Dr. Michela David's presentation from our recent speaker's event discussing anxiety.

1. Anxiety Disorders
Dr. Michela M. David, Ph.D., C. Psych.
Unit Psychologist, Mood Disorders Research and Treatment Service,
Providence Care, Mental Health Services,
Adjunct Assistant Professor of Psychology and Psychiatry,
Queen’s University

2. Anxiety…
 is a natural response to danger or threat
(real or imagined)
 is necessary for our protection!
 makes us think, feel and behave differently,
almost instantaneously
 narrows our thinking to focus on danger
 prepares the body for ACTION using the
fight or flight response

3. The Fight or Flight Response
 When danger is perceived, the brain
sends messages to the Autonomic
Nervous System (ANS)
 It releases chemicals (e.g. adrenaline),
which prepare the body for action (fight
or flight)
 This results in physical symptoms (e.g.
rapid heart rate, sweating)
 These symptoms may be distressing, but
are not dangerous
 The body shuts off this response within a
few minutes

4. Common Emotional
Symptoms of Anxiety
 Feelings of apprehension or dread
 Trouble concentrating
 Feeling tense and jumpy
 Fear / Dread
 Irritability
 Restlessness

5. Common Physical Symptoms
of Anxiety
 Pounding heart
 Sweating
 Stomach upset or dizziness
 Frequent urination or diarrhea
 Shortness of breath
 Tremors and twitches
 Muscle tension
 Headaches
 Fatigue
 Insomnia

6. Common Behavioural
Symptoms of Anxiety
 Watching for signs of danger (hypervigilance)
 Avoidance
 Excessive planning
 Safety Behaviours (such as taking a friend, sitting
on the aisle, taking medications, etc)

7. Common Cognitive Symptoms
of Anxiety:
 Feeling like your mind’s gone blank
 Catastrophizing: expecting the worst to happen
 What ifs...
 Images are very important in anxiety
(e.g. making a fool of oneself; dying)

8. When anxiety lasts too long…
 Anxiety in the absence of real and immediate
danger is no longer adaptive
 Overwhelming anxiety which becomes chronic
and progressively worse is an illness or
“Anxiety Disorder”

9. Signs of an Anxiety
Disorder
 Are you constantly tense, worried, or on edge?
 Does your anxiety interfere with your daily functioning?
 Are you plagued by fears that you know are irrational, but
can’t get rid of?
 Do you believe that something bad will happen if certain
things aren’t done in a specific way?
 Do you avoid certain situations or activities because they
cause you anxiety?
 Do you experience sudden, unexpected panic attacks?
 Do you feel like danger is around every corner?
 Does anxiety cause significant distress and interference in
your life?

10. Anxiety Disorders: Impact
 Anxiety disorders are the most common mental health
problem
 More than ¼ of the people you know will have some
experience with severe anxiety in one form or another
 Anxiety at its worst severely affects functioning
 The anxiety mind-set is “like a computer virus that
invades your operating system” (Clark and Beck, 2012)
 It can lead to complete disability and confinement
 Anxiety disorders are stigmatized like depression,
mainly because of a lack of knowledge

11. The Anxiety Disorders
 Panic Disorder (w or w/o agoraphobia)
 Obsessive Compulsive Disorder
(OCD)
 Generalized Anxiety Disorder (GAD)
 Social Anxiety Disorder (Social
Phobia)
 Specific Phobias
 Post Traumatic Stress Disorder
(PTSD)

12. Panic Attacks
 Most people experience a
panic attack at some time in
their lives
 The person often feels as if
they are having a heart attack
or have to leave the situation
 Reach peak intensity within
10 minutes, and then turn off
 Distressing and debilitating,
but not dangerous

13. Signs and Symptoms of
Panic Attacks:
„ Palpitations, pounding heart
„ Sweating
„ Trembling or shaking
„ Shortness of breath or smothering
„ Choking feeling
„ Chest pain
„ Nausea
„ Dizziness
„ Derealization or depersonalization
„ Fear of losing control or going crazy
„ Fear of dying

14. Some Common
Panic Attack Triggers
External Triggers:
 Small or confined spaces
 Distance from exits
 Crowds of people
 Dentist offices
Internal Triggers:
 Heart palpitations
 Shortness of breath
 Numbness
 Trembling
 Feelings of unreality

15. Agoraphobia
 Panic disorder can be with or without
agoraphobia
 Literally means “fear of the marketplace”
 Agoraphobia is anxiety about being in places
or situations from which escape might be
difficult or help might not be available if one
has a panic attack
 Many anxiety disorders lead to a fear of
leaving home

16. CBT Treatments for Panic
Disorder Emphasize:
 Learning about how the body responds to anxiety
(e.g. the “flight or flight” response)
 Helping people to understand the thinking
patterns which make anxiety worse
 Leaning to stay in the feared situation and gain
control (exposure)

17. Obsessive-Compulsive Disorder
(OCD)
 Repeated, intrusive and unwanted thoughts
(obsessions) and/or repetitive behaviours or
mental acts (compulsions) in attempts to
neutralize anxiety
 Rituals may be to try to control thoughts (e.g.
hand washing to control thoughts of
contamination)
 2.3% incidence; usually appears age 20-30

