What Every Therapist Needs to Know About Anxiety Disorders

Home > Other > What Every Therapist Needs to Know About Anxiety Disorders > Page 1
What Every Therapist Needs to Know About Anxiety Disorders Page 1

by Martin N Seif




  What Every Therapist Needs to Know About Anxiety Disorders

  What Every Therapist Needs to Know About Anxiety Disorders is an integrated and practical approach to treating anxiety disorders for general psychotherapists. What is new and exciting is its focus on changing a patient’s relationship to anxiety in order to enable enduring recovery rather than merely offering a menu of techniques for controlling symptoms. Neither a CBT manual nor an academic text nor a self-help book, What Every Therapist Needs to Know About Anxiety Disorders offers page after page of key insights into ways to help patients suffering from phobias, panic attacks, unwanted intrusive thoughts, compulsions, and worries. The authors offer a rich array of therapist– patient vignettes, case examples, stories, and metaphors that will complement the work of trainees and experienced clinicians of every orientation. Readers will come away from the book with a new framework for understanding some of the most frustrating clinical challenges in anxiety disorders, including “reassurance junkies,” endless obsessional loops, and the paradoxical effects of effort.

  Martin N. Seif, PhD, ABPP, cofounded the Anxiety and Depression Association of America and was a member of its board of directors from 1977 through 1991. Dr. Seif is associate director of the Anxiety and Phobia Treatment Center at White Plains Hospital and a faculty member of New York Presbyterian Hospital/Cornell Medical School. He maintains a private practice in Manhattan and Greenwich, Connecticut, and leads Freedom to Fly, an airport-based program for fearful fliers.

  Sally Winston, PsyD, cofounded the Anxiety and Stress Disorders Institute of Maryland, where she is codirector. She is the inaugural recipient of the Jerilyn Ross Award of the Anxiety and Depression Association of America and has decades of experience treating patients, training therapists, and advocating for public awareness of anxiety disorders and advances in their treatment. She has given training workshops in the US, Canada, Asia, and Africa.

  What Every Therapist Needs to Know About Anxiety Disorders

  Key Concepts, Insights, and Interventions

  Martin N. Seif and Sally Winston

  First published 2014

  by Routledge

  711 Third Avenue, New York, NY 10017

  and by Routledge

  27 Church Road, Hove, East Sussex BN3 2FA

  Routledge is an imprint of the Taylor & Francis Group, an informa business

  © 2014 Martin N. Seif and Sally Winston

  The right of Martin N. Seif and Sally Winston to be identified as authors of this work has been asserted by them in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.

  All rights reserved. The purchase of this copyright material confers the right on the purchasing institution to photocopy pages which bear the photocopy icon and copyright line at the bottom of the page. No other parts of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers.

  Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe.

  Library of Congress Cataloging-in-Publication Data

  Seif, Martin N.

  What every therapist needs to know about anxiety disorders : key concepts, insights,

  and interventions / by Martin N. Seif and Sally Winston.

  pages cm

  Includes bibliographical references and index.

  1. Anxiety disorders. 2. Anxiety disorders—Treatment. 3. Anxiety—

  Physiological aspects. I. Winston, Sally. II. Title.

  RC531.S37 2014

  616.85’22—dc23 2013040802

  ISBN: 978-0-415-82898-7 (hbk)

  ISBN: 978-0-415-82899-4 (pbk)

  ISBN: 978-0-203-51884-7 (ebk)

