An update from the WPA Section on Anxiety and Obsessive-Compulsive Disorders

The WPA Section on Anxiety and Obsessive-Compulsive Disorders focuses its activities on a broad range of common and burdensome psychiatric conditions encompassing anxiety and fear-related disorders, obsessive-compulsive and related disorders, and behavioural addiction disorders, including problematic Internet use. This is an exciting area of developing clinical practice, as anxiety and obsessive-compulsive symptoms are increasingly played out in the digital environment.

The Section provides a forum for clinician scientists and academics to exchange experiences and research advances. It organizes activities at WPA meetings, produces scientific publications and develops guidance on relevant topics, in collaboration with key stakeholder groups such as the World Health Organization (WHO), the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS) (www.icocs.org), the Anxiety Disorders and Obsessive-Compulsive Research Networks of the European College of Neuropsychopharmacology (ECNP) (www.ecnp.eu), and the European Network for Problematic Usage of the Internet (www.internetandme.eu). Here we review some of the Section's recent initiatives and its ambitions for the next five years.

The ICD-11 has refined and expanded the classification of anxiety disorders, and created two new groupings, one for Obsessive-Compulsive and Related Disorders and another for Disorders due to Addictive Behaviours, including several new diagnoses.

The ICD-11 grouping of Anxiety or Fear-Related Disorders differentiates fear-related disorders (i.e., phobias related to discrete aversive situations) from anxiety disorders related to a sustained expectation that diffuse aversive events will occur. Separation anxiety disorder and selective mutism have been moved into this grouping.

Obsessive-compulsive and related disorders often present late for treatment, resulting in poor clinical outcomes. To improve recognition and diagnosis, some members of our Section worked with the WHO to reclassify disparate diagnoses into a single Obsessive-Compulsive and Related Disorders grouping. A seminal field study demonstrated that health care practitioners make more accurate diagnoses of these disorders using the ICD-11 vs. ICD-10¹. Moreover, this new classification has advanced research heuristics establishing compulsivity as a transdiagnostic neuropsychological domain.

Another new ICD-11 grouping was created for Disorders due to Addictive Behaviours. This includes two new disorders – gaming disorder and gambling disorder (on- or off-line) – and a residual category for possible diagnosis of other forms of problematic behaviour with addictive, impulsive and/or compulsive features, including buying or shopping, pornography use, social media use, cyberchondria, digital hoarding, and online streaming.

Evidence of overlap between compulsive and addictive mechanisms and disorders has led to the establishment of the European Network for Problematic Usage of the Internet, bringing together experts in compulsivity, impulsivity and addiction. Seminal consensus papers on diagnosis, underpinning mechanisms, and assessment were published², culminating in a festival of science and arts, a string of educational webinars, a textbook published in the WPA Global Mental Health in Practice Series³, and a popular e-book, Learning to Deal with Problematic Usage of the Internet, translated into five languages and downloaded freely hundreds of times (www.icocs.org).

Interest in anxiety and obsessive-compulsive disorders and in problematic Internet use was sharpened into focus by the COVID-19 pandemic and its aftermath. For those with the above disorders, dangers of infection inherent during the pandemic directly impacted clinical care by increasing social avoidance and preventing engagement in critical therapeutic activities. Inflexible thinking and obsessive health concerns led to public health challenges such as vaccine hesitancy and difficulties emerging from COVID-19 lockdown.

Increased use of digital communication initiated by the pandemic brought many benefits but also new challenges and risks for individuals and civil society. These included problems in balancing time spent on- and off-line, dissemination of abuse and misinformation, and societal fragmentation. Problematic Internet use, an umbrella category representing various forms of maladaptive Internet use involving loss of control or hazardous use patterns, has far-reaching harmful consequences for health and well-being in the individual and society^{2, 4}. Adolescents whose cognitive control is not yet developed and those with certain mental health issues are disproportionately affected by this condition, which can be conceptualized as a marker of disrupted self-management. Critically, during the COVID-19 pandemic, global rates of problematic Internet use increased, reaching 7.9% in a meta-analysis and over 30% in some low- and middle-income countries⁵.

In response to the above scenario, members of our Section published open-access consensus guidance for treating anxiety and obsessive-compulsive disorders and for preventing problematic Internet use during and after the pandemic^{6, 7}.

Responding to the “hidden pandemic” of problematic Internet use, Section members expanded the relevant European Network into a 5-year research programme, Boosting Societal Adaptation and Mental Health in a Rapidly Digitalizing, Post-Pandemic Europe (BootStRaP). This includes partners in >20 countries and a global advisory panel. It aims to reduce the harmful effects of digitalization on mental health by creating an evidence-based suite of digital behavioural health interventions addressing vulnerability to problematic Internet use in young people, whose effectiveness will be tested in a series of randomized controlled trials. The project will also develop a health and social policy toolkit, and standards to promote digital human rights and safeguard vulnerable groups from exploitation.

Advances in the neurobiology and treatment of the Anxiety or Fear-Related Disorders and Obsessive-Compulsive and Related Disorders has resulted in an expanding armamentarium of interventions, reaching beyond traditional models to include techniques such as neuromodulation, immunotherapy and neurosurgery. Section members contributed to a revision of the World Federation of Societies of Biological Psychiatry treatment guidelines^{8, 9}. Another collaboration with the Canadian Network for Mood and Anxiety Treatments and the ICOCS is developing a user-friendly set of international guidelines for obsessive-compulsive disorder for release in 2024.

Addressing a critical knowledge gap, Section members were among a group of experts applying a Delphi method-based consensus approach to produce internationally agreed, consistent and clinically useful criteria for treatment-resistant anxiety disorders, to support future trial design and advance evidence-based stepped-care treatment algorithms¹⁰. Following this initiative, Section members, in collaboration with the ECNP Obsessive-Compulsive Research Network and the ICOCS, will use a similar approach to develop clinically useful criteria for treatment-resistant obsessive-compulsive and related disorders.

Given the global burden of problematic Internet use, its impact on youth, and the need for large-scale public health approaches to address it, Section members have embarked on a Lancet Psychiatry Commission with broad international representation that will focus on particularly vulnerable populations to provide globally relevant recommendations for health and social policy changes.

Contemporary challenges in mental health demand cutting-edge solutions. Theoretical frameworks that take an integrative and transdiagnostic approach, and practical initiatives that are inclusive and have transcultural impact, are needed.

The WPA Section on Anxiety and Obsessive-Compulsive Disorders has embraced the responsibility of contributing to such frameworks and initiatives, focusing on disorders that collectively impact a large proportion of the population. Given the high prevalences and limited resources, there is a pressing need for novel technologies in prevention, diagnosis and treatment.

Our Section has considerable potential to empower clinicians, mental health providers and researchers to advance the field. Colleagues who share our vision and interest are warmly invited to join us and contribute to our shared goals.