Articles - Adult Anxiety

• Performing Despite Panic
• A Mother's Perspective
• Ask the Expert
• If Panic Strikes
• CALM or Diaphragmatic Breathing
• Anxiety Disorders and Their Treatment

An article from Anxiety Disorders Association of America

Spotlight
How to Survive Tough Economic Times
and Manage Your Anxiety

With the nation’s housing market in a slump, stock prices falling, food prices rising, and government bailouts of banks making the news each week, it’s no surprise that many people are feeling anxious about the economy and their financial future.

Anxiety is a normal reaction to these events. It’s your body’s way of telling you to stay alert and work harder to protect your finances and your family’s future.

And many are anxious: Three out of four adults feel stressed about money, and two out of three say the economy contributes significantly to their stress, according to the American Psychological Association. Women are also more likely to be concerned with their economic security, according to a recent poll by the National Women’s Law Center. Fifty-nine percent of women said they were worried about achieving their financial goals in the next five years, compared to 46 percent of men.

But if you find yourself worrying about the economy and your finances for hours each day, to the point where you have difficulty sleeping or concentrating on other tasks even though you are aware your fears are irrational, you may have generalized anxiety disorder.

People with generalized anxiety disorder, or GAD, experience persistent, excessive, and unrealistic worry about issues like money, health, family, or work for six months or longer. They don’t know how to stop the worry cycle and feel it is beyond their control. Physical symptoms of generalized anxiety disorder include fatigue, restlessness, difficulty sleeping, irritability, edginess, muscle tension, and gastrointestinal discomfort or diarrhea.

According to Sally Winston, PsyD, co-director of the Anxiety and Stress Disorders Institute of Maryland, some of her patients are also experiencing the following symptoms:

• Checking online finances every hour.
• Worrying about things that are not at risk, such as bank deposits that are insured by the Federal Deposit Insurance Corporation (FDIC).
• Worrying about standing in food kitchen or unemployment lines.
• Watching TV for hours each day and hearing the same information over and over.

GAD affects 6.8 million adults, or 3.1% of the U.S. population, in any given year. Women are twice as likely to be affected.

Like other anxiety disorders, GAD is treatable. Cognitive-behavioral therapy is effective for many people at identifying, understanding, and modifying thinking and behavior patterns. This helps people with GAD learn to control their worry on their own. Some with GAD also take medication. You may also want to talk to your doctor about adding alternative treatments, such as relaxation techniques, meditation, yoga, or exercise, as part of your overall treatment plan.

“The worst response to feeling anxious is increased substance abuse, especially alcohol,” Winston says. She recommends getting a massage, working out, spending time with pets or children, or drinking a cup of tea.

Because the disorder frequently co-occurs with other health conditions, such as other anxiety disorders, depression, or a sleep disorder, don’t be afraid to raise concerns with your doctor about other symptoms you have that may or may not be related to GAD.

Whether or not you have GAD, you can take these steps to reduce your anxiety in times of economic uncertainty:

• Turn off the TV. Take a break from the bad news, especially if it adds to your fear and anxiety. “Fear is a very powerful motivator, but you should never make a financial decision in the heat of the moment or during an emotionally charged period of time,” says Brian Jones, a financial planner and vice president of CJM Wealth Advisers in Fairfax, Virginia.
• Determine if immediate action is required. Make a plan, Winston advises, whether it’s to call a financial adviser, delay vacation plans, or even to do nothing for right now. Then let your worries take a back seat to the plan and the rest of your day.
• Concentrate on things you can control. If you’re worried about your finances, focus on saving money and paying off debt instead of fretting about the price of groceries or gas. If you’re spending more than you earn, or more than you’re comfortable spending, decide which expenses are important and which aren’t. You can’t control rising prices, but you can control your bank account and how you spend your money.
• Put things in perspective. When it comes to your finances, unless you’ve recently lost your job or you are close to retirement, think in the long term. If you take your money out of the market, you’ll miss the gains when it goes back up, which analysts agree it will eventually do.
• Think conservatively. If you are nearing retirement or are worried about your job or financial security, talk to your financial advisor about diversifying your portfolio to include more low-risk investments that will minimize the impact of a struggling market economy.
• Stay healthy. Get enough sleep, eat healthy, exercise, and allow for personal time. This will help clear your mind of negative thoughts. If you are exhausted — physically or emotionally — it will be more difficult for you to handle stress and anxiety.
• Talk to someone. “If you do have questions, or if you feel paralyzed by fear, go talk to someone who does this for a living,” says Jones, who advised asking friends and family which financial planner they use and recommend if you don’t already have one. Tell that person you’re feeling overwhelmed, and tell them how they can help, or ask for advice. You may also want to talk to a therapist.

