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ABIL ArticlesUnknown author
DEPRESSION
IS PANIC DISORDER A
"MENTAL ILLNESS?"
LIGHT THERAPY AND SEASONAL
AFFECTIVE DISORDER (S.A.D.)
OBSESSIVE COMPULSIVE DISORDER:
THE DISEASE OF DOUBT
PARENTING IN ANXIOUS TIMES
STRATEGIES FOR
CONTROLLING SOCIAL ANXIETIES
TECHNIQUES TO MINIMIZE FEAR
WHY WILL JOHNNY NOT GO TO SCHOOL?
The Anti-Stress Kit
Twin studies are another way to look at the genetics of disease. Knowing that identical twins are genetically the same but non-identical or fraternal twins are only as similar as normal siblings allows researchers to separate out the effects of genes that are passed down from parents to children from the childhood experiences that are also “passed down” in families. Twin studies done in the Department of Psychiatry at VCU by Dr. Kendler and colleagues have shown that, not only do anxiety disorders run in families, but that the main reason for this is due to genetics. However, the genetics of complex illnesses like anxiety disorders are not like that of eye color, where if you inherit “blue eye” gene from each parent then you have blue eyes, but if you inherit one or two “brown eye” genes you have brown eyes. Psychiatric genetic researchers believe that there are many genes that predispose to anxiety disorders only if inherited in some combination. For example, child could inherit some genes for OCD from one parent but not from the other, so that child may or may not develop OCD depending on how many of those genes are necessary for OCD to be manifested. What about the Nurture position? There have been many studies showing that stressful life events (childhood abuse, loss of loved ones, marital conflict, etc) increase the risk of developing an anxiety disorder. In fact, for Posttraumatic Stress Disorder (PTSD), there has to be a serious traumatic event for one to develop this condition. Even twin studies find that genetics does not explain all the differences between who develops an anxiety disorder and who does not. So how can this be reconciled? The way that researchers put together these different pieces of information is by complex illness model. This model states that, for someone to develop an illness like Panic Disorder or OCD, there needs to be a genetic predisposition, serious life stressors, or both. For example, someone could have a very strong family history for anxiety disorders, and therefore have a high likelihood of developing one despite having very few life stressors. For those people with a genetically heightened sensitivity, relatively minor stressors could push them beyond the threshold of becoming ill. On the other hand, someone could also have lived through multiple, overwhelming tragedies and develop an anxiety disorder despite having no family history for one. Most people probably have a combination of both Nature and Nurture working together to produce the illness. Our understanding of the origins of anxiety disorders and other forms of mental illness continues to grow. There are preliminary studies already beginning to point to certain regions of the human genome that may contribute to the genetic risk for Panic Disorder. Other studies are underway searching genes related to other anxiety conditions. Understanding the biologic origins of mental illness will enable researchers to develop better treatments for these and other disorders in the future, bringing greater hope to those who suffer with them and their families.
Jack Hettema, MD, PhD, is an Assistant
Professor of Psychiatry at Virginia Commonwealth University, Richmond,
Virginia. He is the Attending Physician in the VCU Anxiety
Disorders Clinic and a researcher in the area of anxiety disorder genetics
at the Virginia Institute for Psychiatric and Behavioral Genetics at VCU.
ANXIETY IN THE ELDERLY Some anxiety disorders are a residual from an earlier time and some are new in onset. It does appear that traumatic events play a significant role in the development of some anxiety disorders, particularly phobias and more specifically phobias about crime. Women demonstrate higher rates of anxiety disorders than men. The bulk of anxious elderly patients will more likely be seen in a primary care setting than by a mental health specialist. Unfortunately, under presentation by patients and lack of recognition by practitioners leads to under diagnosis and failure to treat. The usual therapeutic approaches are applicable including cognitive therapy, systematic desensitization and biofeedback. Pharmacotherapeutic approaches include a long list topped by selective serotonin reuptake inhibitor antidepressants and benzodiazepine tranquilizers. Care must be taken to guard against side effects, particularly sedation and cognitive impairment.
Dr. Harp is a former President and member of the ABIL Board of Directors. Arnold Schwarzenegger writes in his Encyclopedia of Modern Bodybuilding: "The human body was never designed for a sedentary lifestyle. When we have no physical outlet, tensions build up within us. The body reacts to minor frustrations, such as somebody cutting us off in traffic as life-and-death situations, the 'fight or flight' mechanism is tripped, adrenaline floods our system our blood pressure skyrockets." As such, I think exercise has particular benefits for those of us with anxiety disorders, though it often presents some interesting obstacles to overcome. One deterrent to exercising is that the bodily sensations it generates, namely rapid heartbeat and heavy breathing, are identical to anxiety symptoms. I have had to remind myself at times that these sensations are normal even though I occasionally misinterpreted them as anxiety. The shift from exercise to rest can also be uncomfortable. I’ve experienced anxiety both during exercise and while cooling down; it’s disturbing, but I think that in the end exercise teaches me to manage anxiety symptoms better under circumstances that I feel I have more control over. We know better than anyone else whether we’ve reached our limits or not, when to rest, and when we can push on. Ignoring bodily sensations altogether is a factor for many of us in developing anxiety in the first place. A big part of exercise is getting back in touch with your body. So, you may ask, "Where do I begin?" My advice is to start slow, especially if you have not exercised for quite some time. "Low impact" activities such as walking, riding an exercise bike, or yoga are idea. It's also important to find activities that are convenient and that you enjoy. If you join a gym that's half an hour drive away, or choose to walk only in the park on the other side of town, it’s going to be harder to get motivated! The more fun and convenient an activity you choose, the easier it will be to get going. Having a friend to exercise with helps a lot of people get and stay motivated as well. If you’re having trouble coming up with other ideas for activities, try to think either of something you wanted to try once or something you enjoyed as a child. Another important thing to keep in mind is to set reasonable goals for yourself. Reasonable is the key word here. Most of us are not trying to become professional athletes; we’re trying to become better versions of ourselves. Measure your progress against yourself, not anybody else. One thing I tell myself when I get discouraged in the gym, perceiving someone else as "better" than me is that I’m here for me, first and foremost. Despite the image that the media often projects, we are not all in constant competition with each other. Keep in mind that exercising moderately several times a week is better for you than one really long, intense workout a week. Setting a schedule, such as walking half a mile three times a week, is another good way to start.
