Lecture 8 - Anxiety Disorders I PDF

Anxiety Disorders I: Introduction and Generalized Anxiety Disorder Geneviève Trudel, PhD Candidate University of Ottawa Reminders • In-person midterm – October 19th • Thanksgiving Monday – October 9th ; Class is cancelled • Midterm questions (DEADLINE OCTOBER 5TH) https://uottawapsy.az1.qualtrics...

Anxiety Disorders I: Introduction and Generalized Anxiety Disorder Geneviève Trudel, PhD Candidate University of Ottawa Reminders • In-person midterm – October 19th • Thanksgiving Monday – October 9th ; Class is cancelled • Midterm questions (DEADLINE OCTOBER 5TH) https://uottawapsy.az1.qualtrics.com/jfe/form /SV_0Vxthdq4U26O9j8 Recap from last lecture • Mood disorders II: • Bipolar and related disorders • Any question, comments, reflections? Outline • Introduction to anxiety • General treatment strategies for anxiety • Generalized Anxiety Disorder Anxiety What is anxiety? • Fear: Immediate emotional alarm reaction to present danger or life-threatening emergencies • Anxiety: a mood state that follows from apprehension about (potential) negative future outcomes • Anxiety is future-oriented; anticipating a future negative event • Panic: sudden overwhelming fear or terror • Panic attack: fast onset of panic that includes intense physical symptoms • Is unexpected Is anxiety good or bad? Anxiety serves an important function in our lives. • A moderate level of anxiety is helpful by motivating action and increasing concentration • Anxiety can help us avoid potential threats through problem solving • Too much anxiety can be harmful • Many of life’s most important moments (e.g. weddings, first dates, starting school) involve some degree of anxiety/excitement Accurate alarms are useful while false alarms are unhelpful: unwanted anxiety is like a false alarm Anxiety is a symptom that characterizes many mental disorders 1. Anxiety Disorders 1. 2. 3. 4. 5. Generalized Anxiety Disorder Social Anxiety Disorder Separation Anxiety Disorder Specific Phobia Panic Disorder 2. Obsessive-Compulsive Disorder 3. Post-Traumatic Stress Disorder 4. Illness Anxiety Disorder Causes and prevalence Present moment Birth Psychological factors Social factors Evolution Social, cultural, historical forces Genetics Developmental factors Biological Factors Time Mental disorder Evolution has favored humans who are threat sensitive Social/cultural forces have contributed to anxiety Biological causes • Two major neural circuits control anxiety • Fight or flight system • Panic response to a perceived threat • Corticotropin-releasing factor (CRF) stimulates the hypothalamic–pituitary–adrenocortical (HPA) axis • Leads to specific physiological change (e.g. increased heart rate) • Behavioural inhibition system • Freeze response • Another physiological response to threat • Signals our bodies to stop and evaluate the situation to determine the threat • Which circuit gets activated (and by which threats) is an ongoing area of research Environmental causes of anxiety • Developmental factors • Predictable childhood environment • Parental strategies: allowing children to explore and make mistakes while maintaining a safe environment • Social learning (from parents) that worry is useful • Note possible gene-environment correlations: anxious parents create environments that might enhance anxiety while also passing on genetic vulnerability • Psychological factors • A need for control • Avoidance perpetuates anxiety • Social: Stressful life events can trigger anxiety • Early negative experiences (e.g. dog phobia scary encounter) • Examples: marriage, divorce, school, work, health Anxiety is the most common mental health concern globally Anxiety is the most common mental health concern globally • 8.6% of Canadians aged 12 and over have a diagnosed anxiety disorder (Canadian Community Health Survey, 2016) • According to large population-based surveys, up to 33.7% of the population are affected by an anxiety disorder during their lifetime1 • Anxiety disorders are highly comorbid with other mental health problems • 31% of Canadians diagnosed with a mood disorder have been diagnosed with an anxiety disorder • Up to 50% comorbidity between anxiety and depressive disorders over a lifetime 1Bandelow, B., & Michaelis, S. (2015). Epidemiology of anxiety disorders in the 21st century. Dialogues in clinical neuroscience, 17(3), 327. General treatment guidelines across anxiety disorders Common techniques used across anxiety disorders: • Exposure therapy • Relaxation techniques • Existential techniques • Cognitive-behavioural strategies • Most anxiety disorders are characterized by avoidance, which worsens the anxiety • Exposure is about facing the fear directly Exposure therapy • Many different types of exposure • Imaginal exposure • In-vivo (real-life) exposure • Interoceptive (physical sensations) exposure • Virtual reality exposure • Exposure is often gradual and based on a list of items that clients agree too • Compared to “flooding” (exposing someone immediately to extremely distressing stimuli) “Riddikulus” Can you see any challenges when conducting exposure therapy? Why does exposure work? Reason 1: Habituation Why does exposure work? Reason 2: Inhibitory learning Relaxation techniques • Learning relaxation techniques can help people learn to calm their anxiety • Meditation and/or relaxation breathing • Many types of meditation • Often with a focus on slow deep breaths and concentrating on the present moment • Grounding exercises • 5-4-3-2-1 activity • Using your senses to return to the present moment https://www.youtube.com/watch?v=inpok4MKVLM Existential approaches to anxiety • Rather than focusing on specific strategies to manage anxiety, existential approaches focus on finding meaning in life despite unfortunate truths • Examples • How can we live well despite not having full control over our situations? • What makes a life meaningful? • How do we cope with the inevitable fact that we will die? • Existential approaches often apply philosophical principles to guide existential questions • Stoicism: achieving happiness through cultivating virtues (not material success) and accepting the present moment as it is, regardless of the pleasure or pain it brings Medications for anxiety • Benzodiazepines • • • • • E.g. Xanax, Valium, Ativan Fast-acting central nervous depressant that affects the GABA system Provide effective relief from anxiety, but can be addictive Can be prescribed for managing short-term crises (with caution) Not recommended for managing anxiety in the long-term • SSRIs • Often referred to as “anti-depressants” although are also helpful at managing anxiety • The recommended first line medication treatment for anxiety • Takes several weeks to notice a different Generalized Anxiety Disorder DSM-5 Criteria: Generalized Anxiety Disorder A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). B.The individual finds it difficult to control the worry. C.The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Note: only one item is required in children. 1. Restlessness or feeling keyed up or on edge. 2. Being easily fatigued. 3. Difficulty concentrating or mind going blank. 4. Irritability. 5. Muscle tension. 6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). D.The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. E.The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). F. The disturbance is not better explained by another mental disorder Case Example : Bruce • 67-year-old man • Reports worrying all the time about “everything under the sun”. • He reports trouble sleeping at night because he “worries about his day, his future, his family” • He reports that when he worries, he is irritable, has trouble concentrating, and has significant back and muscle tension. • He reports having always been a “worrier” but that since his husband was diagnosed with cancer two years ago, he has been worrying significantly more. Prevalence • 3% of the Canadian population at a given time • 9% lifetime population • GAD tends to be less severe and debilitating than other disorders, which may prevent people from seeking treatment • 10% of patients at anxiety clinics have GAD; compared to 30-50% for panic disorder • GAD patients often present to their family doctors for treatment • Most common in people over 45 years old CBT model of GAD There are 4 notable features that distinguish people with GAD: 1. 2. 3. 4. Intolerance of uncertainty Positive beliefs about worry Poor problem orientation Cognitive avoidance Treating intolerance of uncertainty • People with GAD avoid uncertain situations and believe that they cannot handle them • Behavioural experiments can test beliefs about the need for certainty • Exposure to situations that lead to uncertainty: • Can lead to habituation (lower anxiety after each practice exercise) • Can lead to the ability to tolerate feeling anxious (“I can do this even if it makes me feel anxious) Treating positive beliefs about worry • Clients with GAD often believe that worrying is necessary and beneficial • Involves discussing the pros/cons of worrying and challenging these positive beliefs • Examples: • Do you actually solve your problems by worrying, or are you just going over the problem again and again in your head? • Has excessive worrying about this topic impacted on your relationships with your family or friends? • Has your excessive worry led to high levels of stress and fatigue? • Do you know anyone who is successful at work and who is not a worrier? Treating poor problem orientation • Many people with GAD use ineffective problem solving strategies, which worsens their anxiety • A component of CBT for GAD is teaching effective problem solving skills • Also involves reframing problems as inevitable aspects of life and that problems can also be opportunities to learn and grow Treating cognitive avoidance • People with GAD try to avoid thinking about unpleasant thoughts and emotions • Invisible strategies: suppressing thoughts • Overt strategies: avoiding certain situations (e.g. school) • Avoidance makes anxiety worse: the more we try to repress our thoughts, the more they come back (e.g. white bear experiment) • Imaginal exposure: imagine making a mistake at work and sit with the anxiety (without doing avoidance strategies) • Write out a “worry script” that describes the worst case scenario Summary • Introduction to anxiety • Fear, anxiety, panic • The role of anxiety • Causes and prevalence • General treatment strategies for anxiety • Exposure and relaxation training • Medications: benzodiazepines • Generalized Anxiety Disorder • Intolerance of uncertainty • Positive beliefs about worry • Poor problem orientation • Cognitive avoidance