PERFORMING DESPITE PANIC
by Leslie Wolos

I'm a professional actress. I have been to countless auditions, performed on many film sets and theatre stages, and met hundreds of new people. No one would know that I suffer from social anxiety and panic attacks.

It's not a constant problem, but there are certain situations that I just can't stand. If I'm asked to improv, for example, (an impromptu scene based on a suggestion), I am overcome with panic. My throat closes up and I can't breathe, I start to shake, and the humiliation of is all causes me to burst into tears, which, of course, is only more embarrassing. This has happened to me several times in front of my peers at acting class, which has forced me to avoid the situation altogether.

I'm not entirely sure why I can perform a play in front of hundreds of people, but I can't get up in front of my own peers to create my own scene, although it might have something to do with the lack of control. Or perhaps, when I'm in a play, I'm using someone else's ideas and I'm hiding behind a character that someone else created. Whereas in improv, I have to use my own thoughts and ideas and that is a very vulnerable situation.

I've always had a problem with situations where I must interact with other teenagers. I find them very intimidating, and being around them makes me want to crawl into a crack in the wall to hide. I wish I could participate easily like everyone else. Before an activity or meeting, I usually tell myself that THIS time I'll make an effort to talk to people and get involved, but often I end up drawing my knees to my chest, making myself as small as possible, and staying off to the side.

Sometimes I completely avoid situations where I would be with other teenagers, even pretending to be sick just to have an excuse not to go.

Despite this problem, I am making progress. This past June, my boyfriend graduated and I had to walk in with him when they introduced all of the grads. I was absolutely terrified of doing this simple thing and my mind raced trying to think of an excuse to get out of doing it. I couldn't let my boyfriend down, so I went ahead with it. I could hardly breathe in the seconds before we were to walk out, but I used a relaxed breathing technique that helps to calm me when I'm anxious. I looked straight ahead, walked quickly and got through it. It was another small step towards conquering a very frustrating problem.

_ _ _ _ _

Leslie Wolos is an 18-year-old professional actress who has appeared in several independent films, 3 episodes of YTV's "The Adventures of Shirley Holmes", and many other theatre productions. She auditioned for the role of Grace in "The Horse Whisperer" and made it to the third round.

She is a published poet, webmistress, and a collector of stuffed sheep. Leslie recently moved to Vancouver to further pursue her acting. Her website is http://welcome.to/lesliewolos

Editor: You will remember Leslie as the red-haired teen-ager in two of ADAM's videos. Thanks for being so candid, Leslie. Wishing you the very best in your career.

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A MOTHER'S PERSPECTIVE
by Kathy Wolos

As I look at my poised, self-confident daughter, I find it hard to believe that certain circumstances will throw her into an absolute panic. She is part of the film industry and is an accomplished actress, but ask her to do an impromptu performance or be the focus of attention in a school social situation and she can't do it. She hyperventilates, becomes shakey and cries - it terrifies her!

She once said to me, "Mom, how will I ever get married? I can't stand to be the centre of attention. How could I cope with walking down the aisle?" What do I say?

She is aware of my journey with my close friend who has conquered her panic disorder. My daughter is familiar with some of the coping techniques my friend used and she, in fact has used these to survive stressful times like her boyfriend's high school prom. As she accompanied him across the dance floor, I could see the quiet terror on her face. She hid it from the rest of the crowd, but I could see her pain.

I suggested she seek some assistance from the classes at ADAM. She seriously considered it but decided that since the panic situations occur occasionally and aren't controlling her life, she would 'deal with it'. I believe she'll tackle her social panic if she feels it is uncontrollable. Until then, I will encourage her to use the coping techniques she has learned and I will silently support her in those very painful panic situations.

Kathy Wolos is a member of ADAM's Board of Directors and chairperson of ADAM's Fund-Raising Committee. She is employed at Grace Hospital as a Registered Nurse and received the 2000 Nursing Excellence Award. She is a professional photographer, a soloist, Peter's wife, Leslie and Tom's mother and an active volunteer.

