Anxiety Disorders Anxiety Disorders 101: An Introduction to the Diagnosis and Treatment of Anxiety Disorders in Adults Sally Winston PsyD ADAA Baltimore March 2010

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Anxiety Disorders Are Chronic Intermittent Disorders

The Anxiety Disorders: Core Issues • • • •

Panic/Agoraphobia: die, go crazy, lose control Social Anxiety : humiliation, dysfunction Obsessive-compulsive: doubt, taboo,safety Post-Traumatic Stress : victimization, defilement, loss of illusions, stuck memories

• Generalized Anxiety: worry, control,tension • Specific Phobia: external danger, risk

• They come back in times of physical or emotional arousal or stress. • The vulnerability to anxiety runs in families and has a biological underpinning. • These are serious disorders beyond typical everyday stress responses. They are stresssensitive, not caused by stress. • They can be treated and managed to full recovery.

What is a Panic Attack? • A false alarm: an emergency fight-or-flight reaction when there is no danger • A cardiovascular work-out you never asked for • Weird intense sensations and scary thoughts that last for a few minutes • Something that screams “do something” when nothing needs to be done

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Panic Disorder Panic Disorder with Agoraphobia Social Phobia Specific Phobia Obsessive-Compulsive Disorder Generalized Anxiety Disorder Acute Stress Disorder Post-Traumatic Stress Disorder

Panic Disorder : Underlying Fears • • • • • •

heart attack stroke pass out brain tumour cancer other medical catastrophe • smother

• vomit • choke • diarrhea / urinary incontinence • go blind • start screaming • lose control • go crazy

Feeling trapped: Agoraphobia is the “what if” phobic complication of panic • • • •

won’t be able to drive won’t be able to sleep won’t be safe alone won’t be able to care for my children • will never be able to go back if I leave • this one is not just a panic attack

• might do something dangerous • might be unable to function (paralyze) • might sound or act crazy • might “cross the line and never get back” • panic won’t end ever

Etiology: No Simple Answer • Probably several distinct dysfunctions can “kick off” panic attacks or lead to periods of sensitization. An example is the “suffocation alarm”. Another is a vestibular problem. • These may vary across and within individuals. • High “anxiety sensitivity” reaction to bodily sensations leads to experience of panic. AS is probably largely constitutional. • Panic patients show cognitive bias towards threat stimuli and superior interoceptive acuity

Hyperventilation FEAR

HYPERVENTILATION

PHYSICAL SYMPTOMS BLOOD pH pCO2

• • • • • • • •

tremors muscle tension anxiety unreal feelings depersonalization sweating in palms

• shortness of breath • pins and needles in extremities • sensation of “air hunger” or “can’t get a good breath” • off balance feeling

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• • • • • • • •

extreme sighing heartburn air swallowing muscle cramps weakness exhaustion lack of concentration feelings of unreality

Social Anxiety Disorder Fear of Humiliation

Hyperventilation • • • • • •

palpitations chest pain dizziness feeling faint visual distortion numbness nightmares sleep disturbance

• • • • • • •

being looked at being judged looking anxious freezing up losing control losing respect being rejected

• • • •

sweating/blushing trembling voice shaking say something stupid or boring • have to leave • look awkward

Common Social Phobic Situations • public speaking • public bathrooms (paruresis) • talking to authority figure • talking to attractive person • making introductions • asking for directions

• writing or eating in front of others • entering crowded room • formal affairs • reading aloud • speaking in class • running into friend

Evaluation Anxiety • Social anxiety occurs both in anticipation and after the challenging event • Experience may be dominated by constant measurement of hierarchical status • Projection of judgmental attitudes and shame may dominate • “Poor self confidence” is often how people describe performance anxiety

Maintenance of Social Anxiety

Comorbidity of SAD

• Avoidance: diminished opportunity to disprove assumptions and beliefs, assault on confidence and self esteem with every avoidance • Worry: ruminative rehearsals escalate anxiety and reinforce catastrophizing • Evaluating performance while performing leads to self-absorption and can interfere

• Lifetime incidence of major depression as high as 70% • Alcoholism rates as high as 35% • SAD precedes comorbid condition 70% of the time • Very high percentage of patients diagnosed as GAD actually have SAD

Specific Phobias (Rule out other diagnoses first) • Animal type • Natural environment type • Others (vomiting, choking, accidental associations) • Blood-injury phobia (very different) • Trauma-based phobias ( authority figures, power tools, the “mundane” such as the dark , strangers, sleeping upstairs, noises)

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Avoidance : Not always based on Fear IF DISGUST OR REVULSION • Assess for “icky-sticky” OCD • Assess for BI “phobia” • Assess for trauma-based phobic response

IF SHAME – Assess level of depression – Assess for traumatic experience – a skill deficit or chronic secrecy about disability?

