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Anxiety Spectrum Updates 2012
Ricardo J. Fermo, MD Medical Director East Cooper Psychiatric Solutions, LLC 1073 B. Johnnie Dodds Blvd. Mount Pleasant, South Carolina 29464 Diplomate of the American Board of Psychiatry and Neurology Diplomate of American Board of Child and Adolescent Psychiatry

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Learning Objectives Review updates on the epidemiology of Anxiety Provide a summary of the disease state (s) Discuss diagnostic criteria for various anxiety disorders Treatment/Goals Discuss evidence-based approaches for treatment-Anxiety ECPSLLC.COM

References NIMH SAMHCA APA CDC CLINICALTRIALS.GOV CLINICAL PRACTICE EVIDENCE BASED MEDICINE WEBSITES GOOGLE SCHOLAR COCHRANE PUBMED DYNAMED EVIDENCE BASED (BMJ)

www.adaa.org www.ocfoundation.org www.socialanxietysupport.com

http://www.adaa.org/

Stress and anxiety are the same thing. True False

The causes of stress are essentially the same for everyone. True False

Anxiety is the most common mental illness in the US: True False

Men are twice as likely to have Generalized Anxiety then Woman? True False

What percentage of people with mental illnesses improve if they receive treatment? 25% to 45% 50% to 70% 70% to 90%

Anxiety as a Normal and an Abnormal Response Some amount of anxiety is “normal” and is associated with optimal levels of functioning. Only when anxiety begins to interfere with social or occupational functioning is it considered “abnormal.”

ANXIETY DISORDERS Anxiety is a normal reaction to stress and can actually be beneficial in some situations. Fear and anxiety are part of life anxiety can become excessive, and while the person suffering may realize it is excessive they may also have difficulty controlling it and it may negatively affect their day-to-day living. Most common of emotional disorders Affects more than 40 million Americans The most prevalent psychiatric disorders

The Fear and Anxiety Response Patterns Fear Panic Anxiety Anxiety Disorder

Definition of Anxiety Anxiety is a feeling of apprehension or fear. The source of this uneasiness is not always known or recognized, which can add to the distress you feel. Anxiety disorders are a group of psychiatric conditions that involve excessive anxiety.

Anxiety Facts Anxiety disorders are the most common mental illness in the U.S., affecting 40 million adults in the United States age 18 and older (18% of U.S. population). Anxiety disorders are highly treatable, yet only about one-third of those suffering receive treatment. Anxiety disorders cost the U.S. more than $42 billion a year, almost one-third of the country's $148 billion total mental health bill, according to "The Economic Burden of Anxiety Disorders," a study commissioned by ADAA (The Journal of Clinical Psychiatry, 60(7), July 1999). More than $22.84 billion of those costs are associated with the repeated use of health care services; people with anxiety disorders seek relief for symptoms that mimic physical illnesses.

Anxiety disorders in the U.S. cost more than $42 billion each year. 1/3 of the total amount spent on mental health care

Anxiety Disorders One-quarter of the U.S. population experiences pathologic anxiety in their lifetime People with an anxiety disorder are three to five times more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders than those who do not suffer from anxiety disorders. Anxiety disorders develop from a complex set of risk factors, including genetics, brain chemistry, personality, and life events. Anxiety and Depression It's not uncommon for someone with an anxiety disorder to also suffer from depression or vice versa. Nearly 70 % of those diagnosed with depression are also diagnosed with an anxiety disorder. Presenting problem for 11% of patients visiting primary care physicians 90% of patients with anxiety present with somatic complaints

Anxiety Nervousness and fear are common human emotions. Adaptive at lower levels; disabling at high levels. Physicians must recognize the difference between pathological anxiety and anxiety as a normal or adaptive response.

Definition of Anxiety Diffuse, unpleasant, vague sense of apprehension Often accompanied by autonomic symptoms such as headache, perspiration, heart palpitations, chest tightness, stomach discomfort and restlessness Presentation depends on perception of stress, personal resources, psychological defenses, and coping mechanisms

Pathological Anxiety Anxiety that is excessive, persistent, easily triggered. Degree of the person’s fear is out-of-proportion to actual danger. Disrupts the person’s life and functioning. Creates intense discomfort. Doesn’t respond to rational reassurance. in pathological anxiety, attention is focused also on the person's response to the threat.

Features of Pathologic Anxiety Autonomy: no or minimal environmental trigger Intensity: exceeds patient’s capacity to bear the discomfort Duration: symptoms are persistent Behavior: anxiety impairs coping and results in disabling behaviors

Etiology Neurophysiology Central noradrenergic systems– in particular, the locus coeruleus is the major source of adrenergic innervation GABA neurons from the limbic system Serotoninergic systems and neuropeptides Cognitive-Behavioral Formulations Developmental (Psychodynamic) Formulations

Common Medical Conditions Associated with Anxiety Disorders Endocrine: thyroid dysfunction, hyper adrenalism Drug Intoxication: caffeine, cocaine Drug Withdrawal: alcohol, narcotics Hypoxia: CHF, angina, anemia, COPD Metabolic: acidosis, hyperthermia Neurological: seizures, vestibular dysfxn

Prevalence Lifetime Prevalence of Common Psychiatric Disorders 17.1% Major depressive disorder1 14.1% Alcohol dependence1 13.3% Social anxiety disorder1 Posttraumatic stress disorder (PTSD)2 7.8% Generalized anxiety disorder (GAD)1 5.1% 3.5% Panic disorder1 Obsessive-compulsive disorder (OCD)3 2.5% 0 2 4 6 10 14 16 18 8 12 Prevalence (%) *In menstruating women. Kessler RC, et al. Arch Gen Psychiatry. 1994;51(1):8-19.1 Kessler RC, et al. Arch Gen Psychiatry. 1995;52(12):1048-1060.2DSM-IV-TR 2000.3 29 of 45

40 million American adults age 18 years and older (about 18%)

Generalized Anxiety Disorder Obsessive-Compulsive Disorder (OCD) Panic Disorder Post-Traumatic Stress Disorder (PTSD) Social Phobia (or Social Anxiety Disorder) Specific Phobia Each anxiety disorder has different symptoms, but all the symptoms cluster around excessive, irrational fear and dread.

Explaining anxiety disorders Learning perspective Biological perspective

Learning perspective Fear conditioning One bad event can lead to classical conditioning of fear Stimulus generalization Fear may broaden: fear of heights fear of airplanes

Learning perspective Reinforcement can help maintain fears. Avoiding or escaping the feared situation reduces anxiety, so the avoiding or escaping behavior is reinforced

Learning perspective Observational learning We learn our fears by watching and listening to others

Biological perspective We are biologically prepared to fear threats faced by ancestors Spiders Snakes Darkness

Biological perspective Genes Some people seem genetically predisposed to particular fears and high anxiety

Biological perspective 35 year old identical twins who independently developed claustrophobia and fear of water

Biological perspective Physiology Brain scans of people with OCD  unusually high activity in certain parts of the frontal lobes

Physiology Generalized anxiety, panic attacks, and OCD are linked with overarousal in brain areas linked with impulse control and habitual behaviors People cannot “turn off” these thoughts.

