The only thing we have to fear is fear itself. Franklin Roosevelt

This issue of the Newsletter focuses on panic disorder and agoraphobia. An estimated 1.5 - 3.5% of people experience panic disorder at sometime in their lives, and up to 50% of these people will also develop agoraphobia. Panic attacks frequently occur among people with other anxiety disorders, and many more people experience milder or less frequent panic symptoms. This Newsletter includes articles on panic, psychological treatments of panic disorder and comorbid panic and alcohol dependence. Stories written by people who have experienced panic and agoraphobia are also included and a section on self-help strategies and guidelines for carers and families. Thank you to all the people who have shared their experiences for this Newsletter, and to Ernie and an anonymous member for their poems on OCD. You may have noticed a new ‘motto’ which appears on the front of this Newsletter : ‘ Promoting Recovery and Empowerment’. This motto arose from a three day management review, training and planning workshop which was attended by the OCADF Committee of Management, staff and volunteers. Many positive outcomes resulted from the workshop, including the development of a 3 year strategic plan for the Foundation, identification and formalisation of standards for our services, and the emergence of a clearer vision for the Foundation. This vision was crystallised within the words of the new mission ‘motto’. We believe that these goals of promoting recovery and empowerment should be the primary focus of all the Foundation’s services, and importantly should underpin the ‘philosophy’ and standards of the OCADF. The new vision and the sense of shared and strong purpose among the Committee, staff and volunteers is very exciting and, I believe, will lead to improved services and support for all those who use our services.

Kathryn I’Anson Director / Newsletter Editor Each of us has unsuspected power to accomplish what we demand of ourselves, if we care to search for it. Claire Weekes OCADF Newsletter WINTER 1998 1 “The term ‘panic’ is derived from the name of the Greek god Pan. According to Greek mythology, the cloven-footed, dwarfish Pan was a lonely and moody god. He had an impish sense of humour and played practical jokes on humans. If a wanderer happened to pass the cave where he was hiding, Pan would jump out with a shrill and terrifying scream. The acute terror felt by the wanderers who experienced this treatment came to be called ‘panic’. A panic is now defined as an episode of intense fear of sudden onset, usually peaking within a minute. The fear, often bordering on terror, is generally accompanied by unpleasant bodily sensations, difficulty in reasoning, and a feeling of imminent catastrophe which can be expressed as ‘Something terrible is happening to me’; ‘I am in great danger’.” PAN Extract from: Panic Disorder : The Facts, by Stanley Rachman and Padmal de Silva, 1996, Oxford University Press.

Panic Attack I have been an anxious person all my life, but the first panic attack struck in my late ‘30’s. Needing to buy a few articles at the local supermarket, I drove there alone one evening, thinking I was in a ‘safe’ situation - the protection of being in the car, not many people about, and only a short distance to travel. I entered the shop and walked towards the rear. After a few steps my legs began to feel strange and weak, my body felt peculiar and light, and my head felt as though it was losing all sense of reality - like withdrawing into a strange dream. A feeling of terror gripped me and I just wanted to run and get out of there. At the same time another strong feeling was trying to get through - to do what I had come for and make the purchases. I forced my body to keep moving and look for the articles - every step was an effort (like wading through cotton wool). I wondered if other people were watching me, noticing my distress. I desperately tried to appear normal and my fear rose as I thought I might embarrass myself and look stupid. Somehow I got the articles from the shelves (not many, thank goodness), managed to pay for them and reach the car. My hands were shaking and I thought I would collapse in a heap. I sank into the car seat thinking that the feelings would subside - but not so! The overwhelming urge now was to get back to the safety of home before I disintegrated, and the only way to do it was to drive myself there. I would not have got out of the car and phoned for help for a million dollars. I started the car and amazingly my feet hit the right pedals and my hand operated the gear stick - but in my mind I was thinking - how do I do this - how do I put in the clutch, change gear and push the accelerator - it all seemed foreign like I had never done it before. As I drove along, all coordination seemed to have left my legs. Instead of my feet moving automatically from pedal to pedal I had to think what to do with them - and the same with the gear stick. My mind seemed to be somewhere else and all my body was consumed with distress. I was terrified that I would suddenly forget everything, my arms and legs would stop functioning and I would have to stop. The traffic was light, I hugged the side of the road, not wanting to stop because I would never be able to start again. Only one kilometre to travel but it seemed like one hundred. Only one red light to pass and I had to get it. One minute to wait until the light turned green and it seemed like one hour. I was a danger on the road. I feared that my shaking feet would miss the pedals and I would stall the car. On finally pulling up outside my front door I leant on the car horn until my husband came outside. When he asked what I thought I was doing, all I could say was ‘I’m frightened - get me inside’. After sitting on the couch for half an hour my body and mind seemed to calm down. I was very bewildered and angry to realise that a panic attack could ‘get me’ in a ‘safe’ situation and cause such distortion of function and feeling. I began to worry about where and when these terrible feelings and sensations would happen again. Anon. OCADF Member, 1998

2 WINTER 1998 OCADF Newsletter

ARTICLES

& RESEARCH

PANIC ATTACKS AND PANIC DISORDER (Extracts from published article, 1998) by Dr. Don Jefferys Clinical Psychologist Associate Department of Psychiatry, Austin Hospital, University of Melbourne

Introduction A panic attack is a discrete period of intense fear or discomfort accompanied by at least four of thirteen possible cardiac, neurological, gastrointestinal, respiratory or psychological symptoms (see Table 1): most report seven to thirteen symptoms. It is the symptom profile that may mimic other medical disorders (see Table 2), that leads to the misdiagnosis and the high utilisation of medical services of those who suffer panic attacks.

TABLE 1 TABLE 2 1. PALPITATIONS , POUNDING HEART OR ACCELERATED MEDICAL DISORDERS AND SUBSTANCES HEART RATE THAT CAN MIMIC PANIC SYMPTOMS 2. SWEATING ALCOHOL WITHDRAWAL 3. TREMBLING OR SHAKING AMPHETAMINES 4. SENSATIONS OF SHORTNESS OF BREATH OR SMOTHERING ASTHMA 5. FEELINGS OF CHOKING CAFFEINISM 6. CHEST PAIN OR DISCOMFORT CARDIAC ARRHYTHMIAS 7. NAUSEA OR ABDOMINAL DISTRESS CARDIOMYOPATHIES 8. FEELING DIZZY , UNSTEADY , LIGHTHEADED OR FAINT COCAINE 9. DEREALISATION (FEELINGS OF UNREALITY) OR CORONARY ARTERY DISEASE DEPERSONALISATION (BEING DETACHED FROM ONESELF ) CUSHING ’S SYNDROME 10. FEAR OF LOSING CONTROL OR GOING CRAZY DRUG WITHDRAWAL 11. FEAR OF DYING ELECTROLYTE ABNORMALITIES 12. PARAESTHESIA (NUMBNESS OR TINGLING SENSATIONS ) HYPERPARATHYROIDISM 13. CHILLS OR HOT FLUSHES HYPERTHYROIDISM HYPOGLYCAEMIA HYPOTHYROIDISM MARIJUANA MENOPAUSAL SYMPTOMS The Panic Attack MITRAL VALVE PROLAPSE A panic attack commonly peaks in ten minutes and lasts for PHEOCHROMOCYTOMA PULMONARY EMBOLUS thirty minutes, with less intense and residual symptoms lasting TEMPORAL LOBE EPILEPSY from minutes to hours. The residual symptoms include TRUE VERTIGO weakness, fatigue, trembling, uneasiness and impaired concentration, symptoms that are often as distressing as those occurring during the attack. It is the escalating intensity of symptoms during an attack that differentiates a panic attack from other anxiety states, particularly generalised anxiety disorder. During the attack, individuals report feelings of impending doom, believe they are going to die, lose control, or go crazy. They often fail to comprehend what is occurring and most desire to escape their situation. Three types of panic attacks are now commonly described. It is the presence or absence of a specific trigger that differentiates between types. Spontaneous or uncued panic attacks occur unexpectedly day or

OCADF Newsletter WINTER 1998 3 night and are often the first attack experienced, an attack vividly recalled by most. Nocturnal panic attacks occur during non-REM sleep; the symptoms are often more intense and worrisome for the sufferer. Panic attacks may be situationally bound, that is, they almost always occur on exposure to, or in anticipation of, entering a feared situation. Situationally predisposed attacks are not necessarily tied to a cue, that is they may or may not happen, they may occur sometimes, or only after repeated exposure while in the feared situation. In contrast to spontaneous panic attacks, those that are situationally bound or predisposed, have a gradual onset and are less intense; they continue, however, to be debilitating and feared. It is the panic attacks that are situationally bound that occur in the other anxiety disorders, social phobia, specific phobia, post-traumatic stress disorder and obsessive compulsive disorder.

Panic Disorder The diagnosis of panic disorder is made if the individual experiences: (a) Recurrent, unexpected panic attacks (b) At least one of the attacks is followed by one month or more of the following: i. Persistent concern about having an additional attack ii. Worrying about implications of the attack iii. A significant change in behaviour related to the attack The frequency and severity of the attack, in those with panic disorder, vary. Some experience panic attacks daily separated by weeks of being panic attack free. In those with panic disorder, limited symptom attacks often occur (less than four symptoms) as do situationally cued and situationally predisposed panic attacks. When panic attacks occur repeatedly, avoidance of the situation associated with the panic attacks may lead to agoraphobia (see Table 3 and Table 4). Studies suggest that one third to one half of those who develop panic disorder, may, at some time, develop agoraphobia. It is those with life-time comorbid anxiety and depressive symptoms who are most likely to do so.

TABLE 3 : ESSENTIAL FEATURES OF AGORAPHOBIA 1. ANXIETY IS EXPERIENCED ABOUT BEING IN A SITUATION WHERE ESCAPE MAY BE DIFFICULT , OR HELP UNAVAILABLE , IF A PANIC ATTACK OCCURS . 2. THE SITUATIONS ARE AVOIDED , OR ELSE ENDURED WITH MARKED DISTRESS OR ANXIETY , ABOUT HAVING A PANIC ATTACK . 3. ENTERING THE FEARED SITUATION IS PRECEDED BY ANTICIPATORY ANXIETY ; THE CORE FEATURE IS CONCERN ABOUT HAVING A PANIC ATTACK .

TABLE 4 : THE MOST COMMON AGORAPHOBIC FEARS

OUTSIDE ALONE AT HOME ALONE

BEING IN A CROWD BEING IN A SUPERMARKET

TRAVELLING ON ANY MODE OF TRANSPORT CROSSING A BRIDGE

STANDING IN A QUEUE SITTING IN A THEATRE

ATTENDING A RESTAURANT

Prevalence and Age of Onset of Panic Disorder Up to 30% of the adult population will, at sometime, experience a panic attack. Epidemiological studies clearly show, however, that the life-time prevalence of panic disorder, with or without agoraphobia, is 1.5 - 3.5% with twice as many women affected as men. Studies suggest, however, that the prevalence with panic disorder presenting in general practice is as high as 10%. Panic attacks can occur across the life span; onset of panic disorder, however, most commonly occurs between late adolescence and mid-thirties.

Course Panic disorder is a chronic waxing and waning condition. For some, the disorder is continuous, for others the disorder is episodic, while panic disorder with agoraphobia may develop at anytime; onset is often within one

4 WINTER 1998 OCADF Newsletter year of the occurrence of regular panic attacks. Regardless of mode of treatment, outcome studies collectively suggest high rates of chronicity.

Comorbidity Comorbidity is the norm with panic disorder with up to 65% reporting further psychiatric diagnoses. Mood disorders are the most common comorbid diagnosis with dysthymia more common than depression. Clinical studies suggest, however, that many with panic disorder experience symptoms of depression but do not reach the diagnostic criteria for major depression. Life-time prevalence rates of depression with panic disorder range from 63 - 68%; the episodes of depression occurring separately, simultaneously or as a complementing factor of the other. When past or present depression is confirmed, the panic disorder is often more chronic and disabling with phobic anxiety symptoms more severe. Studies consistently show that suicidal ideation and suicide attempts are higher in panic disorder than other psychiatric disorders. Up to 20% of those with panic disorder will attempt suicide. Many with panic disorder have a comorbid anxiety disorder; the onset is likely to have preceded the onset of panic disorder. Up to 47% report specific phobia with 30% reporting social phobia. Alcohol use as a mode of self-medication is common in those with panic disorder; up to 82% report, at times, having used alcohol to cope with their panic. Most, (72%) consider it to be effective in alleviating their anxiety. Some 22% of those with panic disorder develop alcohol or substance abuse disorders. Where there is a comorbid personality disorder, treatment outcome is poor. Between 40 - 70% may have a personality disorder, the most common being avoidant, dependent, histrionic and borderline.