Preoccupation, Worry, Rumination and Obsession

Agoraphobia Without Panic • Debilitating or excessive fear of seizures, falling , choking, fainting • fear of getting lost or being alone away from home • fear of being attacked • fear of loss of bowel or urine control • common in the elderly

• Ego-syntonic and ego-dystonic worry (about the future) are very different. • True ruminations (about the past) are more often affective symptoms. • OCD is a disorder of overcontrol, not impulsivity • Degree of “insight” is situationally bound.

OBSESSION • take the form of repetitive thoughts or images which feel uncontrollable • intrusive, unwelcome and unbidden • taboo, repulsive or shocking, unacceptable • arrives with a “jolt” (affective spike) • ego-dystonic (not “my” thoughts) • arrives with a strong urge to resist, control, ignore, suppress or dismiss it

An Obsession is NOT Defined By Content • It is identified by how it FEELS and ACTS • It has a functional relationship to neutralization (compulsion, ritual) • There is a sense of divided consciousness at least to some degree (ego-dystonicity) • Critical feature is how the thought is appraised, evaluated and responded to. • Overvalued ideation is a more fixed, more “believed” thought that is not quite delusional

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OCD Issues • • • • • •

sex perversion violence suicide abuse sin

• • • • • •

blasphemy contamination horror/disgust mutilation disease dangerous mistake

Common Obsessive Thoughts • What if I hurt (abuse, mutilate, murder,sexually assault) my baby (child, loved one, self, stranger)? • What if I lose control and say or do something crazy(insulting, abusive, ridiculous)? • What if suddenly do something dangerous (jump off the balcony, turn the wheel of the car, throw myself in front of the train, stab myself with a knife etc.)

Common Obsessive Thoughts (2) • What if I get sexually aroused in the wrong situation (stare at breasts, feel turned on by my mother/father/child, have a homosexual thought)? • What if I made a terrible mistake and don’t realize it? • What if I get contaminated and have to wash to keep from feeling anxious and keep from spreading it to other things or people who will then get sick?

The Meaning of the Content of Obsessions: Just a Stuck Thought • The content itself is meaningless in the context it occurs. It “means” you are sensitized, have been triggered, and are “resisting” the thought. • An obsession is the opposite of a wish. Thus, people with harming obsessions value nonviolence, people with blasphemy obsessions are religious, people who worry about blurting out something rude are polite people, people who worry about ego-dystonic suicide love life.

Range of Bizarreness

What You Resist Persists

I can’t concentrate (or remember) properly. Did I buy the “best” TV? Did I turn off the hairdryer? Did the condom break and I didn’t notice? Did I lock a child in my freezer inadvertently? I feel like blurting out “you’re fat” when I see a fat person walking by. • I keep seeing an image of me stabbing you in the eye while we are talking. • Am I being taken over by Satan?

Effort works paradoxically in managing anxiety symptoms. Trying to suppress thoughts make them loud, stuck and repetitive, trying to relax in an urgent way makes more tension. Acceptance of symptoms reduces the suffering over them. Anxiogenic anticipation of them encourages their return.

