ANXIETY AND PANIC DISORDERS
CLINIC OF SANTA BARBARA  

ANXIETY DISORDERS


Obsessive Compulsive Disorder (OCD): Obsessive Compulsive Disorder is characterized by reoccurring, troubling, unwanted thoughts and/or repetitive, ritualized behaviors that a person feels driven to perform.  Everyone has little habits, and it is often common to refer to someone that demands their pencils to be lined up properly or their room to always be in order as “OCD”.  However, Obsessive Compulsive Disorder is much more serious and obsessive thoughts and compulsions can significantly interfere with daily life.  Intrusive, unwanted, repetitive and distressful thoughts plague a person to a point that is aptly called obsessive, and may cause the person to perform  “rituals” in an attempt to get rid of the thoughts.  These repetitive behaviors are performed with the hope of making the obsessive thoughts and anxiety go away; however these “rituals” provide only temporary relief.  Many people who suffer from OCD describe their brain as being “stuck” on a particular thought or action—that they have a mental hiccough that just won’t go away.


Obsessions: These involuntary thoughts, images, or impulses occur over and over  again in a person’s mind and are unwelcome and disturbing.  Often accompanied  by such feelings as fear, anxiety, disgust, doubt, or a sensation that things need to be done a certain way, they commonly interfere with the  person while they are trying to focus on an intentional activity or thought.  Common obsessions include:
• Fear of being contaminated by germs or dirt • Fear of causing harm to oneself or others • Intrusive or violent thoughts and images • Disturbing sexual thoughts or images • Excessive focus on religious or moral ideas • Fear of losing or not having things you might need • Fear that things are not organized or aligned “just right.” • Superstitions: excessive attention to something considered lucky or unlucky

Compulsions: Compulsions are repetitive behaviors that seem unstoppable and are an attempt to undo or resolve the obsessive thoughts.  For example, a common obsession is fear of being contaminated by germs.  This may lead to  excessive hand-washing rituals, even to the point where the person’s hands are cracked and bleeding from over-washing.  Though the compulsion is meant to reduce the anxiety of the obsessive thought, it often becomes so time-consuming and demanding that it itself causes a great deal of anxiety.  These compulsive rituals may temporarily reduce anxiety, but the urge to repeat the behavior generally returns very shortly.  Common compulsions include:
• hand washing and/or  excessive cleaning • checking things over and over again • ordering/arranging things until they feel right • touching or counting rituals • praying excessively • hoarding things which have limited value • re-reading or re-writing excessively

Diagnosis: Again, most people from time to time worry that they might have left the stove on or the door unlocked.  But when this worry causes a person to check the stove or lock over and over again every time they use the object, the thoughts have become intrusive and debilitating, and may be considered OCD.  In order to be diagnosed with OCD, your compulsive behavior must take up at least an hour a day, must interfere with your normal activities, or cause great distress because they are so demanding.

The onset of OCD usually occurs during adolescence or young adulthood, but can be seen in  children as young as 2-3 years old.  OCD is often misdiagnosed as oppositional behavior or confused with disorders such as Tourette’s syndrome, depression, and attention deficit disorders. Often people feel embarrassed about their thoughts and actions and successfully hide their behavior from friends, family and doctors.

Treatment: Obsessive Compulsive Disorder is highly treatable.   Exposure and Response Prevention treatment, a specific form of Cognitive-Behavioral treatment involves the repeated exposure to a feared situation or thought while blocking the ritual or compulsion.  Extensive research has shown this to be a highly effective treatment resulting in significant improvement in 70%- 80% of the people receiving treatment. Recent treatment guidelines recommend exposure/response prevention as a first line treatment for both children and adults because of its’ effectiveness. Cognitive therapy is also used to target the persons exaggerated fears and fears of the treatment process. .  Medications may also be helpful in reducing anxiety and helping OCD sufferers engage in exposure/response prevention.

Self-Test: 

• Do you have troubling or distressing thoughts, impulses, or images that occur in your mind over and over again?
• Do you feel like these thoughts or images are impossible to stop even if you try?
• Do you have trouble stopping yourself from doing certain rituals repeatedly, such as counting or checking on things?
• Do you feel like something terrible will happen if these rituals are not performed?
• Do these repetitive thoughts or routines take up more than an hour every day?