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ASK THE EXPERT

John Walker, Ph.D, C. Psych., Coordinator, Anxiety Disorders Program, St. Boniface Hospital, Winnipeg, Faculty of Medicine, University of Manitoba, ADAM board member.

QUESTION: How often does an anxiety problem co-exist with another mental health problem.

Community studies indicate that the anxiety disorders frequently occur together. That is, about half of the people who have one disorder will have a second anxiety disorder also. This may be because there are common features in the development of the anxiety disorders. In terms of people's life span, social anxiety disorder often occurs earliest in life with later development of other disorders.

People coping with anxiety disorders will also commonly have episodes of depression over the course of their life. This may be because of common factors in the development of these problems or because of the stress and demoralization that comes with coping with an anxiety disorder, coupled by the life stresses which occur for all of us.

Another risk for people coping with anxiety disorders is the development of problems with alcohol abuse. This is particularly a problem for young men who may be trying to use alcohol to cope with their anxiety. Individuals who use alcohol heavily are also at risk for the development of new problems with anxiety and depression.

Given these findings there is the possibility that helping people to resolve problems with anxiety early in their life may prevent the development of some of the above mentioned problems. Anxiety problems often develop earlier in the life span than alcohol abuse and depression.

QUESTION: If a person has problems with anxiety and another disorder which do you treat first?

This depends on the individual and their specific situation. Fortunately, the psychological, medication and self-help treatments that are helpful for anxiety are also frequently helpful for depression. As the person's anxiety problem improves, the depression tends to improve also.

If a person is so depressed that poor concentration or lack of energy is a problem, the depression may require attention first.

In the case of heavy alcohol abuse, the person is likely to have to reduce alcohol use drastically (or eliminate it) before they can see an improvement in anxiety or depression.

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If panic strikes, be prepared

1. Learn to recognize your early signs of panic. It is easier to manage mild to moderate anxiety than full blown panic.
2. Observe any tension in your body and release it. For example, if your hands are gripping your chair, relax your hands.
3. Take a couple of slow breaths through your nose. As you inhale, say "peace, calm, safe" As you exhale, repeat "I'm letting go of tension and fear."
4. Distract yourself by talking to another person. This will take your mind off your panic symptoms.
5. Focus on the present. Look around you – pay attention to your environment and look at people, cars, colours in a room. It will take your mind away from your anxious thoughts.
6. Do something physical to expend energy and adrenaline.
7. Don't fight your panic feelings – accept them and 'go with the flow'. Resisting your feelings makes them worse.
8. Use positive self-talk. "Anxiety is horrible but it isn't life-threatening." "This isn't an emergency. This is a panic attack and I know what to do." "These are just my thoughts scaring me – there is nothing dangerous here."
9. Anger and humour can be effective in reducing anxiety. Speak directly to your fear "Get lost. I don't have to put up with you." "Chill out." "So what." Create your own statements and use what works for you.
10. Pat yourself on the back for helping yourself control the panic. It will get easier as you continue to practice your skills.

ADAM. If panic strikes. 2003

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CALM or Diaphragmatic Breathing

·         Easy to Learn, Easy to Use, Portable

·         Numerous Health Benefits

·         Calms the Body – Reduces Physical Symptoms

·         Controls Anxiety

1)     Sit on comfortable chair; feet on floor.

2)     Close mouth; breathe through nose.

3)     Breathe in slowly; pushing stomach out.

4)     Hold a few seconds.

5)     Breathe out slowly.

6)     As you exhale use a silent word: "calm" or "peace" or "safe."

7)     Repeat for 2 minutes; then extend to 5-10 minutes.

8)     Practice during low tension level.

9)     PRACTICE DAILY.

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ANXIETY DISORDERS AND THEIR TREATMENT

Kevin D. Kjernisted, M.D. FRCPC Medical Director, Anxiety Disorders Program, Director of Research, Department of Psychiatry, St. Boniface General Hospital, Associate Professor, University of Manitoba.

Anxiety disorders are very common inflicting approx -imately 25% of the population. These disorders are not minor and for many sufferers cause significant impairment in all aspects of their daily life. Fortunately, within the past decade or so, both pharmacological and cognitive behavioral treatment of the anxiety disorders has evolved significantly. This article will focus on the pharmacological treatment of anxiety disorders. This is not to suggest that the other mainstay of treatment, cognitive behavioral therapy, is not equally as important.

