2. Anxiety Disorders and Addiction Thinking Outside the Medications Box

3. I. Anxiety Disorders II. Influence of Substance Use III. Treatment

4. I. Anxiety Disorders? include “symptoms of anxiety, fear, avoidance, or increased arousal”

5. Major Anxiety Disorders 1. Generalized Anxiety Disorder 2. Panic Disorder & Agoraphobia 3. Specific Phobia 4. Social Phobia 5. Obsessive-Compulsive Disorder 6. Posttraumatic Stress Disorder

6. Generalized Anxiety Disorder A. Excessive worry (apprehensive expectation), occurring more days that not for at least 6 months, about a number of events or activities (such as work or school performance). B. The person finds it difficult to control the worry.

7. Generalized Anxiety Disorder C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). (1) restlessness or feeling keyed up or on edge (2) being easily fatigued (3) difficulty concentrating or mind going blank (4) irritability (5) muscle tension (6) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

8. Panic Disorder & Agoraphobia A. Both (1 ) and (2): (1) recurrent unexpected Panic Attacks (2) at least one of the attacks have been followed by 1 month (or more) of the following: (a) persistent concern about having additional attacks (b) worry about the implications of the attack or its consequences (losing control, having a heart attack, “going crazy”)

9. Panic Attack A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: (1) palpitations, pounding heart, or accelerated heart rate (2) sweating (3) trembling or shaking (4) sensations of shortness of breath or feeling smothering (5) feeling of choking (6) chest pain or discomfort

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

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

12. Specific Phobia A. Marked or specific fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, blood) B. Exposure to the phobic stimulus almost invariable provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack.

13. Specific Phobia C. The person recognizes that the fear is excessive or unreasonable. D. The phobic situation is avoided or else endured with intense anxiety or distress. E. The avoidance, anxious anticipation, or distress in the feared situation interferes significantly with the person’s normal routine, occupational functioning, or social activities or relationships. Or there is marked distress about having the phobia.

14. Social Phobia A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack.

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

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

17. Obsessive-Compulsive Disorder B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive and unreasonable. C. The obsessions or compulsions cause marked distress, are time-consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.

18. Posttraumatic Stress Disorder A. The person has exposure to a traumatic event. B. The traumatic event is persistently re- experienced C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma). D. Persistent symptoms of increased arousal (not present before the trauma). E. Duration of the disturbance is more than 1 month. F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

19. II. Influence of Substance Use

20. Stimulants Use of Nicotine, Caffeine, Cocaine, Amphetamine can: Use of Nicotine, Caffeine, Cocaine, Amphetamine can: –Trigger or worsen anxiety and panic –Disrupt a regular sleep schedule –Trigger a starvation state when not eating regularly –Contribute to gastrointestinal problems

21. Depressants Use of Alcohol, Opiates, or Benzodiazepines can: Use of Alcohol, Opiates, or Benzodiazepines can: –Initially reduce anxiety, but cause anxiety to increase over time (“Rebound Effect”) –Contribute to gastrointestinal problems

22. Hallucinogens Use of Marijuana, mushrooms, mescaline, or LSD can: Use of Marijuana, mushrooms, mescaline, or LSD can: –Induce panic-like sensations (rapid heart rate, fear/paranoia)

23. III. Treatment

24. Pharmaceutical Treatment Benzodiazepine class of medications: Benzodiazepine class of medications: –Are fast acting, potentially addictive –Can lead to development of tolerance, and the experience of withdrawal symptoms when stopped SSRI class of antidepressant medications: SSRI class of antidepressant medications: –Block serotonin re-uptake, and are non- addictive

25. Pharmaceutical Considerations Medications can mask symptoms temporarily, without helping to permanently manage or resolve them Medications can mask symptoms temporarily, without helping to permanently manage or resolve them Short-term relief can take away the motivation to do the work and discipline of learning & practicing either resolution or long-term management strategies Short-term relief can take away the motivation to do the work and discipline of learning & practicing either resolution or long-term management strategies

26. Psychosocial Treatments 1. Stress Management 2. Cognitive Restructuring 3. Exposure Therapy

27. Stress Management Lifestyle Analysis - sleep routine - reduce ETOH and caffeine use - eat regularly (a state of starvation can mirror anxiety symptoms) - exercise!!!

28. Stress Management Life Problem Analysis (finances, raising children, relationships, etc) 1. identify problem 2. brainstorm solutions 3. evaluate brainstorm list 4. develop an action plan 5. re-evaluate plan in an ongoing manner

29. Stress Management Relaxation Training - Progressive Muscle Relaxation - Meditation or Deep Breathing

30. Cognitive Restructuring 1. Identify distortions in thinking a) “Catastrophizing” b) “Magnification” c) “Fortune-Telling” 2. Education that events not likely to happen (reality checking) 3. Counter thoughts with evidence from history, other experiences, and behavioral tests

31. Exposure Therapy Exposure of an individual to the specific fearful situation or object stressor, as able to be tolerated Exposure of an individual to the specific fearful situation or object stressor, as able to be tolerated Gradually activate the anxious feeling Gradually activate the anxious feeling The individual gradually gets used to (habituates to) the feared situation or stressor The individual gradually gets used to (habituates to) the feared situation or stressor

32. Questions or Comments?