Layout of Talk
To explain briefly the mood system in the
brain; and its various functions
To examine the world of Toxic Stress
Acute anxiety (panic attacks and phobias)
Chronic anxiety (Post Traumatic Stress
Disorder, OCD and General Anxiety
Disorder)
The Brain
Is composed of right and left hemispheres
The Mind is a function of the Brain!
We all have an emotional and a logical
brain
Most psychological illnesses are due to a
breakdown in communication between
both
Our Mood System (FLAG) – the
Neuroscience
Is composed of:
Frontal Mood dep’t (our logical brain)
Limbic Mood dep’t (our emotional brain)
Adrenal stress gland and
Glucocortisol – our stress hormone
The first letters make up the word FLAG
Is responsible for our mood; behaviour; and responses to stress and anxiety
Frontal Mood Dept. (Pre Frontal
Cortex) – ‘Logical Brain’
Rational, logical, problem solving
Creative, analytical, planning, short term
memory
Creation and cognitive control of mood
Control of behaviour, particularly
impulsive, self destructive behaviour
Control of our social relationships and
empathy
The Logical Brain (PFC – Frontal
Mood Dept) The Logic Box – in charge of planning and decision making
The Emotional Control Box – in charge of monitoring and modifying emotions (suicide centre)
The Social Control Box – in charge of empathy and making sense of our whole social world
The Attention Box – in charge of focusing attention on our emotions linking them with thoughts and physical reactions to our emotions. It is also where we reappraise emotions – vital for all forms of talk therapy
Limbic System – Emotional Brain
Stress Box (Amygdala) - controls our stress
system, is involved in our processing of
emotions (particularly negative ones) – this is
the heart of the emotional brain and the key
player in anxiety and depression
Memory Box (Hippocampus) – involved in the
creation, storage and retrieval of memories
Pleasure Box (Nucleus Accumbens) – involved
in the enjoyment of food, sex, alcohol
Logic versus emotions
Many assume that our logical brain is more powerful than our emotion brain
In practice there are more connections and pathways emanating from our emotional brain to our logical brain than in reverse
So our lives are ruled more by emotion than logic
Every decision we make each day is made with emotion and logic combined in the dance we call life
Logic versus emotions
When well our emotions and logic are in
harmony
When unwell our negative emotions
overwhelm our logic brain – and classical
examples are anxiety and depression
One of the ways in which our emotional
and logical brains are connected by our
three big mood cables
Functions of the Mood Cables
Serotonin Cable – involved in mood; sex;
sleep; appetite; memory; impulsive
behaviour
Noradrenalin Cable – involved in energy;
sleep; drive; concentration
Dopamine Cable – involved in our sense
of enjoyment of food; sex and anything
else that gives us pleasure
Acute Stress
Dry mouth, stomach in knots, heart
thumping, sweating, mind becomes alert
and vigilant
Fight or flight!
Fuelled by Adrenalin and Noradrenalin
Usually of short duration
Chronic Stress
Fatigue, reduced concentration, sleep
difficulties, reduced interest in food, sex
and drive
Increased feelings of anxiety and
impulsive behaviour
‘Tired but wired’
Fuelled by high glucocortisol levels
Usually of longer duration
What is Toxic Stress?
This relates to where stress becomes so persistent and pervasive that we begin to develop physical and psychological consequences
It is probably the greatest single treat to the physical and mental health of our people
Is a talk on its own – if you want to learn more then read:
Anxiety
Best defined as an uncomfortable state of
hyper-alertness due to fear
Is a normal human emotion
Feelings of anxiety are normal under
threat; and physical change are a normal
part of the anxiety response
Avoidance and safety behaviour are a
normal reaction to anxiety
Anxiety Disorders
Panic attacks/Panicky symptoms - acute
anxiety
Phobias – acute anxiety
Post Traumatic Disorder - chronic
Obsessive Compulsive Disorder - chronic
General Anxiety Disorder - chronic
Acute Anxiety Disorders
Panic attacks/Panic disorder (anxious
about anxiety)
Panicky feelings (anxious about
something)
Phobias (fear of exposure to a thing or
situation where one runs the risk of
becoming incredibly anxious)
Panic Disorder
Affects about 150,000 people in Ireland each year
It is defined as a condition where a person suffers from: recurrent panic attacks where they spend a lot of time worrying about the recurrence of such attacks
and who can clearly identify the first episode from which future episodes emanate
Panic Attacks
Commoner in women
Up to 8% of the population will have at least one episode in their lives; only 5% are recurrent
Commonly associated with general anxiety, depression and addiction
Can occur in any situation or at any time
The fear of getting them (panic disorder) is as big a problem as the attacks themselves
Are caused by acute inadvertent ‘firing of our stress system’ – an Adrenaline rush
Panic Attacks - anxiety about
anxiety
Sweating, palpations, dry mouth,
weakness
Chest pains, hyperventilating, headaches,
Shakes, choking, stomach in knots
I’m going to get a heart attack, stroke,
make a fool of myself, run amok or die!
