Part 4 of a six-part series on mental health in Hamilton.
Anxiety disorders are the most common form of mental illness — about one third of us will experience one in our lifetime.
It was just after 9:30 a.m. on a perfect morning in Washington D.C. and Randi McCabe strolled among monuments on the National Mall, soaking up history and sunshine.
She felt the ground shake under her feet, as though a gigantic dumpster had been dropped next to her.
She turned and saw smoke billowing into the blue sky.
People running, sirens, snipers on rooftops, shouting out of car windows: “Get out of the city!”
Terrorists crashed a jet into the Pentagon. It was 9/11.
She felt anxious — and recognized the symptoms better than most.
She’s a psychologist and heads the Anxiety Treatment and Research Clinic at St. Joseph’s Healthcare. She was in Washington for a conference.
It was natural for anyone to feel it that morning: tension, fear, and a sense of dread, even if you were nowhere near the attacks.
“Anxiety is a normal emotion, we all have it,” McCabe says.
It rises to a disorder when it affects your day-to-day functioning: when it compels you to mow your lawn in the dark because you can’t stand others looking at you, or makes you so anxious getting dressed to go meet friends you vomit and stay home.
These are the types of anxieties her patients face.
“There’s a difference between regular anxiety and an anxiety disorder that can control your life,” McCabe says. “We want to help people get their lives back.”
Randi McCabe at St. Joe’s anxiety clinic says that in a sense a disorder like OCD — obsessive-compulsive disorder — loses meaning in the popular culture, when people quip that they “wish they had a little OCD to keep the house clean.”
But those who are able to joke about a disorder may have never actually experienced it, and wouldn’t want to.
Symptoms of an anxiety disorder include changes in thinking, behaviour, emotions, and physical sensations that cause distress and impair your ability to function at work or socially.
Anxiety disorders are the most common mental illness, and can affect anyone in any walk of life — about 30 per cent will experience one in their lifetime — and are often made worse by an accompanying “comorbid” mood disorder, depression, or substance abuse disorder.
Anxiety has been around as long as humanity. The emotion is an evolutionary adaptation, a reaction in the central nervous system giving our bodies a jolt to react to a challenge or danger; the “fight or flight” mechanism.
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Anxiety is a normal reaction many people experience; an anxiety disorder is diagnosed when symptoms create enough distress that impairs daily living, and an ability to function in such areas as social interactions, family relationships, work or school.
Anxiety disorders sometimes cluster together or merge with other mental illnesses such as substance abuse and depression.
In 2013, 3 million Canadians 18 years or older (11.6 per cent) reported they had a mood or anxiety disorder
More than one-quarter reported the disorder had an “extreme” impact on their life, and one-quarter did not consult a health professional about it.
About 70 per cent of people who reported a mood/and or anxiety disorder said they are taking prescription medication; 95 per cent said a doctor had suggested they take medication. Only 20 per cent have received psychological counselling to manage the disorder in the past year.
Anxiety disorders can have a genetic component but are typically rooted in a combination of biological, psychological, and environmental factors.
Anxiety disorders frequently occur along with depression or substance abuse. People suffering from anxiety disorders are six times more likely to be hospitalized for psychiatric disorders than those who don’t have an anxiety disorder.
People with Generalized Anxiety Disorder (GAD) spend more than five hours a day worrying, while people who worry at a rate that would not be considered a disorder spend slightly less than one hour a day on average worrying.
Those who suffer from anxiety are also at greater risk for developing a number of chronic health conditions, including heart disease.
Marijuana and alcohol are not evidence-based treatments for anxiety.
Women are at double the risk for anxiety disorders as men, and typically occur at a younger age in women, most often between puberty and age 50.
Sources: Statistics Canada; Anxiety and Depression Association of America; Anxiety Disorders Association of CanadaSource: National Alliance on Mental Illness
Panic disorder: Characterized by “panic attacks,” these result in sudden feelings of terror that can strike without warning. Symptoms include chest pain, heart palpitations, upset stomach, a “disconnected feeling,” fear of dying.