Physical Reaction to Anxiety Auditory and Visual Stimuli: sights and sounds are processed first by the thalamus, which filters the incoming cues and shunts them either directly to the amygdala or to the other parts of the cortex. Olfactory and tactile stimuli: Smells and touch sensations Bypass the thalamus altogether, Taking a shortcut directly to the Amygdala. Smells, therefore, Often evoke stronger memories Or feelings than do sights or Sounds.

Physical Reaction to Anxiety Thalamus: The hub for sights and sounds, The thalamus breaks down Incoming visual ques by size, Shape and color, and auditory Cues, by volume and Dissonance, and then signals The appropriate part of the Cortex. Cortex: It gives raw sights and sounds meanings, enabling the brain to become conscious of what it Is seeing or hearing. One region, the prefrontal cortex, may be vital to turning off the anxiety response once a threat has passed.

Physical Reaction to Anxiety Amygdala: emotional core of the brain, the amygdala has the primary role of triggering the fear response. information that passes through the amygdala is tagged with emotional significance. Bed Nucleus of Stria Terminalis: unlike the Amygdala, which sets off an immediate burst of fear, the BNST perpetuates the fear response, causing the longer term unease typical of anxiety.

Physical Reaction to Anxiety Locus Ceruleus: It receives signals from the amygdala and is responsible for initiating many of the classic anxiety responses: rapid heartbeat, increased blood pressure, sweating and pupil dilation. Hippocampus: This is the memory center, vital to storing the raw information coming in from the senses along with the emotional baggage attached to the data during their trip through the amygdala.

Generalized Anxiety Disorder:Biological Causal Factors Genetic factors A functional deficiency of GABA Neurobiological differences between anxiety and panic

Relationship Between Arousal (anxiety) and Performance Yerkes-Dodson Law

Three Components of Anxiety Physical Psychological (Cognition and emotion) Behaviours

The Physical Component Trembling, twitching ,Shaking Dizziness Numbness/Tingling Backache, headache Muscle tension Shortness of breath, hyperventilation Fatigability Startle response Difficulty swallowing Autonomic hyperactivity: Flushing and pallor Tachycardia, palpitation Sweating Cold hands Diarrhea Dry mouth (xerostomia) Urinary frequency Blurred Vision

The Psychological Component Anxious Thoughts Anxious Predictions Anxious Beliefs and Interpretations Difficulty in Attention and Memory Mental Images Unreality/Detachment Hypervigilance Insomnia Decreased libido Lump in the throat

The Behavioural Component Avoidance of Situations and Activities Subtle Avoidance Strategies, Safety Signals, and Overprotective Behaviours Alcohol, Drug, and Medication Use

Anxiety Disorders - DSM-IV 1. Generalized Anxiety Disorder (GAD) 2. Panic Disorder (PD) with Agoraphobia (AG) 3. PD without Agoraphobia 4. Specific Phobia (SP) 5. Social Phobia (SoP) 6. Obsessive Compulsive Disorder (OCD) 7. Post traumatic Stress Disorder (PTSD) 8. Acute Stress Disorder (ASD) 9. Substance-Induced Anxiety disorder (SIAD) 10. Anxiety disorder due some medical illness Dual Diagnosis Disorders

Anxiety disorders Continuous anxiety Episodic anxiety Generalized anxiety disorder Mixed pattern In any situation In defined situation Panic disorder with agoraphobia Panic disorder Phobic anxiety disorder Simple phobia Social phobia Agoraphobia

Epidemiology Overall, anxiety disorders are among the most prevalent of psychiatric disorders. Age; Earlier onset than depression Sex factor; More in females Frequency (Prevalence): 18 %of general population 28% (life time prevalence) Strong genetic component

Shared features of anxiety disorders Substantial proportion of aetiology is stress related. Difference with Psychosis - free of delusions and hallucinations, good insight - Reality testing is intact. Symptoms are ego dystonic (distressing) Disorders are enduring or recurrent. Demonstrable organic factors are absent Note: Hierarchy of Diagnosis Precedence: Psychosis >Depression >Anxiety

Risk Factors/Etiology Psychodynamic theory posits that anxiety occurs when instinctual drives arc thwarted (dissatisfied). Behavioral theory states that anxiety is a conditioned response to environmental stimuli originally paired with a feared situation. Cognitive approach: Selective attention and catastrophic thinking Biologic theories implicate various neurotransmitters (especially: gamma-aminobutyric acid [GABA], norepinephrine, and serotonin) and various CNS structures (especially reticular activating system and limbic system). Other theories: Social and personality factors.

The Psychodynamic Approach to Anxiety Anxiety is a signal that the ego is having a hard time mediating between reality, id and superego. Different anxiety disorders are the result of different defense mechanisms used to cope. Phobia - displacement OCD - reaction formation, undoing PTSD - denial, repression Attachment Theories : Bowlby disturbances in parent-child bond leads to “anxious attachment” and a vulnerability to anxiety disorders later in life.

The Behavioural Approach to Anxiety(learning theory) Behavioral theories:- anxiety is a conditional response to specific environmental stimuli followed by its generalization, displacement, or transference. It may be learned through identification and imitation of anxiety pattern in parents (social learning theory). Mowrer (1948) Avoidance learning (learned behaviour) 1) classical (respondent) conditioning 2) negative reinforcement

The Cognitive Approach to Anxiety Individuals misperceive and misinterpret internal and external stimuli. Selective attention and catastrophic thinking Cognitive Appraisal (perceive threat) Stimulus--->Appraisal---> Response evaluation of stimulus based on memories, beliefs, and expectations. . Albert Ellis identified basic irrational assumptions: It is necessary for humans to be loved by everyone It is catastrophic when things are not as one wants them to be If something is dangerous, a person should be terribly concerned and dwell on the possibility that it will occur One should be competent in all domains to be a worthwhile person The idea is, when these assumptions are applied to everyday life, GAD may develop. Aaron Beck :Those with GAD hold unrealistic silent assumptions that imply imminent danger: Any strange situation is dangerous A situation/person is unsafe until proven safe

The Biological Approach to Anxiety Genetic Component family and twin studies suggest a genetic component in most anxiety disorders panic disorder shows the strongest genetic component and generalized anxiety disorder the least. Neurotransmitter abnormalities - the release of catecholamine (NA, DA) is increased. - decrease level of GABA (GABA inhibit CNS irritability). - serotonin decrease causes anxiety; increased dopaminergic activity is associated with anxiety. Activity in the temporal cerebral cortex is increased. The locus ceruleus, a brain center of noradrengic neurons, is hyperactive in anxiety disorders, especially panic attacks. Elevated responsiveness in the amygdala, part of the fear circuit of the limbic system. HPA axis dysregulation Serotonin and basal ganglia abnormalities in OCD Hormonal theory of PTSD

Other theories: Social factors Early life adversity Stressful events especially those involving threat Lack of support network Personality factors Some personality traits predispose to certain anxiety disorders – avoidant, perfectionist

Depression-Anxiety Comorbidity The lifetime prevalence of depression is 60% in patients with social anxiety disorder Major Depressive Disorder16.2%(lifetimeprevalence) AnxietyDisorders24.9%(lifetimeprevalence) Up to 60% Overlap The lifetime prevalence of depression is 57% in patients with panic disorder Brown TA, et al. J Abnorm Psychol 2001;36:578-584. Kessler RC, et al. JAMA 2003;289:3095-3105. Kessler RC, et al. Arch Gen Psychiatry 1994;51:8-19.