COMPULSION

OCD Rituals

• • • • • •

• • • • • •

feel “driven” yet irrational thoughts or actions repetitive and usually ordered may be bargained with or delayed erase or undo obsessive thoughts “purpose” is to protect self or others from harm, contamination or threat • attempts to keep safety, health, morality, order, or calm

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• • • • • •

washing checking repeating counting correcting hoarding

• • • • •

avoiding ordering undoing monitoring seeking reassurance

Model for Understanding Obsessive Thought Trigger Obsession (intrusion) Interpretation Error Rebound

Neutralization

Interpretation Errors • • • • • • •

Overimportance of thoughts Control over thoughts Inflated responsibility Perfectionism Overestimation of threat Intolerance of uncertainty Fear of consequences of anxiety

Neutralization (Safety Behaviours) • • • • •

Overt compulsions Mental rituals “Coping strategies” Reassurance seeking Avoidance

Certainty is a Feeling Not a Fact An Intolerance of Doubt or Uncertainty Is Central to OCD

Additonal Identified OCD “Types” • • • • •

“Just right” (incompleteness) OCD “Icky-sticky” (disgust-based) OCD Scrupulosity (overblown conscience) Hoarding/collecting/saving sometimes a subtype Pathological doubt (How can I be absolutely sure?) in relationship, sexual orientation, career choice (also philosophical/epistemological issues) • “Health anxiety” and hypochondria

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OCD Spectrum • • • • • • • •

OCD BDD (body dysmorphic disorder) Eating Disorders Trichotillomania, Skin Picking,Nail Biting Tourettes Self-Mutilation Kleptomania Gambling

OCD Spectrum Characteristics: Compulsive --- Impulsive • Overcontrol • Risk Avoidance • Hypervigilance and doubting • Stimulus averse • Compulsions are miserable

• • • •

Undercontrol Risk-seeking Stimulus-seeking Antisocial or selfdestructive • Compulsions are pleasurable

Generalized Anxiety Disorder • • • • • • •

A Caveat about Generalized Anxiety Disorder Epidemiological research suggests that over 90% of patients with GAD have a comorbid medical or psychiatric disorder. In other words, if your only diagnosis is “generalized anxiety”, you are almost definitely missing something.

DSM-IV Problems with GAD • Difficulty concentrating factors more with depression • Muscle tension factors more with GAD • No differences on restlessness, sleep problems, fatigue and irritability • Few physiological measures distinguish the two except dexamethasone suppression and decreased REM latency in depression

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Excessive worry, multiple worries Restlessness Can’t relax Irritability Difficulty concentrating Muscle tension Insomnia

Faulty Beliefs About Worry • • • • • •

Worry protects from external danger Worry means I care Worry keeps me prepared in case Worry is what I do Worry keeps me from behaving badly Worry acts like magic

Research Findings in GAD • Associated with overly-nurturing interpersonal style and excess empathy • Presence of interpersonal problems predicts relapse. Increased tolerance for uncertainty predicts recovery. • Worry prevents emotional processing (anger, grief etc.) as well as action. It is cognition, not affect. • Worriers believe in the usefulness of worry but also endorse meta-worry (worrying is bad for me)

Associated Stress-Related Conditions

Has the Patient Had a Physical? • Many medical conditions are associated with anxiety • Is the patient avoiding a medical evaluation? • Has the patient been dismissed as a complainer or hypochondriac?

• irritable bowel syndrome (IBS) • esophageal reflux • TMJ • globus hystericus • Fibromyalgia • BPV (benign positional vertigo)

Anxiety and Depression Complicate Each Other

Distinguishing Depression and Anxiety (not always easy) • The presence of hyperarousal and hypervigilance vs agitation • Phobic avoidance vs depressive withdrawal • The presence of anhedonia • The nature of sleep problems (e.g. initial vs. terminal insomnia, nocturnal panic attacks) • Family and personal history • Demoralization vs comorbid depression • Unreassurability vs hopelessness

• Demoralization usually follows prolonged anxiety. • In cases where comorbid depression and anxiety disorder are present, untreated anxiety disorder usually preceded the depression, often by years. • Depressed patients with panic attacks respond differently to treatment. • Anxious patients who are also depressed are harder to treat due to poor motivation for exposure and hopelessness about recovery

Substance Abuse and Anxiety Disorders • Substance abuse can cause anxiety (eg MJ can kick off panic disorder or chronic use can induce social anxiety) • Withdrawal can kick off anxiety in predisposed people (esp. alcohol withdrawal) • Anxious self-medicating patients can stumble into addiction • May simply be comorbid conditions • May both be complications of other condition (eg PTSD)

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• mitral valve prolapse • hyperventilation syndrome • PMS/menopause • “atypical chest pain” • “borderline hypoglycemia” • tinnitus