Obsessive-compulsive disorder (OCD): Repetitive, intrusive, irrational and unwanted thoughts/obsessions and/or rituals and compulsions that seem impossible to control. Some compulsions (counting, arranging, cleaning) must be “performed” multiple times each day to momentarily release anxiety that something bad might happen to themselves or a loved one.
Phobias: Disabling or irrational fear of something that poses little or no actual danger for most people, and the fear leads to avoidance of situations or objects that may cause feelings of dread or panic.
Post-traumatic Stress Disorder: Exposure to a traumatic incident involving death or near-death/serious injury, that leads to flashbacks, nightmares, and isolation from social situations and relationships.
Generalized Anxiety Disorder (GAD): Severe, chronic, exaggerated worrying about everyday events; the worrying may last many hours a day for some, and extend at least six months, making it difficult to concentrate enough to carry out routine activities.
Sources: Statistics Canada; Anxiety and Depression Association of America; Anxiety Disorders Association of CanadaSource: National Alliance on Mental Illness
There is no instant cure for anxiety, and everyone responds differently to it, but here is a brief summary of some of the strategies used at the St. Joe’s anxiety disorders clinic that could help you look at your anxiety differently, to perhaps alleviate it:
Recognize the thought distortion your brain is creating. What is at the root of your fear? Try to unpack it, identify what is really bothering you. Keep a “worry journal.” When something is worrying you, write it down. Do this for a week, and then review your list, and also note how each worry is physically making you feel.
Now that you have “identified the monster” (or monsters), how can you find ways to minimize the worry and physical discomfort that comes with it. Try to shift your perspective — not with an unrealistic goal of killing the worry altogether, but shrinking it. Try to replace the worries with stronger and more powerful thoughts.
In a safe and measured way, see if you can expose yourself to your fears in small doses. After you have done that, write down what happened in your Worry Journal: did anything bad happen? Try them again, build confidence.
Try to adopt healthy living habits that will help you better deal with stress when it does rear its head: better sleep habits, healthy diet and exercise; try meditative practices such as yoga.
Sources: Statistics Canada; Anxiety and Depression Association of America; Anxiety Disorders Association of CanadaSource: National Alliance on Mental Illness
But if the mechanism is too readily activated — if you commonly feel fear in seemingly routine situations — it can be physically and emotionally exhausting, and lead to damaging behaviour and poor health.
Some couch the modern “anxiety epidemic” in Western societies as a reflection on the modern man and woman who are unable to process routine stress.
But psychologists say an anxiety disorder is a mental illness, not weakness. The brain is engaging in “cognitive distortion” that sends signals that end up torturing an individual — and weakening them, to be sure.
McCabe doesn’t believe the numbers of people with the disorder is necessarily increasing, but that more are stepping forward seeking treatment because of education about mental health, and because there is less stigma attached than there used to be.
Nick Petrella, who teaches at Mohawk College, co-ordinates the Health, Wellness and Fitness program at the school. For years the former junior hockey and football player kept his diagnosed anxiety disorder and depression a secret, fearing that others would see him as less of a man if they knew.
Three years ago he broke down in tears in front of his class and revealed the truth. And now each year he tells his class about his journey, and also speaks to groups and schools in the community and beyond.
Mohawk, like many other colleges and universities, runs on-campus anxiety-busting activities.
But while Petrella applauds these initiatives, he also thinks the pendulum could swing too far the other way, if exam-time stress, for example, is portrayed as a disorder, when in most cases it is a natural and even productive emotional reaction.
“Research shows that stress can be a good thing, a motivator, if it provokes you to perform. I do think we ultimately need to help build resiliency in students, and children, so they can learn to cope with stress. There is a line there.”
The St. Joe’s anxiety clinic is one of the largest outpatient programs at the hospital and its numbers have skyrocketed, from about 800 in 2007 to more than 2,000 last year.
Treatment at the clinic involves psychotherapy in addition to medication prescribed by psychiatrists, depending on the patient.
Medicinal treatments for anxiety and depression have been around for ages, but since the introduction of drugs that inhibit the central nervous system, their effectiveness and use has increased.
(While medication generally has a proven track record, it is a complex area, with issues surrounding patients following treatment properly and side-effects, as well as the over-prescribing of newer, more expensive types of medications. Mood and anxiety medication for children is another area entirely that is hotly debated.)