Panic Disorder: Panic Disorder is a very treatable illness which consists of reoccurring panic attacks and the persistent fear of having another panic attack.  Panic attacks are described as an abrupt and often spontaneous, overwhelming fear usually peaking within ten minutes and accompanied by physical symptoms such as shortness of breath, dizziness and heart palpitations.  Other physical symptoms that may accompany the panic attack include:

 

  • chest pain
  • sweating
  • trembling or shaking
  • feelings of light headedness or that you are going to faint
  • feelings of choking
  • nausea
  • a sense of things being unreal or depersonalized
  • a fear of losing control or “going crazy”
  • a  fear of dying
  • tingling sensations in the hands and feet
  • chills or hot flashes
  • feelings of imminent danger
  • the need to escape or avoid situations

 

Many people experience isolated panic attacks and develop no further problems, but sometimes reoccurring panic attacks as well as fear and preoccupation with future panic attacks leads to Panic Disorder.  In order to be officially diagnosed with Panic Disorder by the criteria in the DSM-IV (Diagnostic Statistical Manual of Mental Health), a person must experience recurrent and expected or unexpected panic attacks that are followed by at least 1 month of one or more of the following:

  • persistent concern about having additional  panic attacks
  • worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”)
Panic Disorder may seem like a very scary thing, but it is actually one of the most treatable of all psychological disorders.  Cognitive Behavioral Therapy has proven successful at changing the underlying thoughts and beliefs which lead to fear, anxiety and panic disorder.  In numerous research studies, between 80% to 90% became symptom free at the end of treatment.  Additionally, certain kinds of medications may also reduce the severity of panic attacks.  It is unfortunate that although the disorder is extremely treatable, often people spend months or even years suffering from panic attacks.  Due to the symptoms of a panic attack mimicking heart, lung or neurological conditions, many people will make several trips to the doctor convinced something is wrong with their heart or brain.  To make matters more confusing, panic disorder can occur with other disorders such as anxiety disorders, depression, irritable bowel syndrome, asthma, and substance abuse. Some feel embarrassed to share their suffering for fear of being labeled, even by loved ones and doctors.  While they struggle silently, they distance themselves from the very people in their lives whom can provide help.

           

Agoraphobia is often associated with panic disorder. The extreme unpleasantness of a panic attack can cause people to avoid situations or environments where panic attacks have previously occurred, in anticipation of another attack.  This fear, or fear of being in a situation where escape maybe difficult or embarrassing, should a panic attack occur, is called agoraphobia.  Meaning literally, “fear of open spaces,” people suffering from agoraphobia often avoid:  elevators, freeways, shopping malls, enclosed places,  public transportation, or large sports arenas.  This fear of an impending panic attack may shrink one’s safety zone until they are always fearful of another panic attack, and can even lead to being completely housebound.  About one-third of people diagnosed with Panic Disorder develop Agoraphobia.

 

If you’re not certain if you have Panic Disorder, try answering these questions…

 

  • Have you been experiencing reoccurring and “out of the blue” feelings of intense fear or discomfort
  • If yes, did you experience any of the following symptoms during this attack?

            -Feeling of imminent danger or doom

            -need to escape or avoid situations our of fear of having another panic attack

            -heart palpitations

            -sweating

            -trembling or shaking

            -shortness of breath or a smothering feeling

            -a feeling of choking

            -chest pain or discomfort

            -nausea or abdominal discomfort

            -dizziness or light headedness

            -a sense of things being unreal, depersonalization

            -a fear of losing control or “going crazy”

            -a fear of dying

            -tingling sensations in the hands and feet

            -chills or hot flushes

 

  • The month following the attack have you felt persistent concern or worried about having another panic attack?
  • Have you worried about having a heart attack, “losing your mind,” suffocating or fainting?

Have you avoided situations or activities out of fear of having another panic attack?

Social Anxiety Disorder (SAD): Social Anxiety Disorder, often called social phobia, consists of an intense fear of being negatively evaluated or judged in social and/or performance situations. The person may fear making a mistake or doing something embarrassing which would lead to humiliation and disapproval from others.   Most people experience some anxiety in social situations, but a person with Social Anxiety Disorder feels such overwhelming anxiety and distress that it can become debilitating.    Even before a dreaded social event, the person with Social Anxiety Disorder worries excessively, may have difficulty sleeping, and may rehearse the situation over and over again in their mind.  The high levels of anxiety and distress typically lead to avoidance of the feared social situations.  If the person does manage to confront their fears and attend the social event, they often do so after hours of worrying beforehand, extreme discomfort during the event, the desire to escape from the situation and intense analysis of their behavior during the event later.  The anxiety maybe recognized as irrational because it arises from nonthreatening situations, but this preoccupation with acting in a way which causes humiliation can interfere very significantly with occupational performance, school, and social relationships and general daily routines.  

