reality.
• The person has insight and tries to remove these thoughts, but is often unsuccessful.
Particularly when aggressive and sexual thoughts predominate, the person considers
herself ‘bad’. Yet the thoughts continue to haunt her.
Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Diagnosis and Epidemiology
2. Obsessive Compulsive Disorder (1/3)
15
Compulsion
• Compulsion refers to being compelled from within to perform certain ritualistic acts,
because you are afraid that if you don’t, you might end up being harmed.
• Compulsions are repetitive overt behaviours like washing or checking or mental acts
like counting or praying in response to an obsessive thought.
• Compulsions are to be done following rigid rules to prevent or reduce the impact of
some dreaded thing or action.
• After a compulsion is performed the person temporarily feels relieved, but again
succumbs to the same cycle.
Obsessive
Compulsive
Disorder
A psychiatric disorder characterised by intrusive thoughts or images of some negative
event, impulse or thing (obsession) and ritualistic acts to undo or prevent these obsessive
thoughts (compulsion).

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Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Diagnosis and Epidemiology
2. Obsessive Compulsive Disorder (2/3)
16
Content of Obsessive Thoughts
• Unusual fear of contamination
• Fear of harming oneself or one’s own
loved ones
• Religious themes
• Sexual themes - specially the
unacceptable forms
• Wishing ill for others: example -
wishing one’s mother dead
• Doubt about whether one has done
things properly.
Primary Kinds of Compulsive Acts
• Cleaning: like repeated washing
• Checking: like repeatedly coming back home to check if the door
has been locked properly
• Counting: like the number of steps one takes before getting on the
bed
• Repeating: like coming back to the first word of the line as one is
not sure if she has read it properly
• Hoarding: like collecting things, not being able to dispose them off
• Ordering: like arranging books on the table in a particular order
each time one leaves the table
Relation between Obsession and Compulsion
Intrusive thoughts of
negative things, impulses or
events
Repetitive behaviours
(compulsions) that are
believed to protect from the
negative things
Temporary relief from the
intrusive thought, reinforcing
the compulsion
Distress due to inability to
control intrusive thoughts

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Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Diagnosis and Epidemiology
2. Obsessive Compulsive Disorder (3/3)
17
Epidemiology (Prevalence)
• OCD seems to be present in about
2% to 3% of general population.
• The onset is gradual beginning in
adolescence or early adulthood.
• Childhood onset is also possible.
Usually the cases with childhood
onset tend to be very severe. If it
becomes severe, it usually turns
chronic.
• The risk is equal for both sexes.
However, the content of
obsession and compulsion may
vary across age and sex.
Co-morbidity
OCD may occur concurrently with
depression, phobia, panic disorder,
GAD and also body dysmorphic
disorder.
• While in most cases, obsessions and compulsion are coexistent,
there may be cases where only obsession or compulsion
predominates.
• The obsessions and compulsions take plenty of time from one’s
daily routine and slow down the entire life process. For some,
rituals take the whole day resulting in the sufferer’s inability to
anything else at all.
• Sometimes it results in health hazard: you may rub and clean
your skin so much and with such material (like raw dettol) that
there are wounds on your body.
• For most people, there are multiple obsessions and
compulsions.
• The anxiety accompanying OCD is two fold:
• Obsessive thoughts are unpleasant and anxiety provoking.
• Compulsions reduce them to some extent, but the very insight
that one is compelled to do such useless things causes lack of
confidence and severe distress.
• World Health Organization found obsessive compulsive disorder
to be the world’s leading cause of disability.
• It has also been associated with unemployment, marital
problem and separation, and impaired social functioning.

