Layout of Talk

To explain briefly the mood system in the

brain; and its various functions

To examine the world of Toxic Stress

Acute anxiety (panic attacks and phobias)

Chronic anxiety (Post Traumatic Stress

Disorder, OCD and General Anxiety

Disorder)

The Brain

Is composed of right and left hemispheres

The Mind is a function of the Brain!

We all have an emotional and a logical

brain

Most psychological illnesses are due to a

breakdown in communication between

both

Our Mood System (FLAG) – the

Neuroscience

Is composed of:

Frontal Mood dep’t (our logical brain)

Limbic Mood dep’t (our emotional brain)

Adrenal stress gland and

Glucocortisol – our stress hormone

The first letters make up the word FLAG

Is responsible for our mood; behaviour; and responses to stress and anxiety

Frontal Mood Dept. (Pre Frontal

Cortex) – ‘Logical Brain’

Rational, logical, problem solving

Creative, analytical, planning, short term

memory

Creation and cognitive control of mood

Control of behaviour, particularly

impulsive, self destructive behaviour

Control of our social relationships and

empathy

The Logical Brain (PFC – Frontal

Mood Dept) The Logic Box – in charge of planning and decision making

The Emotional Control Box – in charge of monitoring and modifying emotions (suicide centre)

The Social Control Box – in charge of empathy and making sense of our whole social world

The Attention Box – in charge of focusing attention on our emotions linking them with thoughts and physical reactions to our emotions. It is also where we reappraise emotions – vital for all forms of talk therapy

Limbic System – Emotional Brain

Stress Box (Amygdala) - controls our stress

system, is involved in our processing of

emotions (particularly negative ones) – this is

the heart of the emotional brain and the key

player in anxiety and depression

Memory Box (Hippocampus) – involved in the

creation, storage and retrieval of memories

Pleasure Box (Nucleus Accumbens) – involved

in the enjoyment of food, sex, alcohol

Logic versus emotions

Many assume that our logical brain is more powerful than our emotion brain

In practice there are more connections and pathways emanating from our emotional brain to our logical brain than in reverse

So our lives are ruled more by emotion than logic

Every decision we make each day is made with emotion and logic combined in the dance we call life

Logic versus emotions

When well our emotions and logic are in

harmony

When unwell our negative emotions

overwhelm our logic brain – and classical

examples are anxiety and depression

One of the ways in which our emotional

and logical brains are connected by our

three big mood cables

Functions of the Mood Cables

Serotonin Cable – involved in mood; sex;

sleep; appetite; memory; impulsive

behaviour

Noradrenalin Cable – involved in energy;

sleep; drive; concentration

Dopamine Cable – involved in our sense

of enjoyment of food; sex and anything

else that gives us pleasure

Acute Stress

Dry mouth, stomach in knots, heart

thumping, sweating, mind becomes alert

and vigilant

Fight or flight!

Fuelled by Adrenalin and Noradrenalin

Usually of short duration

Chronic Stress

Fatigue, reduced concentration, sleep

difficulties, reduced interest in food, sex

and drive

Increased feelings of anxiety and

impulsive behaviour

‘Tired but wired’

Fuelled by high glucocortisol levels

Usually of longer duration

What is Toxic Stress?

This relates to where stress becomes so persistent and pervasive that we begin to develop physical and psychological consequences

It is probably the greatest single treat to the physical and mental health of our people

Is a talk on its own – if you want to learn more then read:

Anxiety

Best defined as an uncomfortable state of

hyper-alertness due to fear

Is a normal human emotion

Feelings of anxiety are normal under

threat; and physical change are a normal

part of the anxiety response

Avoidance and safety behaviour are a

normal reaction to anxiety

Anxiety Disorders

Panic attacks/Panicky symptoms - acute

anxiety

Phobias – acute anxiety

Post Traumatic Disorder - chronic

Obsessive Compulsive Disorder - chronic

General Anxiety Disorder - chronic

Acute Anxiety Disorders

Panic attacks/Panic disorder (anxious

about anxiety)

Panicky feelings (anxious about

something)

Phobias (fear of exposure to a thing or

situation where one runs the risk of

becoming incredibly anxious)

Panic Disorder

Affects about 150,000 people in Ireland each year

It is defined as a condition where a person suffers from: recurrent panic attacks where they spend a lot of time worrying about the recurrence of such attacks

and who can clearly identify the first episode from which future episodes emanate

Panic Attacks

Commoner in women

Up to 8% of the population will have at least one episode in their lives; only 5% are recurrent

Commonly associated with general anxiety, depression and addiction

Can occur in any situation or at any time

The fear of getting them (panic disorder) is as big a problem as the attacks themselves

Are caused by acute inadvertent ‘firing of our stress system’ – an Adrenaline rush

Panic Attacks - anxiety about

anxiety

Sweating, palpations, dry mouth,

weakness

Chest pains, hyperventilating, headaches,

Shakes, choking, stomach in knots

I’m going to get a heart attack, stroke,

make a fool of myself, run amok or die!