In close, here's a little story that I like to
keep in mind when I’m in the gym. I played lacrosse in college. Even though
I was far from the best player, I enjoyed and stuck with the sport for all
but my last year. One day I observed a conversation between two of my
teammates. One fellow was talking to another about his experiences in
weightlifting in high school. The first guy was inquiring if the other had
won any competitions; he asked in turn if the other had been state champion,
regional champion, county champion, or school champion. The second guy
replied "no" each time. The first guy rebuked, "Well, what were you then?"
The other’s reply? "I was my own champion!"
What is panic disorder?
What is a phobia?
What is agoraphobia?
What is Obsessive Compulsive Disorder?
What is Post Traumatic Stress Disorder?
What are the economic costs of anxiety disorders?
What are the common symptoms of anxiety disorder?
How can ABIL help?
"How can children experience holiday stress?" one might ask. After all, isn't a large part of the holiday season devoted to children? Yes, but think back to your own childhood: can you recall the "anticipatory anxiety" surrounding a hoped for present? Disappointment about a gift not received? Envy of your friends' or siblings' toys? Tension reflecting family stress, exacerbated by family get-togethers under strained conditions? Anxiety and worry about the return to school after a long holiday break? The holidays can be an especially difficult time of year for children, particularly if they have a predisposition toward heightened levels of anxiety.
If we, as
parents
(and other relatives), work to manage OUR stress and tension during this time of
year, we will go a long way towards helping our children experience the joys and
wonder of the season with a minimum of distress. Here are nine tips to keep in
mind as
you prepare for the holidays:
8) Tune in to the signs of stress.
Rare is the child who says, "Hey, listen mom. I think I'm having difficulty
coping
with the demands of the holiday season". Parents have to pick up on cues from
other
sources. Keep in mind that certain physical symptoms may be signs of stress:
unexplained aching muscles, neck aches or backaches, pounding heart,
restlessness,
difficulty sleeping, early-morning awakening (with the exception of Christmas
morning!) and,
conversely, trouble staying awake. Other signs include chronic irritability and
nervous habits such as nail biting and hair pulling. If the child begins to
withdraw
from activities they used to enjoy this may also be a red flag. Of course,
suicidal
thoughts or attempts should be treated as psychological emergencies. Seek a
mental
health professional's care immediately. For other signs of stress, talk to your
child
and seek help from a medical or mental health practitioner if needed. Dr. Falk is a licensed clinical psychologist with expertise in the treatment of anxiety disorders. He practices with Dominion Behavioral Healthcare in Richmond, Virginia.
Dealing with a Loved One’s Illness When You
have Anxiety Related Illnesses Because I have generalized anxiety, I expected to do the usual “what ifs”, but for the most part, I used my hard earned skills to not rush to conclusions and deal with one day at a time. When my husband, “Sam”, did return the doctor’s call, unfortunately it was with the message I’d feared for a very long time. My husband’s annual checkup had shown a suspicious spot in one lung and he needed further tests done. “Sam” had been a smoker for years since the age of 14 (he was 54 at the time), only quitting twice for a period of 3 years total. CT scans and biopsies later revealed lung cancer. Since medical checkups are my major problem area for my anxiety, how could I possibly deal with this scenario? I dealt with it exactly the way I have practiced whenever I experience high levels of anxiety. I meditate, pray, rely on friends and church for prayer, write in a journal, and take one day at a time. I also use anti-anxiety medication to help get the anxiety down to a reasonable level. My most difficult times are waiting for results. Most of us with anxiety related problems actually do very well with problems that are real, it’s the not knowing and the waiting to see which way your life will turn that starts the uncontrolled adrenalin flow that is so uncomfortable. 2001 was a grueling year for us with 4 surgeries and chemotherapy for “Sam” and a new job with going back to school for me, not to mention the emotional turmoil of 9/11 and a son working in New York City! But it is 2003 now. I love my new work and furthering my education! “Sam” is well and we are grateful for each day! Those of us with anxiety related problems short-change ourselves when we don’t give ourselves credit for how great and brave we are each day that we face “fear” and go on. We have a tremendous capacity to change that fear into courage! Claire Weekes, MD, says that fear and courage come from the same place, the pit of your stomach. The next time you feel fear in your middle, try turning it into a feeling of courage! Fostering this feeling of courage, along with the prayer support of church and friends, helped me through this very difficult time. Each “well” check up is accompanied by the usual anticipatory anxiety. I’m so grateful to have learned the skills I need and ABIL has and remains a large part of my support system!