Characteristics: In order to be diagnosed with Social Phobia by the DSM-5 (Diagnostic Statistical Manual of Mental Health) you must:  • Feel a persistent fear of at least one social or performance situation in which you are exposed to possible scrutiny by others. • Recognize that this fear is excessive or unreasonable. • Avoid the situation to an extent where it interferes significantly with your life.

Symptoms are typical for anxiety, and include:  • Blushing • Sweating • Trembling • Difficulty talking • Nausea • Rapid heartbeat • Dizziness • Headaches • Depersonalization or derealization ( the feeling of being disoriented and not being in one’s body or the sense that the situation or place is not real.)

Social Anxiety Disorder may be very specific  to one or several situations such as talking in a group situation or giving a speech (public speaking anxiety) but more typically the person  becomes anxious in a broader spectrum of social settings.  Situations that commonly cause discomfort include:  • Meeting people for the first time. • Participating in small or large group discussions • Being the center of attention such as walking into a room when everyone is already seated. • Being watched or observed while doing something. • Having to speak in public (public speaking anxiety) • Interacting with people of authority.   • Attending parties or other social gatherings • Looking into people’s eyes • Eating in public • Urinating in public situations (shy bladder syndrome)

The disorder affects about 15 million American adults and usually begins in childhood or adolescence.  Social Anxiety Disorder may often be accompanied by other anxiety disorders and lead to depression.  Substance abuse or alcohol abuse may also develop as a way for a person to cope with their anxiety.  

Treatment: Social Anxiety Disorder is very treatable with therapeutic help.  Cognitive behavioral treatment has demonstrated that approximately 70% to 80% will make significant improvement.  Additionally, for some, medication may be helpful in improving treatment and maintaining treatment gains.   If you think you may have Social Anxiety Disorder, try taking this quick self-exam.

Self-Test

• Are you troubled by an intense and persistent fear of a social situation in which people might judge you? • Do fear that your actions in this situation will cause embarrassment or humiliate you? • Do you fear that everyone will notice your signs of anxiety, such as blushing, sweating, or trembling? • Do you feel that this fear or anxiety is excessive? • Do social situations usually cause you to feel anxious? • Have you ever experienced a “panic attack”, during which you were suddenly overcome by intense fear or discomfort in these social situations? • Do you go to great lengths to avoid these situations? • Does all of this interfere with your daily life?

Generalized Anxiety Disorder (GAD): Everyone worries at some point or another, but if you have Generalized Anxiety Disorder, you worry frequently and excessively, have difficulty turning off the worry, fear the worst is going to happen, and have difficulty relaxing.  People with Generalized Anxiety Disorder tend to be chronic worriers and tend to worry about everyday things like work, health, family, relationships, money etc.  Typically, people with chronic worry feel keyed up, tense, restless, irritable, have often have difficulty sleep or concentrating.   Physical symptoms (fatigue, headaches, gastrointestinal problems, difficulty breathing, etc) often accompany this worry and are part of the reason it can be so debilitating.

Symptoms: Some anxiety is normal, but when chronic anxiety becomes so excessive or urgent that it interferes with daily life, it becomes a problem.  A typical person with GAD   may dwell exhaustively on what “might” happen.  They anticipate disaster and hardship in everything they experience.  This anxiety is so powerful that it can cause a person to feel helpless and depressed.  Typical worries include:  • Health • Money • Family problems • Employment problems • Relationships

Once again, people with GAD tend to catastrophize a situation, which causes them excessive worry and anxiety.  For instance, a spouse’s gentle criticism of an outfit might turn into dread that a divorce is imminent.  It is usually recognized that this worrying is excessive, but some justify it by insisting that they are protecting themselves. Most people with GAD do not avoid the dreaded situations, but rather live their lives worrying excessively.  Some, however are so debilitated with physical symptoms from their worry that it does severely interfere with their everyday functioning.  Some psychological symptoms include:  • Chronic worry about events that are unlikely to occur • Inability to shut off constant anxious thoughts • Feelings of dread • Irritability  • Restlessness and inability to relax • Trouble focusing • Trouble falling asleep or staying asleep