There are six main anxiety disorders. These include Panic Disorder with or without Agoraphobia, Generalized Anxiety Disorder, Obsessive Compulsive Disorder, Social Anxiety Disorder, Post Traumatic Stress Disorder, and the Simple Phobias. The first five disorders (excluding simple phobias) respond to treatment with medications. Simple phobias do not benefit from medication of any type and require exposure therapy which involves facing ones fears during therapy sessions and homework involved in cognitive behavioral therapy.

Antidepressants Are The Newer Medications To Treat Anxiety Disorders. Prior to 1990, the medication treatment for the anxiety disorders was rather nonspecific, using mostly benzodiazepines, the family of drugs which includes Valium. The first SSRI, fluoxetine (Prozac) which became available in Canada approximately 10 years ago, heralded the beginnings of more specific and more effective treat-ment for the anxiety disorders. Nowadays benzodiazepines like lorazepam (Ativan), clonazepam (Rivotril) and alprazolam (Xanax) play more of a supplementary role to the main pharmacological treatment for the anxiety disorders which is antidepressants. The antidepressants which have been proven to be most effective for treating anxiety disorders are the specific serotonin reuptake inhibitors (SSRIs) and specific serotonin norepinephrine reuptake inhibitors (SNRIs). SSRIs include fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), paroxetine (Paxil), and citalopram (Celexa). The SNRI presently available to Canadians is venlafaxine (Effexor). It is believed that all of these anti-depressants have their antidepressant and antianxiety effects mediated at least partially through restoring the balance of a neurotransmitter in the brain called serotonin. Serotonin is a fine-tuning, calming neuromodulator which effects a number of other neurochemical systems within the brain. Different SSRIs and the SNRI have received official indications for the treatment of the different anxiety disorders based upon extensive clinical research conducted by their manufactur-ers. Not all SSRIs or the SNRI have official indications for the treatment of all anxiety disorders but in clinical practice we find that when used properly all of the SSRIs and the SNRI seem to be equally effective for all of the anxiety disorders. Different individuals, though, seem to tolerate and respond better to different antidepressants. Sometimes it is a matter of trying different medications to determine which is the best one for that particular person. Most important in the treatment of anxiety disorders is to start the treatment at a low dose. This would be a dose ½ or less of the dose recommended as a usual starting dose if you were using that medication in the treatment of depression.

Early Side Effects. People with anxiety disorders tend, at least sometimes, to be more sensitive to the early side effects of the antidepressants. These side effects are pretty similar among the entire class of SSRIs and SNRIs. Common side effects early in treatment include nausea, headaches, increased or decreased sleep, and sometimes a temporary increase in anxiety and jitteriness. These early side effects tend to be short-lived lasting for 1-2 weeks and most often, especially if one starts with a low dose, the side effects are mild or minimal to none.

Dose Guidelines. Table 1 outlines the recommended starting dose, target dose and therapeutic dose range for each of the SSRIs and the SNRI. Clinical practice has shown us that often times individuals with anxiety disorders require even higher doses of these medications than might be required for the treatment of depression. Therefore, it is best to start at a low dose but over the first six weeks of treatment, gradually increase the dose to a target dose which is usually in the mid range or higher for that particular agent. Also, with the anxiety disorders, the time to onset of a therapeutic benefit may be longer than one would see in the treatment of depression. For depression the initial therapeutic response often takes 3-4 weeks, whereas, for the anxiety disorders sometimes a therapeutic response is not seen for 8-12 weeks after the dose has been titrated up to the target dose. The maximum therapeutic effect may take a number of weeks or even up to six months. These dosing guidelines are outlined in Table 2. The antidepressants tend to treat the anxiety and worries or obsessions of the individual which will help them to be able to face their fears and reverse their avoidant behavior. For maximum benefit though, while on the medication, the patient needs to actively expose themselves to the fears involved in their particular anxiety disorder. This can be facilitated by reading self-help books, or having individual or group cognitive behavioral therapy either with a clinician or through self-help organizations such as the Anxiety Disorders Association of Manitoba (ADAM). In other words, medication alone is usually not sufficient to obtain the maximum improvement from ones illness.

