What is depression?

It is natural to feel sad or down at times. This is a normal part of everyday life. When someone experiences sad or negative feelings that interfere with normal functioning and that last for at least two weeks, they could be suffering from depression. The first sign of depression is often a change in the person’s usual behaviour. Common symptoms of depression include:

• Persistent sad, anxious, or “empty” mood
• Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex
• Feelings of hopelessness and pessimism
• Feelings of guilt, worthlessness, helplessness, self reproach
• Insomnia, early-morning awakening, or oversleeping
• Appetite and/or weight loss or overeating and weight gain
• Decreased energy, fatigue and feeling run down
• Restlessness, irritability, hostility
• Difficulty concentrating, remembering, making decisions
• Persistent physical symptoms such as headaches, digestive disorders, and chronic pain
• Thoughts of death or suicide; suicide attempts

It is important to note that different people experience depression differently (e.g. children may display unusual behavioural problems). In some people depression is characterised not so much by a sad mood, as by increased irritability, unexplained pain, or other symptoms.

Different kinds of depression

• Major depression: A period of deep depression when most of the symptoms of depression are experienced.
• Dysthymia: Only some depression symptoms are present over a long period of time.
• Bipolar disorder: Alternating periods of deep depression followed by extreme highs. This kind of depression is also known as manic-depression.
• Seasonal affective disorder: Depression may occur only during specific seasons of the year.
• Post-natal depression: Feelings of sadness, anxiety, irritability and fear of not being able to cope that occur after childbirth.

Who gets depression?

Depression is a medical disorder that may result in significant distress, and affects people of both sexes, all ages and races, cultures and social classes. Large international studies have shown that about 10% of the general population will suffer from a depressive illness in any given year. Women are twice as likely as men to have depressive symptoms.

What causes depression?

A number of different factors may contribute to the onset of depression. Very often, a combination of these factors play a role in precipitating a depressive illness:

• Vulnerability to depression is likely to be at least partially genetically inherited.
• Psychological make-up and environmental factors, such as increased stress or personal losses.
• Medical conditions such as thyroid problems, strokes, cancer and Cushing’s disease.
• Certain medications, such as steroids, birth control agents and high blood pressure tablets.
• The symptoms of depression are mediated by levels of chemicals, such as serotonin and/or noradrenaline, changing in the brain. Like other medical illnesses, depression can be treated.

What to do and where to go for help

In most cases the best treatment for depression is a combination of medication and psychotherapy.

Medication

Antidepressants are not addictive or habit-forming, and can be safely used over an extended period.

There are different types of antidepressants which treat depression symptoms but have different side-effects, such as nausea, blurred vision, drowsiness, dry mouth, and sexual problems. Inform your doctor if these side-effects are excessively irritating or disturbing or do not go away after a while.

Some improvements may be experienced immediately but the full beneficial effects may only be achieved over a period of weeks or months.
Medication must be taken regularly according to your doctor’s instructions and advice.

The medication should not be stopped or substituted by another without prior consultation with your doctor.
Always inform your dentist or any other prescribing medical professional that you are taking antidepressants, as it is possible that combining drugs can cause severe side-effects.

Benzodiazepines (tranquillisers) may sometimes be prescribed for the short-term control of anxiety symptoms that often accompany depression. These run the risk of dependency though.

Psychotherapy or “talk therapy”

May help you gain self-insight, change negative thoughts and feelings, and learn new behaviours and coping strategies. Talking about your emotions and depression with a trained professional can help reduce, and in some mild to moderate cases, treat symptoms. The different therapy approaches most often used in depression are cognitive behavioural therapy (CBT), interpersonal psychotherapy and psychodynamic psychotherapy.

Self-help techniques

In addition to conventional treatment strategies, these can be beneficial. Reading and learning more about your condition will help you to understand your symptoms and treatment and enable you to make informed decisions about your own well-being. Joining a support group can help you to share ideas and experiences as well as gain reassurance that you are not the only person with depression. Relaxation techniques, exercise and lifestyle changes have been noted as beneficial in managing depression.

Depression is a serious medical illness that may result in significant distress and interference in daily functioning. Nevertheless, the vast majority of people with depression respond well to treatment. The first step in fighting depression is to discuss your symptoms with an experienced professional. So, consult your family practitioner, local clinic or day hospital.

Further resources/ references

Bipolar Association
Tel:  +27 12 348 6057
www.bipolar.co.za   

SA Depression and Anxiety Group
Tel: +27 11 783 1474/6
Fax: +27 11 884 7074
www.sadag.co.za

Download pdf for more information: Mood Disorders

Read more about depression

What is panic disorder?

Panic disorder is characterised by the occurrence of repeated panic attacks, which last anything from a few seconds to a few minutes, but which are experienced as extremely frightening and uncomfortable.

Typically, someone who suffers from a panic attack is overcome by intense feelings of terror and fear that occur initially out of the blue and last only a few minutes. During a panic attack, people may fear they are having a heart attack, or are going crazy.

They report a racing or pounding heartbeat, chest pains, dizziness, light-headedness, nausea, feelings of smothering, breathlessness, tingling or numbness in the hands, hot flushes or chills, a sense of unreality, and a fear of losing control. People with panic attacks often consult various doctors and medical specialists, such as cardiologists, physicians, or neurologists, fearing that they suffer from a life-threatening disease. It is not unusual for many years to go by before an accurate diagnosis is made.

During this time sufferers tend to avoid situations or places (agoraphobia) where the initial attack(s) took place, fearing another attack. This can be very debilitating and unnecessarily limit their lives.

Who gets panic disorder?

Any person may possibly suffer from panic disorder, irrespective of gender, race, or socio-economic status. Studies have shown that about 2 to 4 in every 100 persons may suffer from panic disorder at some time in their lives, and the figure for agoraphobia is even higher.

Panic disorder usually starts between late adolescence and mid-thirties, although children may also suffer from this disorder. The first attack often follows a stressful life event such as the death of a close family member or friend, a loss of a close interpersonal relationship or after a separation. Women are two to three times more likely to suffer from panic disorder than are men.

What causes panic disorder?

It was initially thought that panic disorder was caused by psychological problems. It is now known though that brain chemistry and genetic factors play a role, as well as stressful life events or circumstances. First-degree relatives of people with panic disorder have a five times greater likelihood of developing panic disorder than the rest of the population.

What to do and where to go for help

The most important step is to consult a professional for an accurate diagnosis. Help is available and in most cases is effective in relieving symptoms. Both medication and psychotherapy are used, although a combination of these two treatment methods is often recommended. Self-help cognitive-behavioural techniques are also of value.