  Typeset in Minion

  by Apex CoVantage, LLC

  To David Seif and Emily Seif

  To Frank and Phyllis Margolick

  Contents

  List of Figures and Tables

  Preface

  Acknowledgments

  1 Why Details Make a Difference

  Introduction

  Reasonable Goals

  Techniques Are Not the Answer

  2 The Basics

  Three General Characteristics of Highly Anxious People

  Anxiety Feels Dangerous

  How an Anxiety Disorder Differs from Plain Anxiety

  The Three Types of Triggers

  The Defining Aspect of an Anxiety Disorder

  The Basic Principle: Identify and Treat Avoidance

  3 A Contemporary View of Anxiety Disorders

  Sensitivity and Anxiety

  A Discussion of Causation

  Insight: Cause Versus Maintenance

  Primary Versus Secondary Gains

  Studies on Causation

  The Dilemma of Insight

  Consequences of Affect Intolerance

  The Value of Talking about Anxiety Symptoms

  A Direct Approach to Treating Anxiety Disorders

  The Neurological Perspective: Role of the Amygdala in Sensitization

  The Value of Exposure

  The Fear-maintaining Cycle

  Avoidance, Resistance, Neutralization

  The Phenomenology of Anxiety: Anxiety Alters Consciousness

  With Anxiety, Common Sense Makes No Sense

  The Paradoxical Attitude

  4 The Therapeutic Attitude of Acceptance

  Approaching Anxiety Mindfully

  Embracing Anxiety

  The Role of the Therapist

  Teaching Metaphors

  Essential Elements to the Therapeutic Attitude of Acceptance

  5 Getting Started

  The First Contact Must Instill Hope

  Immediate Help: Embed Information in Your Questions

  Get the Details

  Find Out What They Have Tried

  Introduce the New Paradigm: Offer a More Profound Change Than Techniques

  Provide Information and Answer Questions

  6 Techniques Your Patients Have Probably Already Tried and Misunderstood: What They Are and How to Make Them Helpful

  The Problem with Techniques

  How Techniques Can Be Helpful

  Techniques Are Temporary Help, Not Goals

  Emergency Coping

  Techniques That Can Be Helpful: “What Is,” Not “What If?”

  Anxiety Management Tricks That Easily Backfire

  Diaphragmatic Breathing

  Anxiety Management in Cases of Real Danger, Not False Messages

  Some Issues in Determining Patient Progress

  7 Diagnoses: An Annotated Tour of the Anxiety Disorders

  Specific Phobias

  Panic Disorder

  Social Anxiety Disorder

  Obsessive-compulsive Disorder

  Generalized Anxiety Disorder

  Traumatic Anxieties

  8 Exposure: The Active Ingredient

  Exposure in the History of Psychotherapy

  Exposure Therapy Is More Than “Just Do It”

  Role of the Therapist During Exposure: What to Say and Do

  Exposure Can Be an Intrinsic Part of Diagnosis and Assessment

  Exposure for Patients with Obsessive-compulsive Disorder: Exposure and Response Prevention

  OCD with Purely Mental Obsessions and Compulsions

  The Right Way to Practice Exposure

  9
The Curious Case of Worry

  Varieties of the Worry Experience

  A Caveat: Generalized Anxiety Disorder—Rarely a Stand-alone Diagnosis

  Worry Is Not an Affect: It Is Thinking—And Thoughts Are Not Facts

  Productive Versus Unproductive Worry

  An Important Insight: Some Worry Thoughts Raise Anxiety and Some Lower It

  The Therapeutic Perspective on Worry

  About Worry and Time: The Role of Urgency

  Evaluating Worry

  Rumination: A Different Kind of Worrying

  Coping with Worry: What Doesn’t Work

  Coping with Worry: Strategies That Work

  10 Unwanted Intrusive Thoughts: All Bark and No Bite

  How Unwanted Intrusive Thoughts are Maintained

  Living with Joy Despite Unwanted Intrusive Thoughts

  Treating Unwanted Intrusive Thoughts

  Issues for Therapists: Varieties of Presentation

  Issues for Therapists: Therapist Anxiety and a New Construct

  Exposure to Unwanted Intrusive Thoughts

  11 Classic Pitfalls: Common Mistakes Non-Specialists Make

  Pitfall Number 1: Turning the Causation Arrow Around

  Pitfall Number 2: Pathological Doubt OCD—Misidentifying OCD Thoughts as Issues and the Seduction of Co-compulsions

