What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

  References

  Yehuda, R. and LeDoux, J. (2007) Response variation following trauma: A translational neuroscience approach to understanding PTSD. Neuron 56(1) 19–32.

  Stein, D. J., Fineberg, N. A., Bienvenu, O. J., Denys, D., Lochner, C., Nestadt, G., … Phillips, K. A. (2010) Should OCD be classified as an anxiety disorder in DSM-V? Depression and Anxiety 27(6) 495–506.

  Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, J. R., and Mancill, R. B. (2001) Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample Journal of Abnormal Psychology 110(4) 585–599.

  Acknowledgments

  No book is written without the support of many people, but I wish to specifically express my appreciation to Claire Weeks, Manny Zane, and Herbert Fensterheim, who many years ago introduced me to new perspectives on anxiety. Special thanks to Ron Doctor for his friendship and support, and for starting me out in this project. ADAA has had a tremendous influence on my professional life, and I have benefited much from the work of Reid Wilson and the late Jerilyn Ross. I thank Anna Kaltenboeck, Jerry Gerber, and Sigalit Levy for their editing suggestions, and Molly Winston for her graphics. I am indebted to my learned friend and colleague Carl Robbins for his reading and valuable comments, and thank Kimberly Morrow for her careful editing. My patients teach me and give me pleasure every day, and I am indeed fortunate to have them in my life. I am grateful to my collaborator Sally Winston for trusting me enough to let the world—and not just her colleagues—glimpse her gifts and sensitivity as a clinician. And I thank Laura Goulden for her confidence, encouragement, support, and gracious acceptance of my hectic work schedule.

  Martin Seif

  I would like to acknowledge the influence of a number of individuals who helped to launch my enduring interest in the anxiety disorders, including Douglas Hedlund, Zelda Milstein, and the late Jerilyn Ross whose leadership and advocacy for those suffering from anxiety disorders was of profound importance to the field. My first reading of Hope and Help for your Nerves by Claire Weekes was a paradigm shift for me, preceding the “third wave” of CBT innovation by several decades. For help with the manuscript: my thanks to Ruthellen Josselson for setting us on the right track and to Kimberly Morrow, for her generous editing suggestions. For constant encouragement to explore new ideas and to think carefully about the implications of what I am saying, I am grateful to know and appreciate Carl Robbins. I never stop learning from Reid Wilson. Thanks to Molly Winston for her creative graphics. It would not have been possible for me to complete this work without the daily help of my co-director and closest colleague Steven Shearer. The gifted therapists of the Anxiety and Stress Disorders Institute of Maryland are my support and pleasure. Most importantly, it is my patients who have taught me almost everything about what it is like to have an anxiety disorder and what helps and what doesn’t help to transcend it and to thrive. I want to thank Marty Seif for his friendship, quiet wisdom, and his confidence in me. And to my husband Morton Winston who has been trying to get me to write for 40 years, and who has endured the process so patiently, thank you.

  Sally Winston

  1

  Why Details Make a Difference

  Flight 702 from New York to Los Angeles has boarded. Six frightened fliers are seated in row 17, seats A through F. Each responds “yes” to the following.

  Are you afraid to fly?

  Are you anxious anticipating a flight?

  Would you prefer to avoid flying if you can?

  Are you feeling anxious right now?

  In seat 17A, the passenger is thinking “I don’t know if I can stand it when the doors close. I am going to feel trapped, I won’t be able to leave, I am going to get that unbearable overwhelming rapid heart rate and I won’t be able to breathe right and I don’t know if I can control my reaction and I could just either go crazy or even cause myself a heart attack. Are there straitjackets in case I lose control? What if I lose it and open the door in the middle of the flight? I wonder if there is a defibrillator on the plane.”

  This person has panic disorder. He is terrified of panicking while on the plane, and his fear of flying is a fear of experiencing a panic attack.