Medications for treating panic disorder include those that work immediately but have the limitation that they cause dependence (benzodiazepines), and those that work slowly but that can readily be discontinued (antidepressants). In general, it is suggested that the slow but sure path is the best in panic disorder.

The term “antidepressant” is a poor one, as many of these agents are excellent anti-panic medications. The most widely used antidepressant agents for treatment of panic disorder are the selective serotonin reuptake inhibitors (SSRIs) and venlafaxine (SNRI), which are safe and easy to use.

Perhaps the key element of the psychotherapy (talk therapy) for panic disorder is “exposure” to feared stimuli. Many people with panic attacks begin to avoid places where they experienced panic; a vicious cycle then develops of more and more restrictions. Learning not to avoid is a crucial aspect of treatment.

By continually practicing feeling anxious, and at the same time experiencing that this does not in fact lead to catastrophic results may ultimately overcome panic attacks.

As in the cognitive-behavioural treatment of other anxiety disorders, this approach is difficult insofar as it initially involves increased anxiety levels. There are, however, several ways to help decrease such feelings of anxiety.

Further resources:

SA Depression & Anxiety Group

Tel: +27 11 783 1474/6
Fax: +27 11 884 7074
Internet: http://www.sadag.co.za/

Download pdf for more information : Anxiety disorders 

 Books about Panic Disorder / Agoraphobia

Don’t Panic: Taking Control of Anxiety Attacks (revised edition). Reid R. Wilson. New York, HarperCollins, 1996.
Embracing the Fear: Learning to Manage Anxiety & Panic Attacks. J. Bemis and A.M.R. Barrada. Minnesota, Hazelden, 1994.
How to Help Your Loved One Recover from Agoraphobia. K.P. Williams. New Jersey, New Horizon Press, 1993.
Living with it: A Survivor’s Guide to Panic Attacks. B. Aisbett. Sydney, HarperCollins, 1993.
Overcoming Panic Attacks: Strategies to Free Yourself from the Anxiety Trap. S. Babior and C. Goldman. Minnesota, Pfeifer-Hamilton Publishers, 1996.
Triumph over Fear: A Book of Help and Hope for People with Anxiety, Panic Attacks, and Phobias. R. Ross. New York, Toronto, Bantam Books, 1994.

What is Trichotillomania?

Trichotillomania (TTM) or hair-pulling, has been observed for thousands of years as an aberrant behaviour that often occurs in times in stress, boredom, or frustration. Initially characterized as a rare, untreatable disorder, TTM is now recognized as a relatively common disorder for which several treatment options exist.

TTM is classified in the Diagnostic and Statistical Manual of Mental Disorders (4th edition) (DSM-IV) as an “impulse-control disorder not elsewhere classified” (APA, 1994, p609), and is characterized by the repeated pulling out of one’s hair from any part of the body resulting in noticeable hair loss.

The most common hair-pulling sites are the scalp, eyelashes, eyebrows, pubes, face and extremities. Anxiety virtually always accompanies the illness, with many people describe the hair-pulling as relieving this anxiety.

On the other hand, complications such as fear of losing control and becoming completely bald can cause an extreme heightening of their anxiety. The hair-pulling is generally not painful and may be engaged in from minutes to hours a day and is often done when alone.

TTM has a reported prevalence of 2.0% to 2.5% in the United States. Despite increasing research and clinical focus on TTM locally, the prevalence of TTM in South Africa is not known. Nevertheless, the true prevalence of TTM worldwide may in fact be higher than the US rates indicate as many patients with TTM are very secretive about the disorder.

TTM seems to be more common in women than men: 75% to 93% of clinic patients with TTM are women. This female preponderance may be due (in part) to women’s greater willingness to seek medical care. While TTM can begin at any age, the common age of onset is puberty.

Parents or other family members rarely understand the truly compulsive nature of the problem (saying something like “why don’t you just stop?” or in fact punishing them for hair-pulling) and can add to the person’s feelings of low self-worth.

In addition to the shame and humiliation felt over the inability to control the urges to pull their hair, the sufferer may have to endure ridicule by others – often leading to their avoidance of intimate relationships for fear of having their shameful secret exposed.

As such, TTM contributes to a lifetime of significantly decreased quality of life. Furthermore, TTM appears to be commonly associated with other problematic behaviours (such as nail biting, skin picking, picking at acne, nose picking, lip biting and cheek chewing) as well as other mood, anxiety and substance use disorders.

What causes hairpulling?

There is no one certain cause of TTM. Onset of hair-pulling has been suggested to be associated with a stressful life event such as illness, injury or parental divorce. However, in many cases there is no identified traumatic event or precipitating factor. Family dynamics and modelling may also play a role in the initiation of this disorder. The role of genetic factors in the aetiology of TTM is also being investigated. More recent work suggests that there may be some disruption in the system involved with one or more of the chemical messengers (i.e. serotonin, dopamine) between the nerve cells of the brain. Involvement of the serotonergic and dopaminergic neurotransmitter systems is currently being investigated locally and internationally. This investigation of a genetic basis for TTM is further encouraged by recent findings that genetic variants play a role in disorders with significant phenomenological and neurobiological similarities with TTM, e.g. obsessive-compulsive disorder.

How is Trichotillomania treated?

At this stage, different treatments may need to be tried before finding the one that works. Treatments can be divided into three major groups: medication, behavioural techniques, and hypnotherapy.

Medication

The so-called selective serotonin reuptake inhibitors (SSRI’s) have been the most extensively studied medications in TTM, and are currently the first-line pharmacotherapy.

Unfortunately, it has been suggested that the effectiveness of SSRI’s in patients with TTM may wane with time, i.e. treatment with SSRI’s is often associated with a high relapse rate. Still, SSRI’s are a reasonable first-line agent because of their efficacy in several patients, their favourable side-effect profile, and their efficacy in treating comorbid conditions such as depression and obsessive-compulsive disorder.

Several lines of evidence suggest that the anticonvulsant topiramate might also be effective in the treatment of TTM. The efficacy of this medication is currently under investigation.

Behavioural techniques

In terms of behaviour therapy, habit reversal is the treatment of choice. This method consists of behavioural monitoring, relaxation training, and competing reaction training (substituting a competing behaviour such as clenching a fist in response to the urge to pull hair). One study has suggested that behaviour therapy may be superior to treatment with SSRI’s for reducing the symptoms of TTM.

