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)