Depression and Anxiety Disorders Commonly Occur Together SAD 37%* (SAD + MDD2) Fear/avoidance of social situations Blushing Trembling/shaking Low self- esteem Palpitations Sweating GAD MDD Difficulty concentrating GI complaints Interpersonal sensitivity 62%* (GAD + MDD1) Anhedonia Depressed mood Suicidal ideation Feelings of worthlessness Appetitedisturbance Worry Anxiety Muscle tension Dry mouth Agitation Irritability Sleep disturbance Fatigue Pain *Lifetime prevalence of MDD among individuals with lifetime diagnoses of each anxiety disorder. 1. Wittchen HU, et al. Arch Gen Psychiatry. 1994;51:355-364. 2. Magee WJ, et al. Arch Gen Psychiatry. 1996;53:159-168. 3. DSM-IV-TR™. Washington, DC: American Psychiatric Association; 2000.

Screening and Diagnosis Measurement-Based Care Screening GAD-7, LSAS, PTSD, YBOC Detect depression (PHQ-9, QIDS, CUDOS, Zung) Rule out bipolarity (MDQ, WHO CIDI 3.0) Diagnosis DSM-IVoverview Comorbidity Suicide Assessment Symptom Tracking HAM-A (physician) CGI-A

generalized anxiety disorder (GAD)

Generalized Anxiety Disorder Excessive uncontrollable worry about everyday things. This constant worry affects daily functioning and can cause physical symptoms. GAD can occur with other anxiety disorders, depressive disorders, or substance abuse.

Generalized Anxiety Disorder The focus of GAD worry can shift, usually focusing on issues like job, finances, health of both self and family; but it can also include more mundane issues such as, chores, car repairs and being late for appointments. The intensity, duration and frequency of the worry are disproportionate to the issue

Generalized Anxiety Disorder Characterized by at least 6 months of persistent and excessive anxiety and worry

Generalized Anxiety Disorder (GAD) GAD affects 6.8 million adults, or 3.1% of the U.S. population. Women are twice as likely to be affected as men.   

GAD Epidemiology 5% prevalence in community samples 2:1 female/male ratio Age of onset is frequently in childhood or adolescence Chronic but fluctuating course of illness (worsened during stressful periods)

Generalized Anxiety Disorder (GAD) Patients with GAD suffer from severe worry or anxiety that is out of proportion to situational factors. Must last most days for at least 6 months Described as “worriers” or “nervous”

GAD Symptoms include: Muscle tension Restlessness Insomnia Difficulty concentrating Easy fatigability Irritability Persistent anxiety (rather than discrete panic attacks)

GAD Diagnostic Criteria Excessive anxiety and worry that occurs more days than not for 6 months Difficult to control the worry 3 out of 6 symptoms Anxiety caused significant distress or impairment in function Not attributed to another organic cause

GAD Treatment Cognitive Behavioral Therapy Other Psychotherapies Pharmacotherapy Antidepressants Benzodiazepines Buspirone

Common Causes There is no one cause for anxiety disorders. Several factors can play a role Genetics Brain biochemistry Overactive "fight or flight" response Can be caused by too much stress Life circumstances Personality People who have low self-esteem and poor coping skills may be more prone Certain drugs, both recreational and medicinal, can lead to symptoms of anxiety due to either side effects or withdrawal from the drug. In very rare cases, a tumor of the adrenal gland (pheochromocytoma) may be the cause of anxiety.

Symptoms of Anxiety Anxiety is an emotion often accompanied by various physical symptoms, including: Twitching or trembling Muscle tension Headaches Sweating Dry mouth Difficulty swallowing Abdominal pain (may be the only symptom of stress especially in a child)

Additional Symptoms of Anxiety Sometimes other symptoms accompany anxiety: Dizziness Rapid or irregular heart rate Rapid breathing Diarrhea or frequent need to urinate Fatigue Irritability, including loss of your temper Sleeping difficulties and nightmares Decreased concentration Sexual problems

Generalized anxiety disorder Person is continually tense, apprehensive, and in a state of CNS arousal.

Generalized anxiety disorder Tense and jittery Worried bad things will happen Muscular tension Agitation Sleeplessness

Generalized anxiety disorder Person cannot identify the cause of the anxiety, and therefore can’t avoid or deal “Free floating anxiety”

Generalized anxiety disorder Worry about things that are not too likely to happen Worry more intensely

Generalized Anxiety Disorder Generalized anxiety disorder (GAD) is characterized by unrealistic or excessive worry (generalized free-floating persistent anxiety) about every day events/problems with symptoms of muscle and psychic tension, causing significant distress/functional impairment.

What is Gen. Anxiety Disorder ? Anxiety Disorders are characterized by persistent fear and anxiety that occurs too often, is too severe, is triggered too easily or lasts too long. Compared with others with anxiety disorders, persons with GAD have a better ability to maintain normal work and social relationships in spite of their distress. The “What if?” disorder

DSM-IV Diagnostic Criteria for Generalized Anxiety Disorder A. Excessive anxiety or worry is present most days during at least a six-month period and involves a number of life events. B. The anxiety is difficult to control. C. At least three of the following: 1. Restlessness or feeling on edge. 2. Easy fatigability. 3. Difficulty concentrating. 4. Irritability. 5. Muscle tension. 6. Sleep disturbance. D. The focus of anxiety is not anticipatory anxiety about having a panic attack, as in panic disorder. E. The anxiety or physical symptoms cause significant distress or impairment in functioning. F. Symptoms are not caused by substance use or a medical condition, and symptoms are not related to a mood or psychotic disorder.

Diagnostic criteria of GAD- SUMMARY Excessive Worry About Work Family and Children Health Finances Minor Matters Worry occurs most days (for at least 6 months) Difficult to control worry Associated with disturbed sleep, irritability, restlessness, poor concentration, fatigue, muscle tension

Clinical Features of Generalized Anxiety Disorder A. Other features often include insomnia, irritability, trembling, muscle aches and soreness, muscle twitches, sweaty hands, dry mouth, and a heightened startle reflex. Patients may also report palpitations, dizziness, difficulty breathing, urinary frequency, dysphagia, light-headedness, abdominal pain, and diarrhea. B. Patients often complain that they “can't stop worrying,” which may revolve around valid concerns about money, jobs, marriage, health, and the safety of children. C. Chronic worry is a prominent feature of generalized anxiety disorder, unlike the intermittent terror that characterizes panic disorder.

D. Mood disorders, substance- and stress-related disorders (headaches, dyspepsia) commonly coexist with GAD. Up to one-fourth of GAD patients develop panic disorder. Excessive worry and somatic symptoms, including autonomic hyperactivity and hypervigilance, occur most days. E. About 30-50% of patients with anxiety disorders will also meet criteria for major depressive disorder. Drugs and alcohol may cause anxiety or may be an attempt at self-treatment. Substance abuse may be a complication of GAD.