  Seat 17B is occupied by someone who feels sensations similar to the first person— rapid heart rate, difficulty breathing—but the cognitive focus is interpersonal rather than intrapsychic. He is thinking “I am getting anxious and I feel like I might throw up and get pale and fidgety and the person next to me is going to turn to me and say ‘are you all right?’ and what if I can’t talk properly and by the time we get to our destination, everyone in the plane will know there is a nutcase on this plane. I don’t know if I can keep my anxiety hidden. And what if a flight attendant comes over to try to help me—then everyone in this whole plane will be focusing on me and wondering what is going on. What if I start to look weird and crazy to them? What if someone thinks I am a terrorist?”

  This person is not primarily afraid of the anxious feelings, but of the fact that they could show and someone will judge him badly, exposing him to humiliation, inadequacy, and shame. This person’s fear of flying is an aspect of his social anxiety disorder.

  In seat 17C is someone who is also incredibly upset with the following thoughts: “I know that they clean the planes in a deep way with antibacterial solution every two weeks and that they spray room freshener into the air when they are on the ground because I did the research, but in between flights, they just pick up the trash. I have really been trying to keep my arms and hands off the seat rest because you never know who was sitting here and what germs they could have—it could even be AIDS—and they are only 99% sure that it can’t be transmitted this way and you can’t be sure that this passenger did not have an open wound on their hand anyway. And all of a sudden I am thinking that I may have inadvertently touched the armrest when I was listening to the pilot announcement and OMG what if I get sick and transmit it to my kids? And how about that virus that is going around? I’m trying not to breathe too deeply on this plane, because the inside of the cabin is just one big incubator of germs, and I don’t want them inside of me.”

  This person, who in former times might have been incorrectly labeled “germophobic,” suffers from obsessive-compulsive disorder (OCD). In repeated attempts to lower her anxiety, she tries to avoid exposing herself to germs, and at the same time continually reassures herself that she is overreacting. This self-talk, which comforts her only partially and only for a short time, is called cognitive compulsions. While the idea of the plane crashing (and other dangerous possibilities) may also scare her, right now she is focused on the possibility that being on this flight might harm herself and her children.

  In the next seat over, seat 17D, sits someone whose older brother went down in a plane in Vietnam when she was a child. Every time she has to fly, she has weeks of dreams about fiery crashes, reliving that horrible moment when her mother told her that her brother was dead. She is hyperventilating right now, feels overwhelmed with fear and grief, and would rather be anywhere else. Half of her is presently on the plane and half of her is in the past.

  For this person, flying triggers intensely painful memories of her previous trauma— memories that come alive, feel like real life, and crowd out the present when she encounters triggers connected to them. This woman suffers from post-traumatic stress disorder.

  Seat 17E is occupied by someone worried about the plane crashing and whether or not the pilot has a hangover, and whether or not that rattling sound underneath her seat is normal. But she is also worried that she may have a scratchy throat and what if it ruins her vacation, and what if the airline loses her baggage and what if the person who is supposed to pick her up gets stuck in traffic or forgets. And she just learned that she paid more for her ticket than the OCD person in seat 17C and does that mean she should cancel her plan to go to the expensive restaurant, and—wow—are her muscles going to be sore after sitting for six hours!

  This person i
s in an ongoing and toxic worry state, known as GAD, generalized anxiety disorder, a relentless and rambling set of “what if” worries, which is characterized by—in addition to worry—muscle tension, autonomic arousal, anxious mood, and episodes of panicky feelings.

  And finally in seat 17F is the person with aviophobia—fear of flying—that is a specific phobia (formerly called simple phobia) in which the fear is of an external thing going terribly wrong. This person does not worry as relentlessly as someone with GAD, nor does he obsessively and compulsively check on aspects of his life, like someone with OCD. This person is focused primarily on plane safety, the possibility of weather making his flight more dangerous, how his children might survive his death, and the horror of the image of going down during the crash.