Hypnotherapy

Hypnotherapy has been used in the treatment of TTM, either alone or in combination with another form of therapy, and it has been suggested that hypnosis can bring effective results. Hypnotherapy commonly includes regression to the age of TTM onset to uncover hidden conflicts, relaxation to relive tension, and suggestion to increase awareness and control of hair-pulling.

This treatment method may provide a useful alternative for the patient who refuses medication or is unable to comply with behavioural therapy. It is very important that the therapist implementing hypnotherapy should be adequately trained.

Importantly, even if medical or behavioural treatments are successful in stopping the hair-pulling, the psychological complications (mentioned above) often also require healing with group and/or individual psychotherapy.

Research

As mentioned previously, currently there is a research project undertaken at the MRC Research Unit on Anxiety Disorders (Dept of Psychiatry, Tygerberg), which primarily focuses on the issue of genetic factors in different psychiatric disorders (including TTM) and to the question of susceptibility to these conditions after streptococcal infection. More specifically, this study aims to identify specific genes that contribute to the development of TTM and other similar conditions.

If you need more information on TTM, or are interested in research and want to discuss the matter of participation, the Mental Health Information Centre (MHIC) can be contacted at +27 21 938 9229/9029.

OTHER RESOURCES

Resources are readily available for patients who wish to learn more about their condition and the available methods for treatment:

Books

Stein DJ, Christenson GA, Hollander E. Trichotillomania. Washington DC: American Psychiatric Press; 1999.
Keuthen NJ, Stein DJ, Christenson GA. Help for Hair pullers. Oakland, CA: New Harbinger Publications: 2001.
Goldfinger GR. The Hairpulling Habit and You: How to Solve the Trichotillomania Puzzle. Washington, DC: Writers’ Cooperative of Greater Washington; 1999.

Internet Sites
www.trich.org
Trichotillomania Learning Center
www.home.intekom.com/jly2/index.html

Amanda’s Trichotillomania Guide
Written by Christine Lochner (Clinical Psychologist), MRC Unit for Anxiety Disorders

What is social anxiety disorder?

Social anxiety disorder (or social phobia) is characterised by fears of embarrassment or humiliation in a social or performance situation. While public-speaking is the most common fear amongst the general public, amongst people with social anxiety disorder it is of one or other social interaction. Most frequently these interactions include:

• fear of eating or drinking in front of others
• fear of writing, signing, or working in front of others
• fear of being the centre of attention
• fear of going to parties or dating
• fear of using a public toilet

When the person is faced with a feared social situation, they may experience intense anxiety, including a full-blown panic attack. They may also experience marked anticipatory anxiety prior to the social situation. Symptoms also frequently involve blushing and stuttering.

Social anxiety disorder and shyness

Social anxiety disorder is not simply shyness. People with social anxiety disorder often avoid the social situation they fear, and if faced with it will experience intense distress. In order to be diagnosed with this disorder, the symptoms must cause significant distress or must interfere with important areas of functioning (such as work or family).

Who gets social anxiety disorder?

Social anxiety disorder has been estimated to be present in 3-13% of the population. More women than men suffer from this disorder, and it is found throughout the world. Social anxiety disorder typically begins during adolescence or early adulthood.

What causes social anxiety disorder?

Certain systems in the brain are known to be involved.

• Hereditary, or genetic, factors.
• Environmental factors, such as not learning how to cope in certain social interactions during childhood.

What to do and where to go for help?

Certain specific medications are effective. However, the combination of medication and psychotherapy (talk therapy) has been shown to be a particularly powerful approach in managing social anxiety disorder. Cognitive-behavioural therapy (CBT) is the mainstay of psychotherapy for the treatment of social anxiety disorder.

Further resources

MRC Anxiety Disorders Research Unit

Tel: +27 21 938 9161

Internet: www.mrc.ac.za/anxiety/anxiety.htm

 SA Depression & Anxiety Group

Tel: (011) 783 1474/6

Internet: www.sadag.co.za

Download pdf for more information: Anxiety disorders 

Books about Social Anxiety Disorder (Social Phobia)

Dying of Embarrassment: Help for Social Anxiety & Phobia. B.G. Markway, C.N. Carmin, C.A. Pollard and T. Flynn. Oakland, New Harbinger Publications, Inc., 1996.

The Hidden Face of Shyness: Understanding & Overcoming Social Phobia. F. Schneier and L. Welkowitz. New York, Avon Books, 1996.

Social Phobia: From Shyness to Stage Fright. J.R. Marshall. New York, Basic Books, 1994.

Fred was a 21 year old sales representative, who had seemed to be making steady progress in his career for several years. After the past several months, however, management had noted a substantial decrease in his performance. When confronted about this, he admitted that his mind was no longer fully on his work. In particular, he felt that he had begun to enter a more spiritual realm. In fact, he even stated that at times he could hear and see beings from “beyond the other side”. Fred was referred to the company’s counsellor, who noted that he had difficulty concentrating well, that his logic seemed very unclear, and that he often appeared to lose touch with reality.

Fran was a 28 year old nursing assistant, who had become increasingly withdrawn at work. Although she managed to complete her duties, she was a loner who seemed to have no friends. People found her difficult to talk to, as she seemed to be rather unemotional – as though she didn’t really experience her feelings strongly. She also seemed to show little motivation in her career. Things might have gone on in this way for longer, had Fran not come to the Matron complaining that some of the other nurses were jealous of her, and had organized a vendetta against her. When asked for evidence of this, Fran stated that she simply knew these things.

Signs and Symptoms

“Positive” Symptoms

Hallucinations – abnormal sensory perceptions – for example, hearing voices or seeing people when no-one else is around.

Delusions – false beliefs based on abnormal reasoning – for example, the incorrect conviction that people are out “to get” one.

Disorganized speech or behavior – for example, talking very circumstantially or incoherently, behaving oddly with no clear plan or reason.

“Negative” Symptoms

Affective flattening – reduction in the range and intensity of emotional expression.

Alogia – impoverishment in thinking, for example, restricted amount of spontaneous speech, overly concrete or overly abstract speech. 

Avolition – inability to start and maintain goal-directed activities.

Myths and Facts

Myth

Schizophrenia involves a split personality, as in the Dr. Jeckyll/Mr. Hyde character.

Fact

Schizophrenia is a disorder of the brain, which leads to specific symptoms such as hallucinations and delusions.

Myth

Like the Dr. Jeckyll/Mr. Hyde character, people with schizophrenia are usually dangerous and violent.

