Not Otherwise Specified: Anxiety & the Work of Dr. Robert Hudak
Southwest Pennsylvania National Alliance on Mental Illness (NAMI) held its annual conference at the beginning of April, and one of their afternoon breakout workshop presenters was Dr. Robert Hudak, assistant professor of psychiatry at Western Psychiatric Institute & Clinic, University of Pittsburgh. “Pathways to Hope: Shaping a Positive Future in Uncertain Times” was the conference topic; Dr. Hudak’s contribution was “Coping with Anxiety and Panic Attacks.”
I communicated with Dr. Hudak recently, to clarify some questions, get his take on some extrapolations of anxiety and even to inquire about an interesting diagnostic title he proposed in his presentation.
Conference breakout workshops, be they NAMI or just about any organization, can never do justice to a topic in the short time allotted, but it is always good to get a small group together to at least begin a dialogue.
In his session, Dr. Hudak defined anxiety, reviewed the disorders as classified by the old and up-and-coming Diagnostic and Statistical Manual (DSM), discussed when and how to treat anxiety, and addressed referral concerns. Most of the content described herein is directly from his slide presentation, combined with quotes from my interview with him.
Interestingly, anxiety is “the only psychiatric symptom that is also experienced by individuals with no psychopathology.” Think about what that means. It can be found in normal emotion, or in psychiatric illness. But it can show up as “secondary to a medical or psychiatric illness, or as a primary symptom of a medical illness.” There are two states– not just psychological but also physiological — and four components — somatic, emotional, cognitive, and behavioral.
It is hardly a secret that even mild anxiety can show up in our bodies. The onset of hives for me during teen years, personally, was definitely emotionally-based, no matter how physically those deep red welts marred my arms. And as the emotional and behavioral components of anxiety are “givens,” in a sense, I asked Dr. Hudak to elaborate a bit on some of the cognitive components that might surface.
“The main one is an inability to concentrate or an inability to focus or pay attention,” he replied. “People sometimes complain to me that they feel like they have ADHD because their concentration is so bad.”
Due to internal family conversations that I have witnessed and been a part of at NAMI groups, though, I was thinking along the lines of more severe cognitive impairment even if acutely, as in stress-induced psychotic symptoms, disorganized thinking in how one presents to others, disassociation, or any manipulative behavior.
Given a chance to respond further, Dr. Hudak explained that “diistorted thoughts absolutely occur secondary to anxiety.” He gave the example of a mother who may not let ever her kids leave the house due to fear that they might get into a car accident and die.
“If they do leave, they may be required to check in every few minutes to ensure her they have not died, which most people would consider very extreme.” He goes on to say that “cognitive restructuring (in order to get her to realize that the chances of this happening are extremely unlikely and her reactions are extreme) is a part of the treatment, but only part. Simply doing that alone won’t work. Other behavioral methods are needed as well.”
As for stress induced psychotic-like symptoms, Dr. Hudak felt them “extremely rare” (but I know many family members through NAMI who might disagree!) Most important, as stressed in his workshop, “anxiety is expressed in a wide variety of ways by different individuals.”
The outgoing DSM has obsessive-compulsive disorder (OCD) as an anxiety disorder, but it will apparently be given its own weighted place elsewhere in the new one. Anxiety Disorder NOS (Not Otherwise Specified) will still be there, though, and Dr. Hudak curiously had it labeled “Hudak’s Syndrome.”
“This is a joke I tell to drive home a point. Every major psychiatric category has a NOS category which is generally used as a wastebasket term, for symptoms that don’t appear to be a diagnosable psychiatric condition…. I don’t feel it is a wastebasket term but is an actual separate illness that people can have, and to emphasize that it is different from generalized anxiety disorder.”
He goes on to say that he has certainly heard others comment, as well, that anxiety NOS is an actual illness and not just an NOS category.
His presentation gives an integrated approach for the treatment of all anxiety disorders, with consideration of medications and behavioral therapy, yet he definitely feels, as most, that “cognitive-behavioral therapies are the only ones shown to be effective for anxiety disorders.” These include specific physical techniques to help people cope with anxiety, as well as cognitive ones, such as self-record keeping and progress-tracking. “Thinking skills” also help individuals face situations that cause anxiety.
In his presentation, Dr. Hudak covered panic attacks in depth. I found it interesting to note that he included explaining the harmlessness of panic attacks as a specific, disarming therapeutic technique to be included in treatment.
A thorough look at the latest medications, and the symptoms they best treat, was given via his slide lecture. Some interesting points definitely stood out. He mentions FLAMS (Frontal Lobe Amotivational Syndrome) as a potential severe side effect of SSRI meds. Individuals being treated with these may “feel apathetic and emotionless…. very difficult to treat.”
“Exposure with Response Prevention” was one of Dr. Hudak’s slides and topics. This “teaches people that the physical symptoms of anxiety are normal and OK.” In treatment, a careful attempt to try to raise the heart rate will take place (by doing triggering behaviors and mechanisms).
Dual diagnosis — mental illness and co-occurring substance abuse — is a problem for many. Whether attending AA or NA, or on a treatment with an agonist like suboxone, it has been documented that acute anxiety is one of the most common co-occurring conditions with these patients.
Dr. Hudak feels that the the best way to determine the cause of the anxiety in these circumstances is to get patients sober. Nevertheless, anxiety can and will present in myriad forms, for myriad people, as is clearly pointed by his research and effective presentation.
An effective workbook is referenced in Dr. Hudak’s material — Mastery of Your Anxiety and Worry, by Zinbarg, Craske and Barlow, as well as some local resources for OCD, one of Dr. Hudak’s specialties.
Miles, L. (2013). Not Otherwise Specified: Anxiety & the Work of Dr. Robert Hudak. Psych Central. Retrieved on October 8, 2015, from http://psychcentral.com/lib/not-otherwise-specified-anxiety-the-work-of-dr-robert-hudak/