Long-Term Side Effects. As mentioned above there are potential early side effects of the SSRIs and SNRIs. These usually abate within the first 1-2 weeks. There are side effects though that can persist sometimes indefinitely. For most patients the therapeutic benefits of the medication outweigh the nuisance of the long-term side effects which can include insomnia, fatigue, weight gain, as well as decreased sexual interest, excitement and delayed orgasm. Sometimes these side effects abate with time and ongoing treatment. Other times specific side effects can be managed with dosage adjustment or the addition of other medications as orchestrated by the patient's physician. For example, insomnia may need to be treated by the addition of another medication at bedtime such as Trazodone (Desyrel). This is a sedating antidepressant which like the SSRIs and SNRIs has no addictive potential. Used at low doses ranging between 25-150 mg this can be a very effective medication for improving the quality of sleep.

How Long is Medication Needed? Although there are very few scientific studies guiding us as to how long an individual should stay on antidepressant treatment for their anxiety disorder, clinical practice suggests that once a person is well, it is best to stay on the medication for a minimum of 1-2 years. The medication can then be tapered slowly by decreasing the dose by 1/4 of the maximum dose, every two months. The patient should see their physician every 1-2 months during this tapering period in order to assess for any signs or symptoms suggestive of possible recurrence of the anxiety disorder. If the anxiety disorder recurs, the dosage may need to be increased up to the dose that was beneficial in the first place.

Since anxiety disorders tend to be chronic lifelong illnesses which can come and go, there is no way to predict for any particular individual whether they will need to go on medication again in the future. For many people the best course of action is to stay on the medication indefinitely, especially if for many years they suffered with their anxiety disorder and then on medication their lives completely turned around. Many of these individuals will not want to stop their medication having realized what life can be like without anxiety. Often times cognitive behavioral therapy, done during the time the person is on medication, can provide longstanding or indefinite relief from the anxiety disorder and may prevent the need to go back on medication in the future.

Discontinuation Syndrome. Tapering slowly off the medication is also helpful in decreasing the incidence of what is called the "discontinuation syndrome" which some individuals (approximately 20-40%) experience when stopping their antidepressant treatment. Although not dangerous, this discontinuation syndrome can involve significant symptoms and distress which in many ways seems like a sudden recurrence of the initial anxiety disorder symptoms that brought the patient to treatment in the first place. Common discontinuation syndrome symptoms include dizziness, headache, nausea, flu-like symptoms, achy muscles, agitation, anxiety, weepiness, depressed feelings, and sometimes strange physical sensations such as electric shock like impulses in the head/body or noises/dizziness associated with eye movements. The discontinuation syndrome can last anywhere from a few days to a maximum of 3-4 weeks. It is generally most severe at the beginning and then starts to improve over time. Often times if an individual has this discontinuation syndrome they will automatically fear and assume that they are having a recurrence of their anxiety disorder. In most situations this is not the case. Once the discontinuation syndrome is over the person will feel entirely well.

Combining Benzodiazepines and SSRIs or SNRIs. As mentioned above, benzodiazepines such as lorazepam, clonazepam and alprazolam are not the mainstay medication treatments for anxiety disorders but sometimes are used in order to achieve quick relief from panic attacks and anxiety at the beginning of treatment. Sometimes the doctor may start the patient on both a benzodiazepine and an SSRI or SNRI at the beginning of treatment, leaving the person on the benzodiazepine for 6-12 weeks until such time that the antidepressant (SSRI or SNRI) has had time to start having a therapeutic effect. The benzodiazepine should then be very slowly tapered off, usually by decreasing 1/4 of the total dose every two weeks. This minimizes the risk of any withdrawal syndrome which can include increased anxiety symptoms and insomnia. Some individuals need to stay on the benzodiazepine along with the antidepressant in order to have maximum benefit and symptom resolution.

The Good News. The good news is that the majority of individuals with anxiety disorders can benefit from the two mainstays in the treatment which are medication and cognitive behavioral therapy. Most times people are able to get their lives back when free of their anxiety symptoms and go on to have a healthy, happy, highly functional existence.

Table 2     Antidepressant Treatment for Anxiety Disorders

1. Start low (½ usual dose).
2. Go slow (titrate up over 4-6 weeks).
3. Aim Sufficient (½ maximum dose or higher).
4. Wait longer (8-12 weeks for therapeutic effect).