No ‘obvious’ trigger
Panic Attacks
They are triggered by the emotional brain feeling anxious and it’s stress box advising the adrenal gland to produce adrenaline
And then the same emotional brain misinterpreting the subsequent physical symptoms
Encouraging the adrenal gland to produce a major burst of adrenaline
Triggering the full blown panic attack
Panic Attacks
Initial symptoms (trigger) are simply symptoms of anxiety
We interpret them as ‘dangerous’
Demand they ‘stop’
This makes us more anxious
Triggering a panic attack (severe symptoms of anxiety!)
We then use ‘safety behaviour’ (breathing exercises; A/E; tranquillizers etc)
ABC of a panic attack
A – initial physical symptoms (heart going
quickly or sudden difficulty breathing etc
Danger – I will go mad, have a heart
attack, stroke, die, run amok
B – these physical symptoms must go
away
C – emotion – panic; behaviour – safety
Panic Attacks
Are simply caused by bursts of Adrenaline
These cause all the ‘panic attack’ symptoms
These are ‘uncomfortable but not dangerous’ – the key to managing them
The initial symptoms are simply those of anxiety – and are not dangerous
So panic attacks are simply anxiety about anxiety
Panic Attacks
Best treated with CBT
Avoid tranquillizers
Avoid anti depressants unless depression
is actively present
Are easy to treat if people come for help
If another condition like depression or
addiction are present - may have to be
also managed
Panic Attacks - CBT
Never try and stop an attack - they are simply an
Adrenaline rush (my emotional brain/stress
system is there to ‘protect not kill me’!)
Avoid safety behaviour
Learn that if I do nothing it will pass in 10
minutes; if I try to stop it may last much longer
The value of texting
The initial trigger are simply symptoms of anxiety
– uncomfortable but not dangerous
Panicky Feelings
Symptoms are very similar to those of panic attacks but are less severe and may last longer
Are caused by specific situations or thoughts
Are very common to us all; but if very persistent as in conditions like general anxiety disorder can be very distressing
Must be treated as ‘normal’ and are once again triggered by the emotional brain’s stress box advising the adrenal gland to produce adrenaline
Symptoms are usually physical with a lot of mental worry and overlay present
Phobias
One of the commonest conditions affecting
human beings
Can be defined as: ‘excessive and
persistent fear of being exposed to
particular situations or objects;
where exposure to either leads to an
immediate anxiety response and a need to
avoid the phobic stimuli’
Phobias
Can be classified as simple phobias including:
Exposure to animals or insects (e.g. spiders,
dogs and snakes)
Exposure to situations (e.g. confined spaces,
crowds, open spaces (agoraphobia), lifts,
planes, motorways, blood and so on)
And complex phobias like social phobia (a.k.a.
social anxiety disorder) – where our fear relates
to meeting other people in social situations
Phobias
Agoraphobia is a particularly common distressing condition which affects up to 20,000 people in Ireland
It refers to a ‘fear of open spaces’ and comes from the Greek word agora meaning marketplace
Sufferers may dread leaving the house, entering churches, shopping centres, lifts, supermarkets and other crowded areas
Some will struggle to leave their own bedroom
It is a very isolating condition
The real fear of the sufferer is that they will get a panic attack if they are exposed in such places; so it is not surprising that it is often linked to panic disorder
Phobias
Social phobia (or social anxiety disorder) is a
common disabling disorder where;
the person suffers from intense anxiety in social
situations for a period of greater than 6 months
Experiences a persistent fear of being judged
harshly by others and are embarrassed by their
own actions in social situations
These fears can be triggered by real or imagined
scrutiny by others
Phobias
In social phobia, symptoms of anxiety can be accompanied by blushing, excessive sweating, mind going blank or stammering which are often the presenting symptoms of this condition
Unlike most other phobias continuous exposure to social situations does not lead to any lessening of the condition
Up to 8% of the population suffer from some form of social anxiety
The key behavioural response to symptoms of social phobia is social avoidance which exacerbates the situation
Phobias
There are two main types of social phobia:
‘Performance situations’ (involving
situations where one performs in front of
others or is being observed by other
people)
‘Social interaction situations’ (involving
engaging or interacting with other people)
Phobias
Examples of feared social interaction situations
include:
Initiating or maintaining conversations
Meeting strangers; going to parties or having
friends over for dinner; meeting friends in pub
Expressing personal opinions or being assertive
Talking to people in authority or returning items
in store or food in restaurant
Phobias
Examples of performance situations which
cause problems include:
Public speaking or talking in meetings or classes