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Psychopathology >> Clinical Features of Anxiety Disorders - Obsessive Compulsive Disorder >> Contents
Contents
1. Introduction to Anxiety Disorders
2. Obsessive Compulsive Disorder
3. Case Study
4. Aetiology (Causes)
5. Treatment
18

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Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Case Study
3. OCD Case Study
• Client Background: John is a 25 year old man of considerable intelligence from an upper middle class
family. He is presently employed at a private firm.
• Incident: Once, during the late teens, when he was walking on the pavement he accidentally stepped on
something which he did not bother about at the moment. Later, it came to his mind that it might have
been a used condom. He felt very unclean and washed himself thoroughly.
• Development of Obsession: He knew that his interpretation might have been wrong, but the thought
continued to haunt him. Gradually, he became afraid of stepping over anything dirty on the street -
condom, faeces, or sputum. He is particularly disturbed by vivid imagery of a person soiling the street.
• Now he takes pains to look at the road very carefully before stepping and if ever he sees anything he
avoids that particular street for a few days if possible. The city he lives in is not particularly clean and
often there are dirty things on the street. If he sees anything like this Intrusive imagery of filthy sticky
things haunts him till he is back home and washes himself following certain specific rituals.
• Washing Ritual: He first washes his face ten times, then his arms, chest, back and legs a specific number
of times. He has to take care of his feet particularly, and washes them twenty five times each. The
washing ritual has to be completed irrespective of heat and cold, and irrespective of his health, even if he
has fever. He also has to wash the surface of the soap he uses, as that too might be contaminated.
• Impact on Life: Since he needs about three hours to wash himself, he takes dinner quite late and has
difficulty waking up in the morning and coping with the stress of his job. As he has to avoid certain
streets on certain days, he often reaches his office late.
• His concentration is failing as he is always thinking if there are filthy things stuck in his feet. With
repeated warnings and humiliations from his boss he is thinking about leaving this job and looking for
another with less demanding conditions, even if salary is lower.
19

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Psychopathology >> Clinical Features of Anxiety Disorders - Obsessive Compulsive Disorder >> Contents
Contents
1. Introduction to Anxiety Disorders
2. Obsessive Compulsive Disorder
3. Case Study
4. Aetiology (Causes)
5. Treatment
20

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Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Aetiology
4. OCD Aetiology
21
Causes of OCD
1
Biological Factors
1.1
Genetic Factors
1.2
Evolutionary
Perspective
1.3
Brain and Biochemical
Abnormalities
2
Psychological Factors
2.1
Psychoanalytical
Approach
2.2
Behavioural Approach
2.3
Cognitive Approach

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Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Aetiology
4.1. Biological Factors
22
1. Genetic Factors
• Moderate genetic
inheritance has been
observed in case of OCD.
• There is a moderate
concordance rate for
monozygotic twins.
• One strong evidence in
favour of genetic basis is the
connection of OCD and
Tourette’s syndrome as it
has a strong genetic basis.
• A large number of first
degree relatives of children
with Tourette’s have been
found to have OCD.
• OCD has also been found to
be associated with
childhood autism, another
disease with genetic causes.
2. Evolutionary Perspective
• It suggests that as in the
case of phobia, there is a
preparedness factor in
OCD.
• For example, obsession
about contamination is
much more common than
obsession about pencils.
3. Brain and Biochemical
Abnormalities
• Some parts of the brain, like
caudate nucleus, orbital
frontal cortex and the
cingulated cortex show
excessive metabolic activity
in OCD patients.
• Diseases like encephalitis
and brain tumours have also
been found to ritualistic
behaviour, thus implicating
certain parts of the brain
abnormality for OCD.
• There is also some evidence
that increased activity of the
neurotransmitter called
serotonin and enhanced
sensitivity of the stated
brains structures to
serotonin are also
associated with OCD.