Fact

Schizophrenia is an extremely distressing illness. Most people with this illness are not even noticed by society, but rather suffer in silence.

Myth

People who lose touch with reality (during hallucations and delusions) are “crazies” for whom nothing much can be done.

Fact

Hallucinations and delusions are usually the product of a brain disorder. Fortunately, effective treatments are now available for such conditions.

Causes

It is clear the schizophrenia involves specific brain chemicals and regions. Several factors appear to contribute to its onset, including genetic ones. However, ultimately much remains unknown about the exact causes of schizophrenia.

Best treatment

Specific medications are very useful in controlling the symptoms of schizophrenia. In recent years major advances have been made in this area, and several new agents are now available. In addition, it is important for family to educate themselves about schizophrenia so that they are best able to support the family member with schizophrenia.

Prognosis

Prognoses differ very much from individual to individual. Some people can experience a remarkable return to normal function. Others experience a chronic course with episodes of illness. Usually medication results in a substantial reduction in the symptoms of schizophrenia.

Download pdf for more information: Schizophrenia psychosis

What is obsessive-compulsive disorder (OCD)?

Obsessive-compulsive disorder (OCD) is a psychiatric disorder characterised by obsessions and compulsions.

Obsessions are persistent, “self-generated” (i.e. not delusional or psychotic) thoughts that cause significant distress.

Compulsions are repetitive mental or behavioural acts that the person feels obliged to perform in an attempt to reduce the distress created by the obsessions. However, compulsions are not inherently enjoyable, are often extremely time-consuming and do not result in the completion of a useful task.

OCD is one of the anxiety disorders; the anxiety disorders comprise a category in the standard diagnostic manual known as the Diagnostic and Statistical Manual of Mental Disorders (DSM) that also includes post-traumatic stress disorder, social anxiety disorder (social phobia) and panic disorder.

Although there may in some cases be overlapping symptoms, OCD should not be confused with obsessive-compulsive personality disorder (OCPD).

Despite its name, OCPD does not involve obsessions and compulsions. OCPD refers to a personality, i.e. chronic, pattern of behaviour that involves being preoccupied with order, and includes traits such as perfectionism and inflexibility.

Importantly, both these conditions can cause significant distress for the person and the people with whom he/she shares relationships. Only a few people with OCD have OCPD.

What causes OCD?

There is no single, proven cause of OCD. It is likely that both genetic and environmental factors are involved; i.e. multifactorial causality.

The old belief that OCD was the result only of life experiences has given way before the growing evidence that neurobiological factors are a primary contributor to the disorder. Research suggests that OCD is related to faulty communication between the front part of the brain (the orbital cortex) and deeper structures (the basal ganglia). These brain structures use serotonin, a neurotransmitter (chemical “messenger” between nerve cells). It is believed that an insufficient level of serotonin is prominently involved in OCD. Dopamine systems may also play a role in OCD.

Another theory is that OCD involves various auto-immune reactions (in which the body’s disease-fighting mechanism attacks normal tissue). Evidence to support this is that OCD sometimes starts in childhood in association with strep throat (a sore throat caused by infection with Streptococcus bacteria).

Research suggests that genetics may play a role in development of the disorder in some cases, and a number of genes may contribute to its development. Genetic links are still being studied worldwide – for example the recent collaborative project between the members of the international Obsessive-Compulsive Foundation Genetics Consortium to do a whole genome association scan on DNA samples from OCD patients from all over the world -, but there is significant evidence to suggest that OCD does sometimes run in families, and identical twins have a 70% chance of sharing the disorder.

Who gets OCD and who is at risk?

OCD is a fairly common disorder, affecting between 1% and 3.3% of people.

Onset can begin at any time from preschool age to adulthood (usually before the age of 40 years). Males most commonly start having symptoms as children or as teenagers; females often develop symptoms a bit later, in their late teens or early 20s. One-third to one-half of adults with OCD report that their illness started in childhood. It is just about equally common in males and females.

When a parent has OCD, there is a slightly increased risk that his/her child will develop the condition. However, similar rituals are not inherited. For example, a child may have checking rituals, while her mother presents with contamination fears and washes compulsively.

OCD is not primarily related to stress or psychological conflict, and can be seen in all kinds of personality types. Interestingly, many patients report that their OCD (severity, distress, impairment) increases when their levels of stress increase (e.g. before or during exams).

OCD may also be influenced by hormonal functioning.  In females, in particular, the influence of hormones on the development or manifestation of OCD may not be underestimated.  For example, many females report an increase in their obsessive-compulsive (OC) symptomatology in their pre- / menstrual periods, or OCD onset with pregnancy or shortly after childbirth.  Menopause has also been suggested to mark the onset of OCD in some females.

OCD often occurs along with mood disorders such as depression and bipolar affective disorder (manic depression). In fact, studies of clinical samples have shown that 29.6% – 43% of OCD patients have comorbid depression.

This contributes to the extent of impairment associated with OCD. Indeed, research has also shown that co-existence of OCD and depression is related to chronicity and severity of obsessive-compulsive symptoms, poor response to treatment and bad prognosis.

Symptoms and signs of OCD

OCD usually involves both obsessions and compulsions, although in rare cases, one may be present without the other.

Obsessions:

Obsessions are defined as recurrent and persistent thoughts, impulses or images that the person feels unable to control or prevent. Obsessions are usually experienced as senseless, disturbing and intrusive, and patients try to ignore or suppress them. Anxiety, fear, disgust or doubt often accompany the obsessions.

Common Obsessions:

• Worrying excessively about dirt or germs and that you may become contaminated or contaminate others
• Imagining you have harmed yourself or others; having doubts about safety issues (such as whether you have turned off the stove)
• Fearing something terrible will happen or that you will do something terrible
• Preoccupations with symmetry, or a need to have things “just so”
• Intrusive sexual thoughts
• Intrusive violent or repulsive images
• Excessive religious or moral doubt or guilt; intrusive blasphemous images
• Excessive doubting or indecision: “should I – shouldn’t I?”
• A need to tell, ask or confess

Compulsions:

Compulsions on the other hand, are defined as repetitive and ritualistic behaviour or mental acts, often performed according to certain “rules”

 Common compulsions:

• Washing or cleaning: such as showering repeatedly or washing your hands until the skin is red and painful
• Checking: such as repeatedly checking that you have turned off the stove or locked the front door
• Repeating: such as repeating a name or phrase many times to ease anxiety
• Completing: performing a series of steps in an exact order or repeating them until you feel they are done perfectly
• Repetitive ordering, arranging or counting of objects
• Hoarding: collecting useless items you may repeatedly count or order
• Excessive and repetitive praying
• Repetitive touching

Unlike compulsive drinking or gambling, OCD compulsions are not pleasurable and are often performed to obtain relief from obsessions, i.e. to decrease the extreme anxiety created by these obsessions. For example, you may repeatedly check that you have turned off the stove because of an obsession about burning the house down or you may count certain objects repeatedly because of an obsession about losing them.

