ADHD Association of Great Edmonton January 16, 2013

When Anxiety Becomes a

Problem

Dr. Greg Schoepp, Registered Psychologist Division of Clinical Psychology, University of Alberta Hospital

Greg.Schoepp@albertahealthservices.ca

Presentation Outline

• Introduction • Components of Anxiety • Normal vs. Problem Anxiety • Causes of Anxiety • Types of Anxiety • Treatment for Problem Anxiety • Where to Seek Help • Question and Answer time

Anxiety Component Cycle (Craske & Barlow, 2006)

Anxious thoughts about future negative events

Physical arousal and symptoms of tension

Anxious behaviors and attempts to prevent negative events

Anxiety Facts

• Normal

• Adaptive

• Is not dangerous

• Does not last forever

• Is mostly anonymous

When Does Anxiety Become a Problem

• When our minds and body react as if there is danger when there is no real danger

• Anxiety problems are common. One in four adults will have an anxiety issue in their lifetime.

Anxiety BC

Normal vs Problem Anxiety

Normal Anxiety

• Reasonable

• Productive

• Manageable

• Mobilizing

• Specific

• Time-limited

• Age-matched

Problem Anxiety

• Excessive

• Detrimental

• Difficult to control

• Paralyzing

• Pervasive

• Chronic

• Age-mismatched

Can Occur With …

• Anxiety connection with major depression, substance dependance, suicidal behavior

• Coping with substances

• Disruptive behavior (ADHD, defiance, serious rule breaking behavior); Tourettes/tics; learning issues; pervasive developmental issues; other anxiety issues

ANXIETY TYPES

• Selective Mutism

• Separation Anxiety Disorder

• Specific Phobia

• Generalized Anxiety

• Social Phobia

• Panic Disorder

• Obsessive-compulsive Disorder

• Acute Stress & Post-traumatic Stress Disorder

• Anxiety Disorder N.O.S.

Selective Mutism

• Persistent inability to speak in select social settings

• Normal talk in comfortable, secure, relaxed settings

• Up to 2% primary grade children

• Mutism is attempt to manage fear of speaking

• Specific fear or phobia of being heard or seen speaking in certain circumstances

• Cautious in unfamiliar settings perceived as threatening

• Specific SM vs. generalized SM

• Positive relations with peers, academic progress OK

Separation Anxiety “She won’t be there after school…”

• Distress about separation or even threat of separation

• Crying, clinging, pleading, tantrums, somatic complaints

• Nightmares involving themes of death and loss, associated sleep difficulties

• Avoid school, sleepovers, birthday parties

• Frustrated parents

Specific Phobia – “The needle will really hurt”

• Persistent, marked fear of circumstances or situations, i.e., heights, insects, animals, needles or blood, storms, dark, vomiting

• Individual believes dire outcome from contact with object, i.e., contracting illness from injection

• Avoidance, anxious anticipation, or distress in situation interferes in daily routine

• Child may react with crying, tantrums, freezing, or clinging, not always aware fear is unreasonable

Generalized Anxiety “What if…”

• Excessive worries take over thinking

• Excessive worry about multiple topics (work or school performance, friends or family, health, punctuality, catastrophic events; 2) difficulty regulating worry

• Persistent negative predictions and worst case scenario outlook

• (3/6 symptoms) Poor concentration, irritability, restlessness, fatigue, sleep disturbance, somatic symptoms (headaches, stomach aches), muscle tension

• Seek reassurance, avoid or procrastinate, list making, information seeking, refuse to delegate, self-imposed high standards, fear of failure

• Lacks situational specificity

Social Phobia “Everyone will laugh at me…”

• Intense anxiety and distress in social or performance situations where they face unfamiliar people or possible evaluation. Fears of looking foolish, fear negative evaluation from others, humiliation or embarrassment.

• Performance situations – public speaking, eating in front of others

• Interpersonal situations – attend party, phone use

• Physical symptoms – racing heart, blushing

Social Phobia

• Avoidance and playing it safe

• Anxious thoughts about others, They’ll think I’m weird.

• Anxious personal thoughts, I’ll have nothing to say.

• Focus attention on yourself during social situations. Focus on your performance and how anxious you feel and look.

Panic Attack

• Short burst of severe fear that involves sweating, trembling, shortness of breath, dizziness, heart palpitations

• Peaks within 5 – 10 minutes then subsides

• Children who panic are fearful of the bodily changes

• As child ages, may connect symptoms with thoughts of dying or going crazy

Agorophobia

• Anxiety about being places or situations where escape is difficult or embarrassing

• Anxiety about help not available in event of panic attack

• Avoidance or significant distress in situations

• Alone, away from home, public places, driving, open places

Panic Disorder “I’m going to die”

• Misinterpretation of physical symptoms that something wrong or feeling of loss of control

• With or without agorophobia

• Avoid physical activities, avoid certain food or beverages, travel with companion, sit near doors or exits

• Not common until late adolescence (1% general population), very rare before puberty

• Often incorrectly diagnosed in children

Obsessive-Compulsive Disorder “I’ll get germs and be sick...”