  Pitfall Number 3: Intrusive Thoughts or Doubts about Sexual Orientation or Identity—Misdiagnosing OCD Thoughts as a Sexual Issue

  Pitfall Number 4: Get Your Feelings Out

  Pitfall Number 5: Mistakes in the Application of Exposure-based Treatment

  12 Another View of Resistance: Issues that Interfere with Treatment

  When People Come Back Without Doing Home Practice

  Anticipatory Anxiety: When People Need Help Getting over the Hump

  The Reassurance Junkie: When People Are Constant Callers

  13 Some Hard to Treat Problems: A New Perspective

  Illness Worries (Health Anxiety and Hypochondria)

  Scrupulosity (Religious and Secular)

  Emetophobia (Fear of Vomiting)

  Paruresis (Shy Bladder Syndrome)

  14 Relapse Prevention

  Anxiety Disorders Are Chronic Intermittent Disorders: They Come Back

  The Most Enduring Recovery Is When Symptoms Do Not Matter

  Search and Destroy: The Role of Subtle Avoidance

  The Role of Psychotherapy in Relapse Prevention

  The Proper Place for Stress Management

  Finally

  Appendix 1 Additional Metaphors

  Appendix 2 A Summary of the Labeling Process That Can Be Given to Patients

  Appendix 3 How to Learn Diaphragmatic Breathing

  Appendix 4 Anxiety Diary

  Index

  Figures and Tables

  Figures

  2.1 Three types of triggers

  3.1 Two routes to the amygdala

  3.2 First fear is triggered

  3.3 The labeling decision

  3.4 Second fear labeled danger

  3.5 Second fear labeled anxiety

  3.6 Fear maintaining cycle

  Tables

  8.1 Different kinds of avoidance

  8.2 Comparison of planned and incidental practice

  A4.1 Typical anxiety diary

  Preface

  We are Drs. Marty Seif and Sally Winston, psychologists who specialize in treating anxiety. Since the late 1970s, we have treated thousands of people with anxiety disorders. Dr. Seif is one of the seven founders of the Anxiety and Depression Association of America, which began in 1977. Dr. Winston co-founded the Anxiety and Stress Disorders Institute of Maryland, in 1978. This was before the term “panic disorder” was in the DSM and anxiety specialization was in its infancy. We were both trained as psychodynamic and interpersonally oriented clinicians before learning about cognitive or behavioral therapies. We learned from each other, from other early pioneers, and from our patients, and we helped to create what has become the gold standard treatment for anxiety disorders. We have integrated into our work much of the extensive research done in the last 30 years to improve therapy for people with anxiety disorders.

  State of the art treatment of anxiety has changed rapidly and radically, and it is almost impossible for non-specialists to keep abreast of new findings. One author, while preparing a lecture on OCD for a Grand Rounds in 2010, realized that everything taught about OCD in the 1970s is now understood to be incorrect. Additionally, both authors have made their own clinical discoveries and developed ways to approach certain issues that could be helpful to others. Our goal is to share with psychotherapists of all backgrounds and theoretical orientations the key concepts that we, as specialists, have learned over the course of our professional lives dedicated to understanding and treating anxiety disorders.

  Organization

  We provide information about anxiety and anxiety disorders before going into specifics to treat symptoms. A guiding principle is that the more we can educate a patient about anxiety, the less bewildered and afraid he becomes. We therefore encourage specific guided reading, asking questions, and seeking understanding of what is happening in the brain and the body and the mind. It is our responsibility to answer questions, offer explanations, and correct misinformation. Most people with intense anxiety are concerned that there is something profoundly and irreversibly wrong with their psyche or their body. There is an enormous therapeutic benefit in talking to someone who is knowledgeable, understands their experiences, educates them about what is happening, and also provides them with a model of what is going on in their mind that is in clear and accessible language.

