Anxiety Disorders and Anxiety Disorders and AddictionAddiction

Thinking Outside the Medications Thinking Outside the Medications BoxBox

I. Anxiety DisordersI. Anxiety Disorders

II. Influence of Substance II. Influence of Substance UseUse

III. TreatmentIII. Treatment

I. Anxiety Disorders?I. Anxiety Disorders?

include “symptoms of include “symptoms of anxiety, fear, avoidance, anxiety, fear, avoidance, oror

increased arousal”increased arousal”

Major Anxiety DisordersMajor Anxiety Disorders

1.1. Generalized Anxiety Generalized Anxiety DisorderDisorder

2.2. Panic Disorder & Panic Disorder & AgoraphobiaAgoraphobia

3.3. Specific Phobia Specific Phobia

4.4. Social PhobiaSocial Phobia

5.5. Obsessive-Compulsive Obsessive-Compulsive DisorderDisorder

6.6. Posttraumatic Stress Posttraumatic Stress DisorderDisorder

Generalized Anxiety Generalized Anxiety DisorderDisorder

A. Excessive worry A. Excessive worry (apprehensive expectation), (apprehensive expectation), occurring more days that not occurring more days that not for at least for at least 6 months6 months, about a , about a number of events or activitiesnumber of events or activities (such as work or school (such as work or school performance). performance).

B. The person finds it B. The person finds it difficult to difficult to controlcontrol the worry. the worry.

Generalized Anxiety Generalized Anxiety DisorderDisorder

C. The anxiety and worry are associated with C. The anxiety and worry are associated with three (or more) of the following six symptoms three (or more) of the following six symptoms (with at least some symptoms present for (with at least some symptoms present for more days than not for the past more days than not for the past 6 months6 months). ).

(1) (1) restlessness restlessness oror feeling keyed up feeling keyed up oror on edge on edge(2) being (2) being easily fatiguedeasily fatigued(3) (3) difficulty concentrating difficulty concentrating oror mind going blank mind going blank(4) (4) irritabilityirritability(5) (5) muscle tensionmuscle tension(6) (6) sleep disturbancesleep disturbance (difficulty falling or (difficulty falling or

staying asleep, or restless unsatisfying sleep)staying asleep, or restless unsatisfying sleep)

Panic Disorder & Panic Disorder & AgoraphobiaAgoraphobia

A. Both (1 ) and (2):A. Both (1 ) and (2):

(1) (1) recurrent unexpectedrecurrent unexpected Panic Panic AttacksAttacks

(2) at least one of the attacks have (2) at least one of the attacks have been followed by been followed by 1 month1 month (or more) (or more) of the following:of the following:

(a) persistent (a) persistent concern about concern about having additional attackshaving additional attacks

(b) (b) worry about the worry about the implicationsimplications of the attack or its of the attack or its consequencesconsequences (losing control, having (losing control, having a heart attack, “going crazy”)a heart attack, “going crazy”)

Panic AttackPanic Attack• A discrete period of intense fear or A discrete period of intense fear or

discomfort, in which four (or more) of the discomfort, in which four (or more) of the following symptoms developed abruptly following symptoms developed abruptly and reached a peak within and reached a peak within 10 minutes10 minutes::(1) (1) palpitations, pounding heart, palpitations, pounding heart, oror accelerated heart rateaccelerated heart rate(2) (2) sweatingsweating(3) (3) trembling trembling oror shaking shaking(4) (4) sensations of shortness of breath sensations of shortness of breath oror feeling smotheringfeeling smothering(5) (5) feeling of chokingfeeling of choking(6) (6) chest pain or discomfortchest pain or discomfort

AgoraphobiaAgoraphobia

A. Anxiety about being in A. Anxiety about being in places or situationsplaces or situations from which from which escape might be difficult (or escape might be difficult (or embarrassing)embarrassing) or in which or in which help may not be help may not be availableavailable in the event of having an unexpected in the event of having an unexpected or situationally predisposed or situationally predisposed Panic AttackPanic Attack or or panic-like symptoms. Agoraphobic fears panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of typically involve characteristic clusters of situations that include beingsituations that include being outside the home outside the home alonealone; being in a ; being in a crowd or standing in a linecrowd or standing in a line; ; being being on a bridgeon a bridge; and ; and traveling in a bus, train, traveling in a bus, train, or automobile. or automobile.

AgoraphobiaAgoraphobia

B. The B. The situations are avoidedsituations are avoided (e.g., (e.g., travel is restricted) or else travel is restricted) or else endured endured with marked distresswith marked distress or with anxiety or with anxiety about having a Panic Attack or about having a Panic Attack or panic-like symptoms, or require the panic-like symptoms, or require the presence of a companion.presence of a companion.