• Obsessions - recurrent, persistent, ideas, thoughts, images that are intrusive, regarded as senseless or repugnant

• Dirt and infection, fear something terrible will happen, disease, death, symmetry or exactness, repugnant (sexual, religious thoughts, harming oneself or others)

• Compulsions – relieves distress, repetitive, seemingly purposeful actions performed according to rules, to produce or prevent some further event or situation, mental or observed

OBSESSION

COMPULSION

RELIEF

DISTRESS

Acute & Post Traumatic Stress

• set of symptoms that develop following exposure to traumatic, physically threatening event, witnessed or experienced

• Individual reacted with intense fear, helplessness, or horror

• re-experience trauma; avoidance; and hyperarousal

• Relive or re-experience – nightmares, upsetting memories, act as if trauma happening again, anxiety when reminded of trauma

• Acute < 3 months; Post > 3 months

Viewing The World as Dangerous

• thinking biases - more threatening interpretations of ambiguous situations

• overestimate likelihood of experiencing threatening events in future, overestimating risk

• thinking the worst, catastrophizing

• (children) magical feelings or thoughts – assuming something will happen based on emotions or thoughts

The Anxiety Formula (Chansky, 2004)

Overestimation of threat +

Underestimation of ability to cope =

ANXIOUS RESPONSE

What happened?

My Emotions

My Actions

My Body

My Thoughts

Treatment Components for Anxiety

Relaxation training/Mindfulness

Exposure

Recognize Anticipate Modify

Alternate coping methods

Address anxious thoughts & beliefs

Six Families of Deep Relaxation Smith (2005)

Physical

• Yoga stretching

• Progressive Muscle Relaxation (PMR)

• Breathing exercises

Mental

• Autogenic suggestion

• Imagery or visualization & relaxing self-talk

• Mindfulness

Realistic Thinking

• looking at all aspects of a situation (the positive, the negative, and the neutral) before making conclusions

• Ask yourself

“What am I thinking right now?”

“What is making me feel anxious?”

“What am I worried will happen?”

“What bad thing do I expect to happen?”

Examples of Anxious Thoughts

• “What if I can’t do it?”

• “I’m going to die of a heart attack!”

• “People are going to laugh at me if I mess up during the presentation.”

• “I’m going to go crazy if I can’t stop feeling so anxious.”

• “What if something bad happens to my child?”

Questions to Help with Realistic Thoughts

1. Am I falling into a thinking trap (e.g., thinking worst or overestimating danger)?

2. What is the evidence that this thought is true? What is

the evidence that this thought is not true?

3. Have I confused a thought with a fact?

4. What would I tell a friend if he/she had the same

thought?

5. What would a friend say about my thought?

6. Am I 100% sure that ________ will happen?

7. How many times has _______ happened before?

Questions to Help with Realistic Thoughts cont’d

8. Is ________ so important that my future depends on it?

9. What is the worst that could happen?

10. If it did happen, what can I do to cope with or handle it?

11. Is my judgment based on the way I feel instead of facts?

12. Am I confusing “possibility” with “certainty”? It may be possible, but is it likely?

13. Is this a hassle or truly a horrendous problem?

14. Is there a more rational way of looking at this situation?

Create and Use Coping or Realistic Statements

• “People cannot tell when I am feeling anxious”,

• “This has happened before and I know how to handle it”.

• “There is a chance that I might not do well in tomorrow’s interview, but not performing perfectly on a job interview doesn’t mean I won’t get the job. Even if I don’t get this job, it doesn’t mean I will never get a job. I have always been able to find work.”

Realistic Thinking Example

• Anxious thought (just after a conversation with an attractive looking person)

“He or she didn’t like me. I didn’t know what to talk about. I’m such a loser.”

• A second look …

The Arousal Curve

5

0

10

Anxiety event

Time

Exposure Strategies

• fears faced gradually, slightly difficult to most difficult anxiety exposure

• encourage coping strategies to prolong remaining in situation

• practice and repetition critical

• Individual learns situation is not threatening

• parental involvement critical for children

• specific skills needed to design exposures for target anxiety (e.g. OCD, Social Phobia)

Brenda’s Exposure Hierarchy to feel more comfortable eating in public

• Coffee with co-worker on break

• Go for coffee after movie with girlfriends

• Eat lunch at A&W with friends

• Eat dinner with date at casual restaurant

• Eat dinner at staff Christmas party

• Attend friend’s wedding reception

• Eat dinner at nice restaurant with date

Parent Responses Hirschfield-Becker, D. (2006). Being Brave Program

Unhelpful

• “Oh-no” reaction

• Tensing Reaction

• Escape or avoidance

• Reassurance seeking

Helpful

• “Ho-hum” response

• Relaxation

• Practice staying in situation

• Active coping

Parental Involvement Principles

1. Basic anxiety management skills

2. Helpful vs. unhelpful approaches

3. Gradual exposure ideas

4. Optimistic, coping attitude

5. Relapse prevention ideas

I’m a coping coach!

Seeking Appropriate Help

• Self-help books; websites

• 211 community resource number,

(780) 482-4636 outside Edmonton

• Mental health

• East Edmonton (780) 342-4908

• Northgate Clinic (780) 342-2700

• Northeast Health Centre (780) 324-4027

• Leduc, Sherwood Park, St. Albert, Spruce Grove

Online Resources

• www.anxietyBC.com Comprehensive website about anxiety information, self-help ideas, and when to seek help for adults, parents, and teens

• www.adaa.org Anxiety Disorders of America for information and treatment of child, adolescent, and adult anxiety issues

Seeking Appropriate Help

• Family Physicians Psychiatrists

• Private Psychologists - Psychologists Association of Alberta online referral

search

http://www.psychologistsassociation.ab.ca

• Community Agencies

- The Family Centre

- Cornerstone Counselling

- Catholic Social Services

Further Reading

Discussion

Thank you