  For these reasons, the first parts of this book talk about anxiety from a more theoretical point of view, giving some basic facts as well as the overarching principles upon which they are anchored. Learning about something intrinsically changes our experience of it. When talking about anxiety with patients, there are often new perspectives, new realizations, and resultant therapeutic benefits. For example, it is not uncommon for non-psychotic patients who experience repeated panic attacks to become terrified that they are losing their mind. Simply educating them that they are experiencing panic attacks, which—while profoundly uncomfortable—are treatable and have nothing to do with psychosis, often results in a marked decrease in anxiety. So it is frequently unrealistic to make a distinction between learning about anxiety, and learning how to manage it. The early chapters provide the basic information that forms the core of the assessment and psycho-education phase of treatment.

  In subsequent parts, we address specific topics related to anxiety and some interventions that have been shown to be effective approaches. These chapters are filled with practical suggestions of what to say and do, as well as numerous patient–therapist vignettes to illustrate how to apply basic principles and some of their nuances. We look at exposure-based interventions in detail and explore common misconceptions about the use of anxiety management techniques in both professional and self-help treatment. We examine intrusive thoughts and toxic worry, and some particularly challenging conditions such as anticipatory anxiety, health anxiety and hypochondriasis, scrupulosity, pathological doubt, and reassurance “junkies.” We also look at challenges that commonly plague psychodynamically trained psychotherapists. Finally, we will address relapse prevention, which, in our view, encompasses stress management, lifestyle changes, and relevant psychodynamic, psychosocial, and family therapies.

  Scope

  Traditionally, anxiety disorders have included all those conditions in which anxious arousal, phobias, panic attacks, worry, obsessions, and compulsions are the central features. These form the focus of this book. However, despite the fact that anxiety is a prominent feature of both acute and post-traumatic stress disorders, the American Psychiatric Association has reorganized the structure of the Diagnostic and Statistical Manual (DSM-5), and removed trauma-based disorders from the classification of anxiety disorders. This is because most experts see the fear-ba
sed symptoms as part of a larger complex of shame, anger, guilt, grief, loss, dissociation, emotional dysregulation, numbing, and moral injury. And there is emerging evidence that a different set of neurological changes occur in response to trauma (Yehuda and LeDoux, 2007) as opposed to the other types of anxiety disorders.

  Therefore, whenever dealing with anxiety that has been triggered by a traumatic experience, it is important to obtain a detailed description of the entire symptom picture, which includes: changes in mood and worldview; dissociative and re-experiencing phenomena such as flashbacks and sleep disruptions. If the symptom configuration is primarily anxiety and is, for the most part, functionally no longer associated with the original trauma, then the insights and interventions in this book can be extremely helpful. However, if the symptom picture presented is the full syndrome of post-traumatic stress disorder, including re-experiencing phenomena and shattered illusions of safety—acute or enduring, simple or complex, originating in childhood or adulthood—then different approaches may apply. Concepts in this book may well help with the anxiety symptoms that have developed, but there is a larger arena for interventions that lies outside of the scope of this book.

  In a controversial move, DSM-5 places obsessive-compulsive disorder (OCD) and a variety of related disorders in a chapter separate from other anxiety disorders. This chapter includes OCD, body dysmorphic disorder, and hoarding disorder, as well as hair pulling and skin-picking disorders. This was based partly on emerging biological research demonstrating somewhat different fear circuitry and, possibly, separate genetic transmission mechanisms (Stein, Fineberg, Bienvenu, Denys, Lochner, Nestadt, … Phillips, 2010). OCD is placed immediately next to the anxiety disorders chapter because of the high co-occurrence of OCD with other anxiety disorders (Brown, Campbell, Lehman, Grisham, and Mancill, 2001). We continue to address OCD in this book, as the general principles about what maintains OCD and how best to treat it remain unchanged by this nosological decision.

  Both authors are psychologists who do not prescribe medication, but recognize that psychopharmacology is a legitimate treatment modality for anxiety disorders. We refer many patients for psychoactive medications, particularly if they are too depressed or overwhelmed by their symptoms to be able to make use of the approaches we offer. Despite its standing in the treatment of anxiety disorders, medication will not be addressed in this volume.

 

‹ Prev