Eating or drinking in front of others
Using public restrooms if others are nearby
Playing sports in front of others
Playing music or acting in front of others
Being caught out making mistakes in front of
others
Phobias
Typical thoughts in social situations might be:
‘everybody must like me’
‘I have nothing interesting to say and am boring’
‘I will make a fool of myself; others will notice and find me wanting’
‘if all went well – nobody will notice; if badly then it will be my fault’
Phobias
Learned social behaviours in social situations include:
Staying close to the exit
Trying to cover up blushing (with make up) and excessive sweating (particularly common)
Gripping cups or glasses very tightly
Continuously rehearsing what one is going to say and checking that one is coming over well (self monitoring)
Avoiding eye contact
Social Phobia
The origins lie in our genes, social
upbringing and overtly critical or negative
experiences at home or school including
teasing or bullying
The isolation this condition can produce
can drive some into the world of self harm
Phobias
Treatment of phobias involves:
Lifestyle therapies like exercise, yoga, massage as stress reducing measures
Drug therapies include tranquillizers (to be avoided); anti depressants (generally not of significant help); St Johns worth
Talk therapies include counselling, behaviour therapy and cognitive behaviour therapy (the one of choice)
Phobias
CBT involves the acceptance that phobias are really red herrings (it is not the object or situation which is really my problem – rather the fact that exposure to them will lead me to become incredibly anxious!)
Many simple phobias involving insects, animals etc can be dealt with in a few simple sessions
More complex ones like social phobia may require a more in depth response by fully trained CBT therapist.
Phobias
In agoraphobia – CBT recognizes that the main fear is that the person will have a panic attack if exposed to the open spaces or situations already mentioned
So the therapist will have to teach the sufferer how to deal with a panic attack
Therefore reducing their fear of exposure to such situations
They may also be given graded behavioural exposure exercises to help them get over the problem
Phobias
The real worry for the social phobic person in social situations is that others will ‘see them as they see themselves’;
and they will spend a lot of time checking their own performance and whether they are blushing or sweating (often they have an exaggerated picture of how bad either of these is) and the therapist will challenge this.
CBT will challenge their thinking and their behaviour
Chronic Anxiety
The three main types of chronic anxiety we will examine are :
Post Traumatic Stress Disorder
Obsessive Compulsive Disorder
General Anxiety Disorder
Post Traumatic Stress Disorder
(PTSD) A chronic persistent anxiety state following a serious accident, rape, assault, war etc; which lasts for a period greater than 6 months
Symptoms include ‘flashbacks’; nightmares; a reluctance to deal with the matter; muscle pains; headaches; panicky feelings
Many feel ashamed or guilty they are still alive; and depression is a regular consequence
They may feel constantly ‘on guard’ and are constantly scanning the environment for potential trouble
They may have difficulties with sleep and often misuse or abuse alcohol as a result
PTSD
Drug therapy includes the SSRI’s which can be of help in severe cases particularly if depression is present
Talk therapy includes counselling which can be of considerable help; and CBT which can be very useful
At the heart of the CBT approach is challenging the demand for 100% certainty that they will not be exposed to the trauma again
The classical example is following an RTA
The key is to help the person that there is no such thing as 100% certainty in any area of life
General Anxiety Disorder
Constant bursts of intense anxiety and worrying about our health, family, job etc
Constant sense of foreboding about impending disasters
Mental and physical fatigue, irritable bowel syndrome
Poor concentration and memory
Sleep difficulties and nightmares
Indecisiveness and difficulty coping
Constantly avoidance of everyday tasks
General Anxiety Disorder
Commonly associated with bouts of acute anxiety
Will deteriorate if stress encountered
2/3 will have at least 1 episode of depression during their lives
Many use alcohol to cope so associated with alcohol abuse
Many end up addicted to tranquillizers
Women twice as likely to have it
Often undiagnosed; can be traced back to childhood; deteriorates as we get older
General Anxiety Disorder
Causes are a powerful mix of genetic
predispositions and our upbringing
Key biological mechanism is a hyped up
stress system
particularly our stress box
Seems to have similar genetic pathways to
depression
May be up to 15 resilience genes involved
General Anxiety Disorder
Ideal treatment is holistic
Exercise, nutrition, meditation, yoga all have a role
Avoid alcohol and tranquillizers
CBT very powerful tool
Mindfulness based CBT (MBCT) may be a therapy for the future
SSRI’S helpful (particularly if depression