PSYCHOLOGICAL TREATMENT You must do the OF PANIC DISORDER thing you think you cannot do. by Leora R. Heckelman, PhD. New York Hospital / Cornell Medical Centre Eleanor Roosevelt Reprinted with permission from the ADAA Reporter, Fall 1993

Although there is an ever-increasing body of data B. Diaphragmatic Breathing Retraining: supporting the efficacy of psychopharmacological With detailed information about the treatments for panic disorder, many who suffer physiology of hyperventilation as background, from panic attacks prefer a psychotherapeutic patients are then taught a slow, diaphragmatic treatment either in place of, or in addition to, breathing method. These breathing retraining medication. Four currently recommended non- exercises, (which patients are instructed to practice pharmacological psychotherapeutic treatments for twice daily) are designed to reduce both the panic disorder are described below. frequency and intensity of physical sensations. C. Identifying and Countering Cognitive I. PANIC CONTROL TREATMENT Distortions: (Craske & Barlow, 1990) In the next phase of treatment, patients are Panic Control Treatment (PCT) is a time-limited, taught to identify and challenge aberrant anxiety- cognitive-behavioural treatment which is comprised provoking beliefs. Since catastrophic thinking (i.e., of four basic components: anticipating that a negative situation will have A. Psycho-educational Component: catastrophic consequences) and probability over- In the first phase of treatment, accurate estimation (i.e., the tendency to overestimate the information about the physiology of panic attacks likelihood of a negative event) are characteristic of and hyperventilation is presented in a psycho- patients with panic disorder, these two cognitive educational framework. Patients are taught that a distortions are given special attention. panic attack is the sum-total of physical sensations D. Interoceptive Exposure to Anxiety- brought on by the fight-or-flight response which is Related Body Sensations: harmless to the body and actually serves a survival- Panic disorder is often described as a fear of oriented function in ensuring the arousal necessary fear sensations because it is frequently the for protection from danger. conditioned fearful reactions to anxiety-related body

OCADF Newsletter WINTER 1998 5 sensations (such as shortness of breath, numbness, sensation throughout her body, sensations which tingling, palpitations, dizziness etc.…..) which lead she feels have come completely ”out of the blue”. A to an escalation in anxiety. Interoceptive exposure, catastrophic misinterpretation of these symptoms introduced in the final phase of the Panic Control would involve the belief that she was having a heart Treatment, involves repeated exposures to the fear attack, while, in fact, these same symptoms might sensations themselves. If, for example, a patient result from her having recently finished drinking a responded to dizziness by becoming anxious, she/he large cup of coffee on a day when she had been should be encouraged to spin in a rotation chair rushing because she was late for work. until dizzy and to then practice using the cognitive and breathing strategies to decrease the related A therapist working with this patient in Cognitive anxiety. Therapy would: 1. Help her to focus in on the specific negative PCT is usually completed in twelve, 50-minute, predictions she was making about her individual treatment sessions. In between sessions, symptoms. (I’m thinking these symptoms are patients are asked to keep a log of any panic attacks evidence of a heart attack….. Worrying that I they experience, recording the time, related am having a heart attack is making me feel more external triggers, and any associated physical apprehensive which is making my symptoms sensations, thoughts and behaviours. Once they worse….”) have mastered the breathing and interoceptive- 2. Encourage her to develop rational responses to exposure exercises in the treatment office, patients these anxiety-producing thoughts (“My body is are asked to practice these exercises at home. simply responding to a caffeine rush; these are Based on data from a series of large clinical not necessarily symptoms of a heart attack….”) trials, it appears that approximately two-thirds of 3. Assist her in identifying and challenging the the patients who finish the Panic Control Treatment evidence used to support anxiety-provoking are panic free. This is roughly comparable to the beliefs (“Have I ever felt symptoms such as proportion of patients who remit on these before? Was I having a heart attack then? psychopharmacological treatments. A large, multi- Does the fact that your pulse rate increases or centre NIMH study is currently underway you feel a tingling sensation necessarily mean comparing Panic control Treatment to that you are having a heart attack?”) pharmacological treatment with Imipramine and a 4. Offer more adaptive or realistic interpretations placebo control. Results from this study are as alternatives to these beliefs (“Is it possible forthcoming. that these symptoms are resulting from the fact that I just drank a large cup of coffee, was II. COGNITIVE THERAPY FOR PANIC running fast and was very worried and worked DISORDER up because I was late for work?”) (Clark, 1989; Salkovskis & Clark, 1991) 5. Demonstrate possible alternative causes of fear- Although there is considerable overlap in the inducing body sensations by intentionally procedures used between PCT and Cognitive inducing these sensations. (In this case, the Therapy, Cognitive Therapy (CT) focuses more woman might be encouraged to drink a large exclusively on challenging and changing cognitive cup of coffee just before her session so that she misinterpretations about body sensations. The could observe directly that ingesting large central notion of this treatment is that panic attacks amounts of caffeine can bring about the same can result from the catastrophic misinterpretations symptoms she fears are evidence of a heart of specific bodily sensations which involves a attack). This exercise affords the patient an perception that physical sensations are much more opportunity to disconfirm her negative dangerous than they really are. For example, when predictions about the symptoms and their catastrophizing, a patient who is experiencing consequences. She sees once again that she can shortness of breath would consider this to be experience the constellation of feared symptoms evidence that he will soon stop breathing all (palpitations, pain in the chest, body tingling together and die from suffocation. Catastrophic etc…) but is not in fact, having a heart attack. misinterpretations such as these can lead to At a later point in treatment, Clark encourages a increased apprehension which, in turn can, lead to decrease in the use of safety behaviours (such as increased symptom intensity,…”(Clark, leaning on a wall when feeling dizzy or avoiding 1986,p.463). caffeine) so as to further disconfirm the negative Consider the example of a woman who predictions. reports an increased pulse rate, heart palpitations, sharp chest pains, a “wired-feeling” and a tingling

6 WINTER 1998 OCADF Newsletter Clark’s treatment is generally conducted in twelve, may be elicited. This technique is best individual treatment sessions. Patients are asked to illustrated by example. maintain daily logs monitoring their negative predictions about symptoms and their consequences A high school senior, pressured by a demanding as well as rational responses to these anxiety- academic schedule at a competitive school, recalls producing thoughts. Recent results reported by taking an evening off to watch TV and relax. While Clark and colleagues (1993) indicate that reduction watching her favourite show, she experiences a full in degree of panic and anxiety was significantly blown panic attack. Puzzled, the patient presents better for patients treated with Cognitive Therapy this apparent incongruity to her therapist, stating than for wail-list controls. that she has no idea why she had an attack, especially at a time when she was feeling so relaxed. III. NON-PRESCRIPTIVE TREATMENT Following the guidelines of the reflective (Shear, 1993) listening process, the therapist then reviews the Katherine Shear’s time-limited treatment utilizes scenario with the young woman asking her to psychoeducation and reflective listening strategies to provide more details about the incident and help patients increase their awareness of and encouraging her to recall any body sensations or acceptance of unacknowledged or avoided negative associated internal responses. The patient then affects (such as anger and aggression) which are recalls being approached earlier in the evening by likely to be contributing to the generation and her father who, noticing that she is watching TV, maintenance of panic episodes. suggests that she “use her time more productively” Shear observes that: and help him to balance the family’s budget. At first 1. Because the body sensations associated with the patient reports that she “thought nothing of it” negative affects are typically linked with and agreed to help her father at the end of the next escalating fearfulness of these sensations, show. In response to the therapist’s probing, patients prefer to avoid experiencing these however, the patient then recalls “an increased feelings. heart rate, a knot in her stomach, and flushed 2. Patients who suffer from panic attacks cheeks…” Upon further exploration, the patient experience a diminished sense of safety and acknowledges having felt an initial “flash of controllability of the world around them. As indignation” because her father was not respecting such, they rely more on others to ensure a sense her need to relax. “… But then I felt very guilty for of security and can frequently develop strong thinking this because my father works so hard and dependency needs, a desire to please others and does so much for our family.” an intense fear of abandonment. Given this After clarifying that it was actually irritation perceived dependency, experiencing any with her father that the patient experienced, the negative emotion (such as rage or aggression) therapist can then help her to recognize that she which might threaten interpersonal relations suppressed and ignored this feeling because (i.) she leads to intense anxiety (or guilt) about the was afraid of related anxiety-producing sensations, negative affects. and (ii.) she felt guilty about feeling irritation with her father. Alternative, more assertive methods for The Goals of NPT are Two-Fold: managing and expressing this affect can then be 1. To decrease the fear enhancing features of explored. bodily sensations associated with anxiety/panic as well as with a broad range of negative This treatment has been conducted in 12 weekly, feelings. This goal is addressed through a individual treatment sessions, patients are asked to psychoeducational component which is similar, keep a log recording stressful life events and anxiety although not identical to the psychoeducational episodes useful for providing scenarios for reflective portion of PCT. A strong emphasis is placed on listening and discussion. the harmlessness of the panic sensations and Compared to well-developed and widely- their relationship to protection and survival. studied treatments such as Barlow and Craske’s 2. To improve the ability to accept, modulate and PCT and Clark’s CT, NPT is relatively new. manage negative affects thereby enhancing the Preliminary data (based on a series of case studies sense of controllability of the internal and and one clinical trial) offer support for the efficacy of external world. This goal is approached through NPT. Shear has recently designed a manualized a process of reflective listening in which the treatment protocol; she plans a controlled clinical therapist encourages the patient to discuss trial of this newly-manualized treatment. recent life events and then facilitates recognition and acceptance of the negative affects which

OCADF Newsletter WINTER 1998 7 IV. TRADITIONAL SYSTEMATIC and building toward the higher ranges. Exposure DESENSITIZATION can be done either in vitro (the person closes his/her eyes and imagines being in the feared situation) or in Many patients with panic disorder also experience vivo (the patient actually travels to the specific panic related phobic avoidance (‘agoraphobia’). location/situation and uses the relaxation techniques These patients find themselves avoiding specific to reduce any anxiety he/she might experience in places (subways, elevators, bridges, tunnels, the situation). Over time, and with repeated supermarkets) for fear that they might have a panic exposures in a graded, hierarchical fashion, the attack in these situations and be trapped and unable patient will habituate to the situation and the to escape or get help. None of the above described conditioned fear response associated with the treatments targets this avoidance in particular. situation will diminish. In general, patients quickly Generally, panic related phobic avoidance remits develop a mastery of mild-moderately feared spontaneously once as the fear of panic attacks is situations and soon experience little or no anxiety in addressed. If the phobic related avoidance persists, these situations. Having accomplished this, the a traditional systematic desensitization may be patient is then ready to select a slightly more useful. challenging situation for exposure. In this treatment, the patient is asked to Although patients quickly expand the make a list of all of the situations she/he is avoiding number of situations in which they feel comfortable, or having difficulty enduring for fear of having a treatment which targets the avoidance alone and panic attack and to determine how much anxiety or does not address other features of panic disorder, is distress each situation evokes using a Subject Units only of moderate value. In some cases, however, of Distress Scale (SUDS) rating ranging from 0 (no this type of desensitization is a helpful augmentation distress) to 100 (extreme distress). These situations to PCT or CT. are then hierarchically organized from least stress including (0) to most stress inducing (100). An References Clark, D.M. (1986). A cognitive approach to panic. Behaviour individual might, for example, feel that going with a and Research Therapy, 24:4, 461-470. friend to the corner store to be associated with a Clark, D.M., Salkovskis, P.M., Hackman, A., Middleton, H., SUDS rating of 30, going alone to the corner store Anastasiades, P., & Gelder, M. (1993). A Comparison of to be a 40, going to a large crowded mall with a cognitive therapy,, applied relaxation and imipramine in the treatment of panic disorder. Submitted for publication. friend a 70, and going alone to a mall to be Craske, M.G. & Barlow, D.H. (1990) Therapist Guide for the associated with 100 (or the most distress Mastery of Your Anxiety and Panic (MAP Program). Centre for imaginable). Stress and Anxiety Disorders, University of Albany, State After learning a number of relaxation University of New York, Graywind Publishing Company. techniques (including deep breathing and Salkovskis, P.M. and Clark, D.M. (1991). Cognitive Therapy for Panic Attacks. Journal of Cognitive Psychotherapy: An progressive muscle relaxation) patients begin a International Quarterly, Volume 5, Number 3. process of systematic exposure to the situations in a Shear, K.M. (1993). Non-Prescriptive Treatment Manual for hierarchically graded fashion, beginning first with Panic Disorder. Unpublished manuscript. situations which are moderately anxiety producing

