Anxiety disorders queen's 2013


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Dr. Michela David's presentation from our recent speaker's event discussing anxiety.

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Anxiety disorders queen's 2013

  1. 1. 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
  2. 2. 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
  3. 3. 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
  4. 4. Common Emotional Symptoms of Anxiety Feelings of apprehension or dread Trouble concentrating Feeling tense and jumpy Fear / Dread Irritability Restlessness
  5. 5. 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
  6. 6. 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)
  7. 7. 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)
  8. 8. 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”
  9. 9. 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?
  10. 10. 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
  11. 11. 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)
  12. 12. 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
  13. 13. 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
  14. 14. Some Common Panic Attack TriggersExternal Triggers: Small or confined spaces Distance from exits Crowds of people Dentist officesInternal Triggers: Heart palpitations Shortness of breath Numbness Trembling Feelings of unreality
  15. 15. 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
  16. 16. 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)
  17. 17. 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
  18. 18. 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)
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. Kathleen finds it hard to go anywhere in public because she isself-conscious and feels sure that everyone around her iswatching her intently, even though she knows this is anirrational thought. She fears that she might meet a person sheknows and be forced to say hello to them. She is not sure thatshe can do that. Her voice will shake, her "hi" will sound weak,and the other person will know something is wrong. Above all,she doesnt want anyone to know that she is so afraid. Sheturns her eyes away from anyone elses gaze and hopes thatshe can make it home without having to talk to anyone.
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. Treatment of Specific PhobiasPharmacotherapy (symptom relief)  anxiolyticsCBT 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
  29. 29. 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)
  30. 30. 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)
  31. 31. 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
  32. 32. 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)