Anxiety Disorders Dr. Michela M. David, Ph.D., C. Psych. Unit Psychologist, Mood Disorders Research and Treatment Service, Providence Care, Mental Health Services, Adjunct Assistant Professor of Psychology and Psychiatry, Queen’s University
May 13, 2015
Anxiety Disorders
Dr. Michela M. David, Ph.D., C. Psych.
Unit Psychologist, Mood Disorders Research and Treatment Service,
Providence Care, Mental Health Services,
Adjunct Assistant Professor of Psychology and Psychiatry,
Queen’s University
Anxiety…
is a natural response to danger or threat
(real or imagined)
is necessary for our protection!
makes us think, feel and behave differently,
almost instantaneously
narrows our thinking to focus on danger
prepares the body for ACTION using the
fight or flight response
The Fight or Flight Response
When danger is perceived, the brain sends messages to the Autonomic Nervous System (ANS)
It releases chemicals (e.g. adrenaline), which prepare the body for action (fight or flight)
This results in physical symptoms (e.g. rapid heart rate, sweating)
These symptoms may be distressing, but are not dangerous
The body shuts off this response within a few minutes
Common Emotional
Symptoms of Anxiety
Feelings of apprehension or dread
Trouble concentrating
Feeling tense and jumpy
Fear / Dread
Irritability
Restlessness
Common Physical Symptoms
of Anxiety
Pounding heart
Sweating
Stomach upset or dizziness
Frequent urination or diarrhea
Shortness of breath
Tremors and twitches
Muscle tension
Headaches
Fatigue
Insomnia
Common Behavioural
Symptoms of Anxiety
Watching for signs of danger (hypervigilance)
Avoidance
Excessive planning
Safety Behaviours (such as taking a friend, sitting
on the aisle, taking medications, etc)
Common Cognitive Symptoms
of Anxiety:
Feeling like your mind’s gone blank
Catastrophizing: expecting the worst to happen
What ifs...
Images are very important in anxiety
(e.g. making a fool of oneself; dying)
When anxiety lasts too long…
Anxiety in the absence of real and immediate
danger is no longer adaptive
Overwhelming anxiety which becomes chronic
and progressively worse is an illness or
“Anxiety Disorder”
Signs of an Anxiety
Disorder
Are you constantly tense, worried, or on edge?
Does your anxiety interfere with your daily functioning?
Are you plagued by fears that you know are irrational, but can’t get rid of?
Do you believe that something bad will happen if certain things aren’t done in a specific way?
Do you avoid certain situations or activities because they cause you anxiety?
Do you experience sudden, unexpected panic attacks?
Do you feel like danger is around every corner?
Does anxiety cause significant distress and interference in your life?
Anxiety Disorders: Impact
Anxiety disorders are the most common mental health
problem
More than ¼ of the people you know will have some
experience with severe anxiety in one form or another
Anxiety at its worst severely affects functioning
The anxiety mind-set is “like a computer virus that
invades your operating system” (Clark and Beck, 2012)
It can lead to complete disability and confinement
Anxiety disorders are stigmatized like depression,
mainly because of a lack of knowledge
The Anxiety Disorders
Panic Disorder (w or w/o agoraphobia)
Obsessive Compulsive Disorder
(OCD)
Generalized Anxiety Disorder (GAD)
Social Anxiety Disorder (Social
Phobia)
Specific Phobias
Post Traumatic Stress Disorder
(PTSD)
Panic Attacks
Most people experience a panic attack at some time in their lives
The person often feels as if they are having a heart attack or have to leave the situation
Reach peak intensity within 10 minutes, and then turn off
Distressing and debilitating, but not dangerous
Signs and Symptoms of
Panic Attacks:
„ Palpitations, pounding heart
„ Sweating
„ Trembling or shaking
„ Shortness of breath or smothering
„ Choking feeling
„ Chest pain
„ Nausea
„ Dizziness
„ Derealization or depersonalization
„ Fear of losing control or going crazy
„ Fear of dying
Some Common
Panic Attack Triggers
External Triggers:
Small or confined spaces
Distance from exits
Crowds of people
Dentist offices
Internal Triggers:
Heart palpitations
Shortness of breath
Numbness
Trembling
Feelings of unreality
Agoraphobia
Panic disorder can be with or without
agoraphobia
Literally means “fear of the marketplace”
Agoraphobia is anxiety about being in places
or situations from which escape might be
difficult or help might not be available if one
has a panic attack
Many anxiety disorders lead to a fear of
leaving home
CBT Treatments for Panic
Disorder Emphasize:
Learning about how the body responds to anxiety (e.g. the “flight or flight” response)
Helping people to understand the thinking patterns which make anxiety worse
Leaning to stay in the feared situation and gain control (exposure)
Obsessive-Compulsive Disorder
(OCD)
Repeated, intrusive and unwanted thoughts
(obsessions) and/or repetitive behaviours or
mental acts (compulsions) in attempts to
neutralize anxiety
Rituals may be to try to control thoughts (e.g.