CO-MORBID PANIC DISORDER AND ALCOHOL DEPENDENCE by Cynthia Amundsen MSW; R. Bruce Lydiard Ph.D. M.D., USA Reprinted with permission from the ADAA Reporter, March/April 1994

The co-existence of panic attacks with other disorders is common, but is always well recognized by therapists. In particular, some individuals with panic disorder may consume excessive amounts of alcohol as a way of relieving anxiety. This important issue is discussed by Ms. Amundsen and Mr. Bruce Lydiard, of the Medical University of South Carolina, in the following article. A 58 year old, married, white female is seen by a physician, and is complaining of symptoms which include tachycardia, tremors, dizziness, choking, abdominal upset, numbing, tingling and hot flashes. Furthermore, she verbalizes an overwhelming fear that she is going to lose control, or go crazy. She states these spells are unprovoked, and last approximately twenty minutes. She also relates that she has suffered from these spells for the past thirty-six years. For the past seven years she has avoided driving her car, crossing bridges, and attending church activities. She has become more and more withdrawn and now, almost entirely isolates herself from others. Additionally, while recalling these spells, she now remembers that her mother and possibly a maternal aunt suffered from the same sort of illness and that each of them had been institutionalised on

8 WINTER 1998 OCADF Newsletter mental health wards for treatment of their mysterious illness. To further complicate this patient’s case, she now admits that she is drinking excessively as a means of coping with her anxiety. She finds that when she self- medicates with alcohol, she feels more relaxed and that it “takes the horrifying edge off” the unexplainable spells she has been suffering. She has given up trying to find help and understanding. She has been thoroughly evaluated by a family practice doctor, a cardiologist, an internist and a gynecologist. She has twice gone to emergency rooms complaining of heart attack-like symptoms and was sent home hours later without a diagnosis. She is now taking Xanax, 0.5 mg TID, but her prescribing physician does not know she is drinking as well as taking the Xanax. Obviously, this patient is suffering from panic disorder as do almost 2-5% of the general population. This patient also can be classified as suffering the “dual” diagnosis of alcohol dependence. One study (Helzer and Pryzbeck, 1988), reported that the occurrence of alcoholism is 2.4 times higher in individuals with panic disorder that those with no psychiatric disorder. Evidence from family studies suggests that alcoholism and panic disorder not only co-occur in individuals, but are also manifested in family constellations (Weissman, 1988). Clinicians sometimes fail to assess their patients for a related disorder when either alcohol dependence or panic disorder has been identified. Given that these two disorders co-exist so frequently, failure to recognize either panic disorder in the presence of alcohol dependence or alcohol dependence in the presence of panic disorder can have a deleterious effect on treatment planning, compliance and outcome. For instance, prescribing benzodiazepines for panic disorder may be effective for many individuals but may be a mistake if the patient is currently alcohol dependent. Suggesting standard treatment for alcohol dependence, i.e. A.A. group therapy, etc., may prove effective for an individual who is just alcohol dependent. But for someone with panic disorder, these treatments are insufficient or their own clients with untreated anxiety are often unable to “stand up and tell their story”. Subsequently, these dually diagnosed individuals may be seen as “treatment failure” when the reality may be that the treatment failed them. For dually diagnosed individuals, treatment plans need to be “customized” to their particular disorders, and moreover, the disorders are to be treated simultaneously rather than on a separate and individual basis. After all, the “co”, Latin from com; or akin to; and “morbid”, Latin from morbidus; or diseased nature of the disorders serve to fuel the fire of the other. It then makes sense to treat each disorder in an equally attentive manner. There are many effective treatment strategies for individuals who fall in this dually diagnosed group. Certain pharmacotherapies such as imipramine, a non-addictive tricyclic antidepressant, have been shown to be useful in treating panic disorder. This, coupled with a cognitive-behavioral treatment, is believed to be an essential component of treatment for the following reasons. Panic disorder, especially, not only produces the physical sensations of sweating, tingling, heart palpitations, etc., but also elicits in its victims the very real fear of “O.K., I got through that one, what about the next panic? I will surely die next time.” Even though we know that panic disorder is not fatal, convincing our victims of this is often an arduous task. Relieving their physical symptoms of a panic attack is much easier than relieving their fear of having another attack. Changing their cognitions about the attack, de-mystifying the attack, helping them understand the physiology of the attack, and helping them understand that their alcohol usage only exacerbates their condition, are essential components for their recovery. Funded by the National Institute on Alcohol Abuse and Alcoholism, Lydiard, et.al., (in progress), have collected data on over 50 patients with the dual diagnosis of alcohol dependence plus panic disorder in a double-blind, placebo controlled treatment study. These study patients are seen weekly for a period of six months and their disorders are monitored and followed very closely. Furthermore, in an effort to assist them in simultaneous recovery from their disorders, patients must take part in an alcohol treatment program and this must be completed prior to their weekly out-patient visits. While the results are not yet available, we have seen that those subjects who are able to maintain their abstinence from alcohol also experience relief and, in some cases, completely recover from their panic disorder…… Knowledge gained from this important research work as well as ongoing clinical experiences continue to reinforce the importance of thorough assessments in order to make a differential diagnosis. From this, individualized treatment plans can be formulated which can expedite the course of treatment.

References 1. Helzer, J.E., Frysbeck, T.R.: The Co-Occurrence of Alcoholism with other Psychiatric Disorders in the General Population and its Impact on Treatment. J Stud Alcohol 1988: 49:219-224. 2. Kushner, M.G. Shear, K.J. Beitman, B.D.: The Relation Between Alcohol Problems and the Anxiety Disorders. AMJ Psychiatry June 1990: 147:6. 3. Lydiard, R.B., 1994: NIAAA grant in progress. Imipramine Treatment of Alcoholics with Panic Disorder. 4. Weissman, M.,: Anxiety and Alcoholism, J Clin Psychiatry, October 1988: 49:10 (Suppl).

OCADF Newsletter WINTER 1998 9 INTERNALISING TRUST, THE ROLE OF SELF-HELP by Lynn Maguire President, Phobia Society of Dallas, Texas, USA Reprinted with permission from the ADAA Reporter, Summer/Fall 1995

As a support group facilitator, I want to share with change, but in the process of therapy as well. you some thoughts about self-help. People who call Mental Health professionals can help build trust by: our support groups in Dallas are desperate for help. 1) listening I answer by talking about self-help, planting the seed 2) making an accurate diagnosis that there are many things they can do themselves 3) helping clients manage their symptoms to begin to manage their disorder. I suggest the use 4) providing education about anxiety of our groups, while recommending professional disorders help, including psychotherapy. I agree with the 5) modeling health by setting limits, having noted Dallas psychiatrist, Dr. Jerry Lewis (Swimming good boundaries, using self-control, Upstream: Teaching and Learning Psychotherapy in a encouraging independence, and Biological Era) that psychiatric disorders are expressing emotions appropriately. biopsychosocial disorders. And even though we all 6) being there - honourably and seek simple explanations, suggesting a single cause is consistently, providing the secure base oversimplification. Complex causality requires that clients need so that they may gain exploration. the trust and confidence to leave. Those who call in need don’t trust British psychiatrist John Bowlby (A Secure themselves, their bodies, their doctors, medication, Base) defined the role of parenting as providing a or therapists. Before they can internalize trust, secure base from which the child can journey into TRUST MUST BE BUILT. People with anxiety the world and explore, knowing he can return. In a disorders - particularly panic disorder, agoraphobia, similar manner, he defines the tasks of therapy as GAD and social phobia - are sensitive individuals providing a secure base and encouraging who react with extreme anxiety to body sensations, exploration. But no one gets over a phobia or panic events, objects and certain social situations because disorder in the therapist’s office; we get over it by they misinterpret meanings they attribute to the re-growing ourselves with a new set of healthier situations. They need a reliable way to begin to underlying assumptions with accurate education learn about, manage and lessen symptoms. about our bodies, with increased tolerance for Progress in therapy gives the anxiety client a sense discomfort, with appreciation of our sensitivity, and of self-control, competence and the stuff of self- by getting in touch with our complete repertoire of efficacy; acknowledged and remembered progress is a feelings. basis for trust, not only in themselves as agents of

Research Project Findings : The Relationship between perfectionism, responsibility, anxiety, depression and obsessive compulsive symptoms in a clinical sample. Nicky Rollerson, BA Honours (Psychology), Swinburne University, 1997. Many thanks to all those members of the Obsessive-Compulsive and Anxiety Disorders Foundation of Victoria who in June/July of last year completed a series of questionnaires on OCD for me. The purpose of my research was to examine the relative importance of perfectionism, responsibility, anxiety and depression in maintaining obsessive-compulsive symptoms. In particular I wished to determine whether “inflated responsibility” played a more important role in maintaining “checking” symptoms than it did in maintaining other OCD symptoms and to determine whether perfectionism, or some aspect of perfectionism, maintained OCD “washing” behaviour. The findings of my study indicated that whilst situation-specific inflated responsibility was central to “checking” compulsions it could not account for other OCD symptoms - notably “washing” compulsions or “doubting” obsessions. Although, in general, survey respondents had very high perfectionism scores, perfectionism did not appear to maintain washing compulsions. However, there was a suggestion that the perfectionism scale may not have been sufficiently sensitive to detect high levels of perfectionism and consequently these results were not conclusive. Potentially the most important finding of the research was that a different set of cognitive and mood states appears to maintain different OCD symptoms (eg. washing, checking, doubting), suggesting that cognitive treatment programs should be tailored according to the specific OCD symptoms or mix of symptoms presented by each patient.

10 WINTER 1998 OCADF Newsletter NATIONAL SURVEY OF MENTAL HEALTH and WELLBEING OF ADULTS Extracts from ‘The Well : Newsletter of the Australian Psychiatric Disability Coalition Inc, Autumn 1998, and ARAFEMI News, Volume 5, Issue 1, March 1998.

On 11 March, the Hon. Dr. Wooldridge MP, Minister for Health, launched the report: Mental Health and Wellbeing: Profile of Adults, Australia 1997 . The survey was designed to provide information on the prevalence of a range of major mental disorders for Australian adults. Highlights from the report: • almost one in five Australians met criteria for a mental disorder at some time during the 12 months prior to the survey; • men and women had similar overall prevalence rates of disorder but it is highest in both men and women living alone; • the prevalence of mental disorder generally decreases with age; • prevalence rates are: anxiety disorders 9.7%, affective disorders 5.8% (of which depression is 5.1%), and substance use disorders 7.7% (of which 6.5% is alcohol related); • rates of mental disorder were also highest among those who were separated or divorced (24% for men and 27% for women); • women are more likely than men to experience anxiety disorders and affective disorders; • men were more than twice as likely as women to have substance use disorders with alcohol use disorders being more common than drug use disorders; • rates of mental disorder were highest for those unemployed or not in the work force; • hospital admissions for mental health problems were rare (less than 1% over the 12 month period). The survey looked at comorbidity of mental disorders, that is, the occurrence of more than one disorder at the same time. Nearly one in three of those who had an anxiety disorder also had an affective disorder while one in five also had a substance use disorder. Again there were differences for men and women, with women more likely to have anxiety and affective disorders in combination, while men were more likely to have substance use disorders in combination with either anxiety disorders or affective disorders. The survey used a number of different measures of disability, based on standard international questionnaires, in order to measure the impact of mental disorders and physical conditions on people’s lives. Anxiety and affective disorders generally had a more disabling impact than substance use disorders. Overall, those with anxiety disorders were the most troubled by physical aspects of disability while those with affective disorders fared worst in terms of a measure of mental components. The Mental Health and Wellbeing: Profile of Adults, Australia is available from the Australian Bureau of Statistics (Catalogue No. 4326.0).

