ANXIETY DISORDERS: SYMPTOMS, TREATMENT, AND RESOURCES - ELIZABETH KOSCHMANN, PHD POST-DOCTORAL FELLOW CHILD AND ADOLESCENT PSYCHIATRY UNIVERSITY ...
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Anxiety Disorders:
Symptoms, Treatment, and Resources
Elizabeth Koschmann, PhD
Post-Doctoral Fellow
Child and Adolescent Psychiatry
University of Michigan
Acknowledgements Kate Fitzgerald, MD Joseph Himle, PhD Luan Phan, MD
What is Anxiety? • Stress • Nervousness • Fear • Intimidation • Worry • Uncertainty • Insecurity • Low self-confidence • Low self-esteem
Anxiety serves a purpose “I joined crew because I thought it would be good for me. Everyone on the team is very driven and they mostly get all A’s. They’re really different from the friends I was hanging out with before and it’s had a big impact on me. I don’t party as much anymore and I try a lot harder now. I’m doing a lot better in my classes. It’s been a big turnaround for me academically.”
Anxiety as “Disorder”
• Intense
• Frequent
• Distressing
• Difficult to control
• Gets in the way
"Anxiety itself is neither helpful nor hurtful,
it's your response to your anxiety that is
helpful or hurtful."
Anxiety as “disorder”
Think…
Avoidance
What is avoidance?
I better not go to I can’t take that test
the party – what if – I’ll fail!
people are dancing?
I’m staying home I can’t introduce
– this is the worst myself, I’ll look
hair cut. so stupid.
I better not ask a
I’m not calling – question – everyone
what if he thinks else totally
I’m a total loser? understands this.
Main Anxiety Disorders • Generalized Anxiety Disorder (GAD) • Separation Anxiety Disorder (SAD) • Social Phobia (SoPho) • Specific Phobia (SP) • Obsessive Compulsive Disorder (OCD) • Panic Disorder (PD) • Post Traumatic Stress Disorder (PTSD) • Others
Generalized Anxiety • Excessive worry about every day events / expectations • Usually not one focus of worry • Sense of needing to be perfect • Worries are overwhelming, disabling, interfere with daily functioning (school, work, sleep)
Separation Anxiety • Fear of separating from a primary caregiver • Fear of harm befalling a primary caregiver • Worries are overwhelming, disabling, interfere with daily functioning (school, eating, sleep)
Social Anxiety • Fear of interacting with strangers, peers • Fear of performance situations • Fear of humiliation or embarrassment • Excessive worry about being judged or evaluated by others • Avoidance of anxiety-provoking settings • Worries are overwhelming, disabling, interfere with daily functioning (school, work, sleep)
Obsessive Compulsive Disorder
Obsessions: Recurrent thoughts or images that
are experienced as unwanted intrusions
• Violence • Sexual Behavior
• Contamination • Religious
Compulsions: Repetitive behaviors performed in
response to the obsession with the intention of
reducing distress or preventing undesired
outcomes
• Reassurance seeking • Arranging/Counting
• Checking/Re-doing • Hand washingPanic Disorder • Excessive fear of experiencing symptoms of a panic attack • Worry that escape or help will be unavailable in the event of a panic attack – Can be with or without history of panic attacks
Post Traumatic Stress Disorder
• Exposure to one or more traumatic events
• Abuse • Sexual assault
• Domestic violence • Car accident
• Intrusive thoughts about the trauma
• Excessive worry that the trauma will re-occur
• Avoidance of reminders of the trauma
• Feeling tense, stressed, worried, or irritable
• Difficulty concentratingThe Mechanisms of Anxiety
External
event or
situation.
Perceived as Amygdala:
threatening or Fight, flight, Trigger is
dangerous. freeze reinforced as
system anxiety
engaged. provoking.
Think smoke detector:
Adrenaline,
Anxiety Disorder
Noradrenaline, Cortisol:
• Physical
• Fast HR
symptoms
• Fast breathing
• Cognitive
• Blood circulated
symptoms
to essential
• Avoidance
organs
• Disruption
• PerspirationEtiology of anxiety
Genetics Modeling
Parental Adaptive v.
Anxiety maladaptive
coping
Environment Physiology
Safe v. Unsafe Sleep
Trauma v. Stability Brain Exercise
Function
Nutrition
Drugs/alcohol
Development of anxietyTreatment for Anxiety Medication Talk Therapy -SSRIs even more CBT more effective than effective for anxiety than medication. for depression (CAMS, 2008) (JAMA, Bridge et al, 2007) - 50-60% respond - 60-70% respond
Mechanisms of CBT
1) Learn skills to counteract the anxiety
response
• Deep breathing • PMR
• Guided imagery • Problem solving
• Exercise • Humor
2) Learn skills to manage anxious thoughts
“It probably won’t be as bad as I think.”
“I don’t have to be perfect. Mistakes are
okay.”
3) Un-pair the stimulus (trigger) from the
response (anxiety) through
exposure.CBT Overview
Everyone
will think
I’m stupid.
Stay home, Nervous
skip school. EmbarrassedCBT Overview
I don’t care
Correct faulty thinking what other
people think.