Specific PhobiaSpecific Phobia

A. Marked or A. Marked or specific fear that is excessive specific fear that is excessive or unreasonableor unreasonable, cued by the presence or , cued by the presence or anticipation of a anticipation of a specific object or situationspecific object or situation (e.g., flying, heights, animals, blood)(e.g., flying, heights, animals, blood)

B. B. ExposureExposure to the phobic stimulus almost to the phobic stimulus almost invariable provokes an invariable provokes an immediate anxiety immediate anxiety responseresponse, which may take the form of a , which may take the form of a situationally bound or situationally situationally bound or situationally predisposed predisposed Panic AttackPanic Attack. .

Specific PhobiaSpecific Phobia

C. The person C. The person recognizes that recognizes that the fear is excessivethe fear is excessive or or unreasonable. unreasonable.

D. The phobic situation is D. The phobic situation is avoided avoided or elseor else endured with endured with intense anxietyintense anxiety or distress. or distress.

E. The avoidance, anxious E. The avoidance, anxious anticipation, or distress in anticipation, or distress in the feared situation the feared situation interferes significantly with interferes significantly with the person’s normal routinethe person’s normal routine, , occupational functioning, or occupational functioning, or social activities or social activities or relationships. Or there is relationships. Or there is marked distress about marked distress about having the phobia. having the phobia.

Social PhobiaSocial Phobia

A. A A. A marked and persistent fearmarked and persistent fear of one or of one or more more social or performance situationssocial or performance situations in in which the person is exposed to which the person is exposed to unfamiliar unfamiliar people or to possible scrutiny by otherspeople or to possible scrutiny by others. . The individual The individual fears that he or she will actfears that he or she will act in a way (or show anxiety symptoms) that in a way (or show anxiety symptoms) that will be will be humiliating or embarrassinghumiliating or embarrassing. .

B. B. Exposure to the feared social situationExposure to the feared social situation almost invariably provokes anxiety, which almost invariably provokes anxiety, which may take the form of a situationally bound may take the form of a situationally bound or situationally predisposed or situationally predisposed Panic AttackPanic Attack. .

Obsessive-Compulsive Obsessive-Compulsive DisorderDisorder

A. Either obsessions or compulsions: A. Either obsessions or compulsions: ObsessionsObsessions as defined by (1), (2), (3), and (4): as defined by (1), (2), (3), and (4): (1) (1) recurrent and persistent thoughts, impulses, or recurrent and persistent thoughts, impulses, or imagesimages that are experienced, at some time during that are experienced, at some time during the disturbance, as the disturbance, as intrusive and inappropriateintrusive and inappropriate and that cause marked anxiety or distressand that cause marked anxiety or distress(2) the thoughts, impulses, or images are not (2) the thoughts, impulses, or images are not simply excessive worries about real-life problemssimply excessive worries about real-life problems(3) the person (3) the person attempts to ignore or suppressattempts to ignore or suppress such such thoughts, impulses, or images, or to neutralize thoughts, impulses, or images, or to neutralize them with some other thought or actionthem with some other thought or action(4) the person (4) the person recognizesrecognizes that the obsessional that the obsessional thoughts, impulses, or images are a thoughts, impulses, or images are a product of his product of his or her own mindor her own mind

Obsessive-Compulsive Obsessive-Compulsive Disorder Disorder

CompulsionsCompulsions are defined by (1) and (2): are defined by (1) and (2): (1) (1) repetitive behaviorsrepetitive behaviors (e.g. hand (e.g. hand washing, ordering, checking) or washing, ordering, checking) or mental actsmental acts (e.g. praying, counting, (e.g. praying, counting, repeating words silently) that the repeating words silently) that the person feels driven to perform in person feels driven to perform in response to an obsessionresponse to an obsession, or , or according to rules that must be according to rules that must be applied rigidlyapplied rigidly(2) the behaviors or mental acts are (2) the behaviors or mental acts are aimed at aimed at preventing or reducing preventing or reducing distress distress or or preventing some dreaded preventing some dreaded event or situationevent or situation; however, these ; however, these behaviors or mental acts either are behaviors or mental acts either are not connected in a realistic waynot connected in a realistic way with with what they are designed to neutralize what they are designed to neutralize or prevent or are or prevent or are clearly excessiveclearly excessive

Obsessive-Compulsive Obsessive-Compulsive Disorder Disorder

B. At some point during the course of the B. At some point during the course of the disorder, the person has recognized that the disorder, the person has recognized that the obsessions or compulsions are obsessions or compulsions are excessive excessive and unreasonableand unreasonable. .

C. The obsessions or compulsions cause C. The obsessions or compulsions cause marked distress, are time-consuming (take marked distress, are time-consuming (take more than 1 hour a day), or significantly more than 1 hour a day), or significantly interfere with the person’s normal routine, interfere with the person’s normal routine, occupational (or academic) functioning, or occupational (or academic) functioning, or usual social activities or relationships. usual social activities or relationships.

Posttraumatic Stress Posttraumatic Stress DisorderDisorder

A. The person has A. The person has exposure to a traumatic exposure to a traumatic eventevent. .

B. The traumatic event is B. The traumatic event is persistently re-persistently re-experiencedexperienced

C. Persistent C. Persistent avoidance of stimuli associated avoidance of stimuli associated with the traumawith the trauma and and numbing of general numbing of general responsivenessresponsiveness (not present before the (not present before the trauma). trauma).