18. Treatment for OCD:
 Medications: particularly antidepressants (SSRIs), which
lead to substantial improvement in 40-60% of persons with
OCD
 Cognitive Behavioural Therapy: includes
exposure to feared objects, thoughts and situations ;
cognitive restructuring (e.g. worst thing that could occur…);
response prevention techniques (delay, change or
shorten rituals if they cannot be prevented)

19. Generalized Anxiety Disorder
(GAD)
 excessive and uncontrollable worry about a broad
number of everyday events and activities
 occurs most days for 6 months or longer
 physical symptoms: irritability, sleep disturbance,
etc.
 increased vigilance and scanning
 marked impairment in functioning

20. Worrying is getting worse:
 Society is more anxious than it used to be
 Influence of media and news
 Emphasis on the negative : dirty laundry
 Propaganda
 High stress lives
 Busy society

21. GAD: Incidence, Onset
& Treatment
 5% lifetime incidence; 32% heritability
 peak incidence at age 30-40
 twice as common in women than men
 8-10% prevalence in women age 45 yrs
 most common anxiety disorder in the elderly
 often coexists with depression (39-69%) and
substance abuse
 Most effective treatments: medications (SSRIs;
Buspirone; benzodiazepines); CBT

22. Social Anxiety Disorder
 also known as Social Phobia
 excessive and persistent fear in social or performance
situations
 e.g. fear of being judged negatively, or of making a
fool of oneself
 significant functional disability results from persistent
avoidance

23. Social Anxiety Disorder...
 is the most prevalent anxiety disorder
 is the third most common psychiatric disorder
 typically begins in childhood (14-16)
 may be preceded by a history of shyness
 is a serious condition with a chronic course if left
untreated

24. Kathleen finds it hard to go anywhere in public because she is
self-conscious and feels sure that everyone around her is
watching her intently, even though she knows this is an
irrational thought. She fears that she might meet a person she
knows and be forced to say hello to them. She is not sure that
she can do that. Her voice will shake, her "hi" will sound weak,
and the other person will know something is wrong. Above all,
she doesn't want anyone to know that she is so afraid. She
turns her eyes away from anyone else's gaze and hopes that
she can make it home without having to talk to anyone.

25. Treatment of Social
Anxiety Disorder
 Pharmacotherapy for symptom relief
 Anxiolytics (anti-anxiety)
 low dose antidepressants
 CBT shows best results
 a course of group therapy is very useful
 CBT treatment focuses on more effective coping
and role-playing responses, + gradual exposure to
feared social situations

26. Specific (Simple) Phobia
 excessive and persistent fear of specific
objects or situations that present little or
no actual danger
 Animals: e.g. snakes, insects, mice
 Situational: e.g. flying, going over bridges
 Natural environment: e.g. storms, heights
 Blood-injection-injury: e.g. blood, injections
 Others: e.g. falling down, costumed
characters

27. Incidence and Development
 Phobias are very common, affecting about 12% of
people
 Only disappear 20% of the time w/o treatment
 Phobias develop via three pathways (Rachman,
1976), although many people cannot recall what
precipitated their phobia.
 Traumatic event (e.g. surviving or witnessing a plane crash)
 Observational learning (see mom freaking out when she sees
a spider)
 Information (e.g. warnings on the news, parents being overly
cautions

28. Treatment of Specific Phobias
Pharmacotherapy (symptom relief)
 anxiolytics
CBT is the most effective treatment
 exposure + cognitive restructuring
 Unique case: blood and needle phobias, which are
associated with a rapid drop in blood pressure
 Rx: Exposure + techniques to raise blood pressure

29. Post Traumatic Stress Disorder
(PTSD)
 develops in some individuals following traumatic events (e.g.
war)
 person must have experienced, witnessed or been confronted
with an event or events that involved actual or threatened
death or serious injury, or a threat to the physical integrity of
self or others
 re-experiencing of the traumatic event (flashbacks)
 persistent avoidance of people and places which are reminders
of event
 increased arousal: difficulty concentrating, anger, jumpiness
 lasts more than 1 month (less than 1 month is Acute Stress
Disorder)

30. PTSD Incidence
 1-3.5% lifetime incidence in general population;
women 1.2%, men 0.8%
 incidence is increasing, especially in adolescents
(likely due to increased exposure to violence,
terrorism, etc)
 15% incidence in Vietnam troops
 PTSD is associated with high rate of substance
abuse
 Sexual assault carries highest PTSD risk (60% in
males; 50% in females)

31. PTSD versus Trauma
 Most people who are exposed to trauma do not
get PTSD
 Exposure to trauma can lead to other disorders
as well (e.g. depression)
 Events which are the least likely to occur have
the greatest link to PTSD (Kessler et al, 2005)
 Sometimes PTSD develops in a “straw that broke
the camel’s back” manner

32. Ehlers and Clark:
Cognitive Model of PTSD
 Most comprehensive CBT model of PTSD
 Two processes create perception of threat:
 1. Negative appraisals of trauma and/or its consequences
(e.g. “This means that I will never be a good soldier again”)
 2. Disturbance of autobiographical memory, whereby
memories become disconnected from their context and from
intellectual understanding of the trauma (distorted events persist
as if they were real; e.g. person believes they drove through
flashing light at crossing when there were none)
 These processes are compounded by unhelpful coping (e.g.
thought suppression and avoidance)