Not all obsessive-compulsive behaviours are OCD. Some rituals (such as religious practices, exercise routines) are part of daily life. Normal worries, such as contamination fears, may increase during times of stress, such as when someone in the family is sick.You may have OCD if your obsessions or compulsions

• Cause you marked distress
• Persist and take up a lot of time (over an hour a day). People with OCD may spend hours each day performing compulsive acts
• Significantly interfere with your normal routine, work, social activities or relationships
• Are senseless

People with OCD are usually aware that their obsessions or compulsions are excessive or senseless, and are more than just normal worries. “OCD with poor insight” is diagnosed when someone with OCD does not recognise that his or her beliefs and actions are unreasonable or excessive.

OCD symptoms usually have a “waxing and waning” course, i.e. tend to come and go over time, and vary in intensity. Some symptoms may be mild and fairly easy to ignore; others cause severe distress and disability.
As noted before, people with OCD also often have depression or depressive symptoms, including:

• Guilt
• Sadness
• Low self-esteem
• Anxiety
• Fatigue

Some stressors may even worsen OCD symptoms, examples of such environmental stressors include the following:

• Abuse
• Changes in living situation
• Illness
• Occupational changes or problems
• Relationship concerns
• School-related problems

How is OCD diagnosed?

OCD tends to be under-diagnosed. Because of the stigma of mental illness, people may hide symptoms and avoid seeking professional help. Not surprisingly, OCD has been described as a “secretive illness”.

People with OCD may also be unaware that they have a recognisable and treatable illness. Thanks to recent awareness campaigns and destigmatisation efforts by the media and mental health organisations, this situation is improving. Some health professionals are, however, still unfamiliar with OCD symptoms.

There are no laboratory tests for OCD; diagnosis is based on assessment of your symptoms. Your doctor will ask you, and often people close to you, about your symptoms, and pose specific questions about the type of obsessions or compulsions you experience. You will also be asked how much time you spend doing rituals/obsessing every day. (For example, if you take more than an hour per day performing senseless rituals, you may have OCD.)

Your doctor will also check whether a medication or drug you may be taking at the time is not making your symptoms worse.

How is OCD treated?

Combining antidepressant medication and cognitive-behavioural therapy (CBT) has been found to be the most effective treatment for OCD. Treatment of OCD is a long-term commitment. Both kinds of treatment may take several months to be effective, but a good response is often seen in time. The patient’s commitment and active participation in treatment, together with the support of his/her family, and a good trusting relationship with a therapist, is of the utmost importance in recovery.

Medication

Medications most commonly prescribed for OCD are antidepressants called selective serotonin reuptake inhibitors (SSRIs), notably, fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Aropax), fluvoxamine (Luvox), and citalopram (Cipramil).

Another medication used is clomipramine (Anafranil), which is a non-selective SRI, meaning it affects other neurotransmitters besides serotonin, and might have more side effects.

The SSRIs are usually easier for people to tolerate. All these antidepressants are equally effective, although for any particular person one agent may be better than another.

Most people notice some benefit from these medications after four to six weeks, but it is necessary to try the medication for 10 to 12 weeks to see whether it works or not. If you do experience distressing side-effects, your doctor can try reducing the dose, or adding or switching to a different medicine. Indeed, when the medication (an SSRI) has proved ineffective after 10 to 12 weeks, a different SSRI can be tried.

Alternatively, another medication can be added to the first, or adding CBT may render treatment more effective.

Very importantly: Before deciding that a treatment has failed, your therapist needs to be sure that the treatment has been given in a large enough dose for a sufficient period of time.

Fewer than 20% of people treated with medication alone will have their symptoms resolved completely, so medication is often combined with CBT for better results. The need for medication depends on the severity of your OCD and your age.

In milder OCD, CBT alone may be used initially, but medication may be added if CBT proves ineffective. People with severe OCD or complicating conditions (such as depression) often start with medication, adding CBT once the medicine has provided some relief.

In younger patients doctors are more likely to use CBT alone. However, if a trained cognitive-behavioral psychotherapist is unavailable, medication may be used.

Cognitive-behavioural therapy (CBT)

Behaviour therapy helps you learn to change your behaviour and feelings by changing your thoughts. Behaviour therapy for OCD involves exposure and response prevention (E/RP), and cognitive therapy.

Exposure involves gradually exposing yourself to feared stimuli. For example, people with contamination obsessions are encouraged to touch “dirty” objects (like money) until their anxiety recedes. Anxiety tends to decrease after repeated exposure until the contact is no longer feared.

Exposure is most effective if combined with response or ritual prevention, in which rituals or avoidance behaviours are blocked. If, for example, you wash your hands compulsively, your therapist may stand at the sink with you and encourage you not to wash your hands until the anxiety recedes. As such, E/RP may be quite stressful, but it is effective in reducing anxiety and rituals in the long run. All exercises during therapy are discussed and agreed upon before implementation.

Cognitive therapy, the other component in CBT, is often added to E/RP to help reduce the exaggerated thoughts and sense of responsibility that often occurs in OCD. Cognitive therapy helps you challenge the faulty assumptions of your obsessions, and so bring anxiety and the urge to respond with compulsive behaviour under control.

Gradual CBT involves practice with the therapist once or twice a week and doing daily E/RP “homework”. Homework is necessary because many of the elements that trigger OCD occur in your own environment and often cannot be reproduced in the therapist’s office. According to research, people who complete CBT have a 50%–80% reduction in symptoms after 12–20 sessions.

Intensive CBT, which involves two to three hours of therapist-assisted E/RP daily for three weeks, may work even more quickly. In rare cases where OCD is very severe or complicated by another illness, or involves severe depression or aggressive impulses, hospitalisation may be recommended for intensive CBT.

Other techniques, such as thought stopping and distraction (suppressing or “switching off” OCD symptoms) may sometimes be helpful.

Other treatments

In adults with very severe OCD, neurosurgery (e.g. high-frequency electrical deep brain stimulation (DBS)) to interrupt specific malfunctioning brain circuits may be recommended.