Anxiety Disorder is a Family Affair • • • • •

It runs in families It affects each family member in some way Family processes may maintain symptoms Recovery takes place in a family context Anxiety disorders, while not caused by stress, are stress-sensitive

Anxiety Disorders Treatment: What doesn’t work or only works for a bit

Treatment

Targets for Therapeutic Intervention • • • • • • • •

• Relaxation training and “healthy lifestyle” • Exerting more will power (including “white knuckling” repeated exposure) • Breathing re-training as a “coping skill” • Thought suppression and thought stopping (rubber band on wrist) • Distraction, affirmation and imagery techniques (positive thoughts) • Analyzing the meaning of the symptoms for insight. • Logical refutation of facts and probabilities • Compassionate repeated reassurance and support

Components of CBT

Misinformation and misattribution Risk and threat assessment Paradoxical effort Anxiety sensitivity and false beliefs about worry Alexithymia and affect intolerance Vigilance and arousal Avoidance (affective and behavioral) Inability to comfort self (self-contempt)

• Psychoeducation and rationale • Exposure (interoceptive, imaginal ,in vivo) • Response prevention (behavioral , cognitive and affective) • Affect tolerance training, cognitive defusion (mindfulness) and sometimes breathing retraining and other skills • Relapse prevention (stress management, family and insight-oriented therapies)

ACCEPTANCE NOT CONTROL

The Key is Attitude Towards the Content of the Mind

• No technique, coping skill, behaviour therapy or practice will ultimately work if the patient remains afraid of and struggling against the sensations of arousal or the intrusions of anxious thoughts. This is the basic paradox to be learned over time. • Motivated patients get worse if they try too hard or urgently

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• Decrease resistance to thoughts by making them unimportant • Draw back and observe thoughts and sensations (mindfulness) • Develop humour and metaphors to teach acceptance • Thoughts and urges not dreaded, avoided, or “controlled” eventually become unstuck and occur less often

Metaphors Be With You • • • • • •

Don’t bleed before you are cut Mud on the windshield Big screen TV next door (lost remote) Car without a break Whack-a-mole Let go vs let be

Reframe Catastrophic Interpretations of Sensations and Thoughts: Reduce Anxiety Sensitivity • • • • •

Lightheadedness is not imminent syncope Feeling out of control is not being out of control Depersonalization is not related to psychosis “Jelly legs” is extra strength for running Crazy thoughts do not make a crazy person; everyone has them • If our emergency response system could kill us, what a design flaw!

Assess and Treat Metacognitions (Not Content) • The purpose of changing faulty appraisals is to give courage and motivation for exposure tasks, to change the relationship to intrusive thoughts and to stop efforts at thought suppression

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Psychoeducation • describe what the disorder is and what it is not • explain biological underpinnings, including role of hyperventilation. genetics, conditioning and neurotransmitters as relevant • address “what ifs” directly • address family concerns

• explain fear-of-fear, the role of false beliefs and anxiety sensitivity • address in detail why selfhelp efforts and past treatments failed • address what “recovery” means • demystify everything and answer all questions

Anticipatory Anxiety • Worry and dread place the patient in the future and rob him/her of the present • Change “what if?” to “what is” • Change from cognition (thinking) to sensory modalities to switch to the here and now • Do this “while you are anxious”, not “in order to relax” (passive attitude)

Exposure Should Address Underlying Fears • Social phobia exposures are to feelings of embarrassment. • Panic disorder exposures are to sensations and thoughts of panic. • OCD exposures are to obsessive thoughts and images. • Specific phobia exposures are to the external phobic objects.

Challenge Distortions Assumptions and Predictions • • • • •

Discomfort is bad and should be avoided I should be “in control” Certainty is possible Risk can be measured by how it feels All-or-nothing thinking

Breathing Retraining: To lower level of arousal

Where do Self Regulation Skills Like Breathing Re-training Fit in? • In lowering overall level of sensitization (daily practice, not emergency coping) • In relapse prevention • During management of anticipatory arousal if done with attitude of non-urgency (“while” you have symptoms, not “in order to stop or fix or prevent symptoms) VERY TRICKY

Response Prevention

• Reduces bewilderment and gives a sense of mastery, but calms only if done without urgency and “effort to relax” • First teach interoceptive awareness • Demonstrate abdominal , slow , low , even, natural, effort-free breath. • Practice

• Change reaction to symptoms of arousal from catastrophizing to non-judgmental acceptance and even to curiosity. Become MINDFUL • Eliminate rituals and compulsions (behavioral and cognitive), neutralizing, decisions to avoid, anxiety sensitivity distortions (eg “I can’t handle this”) • Confront demoralization and self-contempt

But how do you actually get people to do what they fear ?