No ‘obvious’ trigger

Panic Attacks

They are triggered by the emotional brain feeling anxious and it’s stress box advising the adrenal gland to produce adrenaline

And then the same emotional brain misinterpreting the subsequent physical symptoms

Encouraging the adrenal gland to produce a major burst of adrenaline

Triggering the full blown panic attack

Panic Attacks

Initial symptoms (trigger) are simply symptoms of anxiety

We interpret them as ‘dangerous’

Demand they ‘stop’

This makes us more anxious

Triggering a panic attack (severe symptoms of anxiety!)

We then use ‘safety behaviour’ (breathing exercises; A/E; tranquillizers etc)

ABC of a panic attack

A – initial physical symptoms (heart going

quickly or sudden difficulty breathing etc

Danger – I will go mad, have a heart

attack, stroke, die, run amok

B – these physical symptoms must go

away

C – emotion – panic; behaviour – safety

Panic Attacks

Are simply caused by bursts of Adrenaline

These cause all the ‘panic attack’ symptoms

These are ‘uncomfortable but not dangerous’ – the key to managing them

The initial symptoms are simply those of anxiety – and are not dangerous

So panic attacks are simply anxiety about anxiety

Panic Attacks

Best treated with CBT

Avoid tranquillizers

Avoid anti depressants unless depression

is actively present

Are easy to treat if people come for help

If another condition like depression or

addiction are present - may have to be

also managed

Panic Attacks - CBT

Never try and stop an attack - they are simply an

Adrenaline rush (my emotional brain/stress

system is there to ‘protect not kill me’!)

Avoid safety behaviour

Learn that if I do nothing it will pass in 10

minutes; if I try to stop it may last much longer

The value of texting

The initial trigger are simply symptoms of anxiety

– uncomfortable but not dangerous

Panicky Feelings

Symptoms are very similar to those of panic attacks but are less severe and may last longer

Are caused by specific situations or thoughts

Are very common to us all; but if very persistent as in conditions like general anxiety disorder can be very distressing

Must be treated as ‘normal’ and are once again triggered by the emotional brain’s stress box advising the adrenal gland to produce adrenaline

Symptoms are usually physical with a lot of mental worry and overlay present

Phobias

One of the commonest conditions affecting

human beings

Can be defined as: ‘excessive and

persistent fear of being exposed to

particular situations or objects;

where exposure to either leads to an

immediate anxiety response and a need to

avoid the phobic stimuli’

Phobias

Can be classified as simple phobias including:

Exposure to animals or insects (e.g. spiders,

dogs and snakes)

Exposure to situations (e.g. confined spaces,

crowds, open spaces (agoraphobia), lifts,

planes, motorways, blood and so on)

And complex phobias like social phobia (a.k.a.

social anxiety disorder) – where our fear relates

to meeting other people in social situations

Phobias

Agoraphobia is a particularly common distressing condition which affects up to 20,000 people in Ireland

It refers to a ‘fear of open spaces’ and comes from the Greek word agora meaning marketplace

Sufferers may dread leaving the house, entering churches, shopping centres, lifts, supermarkets and other crowded areas

Some will struggle to leave their own bedroom

It is a very isolating condition

The real fear of the sufferer is that they will get a panic attack if they are exposed in such places; so it is not surprising that it is often linked to panic disorder

Phobias

Social phobia (or social anxiety disorder) is a

common disabling disorder where;

the person suffers from intense anxiety in social

situations for a period of greater than 6 months

Experiences a persistent fear of being judged

harshly by others and are embarrassed by their

own actions in social situations

These fears can be triggered by real or imagined

scrutiny by others

Phobias

In social phobia, symptoms of anxiety can be accompanied by blushing, excessive sweating, mind going blank or stammering which are often the presenting symptoms of this condition

Unlike most other phobias continuous exposure to social situations does not lead to any lessening of the condition

Up to 8% of the population suffer from some form of social anxiety

The key behavioural response to symptoms of social phobia is social avoidance which exacerbates the situation

Phobias

There are two main types of social phobia:

‘Performance situations’ (involving

situations where one performs in front of

others or is being observed by other

people)

‘Social interaction situations’ (involving

engaging or interacting with other people)