NEW RESEARCH New Research Project : Prospective Memory and Obsessive Compulsive Disorder LaTrobe University, Graduate Diploma in Health Psychology. This research project will investigate the role of memory in checking compulsions. The researcher is seeking people aged between 18 and 60, who have been diagnosed with OCD and have checking compulsions to participate in this study. The study will involve performing a computer task and answering some questionnaires. If you are interested, contact Jessica Bernales at OCADF on 9576 2311.

Social and Emotional Development Study at the University of Melbourne There is an exciting and important study on children’s social and emotional development taking place at the University of Melbourne. Parents with 2 year old children have the opportunity to visit our playroom, twice in the next few months and again in two years time, earning $30.00 per visit. Transport can be arranged if necessary. The study will examine how child characteristics such as temperament interact with styles of parenting and family characteristics to influence the later development of problem behaviours such as anxiety, depression, social withdrawl, and aggression in the child. The knowledge gained from this project will have important implications for preventing emotional and behavioural disorders in children. The study has been approved by the University of Melbourne Ethics Committee. The researchers are particularly interested in including in their project some parents who themselves experience anxiety or depression and have two year old children. If you are interested in participating or would like further information please contact Sheryl at Melbourne University on 03 9344 6370.

OCADF Newsletter WINTER 1998 11 Book Reviews

“Complete Self-Help for Your Nerves” by Dr. Claire Weekes Harper Collins, Australia, 1962/ 1997, 160pp. REVIEW BY CHERIE LACIS , OCADF VOLUNTEER - HELP LINE TEAM & RECOVERY PROGRAMME LEADER

Dr Weekes sets out to explain how a nervous breakdown begins and develops and how it can be cured. She states simply that a cure can be achieved if we use our innate courage and perseverance and emphasises that the power is within us to achieve the goal of recovery from a ‘nervous breakdown’ no matter how difficult our plight is. Dr Weekes states - “Each of us has unsuspected power to accomplish what we demand of ourselves, if we care to search for it. You are no exception. You can find it if you make up your mind to, however great a coward you may think yourself at this moment. I have no illusions about you”. An important element in the key to our recovery is understanding the notion of nervous fatigue which can manifest as muscular, mental, emotional and spiritual fatigue. Apparently any individual can suffer from any one or all of these fatigues and not be deemed as nervously ill. Essentially an individual crosses the line from being nervously fatigued to nervously ill when one fears the effects of nervous fatigue and this fear interferes with one’s life thus creating an anxiety state. The phrase ‘fear of fear’ comes to mind. The anxiety sufferer becomes fearful of the symptoms of anxiety thus perpetuating a ‘web of fear’. Dr Weekes explains the four types of nervous fatigue as follows: • Muscular fatigue relates to the physical aches that are experienced when muscles are subjected to constant and severe tension resulting in physical symptoms such as blurred vision and headaches. • Emotional fatigue occurs when our nerves are subjected to strong emotions over a prolonged period of time and become sensitised to the slightest provocation. Dr Weekes describes how a ‘fear-adrenaline-fear cycle’ can set in thus perpetuating anxiety. Fear can activate the hormone adrenaline which in turn intensifies and creates more fear and then more adrenaline results thus creating a debilitating cycle. • Mental fatigue can result from constantly thinking about and being pre-occupied with the concerns of being in an anxiety state. • Fatigue of the spirit can be experienced when the constant struggle and battle with anxiety wear us out and flatten our hope and courage. Dr Weekes alludes to ‘that persistent inner voice’ that seems to urge the anxiety sufferer to not have faith in themselves. The inner voice may say ‘Others can do it, others can recover, but not you!’ Dr Weekes advises that in a sensitised person this voice is only natural, however don’t be fooled by it. You have the capacity to move forward. Dr Weekes treatment for anxiety and a cure is based on four concepts: 1. Facing 2. Accepting 3. Floating 4. Letting time pass • FACING requires the individual to acknowledge and understand that the cure comes from within. It means facing the things and situations that make us fearful as well as facing the nervous symptoms that many of us would rather avoid. According to Dr Weekes the notion of facing fearful situations but having the option of retreating if we panic or go beyond our ‘comfort zone’ does not facilitate a long-term cure. Instead, it is necessary to face fear and panic symptoms and to learn to deal with them. The long term goal is for the individual to learn to cope with panic so that it no longer matters if it does happen. An old Chinese proverb ‘Go straight to the heart of danger, for there you will find safety’ reflects this concept. • ACCEPTING involves learning to co-exist in a kind of truce with the physical symptoms of anxiety and panic no matter how uncomfortable they can get. Fighting fear and its often terrible physical symptoms can spark more fear and thus perpetuate anxiety and panic. Desensitisation to fear lies in acknowledging the physical symptoms and discomfort and to trying to flow with it. The aim of acceptance is to try not to fuel existing fear with more fear. Obviously this isn’t easy and requires practice. Dr Weekes states that by

12 WINTER 1998 OCADF Newsletter practicing accepting, “… you earn the little voice that says, ‘It doesn’t matter anymore if panic comes!’ this is the only voice to listen to. It is your staff, and will always come to help you in setbacks, even if you find yourself almost helpless on the floor”. • FLOATING encapsulates the idea that instead of fighting and forcing our way past anxiety and fear it is more effective to physically and mentally take the path of least resistance and float towards, through and past the anxiety. Dr Weekes likens the sensation to floating on a cloud or water. The aim of floating appears to be to remove the rigid and exhausting physical and mental fight that panic and anxiety sufferers find themselves involved in when confronting fear thus removing another source of fear. Indeed, floating can be a very pleasant antidote to fear and panic. • LETTING TIME PASS asks from us an understanding that recovery can take time. It takes time for a nervously sensitised physical body to heal and for the heightened memory of fear and panic to gradually extinguish. We live in a society that fosters an expectation that life can be instant and fast, and these concepts can be counterproductive to a recovery that requires time. Dr Weekes counsels that setbacks on the road to recovery should not create dismay, but instead be expected and accepted. Setbacks provide us with an opportunity to build and forge our recovery on repeated practice and experience so that the techniques become truly ingrained in us.

“Complete Self-Help for Your Nerves” provides a wealth of practical information in addition to the practical techniques discussed in this review. The familiar physical aspects of anxiety such as churning stomach, sweating hands, racing heart, trembling and inability to take a deep breath, amongst many others are examined. The ‘all too familiar’ problems such as sorrow, guilt, obsession, sleeplessness, depression and loss of confidence are discussed, thereby providing useful information that the anxiety sufferer can tap into. The use of anxiety sufferer’s experiences to illustrate discussion helps this text to ‘come alive’ and provides practical examples that enhance understanding of the concepts discussed. An aspect of Dr Weekes attempt to facilitate the reader’s understanding and recovery from anxiety is the role and power of our thoughts in creating and perpetuating anxiety. The saying ‘Your thoughts are your reality’ comes to mind. I gleaned an impression from this book that Dr Weekes has great faith in our ability to heal our nerves. The practical advice and strategies contained in this book as well as its optimistic tone and faith provide the reader with access to the skills and courage to help themselves onto the path to recovery. An unsolicited piece of advice from this reviewer to the anxiety sufferer would be “Just read it!”

Dr. Weekes books are available from major book retailers, the Open Leaves Bookshop and may be available in your local public library. Dr Weekes Self Help Audio Cassettes are available from : Claire Weekes Publications Pty Ltd, PO Box 377 Woden ACT 2606 Australia, or contact the OCADF on 03 9576 2477 for an order form. The Audio Cassettes titled ‘Hope and Help for your Nerves’ have been highly recommended by many of our members.

“The Treatment Of Anxiety Disorders: Clinician’s Guide And Patient Manuals” by Gavin Andrews, Rocco Crino, Lisa Lampe, Caroline Hunt, Andrew Page Cambridge University Press, Australia/USA, 1994, 392 pages - set of five manuals. REVIEW BY LYNNE MAGUIRE , DIRECTOR OF THE PHOBIA SOCIETY OF DALLAS , TEXAS Reprinted with permission from the ADAA Reporter, Spring 1995

The Treatment of Anxiety Disorders by Gavin Andrews et al is a well-referenced resource book and treatment guide, focusing on panic disorder and agoraphobia, social phobia, specific phobias, obsessive-compulsive disorder, and generalized anxiety disorder, with each topic containing chapters on the syndrome and its treatment, a clinician’s guide (the art of therapy), and a patient treatment manual (also packaged separately for patient use). Writing for clinicians who want detailed information about the cognitive/behavioral treatment of anxiety disorders, the authors state (p.211): “It is useful to implicitly convey the expectation that the patient has the resources to achieve the task.” And that task, for panic disorder and agoraphobia, is threefold: long- term management of panic symptoms, elimination of avoidance and reduction in overall vulnerability to the disorder by effectively changing the “nervous personality” - sensitive, emotional and prone to worry. The

OCADF Newsletter WINTER 1998 13 chapter “Obsessive Compulsive Disorder: Treatment” simplifies the goal as having “the individual control the disorder rather than the obsessional disorder control the individual” (p. 270). Andrews et al proceed, guided by patient treatment manuals that have evolved over fifteen years of treatment of the disorders at the Clinical Research Unit for Anxiety Disorders, University of New South Wales at St. Vincent’s Hospital, Sydney, Australia. “Patients need to become their own therapists,” say the authors (p.23), as they present a patient-directed format for graded exposure, a format that leads to minimal dependence on the therapist, maximal development of self-efficacy, and a realization upon completion, that the outcome of the treatment was as a result of the client’s own work. Also included in the manuals are sections on the nature of anxiety, the control of hyperventilation, relaxation training, and cognitive restructuring. Topics restricted to a single manual include exposure to symptoms (“Panic Disorder and Agoraphobia”), assertiveness (“Social Phobia”), and problem solving (“Panic Disorder and Agoraphobia”). The Treatment of Anxiety Disorders concludes with brief looks at post traumatic stress disorder, adjustment disorders and secondary anxiety. In summary, the book details cognitive-behavioral therapy for the most common anxiety disorders. The authors note that, in many instances, etiology is complex and not fully understood; however, that does not alter the efficacy of the treatment modality. As long as patients understand that the long-term goal is management of anxiety and not its elimination, they can expect “efficient and effective” treatment.

COOK B Self Help Books OOK

Panic Disorder : The Facts Stanley Rachman and Padmal de Silva, Oxford University Press, 1996

Overcoming Panic : A Self Help Guide using Cognitive Behavioral Techniques Derrick Silove and Vijaya Manicavasagar, Robinson Publishing Ltd, 1997

Living With It (1993). Living It Up (1994). Letting It Go (1996). (3 books) Bev Aisbett, Harper Collins Publishers.

Anxiety, Phobias and Panic : A Step by Step Program for Regaining Control of your Life. Reneau Z. Peurifoy, Warner Books, 1988/95

Managing Stress : A Lifestyle Approach David Barlow and Ronald Rapee, AUS, 1997

Overcoming Shyness and Social Phobia: A Step by Step Guide. Ronald Rapee, AUS, 1998

Practitioner Book : Treating Panic Disorder and Agoraphobia : A Step by Step Clinical Guide Elke Zuercher-White, USA, 1997

Books available from Open Leaves Bookshop, 79 Cardigan Street, Carlton, Vic., 3053. Telephone 03 9347 2355, Fax 03 9347 1430. (Note Change of Address).

Introducing MyHalo’s OCD HomePage About the Author : Hi my name is Michael and in the last 6-7 months have been diagnosed with OCD. I am currently on medication which is proving to be of some benefit, as well as exposure therapy. I am of Ukranian background, eg: the name Myhalo means Michael in Ukranian. This page is designed for people who have been diagnosed with OCD and should be used as a guide only. HomePage Address : http://www2.one.net.au/~myhalo/index.html Michael’s OCD Australia Chat Line is available through this website.

Congratulations to Michael for setting up this homepage - the first Australian OCD website (as far as we know). Work is currently commencing on the OCADF’s website which hopefully will be published in a few months.