Physical symptoms may or may not accompany the disorder and include:  • Lack of energy or fatigue • Trembling • Muscular tension, aches, or soreness • Stomach problems (nausea or diarrhea) • Headaches • Chest pains • Grinding of teeth • Dry mouth • Sweating or hot flashes • Dizziness or lightheadedness

Diagnosis:  In order to be diagnosed with GAD a person must feel intensely anxious on a day-today basis for six months or more.  A person must also feel at least a few of the above symptoms and find it difficult to control their worry.  People with GAD often seek the help doctors due to their physical symptoms accompanying the disorder instead of seeking the help of psychologists.  It is sometimes hard to diagnose because it lacks the dramatic symptoms of other anxiety disorders, but it is no less debilitating.  If you think you may have GAD, try asking yourself some of the questions below.

Self-Test:

Are you troubled by excessive worry occurring more days than not for at least six months? Do you have unreasonable worry about a number of daily events or activities? Are you able to control or stop this worry? Are you bothered by some of the symptoms listed above? Do your anxieties or your physical symptoms interfere with your daily life?

Specific Phobia: A phobia is a term used to describe an unreasonable or irrational fear experienced when exposed to a specific object or situation. A specific phobia should not be confused with an everyday fear, as the difference is that a phobia is characterized by irrational and involuntary fear.  This fear may cause people to dread everyday situations or objects, even when they logically know there isn’t any danger at all.  The result is usually outright avoidance, with the affected person sometimes not even able to talk about the feared situation or object.  Usually the onset of a specific phobia is abrupt, and occurs in a situation that did not previously cause anxiety.  Sometimes phobias develop in childhood, but for the most part phobias form out of the blue in adolescence or early adulthood.  In adult cases, the phobia is usually consciously recognized to be an overreaction, but this knowledge does nothing to soothe the person’s fear.

Categories of Phobias:

 Animal Type-

Relating to animals, such as arachnophobia (fear of spiders), ophidiophobia (fear of snakes).

 Natural Environment Type-

Related to fear of objects or situations in the natural environment, such as acrophobia (fear of heights), aquaphobia (fear of water), or astraphobia (fear of thunderstorms).  This category usually forms during childhood.  As some of these fears can be adaptive, it is important to distinguish passing fear from a true phobia is these situations.

 Situational Type-

Includes claustrophobia (fear of confined spaces) and nyctophobia (fear of the dark).

 Blood/Injection/Injury Type-

Includes fear of bodily injury of any kind, injection of own body with a needle, and hemophobia (fear of blood).

 Other-

Includes triskaidekaphobia (fear of the number thirteen), and coulrophobia (fear of clowns) among other things.

 Symptoms: Phobias can severely disrupt daily routines.  Often avoidance of the object or situation reduces one’s self esteem and can interfere with social relationships due to desperation to avoid phobic fear.  A person introduced to a phobic event or object will show severe signs of discomfort and anxiety, sometimes resulting in a panic attack.  According to the Diagnostic Statistical Manual of Mental Health, to be diagnosed with a specific phobia:
-You must show marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (flying, animals)

-Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response

-The person recognizes that the fear is excessive or unreasonable (in adults)

-The phobic situation is avoided or else is endured with intense anxiety or distress

-The avoidance, anxious anticipation, or distress in the feared situation interferes significantly with the person’s normal routine

-The fear persists for 6 months

 Causes: Here are some ways in which phobias may form:

 -Direct Experience – The object or situation is experienced directly and a fear response forms

 -Observing – witnessing a fear response in another person can cause a fear response in observer

 -Word of Mouth – Being told about the dangers of an object or situation can cause an inappropriate fear response to form

 
Treatment
Luckily, Specific Phobias are highly treatable!  In order to extinguish a phobia, graduated exposure exercises are generated by you and your therapist in order to slowly get over the fear.  For example, a person with a fear of spiders might start with a session in which they are looking at pictures of spiders.  The next session might introduce a real spider, but keep it far away and in a cage.  The object of this treatment is to slowly and non-threateningly introduce the feared object so a person can gradually adjust to its presence.

 How can I tell if it’s a phobia?

Are you troubled by

  • Powerful and continuing fear of social situations with strangers?
  • Fear of situations or places in which receiving help or escaping could be difficult?
  • Shortness of breath or racing heart for no obvious reason?
  • Unreasonable and persistent fear of an object or situation?
  • Difficulty traveling alone?
  • Intense uneasiness when even hearing about a certain object or situation?

 

 

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