An Introduction to Anxiety Disorders

1. An Introduction to Anxiety Disorders Dr. Sally Winston, Licensed Psychologist Co-Director, Anxiety and Stress Disorders Institute of Maryland May 2012

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

3. 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

4. Anxiety Disorders Are Chronic Intermittent Disorders • They come back in times of physical or emotional arousal or stress. • The vulnerability to anxiety is biological and symptoms are real, not imaginary (but not dangerous). • These are serious disorders beyond typical everyday stress responses. They are also the gateway to many other disorders. • They can be treated and managed to full recovery if treatment is evidence-based

5. Anxiety Disorder is a Family Affair • It runs in families • Family processes may maintain symptoms • Recovery takes place in a family context • Anxiety disorders, while not caused by stress, are stress-sensitive

6. Panic Disorder and its Phobias

7. 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

8. Panic Disorder : Underlying Fears • heart attack • stroke • pass out • brain tumor • cancer • other medical catastrophe • smother • vomit • choke • diarrhea / urinary incontinence • go blind • start screaming • lose control • go crazy

9. 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

10. 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. Another is a history of asthma. Another is the chronic hyperarousal of childhood trauma. • High “anxiety sensitivity” reaction to bodily sensations and to anxious thoughts leads to experience of panic. AS is probably largely constitutional. • Panic students show cognitive bias towards threat stimuli and superior interoceptive acuity

11. FEAR HYPERVENTILATION PHYSICAL SYMPTOMS BLOOD pH pCO2

12. Hyperventilation • palpitations • chest pain • dizziness • feeling faint • visual distortion • numbness • nightmares • sleep disturbance • extreme sighing • heartburn • air swallowing • muscle cramps • weakness • exhaustion • lack of concentration • feelings of unreality

13. Hyperventilation • 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

14. Social Anxiety Disorder

15. Social Anxiety Disorder Fear of Humiliation • being looked at • being judged • looking anxious • freezing up • losing control • losing respect • being rejected • be a loser • sweating/blushing • trembling • voice shaking • say something stupid or boring • have to leave • look awkward • medical symptoms show

16. 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

17. 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

18. Maintenance of Social Anxiety • 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

19. Co-morbidity of SAD • Lifetime incidence of major depression as high as 70% • Alcoholism rates as high as 35% • SAD precedes co-morbid condition 70% of the time • Very high percentage of students diagnosed as GAD actually have SAD

20. Specific Phobias

21. Specific Phobias • Animal type • Natural environment type • Emetaphobia (vomiting), fear of choking, falling • Blood-injury phobia (very different) • Trauma-based phobias ( authority figures, power tools, the “mundane” such as the dark , strangers, sleeping upstairs, noises) • PANIC DISORDER, SOCIAL ANXIETY, AND OCD CAN LOOK LIKE MULTIPLE PHOBIAS • Driving phobia can be panic, OCD, PTSD, specific. • Germ phobia is OCD

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

23. Avoidance is Not Always Anxiety • It can be shame • It can be revulsion or disgust • It can be withdrawal or depression/hopelessness • It can be overwhelmed by external stressors and actually a survival method • It can be true inability and expectations of failure

24. Obsessive-Compulsive Disorder

25. Preoccupation, Worry, Rumination and Obsession • Ego-syntonic and ego-dystonic worry (about the future) are very different. Worry is an anxiety symptom. • True ruminations (about the past) are more often depression symptoms. • OCD is a disorder of over-control, not impulsivity. An obsession is not the same as a simple worry. • Degree of “insight” is situationally bound.

26. 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

27. OCD “topics” • sex • perversion • violence • suicide • abuse • sin • right and wrong • blasphemy • contamination • horror/disgust • mutilation • disease • dangerous mistake • incompleteness

28. 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

29. 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.)?

30. 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? • What is there is a monster inside of me I am barely holding back?

31. 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 non-violence, 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.

32. Range of Bizarreness • 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?

33. What You Resist Persists • 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.

34. Compulsion • 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

35. OCD Rituals • washing • checking • repeating • counting • correcting • hoarding • avoiding • ordering • undoing • monitoring • seeking reassurance • cognitive rituals

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

37. Interpretation Errors in OCD and GAD • Over-importance of thoughts • Control over thoughts • Inflated responsibility • Perfectionism • Overestimation of threat • Intolerance of uncertainty • Fear of consequences of anxiety

38. Neutralization (Safety Behaviors) • Overt compulsions • Mental rituals • “Coping strategies” • Reassurance seeking • Avoidance

39. Certainty is a FeelingNot a Fact An Intolerance of Doubt or Uncertainty Is Central to OCD

40. Additional Identified OCD “Types” • “Just right” (incompleteness) OCD • “Icky-sticky” (disgust-based) OCD • Scrupulosity (overblown conscience) • Pathological doubt (How can I be absolutely sure?) in relationship, sexual orientation, career choice (also philosophical/epistemological issues) • “Health anxiety” and hypochondria

41. OCD Spectrum • OCD • BDD (body dysmorphic disorder) • Trichotillomania, Skin Picking, Nail Biting • Tourettes • Hoarding Disorder • Kleptomania • Gambling

42. Generalized Anxiety Disorder

43. Generalized Anxiety Disorder • Excessive worry, multiple worries • Restlessness • Can’t relax • Irritability • Difficulty concentrating • Muscle tension • Insomnia

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

45. 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

46. Other Considerations

47. Physical Checkup Needed • Many medical conditions are associated with anxiety • Is the student avoiding a medical evaluation? • Can the student afford a medical evaluation? • Has the student been dismissed as a complainer or hypochondriac?

48. Associated Stress-Related Conditions • irritable bowel syndrome (IBS) • esophageal reflux • TMJ • globushystericus • Fibromyalgia • BPV (benign positional vertigo) • mitral valve prolapse • hyperventilation syndrome • PMS/menopause • “atypical chest pain” • “borderline hypoglycemia” • tinnitus

49. Depression and Bipolar Disorders

50. Depression and Anxiety • Agitation and anxiety are different • Phobic avoidance or depressive withdrawal? • The presence of anhedonia indicates depression • The nature of sleep problems (e.g. initial vs. terminal insomnia, nocturnal panic attacks) • Family and personal history • Demoralization can lead to depression • Depression triad: hopeless, worthless, guilty