14 WINTER 1998 OCADF Newsletter

This section of the newsletter features information, ideas and self-help strategies which may help OCD and Anxiety Disorders sufferers and their families. Also, this section will include stories of recovery and hope that members may wish to share. I would welcome any contributions to this section - no one The knows better what will make a real difference than the individuals who live with these disorders and their families - so please share with other readers of this newsletter those things which have helped you. Opening Editor.

Door LIVING WITH AGORAPHOBIA

by Judy Fraiia At the tender age of fourteen I was already in the work force. Thanks to anxiety disorders which invaded my brain at about age five a decent education wasn’t really an option. I was never able to fit in at school, I felt like an alien, it was as though I was sending out an “aura” saying “don’t come near me, I’m weird, and I’m not worthy of your friendship”. So here I was behind the counter at Coles. At first it was quite pleasant being shifted from glass wear then on to brick-a-brack

Strategies and finally doing the rounds at all the different counters; my favourite for Coping being the crockery department - I’ve never forgotten how to pack and Recovery cups. Stories My first panic attack at the age of 14 will be forever indelible in my mind. Little did I know then that they were to continue on until the age of 47. I’ve been free of these wretched things for six years. I wasn’t feeling particularly stressed on the day of my initial panic attack which overpowered me with a direct hit. My first thought was that fainting was a strong possibility and that my legs felt like aeroplane jelly made with an extra cup of water - very wobbly. I wondered if I was dreaming, I certainly didn’t feel real, nothing seemed real, What was I doing here? Who was I? I wanted to run from this unreality but where was reality? If the tea room was some sort of safe haven, I wasn’t sure my legs could transport me such a distance. At this stage I felt stiff all over. Voices were swirling, customers and voices of management united, the sound of the fans overhead were menacing. I managed to totter back to the aisle of my counter with great difficulty with robotic like movements. “Miss Pedler, please serve the customer” shouted Mr Sillborn the floor walker. I think that’s my name but I’m not sure, anyway thank God for the customer who brought me back to earth. Such was the extent of my fear that I had a very clear understanding of how a prisoner about to be executed would feel. I was plagued with panic attacks and Agoraphobia from that day on. Long distance travel made me feel extremely uncomfortable, long roads of never ending bitumen and copy cat trees did nothing for me, and when a small town loomed in the distance I somehow felt relieved. I felt safer amongst houses and shops. Going to church was a nightmare and anticipation would start to build a good day beforehand. I always prayed that our reliable old station wagon would refuse to start but it never missed a beat and it became quite apparent that I was in for an hour of terror. As far as the Church went, I know I would have fared much better had I been able to sit in the back pew for a quick exit. My husband was oblivious to my blind terror and thought he was doing me a favour by guiding me to the absolute front row of seats. Thank goodness for the candle that flickered in uneven licks of orange flame, that was something for me to centre my concentration on. My gaze didn’t waver from that holy flame save except when the donation plate was passed around which would mean that the end was near, and just maybe I might be able to survive this ordeal. School meetings or any other meetings for that matter were other outings that I endeavoured to avoid at all costs. Driving to a school meeting at night was a terrifying experience whereby I felt I

OCADF Newsletter WINTER 1998 15 was engulfed by sheer darkness. If the meeting was to be held during the winter months there was always the strong possibility of being confronted by fog as I travelled homeward. I’d try not to look at my watch during meetings and hope that the speaker wouldn’t speak one minute longer than he should. The worst thing a person with agoraphobia can hear at any meeting is for the speaker to say “I’ll get back to that later”. “No, do it now, get it over with” I scream within. I wonder how much later and I wait with urgency for him to ‘get back to that a bit later’, knowing that then the meeting might be nearing the end. When I had agoraphobia and panic attacks my whole body was on guard and I can never remember being in a relaxed state. As far as looking forward to anything, forget it, even stepping outside my bedroom was like stepping into the unknown. The supermarket was an evil place with rows and rows of identical aisles with “NO SEATS” and nothing to hang on to, and someone should tell management that the lights are far too bright. By the time you wobble to the check-out there is never any chance of you being able to sail right on through. There is always the inevitable QUEUE that can tip scales and break you just when you thought you had conquered your fear of the dreaded supermarket, and you have just been praising yourself for being so brave. I would never venture into a bank or post office if they didn’t offer a hand rail with which I could clamp onto with all my might. I would stand in the queue, my white knuckles in full view, cursing that woman six ahead of me chatting to the teller in an idle manner - she’s in no hurry. Doesn’t she know that I could faint at any moment. That woman at the end teller has brought in a sack of coins to be counted, she had to pick today didn’t she? “I don’t know if I can wait any longer”. I often think there should be a special fast moving line for people with panic disorder and agoraphobia, two tellers to ease the load and a stool to sit on while you wait. Public transport is a problem when you have agoraphobia - trains, buses etc. In fact it was not so much the trains and buses that were the problem, but the people that clamber on. I found that the more people that climbed on to the train the bigger the urge I had to jump off at the next station if I could last that long. I was almost tempted to try it when the train slowed down. All people with agoraphobia would know about shopping centres. They just go on and on. There’s no joy in it - if only I could be like all those people - standing, looking at window displays and shopping. How can they be so relaxed? If I had had three wishes it wouldn’t be for that never ending box of tim tams, or to be beautiful or rich. My only wish would have been to be free of agoraphobia and panic attacks. I looked at those calm, relaxed shoppers and I envied them. I’m here to tell you that as a fully recovered agoraphobia sufferer, that you can conquer this beast once and for all. I made a decision six years ago that I had had enough of panic and agoraphobia dominating my life. I was not prepared to put up with it any longer. My decision to live a normal life was made, but I knew the road ahead was going to be rough. I decided that I would go ‘cold turkey’, rather than doing it in easy steps. I suppose I am lucky in that, by nature, I am a very determined person and I never go back on a decision. I set my rules and then put all my effort into adhering to them. One rule was to go into town, at least once a week, even if I didn’t need to. I was to stay in town for two hours, go into shops and browse, and sit down in a coffee shop for a leisurely cup of coffee. If I met someone in town that I knew, I wasn’t to hurry off with an excuse of a pressing matter. I was to converse with the person - even if I had to lean against a shop window for support or sit down on a bench. I managed, during my first trip to town, to achieve these goals without experiencing overwhelming panic. I was very pleased with myself, and knew that I was on the right track. I realised that having done it once, I could do it again, and then again.

16 WINTER 1998 OCADF Newsletter Another rule was to attend every school meeting. If I got there early I could get a seat near the door, but I would not allow myself to leave during the meeting and even made myself stay afterwards to have tea and cakes with the other mums. I won’t say I wasn’t terrified, but I did it, and each time the fear became less. Going to church was a similar situation. I sat down near the back and near a window. Being able to watch the trees outside swaying in the wind was a plus. The movement of the wind had a very calming effect on me, and also some sounds like wind chimes, rain, and the cat purring. Also the feel of things like a cold cement surface under my feet or touching a rough surface would help to bring me back to reality. I would try to focus on these calming sensory experiences whenever I felt my anxiety rising. I would also often attempt to distract myself from the panic - if I was in a dreaded queue in the supermarket I would talk to the person in front of me, pick up a magazine to read or count the money in my purse. There were many other things that helped me to overcome agoraphobia and panic. Most importantly, I educated myself about the disorders and ways of overcoming them. I found a good professional therapist who knew about treating these problems, and I joined the Foundation and became a volunteer. All of this, combined with my decision to overcome agoraphobia and panic and my self-help techniques, effectively put me back in control and on the road to recovery. It wasn’t easy, and sometimes when I had a set-back, I wondered if I would ever fully conquer my fears. In the end, my determination and hard work paid off. Even though I still get anxious sometimes - like we all do, I haven’t had a full-blown panic attack for five years. Best of all, my life is no longer controlled by fear. I can now go anywhere, and do anything I want to - even flying in a plane (which I have discovered I really enjoy), without cowering under that terrible and constant burden of panic.

“GET OUT ME” If the memory becomes null and void by Ernie Vaszilcsin One fact is not so difficult to avoid You don’t forget the pain of thought Very down when last I was here And actions, hoping not to be caught Rain poured like new year’s eve beer There are others like us on this planet Even then the creepers were wilting A skeleton hidden in everybody’s On grey sides of the city buildings closet! Even the bird of paradise flew away When it spotted this face of pain! Chorus.

Chorus : Temple of the body host to a parasite Get out of me, sil-vous-plait In our own ways, can give in or fight I don’t want you anyway Is it the chemicals in our craniums? In this doomed partnership Heredity clogging the mechanisms? Wrong track, wrong locomotive Our drive is hope, say the doctors Won’t be your pawn, would kill Until then, we’ll keep the house in You somehow and call it checkmate! order!

Chorus.

OCADF Newsletter WINTER 1998 17 FEAR IS A FAMILY AFFAIR: DEALING WITH THE FEELINGS By Sally Winston, Psy.D., Co-director of The Anxiety and Stress Disorders Institute of Maryland, Towson, MD, U.S.A.. Reprinted with permission from the ADAA Reporter, August/September 1994

For each of the millions of people who have an anxiety disorder there are many millions more who are called upon to help a son, daughter, brother, sister, husband, wife, relative or friend who is struggling in a web of fear and misunderstanding. When one person in a family hurts everybody is affected.

Panic Disorder: Common Reactions of Loved Ones

Bewilderment How can this possibly be “only anxiety”? Fear What if she/he really is dying or going crazy? What if the doctors really have missed something? Anger Will she/he ever be well again? This is not the person I married! Helplessness I don’t know how to be of any help! Nothing I say or do is right! Resentment What about my needs, feelings and anxieties? She/he is exaggerating! She/he is trying to control me! Trapped I can’t leave when she/he is so ill! She/he smothers me - I have no freedom! Depressed We never have any fun anymore. We are never really happy. Guilty Is it my fault that she/he got like this? Is there something seriously wrong with our marriage? Worried Will she/he want to leave me after recovery? Will our children turn out like this? Lonely I can’t burden her/him with my feelings? I can’t tell others just what we’ve been going through.

Panic Disorder: Guidelines for Loved Ones Who Want to Help. Strive NOT to say:

“Relax!” “Calm down!” “Control yourself!” “Think of something else!” “Do something to distract yourself!” “Don’t be anxious!” “Don’t be a coward.” “You can fight this!” “Let’s see if you can do this yet.” (test) “Don’t be ridiculous.” “You’re just being a hypochondriac!” “Are you okay?” (checking) “You have to stay.” “It’s no big deal to get anxious - I get anxious too.” “Don’t embarrass me.” “When are you going to …” “What are you going to do next?” “Aren’t you sick of living this way?”

Remember to say:

“You can do it no matter how you feel.” “Tell me what you need now.” “Face the fear and it will disappear.” “Stay in the here-and-now.” “Go ahead and have the panic now - I’m here for you.” “Don’t anticipate.” “Don’t add the second fear.” “It’s not the place, it’s the thought.” “Don’t fight it.” “Don’t what if.” “I know it feels dangerous, but it’s not dangerous.” “Breathe slow and low.” “Remember your coping skills.” “I’m proud of you.” “You’re courageous.”

18 WINTER 1998 OCADF Newsletter

Other Guidelines to Remember

1. Don’t make assumptions about what she/he needs - ask!’ 2. Be predictable. 3. Let her/him set the pace for recovery. 4. Strive to find something positive in every effort. 5. Don’t enable avoidance - negotiate one step forward. 6. Don’t sacrifice your own life and build resentments. 7. Don’t panic when she/he is having panic. 8. It’s okay to be anxious yourself and to say so. 9. Be patient and accepting, but don’t settle. 10. Reassurance has its limits. 11. Setbacks are an integral part of recovery - although she/he may feel miserable during a setback, people don’t “go back to square one.” 12. Nothing is learned about coping if there is no anxiety; but, little can be learned when anxiety overwhelms. Practice should aim for moderate levels of anxiety. 13. Remember that she/he is usually giving a best effort: 14. She/he is trying to survive, not control. 15. She/he is not resisting recovery - she/he is afraid. 16. She/he is not being selfish - she/he is self-centered. 17. She/he is much angrier at herself/himself than you are. 18. New assertiveness may offend you or mix up the status quo. Distinguish between support and co-dependency. Take care of your own “stuff”. Seek counselling for yourself or for you and your partner jointly if needed. 19. Participate and support when asked - don’t get involved unless wanted. 20. Try to avoid motivating with guilt. 21. Read about panic disorder to further your understanding. 22. Remember that your partner is the authority on what she/he feels.