Differential Diagnosis of Generalized AnxietyDisorder Substance-Induced Anxiety Disorder: Substances such as caffeine, amphetamines, or cocaine can cause anxiety symptoms. Alcohol or benzodiazepine withdrawal can mimic symptoms of GAD. These disorders should be excluded by history and toxicology screen. B. Panic Disorder, Obsessive-Compulsive Disorder, Social Phobia, Hypochondriasis and Anorexia Nervosa 1. Many psychiatric disorders present with marked anxiety, and the diagnosis of GAD should be made only if the anxiety is unrelated to the other disorders. 2. For example, GAD should not be diagnosed in panic disorder if the patient has excessive anxiety about having a panic attack, or if an anorexic patient has anxiety about weight gain.

C. Anxiety Disorder Due to a General Medical Condition. Hyperthyroidism, cardiac arrhythmias, pulmonary embolism, congestive heart failure, and hypoglycemia, may produce significant anxiety and should be ruled out as clinically indicated. D. Mood and Psychotic Disorders 1. Excessive worry and anxiety occurs in many mood and psychotic disorders. 2. If anxiety occurs only during the course of the mood or psychotic disorder, then GAD cannot be diagnosed.

Course and prognosis Course is chronic; symptoms may diminish as the patient get older. With time, secondary depression may develop. This is not uncommon if the condition is left untreated.

Treatment of Generalized Anxiety Disorder The combination of pharmacologic therapy and psychotherapy is the most successful form of treatment.

I. Pharmacotherapy of Generalized Anxiety Disorder: ,Fluoxetine

Antidepressants 1. SSRIs and Venlafaxine a. The onset of action of antidepressants is much slower than the benzodiazepines, but they have no addictive potential and may be more effective. An antidepressant is the agent of choice when depression coexists with anxiety. b. The side-effect profile for GAD patients is similar to that seen with depressive disorders. 2. Tricyclic antidepressants are also effective in treating GAD, but adverse effects limit their use.

Treatment Options Antidepressant Medications Selective Serotonin Reuptake Inhibitors (SSRI) Serotonin and Norepinephrine Reuptake Inhibitors (SNRI) Norepinephrine-dopamine Reuptake Inhibitors Mixed Selective Serotonin Reuptake Inhibitors and Receptor Blockers Tricyclic Antidepressants (TCA) Monoamine Oxidase Inhibitors (MAOI) Nonpharmacological Therapy Psychotherapy Cognitive Behavioral Therapy (CBT) Interpersonal Therapy (IPT) Biofeedback? Exposure Response Treatment Trauma Focused CBT DBT

AlternativeTreatments Acupuncture Aromatherapy Breathing Exercises Exercise Meditation Nutrition and Diet Therapy Vitamins Self Love

Factors to Consider in Choosing an Medications for Anxiety Patient preference Nature of prior response to medication Relative efficacy and effectiveness Safety, tolerability, and anticipated side effects Co-occurring psychiatric or general medical conditions Potential drug interactions Half-life Cost

B. Buspirone a. Buspirone is an effective treatment for GAD. It lacks sedative effects. Tolerance to the beneficial effects of buspirone does not seem to develop. There is no physiologic dependence or withdrawal syndrome.

C. Benzodiazepines 1. Benzodiazepines can almost always relieve anxiety if given in adequate doses, and they have no delayed onset of action. 2. Benzodiazepines have few side effects other than sedation. Tolerance to their sedative effects develops but not to their antianxiety properties. 3. Drug dependency becomes a clinical issue if the benzodiazepine is used regularly for more than 2-3 weeks. A withdrawal syndrome occurs in 70% of patients, characterized by intense anxiety, tremulousness, dysphoria, sleep and perceptual disturbances and appetite suppression. 4. Slow tapering of benzodiazepines is crucial (especially those with short half-lives).

Comparison of Benzodiazepines

II. Non-Drug Approaches to Anxiety 1. Patients should stop drinking coffee and other caffeinated beverages, and avoid excessive alcohol consumption. 2. Patients should get adequate sleep, with the use of medication if necessary. Moderate exercise each day may help reduce the intensity of anxiety symptoms. 3. Psychotherapy a. Cognitive behavioral therapy, with emphasis on relaxation techniques and instruction on misinterpretation of physiologic symptoms, may improve functioning in mild cases. b. Supportive or insight oriented psychotherapy can be helpful in mild cases of anxiety.

GOOD SLEEP HYGENE No sleeping during the day (If you have to no longer than 30 mins) Don’t lay in bed if not sleepy Get out of bed if unable to sleep No milk during the evening No caffeine No Nicotine No Alcohol Warm baths, no showers No exercising before going to bed but exercise in the morning Sleep at the same time every night Wake up at the same time every morning Make sure bed and pillow is comfortable, primarily for sleep with appropriate room temp (Cool about 60 degrees), noise free (some sleep better with white noise). Remember Cool, dark and quiet) Jot down all of your concerns and worries Avoid “Over the counter” sleep aides Don’t over sleep Set your body clock (wake up to light) Develop a bedtime routine No TV in bed ECPSLLC.COM

Other Psychological managements: Education about nature of disorder Progressive muscle relaxation Structured problem solving Graded exposure to difficult situations Support (guidance, advice, development of coping strategies) Counselling Stress management (relaxation, meditation, exercise regimens that improve stress recovery)

Combination Maximize benefit by affecting multiple neurotransmitters Could increase adherence and lower drop-out rates Could target side effects of first agent (eg, insomnia, fatigue, sexual dysfunction) Papakostas G. J Clin Psychiatry. 2009;70(S6):16-25.

(SOCIAL PHOBIA)

social anxiety disorder

Social Anxiety Disorder 15 million, 6.8% Equally common among men and women, typically beginning around age 13. (According to a 2007 ADAA survey, 36% of people with social anxiety disorder report experiencing symptoms for 10 or more years before seeking help. Comorbityexisits

Social Phobia General characteristics Fear of being in social situations in which one will be embarrassed or humiliated

Social Phobia Interaction of psychosocial and biological causal factors Genetic and temperamental factors Perceptions of uncontrollability Cognitive variables

Social phobias Shyness to the extreme Persistent, irrational fear linked to presence of others Fear of being scrutinized or negatively evaluated by others

Social phobias Person with social phobia may avoid Speaking Eating out Going to parties Anything in the presence of others

CONCERN Very Under diagnosed and Therefore undertreated. Can cause severe impairment in social, occupational and academic functioning Can Lead to Avoidant Behavior

DIAGNOSIS Fear or avoidance of social or performance situations Situations avoided, or endured with anxiety or distress Patients recognize symptoms as excessive or unreasonable Very distressing or disabling .

Feared/Avoided Situations Public speaking/performing Eating, drinking, writing, working while being observed by others Social events Dating Meeting new people Being center of attention Using public bathroom

Common Somatic Complaints Stuttering Blushing Palpitations Sweating Trembling Shaking

Spectrum of Social Discomfort Transient Low interference Low avoidance Chronic High interference High avoidance Shyness Nongeneralized SAD Generalized SAD Avoidant personality disorder

Treatment Goals Eliminate anxiety/phobic avoidance Eliminate functional disability Treat associated comorbidities Choose therapy that is tolerable for the long term

Social Phobia: Treatment Antidepressants, SSRI’s and MAOI’s High potency benzodiazepines Low doses of beta blockers are helpful for public speaking (if only an occasional event); this alleviates the autonomic symptoms Psychotherapy-cognitive restructuring

Treatment Medication Management Psychotherapy Combined Medication Management and Psychotherapy Practice Practice Practice!