Phobias

Examples of feared social interaction situations

include:

Initiating or maintaining conversations

Meeting strangers; going to parties or having

friends over for dinner; meeting friends in pub

Expressing personal opinions or being assertive

Talking to people in authority or returning items

in store or food in restaurant

Phobias

Examples of performance situations which

cause problems include:

Public speaking or talking in meetings or classes

Eating or drinking in front of others

Using public restrooms if others are nearby

Playing sports in front of others

Playing music or acting in front of others

Being caught out making mistakes in front of

others

Phobias

Typical thoughts in social situations might be:

‘everybody must like me’

‘I have nothing interesting to say and am boring’

‘I will make a fool of myself; others will notice and find me wanting’

‘if all went well – nobody will notice; if badly then it will be my fault’

Phobias

Learned social behaviours in social situations include:

Staying close to the exit

Trying to cover up blushing (with make up) and excessive sweating (particularly common)

Gripping cups or glasses very tightly

Continuously rehearsing what one is going to say and checking that one is coming over well (self monitoring)

Avoiding eye contact

Social Phobia

The origins lie in our genes, social

upbringing and overtly critical or negative

experiences at home or school including

teasing or bullying

The isolation this condition can produce

can drive some into the world of self harm

Phobias

Treatment of phobias involves:

Lifestyle therapies like exercise, yoga, massage as stress reducing measures

Drug therapies include tranquillizers (to be avoided); anti depressants (generally not of significant help); St Johns worth

Talk therapies include counselling, behaviour therapy and cognitive behaviour therapy (the one of choice)

Phobias

CBT involves the acceptance that phobias are really red herrings (it is not the object or situation which is really my problem – rather the fact that exposure to them will lead me to become incredibly anxious!)

Many simple phobias involving insects, animals etc can be dealt with in a few simple sessions

More complex ones like social phobia may require a more in depth response by fully trained CBT therapist.

Phobias

In agoraphobia – CBT recognizes that the main fear is that the person will have a panic attack if exposed to the open spaces or situations already mentioned

So the therapist will have to teach the sufferer how to deal with a panic attack

Therefore reducing their fear of exposure to such situations

They may also be given graded behavioural exposure exercises to help them get over the problem

Phobias

The real worry for the social phobic person in social situations is that others will ‘see them as they see themselves’;

and they will spend a lot of time checking their own performance and whether they are blushing or sweating (often they have an exaggerated picture of how bad either of these is) and the therapist will challenge this.

CBT will challenge their thinking and their behaviour

Chronic Anxiety

The three main types of chronic anxiety we will examine are :

Post Traumatic Stress Disorder

Obsessive Compulsive Disorder

General Anxiety Disorder

Post Traumatic Stress Disorder

(PTSD) A chronic persistent anxiety state following a serious accident, rape, assault, war etc; which lasts for a period greater than 6 months

Symptoms include ‘flashbacks’; nightmares; a reluctance to deal with the matter; muscle pains; headaches; panicky feelings

Many feel ashamed or guilty they are still alive; and depression is a regular consequence

They may feel constantly ‘on guard’ and are constantly scanning the environment for potential trouble

They may have difficulties with sleep and often misuse or abuse alcohol as a result

PTSD

Drug therapy includes the SSRI’s which can be of help in severe cases particularly if depression is present

Talk therapy includes counselling which can be of considerable help; and CBT which can be very useful

At the heart of the CBT approach is challenging the demand for 100% certainty that they will not be exposed to the trauma again

The classical example is following an RTA

The key is to help the person that there is no such thing as 100% certainty in any area of life

General Anxiety Disorder

Constant bursts of intense anxiety and worrying about our health, family, job etc

Constant sense of foreboding about impending disasters

Mental and physical fatigue, irritable bowel syndrome

Poor concentration and memory

Sleep difficulties and nightmares

Indecisiveness and difficulty coping

Constantly avoidance of everyday tasks

General Anxiety Disorder

Commonly associated with bouts of acute anxiety

Will deteriorate if stress encountered

2/3 will have at least 1 episode of depression during their lives

Many use alcohol to cope so associated with alcohol abuse

Many end up addicted to tranquillizers

Women twice as likely to have it

Often undiagnosed; can be traced back to childhood; deteriorates as we get older

General Anxiety Disorder

Causes are a powerful mix of genetic

predispositions and our upbringing

Key biological mechanism is a hyped up

stress system

particularly our stress box

Seems to have similar genetic pathways to

depression

May be up to 15 resilience genes involved

General Anxiety Disorder

Ideal treatment is holistic

Exercise, nutrition, meditation, yoga all have a role

Avoid alcohol and tranquillizers

CBT very powerful tool

Mindfulness based CBT (MBCT) may be a therapy for the future

SSRI’S helpful (particularly if depression

present) but must be used sensibly and can never replace psychological Tx

Obsessive Compulsive Disorder

(OCD) OCD affects between 20 and 30,000 people in Ireland

It is a very distressing condition

It is characterized by persistent obsessive thoughts usually followed by repeated compulsive behaviour to ease the anxiety created by the former