Arguably the most exciting frontier for treatment is cognitive behavioural therapy (CBT).
This form of psychotherapy capitalizes on the brain’s “neuroplasticity” — the brain’s ability to reorganize itself by forming new neural connections throughout life.
“CBT changes the way people’s brains work, it is well established in the research,” says Karen Rowa, a psychologist at St. Joe’s.
“We can train the areas of the brain that get activated or how they get activated. People can change how they think, and that can change how your body reacts to stressors.”
“Our thoughts impact the way we feel. Are our thoughts always realistic? No. And they are not always true, either.”
Rowa is speaking to a group of about 10 patients at a session in the anxiety clinic at St. Joe’s.
She is teaching them to recognize anxiety in their daily lives and to note how it is affecting them, all toward the goal of “shrinking the monster.”
The sessions run once a week for 12 weeks. The participants are outpatients that have been referred to the clinic by family doctors.
Group therapy has helped the clinic reduce wait times; in 2012 patients waited up to 15 months to be seen, but that has been reduced to one or two months.
Groups include social anxiety, panic disorder, OCD, post-traumatic stress disorder (PTSD), generalized anxiety, and perfectionism.
One of the teachings in the OCD group is that, for those who frequently have odd or morbid or deviant sexual thoughts that pop into their head, that this is normal — that most people have these blips in thought. The key thing is to recognize that it’s normal, and move on, and not obsess over it and feel badly and withdraw as a result.
The core strategy in a CBT group is to educate patients about their anxiety, and “get a sense of where the anxiety lives” and “normalize” the experiences causing them stress; understand how common it is, and then counter it by gradually re-exposing themselves to those experiences.
Rowa tells the group it is about the “and then what?” question: You feel anxiety or panic about something about to happen — you are afraid to call someone by name fearing you will get the name wrong — but what will happen if you do it? Will it be so terrible if you call them the wrong name?
“The person will correct you,” Rowa says. “And? And then what? It won’t be so terrible. What is the worst thing that could happen?”
If they can train their brains to answer that “and then what?” question routinely, it will alleviate the anxiety of the unknown or worst-case scenario.
Patients at today’s session talk about physical discomfort they felt from anxiety the past week, to illustrate the link between their thoughts and how their bodies react.
A woman says one night she was excited to go out with friends but started to feel so anxious, and sick, she couldn’t leave the house.
“Avoidance often provides some relief, but it kicks you in the butt, too, the regret,” says Rowa.
“I know that avoiding it will make me feel worse, but I just can’t do it at the time.”
Audrey Aiken and Karen Rowa with teaching slides on the screen in a seminar room. The slides are about “cognitive distortions.” Rowa, psychiatrist, together with Aiken, left, psycho-therapist, lead anxiety disorders group therapy sessions at St. Joe’s that help people identify and deal with anxiety. Gary Yokoyama, The Hamilton Spectator
Audrey Aiken, a registered psychotherapist, writes down the woman’s thoughts on an overhead projection. This is part of the therapy; identify what is torturing you, and unpack it.
They also teach breathing exercises: breathe from the diaphragm, not chest; chest breathing promotes shallow, rapid breaths and can lead to a panic attack.
Today’s session is about “cognitive distortions” — how the brain blows anxiety out of proportion. These include:
Catastrophizing: It’s snowing outside, you will crash and die driving to work.
Probability Overestimation: You will contract Ebola; your plane will crash.
All or Nothing Thinking: My new colleagues at work will either love me or hate me.
Mind Reading: That person didn’t say hello back to me because they don’t like me.
“Should” Statements: I “should” know why I feel weak today, why don’t I?
Fortune Telling: If I go to this event I will not have a good time.
Intolerance of Uncertainty: I don’t know who will be at the meeting. What is the meaning of life? Will my kids grow up to be decent people?
Their homework is recording in their journals thought distortions they notice this week and sharing them with the class.
The patients are all ages. One woman in the session, perhaps in her early 30s, speaks up frequently, is animated, engaged, clearly getting the most out of the teaching.
But then, with 20 minutes left in class, she seems to turn inside herself, pulls the hood of her sweater over her head, stares at the table, her face red, eyes tearing. It is like someone else has taken over her brain, even surrounded by all the positive talk and learning.