present) but must be used sensibly and can never replace psychological Tx
Obsessive Compulsive Disorder
(OCD) OCD affects between 20 and 30,000 people in Ireland
It is a very distressing condition
It is characterized by persistent obsessive thoughts usually followed by repeated compulsive behaviour to ease the anxiety created by the former
Obsessions are intrusive anxiety provoking thoughts, ideas or images
Compulsions are repetitive rituals or mental actions performed as a result of obsessions in order to decrease anxiety and often to remove contaminants
OCD
Eventually people with OCD build into their lives a complex series of safety and avoidant behaviours which cause chaos in their life
They do recognize these obsessive thoughts as intrusive and troublesome and coming from their own minds but are unable to stop them
The modern view of this illness is that it is a form of behaviour addiction similar to other addictions
The obsessive thoughts and compulsions use up all the persons energies due to the incredible symptoms of anxiety they provoke
This illness can take up to 10 years to be diagnosed
OCD
Obsessive thoughts may relate to:
Fear of contaminating themselves (dirt, germs, blood or bodily fluids, faeces etc)
Fears over personal health
Fears of harming themselves or those close to them
Fears of hurting others
Fears over being gay or paedophiles
Fears of offending god
Fear that something terrible will happen
OCD
Examples of compulsive behaviours include:
Cleaning (particularly hand washing or home
cleaning)
Checking (e.g. front doors or light switches)
Counting or making lists
Arranging (everything in the room must be in the
right place to maintain control)
Making lists and hoarding
OCD
These compulsions persist as the sufferer gets a
short term relief from anxiety from the obsessive
thoughts; but eventually become the problem as
they have to increase to get the same relief (just
like tolerance in addiction)
Some obsessive thoughts and compulsions go
hand in hand (contaminant obsessions with
hand washing; or wiping down door handles in
toilets etc; or obsessive thoughts about the door
being unlocked with checking the door)
OCD
It is slightly more common in women and
can start as young as 10
Women suffer more from contaminant
obsessions and cleaning rituals
Men suffer more from symmetry, order
and sexual obsessions
Depression is quite common as a
secondary consequence of OCD (65%)
OCD
The first illness where clear neurobiological pathways were identified on neuroimaging of the brain
It is caused by a breakdown in information between the social behaviour box, the attention box and an area called the caudate nucleus
Normally when we get a simple thought like the ‘front door is not locked’ it is the social behaviour box that is activated
It passes information to the attention box which initiates the behaviour appropriate – i.e. ‘we check the door’
It is the caudate nucleus which like a gear change in a car allows us to then move on to the next relevant thought or action
OCD
In OCD the caudate nucleus is ‘stuck in gear’
and unable to move our thoughts on
So the brain ends up back in the social
behaviour box with the same thought – ‘is the
door locked?’ and the process restarts again
When a person with OCD with therapy begins to
improve the over activity in all three area on
scanning goes back to normal!
OCD
Causes are felt to be genetic (polygenetic) and upbringing; and in some cases in children can be triggered by infection
Severity can vary from mild to severe and it gets worse with age if untreated
Shame is the commonest reason for sufferers not presenting earlier for help
It is often family pressure that encourages them to present
OCD
Drug therapies are more important in this
condition than most other anxiety disorders
The main ones are the SSRI’s normally used to
treat depression
They act on the social behaviour box and can
take up to 8 weeks to kick in
St John’s Worth is also used in some countries
Drug therapy can improve situation by up to 50%
OCD
Talk therapies lie at the heart of the treatment of this condition and include counselling, behaviour therapy and in particular CBT
Lifestyle therapies are as always of importance in the holistic treatment of OCD
Counselling is of more help in dealing with the relationship consequences of this condition
CBT and behaviour therapies challenge the compulsive behaviour and the demand for control that lie at the heart of this condition
Conclusion
The secret to anxiety disorders is to:
NORMALIZE the symptoms of anxiety
The symptoms are usually uncomfortable
but not dangerous
Always challenge safety or avoiding
behaviour
Further information
For those who would like to investigate much of the neurobiological/clinical data which we just touched on in this talk might find it interesting to read my 4 books:
‘Flagging the Problem – a new approach to mental health’ (Liberties Press)
‘Flagging the Therapy – pathways out of depression and anxiety’ (Liberties Press)
Flagging Stress – toxic stress and how to avoid it (Liberties Press)
‘Flagging Depression – a practical guide’ (Liberties Press)
Flagging Depression