Do People Recover From Panic Disorder? For most people, effective treatment requires some combination of efforts to help change catastrophic thinking, training in techniques to manage anxiety and efforts to practice those skills repeatedly in real-world anxious situations. Treatment is sometimes supplemented with one of several possible choices in medication, individual therapy focused on other contributing factors and/or marital or family therapy, as indicated. Medication can sometimes be useful; however, for most people without other complications, medication is rarely the heart of treatment, particularly since the available choices have pros and cons that we can discuss with you. With commitment to treatment, you can reasonably expect to recover. Our estimates are that 75-80% of those who seek treatment recover to the point where panic and avoidance are not significant factors in their everyday life.

OCADF Newsletter WINTER 1998 19

THE APPOINTMENT - A Short Play

Cast : Patient, Nurse, Doctor

PROLOGUE Patient : I’ve lived with symptoms many years, The ones that fill your mind with fears. Just short of taking to the drink I forced myself to see a shrink.

PATIENT ENTERS DOCTOR’S WAITING ROOM Nurse : Make yourself comfy for an hour Doctors gone to have a shower. And see that bottle on the shelf, Please pour the contents on yourself.

Patient : How very strange - what do you mean? I never wash with Pine-o-cleen! (Then looking round the room I saw several hundred bottles more.)

Nurse : Just simmer down - don’t get upset, You’ll only get a little wet. You’ve got no problem anyway, He makes me do it every day. Go back and sit down on the chair, I’ll let the Doctor know you’re there.

PATIENT ENTERS DOCTOR’S OFFICE AFTER LENGTHY WAIT Doctor : It seems a funny thing to ask, Don’t speak ‘til I put on my mask, Because it scares me half to death If I come in contact with your breath.

Patient : Doctor, you’ve really got me worried, You look all tense, upset and flurried. Let’s throw away the disinfectant Doctor: (His eyes lit up - he looked expectant).

Doctor : Do you really think I could? My wife keeps saying that I should. It’s bringing me quite close to tears, Been stuck like this for twenty years.

SEVERAL HOURS LATER Patient : Well, I thought we’d never do it (But I talked the doctor through it. We went outside and got a bin, And then we threw the bottles in.)

Doctor : Gosh - I’m ever so relieved, A marvellous breakthrough we’ve achieved. What on earth had hold of me?

Patient : I think its’ name is OCD.

OCADF Member, 1998

20 WINTER 1998 OCADF Newsletter Battling Panic : Doctor as Patient by Dr. Ellyn Geller, Ed.D. Counselling Psychologist, New Jersey, USA Reprinted with permission from the ADAA Reporter, Spring 1995

As a practicing psychologist treating people My therapy continued, my attacks with anxiety disorders, my best textbook continued, and my education had begun. For has been my personal experience with one year I kept a daily symptomatology log, anxiety, panic disorder and post-traumatic my attempt to find some pattern to my stress disorder. Over the past seven years, distress. That was never to happen. I began my journal reflects the bumpy road I travel. reading everything on the subject I could First Attack find. I joined ADAA and found support and As I was leading my Monday night therapy more resources. group, I began to feel strange. My heart Six Months Later began racing wildly. I felt nauseous, The attacks, though milder and less constriction in my sternum, cold sweat and frequent, still come. There is, for the most feelings of losing consciousness. I excused part, no correlation to when an attack occurs myself, went out for some air, sat in my and to what is happening in my life. I just office and tried to recoup and to regroup. I lose myself; go flat; feel off. My most reviewed the emotional content of the group vulnerable times continue to be when I let session. That didn’t seem to be an obvious down, relax, go to a theatre, lie in bed - when trigger. I took some deep breaths, I am not actively distracted. Those are the determined that this would pass, and times when I can’t “get the panic out of the returned to the group. The symptoms panic” and wonder if a medical problem has increased and so did my terror. I left again, been overlooked or if my body has built up a knowing it was a heart attack. I went back tolerance to my medication. in and announced my diagnosis to the group, I have noticed some correlations that not knowing what else to do. One group CAN precipitate symptomology. Something member, a rescue squad worker, took my occurs that I’m not expecting, or fails to hand, felt my pulse, asked me to describe my happen when I am expecting it, and I feel symptoms and calmly reassured me that I terror. Unharnessed or accelerated internal was NOT experiencing a heart attack. I stress can cause an attack. I can be hung in, encouraged the group to get back to listening to a client, speaking with a friend, its business and was able to settle down reading, watching TV, and I become very enough to get through the session. Their affected. Often after eating I don’t feel diagnosis was that my bra was too tight! I well. I continue to wonder if this could be didn’t know for many months that what I had food allergies or something gastrointestinal. experienced was to be the first of many, Can this all really be panic disorder? many panic attacks. My therapist did not One Year Later provide a label. After a complete medical This is the second anniversary of my first work-up, my internist (to my utter chagrin panic attack. I’m pleased to report that I’m and amazement) made the diagnosis. I went almost well. Today is a world of difference home mumbling that I was the psychologist, from even a few months ago. Just as not she, and proceeded to open the suddenly as the attacks appeared, they Diagnostic Statistical Manual looking for seem, for the most part, to have information that would confirm panic disappeared. My gratitude has no words. I disorder. I found that out of a possible 12 never thought the attacks would last this symptoms, I was suffering from 10.

OCADF Newsletter WINTER 1998 21 long, and, if they did, I never thought I’d of work. I was over the bridge before I make it. knew it. I knew exactly what he was doing. This Week (Five Years Later) It was an empowering experience. I felt so Today, I conquered the bridge! It’s tiny and supported in such a respectful way. Coming I have to cross it, but I found a way. Two back, I didn’t need to call. I stopped on the friends, a psychologist and a psychiatrist live bridge, kept breathing and then kept going. on the other side. I called and asked if they The anchor of having that phone number would mind if I called them on my car phone taped to my dashboard was reassuring! I will for support while I was crossing. They be eternally grateful that I have found help agreed and I called at the light before the and ways to help myself, and that I can and bridge. Tony did an excellent strategic do function with a fairly satisfying quality of intervention, keeping me distracted with talk life.

SELF-HELP STRATEGIES from -‘ Freedom from Fear’ : Booklet on Panic Disorder and Agoraphobia compiled by the Box Hill Agoraphobia Support Group

TAKING CONTROL Asserting Yourself. Saying NO and not feeling guilty. ASSERTION: Assertion involves standing up for personal rights, and expressing thoughts, feelings and beliefs in direct, honest and appropriate ways which do not violate another person’s rights. Practise assertive behaviour and check your ‘self-talk’ for rational/irrational thoughts.

PERSONAL RIGHTS: STAND UP FOR YOURSELF: 1. The right to act in ways that promote your • say “no” when you don’t want to do dignity and self-respect something as long as other’s rights are not violated in • set limits on your time and energy the process. • respond to criticism and anger 2. The right to be treated with respect. • express, support or defend your opinion 3. The right to say NO and not feel guilty. COMFORTABLY EXPRESS YOUR 4. The right to experience and express your HONEST FEELINGS: feelings. • disagree 5. The right to take time to slow down and • show anger think. • show affection or friendship 6. The right to change your mind. • 7. The right to ask for what you want. admit fear or anxiety • 8. The right to do less than you are humanly express agreement or support • capable of doing. be spontaneous 9. The right to ask for information. EXERCISE YOUR PERSONAL RIGHTS: 10. The right to make mistakes. • express an opinion 11. The right to feel good about yourself. • work for change ACT IN YOUR OWN BEST INTEREST: • respond to a violation of your own or others’ • make your own life decisions eg. in career, rights relationships, life-style, time schedule DO NOT DENY THE RIGHTS OF • take initiatives eg. in conversations, OTHERS: organising activities, relationships • do not unfairly criticise others • trust your own judgement • do not behave hurtfully • set your won goals • do not resort to name calling, intimidation, • interact socially eg. in a support group, with manipulation or control. friends, etc.

22 WINTER 1998 OCADF Newsletter TAKING RESPONSIBILITY Ten Commandments When Panic Starts : Stop and go over what you have to do by reading through the ten rules below. 1. Remember that the feelings are nothing more than an exaggeration of the normal bodily reactions to stress. 2. They are not in the least harmful or dangerous - just unpleasant. Nothing worse will happen. 3. Stop adding to panic with frightening thoughts about what is happening and where it might lead. 4. Describe carefully to yourself what is really happening in your body at this moment, not what you fear might happen. 5. Now wait and give the fear time to pass, without fighting it, or running away from it. Just accept it. 6. Notice that once you stop adding to it with frightening thoughts, the fear starts to fade away by itself. 7. Remember that the whole point of practice is learning how to cope with fear - without avoiding it. So this is an opportunity to make progress. 8. Think about the progress you have made so far, despite all the difficulties, and how pleased you will be when you succeed this time. 9. Now begin to describe your surroundings to yourself and then plan out in your mind exactly what to do next. 10. Then, when you are ready to go on, start off in an easy, relaxed way - there’s no need for effort or hurry.

When you have got to know them well, it may be enough to run through the list of reminders below: 1. THE FEELINGS ARE NORMAL BODILY 6. NOTICE WHEN IT FADES. REACTIONS. 7. IT IS AN OPPORTUNITY FOR 2. THEY ARE NOT HARMFUL. PROGRESS. 3. DON’T ADD FRIGHTENING THOUGHTS. 8. THINK OF WHAT YOU HAVE DONE. 4. DESCRIBE WHAT IS HAPPENING. 9. PLAN WHAT TO DO NEXT. 5. WAIT FOR FEAR TO PASS. 10. THEN START OFF SLOWLY. Reprinted with kind permission of Robyn F. Vines.

COPING WITH A PANIC ATTACK - Breathing Control During a panic attack you are extremely likely to breathe very fast and/or deeply. This will have the effect of reducing the amount of carbon dioxide you have in your lungs, which in turn will create a lot of unpleasant body sensations, which are likely to make you more afraid. A vicious circle of fear leading to overbreathing, which leads to unpleasant body sensations (faintness, dizziness, tingling, headaches, racing heart, flushes, nausea, chest pain, shakiness, etc.), which cause more fear, which leads again to overbreathing and so on, gets established. To stop this nasty process, you have to raise the amount of carbon dioxide in your lungs. You can do this two ways: 1. If you have a paper bag handy, hold it tightly over your nose and mouth so no air can get into your lungs from outside the bag and breathe the air in the bag for several minutes until you calm down. 2. If a bag is not handy or it would be embarrassing to use one (say in a supermarket) then you should change your breathing so you breathe in less air in a given period of time. You can probably do this most easily by slowing down your breathing in small steps. Attempt to breathe in smoothly and slowly and to let your breath out just as slowly. As you slow your breathing down, you are bound to increase the depth of each breath. However, try to avoid a very big increase in depth because that would undo the good you have done by slowing down. The ideal you are aiming for is smooth, slow, regular and fairly shallow breathing. If you have managed to slow down for a few seconds but feel out of breath, and have a strong urge to take a quick gulp, don’t . Resist it by swallowing a couple of times, That should get rid of the urge; if it doesn’t, then go ahead, take a gulp BUT once you’ve let the air in HOLD IT in for about five seconds and then let it out SLOWLY. If you can hold a gulp for a few seconds, you prevent it from lowering your carbon dioxide level. To sum up, breathe in and out as slowly and evenly as you can and avoid any big increase in depth as you do so. To help yourself slow down you could: a) remember how you breathed on the tape and try to do that, b) count to yourself while breathing, and to start off, you might say “one thousand” to yourself while breathing in and “two thousand” while breathing out, so your breathing would be:

in out in out “one thousand” “two thousand” “one thousand” “two thousand” (continue for two to five minutes) Source Unknown. OCADF Newsletter WINTER 1998 23

Letters

to the Editor

Letters to the editor must include the writer’s name and address. Anonymous letters will not be published, however the writer’s name may be withheld if requested. Publication of letters will be subject to the approval of the OCADF Committee of Management, however published letters should not be considered as representing the views of the Committee.