Social Effects of Anxiety Depression Not as involved with family and friends the way you used to be Lowered quality of relationships Low energy Lack of motivation to do the things you once looked forward to doing Unable to convey the person that you are Fear and avoidance of situations where previous attacks occurred

http://www.socialanxietysupport.com/disorder/liebowitz/

Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorder (OCD) 2.2 million, 1.0% Equally common among men and women.  The median age of onset is 19, with 25 percent of cases occurring by age 14. One-third of affected adults first experienced symptoms in childhood. Hoarding is the compulsive purchasing, acquiring, searching, and saving of items that have little or no value.

Obsessive-Compulsive Disorder Characterized by uncontrollable obsessions and compulsions which the sufferer usually recognizes as being excessive or unreasonable. Obsessions are recurring thoughts or impulses that are intrusive or inappropriate and cause the sufferer anxiety: Thoughts about contamination, for example, when an individual fears coming into contact with dirt, germs or "unclean" objects; Persistent doubts, for example, whether or not one has turned off the iron or stove, locked the door or turned on the answering machine; Extreme need for orderliness; Aggressive impulses or thoughts, for example, being overcome with the urge to yell 'fire' in a crowded theater

Obsessive-Compulsive Disorder Compulsions are repetitive behaviors or rituals performed by the OCD sufferer, performance of these rituals neutralize the anxiety caused by obsessive thoughts, relief is only temporary. Cleaning. Repeatedly washing their hands, showering, or constantly cleaning their home; Checking. Individuals may check several or even hundreds of times to make sure that stoves are turned off and doors are locked; Repeating. Some repeat a name, phrase or action over and over; Slowness. Some individuals may take an excessively slow and methodical approach to daily activities, they may spend hours organizing and arranging objects; Hoarding. Hoarders are unable to throw away useless items, such as old newspapers, junk mail, even broken appliances In order for OCD to be diagnosed, the obsessions and/or compulsions must take up a considerable amount of the sufferers time, at least one hour every day, and interfere with normal routines .

Obsessive-Compulsive Disorder Obsessions- repetitive unwanted ideas that the person recognizes are irrational Compulsions- repetitive, often ritualized behavior whose behavior serves to diminish anxiety caused by obsessions

Obsessive-Compulsive Disorder Prevalence and age of onset Characteristics of OCD Types of compulsions Comorbidity with other disorders

Common Examples of OCD

OCD is not OCPD Obsessive-Compulsive Disorder is different from obsessive compulsive personality disorder (OCPD) OCPD: a pervasive pattern of preoccupation with orderliness, perfectionism and control that begins by early adulthood

Obsessive-Compulsive Disorder:Psychosocial Causal Factors Psychoanalytic viewpoint Behavioral viewpoint The role of memory Attempting to suppress obsessive thoughts

Obsessive-Compulsive Disorder:Biological Causal Factors Genetic influences Abnormalities in brain function The role of serotonin

OCD Treatment Serotonin reuptake inhibitors Clomipramine, a serotonergic tricyclic antidepressant Psychotherapy: exposure and response prevention

Panic Disorder

Panic Disorder 6 million, 2.7% Women are twice as likely to be affected as men.  Very high comorbidity rate with major depression.  

Epidemiology of Panic Disorder Panic disorder has a lifetime prevalence of 1.5-3.5% 2:1 female/male ratio ? Of true gender difference versus men tend to self-medicate with alcohol and are less likely to seek treatment. Onset is late teens through third decade of life.

Panic Disorder With and Without Agoraphobia Panic disorder Panic versus anxiety Agoraphobia Agoraphobia without panic

Panic Disorder Prevalence and age of onset Comorbidity with other disorders Biological causal factors The role of Norepinephrine and Serotonin

Panic Attack Discrete episodes of intense anxiety Sudden onset Peak within 10 minutes Associated with at least 4 of the 13 other somatic or cognitive symptoms of autonomic arousal

Panic Attack Symptoms Cardiac: palpitations, tachycardia, chest pain or discomfort Pulmonary: shortness of breath, a feeling of choking GI: nausea or abdominal distress Neurological: trembling and shaking, dizziness, lightheadedness or faintness, paresthesias

Panic Attack Symptoms Autonomic Arousal: sweating, chills or hot flashes Psychological: Derealization (feeling of unreality) Depersonalization (feeling detached from oneself) Fear of losing control or going crazy Fear of dying

Panic Disorder A syndrome characterized by recurrent unexpected panic attacks (at least 4 in one month) Attacks are followed for at least one month with: Concern about having another attack Worry about implications of the attack Behavior changes because of the attacks

Agoraphobia Complication of panic disorder Means “ fear of the market” Anxiety or avoidance of places or situations from which escape might be difficult, embarrassing, or help may be unavailable. Restricts daily activities

Agoraphobia Agoraphobia The patient may avoid crowds, restaurants, highways, bridges, movie theaters etc. In its most severe form, the patient may become dependent on companions to face situations outside the home. Some individuals become homebound.

Differential Diagnosis of Panic Disorder Not due to another anxiety disorder Not due to effects of a general medical condition Cardiovascular disease Pulmonary disease Neurological disease Endocrine disease Drug intoxication or withdrawal Other (lupus, infections, heavy metal poisoning, uremia, temporal arteritis)

Panic Disorder: Costs 200,000 normal coronary angiograms/yr in the U.S. at a cost of 600 million dollars: 1/3 of these patients have panic disorder ½ of patients referred for non-invasive testing for atypical chest pain and who have normal tests have panic disorder 1/3 patients undergoing work-up for vestibular disorder with c/o dizziness have panic disorder

Panic Disorder: Comorbidity Panic disorder patients have an increased personal and family history of other anxiety, mood and substance abuse disorders. Major depression is a co-morbid diagnosis in 1/3 of cases presenting for treatment Untreated patients have high risk of suicide

Panic Disorder: Treatment About 80% of patients will respond to treatment Antidepressant medications are effective Serotonin reuptake inhibitors (SSRI) are first line therapy Tricyclic antidepressants (TCA) and monoamine oxidase inhibitors (MAOI’s) are also used.

Panic Disorder: Treatment Sedative-Hypnotics: benzodiazepines are ideally used in the short term before an antidepressant has had time to work Cognitive Behavioral Therapy (CBT): helps patients overcome a learned pattern of catastrophically misinterpreting the physical symptoms associated with panic attacks.

Panic Disorder The abrupt onset of an episode of intense fear or discomfort, which peaks in approximately 10 minutes, and includes at least four of the following symptoms: A feeling of imminent danger or doom The need to escape Palpitations Sweating Trembling Shortness of breath or a smothering feeling A feeling of choking Chest pain or discomfort Nausea or abdominal discomfort Dizziness or lightheadedness A sense of things being unreal, depersonalization A fear of losing control or "going crazy" A fear of dying Tingling sensations Chills or hot flushes

Panic Disorder There are three types of Panic Attacks: 1. Unexpected - the attack "comes out of the blue" without warning and for no discernable reason. 2. Situational - situations in which an individual always has an attack, for example, upon entering a tunnel. 3. Situationally Predisposed - situations in which an individual is likely to have a Panic Attack, but does not always have one. An example of this would be an individual who sometimes has attacks while driving.