D. Persistent symptoms of D. Persistent symptoms of increased arousalincreased arousal (not present before the trauma). (not present before the trauma).

E. Duration of the disturbance is more than E. Duration of the disturbance is more than 1 1 monthmonth. .

F. The disturbance causes F. The disturbance causes clinically significant clinically significant distress or impairmentdistress or impairment in social, occupational, in social, occupational, or other important areas of functioning. or other important areas of functioning.

II. Influence of II. Influence of Substance Use Substance Use

StimulantsStimulants• Use of Nicotine, Caffeine, Use of Nicotine, Caffeine,

Cocaine, Amphetamine Cocaine, Amphetamine can:can:

– Trigger or worsen anxiety Trigger or worsen anxiety and panicand panic

– Disrupt a regular sleep Disrupt a regular sleep schedule schedule

– Trigger a starvation state Trigger a starvation state when not eating regularlywhen not eating regularly

– Contribute to Contribute to gastrointestinal problemsgastrointestinal problems

DepressantsDepressants

• Use of Alcohol, Opiates, or Use of Alcohol, Opiates, or Benzodiazepines can:Benzodiazepines can:– Initially reduce anxiety, but Initially reduce anxiety, but

cause anxiety to increase cause anxiety to increase over time (“Rebound over time (“Rebound Effect”)Effect”)

– Contribute to Contribute to gastrointestinal problemsgastrointestinal problems

Hallucinogens Hallucinogens

• Use of Marijuana, Use of Marijuana, mushrooms, mescaline, mushrooms, mescaline, or LSD can:or LSD can:

– Induce panic-like Induce panic-like sensations (rapid heart sensations (rapid heart rate, fear/paranoia) rate, fear/paranoia)

III. TreatmentIII. Treatment

Pharmaceutical Pharmaceutical TreatmentTreatment

• BenzodiazepineBenzodiazepine class of medications: class of medications:– Are fast acting, potentially addictiveAre fast acting, potentially addictive– Can lead to development of tolerance, and Can lead to development of tolerance, and

the experience of withdrawal symptoms the experience of withdrawal symptoms when stoppedwhen stopped

• SSRISSRI class of antidepressant class of antidepressant medications:medications:– Block serotonin re-uptake, and are non-Block serotonin re-uptake, and are non-

addictiveaddictive

Pharmaceutical Pharmaceutical ConsiderationsConsiderations

• Medications can mask symptoms Medications can mask symptoms temporarily, without helping to temporarily, without helping to permanently manage or resolve thempermanently manage or resolve them

• Short-term relief can take away the Short-term relief can take away the motivation to do the work and motivation to do the work and discipline of learning & practicing discipline of learning & practicing either resolution or long-term either resolution or long-term management strategiesmanagement strategies

Psychosocial TreatmentsPsychosocial Treatments

1.1. Stress Management Stress Management

2.2. Cognitive RestructuringCognitive Restructuring

3.3. Exposure TherapyExposure Therapy

Stress ManagementStress Management

Lifestyle AnalysisLifestyle Analysis- sleep routine- sleep routine- reduce ETOH and - reduce ETOH and

caffeine usecaffeine use- eat regularly (a state of - eat regularly (a state of

starvation can mirror starvation can mirror anxiety symptoms)anxiety symptoms)

- - exercise!!!exercise!!!

Stress Management Stress Management

Life Problem AnalysisLife Problem Analysis (finances, (finances, raising children, relationships, etc)raising children, relationships, etc)

1. identify problem1. identify problem

2. 2. brainstormbrainstorm solutions solutions

3. evaluate brainstorm list3. evaluate brainstorm list

4. develop an action plan4. develop an action plan

5. re-evaluate plan in an ongoing manner5. re-evaluate plan in an ongoing manner

Stress Management Stress Management

Relaxation TrainingRelaxation Training- Progressive Muscle - Progressive Muscle

RelaxationRelaxation

- Meditation or Deep - Meditation or Deep BreathingBreathing

Cognitive RestructuringCognitive Restructuring

1. Identify 1. Identify distortions in thinkingdistortions in thinkinga) “a) “CatastrophizingCatastrophizing””b) “b) “MagnificationMagnification””c) “c) “Fortune-TellingFortune-Telling””

2. 2. EducationEducation that events not likely that events not likely to happen (reality checking) to happen (reality checking)

3. 3. Counter thoughtsCounter thoughts with evidence with evidence from history, other experiences, from history, other experiences, and behavioral testsand behavioral tests

Exposure TherapyExposure Therapy

• Exposure of an individual to Exposure of an individual to the specific fearful situation or the specific fearful situation or object stressor, as able to be object stressor, as able to be toleratedtolerated

• Gradually activate the anxious Gradually activate the anxious feelingfeeling

• The individual gradually gets The individual gradually gets used to (used to (habituates tohabituates to) the ) the feared situation or stressorfeared situation or stressor

Questions or Comments?Questions or Comments?