  We use fear of flying in this example, but the same variety of experience and complexity of phenomenology is true for all anxiety presentations. All these people are “phobic” of flying, yet each is going through a very different experience, and will need differing types of treatment. While each may need to take a flight eventually for exposure to feared thoughts, sensations, memories, and emotions, the work to get there will be different indeed. This is why details make such a difference. Similar fears may require dramatically different treatment. “Feeling anxious” can mean profoundly different things for different people, and understanding the range of experience informs accurate diagnosis and guides how to help at every step of the way.

  Introduction

  Anxiety disorders are the most common psychological problem (Robins and Regier, 1991), and are also the most treatable (Barlow, 2004). The rise of effective therapy for these disorders is relatively new, and the media have seized on modern approaches as a panacea for anxious people. While cognitive-behavioral therapies (CBTs) have made significant advances in this field, most patients with an anxiety disorder cannot be fully treated with just a few simple applications of CBT principles.

  However, we believe that psychotherapists of all backgrounds and training can add the contributions of anxiety disorder specialists to their own repertoire. We intend to provide keys to better understand and help highly anxious patients. We present effective ways to conceptualize and treat people with overwhelming anxiety, so that their lives will no longer be run by anxiety, and there will be room for joy and emotional flexibility.

  People with anxiety disorders can be extraordinarily “good” patients. Unless in the midst of an acute anxiety episode, they are usually polite, cooperative, compliant, and responsible. They are interesting to be with. Unfortunately, their anxiety symptoms often do not improve. One therapist called them annuities, in that some continue to come and pay for treatment for the rest of our professional lives. Treating a person with severe anxiety requires augmenting some of the traditional psychotherapeutic assumptions with alternative approaches that can be more helpful. Here are some key points.

  It is of primary importance to have a clear idea of what patients fear, since particular fears lead to differing forms of treatment. There are great benefits in accurately diagnosing and conceptualizing each anxiety disorder. Specific differential diagnoses can be essential—such as distinguishing anxiety from agitation, thoughts from impulses, obsessions from rumination—because the approach is quite different for each of these. For example, OCD can look like a multitude of different disorders— from psychosis to depression to agoraphobia—and the proper diagnosis informs how best to proceed.

  The popular notion that CBT involves “changing the thought in order to change the feeling” is fallacious. A more accurate formulation of modern anxiety treatment stresses better tolerance of distressing feelings, focusing not on changing thoughts to change feelings, but on how patients tolerate and evaluate what they think and feel. What matters most is not what they feel, but how they feel about what they feel. This concept— sometimes called “anxiety sensitivity”—is at the foreground of contemporary anxiety treatment. People with anxiety disorders are sensitive to and afraid of anxiety. The goal is to change the relationship between the patient and anxiety symptoms, reducing distress, and promoting psychological flexibility.

  What matters most is not what they feel but what they feel about what they feel.

  There are many times when responding to a highly anxious patient in a reassuring manner actually reinforces and empowers anxiety. When treating people with an anxiety disorder, once a safe therapeutic relationship has been established, their immediate comfort is not always our goal. In fact, when striving for present comfort becomes predominant, it often leads to increased anxiety in the long run. There is a significant element of paradox when treating anxiety disorders. There is an art and skill to integrating the approach presented in this book with one that is also supportive and empathic. The goal is to relieve suffering, as opposed to just providing transitory comfort.

  Anxiety motivates avoidance, which in turn keeps the anxiety strong. So when dealing with highly anxious patients, the therapist sometimes needs to take a more direct approach and act like an educator or coach. Especially at the start of treatment, there is nothing more valuable than taking a teaching role and directly explaining what is happening physiologically and mentally to bewildered patients. It gives people courage and decreases shame and bewilderment when they know what is happening. Therapists who focus primarily on dynamic issues and the therapeutic dyad may doubt our stance, but it is our experience that the therapeutic process and patient–therapist relationship is strengthened, not compromised.