Changing the brain does not happen quickly.
Genetics play a role in developing social anxiety; to some degree we inherit temperament, which frames how we encounter stressful situations. Rowa says 10 per cent of adults have social anxiety.
And then there are perfect storms of anxiety, where both genetics and a traumatic event can trigger a cluster of disorders.
Shari suffered from severe depression and PTSD. She was treated at the anxiety disorders clinic at St. Joe’s. Her anxiety became so severe she stayed primarily in bed for seven months. Life is great now and she has never been happier; takes her meds, and has cognitive behaviour therapy tools she learned at the clinic, ready for anything that happens to her. Shari is seen here with her dogs Jake, Kelsey, and Kali. Cathie Coward, The Hamilton Spectator
That was the case with Shari — she agreed to a photo, but asked that her last name not be published — who received death threats in her job as a social worker years ago, which ultimately led to a diagnosis in her late 40s of post-traumatic stress disorder, obsessive-compulsive disorder, agoraphobia (she was afraid to leave the house), panic disorder, and generalized anxiety.
She was treated by McCabe for four years, and after therapy, and medication that she continues taking, she emerged on the other side happy and content with her life.
“CBT changed the way I saw everything, it saved my life.”
She wears her wisdom acquired from CBT on her sleeve, or rather wrist; a tattoo that reads “Let It Be.”
Ashley Owen, a patient in the fall CBT group session, figures some of what ails her is rooted in her genes, and past experiences.
She is 25 and has been diagnosed with generalized anxiety disorder. As a teenager growing up in Dundas, kids teased her in school and she says her best friend betrayed her. “I can’t tell you how many days I cried after that.” She attended youth anxiety clinics, which she thinks helped.
She has been paralyzed by fear of failing; has avoided job interviews because she’s certain they will go badly. Sometimes her expectations that she will be overwhelmed on the job have been self-fulfilling.
She worked a concession stand at Tim Hortons Field during the Pan Am Games and at the end of one nine-hour shift, when her booth ran out of cash for change, things got chaotic, she perceived she was going to fail, that she was going to blow it — “I just thought, ‘I can’t do this'” — and ended up sitting curled in a ball on the ground, in tears, unable to move.
She has not taken medication, although her family doctor prescribed it to help her avoid panic attacks. She wants to see how far she can go with CBT therapy at the clinic first.
“What if the meds change a fundamental part of who I am?” she asks.
(Medication is designed to repress anxiety, which invariably alters behaviour. Whether this equates to changing who you are, or revealing who you are, seems an open question.)
Chatting over coffee in Dundas, Owen is open, funny, and expressive. The only hint of her anxiety is that she avoids eye contact. What you can’t see is how her hands shake and she perspires, talking with someone outside what she calls her comfort “bubble.”
She is critical of teenagers she sees on social media self-diagnosing their anxiety. If you think you have it, she says, see a doctor, but don’t chalk up stress over school or social life to a disorder. Because she knows what the real thing feels like.
She says the CBT sessions seem to be helping, although she had to break through the anxiety wall of attending the session at all.
“I was worried that people were judging me for my opinions. But sitting there listening to others, you realize that all these different people have a lot of the same worries as you.”
It is tempting to think of anxiety as a modern affliction. And certainly it has evolved, reflecting a moment in history where people worry over everything from Donald Trump to the number of likes on their Facebook page to viruses biological and cyber; where stress builds chasing happiness or perfect health in an age where we have never been healthier. (Psychiatrist Arthur Barsky called modern society “the worried well.”)
Who knows what troubled the ancient Greeks, but their physicians diagnosed anxiety as an illness.
Thinkers from the Stoic school of philosophy, notably Epictetus, were essentially teaching cognitive behaviour therapy 2,000 years before the notion existed.
“We are disturbed not by what happens to us, but by our thoughts about what happens,” Epictetus said.
And this: “Some things are in our control, and some things are not. It is only after you have faced up to this fundamental rule and learned to distinguish between what you can and can’t control that inner tranquility and outer effectiveness become possible.”
Those are just words, and old ones at that, but as a therapeutic starting point they are perhaps just what the doctor ordered.