DEPRESSION Clinical depression is not a character flaw. It is an illness. It is not simply in our head. Depression may be experienced in different ways. Some people suffer only once in their lifetime due to some situational and transient event. Some never go a day without experiencing some agonizing feelings regarding depression. There are long-term depressions, major depressions that are subject to biological, situational events. Some depressive disorders are not very obvious, such as childhood depression. Sometimes there is a disorder called "SAD" or Seasonal Affective Disorder. In addition to early adolescent or early adult experiences of depression, a cloud and intense overwhelming black feeling may also occur much later in life, such as moving to retirement. Typically, the person who experiences depression has a feeling of loss of energy, fatigue, they feel dragged down or empty. They may feel anxious, there is a loss of interest in pleasurable activities, there is a disturbance in sleep patterns, over-sleeping, frequent waking up in the morning, there frequently is a change of appetite, there can be weight gains and weight losses, there may be recurring thoughts of death, suicide attempts, chronic and ongoing pessimistic, hopeless feelings, feeling worthless, guilty, there may even be memory lapses, a loss of concentration or an inability to make decisions, and sometimes there are physical symptoms or pain, not actually caused by a physical disease, such as, headaches or stomachaches, neck aches, backaches. As noted above, depression can be caused from environmental experiences, chemical and psychological events, and genetics. The cost of being depressed can be quite significant to the overall productivity of the American public. One in nine Americans will have a depressive episode at some time during the year. One in twenty Americans suffer from a depressive episode sever enough to require medical intervention. Twice as many women are currently being treated for major depression than men. Last year, illnesses due to various forms of depression cost the economy approximately $44 million according to a MIT study. Those of us who have not retired also experience that depression contributes to work time and robs us of valuable enjoyment in our ability to experience satisfaction, pleasure, meaning, and connectedness. Depression has been existent and recorded as early as the Roman era. Depression is significantly affected by three types of chemicals located in the brain. These are serotonin, norepinephrine, and the chemical, dopamine. Imbalances in any of these brain chemicals, called neurotransmitters, cause the psycho physiological phenomena of depression. It must be remembered that most human depressions occur for a variety of reasons that include psychological and social ones. Genetics does play a role in passing some forms of depression but is only part of the explanation. It is fairly well documented that identical twins are more prone to have common manifestations of depression as compared to fraternal twins or people in the general family situations. Depression has struck people from all walks of life. It is believed that individuals from less resources and who struggle day-to-day financially are more prone to depression than those with more resources and means. However, this is not to indicate that people with fewer resources are less happy than those with more, only that struggles and stresses sociologically may play a larger role with some individuals than others. There have been famous people who have suffered from chronic depression, which included Abraham Lincoln, Oliver Cromwell, Samuel Johnson, Martin Luther, Vincent Van Gogh, Ernest Hemmingway, Patty Duke, Sylvia Plath, and Mike Wallace, to name only a few. It is good to know that depression is treatable. There are various treatment options available to people who suffer with depression. There are endless varieties of treatment ranging from physical exercise, the use of multiple vitamins, a complete array of psychotropic and electro-convulsive therapy. Newer and more effective medications are frequently flowing onto the market providing many more useful and effective solutions for individuals experiencing different types of depression. It is strongly encouraged that even though a chemical is used as a major means to reduce or clear up the feelings and agony of depression, there is always a need for living healthy lifestyles, eating nutritionally well, sleeping adequately, exercising on a regular basis, and pursuing satisfying activities. Research is now supporting that the power of spirituality and relationships contribute significantly to the overall state of happiness and freedom from impairing depression.
When a person suffers from depression, it takes considerable courage to
recognize
that help is needed. When an individual chooses to reach out for help, once
a good
diagnosis is obtained from a doctor or therapist developing a good clinical
history,
appropriate medications recommended, a careful look at one's total
psychosocial health
profile outline, the healing process then sets in. This is a slow healing
process,
it must take time, patience, support, ongoing care with setbacks and undergirded
with perseverance, determination, belief, faith, prayer and everlasting hope
that a
combination of all chemical, psychotherapeutic, and social caring, there is
light and a
beautiful rainbow at the end.
IDEAS FOR A LESS STRESSFUL HOLIDAY SEASON
IS PANIC DISORDER A
"MENTAL ILLNESS?" One underlying concern seems to be "Am I crazy?", since someone with a mental disorder could become crazy. The fear of "going crazy" from a panic attack is one of the most frequently stated fears of people with panic disorder, and one of the most unrealistic and unfounded fears. In my experience and the experience of numerous mental health professionals, no one has "gone crazy" from a panic attack. There are no documented cases in the scientific literature of someone losing touch with reality or becoming psychotic as a result of a panic attack. Reassuring yourself and believing that you will not go crazy or lose control actually is a useful strategy to reduce the frequency and intensity of panic attacks. A related concern is that, if panic disorder is a mental disorder, then others will associate having panic disorder with being crazy. This is the issue of stigma, the tendency of others to perceive people with mental disorders as being different or less valued. It is important to recognize that mental disorders include a wide array of problems, most of which are not considered mental illnesses by lay people. By definition, I have a mental disorder diagnosis of caffeine dependence (I can tolerate a lot of coffee and go into withdrawal without it). The diagnostic manual for mental disorders also includes dependence on cigarettes (nicotine dependence), and the worsening of physical problems such as ulcers or headaches due to stress (psychological factors affecting physical condition). Clearly, some mental disorders carry little stigma and are well accepted by our society. Panic and phobic disorders, however, are not as well-accepted or understood by our society. Although better accepted than severe mental disorders such as schizophrenia or manic-depression, most of you have experienced negative reactions from people who are uninformed about panic and agoraphobia. They may act fearful of you, blame you for having panic attacks, treat you like an invalid, or wonder why you do not have the will power to "get over it." Unfortunately, our society still imparts some sense of shame to people who have panic and agoraphobia. Because of these negative effects associated with having a "mental disorder," there has been a substantial effort to label panic and phobias as "biologic disorders." Although some of the causes of panic and agoraphobia are biologic, some are psychosocial as well (e.g., learning history, stressors, life changes). Schizophrenia and manic-depression have much stronger biological causes than panic disorder, but this does not reduce the stigma associated with these disorders. By describing panic and phobias as biologic disorders, we hope that others will see these problems as no different than having cancer, heart disease, or any other "physical disorder." Actually, the distinctions between physical and mental disorders has become blurred as biologic causes are found for mental disorders and psychosocial causes are found for physical disorders. Indeed, both biologic and psychosocial factors play a role in nearly all disorders, physical and mental. By trying to re-label panic and phobias as physical disorders, we attempt to avoid the stigma of a mental disorder, but we also perpetuate the idea that mental disorders indicate something bad about a person and indirectly reinforce the stigma of mental disorders. Instead of avoiding the label of "mental disorder," I challenge us to accept and even embrace the idea that panic and phobias are mental disorders. By doing so we can educate others, both by our words and actions, that having a mental disorder such as panic or phobia is no different than having any disorder, physical or mental, and begin to change the beliefs and biases of our society regarding mental disorders.
