1. The Nature and Treatment of Anxiety Disorders Dr. Randi McCabe Associate Director, Anxiety Treatment & Research Centre St. Joseph’s Healthcare Assistant Professor, Department of Psychiatry & Behavioural Sciences, McMaster University McMaster Mini Med School

2. Objectives Understand different anxiety disorders Overview of treatment strategies

3. The Case of Jason S. 21-year-old college student referred to anxiety clinic for anxiety symptoms Varsity hockey player Applying to law school Stressful schedule Supportive relationship

4. Case of Jason S. continued… Acute episodes of intense physical symptoms Difficult to maintain daily activities due to symptoms Weight loss 10-15 lbs. Avoidance of a range of activities and situations (e.g., socializing, restaurants, gym) Physical tests negative

5. The Nature of Anxiety and Fear Normal Emotions Purpose Three Components

6. Three Components of Anxiety Physical Feelings Cognition (Thoughts, Interpretations, Images) Behaviours

7. The Physical Component »Increased Heart Rate »Breathlessness »Dizziness »Shaking »Sweating »Unreality/Detachment »Blurred Vision »Blushing »Numbness/Tingling

8. The Cognitive Component »Anxious Thoughts »Anxious Predictions »Anxious Beliefs and Interpretations »Biases in Attention and Memory »Mental Images

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

10. An episode of intense fear or discomfort that peaks rapidly (within 10 minutes) and in which at least 4 of the following symptoms were experienced: palpitations, pounding or racing heart sweating trembling or shaking shortness of breath or smothering sensations feeling of choking chest pain or discomfort nausea or abdominal distress feeling dizzy, unsteady, faint or lightheaded feeling unreal or detached fear of losing control or going crazy fear of dying numbness or tingling sensations chills or hot flushes What is a Panic Attack?

11. o Panic Disorder with or without Agoraphobia o Specific Phobia o Social Anxiety Disorder (Social Phobia) o Obsessive Compulsive Disorder (OCD) o Generalized Anxiety Disorder (GAD) o Post Traumatic Stress Disorder (PTSD) The Anxiety Disorders

12. Prevalence and Age of Onset Avg. Onset Prevalence Panic Disorder late-teens/ mid-30’s1.5 -3.5% Specific Phobia 10 -11.3% situationalchildhood/ mid-20’s natural environmentchildhood/ early adult animal childhood blood/injectionchildhood Social Phobia mid-teens 3 -13% OCD 6-15 yrs M/ 20-29 yrs F 2.5% GAD childhood/ adolescence 5% PTSD any age 1-14%

13. Recurrent, unexpected panic attacks and at least one month of: concern about additional attacks OR...worry about the implications of the attack or its consequences OR...a significant change in behaviour related to the attacks Panic Disorder

14. Anxiety about being in places or situations from which escape might be difficult or embarrassing in the event of a panic attack Examples Enclosed Places Standing in Lines Driving Public Transportation Being Alone Crowds Shopping Malls and Supermarkets Agoraphobia

15. Excessive fear of a specific object or situation causing significant distress or impairment Common Specific Phobias Animals and Insects Blood and Injections Heights Storms or Water Flying Enclosed Places Driving Choking Vomiting Specific Phobia

16. Social Anxiety Disorder (Social Phobia) Intense fear of social or performance situations causing significant distress or impairment Common Feared Situations Parties Meetings Public Speaking Performing Eating, Drinking, or Writing in Public Crowded Places Initiating and/or Maintaining Conversations

17. Obsessive-Compulsive Disorder Recurrent and persistent Obsessions intrusive thoughts, impulses, images and/or Compulsions repetitive behaviours or mental acts Symptoms cause marked distress or impairment Time consuming (more than 1 hour/day)

19. Obsessions Contamination Obsessions Excessive Doubting Need for Symmetry Accidental Harm to Others Aggressive Obsessions Religious Obsessions Accidental Harm to Others Compulsions Checking Washing and Cleaning Need to Ask or Confess Symmetry and Precision Hoarding Repeating Actions or Words

20. Hoarding

21. Generalized Anxiety Disorder 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

22. Posttraumatic Stress Disorder Exposure to a traumatic event Reaction to the event involves extreme fear Symptoms Reexperiencing of the trauma Avoidance of trauma-related cues Numbing of emotional responsiveness Chronic overarousal

23. The Case of Jason S. DIAGNOSIS Jason’s symptoms fit the profile of…. which anxiety disorder?

24. Anxiety and Panic: An Integrated Causal Model Biological Factors Psychological Factors Environmental Factors genetics neurobiology sense of controllability conditioning (learning experiences) cognitions/expectancies of danger anxiety sensitivity stressful life events social pressures to succeed

25. Cognitive Treatments Exposure-Based Treatments Relaxation-Based Treatments Ritual Prevention Applied Tension for Blood Phobia Psychological Treatments Biological Treatments Medications

26. Cognitive Behavioural Therapy COGNITIVE STRATEGIES In anxiety, thoughts revolve around: "probability overestimation” "catastrophizing the consequences” That is people overestimate that something bad will happen, and that when it happens, they will be unable to cope.

28. BEHAVIOURAL STRATEGIES controlled exposure to the feared situation anxiety responses are allowed to "habituate" or decrease without interference teaches the person that the situation is not dangerous, and that anxiety will diminish. Cognitive Behavioural Therapy

29. Medications Selective Serotonin Re-Uptake Inhibitors (SSRIs) Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Fluvoxamine (Luvox) Citalopram (Celexa)

30. Medications Other Antidepressants Venlafaxine (Effexor) Imipramine (Tofranil) Clomipramine (Anafranil) Anti-Anxiety Medications (Benzodiazepines) Alprazolam (Xanax) Clonazepam (Rivotril) Lorazepam (Ativan) Diazepam (Valium)

31. "Of course you're furious over the price of your medication, Mr. Grimwald -that's one of its side effects ”

32. Choosing a Medication Research on effectiveness Side effect profile Previous response to medications Previous response of a family member Additional problems present (e.g., depression) Cost

33. Specialty Clinics Private Psychiatrists Private Psychologists Family Doctor Other Mental Health Practitioners Support Groups Self-Help Approaches Treatment Options

34. The Case of Jason S. TREATMENT What treatment components would we include?