Panic disorders with or without agoraphobia
A panic disorder, sometimes referred to as an anxiety attack, is characterized by a heightened state of physiological arousal and extreme anxiety. Often the individual experiences shortness of breath and at times can hyperventilate. Other characteristics can include feeling of doom, chest tightness or discomfort, heart pounding, light headedness, dizzy spells, numbness and tingling, nausea. Individuals frequently go to the ER because they are concerned with heart attacks or other medical problems of an urgent nature. It is important to rule out a medical cause first if that is suspected. Subsequent to the onset of panic symptoms, individuals often worry about having another one. They will avoid situations in which they might experience a panic attack. Very commonly people with panic attacks develop agoraphobia--the avoidance of specific places where having a panic attack may be embarrassing or difficult to leave—which can lead to becoming homebound. The severity and presentation of panic disorder varies between individuals. Panic attacks can be of insidious nature as well—coming on without warning.
Generalized Anxiety Disorder
GAD tends to be a “basket category” for anxiety. It refers to the individual’s excessive tendency to worry about much of anything and everything, often times along with physical symptoms of anxiety and tension. Often the individual is referred to as having a “worry brain”.
Individuals with social anxiety or phobia tend to avoid situations that involve interactions with others. The range of social situations avoided depends on the individual. Some individuals are born with sensitive and shy or slow to warm up temperaments. Others may become socially anxious as a result of adverse circumstances. Often impairment in performance type situations is observed. Performance can be with respect to speaking publicly in front of others, to engaging in what seems like simple interactions such as asking for help in a store or ordering off a menu. Individuals tend to worry that others might be judging them in a negative light.
Extreme fear is experienced in response to specific objects or situations. Categories of phobias include but are not limited to animals and insects (e.g. spiders), situations (e.g. flying), things to do with the natural environment (egs. storms and heights), blood-injection, clowns, etc.
Post-traumatic Stress Disorder
Post-Traumatic Stress Disorder happens to individuals who have been subjected to, directly witnessed, or heard about someone experiencing actual or threatened extreme situations such as death, serious illness, car accidents, physical or sexual violence. There can be one occurrence or repeated occurrences of exposure to these events. People with PTSD may experience intrusive symptoms associated with the traumatic events, e.g. flashbacks or nightmares, a persistent avoidance of situations representing the event, or avoidance of activities or social situations, negative alterations in thinking and moods, being easily startled, hypervigilance or problems concentrating. At times dissociative symptoms occur such as “derealization” and “depersonalization”. Derealization is the experience that one feels disconnected from others or the environment. Depersonalization is the experience one feels as being disconnected from aspects of themselves. For example, one might experience their arm as not being connected to their body despite knowing it is.
Obsessive-Compulsive Disorder or OCVD is characterized by an obsession and/or a compulsion. An obsession is an unwanted, intrusive thought or image that presents over and over. A compulsion is a repetitive behavior that one engages in to avoid or diminish anxiety associated with the worry. Often an obsession will lead to a compulsive behavior even though that compulsion may not be obvious. Typical OCD thoughts and behaviors have to do with fears of contamination, safety, concern of self-harm or of harming others, perfectionism. Excessive handwashing, checking, list making, need for reassurance are common compulsive behaviors. Superstitions, trichotillomania (hair pulling), skin picking, body dysmorphia (which refers to the constant need for improving ones physical appearance) also fall into OCD categories. Although OCD generally has its own course of onset, sometimes it can be triggered or caused by traumatic events in which OCD becomes the source of dealing with the trauma.
The emotion of anxiety contains a cognitive (thought) component, a behavioral component (action vs inaction) and a physiological arousal. All co-occur within a context or environment and can be influenced by changes within that context. Treatment of anxiety disorders addresses all of the emotion components:
1. Finding more adaptive cognitions is key. Through cognitive therapy, the patient learns how they process information in a distorted manner. They can then modify their thinking process to be more adaptive and realistic. Often the individual knows some of their thinking leads to unrealistic appraisal of danger and fear. Teaching ways to manage the distorted thoughts can be helped by a. exposure to the thoughts such as obsessions with OCD and b. some form of meditation, like mindfulness meditation, to train the brain to calm and refocus itself.
2. The behavioral component is addressed by getting the individual to confront actual or imagined situations they avoid in a controlled environment and with the help of the therapist. An example is gradual exposure to social situations in a person with social phobia. In this approach the part of the brain which cannot be convinced by logic (e.g. I know people aren’t judging me but I cannot help but think that), learns through experience the feared situation is actually safe.
3. The physiological arousal associated with anxiety can be managed through relaxation and breathing techniques. Examples include deep breathing and breath awareness (from mindful meditation practices), progressive muscle relaxation. Often exposure to physiological symptoms, particularly with panic disorder, is very helpful to calming the anxiety as a whole.
Medications can address anxiety disorders by reducing the physical arousal and the mental sense of anxiety and apprehension. This will lead to the ability to more clearly and objectively assess the situations, and also the ability to learn the skills practiced in therapy. Medications can also help with depression, which is very commonly associated with anxiety disorders. Medication can also address insomnia, fatigue, and lack of energy, as well as nightmares and flashbacks associated with PTSD.
a. Panic disorder: requires exposure to physiological symptoms. That may range from teaching the individual how to recreate specific symptoms to inducing them to having a panic attack. This allows the individual to gain mastery over their symptoms as opposed to the panic attacks controlling them. Secondly, if the individual is avoiding situations where panic attacks occur, they are instructed to face those situations so they can regain confidence they are indeed safe.
b. Social anxiety or phobia: Requires teaching the individual to face social situations they are avoiding in a stepwise and controlled manner. Sometimes further social skill development is necessary. Role playing social situations in therapy sessions can be beneficial to attaining success in real life. Through these experiences, patient regains the lost sense of control.
c. Post-Traumatic Stress Disorder: In initial stages of treatment, facilitating opening up about the trauma in a safe and accepting environment can be helpful. Eventually exposure to avoided situations that remind the individual of the trauma is necessary. Exposure to the actual memories that elicit emotional responses is critical. The goal is to reduce the intense emotional reactivity to recall of those memories. Imaginal exposure, EMDR, Short-term Dynamic psychotherapy are types of exposure therapies that have proven effective.
d. Obsessive-Compulsive Disorder: Exposure and-Response Prevention therapy has been the effective treatment of choice. The idea is to have the individual “expose” themselves to the avoided worry thoughts while preventing them from engaging in a behavior (i.e. the compulsion) that has served to provide temporary relief from the worry. An example is purposefully creating a situation where the individual believes their hands are contaminated and then preventing them from washing their hands.
e. Generalized-Anxiety Disorder: Cognitive therapy is the preferred treatment. The individual is educating on the adaptive nature of worrying but then learn to tolerate their uncertainty. They also work on correcting distortions in their thinking.
f. Specific phobia: A response hierarchy is developed to help the individual gradually develop greater tolerance for an avoided situation or thing. Exposure to the avoided situation can start out as an “imaginal” one and then proceed to “in vivo” which is in real life.