IT WORKED FOR ME! I started taking yoga in March of this year and my instructor really focused on the proper way to breathe. The focus on proper breathing (smooth diaphragmatic breathing) not only helped the way I practiced yoga, but it also made me think about how my breathing can affect how calm or anxious I feel throughout the day. Even though I don’t have the time to practice yoga every day, I do have the time to take breathing breaks several times a day. Whenever you have a few minutes of "me" time (which is hard when you’re a stay at home mother of two young children), I focus on my breathing. When you really focus on your breath, you can tune out all those other thoughts in your head for just a few minutes which can really make you more relaxed. Over the past few months, I’ve found that it has become easier to control my breathing....to slow it down and make it deeper... to actually control how anxious or calm I feel. We all want to fee "in control" and I believe that if you practice breathing properly, you will not only start breathing correctly without thinking about it, but you will be able to control your breathing when you feel anxious. Try this out... it worked for me! Here’s what I learned in yoga: Start by lying flat on your back. Place your hand on your stomach. Breathe normally and notice whether your hand rises as you inhale. To breathe properly, your stomach area must rise as your diaphragm expands. When you exhale, you should push the air out of your stomach. If only your chest rises, you may be a shallow breather. My yoga instructor said she used to be a reverse breather... her stomach lowered as she inhaled and rose as she exhaled. In yoga we breathe using the three part breath: slowly breathe through your nose and bring the air into your stomach first, then your middle chest and then the upper chest. Then slowly breathing through your nose again, exhale the air out of your upper chest first, then the middle chest and then your stomach. Think of filling an empty glass. You fill the bottom first, then the middle, then the top. When you empty the glass, you empty the top, then the middle, then the bottom. Keep the breath smooth and relaxed and never strain. Try breathing in to a count of five and breathing out to a count of five. As you practice more and more, try breathing in to a count of five and breathing out to a count of ten. Concentrate on the air moving in and out. I found that lying down helped in the beginning, but once you practice enough you can do it sitting or standing as well. Don’t get discouraged if it’s hard at first. It takes a lot of time and practice before it becomes automatic. Try to practice for five minutes twice a day. Be more conscious of how you breathe throughout the day and try this when you feel that tension or anxiety creeping up. For more information, there are lots of books, tapes and internet sites about yoga.
LIGHT THERAPY AND SEASONAL
AFFECTIVE DISORDER (S.A.D.) Typical symptoms of SAD include: Mood disturbance that includes increased sadness, irritability, and anxiety. Increased appetite that includes cravings for carbohydrates and sweets. Sleep and activity changes that include sleep disturbance, lower quality of rest, & daytime fatigue.
Phototherapy, or bright light therapy, has been widely demonstrated to be an
effective treatment for SAD. It has been shown to help suppress the brain’s
secretion of
melatonin. Light therapy requires the use of a very bright light-one that is
approximately 20 times greater than normal room lighting. Daily use,
typically in the
morning, is likely to have the best effect. Light boxes, which are
considered safe when
used appropriately, may be covered by insurance and there are numerous
sources from
which to obtain them. For those who suffer from mild symptoms of SAD, simply
spending
more time outdoors (at least one hour) during the day should help. If
phototherapy
fails to help, an antidepressant drug may prove effective. Discuss your
symptoms with
your doctor and/or mental health professional and for more information about
SAD
and/or light treatment contact: The National Mental Health Association
and/or Society
for Light Treatment and Biological Rhythm.
Living with Anxiety One day out of desperation and exhaustion, he learns some ancient old practices that are believed to be surefire ways to experience peace and rest which will allow him to sleep through the night. He begins this daily self-help prescription: first, there is 10-15 minutes of quiet relaxation; followed by brief readings from any book that encourages reflections and is positive; then a brief journaling in his diary--no more than a page; and lastly, some exercise--aerobics or yoga, taking a ride, a long walk or run, or a trip to the health club.
One week later, he experiences relief. Two weeks later, he begins to feel
revived
and three weeks later, there is peace and hope to cope with the anxiety
still felt and
there are new possibilities and hope that allows him to live happily with
his
anxiety.
Medications Used to Treat Anxiety Disorders Some may wonder why it is important to treat anxiety. People suffering with anxiety are at high risk for another anxiety disorder, depression, substance abuse, and suicide attempts. In addition, these people are high users of health care. Fortunately, anxiety disorders are highly treatable. Treatments for anxiety include psychosocial treatments; examples are cognitive behavioral therapy, exposure therapy, management and relaxation therapy, psychotherapy, and medication therapy. (1) Often the combination of non-medication therapy along with medication is more effective than either therapy alone. The rest of this article will focus on medication therapy. (2) Benzodiazepines are a class of medications that work in the brain at the GABA receptors. Examples include Valium (Diazepam), Klonopin (Clonazepam), and Ativan (Lorazepam). Advantages of using benzodiazepines are that they can be fast acting and are well tolerated. Disadvantages include possible drowsiness and physical dependence leading to withdrawal symptoms. Because of the potential for physical dependence, benzodiazepines are not desirable for those with a history of drug or alcohol abuse. These medications should be used short-term, except in the treatment of panic disorder. Benzodiazepines are used to treat panic disorder, OCD, and PTSD. Selective Serotonin Reuptake Inhibitors (SSRI) are another newer class of medications used for anxiety disorders are well as depressive disorders. They increase the amount of serotonin in parts of the brain. They include Celexa (Citalopram), Luvox (Fluoxamine), Paxil (Paroxetine,), Prozac (Fluoxetine), and Zoloft (Setraline). The advantages of SSRIs are that they are safe and effective for long-term use. They have fewer side effects compared to other classes. Side effects that some people experience with SSRIs are nausea, vomiting, diarrhea, insomnia (especially if taken at night), sexual dysfunction, and weight gain or loss. People can feel badly if they stop taking these medications without “tapering” down the dose. SSRIs take 2 to 6 weeks for their full effect. SSRIs are the first choice for long-term treatment of anxiety. It is recommended to start at low doses and work up to the desired dose. Most side effects go away after a few days to a week. If one SSRI is not effective or causes side effects, one can try another SSRI. SSRIs are used to treat GAD, PD, OCD, and SAD. Tricyclic Antidepressants (TCA) are another older class of medications used for anxiety and depression. Examples include Elavil (Amitriptyline), Anafranil (Clomipramine), and Sinequan (Doxepin). An advantage to TCAs is that they have been studied and used longer than other agents. The side effects can be a disadvantage. They include drowsiness, dizziness, dry mouth, constipation, weight gain, sexual dysfunction and bad heart effects. TCAs take 2 to 6 weeks for their full effect. They have more side effects than SSRIs, but work well to treat anxiety. Many have generic formulations and are less expensive than other classes. TCAs are used to treat GAD, PD, PTSD, and OCD (Anafranil only). There are other antidepressant medications used for anxiety disorders as well. The include Effexor (Venlafaxine), Desyrel (Trazodone), Serzone (Nefazadone), and Wellbutrin (Buproprion). These medications work in the brain by increasing serotonin and norepinephrine. Again they provide more options for treatment to the many patients who need treatment. These tend to have less sexual side effects than SSRIs or TCAs. Like SSRIs and TCAs they take 2 to 6 weeks for their full effect. They can be prescribed to treat GAD, PD, SAD, and OCD. Monoamine Oxidase Inhibitors (MAO-Inhibitors) are an older class of medications used for anxiety as well as depression. The only advantage to this class is that they may work for many people for whom other medications did not work. Examples of MAO-Inhibitors are Nardil (Phenylizine) and Parnate (Tranylcypromine). Disadvantages include they take 2 to 4 weeks to work and patients have to adhere to a strict diet. One cannot eat or drink foods high in tyramine (e.g. aged cheese, red wine, fermented foods) because a food-drug interaction can lead to dangerously high blood pressure and other life threatening events. There can be serious drug interactions with MAO-Inhibitors as well. It is important not to take an SSRI within 2-6 weeks of taking an MAO-Inhibitor. This class of medication is used to treat people with PD, SAD, and PTSD. Beta-Blockers are used often by musicians and those anxious about public speaking. Inderal (Propranolol) and Tenormin (Atenolol) are two beta-blockers. The fact that they act quickly (like benzodiazepines) but are not habit forming, makes them advantageous. They work in the body (not really the brain) to control symptoms of anxiety (racing heart, shaky hands) but do not treat anxiety. These medications should be avoided in patients with different lung problems like asthma. The anticonvulsant (anti-seizure medication) Neurontin (Gabapentin) can be used to treat anxiety. It is not the first or second choice of providers to treat anxiety. However, it is another option for treatment. Neurontin works in the brain by increasing Serotonin and Norepinephrine. A side effect of Neurontin is drowsiness. Buspar (Buspirone) works in the brain to treat anxiety. Its advantage is that it is not habit forming. Patients with GAD may especially benefit from Buspar. The disadvantage is that it takes 2 weeks for its full effect. It is not as effective for those patients who have used benzodiazepines before. Many Americans have turned to alternative medications. St. John’s Wort, Kava Kava, and Valerian have been used. Unfortunately, we have have no information on the safety or efficacy of these substances. There was a recent study with St. John’s Wort and Paxil with patients with mild depression. The St. John’s Wort was not effective. St. John’s Wort is thought to work like MAO-Inhibitors; therefore the risk of food and drug interactions is concerning. The FDA does not regulate alternative medications. So the amount of an ingredient in one pill may be different from the next. In addition, the part of the plant from which the drug is made may not be consistent. My personal view is to avoid self-treatment of anxiety (or any) disorder and to use medications or therapy that have been proven to be safe and effective. It is important for people with anxiety to avoid certain substances and medications. Caffeine is present in many sodas as well as Excedrin, BC, and Goodies powders. Limiting caffeine is crucial. Psuedoephenedrine is a decongestant found in cold medications and in diet pills; it is a stimulant and can worsen anxiety. Theophyline and albuterol are medications used for breathing disorders like asthma; they may worsen anxiety symptoms. Ma Huang is an alternative medication that acts like a stimulant is used for energy or as a diet suppressant. Ma Huang should be avoided as well. Steroid medication like prednisone can worsen anxiety. Patients with anxiety should avoid excess alcohol intake as well.
In conclusion, anxiety is common, it is treatable, and there is hope. Speak
with
your health care provider about what type of therapy is best for you.
OBSESSIVE COMPULSIVE DISORDER: THE DISEASE OF DOUBT In brief, OCD is an illness of repetitive thoughts, ideas, or images ("obsessions") which cause fear or other bad feelings such as guilt. These negative feelings in turn lead to "compulsive" or ritualistic acts or thoughts which help relieve the discomfort. (2) A person with OCD can experience a multitude of obsessions and compulsions. Common obsessions include: fear of becoming contaminated, constant doubt or mistrust of self, need for symmetry, and fear of becoming aggressive toward friends and loved ones. An important part of OCD is that the person experiencing these obsessions knows somewhere inside themselves that these thoughts do not make sense. Although they realize this, they can't seem to get the thoughts out of their heads. Most people have these types of thoughts at some time in their lives, however they tend to easily dismiss them. The person with OCD gets the thought locked in their brain. Typically, in an attempt to make the thought and the anxiety caused by the thought go away, the person with OCD begins to make up rituals designed to reduce the anxiety. Common rituals, usually referred to as compulsions, are: checking to make sure the person didn't hurt someone, won't hurt someone, and has made their home or space safe; over-washing their bodies, hands, and inanimate objects; counting and having numbers which have special significance; making sure objects in their home and workspace are symmetrical.
There are several theories as to why OCD exists, the most common being that
it has
neurobiological roots. There are naturally existing pathways in the brain
that help
people adapt when there is a sense of danger (real or perceived). When a
person
without OCD realizes there is no danger, their fear dissipates. In the
person with OCD,
it is as though their danger sensor is broken and the situation continues to
be
perceived as dangerous. The first are behavioral techniques: exposure and response prevention. Exposure amounts to systematic, gradual exposure to anxiety-provoking stimuli, for example, for a patient afraid of contamination by germs, the exposure trial might involve having the patient clean a toilet without using gloves. Response prevention amounts to helping the patient avoid rituals, such as avoiding hand washing. The rituals, if carried out, usually reduce anxiety. With response prevention, the initial experience is that the patient will encounter considerable anxiety as he or she avoids the ritualistic behavior. Yet, with repeated exposures or response prevention, gradually the anxiety diminishes. This is an emotionally difficult treatment to embark upon, but is one shown to be successful in 65 to 75 percent of patients - given an adequate number of trials, typically 20 to 25 sessions.
Medication treatment has become more successful with the advent of selective
5-HT
antidepressants. These medications are give to OCD patients even if they are
not
clinically depressed. In addition to their antidepressant effects, these
drugs reduce
OCD symptoms directly. Treatment with medications for OCD generally requires
doses
higher than those used to treat clinical depression. Psychotropic
medications are felt
to be effective in 50 to 65 percent OCD cases. Unfortunately, if patients
stop
medications, there is a 95 percent relapse rate; thus chronic treatment is
necessary. In
all likelihood, combined behavioral and pharmacological treatment offers the
best
promise for successful outcome. (4)
PARENTING IN ANXIOUS TIMES I think there are several reasons for our heightened sense of anxiety. First, and most clearly, we have lost our sense of American invulnerability since September 11, 2001. Where we used to feel protected by our history, our strength, our weapons arsenal, and our location between two oceans, we now know we can be attacked and harmed without warning. Second, we are flooded by media reports of terrible events in our country and around the world. Finally, many of the recent events which have provoked national anxiety have occurred here in Virginia, including the crash of the terrorist-commandeered airplane into the Pentagon and several of the sniper killings. Events that take place far away don’t affect us as much; for example, how many of us have known about, much less worried about, the serial killer who has murdered several people over the past year in Louisiana?
We all need to find ways to manage our anxieties, particularly in times like
these.
That is especially true for children, who lack the adult abilities to take
distance
on events and develop and institute a plan to deal with their worries.
Children
experience anxiety without the coping skills we develop as we get older to
manage it.
Moreover, they often feel the anxiety their caretakers feel, without knowing
why they
feel the way they do. What can you do to help your children cope? Here are
nine
ways you can help your children deal with their anxiety in the face of
fear-inducing
events:
PREGNANCY AND PANIC I moved from Richmond, Virginia, to West Palm Beach, Florida during the second trimester, which meant changing doctors. When my new doctor learned of the medications I was taking he became very concerned and started talking about possible birth defects, and how my baby would have to be put on drugs after delivery to deal with the withdrawal. He then rushed me to a hospital in Fort Lauderdale, Florida to begin getting me off the medication. Needless to say, this was all pretty frightening. They proceeded very cautiously because I was pregnant, but within four weeks I was off all my medications. The withdrawal from the medication wasn't fun, but I still don't know how much of that was withdrawal, and how much was pregnancy, and how much was panic. Now here I was in a new city, with no friends or family, pregnant, with no medication. If I could have crawled under the covers and stayed there I would have, but luckily life doesn't work that way. And to my surprise, I was able to handle many new, and possibly difficult situations with ease. I've heard that the hormones your body produces while you are pregnant can block panic, and that may account for some of it. I also discovered that people are extra friendly and forgiving to a pregnant woman, which gave me a great deal of security. I knew that if I was in a line and began to feel panic I could simply ask someone to hold my place while I went to the bathroom, or ask if I could go ahead of them because I wasn't feeling well. By my seventh month I was feeling great. I was experiencing no anxiety, other than the "normal" new mother concerns. The doctor had ordered two ultra sounds, because of the medications, and our little boy looked just fine. And although I realized at this point that I couldn't just order a C-section, I was relaxing more and more about the idea of going through labor. After all, the doctors will only let you labor for twenty-four hours, and I could handle anything for twenty-four hours. I began using the same tools I use to deal with anxiety to prepare for the upcoming event. I used a lot of visualization, and rational self talk, along with relaxation techniques which I planned to use during labor. My husband and I took a Lamaze Course, which I highly recommend for all new parents. The fear of the unknown is hard for me and this course answered a lot of my questions, dispelled a lot of myths, and gave me tools to practice so that I felt more in control of the situation. Being the typical "high anxiety personality" I had my Lamaze bag packed six weeks before my due date. My husband and I practiced our breathing techniques regularly, and we even made up a computerized chart to time my contractions. (The nurses loved it!) At this point I was pretty confident about my ability to handle labor, but I was still trying to figure out how to get out of going through the delivery.
By the ninth month I was more than ready to have this baby. I had gone over
my list
of final questions with my doctor. I must say I was a little disappointed
with some
of the responses I got. I had been told that there was a mild tranquilizer
that
could be given early in labor if the mother was very anxious. As my doctor
knew of my
panic disorder, I asked that this be made available to me if I needed it,
and was
told, "Don't worry honey, everyone's a little nervous before they have a
baby." I
explained my circumstances again, thinking the doctor sees a lot of
patients, maybe he
forgot. He then told me I could go back on my medication if I thought it was
really
necessary. It was lucky for him that I was too big to move quickly, or I
might have
strangled him. After all we went through five months earlier to get off the
medications, and now he changed his mind. I know doctors differ on whether
the antidepressants
and tranquilizers are safe for pregnant women, but I assumed my doctor had
only one
opinion. Labor and delivery were not as bad as I imagined. (And my husband was a fantastic coach, even though he was class clown at our Lamaze class.) I heard so many horror storied, but I found that if I relaxed, used a lot of the same tools we use to deal with panic attacks and anxiety, and if I just went with the contractions instead of trying to control them (that "Control" word again!), time just seemed to slip by. Before I knew it my new baby boy was in my arms and I was officially a MOM.
We brought him home two days later. I had spent so much time preparing for
the
birth, but no one prepared me for the first few weeks at home. Between the
hormones, the
lack of sleep, and the new person who literally depended on me for his
life...I was
overwhelmed and had a lot of anxiety. My Mom stayed with me for the first
week, and
when she left I wanted her to take him with her (she didn't!)! I thought I
was going
to fall apart, but to no one's surprise but my own, I turned out to be a
pretty
good Mom. I still worry about what kind of an example I'll set for my sons...will panic and anxiety be a part of their lives? My husband and I joke that along with saving for their college educations, we are also saving for their therapy. I know that they will probably pick up some of my "high anxiety personality" traits, but I also believe that I am teaching them healthy coping skills to deal with stress. I hear TJ tell Patrick to "Just take a slow deep breath when the blocks fall over, and then start again"; and I hear him tell his friend that "Mom says it is important to face your fears, because they are never as big as you imagine". Having children has been a real blessing for me. I've pushed myself to do things for my sons that I would have done for "just" me. I've become less of a perfectionist (there is no such thing as a perfect parent!). I have also learned not to try and control EVERYTHING. It's not possible with kids, so why try. I've gotten back my sense of humor (which every parent desperately needs at times), but most importantly, it has helped me to reach a long term goal which I set years ago when panic was controlling my life. I wanted to learn how to have fun again. Now when I see the wonderment and excitement in my kids' eyes over their latest discovery, or I sing "Head, Shoulders, Knees and Toes" in my Barney voice in my PJ's at 7:00 a.m., I feel a joy and playfulness I've never known. I'm learning to enjoy each moment, and I'm grateful for the opportunity to see life through the eyes of a child.
STRATEGIES FOR
CONTROLLING SOCIAL ANXIETIES
STRESS BUSTERS Mr. Judge* impressed me as an affable, confident individual on our first meeting. A sales representative for a local manufacturing company, he is a large man with a deep voice and a pleasant smile. However, I was struck by an obvious incongruity as I greeted him in my waiting room prior to our intake interview. I noticed that his handshake was firm but that his hands were as cold as ice and nearly dripping with moisture. During the course of our first session, my initial impression was further altered as Mr. Judge complained of unbearable anxiety when he was involved face-to-face interactions, especially if he was asked a question. He described a stream-of-consciousness in these situations that consisted of constant monitoring of his behavior and physical sensations (“my mouth is dry…did I pronounce that word incorrectly?...my voice just quivered…”) and constant concern that he was being judged negatively. He related a long history of failed attempts to deal with his anxiety through chemical means, including alcohol and benzodiazepine abuse, and outright avoidance. Mr. Judge had a pattern of getting “sick” or oversleeping before important meetings, and this was creating conflict with his new employer. He avoided direct interaction and phone calls, finding ways to conduct business by letter or e-mail if at all possible. If he had to meet with his employer or a customer, he was only able to endure these interactions with great distress. He had recently completed his third residential treatment program for substance abuse and was seeking help through cognitive behavioral psychotherapy. Mrs. Wright* was a petite, neatly dressed and impeccably groomed woman in her thirties who was somewhat embarrassed when asked to describe why she was coming to me for psychotherapy services. With time and reassurance, she was able to describe a problem that she was sure was unique to her and that was causing increasing difficulty in her life. Although she was employed as an executive secretary, she was exquisitely fearful that she might make a mistake when using a pen and paper. Her fear was so great, that she tried to avoid any situation that might involve writing in front of others. Accepting packages at work, filling in forms, taking phone messages, writing checks, and signing charge card slips were activities that prompted a pounding heart, breaking out in a sweat, feelings of choking, hot flashes and trembling and shaking. The list of situations she tried to avoid was growing, as was her fear. Her fear and avoidance were clearly interfering with her ability to do her job, as well as her ability to conduct many routine activities of daily living. Both Mr. Judge and Mrs. Wright suffer from Social Anxiety Disorder (also known as Social Phobia), a common and often chronic disorder that involves overwhelming anxiety and excessive self-consciousness in everyday social situations. It can result in significant impairment in educational, vocational, and social functioning. Social Anxiety Disorder (SAD) differs in important ways from the everyday signs of anxiety that are normal for individuals in performance or evaluative situations. Most readers of the ABIL Newsletter are aware that anxiety, when everything is “working right”, is a helpful emotion that serves to protect us and enhance our performance. Consider the person who has been asked to make a speech or presentation before a group of co-workers. As he or she stands before the group, there may be some awareness of the physical correlates of anxiety, such as muscle tension, elevated heart rate, feeling of dry mouth, and so on. At the same time, anxiety is aiding the individual through elevated energy levels, increased alertness, improved memory and reaction time. As the individual begins his or her talk and the audience “warms to the subject”, the feelings of discomfort diminish quickly and do not interfere with the delivery of the talk. The key to differentiating between normal anxiety in social situations and SAD is this: does the social anxiety cause excessive distress or interfere to a significant degree with goals and objectives? There are three main parts to Social Anxiety Disorder: the physiological, cognitive and behavioral components. The physiological component involves what you feel in your body. This may include pounding and racing heart, muscle tension, dizziness, nausea, tremors, blushing, sweating, gastrointestinal discomfort and diarrhea. About fifty percent of individuals with SAD experience the onset of these symptoms so rapidly as to meet criteria for panic attack. The cognitive component of anxiety involves thoughts and mental images. For individuals with Social Anxiety Disorder, these thoughts often involve negative predictions and evaluations of their own performance (“I won’t know what to say” or “I looked dumb when I did that”) as well as negative thoughts about how others are judging them (“They think I’m incompetent” or “He thinks I’m weird”). The individuals with SAD may also experience worried thoughts and anxious feelings far in advance of an upcoming social event or interaction. Thoughts and worries may be specific and limited in their scope, as in Mrs. Wright’s case, or more broad and general, applying to most social situations the sufferer finds him or herself in. The behavioral component of anxiety refers to what a person does. The person with Social Anxiety Disorder will most frequently attempt to avoid situations that they know will provoke anxiety. Unfortunately, this is only a short-term solution that actually reinforces the anxiety. Once this patter begins, a kind of “snowball effect” takes place. The individual begins avoiding more and more social situations that may cause anxious feelings. Social Anxiety Disorder is the most common type of anxiety disorder and the third most common mental disorder in the population. It occurs more frequently in women than in men, perhaps twice as often, although higher proportions of men seek help for this disorder. SAD usually has its onset in the mid-teen years, but can also begin in early childhood. Many individuals with this disorder report having been painfully shy and inhibited as children. Scientists most often think of SAD as a biopsychosocial disorder that results from a combination of an inherited biological predisposition to elevated levels of anxious apprehension and certain types of life experiences. SAD may begin abruptly, following a particularly stressful or humiliating experience, or it may begin gradually, becoming more and more distressing and debilitating over time. Untreated, the disorder is generally chronic although its severity may fluctuate with life stressors. If you think you may have SAD, contact a licensed mental health professional experienced in the diagnosis and treatment of anxiety disorders. The good news is that research has shown that there are two effective forms of treatment available to help the individual who suffers from Social Anxiety Disorder: medication and a type of short-term psychotherapy. Medications are helpful to many. Physicians have a variety of agents to choose from, including the antidepressants such as selective serotonin reuptake inhibits (SSRIs) and monoamine oxidase inhibitors (MAOIs), as well as drugs known as high-potency benzodiazepines. Cognitive-behavior therapy (CBT) is psychotherapeutic approach with well-documented effectiveness. CBT treatment of Social Anxiety Disorder involves a number of techniques, including exposure therapy, anxiety management training, and cognitive restructuring. CBT is effective in both individual and group therapy modes, but it is easy to see why group therapy is generally the preferred mode: the individual has an opportunity to regularly expose themselves to a situation which can serve as a laboratory for trying out new coping skills. Because of the benefit of regularly meeting in a group setting, support groups can provide a very valuable component of the total treatment plan, especially if the support group member is involved in individual treatment or wants to maintain or extend the level of improvement that they have made through therapy and/or medication. Groups such as those sponsored by ABIL provide an accepting and supportive environment in which individuals with Social Anxiety Disorder can share concerns and strategies for managing anxiety. Group members can “titrate their dosage” of exposure to social interaction in group. That is, they may participate as much or as little as they like. For example, the member might choose to take a big leap and introduce himself or herself and share their goals and challenges right off the bat. If this represents too much of an initial risk, the member might choose to sit back and listen for a few sessions. The group setting and consumer-based nature of ABIL provides an excellent opportunity for the person with Social Anxiety Disorder to gradually build and practice effective social skills. Opportunities for participation in on-going groups, serving as facilitator, or working on the governance of ABIL provides avenues for the SAD sufferer to master their social anxiety and build relationships. ABIL has much to offer individuals with SAD as well as those coping with other anxiety disorders.