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Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Aetiology
4.2. Psychological Factors
23
1. Psychoanalytical Approach
• It attributes obsession to a
fixation to the anal phase of
life.
• Too strict toilet training
predisposes the child towards
over- conscientiousness.
• The unconscious impulse to
soil and play with filth, natural
in a child of anal phase is so
strongly prohibited that the
child takes recourse to
defenses like reaction
formation by being overly
clean and undoing by rituals.
• Paradoxically, obsession also
provides a way of vicarious
satisfaction of the prohibited
impulse. If you are thinking for
the whole day about how to
stay away from dirt, you are, in
a way, thinking of dirt only.
2. Behavioural Approach
• Neutral stimuli may be associated
through classical conditioning with
frightening ideas and become
capable of eliciting intense anxiety.
• Example: John may have acquired
the fear of dirty things on the
street because he was thinking of
something negative while walking
on the street, and the object on the
street became associated with it.
Since the connection wasn’t logical,
he couldn’t explain it.
• Since compulsions reduce anxiety
to a large extent, they become
reinforced and continue in a
cyclic manner.
• So, if the person is exposed to the
object of obsession, and the
ritualistic compulsive behaviour is
prevented, the reinforcement of
the compulsion would stop. He
would, gradually, understand that
anxiety reduction is possible
without compulsive acts.
3. Cognitive Approach
• It suggests that there are negative automatic
thoughts behind obsession.
• Persons with OCD are often excessively
responsible and perfectionistic. This may be due
to childhood training. But, if they think of
something obnoxious, which we all do
occasionally, they cannot separate it from acting
it out in reality. This is called thought-action
fusion.
• This fusion makes it easier for catastrophic
thinking to take place. Of course, if you think
that some harm may come to your friend, and
you confuse it with your actually harming the
friend, the results would be catastrophic.
• Cognitive bias is apparent in obsession. Their
attention easily goes to the concern of obsession
in comparison to any other neutral stimulus.
• They have information processing issues
• Their memory seems to be selectively distorted
as they cannot remember if they have done
a thing properly or not, resulting in repetitive
behaviour.
• They also have difficulty in suppressing
irrelevant information.

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Psychopathology >> Clinical Features of Anxiety Disorders - Obsessive Compulsive Disorder >> Contents
Contents
1. Introduction to Anxiety Disorders
2. Obsessive Compulsive Disorder
3. Case Study
4. Aetiology (Causes)
5. Treatment
24

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Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Treatment
5. OCD Treatment
25
Treatment of OCD
1
Pharmocology
2
Psychological
Approaches
• Clomipramine and Fluoxetine are used most
frequently with OCD cases.
• The improvement rate is moderate.
Particularly when the medicine is discontinued
there is chance of relapse unless behaviour
therapy has been continued along with
medicine.
• Psychoanalytically oriented therapy or insight
therapies are of little use for OCD patients.
• Exposure and Response Prevention (ERP) works
best for OCD.
• In E&RP you need to encourage the person to
expose themselves to their obsessions.
• Then they must prevent themselves from the
ritualistic acting out of the compulsions to get
rid of the anxiety generated by the obsession.
• As they are repeatedly faced with their fear and
can reduce their anxiety without compulsion
they get ‘habituated’ to the new experience.
Behaviour therapy and
medication are most popularly
used modes of therapy.
Behaviour therapy has higher
percentage of completed
treatment, compared to
medication.
OCD is one of the most difficult to
cure diseases. However, even if the
entire range of obsessive thoughts
and compulsive acts cannot be
cured, the severity can be
considerably reduced to enable
one to lead a successful life.

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Exposure and
Response
Prevention
• A behavioural treatment of Obsessive Compulsive Disorder where the person is exposed
to the feared thought and the compulsive act is prevented.
• Gradually, the person becomes habituated to dealing with the obsessive anxiety without
resorting to the compulsion.
Psychopathology >> Clinical Features of Anxiety Disorders – Obsessive Compulsive Disorder >> Treatment
5.1. ERP Definition and Example
26
Example Situation: You want to treat a lady who is bothered by the intrusive thought of
possible harm to her husband, and then counts up to seven to protect him from the
harm.
Step 1
Exposure
• You allow her to be
subject to the thought
Step 2
Response Prevention
• You have to prevent her
from counting.
• You may distract her by
discussing the possibility
of the harm and after
some talking she may feel
the fear of harm a bit less.
Step 3
Reinforcement
• You reinforce this
behaviour and ask her to
practice it.
• You can give her
homework as well so that
she may record the
number of successful
response prevention at
home.
• Gradually she becomes
convinced that obsessive
anxiety may go away
even without the counting.

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