DBS of specific brain targets, introduced in the early 1990s for tremor (e.g. in Parkinson’s disease), has gained widespread acceptance as a treatment method because of its less invasive, reversible, and adjustable features and is now utilized for an increasing number of movement and psychiatric disorders. The use and efficacy of this method for OCD is still under investigation.

People with OCD may have substance-abuse problems, sometimes as a result of attempts at self-medication, and this usually also needs specific treatment. Also, when someone with OCD also presents with bipolar disorder, it has been suggested that the bipolarity takes precedence in treatment considerations.

Maintenance treatment

Once OCD symptoms are eliminated or greatly reduced, these gains must be maintained. Most experts recommend monthly follow-up visits for at least six months and continued treatment for at least a year before trying to stop medication or CBT.

Relapse is common when medication is withdrawn, particularly if you have not had CBT. It is recommended that you continue medication if you don’t have access to CBT.

People who have repeated episodes of OCD may need to receive long-term prophylactic (preventative) medication.

Discontinuing treatment

If you don’t need long-term medication, most experts recommend gradual discontinuation of medication, while receiving CBT booster sessions to prevent relapse. It is harder to get OCD under control than to keep it there, so don’t risk a relapse by reducing or stopping your treatment without your doctor’s advice.

Education and family support

Include your family in your therapy, and educate all concerned about the illness. This will help you manage your OCD and ensure you get the best treatment.

Consider joining a support group: this helps you feel less alone and learn new strategies for coping with OCD. (The OCD Association of South Africa or the Mental Health Information Centre (MHIC) can give information about support groups in your area.)

When someone with OCD denies the problem or refuses to be treated, family members can help by ensuring the person has access to information about the disorder and explaining that there are effective treatments.

OCD can cause considerable disruption for other family members, who may get drawn into the ill person’s rituals. The therapist can help family members learn how to become gradually disengaged from these.

A calm, supportive family can help improve treatment outcome. Ordering someone with OCD to simply stop their compulsive behaviour is seldom helpful and can make the person feel worse. Instead, praise any successful attempts to resist OCD, and focus on positive elements in the person’s life. Treat people normally once they have recovered, but be alert for telltale signs of relapse. Point out any early symptoms in a caring manner.

What is the outcome of OCD?

OCD symptoms often create problems in daily living and relationships. In extreme cases, people become totally disabled and cannot leave home because they spend their time engaged in rituals or obsessive thoughts.

Without treatment, the disorder may last a lifetime, becoming less severe from time to time, but rarely resolving completely.

In some people, OCD occurs in episodes, with years free of symptoms before a relapse. Even with treatment, however, OCD can come and go many times during your lifetime. Although OCD is completely curable only in some individuals, most people achieve relief with comprehensive treatment.

In children and adolescents, OCD may worsen or cause disruptive behaviours, exaggerate a pre-existing learning disorder or cause problems with attention and concentration. These disruptive behaviours will often resolve or improve when the OCD is successfully treated.

See your doctor if you:

• Suspect you or a family member may be developing symptoms of OCD.
• Experience worsening OCD symptoms that aren’t relieved by strategies you learned in CBT.
• Experience changes in medication side effects.
• Have new symptoms that may indicate development of another disorder (such as panic attacks or depression).
• Are going through a life crisis that might worsen your OCD.

Can OCD be prevented?

At present there is no known prevention for OCD. However, early diagnosis and correct treatment can help people avoid the suffering associated with the condition and lessen the risk of developing other problems, such as depression or relationship and work difficulties.

What OCD research is being done in South Africa?

There is an on-going OCD research project conducted at the MRC Research Unit on Anxiety Disorders (Dept. of Psychiatry, University of Stellenbosch).

This Unit is also part of the above-mentioned international collaboration (the OCDFGC).  The OCD project at the MRC Unit primarily focuses on investigation of the phenomenology (including OCD symptom subtyping) as well as the role of genetic factors in the development of OCD. Other factors that are also evaluated include age of onset, response to medication treatment, comorbidity of OCD spectrum disorders, personality features, history of group A streptococcal infection and rheumatic fever, and family history of OCD and other psychiatric disorders.

We are continuously updating the project and expanding the various tools used for assessment in order to keep up to international standards.  Our focus now include investigation of brain-structure and -functioning in patients with OCD and the assessment thus includes both neuropsychological testing as well as brain imaging.

Participation entails a once-off consultation (and referral for treatment if required), is cost-free and takes approximately two to three hours. If scanning and neuropsychological testing are involved (in addition to the initial comprehensive diagnostic interview), 2-3 additional sessions will be needed.

Blood will be drawn from participants and their parents (if possible, if not, saliva samples would be adequate) to get to the genetic material (also known as DNA). Even though the Unit is situated in the Western Cape, there are recruitment centres in Gauteng and the Eastern Cape.

For more information, contact Prof. Christine Lochner at the MRC Unit on Anxiety and Stress Disorders on 021 938 9179 (email: cl2@sun.ac.za)

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Introduction

Two major kinds of medication are used in the treatment of anxiety disorders. These can be characterised as the “slow but steady” kind, and the “fast and tricky” type.

Each type of medication has advantages and disadvantages. “Slow but steady” applies to the various antidepressants used to treat anxiety disorders. The term “antidepressant” is a poor one as these medications are certainly useful for depression (for which they are invariably first registered), but they are also very effective in treating most of the anxiety disorders.

Different antidepressants are, however, useful for treating different anxiety disorders. These medications are “slow” in that a positive response is seen only several weeks after the medication is first taken. They are “steady” in that they have relatively few side effects, and in that they can be discontinued whenever the person wants without undue problems. With most of these agents it is usually wise to taper the medication gradually rather than to suddenly discontinue it, but this is readily done.

“Fast and tricky” is a term that applies to several other agents, including alcohol, and benzodiazepines (also known as tranquillisers or sleeping tablets). The advantage of these medications is that they work immediately to decrease both the feelings of anxiety and the physical symptoms of anxiety.

They are therefore particularly helpful for use on an “as needed” basis, or for the short-term control of anxiety symptoms. Benzodiazepines are associated with side effects such as mild cognitive impairment and motor vehicle accidents, so care needs to be taken when operating vehicles or machinery.

Furthermore, sudden discontinuation of benzodiazepines leads to marked symptoms of anxiety (in other words, they cause dependence). Occasionally, various drugs other than antidepressants or benzodiazepines are prescribed for the treatment of anxiety disorders.

Are anti-anxiety medications dangerous?