Obsessions are intrusive anxiety provoking thoughts, ideas or images

Compulsions are repetitive rituals or mental actions performed as a result of obsessions in order to decrease anxiety and often to remove contaminants

OCD

Eventually people with OCD build into their lives a complex series of safety and avoidant behaviours which cause chaos in their life

They do recognize these obsessive thoughts as intrusive and troublesome and coming from their own minds but are unable to stop them

The modern view of this illness is that it is a form of behaviour addiction similar to other addictions

The obsessive thoughts and compulsions use up all the persons energies due to the incredible symptoms of anxiety they provoke

This illness can take up to 10 years to be diagnosed

OCD

Obsessive thoughts may relate to:

Fear of contaminating themselves (dirt, germs, blood or bodily fluids, faeces etc)

Fears over personal health

Fears of harming themselves or those close to them

Fears of hurting others

Fears over being gay or paedophiles

Fears of offending god

Fear that something terrible will happen

OCD

Examples of compulsive behaviours include:

Cleaning (particularly hand washing or home

cleaning)

Checking (e.g. front doors or light switches)

Counting or making lists

Arranging (everything in the room must be in the

right place to maintain control)

Making lists and hoarding

OCD

These compulsions persist as the sufferer gets a

short term relief from anxiety from the obsessive

thoughts; but eventually become the problem as

they have to increase to get the same relief (just

like tolerance in addiction)

Some obsessive thoughts and compulsions go

hand in hand (contaminant obsessions with

hand washing; or wiping down door handles in

toilets etc; or obsessive thoughts about the door

being unlocked with checking the door)

OCD

It is slightly more common in women and

can start as young as 10

Women suffer more from contaminant

obsessions and cleaning rituals

Men suffer more from symmetry, order

and sexual obsessions

Depression is quite common as a

secondary consequence of OCD (65%)

OCD

The first illness where clear neurobiological pathways were identified on neuroimaging of the brain

It is caused by a breakdown in information between the social behaviour box, the attention box and an area called the caudate nucleus

Normally when we get a simple thought like the ‘front door is not locked’ it is the social behaviour box that is activated

It passes information to the attention box which initiates the behaviour appropriate – i.e. ‘we check the door’

It is the caudate nucleus which like a gear change in a car allows us to then move on to the next relevant thought or action

OCD

In OCD the caudate nucleus is ‘stuck in gear’

and unable to move our thoughts on

So the brain ends up back in the social

behaviour box with the same thought – ‘is the

door locked?’ and the process restarts again

When a person with OCD with therapy begins to

improve the over activity in all three area on

scanning goes back to normal!

OCD

Causes are felt to be genetic (polygenetic) and upbringing; and in some cases in children can be triggered by infection

Severity can vary from mild to severe and it gets worse with age if untreated

Shame is the commonest reason for sufferers not presenting earlier for help

It is often family pressure that encourages them to present

OCD

Drug therapies are more important in this

condition than most other anxiety disorders

The main ones are the SSRI’s normally used to

treat depression

They act on the social behaviour box and can

take up to 8 weeks to kick in

St John’s Worth is also used in some countries

Drug therapy can improve situation by up to 50%

OCD

Talk therapies lie at the heart of the treatment of this condition and include counselling, behaviour therapy and in particular CBT

Lifestyle therapies are as always of importance in the holistic treatment of OCD

Counselling is of more help in dealing with the relationship consequences of this condition

CBT and behaviour therapies challenge the compulsive behaviour and the demand for control that lie at the heart of this condition

Conclusion

The secret to anxiety disorders is to:

NORMALIZE the symptoms of anxiety

The symptoms are usually uncomfortable

but not dangerous

Always challenge safety or avoiding

behaviour

Further information

For those who would like to investigate much of the neurobiological/clinical data which we just touched on in this talk might find it interesting to read my 4 books:

‘Flagging the Problem – a new approach to mental health’ (Liberties Press)

‘Flagging the Therapy – pathways out of depression and anxiety’ (Liberties Press)

Flagging Stress – toxic stress and how to avoid it (Liberties Press)

‘Flagging Depression – a practical guide’ (Liberties Press)

Flagging Depression