hand washing to control thoughts of
contamination)
2.3% incidence; usually appears age 20-30
Treatment for OCD:
Medications: particularly antidepressants (SSRIs), which
lead to substantial improvement in 40-60% of persons with
OCD
Cognitive Behavioural Therapy: includes
exposure to feared objects, thoughts and situations ;
cognitive restructuring (e.g. worst thing that could occur…);
response prevention techniques (delay, change or
shorten rituals if they cannot be prevented)
Generalized Anxiety Disorder
(GAD)
excessive and uncontrollable worry about a broad
number of everyday events and activities
occurs most days for 6 months or longer
physical symptoms: irritability, sleep disturbance,
etc.
increased vigilance and scanning
marked impairment in functioning
Worrying is getting worse:
Society is more anxious than it used to be
Influence of media and news
Emphasis on the negative : dirty laundry
Propaganda
High stress lives
Busy society
GAD: Incidence, Onset
& Treatment
5% lifetime incidence; 32% heritability
peak incidence at age 30-40
twice as common in women than men
8-10% prevalence in women age 45 yrs
most common anxiety disorder in the elderly
often coexists with depression (39-69%) and
substance abuse
Most effective treatments: medications (SSRIs;
Buspirone; benzodiazepines); CBT
Social Anxiety Disorder
also known as Social Phobia
excessive and persistent fear in social or performance
situations
e.g. fear of being judged negatively, or of making a
fool of oneself
significant functional disability results from persistent
avoidance
Social Anxiety Disorder...
is the most prevalent anxiety disorder
is the third most common psychiatric disorder
typically begins in childhood (14-16)
may be preceded by a history of shyness
is a serious condition with a chronic course if left
untreated
Kathleen finds it hard to go anywhere in public because she is
self-conscious and feels sure that everyone around her is
watching her intently, even though she knows this is an
irrational thought. She fears that she might meet a person she
knows and be forced to say hello to them. She is not sure that
she can do that. Her voice will shake, her "hi" will sound weak,
and the other person will know something is wrong. Above all,
she doesn't want anyone to know that she is so afraid. She
turns her eyes away from anyone else's gaze and hopes that
she can make it home without having to talk to anyone.
Treatment of Social
Anxiety Disorder
Pharmacotherapy for symptom relief
Anxiolytics (anti-anxiety)
low dose antidepressants
CBT shows best results
a course of group therapy is very useful
CBT treatment focuses on more effective coping
and role-playing responses, + gradual exposure to
feared social situations
Specific (Simple) Phobia
excessive and persistent fear of specific
objects or situations that present little or
no actual danger
Animals: e.g. snakes, insects, mice
Situational: e.g. flying, going over bridges
Natural environment: e.g. storms, heights
Blood-injection-injury: e.g. blood, injections
Others: e.g. falling down, costumed
characters
Incidence and Development
Phobias are very common, affecting about 12% of
people
Only disappear 20% of the time w/o treatment
Phobias develop via three pathways (Rachman,
1976), although many people cannot recall what
precipitated their phobia. Traumatic event (e.g. surviving or witnessing a plane crash)
Observational learning (see mom freaking out when she sees
a spider)
Information (e.g. warnings on the news, parents being overly
cautions
Treatment of Specific Phobias
Pharmacotherapy (symptom relief)
anxiolytics
CBT is the most effective treatment
exposure + cognitive restructuring
Unique case: blood and needle phobias, which are
associated with a rapid drop in blood pressure
Rx: Exposure + techniques to raise blood pressure
Post Traumatic Stress Disorder
(PTSD)
develops in some individuals following traumatic events (e.g. war)
person must have experienced, witnessed or been confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
re-experiencing of the traumatic event (flashbacks)
persistent avoidance of people and places which are reminders of event
increased arousal: difficulty concentrating, anger, jumpiness
lasts more than 1 month (less than 1 month is Acute Stress Disorder)
PTSD Incidence
1-3.5% lifetime incidence in general population;
women 1.2%, men 0.8%
incidence is increasing, especially in adolescents
(likely due to increased exposure to violence,
terrorism, etc)
15% incidence in Vietnam troops
PTSD is associated with high rate of substance
abuse
Sexual assault carries highest PTSD risk (60% in
males; 50% in females)
PTSD versus Trauma
Most people who are exposed to trauma do not
get PTSD
Exposure to trauma can lead to other disorders
as well (e.g. depression)
Events which are the least likely to occur have
the greatest link to PTSD (Kessler et al, 2005)
Sometimes PTSD develops in a “straw that broke
the camel’s back” manner
Ehlers and Clark:
Cognitive Model of PTSD
Most comprehensive CBT model of PTSD
Two processes create perception of threat:
1. Negative appraisals of trauma and/or its consequences
(e.g. “This means that I will never be a good soldier again”)
2. Disturbance of autobiographical memory, whereby
memories become disconnected from their context and from
intellectual understanding of the trauma (distorted events persist
as if they were real; e.g. person believes they drove through
flashing light at crossing when there were none)
These processes are compounded by unhelpful coping (e.g.
thought suppression and avoidance)