No medication is made available to the South African public until it has been through strict testing. However, all medications have some type of side effects due to the way in which they work.

Also, there is a range of special situations in which taking medication can be dangerous. People who have pre-existing medical illness, who are on multiple medications or herbal products, or who are pregnant or breast-feeding, should take medication only under the supervision of an experienced psychopharmacologist.

Finally, you need to have a relationship with a professional (general practitioner or specialist psychiatrist) with whom you are able to discuss medications. One of the single biggest reasons that anti-anxiety medications don’t work is that people do not take them correctly. In particular, they discontinue their medications too early.

Antidepressants

It is important to note that the antidepressants are the best medication treatment for many of the anxiety disorders over the long haul. Even though it may take several weeks before symptoms feel better, these agents are generally easier to take and are effective. Many of these agents are now available in a more inexpensive, generic form.

Several different kinds of antidepressants are available

Tricyclics: Tricyclic antidepressants have been available for many years. These agents are effective in some anxiety disorders (such as panic disorder), but not others (such as social anxiety disorder).

The main problem with these agents is that many are associated with inconvenient side effects, in particular dry mouth, blurry vision, and other so-called “anticholinergic” effects. On the other hand, there are newer tricyclics where such side effects are relatively infrequent.

MAOIs: Another class of medication that has been available for many years is the monoamine oxidase inhibitors (MAOIs). These are very effective for a number of anxiety disorders (e.g. panic disorder, social anxiety disorder), but again not for all (e.g. obsessive-compulsive disorder). The main problem with this class of medication is that it requires a careful diet.

Certain foods (in particular, cheese) and certain other medications (such as other antidepressants) are dangerous in combination with MAOIs. A reversible inhibitor of monoamine oxidase A (RIMA), which does not require dietary restrictions, has been introduced more recently.

SSRIs: Several medications are available in this class. The selective serotonin reuptake inhibitor (SSRI) which has achieved the widest media coverage is Prozac (fluoxetine). Unfortunately, much of this media has been hype, with Prozac touted as either a miracle drug, or a dangerous medication that can cause people to commit suicide. Prozac is no more powerful or dangerous than any other SSRI.

These agents have the advantage that they work on only one very specific receptor in the brain and therefore have fewer side effects than the older tricyclics. Their advantage lies in their efficacy against depression and many anxiety disorders. Side effects include nausea and agitation (which tend to be short-lived) and delayed orgasm in some patients.

Other: A range of more recently introduced antidepressants are also available. These include the serotonin and noradrenaline reuptake inhibitor, venlafaxine, the noradrenergic and specific serotonergic antidepressant, mirtazapine, and the selective noradrenergic reuptake inhibitor, reboxetine.

These agents have somewhat different side effect profiles than do the SSRI’s, so they may be useful for people who have experienced SSRI side effects (such as delayed orgasm). There is growing evidence for the use of some of these newer agents in some anxiety disorders, but further research is still needed.

What about herbal medications?

Many people feel that while medications from a pharmacy are synthetic, herbs are in some way a more natural alternative. It is certainly true that a range of plant products can be useful for mood and anxiety symptoms.

However, the contrast of synthetic medications and natural herbs is too simplistic. For one thing, many medications were in fact originally developed from plants. And conversely, many herbs work in very similar ways to medications, and so have similar benefits and side effects.

How long will I need to take medication?

This is one of the main concerns of people taking medication. It is important to emphasise that the antidepressants are not associated with dependence and so can be stopped at any point in time.

On the other hand, it should also be emphasised that discontinuing medication too early is associated with a high risk of relapse. All too often, people feel better after taking 3 or 4 months of medication and so stop their medications at that point. Unfortunately, symptoms frequently return a few weeks later.

Three principles need to be considered when taking psychiatric medications.

Firstly, medication should be continued for at least 6 to 9 months after symptoms have responded to treatment. This will lower the chances of relapse once the medication is no longer present.

Secondly, medication should be tapered gradually rather than discontinued abruptly. This not only avoids certain physical symptoms that can be seen after abrupt discontinuation of some antidepressants, but it also provides the person a chance to gradually accommodate to life without medication.

Thirdly, the use of cognitive-behavioural therapy has been shown to decrease the chances of relapse after medication discontinuation. It is worthwhile learning the principles of this therapy before discontinuing medication, and making sure that these are applied during the discontinuation period.

Further references/ resources

Medicines Control Council, Pretoria: +27 12 312 0000
Medicines Information Centre, University of Cape Town: +27 21 406 6829
Poison Information Centre, University of Stellenbosch: +27 21 931 6129

What is insomnia?

Insomnia is a common health problem that affects roughly one third of the population. It is the inability for an individual to fall asleep and/or to maintain sleep, resulting in sleep that does not allow the body to recover from daily wear. About 10% of adults suffer from insomnia.

All people need 6 to 10 hours of sleep a night. Less than 4 hours or more than 9 hours is associated with an increased risk of death. Sleep latency is the time needed to fall asleep and is on average 15-20 minutes. Insomnia is associated with an involuntary increase in sleep latency.

Features of insomnia

Difficulty falling and/or staying asleep.
Inability to remain awake during the day, especially in a warm room, on a full stomach, and in the presence of white noise.
Insomniacs usually feel lethargic and tired during the day.
They may also have microsleeps (naps) during the day of which they may not be aware. Insomnia and sleep deprivation is associated with an increased incidence of accidents especially by those persons operating dangerous machinery, as well as an increased incidence of road traffic accidents.

What causes insomnia?

Alcohol: More than 2 drinks close to bedtime changes sleep structure and results in poor quality sleep.

Psychiatric disorders: Depression and anxiety disorders are associated with insomnia.

Medication: Numerous medications are associated with insomnia. Stimulants such as coffee, tea, chocolate, nicotine, and amphetamines cause insomnia. Certain psychiatric medications are associated with insomnia.

Medical conditions: Any disease that is associated with chronic pain may result in insomnia. Heart-lung conditions that cause orthopnoea (difficulty breathing) cause insomnia. Urinary frequency and diuretic medication can also lead to insomnia.

Sleep apnoea: This condition is associated with ear-nose-and-throat obstruction.

Circadian rhythm: Humans have an internal biologic clock that determines their sleep-wake cycle. Any disturbance of this cycle will result in insomnia. Crossing time zones results in jetlag that is often associated with insomnia during the night and somnolence (sleepiness or unnatural drowsiness) during the day.

Environmental changes: Changes in sleep environment such as going on vacation or sleeping in different places when on call can result in insomnia.

Nocturnal myoclonus or restless legs syndrome consists of constantly jerky leg movements throughout the night.

What to do and where to go for help

Many insomniacs attempt to treat themselves through various methods ranging from alcohol use to over-the-counter medications and prescriptions. However, effective behavioural and medication treatments are available and often a combination of the two help in the treatment of insomnia.

The most common medications that are used in the treatment of insomnia are hypnotics. These are drugs that bring on sleep and are primarily used for the short-term management of insomnia. Antidepressants can be used to not only address the sleep symptoms of depression, but have also been found to have sleep-improving properties.

Behavioural treatments produce reliable and lasting benefits for many insomnia patients and avoid the undesirable consequences of many medications. Various techniques include: stimulus control, sleep restriction, progressive muscle relaxation, biofeedback, imagery training, paradoxical intervention, and natural substances.

Sleep hygiene education is a technique used to help patients identify lifestyle and environmental factors that may make it difficult to achieve or maintain sleep.

Useful tips

Avoid stimulants such as caffeine and nicotine before bedtime
Do not use alcohol as a sleep aid and avoid alcohol before bedtime
Exercise regularly but not within 3 hours to bedtime
Minimise light, noise, and extreme temperatures during sleep
Eat only a light snack before bedtime, if hungry
Do not watch the clock after going to bed
Do something relaxing before bedtime, e.g. having a hot bath
Use the bed only for sleeping or sex
Do not nap during the day (except in the elderly)
Get up at the same time each day, even when tired
If not asleep within 20 minutes of going to bed, do a low energy activity (e.g. reading) in another room until tired and then return to bed.
Cognitive therapy is a useful technique for sufferers who often display unrealistic sleep expectations, which leads to performance anxiety due to excessive effort at trying to control the amount and quality of sleep.

Summary

Insomnia disturbs the normal restorative functions of sleep and therefore decreases daytime alertness. This is associated with an increased risk of involvement in accidents. Psychiatric, medical and substance use disorders are associated with insomnia. Non-medication treatment options on their own or with a short (two weeks) prescription of a hypnotic, resolve most cases of insomnia.

Further references/ resources

Sleep Laboratories

Greenacres Hospital: +27 41 363 3504
Groote Schuur Hospital: +27 21 404 4371
Lorne Street EEG & Sleep Lab: +27 31 309 5059
Pretoria Academic Hospital: +27 12 354 2282
Tygerberg Hospital: +27 21 938 5500
Universitas Hospital: +27 51 405 3610
Wits University:+27 11 717 2506

What is generalized anxiety disorder?

The term “generalized anxiety disorder” (GAD) refers to a condition characterised by excessive worry. In some ways, the term “tension disorder” is a better one because both mental tension (e.g. worry, irritability) and physical tension (e.g. muscle tension, insomnia) are experienced.

People with GAD worry about everyday life circumstances (e.g. job responsibilities, finances, the health of family members) or about more minor matters (e.g. household chores, keeping appointments). The worries are experienced as difficult to control, and they are clearly distressing or interfere significantly with work or with social functioning.

The worrying is accompanied by one or more of a range of physical symptoms, such as restlessness, getting tired easily, difficulty concentrating, irritability, muscle tension, and disturbed sleep.

The particular symptoms of generalized anxiety disorder may differ somewhat from person to person. For example, some people may experience mostly cognitive symptoms (i.e. worry), while in other people the bodily symptoms (e.g. aches and pains) are experienced as the main problem.

Worries are not always GAD

The worries of generalized anxiety disorder need to be distinguished from the depressed thoughts of depression and the obsessions of obsessive-compulsive disorder (OCD).

The disorder that most closely overlaps with GAD is in fact depression; many people with GAD also have depressed mood, and many people with depression also have significant worries. The obsessions of OCD tend to be relatively senseless in comparison to the more understandable worries of GAD.

A number of different general medical disorders may present with symptoms of anxiety; it is important not to misdiagnose GAD in these cases. Certain foods (e.g. caffeine), medications (e.g. stimulants), and substances (e.g. alcohol) may also contribute to increased anxiety.

GAD should be differentiated from normal anxiety. The distinction between normal anxiety and a clinical disorder such as GAD rests on the extent of distress and dysfunction associated with symptoms. The worries of GAD are of course more pronounced, more pervasive, and more likely associated with physical symptoms than are ordinary worries.

Who gets GAD?

Around 3% to 8% of the general population will suffer from GAD at some point in their lives. The prevalence of the disorder is higher, however, in people who are already visiting a general practitioner. GAD is also more common in people with another psychiatric disorder, including another anxiety disorder. Finally, GAD is somewhat more common in women than in men.

Most people with GAD say that they have suffered from excessive worrying all their lives; the condition may start at a young age and may continue for many years. Symptoms often worsen during stressful times.

What to do and where to go for help?

There are several different medications that can be used for the treatment of generalized anxiety disorder. These include benzodiazepines (tranquillisers), buspirone (Buspar), and antidepressants such as the tricyclic antidepressants, venlafaxine, and selective serotonin reuptake inhibitors (SSRIs).

People with GAD can be seen as viewing the world through a lens which colors everything with negative predictions. Psychotherapy (talk therapy) focuses on attempting to change this lens (technically, this is the “cognitive” part of “cognitive-behavioural therapy”).

Steps in the cognitive-behavioural therapy of GAD can include self-monitoring and cognitive restructuring. Self-monitoring involves paying closer attention to one’s thoughts and feelings. In some ways this is an exposure (“face the fear”) technique, but the technique is also useful in demonstrating to oneself the connection between fearful thoughts about the future and feelings of anxiety.

Cognitive restructuring involves providing good counter-arguments which dispel the logic of worry and fear found in GAD. Common cognitive distortions in GAD include probability overestimation, catastrophising, and all or nothing thinking. Overcoming such distortions may well require the help of a professional.

Further resources/ references

SA Depression & Anxiety Group

Internet: www.sadag.org.za

Download pdf for more information : Anxiety disorders 

Books

Chronic Anxiety: Generalized Anxiety Disorder and Mixed-Depression. Ronald M. Rapee and David H. Barlow (Eds). Guilford Press, 1991.
Generalized Anxiety Disorder: Diagnosis, Treatment and Its Relationship to Other Anxiety Disorders. David Nutt, Spilios Argyropoulos and Sam Forshall. Bladwell Science Inc., 1999.
Overcoming Generalized Anxiety Disorder: Client Manual. John White. New Harbinger Publications, 1999.