“Avoiding Stress”: Double Edged Sword

• Explain everything, including the cost of not facing the fears, and the reasons why every other effortful attempt to get better has not worked. (motivational interviewing) • Use the relationship – empathy, authority, confidence and modeling. • Graduated, supported, and praised.

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• What is stressful to the mind and body is different for different people • Living a healthy lifestyle will not prevent an anxiety disorder, but unhealthy living can make it worse • Dropping out of life or limiting one’s activities can lead to depression and substance abuse, impacted relationships and work, loss of autonomy and more stress.

Relapse Prevention: A Realistic Definition of Recovery • These are chronic intermittent conditions • Periods of stress will likely provoke the return of intrusive thoughts, “what ifs”, and conditioned responses, along with urges to avoid or neutralize • The notion of “cure” is a double-edged sword, in that re-sensitizations will be received as relapse or failure

Relapse Prevention: Frequency and Intensity of Symptoms Varies With Mood and Stress • • • • •

Exercise/play Diet/sleep hygiene Caffeine/alcohol Family issues Mindfulness meditation

• • • • • •

Assertiveness training Time management Anger management Conflict resolution Spiritual practice Nurture friendships

Historical Antecedents • • • • • • • • •

anxious temperament early loss (fear of abandonment) parental reversal (separation guilt) overprotection (dangerous world view) critical rearing (perfectionism) overvaluation of stoicism (fear of affect) parental loss of control (fear of impulses) disrespectful nurturance (poor self-comfort) stressful/traumatic life events

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Best Definition of Recovery • When the appearance of symptoms doesn’t matter – when anxious thoughts or sensations don’t make you do anything different, feel bad about yourself or interfere with living. • When “hiccups of the mind” and sensations of arousal can come and go without consequence, compulsion, avoidance or anguish • When the return of symptoms becomes possible information about stress or mood

Relapse Prevention: Common Psychotherapy Issues • • • • • • •

Perfectionism and self esteem Conflict over dependency issues Avoidance of confrontation/action/committment Avoidance and fear of affect Alexithymia Judgmentalism and projection Exploration of historical antecedents

Family Issues • Families are frightened, hopeless, depressed and frequently very angry • Well-intended “help” may be undermining recovery • Anxiety disorder is often multigenerational • Children-at-risk can be inoculated cognitively and behaviorally

Anxiety Patients and Medications • • • • •

They are more afraid of side effects They HAVE more side effects They may need homeopathic starting doses They often take LESS than prescribed Watch out for: OTC meds, esp.decongestants, corticosteroids,caffeine,asthma meds,alcohol (especially the day after), street drugs. • Getting off and getting on medication takes longer than the books say.

TAKE HOME MESSAGE II: Your Brain is Not Your Friend • It is primitively wired to be fearful and issue warnings. It is not always right. • Because something crosses your mind does not mean it is important • You don’t have to respond to it even if your body does.

TAKE HOME MESSAGE IV: If Fears are Irrational • Go gently towards (not away from) what makes you anxious • Be willing to feel strange sensations and think odd thoughts. Just observe. Don’t fix. • Be compassionate towards yourself • Let time pass.

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TAKE HOME MESSAGE I • Anxiety is present in us all. Know when it is a normal response to life problems for which general counseling is likely to help, when it is anxiety disorder requiring very specific therapies and when it is the tip of a complex iceberg requiring complex interventions.

TAKE HOME MESSAGE III: ACCEPTANCE NOT CONTROL No technique or coping skills or practice will ultimately work if you are still terrified of the sensations and intrusive thoughts of anxiety and you are still struggling to keep them from occurring. Doubts and uncertainty are inevitable and without some risks, there is no full living.