  There is a widely held view that anxiety symptoms have meanings and are manifestations of underlying causes, and that uncovering the meaning will result in the elimination of symptoms. However, intense anxiety symptoms show most reduction when the processes that maintain them, not their original causes, are addressed directly. The most effective route is to first help patients manage the anxiety before focusing on any uncovering processes. The best roles for the pursuit of insight and meaning in the overall treatment of an anxiety disorder will be elaborated.

  Finally, it is primarily avoidance of all kinds—cognitive, behavioral, and emotional— that fuels and maintains anxiety (Taylor and Asmundson, 2004). This means that exposure to the experience of anxiety is essential for effective therapy (Hayes, Wilson, Gifford, Follette, and Strosahl, 1996). We provide a framework for integrating exposure into treatment and for understanding and teaching anxiety management tools and attitudes in a way that can provide a lasting change in the patient’s quality of life.

  Exposure can add to the complexity of the therapeutic relationship, since patients will need to feel particularly safe within the therapy. A trusting and safe relationship forms the emotional platform upon which patients allow themselves to risk exposure to anxious triggers, and the resultant discomfort and uncertainty. Anxiety creates a sense of danger, and that danger is best tolerated within the context of a positive relationship with the therapist. It is a challenge for any therapist to maintain a sense of safety within the therapeutic relationship while deliberately encouraging the patient to undertake feeling as if they are in danger; as therapists, our instincts push us to reassure and comfort patients whenever they are uncomfortable. Anxiety disorder therapy requires that we must frequently resist these instincts.

  The vast majority of time, however, treating anxiety disorders will be similar to treating patients with other problems. Anxiety disorders occur and are maintained within contexts. Most of the work identifying triggers and noticing patterns of emotional and cognitive factors is akin to teaching patients how to be aware of their inner life when anxiety is making it difficult for them to do so.

  Reasonable Goals

  Patients often wish there were some magic wand that would erase their anxieties quickly. But erasing their anxiety doesn’t mean that they are recovered. Anxiety disorders are chronic intermittent disorders (Kessler, Ruscio, Shear, and Wittchen, 2010). They tend to recur because they have a strong biological underpinning (Hettema, Neale, and Kendler, 2001). If patients
don’t know how to manage anxiety, if they don’t understand how to face anxious arousal and thoughts, then they will always be afraid of their recurrence. In that case, even the complete absence of symptoms would not meet our definition of recovery. Recovery requires that patients feel confident in their ability to manage anxiety whenever it shows up, and to be willing to explore whatever aspects of life they wish, free of the fear of anxiety. The less bothered they are by whatever anxiety occurs, the closer they come to what we mean by recovery. Recovery doesn’t mean there will be no anxiety, since that is a normal part of growth, excitement, and change. It is when anxiety gets out of hand, when it limits where one goes, interferes with relationships, identity and mood, when it causes additional suffering—that is the sort of anxiety we address in this book.

  Anxiety disorders are chronic intermittent disorders. They tend to recur because they have a strong biological underpinning.

  Techniques Are Not the Answer

  This is not a book about techniques for reducing anxiety. The following story illustrates the place that techniques hold in the overall treatment:

  A man couldn’t get his furnace to work properly. He had heating experts come to his house, each would replace a part or two, and within 24 hours the furnace would always stop working. Finally, a friend recommended “a real genius.” This man came to the house and spent 20 minutes looking here, tapping there, and listening to all the sounds that came out of the heating system. He then took a hammer and struck it vigorously on the outside of the furnace. Immediately, it started working perfectly. The owner was amazed. “How much do I owe you?” he asked. The repairman replied, “Let’s make sure that takes care of it. I’ll check on you next week.” A week later the repairman called and the furnace was still purring away perfectly. Then the owner got a bill for a thousand dollars. Astonished at the price, he called up the repairman and said, “That’s ridiculous. All you did was give the furnace a bang. That isn’t worth anything like a thousand dollars!” The repairman replied, “Hold off, I’ll send you an itemized bill.” Three days later it arrived in the mail. It said: