Preventing and Treating an Anxiety Disorder
Rachel Pauli: Welcome to today’s webinar, ‘Preventing and Treating an Anxiety Disorder’.
My name is Rachel Pauli, and I will be the host for today’s webinar. We are very fortunate to have Dr. Samantha O'Connell as our presenter.
Dr. O’Connell earned her PhD in Clinical Psychology from Suffolk University and she currently performs neuropsychological assessments for the Integrated Center for Child Development and works as an outpatient therapist for families, couples and individuals across the developmental lifespan, where she specializes in cognitive behavioral treatment.
So without further delay, Dr. O’Connell, I will turn things over to you.
Dr. Samantha O'Connell: Hi everybody! Thank you so much for having me here to talk about something that we all feel, at least from time-to-time, anxiety. Be sure there is, if we did not feel any anxiety at all, it will be really, really unsafe. Anxiety helps us make decisions, which do indeed keep us physically and emotionally protected.
So what we are going to be talking about today though, is when we have those worried feelings and those thoughts that really actually cause us more harm than good.
And often that's happening because these thoughts and these feelings they happen when there really isn't a threat to our emotional or physical safety. Or maybe there is a threat, but it really doesn't necessitate the degree of worry that we are experiencing.
So that's the kind of anxiety that I am talking about. We would never want to have anybody treated for an anxiety after me. We need anxiety. We will talk a little bit more about the biological needs for anxiety and why we need to have it.
But again, it's when it's causing us that distress and disturbance and getting in the way, that's when it might meet the threshold for an anxiety disorder. So, today, let's talk about preventing and treating the kind of situations that might lead to that.
But before I begin, I’d like you all think for a minute about alarm. Let's just get warmed up here in a different way. What kind of alarms do we know about?
Let's just think about different types of alarms. Maybe some of you are thinking about an alarm clock, right? Maybe some of you are thinking about a car alarm, maybe a smoke detector, what do these alarms tell us? Basically, they give us messages to do something. It's a message to get up, move, danger, fire. These alarms keep us doing what we need to do, and there are also messages that absolutely keep us safe. So think about these alarms, right? They give us these messages, they keep us safe, they keep us moving, they tell us to do things.
But now, think for a minute about the times when these alarms have gone out accidentally or when there is no real threat or problem or need to do anything.
Maybe your alarm clock goes off on a Saturday and that is a no workday for you. Does it sound the same? Yes, of course, that loud, annoying beeping, but isn't it great if that goes off and you actually have two more hours of sleep, right? But that's not anxiety.
But, the alarm clock is going off, but you don't really need to get up and do anything, okay. What about that smoke detector? Are any of you are fabulous cooks like me who maybe, just maybe or trying to roast some brussels sprouts but got distracted playing Pokémon, maybe, and that alarm went off? I don't know. But does it sound the same? Yes, loud and annoying beeping. It's not like a lighter tone that tells us, hey! Your cooking really isn't so great! No, it sounds the same as if there actually were a fire in your house. And what about a fire drill? Right? Same exact sound.
So let me bring you back to our topic today. Anxiety is actually our body's alarm. So it's that alarm feeling that we get in a variety of sensations that it's our body saying like, oh, okay, there is danger here, I would need to do something, right? And it keeps the pace, just like those fire alarms do, the smoke detectors, right? We feel anxiety when we see a bear in the woods, so we run, or there is actually a couple of responses, there’s three, there’s flight, fight or freeze. Those are the responses that our anxiety sensor in our brain, our amygdala tells us to do. So we retrieve that in the woods and we fight, probably not recommended, but one response to threat or flee, we run out of there, right? Or some -- we see this actually in nature, that some animals freeze, they freeze up in order to protect themselves.
But basically anxiety is that alarm, it tells us we need to do something. We feel tension when we have to present at work and it helps us, it helps us mobilize around preparation.
Maybe we are in our car and somebody cuts us off and our heart starts beating fast. That alarm is necessary. There is actually some awesome things that our body does when the different parts of the sympathetic and parasympathetic nervous system are activated.
So when we actually perceive a threat, like our seeing actually we get or people dilate and we actually can see better in the dark. However, our blood rushes to either our major muscle groups or internal organs so that if in some accident our limbs were cut off, we will actually survive. I know it's gross, but it's actually kind of cool. These body's super-powers that we have in response to threat. So we need anxiety, we need tension, it’s our alarm system, right?
But, just like my smoke detector in a house, some people’s body alarm is wired to be a bit more sensitive or it becomes more sensitive due to the things that have happened. So we talk about a full-blown anxiety disorder, we are talking about the body’s alarm being overly sensitive. While there is no threat, it actually feels like a threat and it sounds like there is a threat, and just like that fire drill, a fire alarm, or the alarm clock, like the sound, the feel, everything is exactly the same. So people who truly struggle with an anxiety disorder, it actually feels in their body, in their mind, is this the responding to a real threat?
So, it’s hard to figure out that there's not a dangerous threat and it's really hard to change behavior. So we are going to be talking a little bit about these things, but I just wanted to warm you up with this idea, think about anxiety as an alarm, we need an alarm, but sometimes those alarms are a bit too sensitive.
So what are we going to do today? There is a number of objectives that I hope to accomplish with you out today. I’d like to just simply define anxiety and then to cover a little bit more specific. We will talk a little bit about the six specific types of anxiety disorders. I will also discuss causes and risk factors for developing an anxiety disorder, like who gets it and when do they get it, why might they get it, and also my favorite part is, what do we do about it? And I feel anxiety disorder is the most researched emotional problem out there. They have the most empirically validated treatments, what does that mean? EVTs, Empirically Validated Treatments, that means they have been researched a whole lot, we actually know what works and our research is so promising, I love actually treating anxiety disorders because they are some of the most -- there has been so many things that we know work and so it’s really promising and inspiring because the treatments do work. So we will talk a little bit about those, and then we will review some prevention and some reduction strategies for anxiety disorders. Of course, all of us experience anxiety, but anxiety disorders when it’s causing that stress and that disturbance in your life, that’s disordered anxiety, and other interesting thing is that women are also more than twice as likely to have anxiety disorders than men.
We are still trying to figure out why that is, is it that women tend to be more expressive and are talking more about it or as men might be more internalizing as a different thing in them. We don’t really know that yet, but there do seem to be more twice as many women that are likely to have anxiety disorders.
And another interesting thing is that one-half of those diagnosed with depression also have anxiety disorders. You know, anxiety and depression are so intertwined that it really is hard to disentangle it at sometimes, a lot of the time. So, what is anxiety? All right, well, we've already compared it to an alarm and it is an alarm. It’s a reaction, it’s a reaction to a real threat or an imagined threat, but you have to remember that the reactions feel the exact same as if it was a real threat or if it’s not, it’s basically the reaction.
It also works for if we don’t understand we probably criticized along with anxiety. We might say, how could you think that, how could you feel that? So, remember, in their biology, in their mind it is actually feeling like a threat and we are all wired to respond to that threat in a flight, fight and freeze manner. Some people again that wiring has just become a bit sensitive and we wouldn’t criticize our -- well, might be annoyed by our alarms that are a little bit too sensitive or our car alarms that go off, but we think about it in a different way, it’s wiring, and it is much that way with people as well.
In our body, it’s in our mind, it’s a general feeling of uneasiness or dread. Again, it’s a normal response to dangers, threat or extreme stress, and it really is normal and adaptive to feel this uneasiness or dread, but for some of this, this has gone on way beyond being adaptive and it has become a problem, it's really getting in the way.
So let’s talk a little bit about what causes anxiety disorders. There’s a number of bullets here, but we really can subsume them all under the biopsychosocial theory. So bio, the biology, we know that there is a huge link between genetics and biochemistry whereas a person who may have the wiring it’s just more likely to lead to an anxiety disorder. Genetics do seem to play a big role. We know that if you’ve had anxious parents then you are more likely to be an anxious person. Again, we can talk a little bit about your upbringing where you are always exposed to somebody worrying about things, this is how you learned the procedural world, so that could be part of it, but we know even in studies where parents and family members have been separated that there does seem to be a likelihood between genetic offspring that there is more of a likelihood if this anxiety runs in your family.
Some of us are just wired differently, our temperaments are different, we can see in babies and in little children that their regulatory system just might be overactive or more sensitive. We might interpret body signals different. Some people feel up the senses more acutely. Lights are brighter, sounds are louder, some of these are early indications, especially the sound being louder and just more obnoxious to you, but often it’s a little -- one of those little signs we see in children that tends to be kind of a flag for, oh, this person might be at risk with what’s intervene here. So just in our biochemistry we have more of those excitatory synapses. Some of us have these things because of the things we have been exposed to. You know, traumas, different life events.
Sometimes there is more of invisible things that happen within our neuropsychological system, maybe our verbal intellect, it’s a lot higher than our nonverbal intellect. No one knows this, but inside the world can just feel a little bit less predictable which could then lead to just feeling more tension and more anxiety, we have nothing to do with that, it’s a biochemistry.
There is also some idea about personality being a factor here, you know, there is research on the ”Type A” personality that people who seem to have some of these traits, who are very, very driven, even driven to perfectionism they might be more likely to develop anxiety. People with coping skills, those just haven’t learned appropriate coping skills might be more likely as well. Again, there is that upbringing, right? What were you exposed to? What were the messages that you were given? Was your life indeed more unsafe? Because that can have you perceive the world in a way that may be more threatening and that when you're out of that situation that life event still exists, the world is threatening but it might not be, right? It might just be that learning sensitivity. So these are all things that we have to disentangle. And then in the end some of the treatments might actually be the same, but just know that there is no one-size-fits-all for what causes anxiety disorders, it can be biological, it can be psychological, how do you view -- what happens to you, how do you view, why certain things happen the way you do, why they do, and then there is social learning. What are the messages that our life experiences and the people in our life have taught us, the better or worse, they can lead to some tension, and tension and anxiety as well.
And what about life events? We know that some anxiety disorders are highly tied up with life events; traumas, neglect, things like that, and then there is also substance abuse. The use of substances and also the withdrawal of substances can really take on a different form and cause some – be it a trigger for some more serious anxiety disorders. So again, not one-size-fits-all, there is a myriad of things that can cause anxiety disorders.
So what are the different types? So we have kind of come up with a bunch of different categories and I would like to go through each one of these. Again, as we go through these I know often people start thinking, oh, I have that, I have that, that happens to me sometimes. And note that all of us have some of these sometimes from time-to-time. Again, we have to think about, you know, before we go diagnosing ourselves or a friend or a family member, we have to think about the distress and the disturbance. How distressful is this making you feel and how disruptive in your life is it. Those have to be there, the disruption in life before we could actually diagnose an anxiety disorder.
So Generalized Anxiety Disorder, this is where people have excessive, uncontrolled, often irrational thoughts about a number of things. People who have Generalized Anxiety Disorder or GAD anticipate disaster all the time or at least most of the time, and disaster across health domains, might be worried about accidents, terms, messing up, social situations. We will talk more about Generalized Anxiety Disorder because it is one of the more common. But before we do that let's talk a little bit more about some of these other less common that’s so quite prevalent anxiety disorders.
So Panic Disorder; what is a panic disorder? Well, it’s really characterized by people experiencing the sudden unexpected sometimes really out of the blue fear or discomfort in their body. Some of the other anxiety disorders we can say like yeah, okay, scared about social situations or yeah, won’t ever if I play, I don’t play in phobia. But a panic disorder -- the actual fear comes from misinterpreting what’s happening inside your body. Your heart starts racing, you start feeling you are becoming out of breath, shortness of breath, sweating, feeling weak or dizzy, getting tingling, hot flashes, and interpreting those in your mind as this is a threat, this is a danger.
Most people who have panic disorder, in the midst of a panic attack, think they are going to die. Those bodily signals are literally telling you, you are having a heart attack, you are going to die, and it’s kind of so internal, it’s just the wiring has -- the wiring has become very sensitive but what the sensitivity is too is much happening inside your body.
So panic disorder is a really interesting one and the treatments for panic disorder can actually be different than the treatment for other anxiety disorder where we know more about what we are actually trying to avoid or be anxious about.
It’s important to note that many of the symptoms of panic disorder mimic those of heart disease, thyroid problems or breathing disorders. So it is important to rule those things out and many people do find themselves in the emergency room because it really does, feel like a heartattack or something like that.
Another type of anxiety disorder is Obsessive Compulsive Disorder and what this one is, is it’s marked by chronic so happening over time, long lasting disorder where a person has uncontrollable -- that’s a big one there, lost control, the current thought that we call obsession, thoughts that are happening, or you cannot get them out of your head, and again, it’s causing distress and disturbance. You are really struck on a thought and/or a behavior, a compulsion. So we have to complete this urge or repeat this urge over, and over, and over, and over again to the point where it can take a considerable amount of time in your life.
There’s all kinds of Obsessive Compulsive Disorder sort of categories that can be intrusive thoughts about feeling like you are going to harm someone when you won’t, feeling like you are going to harm yourself when you won’t that might be a different type of a mental health issue, feeling like you are going to be infested with germs or bugs if you don’t complete an action.
So the treatments for Obsessive Compulsive Disorder often have some sort of exposure component where a person is exposed to things to learn that actually the worse won’t happen, but again, the treatments are pretty sophisticated and pretty neat to actually to see them work.
Specific phobias are marked by a rational fear. So a person will feel like there is an intense fear. There could be like some -- let’s say someone has a dog phobia, a dog could hurt you but the fear is proportionally greater than the actual danger or threat. So some common phobias are animal phobias, dogs, snakes, but there are also situational phobias like I said, flying, riding on public transportation, going over bridges, or being in places like elevators. But again, while at those situations there could be some danger, the wiring is so sensitive that it’s an intense fiery action that again causes that destruction and that disturbance of your life. Many people just avoid the thing that they are phobic until it causes that major disruption.
I recently was working with a man who had an intense phobia of flying forever and he just didn’t get on flights. He took long trips but then he had a family and he was promoted to a job that had him fly around or that required him to take a few trips per year and he really wanted this job and he wasn’t going to be able to get it, and so only then if he motivates to treat his flight phobia and it works then he was able to move forward. So until that level of distress and disturbance where it peaks, maybe you are not so motivated, right?
Our natural reaction to anxiety is to avoid it. All right? We run away, we get out of there, it doesn’t feel good. Only problem is that it’s perpetuated over-and-over again and we don’t get any other information to suggest, maybe we will be safe because we are struck in that anxiety avoidance cycle. So we’ll talk a little bit more about that.
What’s social anxiety? Well, social anxiety is different from shyness. Right? Shyness is a personality trait -- there is a whole spectrum of being shy, being more introverted, extraverted, but real social anxiety disorder is much like a person with this intense fear of being evaluated negatively, they are going to make mistakes. They are going to be humiliated, embarrassed. There are stops that are distorted, so they are not quite accurate. Everybody will think that I am X, Y and Z, when really that probably isn’t true. So it marks with this very black-and-white thinking about the way that they will be judged and an intense anxiety reaction that goes with that. So people are really uncomfortable in social situations, they avoid social situations, they may spend a whole lot of time after situations, analyzing it, and thinking about all of the flaws; so really focusing on that. And then of course is the physical symptoms like with all of these anxiety disorders of a fast heartbeat, may be some GI issues, muscle tension, et cetera.
Post-traumatic stress disorder is an anxiety disorder that is a reactive disorder, and what that means is, in order to be diagnosed with PTSD or post-traumatic stress disorder, something really bad or dangerous hazard happened to you and you had to have experienced an intense fear reaction. So a lot of people have been involved in traumatic events, think of all of our soldiers and our servicemen and women. Not every one of them develops post-traumatic stress disorder but some do.
And again, there is a whole lot of biological, psychological, social learning factors that could be to who gets it and why. And some of those factors we have no control over. But basically, you have to be involved in a traumatic event where you really felt shock, nervousness, fear, guilt, and some of these situations can be quite non-traditional, they can be situations where you felt like your integrity was extraordinarily compromised.
But what happens is, we all are likely to feel stressed when something really scary or hazardous happens to us, but when it takes on the level of abnormal post-traumatic stress reaction or post-traumatic stress disorder, is it continues and it goes on, and it even increases to the point where life is really disrupted.
A person that has to re-experience the event in some way whether that be through reliving it in our mind or through dreams, those symptoms of hyperarousal feeling really just revved up, even when the situation doesn’t call for it. There is an avoidance of situations that remind you of the traumatic event. So there is a whole bunch of different symptoms that go along with the post-traumatic stress disorder and then it really is often marked with just having these negative thoughts and feelings; and again, really getting in the way of your life.
What is Generalized Anxiety Disorder? So this is -- this is a more common one and it’s often difficult to define because it’s very broad-based. So Generalized Anxiety Disorder is marked by again thoughts, feelings and reactions. The emotional thoughts are having constant worries persistently, feeling dreadful, nervousness, often the person is crying uncontrollably or excessively.
Behaviorally, it can be really hard to concentrate. Thinking about a whole of those things that could go wrong, you might be avoiding situations, a whole lot of situations that make you anxious.
Feeling restlessness and becoming tired. Think about treading water, if you are constantly treading water, your body is constantly working, what’s eventually going to happen? Fatigue.
When a person feels anxious all of the time, it’s bound to take a toll on their system. All of that stress, all of that triggering of the nervous system over and over and over and over again definitely leads to fatigue. So that’s a big factor there.
Physically, it’s often marked by stomach issues, tightening of muscles, tension and then of course, sleep problems and a whole lot of other problems.
So, of course, let’s take a moment, we all feel anxiety, we all feel worries. But, this chart here is to really help you disentangle, all right, what’s normal worry. I said earlier on, and we don’t want anyone to have an anxiety after me, we don’t ever want anyone to not feel anxiety because it biologically keeps us safe, mobilizes us, and there are threats out there, right? But what’s normal worry versus GAD or Generalized Anxiety Disorder?
In normal worry, your worry doesn’t get in the way of your daily activities or responsibilities. Sometimes it trips you up a bit but not in an ongoing way, it doesn’t get in the way. For Generalized Anxiety Disorder, it significantly disrupts your job, your activities, your social life, you are just not able to function the way you would want to.
In normal worry, you can control your worrying, you can sort of put it in its place, address it when needed, but push it aside, compartmentalize it if you will. In Generalized Anxiety Disorder, it feels absolutely uncontrollable. That alarm is going off and you do not know how to shut it off, it constantly feels like there is danger and there is a threat.
For normal worry, your worry is long present, they don’t cause you significant stress. And they maybe like contained a small number of realistic concerns, maybe concerns in our world, concerns about our children, but for GAD, you worry about all kinds of things, and you are constantly, constantly expecting the worst.
So normal worry, your bouts of worrying really only last for a short time period, but for GAD, you have been worrying about things almost every day for at least six months.
So I hope that this chart helps you disentangle a little bit. Normal worry is in all of us, but if you feel like some of your symptoms are crossing over to that other column, there might be time to do something about that.
So let's talk a little bit about strategies to help prevent and reduce anxiety. So one of the first things that's really helpful is knowing your stresses, knowing what triggers your anxiety, and then kind of having some honest awareness, determining how do you react or cope with stress.
Doing things to increase your resilience. This could include surrounding yourself with people who really build you up, who are role models. It could be things like taking care of yourself, giving yourself adequate sleep and nutrition. All of these things can increase your resilience.
Keeping an optimistic mindset, knowing that things are going to happen, but resilience is not just bouncing back but rolling forward when things do happen.
Checking -- if you are having some instant symptoms, checking with your healthcare provider. There are other medical conditions that look like anxiety, hypothyroidism, different things, so of course checking that out first.
Setting boundaries so that you know what you can handle, what you can't. Talking with people about what your boundaries might be. This in a sense, not to avoid the things that make you uncomfortable or upset, but to prevent yourself from becoming so overwhelmed that you get tunnel vision.
Practicing stress reduction techniques such as breathing techniques and mindfulness can really be helpful to some people, and living a healthy lifestyle. We have touched on those. We know that nutrition, sleep, exercising, all of these things, really correlate with people who have fewer symptoms of anxiety.
If you have some anxiety, ask for help. Find a support group, there actually is a lot out there. You can surround yourself with positive people you enjoy and keep that mindset that sometimes life is stressful, it of course is stressful, but trying to practice, thinking about things in another way, really being a detective and gathering the data. I feel fear, feeling like fear, it's I think this is a situation of stress, and I go, to really support that. Take a step back and figure out what's the evidence to support this anxious thought, because really, anxious thoughts are just guesses. They really are guesses. So what we -- what do we have to do? What did we do in -- why didn't I hose down my house when my alarm went off last night? Why aren't we arresting people who just bang into our car and have our car alarm go off?
Well, we stick around and we look for clues, right? So when you find yourself having some anxious thoughts, step back, put that detective hat on and look for some clues, what is the evidence to support this anxious thought, which is just a guess, and what's the evidence that doesn't support it?
So there is a lot of nice little techniques that you can do here, and also, of course, limiting alcohol and caffeine and substance use, is known to be helpful with that.
But if you have found yourself crossing over to the line of, yeah, this feels like an anxiety disorder, there are a lot of different treatments. Some people are truly helped by medications that help reset the regulatory system there, the different chemicals in their brain that lead to that anxiety response.
Cognitive-behavioral therapy is very, very well-researched. In a sense what cognitive therapy does, cognitive-behavioral therapy is that the clinician might ask you to think about the situation and then think about the thought, and then think about the results and feelings.
So I have to give a presentation and everyone is going to think I am a loser, I am only – what we thought of is not a loser if I don't give it. And so my thought is that, my feeling that is anxiety when I think about giving the presentation, so my behavior then is, no, I am not going to give that presentation. Great! I feel better. But I never got anymore data to suggest it, or maybe people won't think I am a loser with my presentation.
So a cognitive-behavioral therapist might start first with those thoughts and help you disentangle what's the evidence for, what's the evidence against, is there another way to think about it, and maybe I’d come to think, oh! Maybe I’ll think I have something good to say, and they still be anxious, and I am most anxious. I give a presentation, maybe I get some good feedback.
Now, I have new data and that might be more likely to stop avoiding. We do know that the more we avoid, the higher our baseline anxiety becomes.
So a cognitive behavioral therapist can help you better understand that relationship between what we think, how we feel, and what we do, that’s highly effective. Many people are also very helped by relaxation techniques, deep breathing, imagery, yoga, all of these things have been supported as validated treatments for anxiety.
So just to remember we all can develop anxiety disorder as they can vary. Symptoms include cognitive effects, difficulty concentrating, falling asleep. They also can be behavioral, impact your life. Learning these strategies can take time to practice, try out those different thoughts for different issues. They may feel uncomfortable, they may not feel like you are broken in shoes, but just like we need to get new shoes because they are not protecting our feet anymore, we need to get new socks sometimes. No, they are not going to feel like yours, but you have to try them on and keep wearing them in order to actually – for them to become part of you, for them to become helpful.
So as with any mental health disorders they are highly treatable which is such a positive aspect of such a silver lining here.