Dear Editor, I began to recover from chronic anxiety, panic attacks & OCD when I stopped seeing a Psychiatrist. I feel my story really needs to be told. It begins with a letter (slightly modified) written to the psychiatrist who attempted to treat me. ‘Dear Dr…. I became really ill under your care. I now know why. You led me to believe that I had a mental illness-Genetic disposition/Chemical imbalance. Instantly control was been taken. Any attempt on my part to discuss feeling or causes was discounted by you as a waste of time. Your treatment CBT * and Drugs were ineffective. CBT tried to impose an external thought system which was totally devoid of my emotions. I festered in an emotional sewer which was fanned by your treatments and beliefs. This caused me to be nearly admitted into a mental hospital. You wanted to repress the whole bloody mess with medication. I was fortunate to leave the medical model. I found a talented psychologist who listened and encouraged me to express everything - feelings and experiences. She was vigilant in her ability to listen and clever in her ability to connect emotional issues together. The puzzle was beginning to take shape and my anxieties had a healthy contribution to make toward its solution. I wasn’t a sick person but very human. I could now acknowledge my feelings and parent them. Control was returning and a trust in myself was developing. These days the trust in my self and life continues to strengthen. I experience far less anxiety and am far more in tune with who I am.’ End of Letter. My experiences give rise to some very serious questions. a) Should anxiety difficulties be treated as an emotional trouble or a mental illness? b) Why was I given such free and easy access (GP referral & Medicare funded) into a medical psychiatric system. c) Under a medical view I was led into a world of madness. Why was I only offered deeper involvement within it? d) Why didn’t the system initially help me to deal with my difficulties on an emotional level? These issues need attention now. I would suggest to anybody currently beating their heads against a brick wall, to move on. Positive alternatives can be affordable. The psychologist I found cost me $20 per hour. I feel so glad to be rid of psychiatric beliefs and treatments. I feel so incredibly lucky to have found a talented psychologist. I feel so fortunate to once again be part of life. Yours sincerely, Tim Hannigan March 1 st 1998

Ed: I’m glad to hear that you found a professional who provided the right type of treatment for you. Your letter raises some important issues - in particular, the sometimes rigid way in which treatments are applied without reference to the specific needs of the individual client. There are several factors which will determine if cognitive behavioural therapy will be effective for any particular person, and while I have known many people who have benefited from CBT and medication, I believe that some people would gain better outcomes from treatment if emotional, identity, relationship and other life issues were dealt with as well. At the heart of this matter, I believe, is that treatment should be tailored for each person - taking into account their general emotional state, personality, the influence of past and present relationships, core beliefs, and so on. The client should also be treated with dignity and respect - which would include the professional explaining the treatment programme in detail to the client, providing justification for the treatment, sharing their own experience and skill in applying the treatments, and encouraging input from the client every step of the way. During my past eight years at the Foundation I have talked to thousands of people with anxiety disorders - as mentioned, many have benefited from CBT and medication, but I have also spoken to other individuals who have found relief from their symptoms and associated problems from a whole range of different types of therapies, and for some spiritual and philosophical pathways have led to major positive changes. Many others I know are still suffering and are continuing to search for help which seems elusive. I believe we are still some way from having a ‘treatment package’ for OCD and anxiety disorders which will be right for everyone, and even though some treatments have been found to be effective, they are not always accessible or delivered with sufficient expertise. At the Foundation we promote and encourage a ‘self-help philosophy’ and discourage a total reliance on a ‘only-the-doctor-can-help-me philosophy’. Discovering one’s own inner strengths and power, we believe, may be fundamental to recovery whatever path is followed. I would be interested to hear other’s opinions on these issues, and the other issues which Tim has raised in his letter.

24 WINTER 1998 OCADF Newsletter A Review of ‘As Good As It Gets’ by David McVilly OCADF Member and OCD Sufferer.

If you wish to learn about Obsessive Compulsive Disorder, don’t expect to learn anything from this film. This comedy- drama is almost a fairy tale. A nasty self-centred man encounters a beautiful waitress concerned for her allergic son and then her loneliness and a sensitive gay artist who owns a cute fluffy dog. They all live happily ever after thanks to the fact that the nasty man has the money to do something for the others and so change himself. Beast falls in love with Beauty and the film is concerned with Beauty’s reluctant falling in love with Beast. The gay artist acts as the catalyst for this transformation. Imposed on this plot is the theme of Obsessive Compulsive Disorder as suffered by the Beast. This disorder is used to get some laughs, and also to emphasise the degree of self-centredness in the Beast who is entirely obsessed with his rituals and his own life as a writer of romantic novels for women. Unfortunately, Melvin’s OCD is presented superficially and as a selfish disorder, which makes the sufferer repulsive and unlovable and not able to love anyone but himself. Towards the end of the picture he begins to take the pills which will make him a better man, although it is unclear whether this is the cause of his transformation or the love of Beauty. The fact that OCD is a theme of the film indicates a greater awareness of the existence of the illness although Jack Nicholson admitted in an interview that before he made the film he did not know anything about OCD. Melvin will not walk on cracks on the footpath or on tiling or any other floor covering, he locks the many locks on his door and turns the light switch on and off five times when entering his residence, he washes his hands and showers for inordinately long times, he avoids touching people or things without the protection of gloves, he eats his breakfast in the same restaurant always using throwaway plastic cutlery and he is a man of rigid routines. And yet he is able to allow the dog which he has previously tried to kill, to live with him, he is able to play the piano, he is able to live with the gay artist who he spends the first half of the film insulting, he is able to write best-selling romantic novels for women and he is able to fall in love with the waitress who sees his rudeness and selfishness every day. It is all too much like a fairy tale, for Melvin shows hardly any sign of panic, anxiety nor depression. Perhaps I should accept the character and not take the picture so seriously. But I am an OCD sufferer, and as such I think that the film could mislead its viewers about the illness. First, Melvin does not have OCD as I know it but rather has rituals and ways of thinking taken from reports about OCD and secondly, although mental illness is often a cancer of the personality which can repel people and prevent the sufferer from being able to love, it is an illness, not part of a nasty, misanthropic character who is to be morally condemned or laughed at. The biggest fear of most OCD sufferers is that they might hurt someone or something but this hardly ever happens. Many people think that they understand the illness because they have had an uncertainty about whether they turned off the gas or the iron, but they do not realise that the doubts and uncertainties of the sufferer can cripple him and send him into depression. The film is a success as entertainment and Jack Nicholson’s character is an unforgettable one. But it is worth pointing out that although sufferers of OCD often find that it is helpful to laugh at their disorder, this is only possible when they are not in OCD mode; that is those times when the chemicals of their brain have changed. When the attack is over it is sometimes possible to discuss it and sometimes laugh at it, although to laugh at something so painful is often impossible. None of this is conveyed in the film. Why should it? Most films are meant to entertain and to act as an escape from real life, and most of them, like their audiences, cannot stand too much reality.

David McVilly

What lies behind us, and what lies before us are tiny matters, compared to what lies within us. Emerson

Our life is the creation of our mind. Dhammapada

OCADF Newsletter WINTER 1998 25

OCD & Anxiety HelpLine (03) 9576 2477

Monday --- Friday 10.00 am --- 4.00 pm The HelpLine team provide counselling, information and referral advice to people with OCD and Anxiety Disorders, and their families.

Educational Seminars 1998

Venue : `The Peppercorn Club', 584 Glenferrie Road, Hawthorn, 3122 (next to Hawthorn City Library). Time : 7.30 pm, First Thursdays : Educational Seminars, Third Thursdays : Support & Social Groups Entrance Fee : $2.00 - Members, $4.00 - Non-members (First Thursdays only)

June 4 ththth Nutrition and Mental Health Dr. Ian Brighthope Brighthope Centre for Integrative Medicine

July 2 ndndnd OCD --- Across the Lifespan Dr. Don Jefferys Clinical Psychologist, The Melbourne Clinic

August 6 ththth How to get a good night’s Sleep Ms. Catherine Madigan Private Psychologist

September 3 rdrdrd ‘Reading, Writing & Arithmetic’ : The Different Faces of OCD Dr. Scott Blair-West Psychiatrist

October 1 ststst Assessment and Treatment of Depression Ms. Celia Horden & Ms. Kylie Wainright Psychology Registrars, Dept. Psychological Medicine, Royal Melbourne Hospital

November 5 ththth Video Night Presentation of educational and documentary videos on anxiety disorders.

Thanks to the Anxiety Disorders Association of America for permission to reprint articles from the ADAA Reporter. The ADAA hosts an annual National Conference, publishes a Newsletter and Journals and has an extensive publications list for their Bookstore. If you are interested in further information about the ADAA, write to - 6000 Executive Blvd., Suite 513,Rockville, Maryland, USA, 20852.

26 WINTER 1998 OCADF Newsletter Treatment Programmes and Clinics for OCD & Anxiety

OCAD Foundation SOCIAL ANXIETY DISORDER RECOVERY PROGRAMME The first Social Anxiety Recovery Programme was recently completed. The programme combined cognitive and behavioural techniques, anxiety management, relaxation training, self-help techniques, and focused on a range of other issues which affect recovery - self-esteem, social and conversation skills, relationship and communication difficulties, beliefs, and negative thinking. Six people with social anxiety disorder participated in the programme and all made some progress in achieving their goals. Special thanks to Harry Ball, Cherie Lacis and Rachel Burdman who assisted in the planning and leadership of this programme. The next Social Anxiety Disorder Recovery Programme will be commencing in September 1998. If you are interested please call the OCD & Anxiety HelpLine for further information or to add your name to the ‘registration of interest’ list. Recovery programmes for people with OCD and Panic Disorder are currently under development. A pilot programme for OCD may be commenced in Wodonga during the second half of this year. Further programmes are planned for 1999.

Monash Medical Centre Department of Child and Adolescent Psychiatry, 246 Clayton Road, Clayton, 3168 OBSESSIVE COMPULSIVE DISORDER CLINIC A treatment programme to help young people (8 - 18 years old) to more effectively manage OCD. Time-limited cognitive behavioural treatment either with or without medication; assessment, treatment and follow-up phases; includes the young person and his/her parents; cost-free; a research component focuses on the evaluation and efficacy of the treatment programme. For appointments or information contact Judy Tomlinson, Clinic Coordinator, telephone (03) 9550 1300.

Royal Melbourne Hospital DEPRESSION AND ANXIETY CLINIC Assessment, Individual Therapy and OCD & Anxiety Cognitive-Behavioural Group Therapy Programmes. Enquires - telephone (03) 9342 7705

The Melbourne Clinic OBSESSIVE COMPULSIVE DISORDER THERAPY PROGRAMME 1998 (Private Insurance Recommended) This intensive programme is based on Cognitive Behavioural Psychology. The aim is to teach practical, self-help strategies for change, including exposure and response prevention, habit breaking, cognitive controls, and goal setting. Clinical Director : Christopher Mogan. Program Charge Nurse : Kerryn Addison. Enquires - (03) 9429 4688.

Tranx PANIC & ANXIETY DISORDERS TREATMENT CENTRE Rear 1423 Toorak Road, Burwood. Telephone 03 9889 7355. Fax 03 9889 1022 Treatment programmes include : education, relaxation training and breathing control, letting go of fear, changing fearful thinking and beliefs, building self- esteem, handling emotions, controlling panic attacks, assertiveness skills, supported gradual exposure. The Centre does not use prescribed drugs in their treatment programme. Tranx is a non-profit organisation. Counselling fees are kept to a minimum and may be negotiable in cases of financial hardship. For further information ring Gwenda Cannard, Director of Tranx on 9889 7355 .