*Patients’ identities have been protected by use of pseudonyms and merging
case
details.
The key to the successful outcome of any coping skill utilized is to practice continuously. It is practice; it is not a test. There are no pass or fail criteria. No one is expected to perform any skill comfortably the first time - or even the fiftieth. Walking and bike riding are skills that take persistence, practice and patience. While learning to ride a bike, one keeps practicing and gradually progresses until eventually riding becomes a thoughtless skill. Occasionally you may fall off, but you get back on and keep riding; you never have to start from the beginning again. Learning to use the coping skills is no different. Frequently it becomes hard to remain patient. After all, most people have lived "fearless" up to this point. It is hard to understand. Although it may be important for some to figure out why they suffer from panic attacks, the essential part is doing something about the fear and being able to control it. Unfortunately, there is no overnight cure. Successful recovery depends on motivation and practice and a combination of coping techniques. Panic disorder is very treatable. Nine out of ten people can get better. This is very encouraging. I am continuously in awe of the hurdles and goals I've seen accomplished by people with panic disorder. Watching people face their fears gives me the ultimate high.
This self-doubt comes whenever we change roles in any way and probably the major descriptor here is change. You may wonder if being the family social director and administrator, taxi-driver, arbitrator, chef, seamstress/laundress/maid prepares you well for your new career. The truth is – it does! Arbitrating a family squabble may give you valuable experience in helping others to reach compromise agreements on the job. Planning and budgeting for family meals is good experience for planning a project and working within the corporate budget. Make a list of these kinds of skills, so you can check it against your self-doubts. Accepting a new role also means being seen by others in a new way. Arbitration skills your family may have taken for granted, your co-workers and supervisors may compliment you on. Still, despite everything you can do, there will be the normal anxiety and adjustment that comes from launching yourself on this exciting (yes, exciting) new adventure. Some of the things you might do to help yourself through this time of transition are: First, start slowly. Nobody says you have to start school or a new job full-time. You may choose to work or go to school full-time, but remember part-time could be an option. Secondly, invest in help with housework and laundry, whether you employ your family or whether you hire someone outside the family. Set aside time for yourself and for your family. Part of this time may be used to talk through difficult situations and to divide up new responsibilities while you are making your transition. The rest of the time should be used for sharing and leisure. Take a time management course if you are not particularly well organized. It may also help to take a study skills course if you are going back to school and are concerned about your ability to be a student again. Get a new hairstyle or outfit or other pick-me-ups so that you know you look your best. Look for things that are easy care, whether they are hairstyles or clothing. This will be a time and energy saver.
Finally, recognize that there will be a period of adjustment and take
measures to
take care of yourself. Plan to put off major projects so that you are not
making any
other major changes at this time. Be prepared that there is an adjustment
for
everyone in your family. Keep your sense of humor. A time of change is a
time of growth and
readjustment. Recognize the humor and excitement in making this change.
Usually the times that food screams the loudest are when I’m tired or sad or just generally stressed out. Sometimes I say a firm “NO”; other times I meekly give in, almost as if a piece of me cannot live without it. This is the time of year when the urge and the urgency kicks into high gear. It will soon be summer and that means bathing suits, slim bodies, and dark tans ~ for some. For others it means resolving to give up sweets (or food in general) in order to lose that “however many” pounds before the warm weather. It is no accident that the moment one decides to starve herself, the urge to eat something becomes more urgent. If we look at that urge and urgency from a basic learning point of view, we may see some logical reasons for its intensity. First look at the role food plays for a compulsive eater and why. In our society, food is love. When a child has been “good”, she is rewarded with a cookie; when tears come, she is given a lollipop; when she gets older, boxes of candy and special dinners are given as tokens of love. Once this person learns that food makes her feel better (quickly), food is going to be the anesthetic she reaches for almost instinctively. There are many pieces involved in escalating the urge and urgency cycle. A complete piece of this cycle is deprivation which can be emotional or physical and does not have to be consciously realized to be causing urges for food. Emotional deprivation indicates that one is not taking care of her emotional needs for nurturing: an emotionally deprived person is likely to be non-assertive, feel misunderstood, and probably does not know how to nurture herself in ways other than with food. That deprived feeling, which all of us experience on occasion, I call a “frayed end”. When a boss yells and an employee feels she must take it, there are bound to be feelings of hurt and helplessness; these feelings cause a frayed end. If someone forgets a special occasion and the forgotten person is feeling that she has no right to mention it, that too, is a frayed end. Those frayed ends nag at us, very subtly, until suddenly we are pulling into the store or opening the refrigerator door to anesthetize them. Psychologist Fritz Peris suggested that humans have a need for closure, for finished business. Part of his work expanded on the Gestalt psychologist theory that incomplete “Gestalten” causes psychological energy to be spent smoothing or trying to complete events. With that in mind, it is possible that it is not the peanut butter cups that are screaming from the shelf but |