Panic and the Brain

Panic Disorder Genetic factors Cognitive and behavioral causal factors Interoceptive fears

Panic Disorder: The Cognitive Theory of Panic

Panic Disorder: The Cognitive Theory of Panic Perceived control and safety Anxiety sensitivity as a vulnerability factor for panic Safety behaviors and the persistence of panic Cognitive biases and the maintenance of panic

Treating Panic Disorder and Agoraphobia Medications Behavioral and cognitive-behavioral treatments

Post-traumatic stress disorder (PTSD)

Posttraumatic Stress Disorder (PTSD) 7.7 million, 3.5% Women are more likely to be affected than men.  Rape is the most likely trigger of PTSD: 65% of men and 45.9% of women who are raped will develop the disorder.  Childhood sexual abuse is a strong predictor of lifetime likelihood for developing PTSD.  

Post Traumatic Stress Disorder (PTSD) Patients with PTSD have experienced a trauma and develop disabling symptoms in response to the event. Symptoms usually begin within 3 months of the trauma Syndrome can occur at any age

Definition of Trauma The person experienced, witnessed or learned of an event that involved actual or threatened death, serious injury, or threat of harm to self or others The person’s response involved intense fear, helplessness or horror

Diagnosis of PTSD Symptoms must be > one month duration and include: Re-experiencing symptoms Avoidance symptoms Emotional numbing Hyperarousal symptoms

Re-experiencing Symptoms There are recurrent, intrusive thoughts of the event (can’t not think about it) Dreams (nightmares) about the event Acting or feeling the event is recurring, or sense of living the event (flashbacks) Psychological or Physiological Distress upon exposure to reminders or cues of the event.

Avoidance/Numbing Symptoms Avoid thoughts, feelings, places or people that arouse memories of the event Being unable to recall important parts of the event Decrease interest in activities Feeling detached or estranged from others Decreased range of affect Sense of foreshortened future

Hyperarousal Symptoms Patient experiences at least two of the following: Insomnia (falling or staying asleep) Irritability or outbursts of anger Decreased concentration Hypervigilance Increased/exaggerated startle response

Post-Traumatic Stress Disorder Critical Component Symptoms occurs AFTER a traumatic stressor

Types of Traumas Natural earthquakes floods fires Human induces war crimes of violence

Types of Trauma Sexual abuse Rape Physical abuse Severe motor vehicle accidents Robbery/mugging Terrorist attack Combat veteran Natural disasters Being diagnosed with a life threatening illness Sudden unexpected death of family/friend Witnessing violence (including domestic violence) Learning one’s child has life threatening illness

Co-Morbid Diagnoses Alcoholism 75% for Vietnam Veterans with PTSD Depression 77% of firefighters with PTSD also have depression Generalized Anxiety Panic Attacks

Symptoms Categories Intrusive distressing recollections dreams flashbacks psychological trigger reactions physiological trigger reactions

Symptoms Categories Avoidance avoid thoughts, feelings or discussions avoid activities, places memory blocks anhedonia (without pleasure) numb alexithymia (emotions unknown) feeling of doom

Symptom Categories Hyperarousal Symptoms sleep disturbance anger problems concentration startle response “on guard” hypervigilence

Diagnoses Acute Stress Disorder new to DSM-IV (1994) symptoms 2 days to 4 weeks following traumatic event PTSD new to DSM-III (1980) symptoms beyond 4 weeks delayed onset

Post-Traumatic Stress Disorder Exposure to traumas such as a serious accident, a natural disaster, or criminal assault can result in PTSD. When the aftermath of a traumatic experience interferes with normal functioning, the person may be suffering from PTSD. Symptoms of PTSD are: Reexperiencing the event, which can take the form of intrusive thoughts and recollections, or recurrent dreams; Avoidance behavior in which the sufferer avoids activities, situations, people,and/or conversations which he/she associates with the trauma; A general numbness and loss of interest in surroundings; Hypersensitivity, including: inability to sleep, anxious feelings, overactive startle response, hypervigilance, irritability and outbursts of anger.

Who Is Vulnerable? All ages Both genders Across Cultures and ethnic groups

PTSD Treatment Psychotherapies Exposure-based cognitive behavioral therapy Psychotherapy aimed at survivor anger, guilt and helplessness (victimization) Pharmacological treatment targets the reduction of prominent symptoms SSRI’s are first line therapy Atypical antipsychotics are being increasingly used

Specific Phobia

Specific Phobias 19 million, 8.7% Women are twice as likely to be affected as men. Related Illnesses  Many people with an anxiety disorder also have a co-occurring disorder or physical illness, which can make their symptoms worse and recovery more difficult. It’s essential to be treated for both disorders.

Epidemiology of Specific Phobias Lifetime prevalence is 10% of the population Age of onset varies with subtype Childhood onset for phobias of animals, natural environments blood and injections Bimodal distribution (childhood and mid-twenties for situational phobias

Phobic Disorders Phobias Specific phobias Social phobia Agoraphobia

Specific Phobias

Specific Phobias Psychosocial causal factors Genetic and temperamental causal factors Preparedness and the nonrandom distribution of fears and phobias Treating specific phobias

Specific Phobia Marked and persistent fear that is excessive and unreasonable of a specific object or situation Exposure to the phobic stimulus will provoke an anxiety response

Phobia Subtypes Animals or insects Natural environment– storms, water, heights Blood, injury, injection, medical procedure Situational flying, driving, enclosed places Having a phobia of a specific subtype increased the chances of having another phobia within that subtype

Specific Phobia Treatments Flooding-exposing the person to the feared stimulus Exposure therapy works to desensitize the patient using a series of gradual, self-paced exposures to the phobic stimulus; uses relaxation, hypnosis, breathing control and other cognitive approaches Benzodiazepines or Beta blockers are useful acutely

Specific Phobia: Treatment Example: Fear of Flying Visualize a plane. Look at a plane in the sky. Drive by an airport. Go to a museum that has planes. Same museum—visualize going inside. Go inside. Go to airport and watch planes take off and land. Visualize yourself on a plane flying. Omnimax theater experience. The real thing.

Treatment of Anxiety Disorders Medications Specific types of psychotherapy Comorbidities History

How to Get Help for Anxiety Disorders See our MD See A Clincian Support Groups CBT Cut Caffiene, Alcohol, Drugs, Cold Medicaations Internet Family Support Systems

Role of Research in Improving the Understanding and Treatment of Anxiety Disorders Role of Genes Enviormental factors Physical and psychological stress Diet Brain imaging technology Neurochemical techniques – Amygdala and Hippocampus Developing Medications and behavioral therapies

PSYCHIATRIC MANAGEMENT Establish and maintain a therapeutic alliance Complete the psychiatric assessment Evaluate the safety of the patient Establish the appropriate setting for treatment Evaluate the functional impairment and quality of life Coordinate the patient’s care with the other clinicians Monitor the patient’s psychiatric status Integrate measurements into psychiatric management Enhance treatment adherence Provide education to the patient and the family ECPSLLC.COM

Monitor psychiatric status and safety. Monitor the patient for changes in destructive impulses to self and others. Be vigilant in monitoring changes in psychiatric status, including major depressive symptoms and symptoms of potential comorbid conditions. Consider diagnostic reevaluation if symptoms change significantly or if new symptoms emerge.