More
Go to school. confident.
Expose to Teach
feared situations. relaxation
skills.Where to get treatment? • Primary care provider – referral • Psychological Clinic – UM facility http://www.psychclinic.org/clinical_services/ • CAPS – student services http://www.umich.edu/~caps/ • PES – for emergency situations http://www.psych.med.umich.edu/pes/ • UM Clinical Studies https://www.umms.med.umich.edu/
90
80
70
60
50
40
30
20
10
0
CBT/Sert Sert CBT PboCognitive-Behavioral
Treatment of Social Anxiety
Disorder
Joseph A. Himle, Ph.D.
Joseph Himle, Ph.D.DSM-IV Social Anxiety Disorder
• Fear/avoidance of social situations
• Feared situations avoided or endured with
intense anxiety or distress
• Fear recognized as excessive or unreasonable
• Fear/avoidance interferes with work, social,
family activities
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC,
American Psychiatric Association, 1994.Social Anxiety Disorder
Common Fears
• Participating in small groups
• Eating, drinking, writing in public
• Talking to authority figures
• Performing or giving a talk
• Attending social events
• Working while being observed
• Meeting strangers or dating
• Using public bathroom
• Being center of attentionPrevalence Of Social Anxiety Disorder
20
14.4
15 13.3
Prevalence
(%) 10
4.5 4.9
5
0
General Population* Primary Care**
Lifetime Prevalance One-month Prevalence
* Magee et al. Arch Gen Psychiatry. 1996;53:159.
**Weiller et al. Br J Psychiatry. 1996;168:169.Comorbidity And Social Anxiety Disorder
70
60
50
Lifetime 40
Prevalence
(%) 30
20
10
0
Simple Agora- Alcohol Major Dysthymia OCD
Phobia phobia Abuse Depression
Schneier et al. Arch Gen Psychiatry. 1992;49:282.Treatment Utilization And Financial
Dependency
45
40
35
30
Rate/100 25
20
15
10
5
0
Medical Psychiatric Financial
Dependency
Uncomplicated Comorbid No Social
Social Anxiety Disorder Social Anxiety Disorder Anxiety Disorder
(N=112) (N=249) (N=9953)
Schneier et al. Arch Gen Psychiatry. 1992;49:282.Suicidality In Social Anxiety Disorder
20
15
Rate/100
10
5
0
Suicide Attempt(s)
Uncomplicated Comorbid No Disorder
Social Anxiety Disorder Social Anxiety Disorder (N=9953)
(N=112) (N=249)
Schneier et al. Arch Gen Psychiatry. 1992;49:282.Treatment of Social Anxiety Joseph Himle, Ph.D.
Medication
Selective Serotonin Reuptake
Inhibitors (SSRI)
MAO Inhibitors
Beta Blockers
Benzodiazepines
Joseph Himle, Ph.D.Behavioral Treatment
Exposure Therapy
Gradual confrontation of
progressively more challenging
social encounters
Prolonged sessions (90 minutes)
Frequent sessions (daily is best)
Focus attention on phobic stimulus
End session only when anxiety
improves
Joseph Himle, Ph.D.Common Exposure Tasks
Telephone businesses for hours
Telephone businesses to inquire
about a specific product - Brief---
>Prolonged
Visit stores and inquire about
products -
– Brief ---> Prolonged
Toastmasters
Church Groups
Ph.D.
Joseph Himle,Common Exposure Tasks
(cont.)
Family members
Neighbors
Co-workers (new job - part time)
Volunteer
Speech class
Coffee shops, restaurants,
nightclubs
Joseph Himle, Ph.D.Pitfalls to Exposure
Therapy for Social Phobia
Difficult to carefully grade exposure
- especially later in treatment
Prolonged exposure often difficult
People do not always co-operate
Difficult to consistently end on a
good note
Social skills deficits
Joseph Himle, Ph.D.Behavioral Treatment:
Social Skills Training
Non-verbal social skills
– Personal space issues
– Movement
– Eye contact
– Nods, grunts, uh-huh, yes
– Affect matching
– Grooming, dressing, hygiene
Joseph Himle, Ph.D.Social Skills Training
(cont.)
Verbal skills
– Open-ended questions
– Second questioning
– Managing disagreement
– Controversial topics
– Topics to choose from
• Weather, current event, setting, work,
family
Joseph Himle, Ph.D.Cognitive Therapy of
Social Phobia
Work together to discover errors in
thinking
Respond to inaccurate thoughts
with more reasonable self-
statements
Collaborative empiricism
Joseph Himle, Ph.D.Cognitive Therapy of
Social Anxiety (cont.)
Common cognitive distortions
– Magnification - “It would be horrible if I didn’t
know what to say”
– All or Nothing Thinking - “Why did I say
that… I made a complete fool of myself”
– Mind Reading - “He looked away, he must
think I am weird”
– Fortune Telling - “Why bother to talk to her,
she will just reject me like all the others”
Joseph Himle, Ph.D.Cognitive Therapy of
Social Anxiety (cont.)
Sources of information used to
counter distorted thinking
– Client’s past history
– Others with social phobia
– Others without social phobia
– Behavioral tests
– “Blunder” tests
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