1. MOOD and ANXIETY DISORDERS IN TSC Dr Petrus de Vries, Developmental Neuropsychiatrist & Lorraine Cuff, CBT Therapist October 2009

2. Mental Health problems in adults with TSC High rates of a number of mental health problems in TSC Children and adolescents: Autism spectrum disorders, ADHD (25-50%) Adults: Mood and Anxiety Disorders (30- 60%) What causes these?

3. Anxiety Disorders in TSC Different types: Panic Attacks Agoraphobia Social Phobia Specific Phobias Generalised Anxiety Disorder (GAD) Obsessive-Compulsive Disorder (OCD)

4. Management of Anxiety Two main strands of treatment: 1.Medications (e.g. SSRIs) 2.‘Talking Therapies’ such as Cognitive Behavioural Therapy (CBT) The best effects are seen when medications and CBT are combined.

5. WHAT IS ANXIETY? A NATURAL EMOTIONAL AND PHYSICAL RESPONSE TO ENVIRONMENTAL AND/OR INTERNAL STIMULI WHICH ACTS AS A PROTECTIVE FACTOR TO KEEP US SAFE ( See Fig. 1)

6. Fight/flight - Physical Responses Muscle tension and pain – result of increased blood flow to muscles Sweating – the body’s way of cooling itself down Feeling sick – result of adrenaline being released Hyperventilation – increased breathing which increases oxygen, supplying oxygen rich blood to muscles Heart pounding – increased heart rate to pump blood to all muscles giving the ability to run away faster - Flight Feeling hot – result of increased blood flow around the body Shakiness – effect of adrenaline being released into the body Feeling the urge to empty bladder and/or bowels – the body’s way of ‘lightening the load’ enabling greater flight Cognitive Responses Fear through increased adrenaline Thoughts of danger which increase alertness and make the person ‘scan’ for danger Fig. 1

7. WHEN DOES ANXIETY BECOME A DISORDER? ANXIETY RESPONSES BECOME ANXIETY DISORDERS WHEN DISTORTED THINKING, STRESS, PHYSICAL SYMPTOMS AND AVOIDANCE INCREASE AND CREATE SIGNIFICANT PROBLEMS IN DAILY LIFE.

8. WHAT IS COGNITIVE BEHAVIOURAL THERAPY? A therapy using a mixture of cognitive (thought processing) and behavioural techniques to look at the links between a person’s environment, thoughts, feelings and behaviours and the impact of these on their health and functioning Cognitive techniques address thoughts and thought patterns which may be ‘unhelpful’ and may trigger and/or increase anxiety Behavioural techniques address behaviours which may be used by a person to reduce their anxiety or avoid it altogether

9. Principles of CBT A person’s environment, emotions, thoughts (cognitions) and behaviours are all linked (see fig. 2). Our thoughts, ideas, mental images, beliefs and attitudes can sometimes be ‘errors’ which are unhelpful and lead to emotional disturbances and physical reactions. These emotional and physical disturbances result in behavioural patterns which are intended to reduce anxiety (safety and escape behaviours) or avoid anxiety- provoking situations (avoidance behaviours). Although the behaviours may initially reduce the physical symptoms of anxiety, in the longer term they make the symptoms worse and create vicious cycles (see fig 3).

10. Fig. 2 Overly negative Self-critical Thinking things are going to go wrong Thinking there is danger Imagining people will judge you harshly Imagining that you will look foolish Unpleasant Anxious Angry Depressed Heart pounding Feeling hot Sweaty Shakiness Headache Stomach ache/cramps Nausea Avoid situations Run away from situations (escape) Give up Don’t try to go places or do things

11. WHAT IS THE AIM OF CBT? To increase self-awareness To encourage a better self-understanding To help us recognize the ‘negative traps’ or ‘vicious cycles’ we get caught in (see fig. 3) To improve self-control by developing more appropriate cognitive and behavioural skills

12. Stallard, P. 2002Fig. 3 SITUATION

13. WHAT CAN YOU DO? COGNITIVE Identify negative thoughts and thinking patterns which make you feel unpleasant using a thought diary (Appendix A) Label the type of ‘thinking error’ (Appendix B) Develop balanced thinking by looking for evidence for and against the thoughts and finding new evidence you might otherwise miss Learn new skills i.e. distraction, positive self-talk, problem-solving skills BEHAVIOURAL Activity monitoring – link activity, thoughts and feelings Become more active – this leaves you less time to worry or listen to your negative thoughts Increase pleasant activities Break tasks into small achievable steps Face your fears – try to break negative cycles by dropping avoidance, escape and safety behaviours

14. SITUATIONFEELINGUNHELPFUL AUTOMATIC THOUGHTS HOW MUCH DO I BELIEVE THE THOUGHT? WHAT ARE THE THINKING ERRORS? CHALLENGE WHAT IS THE EVIDENCE AGAINST THIS THOUGHT? ALTERNATIVE THOUGHT WHATS ANOTHER WAY OF VIEWING THE SITUATION? HOW MUCH DO I BELIEVE MY ORIGINAL THOUGHT NOW? Meeting new people AnxietyNobody will like me I believe this 90% Black and white thinking Catastrophizing Mind reading I have other friends People ask my opinion about things I am just nervous about meeting new people Most people get nervous 30% Appendix A