PE • History of the present illness and current symptoms • Psychiatric history, including symptoms of mania • Treatment history with current treatments and responses to previous treatments • General medical history • History of substance use disorders • Personal history (e.g., psychological development, response to life transitions, major life events) • Social, occupational, and family histories • Review of the patient’s medications • Review of systems • Mental status examination • Physical examination • Diagnostic tests as indicated

Items to Monitor Throughout Treatment Symptomatic status, including functional status, and quality of life Degree of danger to self and others Signs of “switch” to mania Other mental disorders, including alcohol and other substance use disorders General medical conditions Response to treatment Side effects of treatment Adherence to treatment plan

Selection of Treatment: Make Your First Choice Count! Aim for remission of symptoms Choose agents with proven efficacy Use optimal dose Minimize dropout Consider efficacy/tolerability/safety profile Maximize adherence Prevent relapse/recurrence Achieve remission of symptoms! Adequate duration American Psychiatric Association. Am J Psychiatry. 2000;157(4 suppl):1-45.

Summary and Take-Home Messages Patients can have a high rate of nonadherence with SSRIs due to adverse events First few weeks of therapy are critical Monitor medication compliance during this time period Choose a medication that is effective and generally well tolerated across indications

Onset of Adverse Events and Efficacy Therapeutic Effect Adverse Events Antidepressant Therapy Time Adapted from American Psychiatric Association. Am J Psychiatry. 2000;157(Suppl 4):1-45. Bull SA, et al. Ann Pharmacother. 2002;36:578-584.

Side effects of antidepressant medications 1. Selective serotonin reuptake inhibitors a. Gastrointestinal b. Activation/insomnia c. Sexual side effects d. Neurological e. Falls f. Effects on weight g. Serotonin syndrome h. Drug interactions i. Discontinuation syndrome

Side effects of antidepressant medications 2. Serotonin norepinephrine reuptake inhibitors Venlafaxine, Desvenlafaxine, Duloxitine Nausea Dry mouth Sweating Agitation Sedation Weight Sexual Dysfunction Elevated Blood Pressure

Side effects of antidepressant medications 4. Tricyclicantidepressants a. Cardiovascular effects b. Anticholinergic side effects c. Sedation d. Weight gain e. Neurological effects f. Falls . g. Medication interactions

Side effects of antidepressant medications 5. Monoamine oxidase inhibitors a. Hypertensive crises b. Serotonin syndrome c. Cardiovascular effects d. Weight gain e. Sexual side effects f. Neurological effects

Buspar Nausea Dizziness

Psychotherapy . Specific psychotherapies Cognitive and behavioral therapies Interpersonal psychotherapy Psychodynamic psychotherapy Problem-solving therapy Marital therapy and family therapy Group therapy Implementation Combining psychotherapy and medication

Complementary and alternative treatments a. St. John’s wort b. S-adenosylmethionine c. Omega-3 fatty acids d. Folate e. N-Acetyl Cysteine f. Acupuncture G. Yoga

Assessing response and adequacy of treatment

Potential Reasons for Treatment Nonresponse Inaccurate diagnosis Unaddressed co-occurring medical or psychiatric disorders, including substance use disorders Inappropriate selection of therapeutic modalities Inadequate dose of medication or frequency of psychotherapy Pharmacokinetic/pharmacodynamic factors affecting medication action Inadequate duration of treatment Nonadherence to treatment Persistent or poorly tolerated side effects Complicating psychosocial and psychological factors Inadequately trained therapist or poor “fit” between patient and therapist

Treatment Should Be Discontinued Gradually Most antidepressants need to be tapered Gradually taper dose (1 dosage level per week)1 Longer-term treatment may require slower taper1,2 Discontinuation symptoms are possible soon after stopping drugs with short half-lives1,2 Counsel patients on possible discontinuation symptoms, including: Agitation, anorexia, diarrhea, dizziness, dry mouth, insomnia, nausea, nervousness, sensory disturbances, somnolence, and sweating1 1. EFFEXOR XR® (venlafaxine HCl) Prescribing Information. 2. American Psychiatric Association. Am J Psychiatry. 2000;157(4 suppl):1-45.

Considerations in the Decision toUse Maintenance Treatment

SPECIFIC CLINICAL FEATURES INFLUENCING THE TREATMENT PLAN Psychiatric Factors Demographic and Psychosocial Variables Co-occurring psychiatric disorders Demographic and Psychosocial Variables Treatment Implications of Co-occurring General Medical Conditions

Co-occurring psychiatric disorders Dysthymic disorder Affective disorders Dementia Substance use disorders Personality disorders Eating disorders

Treatment Implications of Co-occurring General Medical Conditions 1. Hypertension 2. Cardiac disease 3. Stroke 4. Parkinson’s disease 5. Epilepsy 6. Obesity 7. Diabetes 8. Sleep apnea 9. Human immunodeficiency virus and hepatitis C infections 10. Pain syndromes 11. Obstructive uropathy 12. Glaucoma

Unmet Needs in Anxiety Underdiagnosed therefore untreated Faster improvement Fewer side effects and better tolerability Greater efficacy Long term efficacy Source: Datamonitor, Stakeholder Insight: MDD, Q1.2; Adult population figures from www.census.gov and MDD prevalence rates applied.

National Survey Dispels Notion that Social Phobia is the Same as Shyness social phobia is not simply shyness that has been inappropriately medicalized social phobia affects a minority of youth and only a fraction of those who consider themselves to be shy the greater disability that youth with social phobia experience and the greater likelihood that they will have another disorder they are not more likely to be getting treatment compared to their peers, questioning the notion that these youth are being unnecessarily medicated.

About half of adults with an anxiety disorder had symptoms of some type of psychiatric illness by age 15, a NIMH-funded study shows. Results from a small clinical trial suggest that it might be possible, using computer-based training, to help children with anxiety shift their attention away from threat. Normal human shyness is not being confused with the psychiatric anxiety disorder known as social phobia, according to an NIMH survey comparing the prevalence rates of the two among U.S. youth.

Anxiety as a personality trait appears to be linked to the functioning of two key brain regions involved in fear and its suppression, according to an NIMH-funded study. Differences in how these two regions function and interact may help explain the wide range of symptoms seen in people who have anxiety disorders. The study was published February 10, 2011 in the journal, Neuron.

Youth with obsessive compulsive disorder (OCD) who are already taking antidepressant medication benefit by adding a type of psychotherapy called cognitive behavior therapy (CBT), according to an NIMH-funded study published September 21, 2011, in the Journal of the American Medical Association.