OCADF Newsletter WINTER 1998 27 WS OCAD FOUNDATION NE

OCADF awarded PBI Status organising the 3 rd Carers of the Mentally Ill The OCAD Foundation was awarded Public Conference to be held in October 1998. Benevolent Institution (PBI) Status by the Australian Closure of the Yarra Valley OCD Tax Office at the beginning of 1998. Amendments Support Group to the OCADF’s Constitution were approved by the Therese De Pos, convenor of the Yarra Valley OCD membership at the AGM meeting in November Support Group, recently informed the OCADF that 1997 and ensured that the Statement of Purposes after several years of operation the Group has accurately reflect the aims and activities of the decided to close. The Yarra Valley Group has Foundation. These amendments enabled the ATO worked very hard during the past years to to acknowledge the public benevolent status of the disseminate information about OCD throughout the OCADF. Many benefits occur with PBI status local community and provide support to people including exemption from sales tax on goods and with OCD and their families. The Committee and other tax exemptions. The Foundation will now be members of the OCADF extend sincere eligible to apply for project funding from appreciation to Therese and all the members of the philanthropic organisations which allocate grants to Yarra Valley Support Group for their dedication and charities. Also, all donations over $2.00 to the hard work in providing an excellent support group OCADF are now tax deductible. and educational services to the Yarra Valley during Thanks to Hawthorn Community Chest the past years. The OCAD Foundation recently received a grant Submission to Human Services from Hawthorn Community Chest of $1,525.00 to The OCADF has recently placed a submission for purchase a video camera and tripod. The OCADF further recurrent funding to the Department of Committee of Management extends its sincere Human Services. The submission requests an thanks and appreciation to the Hawthorn appropriate level of funding for the operation and Community Chest for this grant. The video camera development of the Foundation’s state-wide will primarily be used to video tape the Foundation’s educational and support services. Funding to obtain Educational Seminars which are held at Hawthorn the OCADF’s own premises has also been each month. The Seminar Tapes will be copied and requested. made available to OCADF support groups around Public Talks Victoria. Later this year, the OCADF also intends to The Director and some volunteers have presented obtain a television and video player so that many public talks on OCD and anxiety disorders individuals will be able to attend the OCADF office during the past six months. Talks have been to view the Seminar Tapes and other educational presented for : AidsLine, Schizophrenia Fellowship video tapes. More information on this new service Outreach Service, Monash University Disability will be provided in the next newsletter. Liaison Unit, Inner South Division of General Conferences - 1998 - 1999 Practice and Olympic Village Primary School. The OCADF Committee of Management recently Media made a decision to put on hold the planning of our The OCADF is currently assisting A Current Affair next national conference. The conference was and 60 Minutes in the development of stories on intended to be held in early 1999, however due to obsessive compulsive disorder and anxiety. Keep an our current funding restrictions and decreased staff eye on these programmes in the near future for hours it has been extremely difficult to devote the these stories. Thanks to those members who have necessary time required for planning the conference. agreed to participate and help educate the The Committee decided that other service priorities community about OCD and anxiety disorders. are of greater importance at the present time - Fundraising - Rock ‘n’ Roll Event including developing and running our new recovery Thank you to Sharon Hawley for her hard work in programmes, and have therefore deferred the putting together a successful fundraising event for planning of the next conference until early next year. the OCADF. The Rock ‘n’ Roll evening was held on As a member of the Carers of the Mentally Saturday 30 th May, and a great time was had by all Ill Network, the OCADF is involved in planning and who attended.

28 WINTER 1998 OCADF Newsletter OCADF Social Group Activities Calendar 1998

Saturday 27 th June Lone Star Steakhouse & Saloon Location : Cnr. Warrigal & Waverley Rds., Chadstone. Time : 6.00 pm.

Sunday 26 th July Movie Movie details to be confirmed. Venue : Brighton Dendy Twin Cinemas Location : 26 Church Street, Brighton. Time : 1.30 pm.

For further information please contact the OCAD Foundation on 03 9576 2477 Monday to Friday between 10.00 am and 4.00pm

OCADF LINKS

Centre for Adolescent Health : Community Resource Unit William Buckland House, 2 Gatehouse Street, Parkville, 3052, Phone: 9345 5890 Fax: 9345 6502 The Centre for Adolescent Health is a Victorian Health Promotion Foundation Centre established in collaboration with the University of Melbourne, Royal Children’s Hospital, Royal Melbourne Hospital and the Royal Women’s Hospital. CHAT : Confident Happy Adolescents Talking CHAT is a social skills peer support program for 11 - 19 year olds who are shy or isolated. CHAT is for you if • you feel shy, left out or lonely, you are not coping with social stresses, you think you are the only one who feels like this CHAT is a friendly group where you can explore and practice new ways of relating. It runs over eight weeks and involves fun activities, games & art, besides talking and discussing friendships and feelings. So why not try it? Contact Jane Maher on 9345 7986 P.A.T.S. Peer support for young people whose parents are living with mental illness. P.A.T.S. is a peer support group for young people who have a parent with mental illness. 13 to 18 year olds interested in exploring the issues around mental illness, socializing and having fun are welcome to join our six week groups at The Centre for Adolescent Health. Topics covered include: dealing with feelings like guilt anger and embarrassment; telling friends and seeking support; reducing conflict at home; fear about mental illness in yourself; how to cope and feeling happier. You can say as much or as little as you want to, but it’s great to meet others in a similar situation. The program includes some social outings and there are opportunities to join with other groups of young people in the Centre. Please phone Helen Rimington on 9345 7950 for more information.

OCADF Newsletter WINTER 1998 29 A NEW MENTAL HEALH INFORMATION SERVICE FOR RURAL AND REMOTE AUSTRALIA: M H I R R A

The Gilmore Centre (previously known as the Steering Committee was formed, appropriate Australian Rural Health Research Institute, based at software was identified, and the process of setting Charles Sturt University in Wagga Wagga) received up the database of mental health services and funding for a proposal aimed at improving access to associated organisations across the country began. mental health information for people in rural and As a means of supporting the Information remote areas of Australia. This proposal was funded Officer with planning and delivering the service, a through the first National Mental Health Strategy, Reference Group was formed consisting of a with a sum of $108,000 allocated for a period of number of specialists including indigenous and ethnic two years. From June 1996 to March 1997 the main mental health, rural/remote emergency and focus was the identification of information needs of education services, nursing, policy/politics, rural consumers and of a vehicle for disseminating legislation and the mental health consumer this information. A National Summit for Health consultancy. Following its official launch at the 1998 Information Clearinghouse Providers and Database Rural Mental Health Conference at Ballina, NSW on Administrators was organised in April 1997. The 27 th February by the local Member for the Federal aim of this was to ensure that the plethora of similar seat of Richmond, Mr Larry Anthony, the MHIRRA work already being undertaken around the country information service commenced operation on 2 nd not be duplicated due to lack of consultation. All March. too often funding has been allocated for a database, Initial hours of operation are weekday the database completed and then put onto a shelf afternoons only (from 1.30pm to 4.30pm Australian with no means of accessing its contents. Eastern Standard Time, adjust for daylight saving) so It was concluded that the best means for that the Information Officer can utilise the mornings rural/remote people to access this kind of to attend to promotion of the service, chasing information would be via the telephone. The refund options, and maintaining the currency of the Charles Sturt University team signed a database. Once refunding has been established, Memorandum of Agreement in May 1997 with the these hours may then be extended to service the NSW Association for Mental Health, the agreement different time zones more adequately. being that NSWAMH would collaborate with CSU The MHIRRA team are hoping to secure to develop and deliver a rural and remote mental refunding through the second National Mental health information service by 31 May 1998. Health Strategy. If you are interested in assisting in NSWAMH then employed two part-time workers as the project or supporting refunding endeavours then core personnel on the project: a Database please, do not hesitate to contact the MHIRRA team Administrator and an Information Officer. A on 02 9879 5341.

MENTAL HEALTH WEEK 1998 Mental Health Week offers us the opportunity to promote a strong message to the public about looking after themselves and their minds. In past years the week has often been viewed as an ‘illness’ focused event, with the emphasis on providing activities for consumers and service providers within the psychiatric field. In many ways the week has then preached to the already converted and focuses public attention on disability rather than ability. In addition to the established participants in Mental Health Week, this year we are hoping to access a broader range of people. With the theme of Mental Health What Do You Know? we aim to raise awareness of looking after your mental health and creating an environment where people can discuss their emotional well- being. The long term benefits of such community awareness would hopefully be greater acceptance and understanding of mental illness. The Mental Health Foundation is again coordinating Mental Health Week and is working hard with the aid of the Mental Health Week Advisory Committee to develop an exciting and diverse programme for 1998. The week will again commence with the official launch where we are aiming to attract as much public attention as we can towards mental health. Enquiries about Mental Health Week can be made by ringing the Mental Health Foundation (Vic) on 9427 0406.

Mental Health - What Do You Know?

30 WINTER 1998 OCADF Newsletter OCADF Publications : ORDER FORM

Nine, Ten, Do It Again : A Guide To Obsessive Compulsive Disorder. 2 nd Ed. By Kathryn I’Anson, Director, OCADF. 1997.

Resource Kit For School Personnel : Obsessive Compulsive Disorder (OCD) in Childhood & Adolescence Editors : Kathryn I’Anson, Director, OCADF; Audrey Orr, School Education Coordinator, OCADF; Judy Tomlinson, Coordinator, Parent’s & Children’s Support Group, OCADF. 1997.

Anxiety Disorders In The 90's : A Time For Optimism - 1995 Conference Proceedings Editors : Dr Don Jefferys, The Melbourne Clinic, Associate Dept of Psychiatry, Austin Hospital, A/Professor John Tiller, Royal Melbourne Hospital. OCADF, 1995.

OCD & Anxiety Disorders Information Package For Professionals and Mental Health Services (information for clients). A range of information sheets, pamphlets, booklists, self- help strategies, and information for carers. Covers OCD, Hoarding, Trichotillomania, Body Dysmorphic Disorder, Social Anxiety Disorder, Panic Disorder and Agoraphobia, Specific Phobias + overview of all anxiety disorders. Free copy of latest OCADF Newsletter included.

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Return to: OCAD Foundation (Inc) Vic, PO Box 358, Mt Waverley, Victoria, 3149, Australia Cheques payable to the OCAD Foundation (Inc) Vic For orders from outside Australia, please send BankDraft in Australian Dollars and add 30% postage.

OCADF Newsletter WINTER 1998 31 32 WINTER 1998 OCADF Newsletter

These persons, professionals, and organisations have been awarded a ‘Friend of the Foundation’ certificate, Friends in appreciation and recognition of various of the contributions (educational forums, articles, conference papers, donations, Foundation sponsorship, organisational services, provision of specialised professional services) which have supported the aims, services and development of the OCAD Foundation of Victoria.

Dr. David Ames Dr. Don Jefferys Mr. Justin Robinson Mr. Edwin Belfield Prof. Michael Jenike Dr. Des Roman Mr. Nigel Bennett Professor Gordon Johnson Ms. Jerilyn Ross Dr. Scott Blair -West A/Prof. Fiona Judd Dr. Hilary Schofield Ms. Sharon Bretz Mr. John Julian Dr. Jeffrey Schwartz Prof. Graham Burrows Mr. David Kennan Dr. Issac Schweitzer Dr. Sally Coburn A/Prof. Neville King Mr. Phillip Smith Mr. Rocco Crino Mr. Fredrick Krasey A/Professor Sue Spence Prof. Jonathan Davidson Mr. David Kwasha Ms. Ruth Stokes Mr Robert Doyle MP Dr. Michael Kyrios Dr. Eng Seng Tan Mr. Ian Farnbach Dr. Lisa Lampe A/Prof. John Tiller Dr. Peter Farnbach Dr. David Leonard Mr. Robert Tomlian Dr. Rosemary F awns Dr. Peter Marriott Prof. Bruce Tonge Ms. Evelyn Field Mr. Campbell McComas Mrs Lois Van Dyk Mr. Robin Flintoft Dr. John McEncroe Ms. Robyn Weir Mrs Judy Fraiia Professor Sandy McFarlane Mrs Lynn Williams Mr. John Geros Dr. Rowan McIntosh Ms. Karen Wilson Mrs Poppy Geros Mr. Chris Mogan Mr. Chris Grace Prof. Stuart Montgomery ORGANISATIONS : Ms. Jan Gray Dr. Kate Moore Eli Lilly Australia P/L Mr. Angus Hastie A/Prof. Phillip Morris Ciba -Geigy Ms. Annie Hayball Dr. Trevor Norman Pfizer P/L Dr. Paul Holman Ms. Vanessa Potter Revelation Enterprises A/Prof. David Horne Dr. Sheila Parks Roche Products Pty. Ltd Ms. Kathryn I’Anson Ms. Karen Pfister SmithKline Beecham Ms. Lindsay Image Ms. Kamila Raniga The Melbourne Clinic Professor Basil James Prof. Steve Rasmussen Upjohn P/L

OCADF Newsletter WINTER 1998 33