Anxiety Linked to Smarts in Brain StudyTendency to worry may have evolved along with intelligence in humans, researchers say

Health Tip: When Your Child is Stressed Stress is a fact of life, and children are no less immune than their parents. How can you recognize if your child is "stressed out?" The American Academy of Pediatrics mentions these possible warning signs: Having physical problems, such as stomach ache or headache. Appearing agitated, tired or restless. Seeming depressed and unwilling to talk about his or her feelings. Losing interest in activities and wanting to stay at home. Acting irritable or negative. Participating less at school, possibly including slipping grades. Exhibiting antisocial behavior (stealing or lying), avoiding chores or becoming increasingly dependent on his or her parents.

Mental Stress May Be Harder on Women's Hearts Researchers Find Blood Flow to Women's Hearts Doesn't Increase in Face of Stress

Psychoeducation: Perhaps one of the most difficult aspects of coping with Social Phobia is simply understanding what it is, where it came from, why it's so hard to change, and how it keeps coming back with a vengeance. Psychoeducation involves you and your therapist working together to develop a better way to understand your Social Phobia, and subsequently, how to work with it. Cognitive Restructuring: As discussed earlier, individuals with Social Phobia frequently hold negative beliefs about themselves and others, which often show up as unhelpful thoughts in social situations. Cognitive restructuring is an important component of CBT, and it involves working with your therapist to identify these thoughts and look for patterns within them. As you become skilled at noticing these thoughts, you then develop strategies for gaining flexibility in your thinking and considering more helpful ways of looking at your experiences. In Vivo Exposure: In vivo (real life) exposure is another core element of CBT for Social Phobia. You and the therapist identify situations that you avoid because of Social Phobia, and then gradually enter these situations while accepting your anxiety and allowing it to naturally dissipate. While this step probably sounds quite intimidating, it is important to know that exposure is done at a very gradual, planned pace, and that your therapist will support you throughout the process. Many clients report exposure practices as being among the most useful elements in their treatment. Interoceptive Exposure: Some individuals with Social Phobia are fearful not only of social situations, but also of the anxious physical sensations (such as blushing, shaking, sweating, etc.) that can accompany them. Interoceptive exposure practices deliberately bring about these sensations through such activities as wearing a warm sweater to induce sweating in social situations. Just as exposure to feared situations leads to reductions in situational fear, exposure to feared sensations will lead to a reduction in anxiety over experiencing these feelings in social situations. Social Skills Training: In the midst of a tense social situation, many people with Social Phobia fear that they do not have the necessary social skills to successfully navigate the exchange. While this may be due to negative self-talk and self-consciousness (rather than an actual lack of skill), many people find it helpful to discuss such topics as carrying on conversations, being assertive, and effective listening. Social skills training provides a chance to work on these areas in therapy.

Anxiety Disorder Association of American (ADAA) The ADAA brings together professionals from many disciplines including psychiatrists, psychologists, social workers, physicians, nurses, etc. Through networks, the ADAA increases awareness about anxiety disorders, provides education resources, offers access to care, and supports research. www.adaa.org

http://www.ocfoundation.org/

Yoga Accupuncture Warm bath, soothing music, exercise, massage, stay away from caffeine, Alcohol?, balance diet, avoid eating to relieve stress, appropiate meal times Alternative and Supplemental Medication Books/Autotapes Podcast Meditation and Mindfullness

http://www.nimh.nih.gov/

Concluding Thoughts — There is a clear and pressing need for faster, robust and well tolerated therapy/therapies. Thinking is rapidly changing and evolving – combination strategies from treatment initiation may be the new frontier for patients who need greater efficacy than antidepressant monotherapy. Personalized medicine may be needed to address genetic differences in depressed individuals to achieve and maintain remission.

EDUCATIONAL RESOURCES FOR PATIENTS AND FAMILIES http://www.adaa.org/ Healthy Minds, Healthy Lives National Alliance on Mental Illness National Institute of Mental Health National Center for Complementary and Alternative Medicine Postpartum Support International MentalHelp.net

rx http://www.ocfoundation.org/CBT.aspx#ERP OCD cannot be prevented. However, early diagnosis and treatment can help reduce the time a person spends suffering from the condition

http://www.nami.org/

Epidemiology of PTSD Prevalence is 1% in the general population, and can be as high as 25% in those who have experienced trauma In combat veterans, prevalence is 20% Very high prevalence in women who are victims of sexual trauma

PTSD Costs Patients with PTSD are frequent users of the health care system Patients usually present to primary care physicians with somatic complaints After panic disorder, PTSD is the most costly anxiety disorder

Social Phobia Fear of being exposed to public scrutiny Fear of behaving in a way which will be humiliating or embarrassing Symptomatic resemblance to panic disorder with anticipatory anxiety (person may be anxious/worrying far in advance of the event) Extensive phobic avoidance

Social Phobia Distinction: anxiety only occurs when the patient is subject to the scrutiny of others (public speaking, oral exam, eating in the cafeteria) Phobic stimulus is avoided or endured with intense anxiety Fear and avoidant behaviors interfere with person’s normal routine or cause marked distress

Epidemiology: Social Phobia Prevalence rates vary depending on study; overall range is 3 –13% of the population Onset in adolescence Prevalence greater in females, but greater for males in clinical samples Frequent comorbidity with depression and substance abuse

Obsessive Compulsive Disorder (OCD) Obsessions: recurrent, intrusive, unwanted thoughts (i.e. fear of contamination) Compulsions: behaviors or rituals aimed at reducing distress or preventing a dreaded event (i.e. compulsive handwashing)

OCD Symptoms Recurrent obsessions and/or compulsions are severe enough to consume more than one hour/day Person recognizes the obsession as a “product of his/her own mind”, rather than imposed from the outside, and that they are unreasonable or excessive

OCD Symptoms The obsessions are “ego-dystonic” (not enjoyable for the ego), as opposed to “ego-syntonic” (the ego likes it)

Common Obsessions Contamination Repeated doubts Order Aggressive or horrific images Sexual/pornographic imagery Scrupulosity

Obsessions and Common Compulsive Responses Contamination: cleaning, hand washing, showering Repeated doubts: checking, requesting or demanding reassurances from others, counting Order: checking, rituals, counting Aggressive or horrific images, checking, prayers, rituals Sexual/Pornographic imagery: prayer/rituals

Epidemiology of OCD Lifetime prevalence is 2-3% in the general population Mean age of onset is mid-twenties, although men may develop symptoms earlier Less than 5% of patients develop disease after age of 35 years Chronic course, stress can exacerbate symptoms

Substance Induced Anxiety Disorder Prominent symptoms of anxiety that are judged to be the direct physiological consequence of a drug or abuse, a medication or toxin exposure

Panic Attacks and Panic Disorder Panic Attacks Agoraphobia without a history of panic disorder Panic Disorder without agoraphobia Panic Disorder with agoraphobia

Post Traumatic Stress Disorder Characterized by the re-experiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the trauma Symptoms present for at least one month If event just occurred and/or symptoms present for less than one month, a diagnosis of Acute Stress Disorder is given

Specific Phobia Clinically significant anxiety provoked by exposure to a specific feared object or situation, often leading to avoidance behavior

Obsessive Compulsive Disorder Characterized by obsessions that cause marked anxiety or distress and/or compulsions that serve to neutralize anxiety

Substance Induced Anxiety Disorder Anxiety Disorder not otherwise specified

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