What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

  Charge for banging on your furnace to fix it: $1.00

  Charge for knowing where to bang on your furnace to fix it: $999.00

  Anyone can bang on a furnace, just like anyone can use anxiety management techniques. Techniques themselves are neither a help nor a hindrance, and are trivial compared with the knowledge required to utilize them properly. A technique is merely a tool, and the real work is learning how to use it to ensure an optimal outcome.

  Our approach is evidence informed, but not a formula or protocol for approaching patients. It is full of ideas of things to say and do in session, and it discusses a wide range of techniques, but, more importantly, it is about attitude. It is about helping people to change their attitude, reactions, responses, and beliefs about the contents of their minds and how their bodies feel. It is about changing the relationship between patients and their anxiety.

  An essential point is that anxiety symptoms cannot be vanquished with effort. Anything—no matter how calming it may seem to be—if done to suppress or fight, counteract or distract, analyze or get rid of, keep at bay or otherwise avoid these feelings will ultimately fall short of ending anxiety. Anything done with urgency and intensity will fall prey to the paradoxical nature of the symptoms. Anxiety is best embraced and allowed. Otherwise, it will try to overpower, fight to take over, and cause additional suffering. So we as therapists must climb on board and embrace this attitude as well: techniques are of limited help (and can be counterproductive) unless one knows the proper attitude with which to apply them. Despite the wish to comfort and contain our patients’ immediate distress, we guard against the misapplication of techniques—not only those we suggest, but also ones patients may already be using unproductively. It may take some time to demonstrate the power of this attitudinal shift, but the results can be transformative.

  Anxiety symptoms cannot be vanquished with effort.

  References

  Robins, L. N. and Regier, D. A. (1991) Psychiatric disorders in America: The epidemiologic catchment area study. New York, NY: Free Press.

  Barlow, D. H. (2004) Anxiety and its disorders: The nature and treatment of anxiety and panic. New York, NY: The Guilford Press.

  Taylor, S. and Asmundson, G. J. G. (2004) Treating health anxiety: A cognitive-behavioral approach. New York, NY: The Guilford Press.

  Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., and Strosahl, K. (1996) Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology 64(6) 1152–1168.

  Kessler, R. C., Ruscio, A.M., Shear, K., and Wittchen, H. U. (2010) Epidemiology of anxiety disorders. Behavioral neurobiology of anxiety and its treatment. Heidelberg, Germany: Springer 21–35.

  Hettema, J. M., Neale, M. C., and Kendler, K. S. (2001) A review and meta-analysis of the genetic epidemiology of anxiety disorders. American Journal of Psychiatry 158 (10) 1568–1578.

  2

  The Basics

  Three General Characteristics of Highly Anxious People

  The vast majority of highly anxious patients will share three characteristics. The first characteristic is sensitivity to certain triggers. They experience this as a whoosh of fear, and there is a characteristic physiological arousal that is triggered by the fear circuitry of the brain that includes the amygdala and is automatic and reflexive.

  The second characteristic is their disproportionate focus on the future. They are constantly asking “what if” questions. Most highly anxious patients spend very little time focusing on the present. This is unfortunate, because the more one focuses on the present, the less one tends to experience anxiety. Anxious thoughts and feelings are almost always involved with the future, and people do best in highly anxious situations when they stay as close to the present as possible.

  The third characteristic is a consistent tendency to catastrophize. Patients typically imagine worst-case scenarios in sensitized situations. So, not only will they get into “what if?” future thinking, but the content of their “what if?” thoughts will be worst case, with a huge focus on the risks and almost none on the rewards. If there are a thousand possible outcomes in a future situation—mostly benign—they will spend a disproportionate amount of time and mental energy concerned with the one or two outcomes that are disastrous. So, depending on the particular sensitivity, a sore throat could be cancer, or a pain in the arm might indicate a possible tumor. If prescribed a medication, they might focus on the possibility of getting one of the worst and most serious side effects. If they are about to give a speech, they are visualizing freezing or panicking or vomiting at the podium. If they are going somewhere, getting to their destination uneventfully is rarely considered. It is their tendency to focus on what can go wrong (even if highly unlikely), than to consider any of the many possibilities of things going right.

  Anxiety Feels Dangerous

  On the surface, there is nothing logical about anxiety disorders. If fears were based on logic, greater danger would produce greater fear. But that is not true, and patients are often fearful of situations that are very safe, yet sometimes unafraid of activities that carry a much higher risk of danger. Looking at the inner life of anxious patients, however, anxiety disorders follow impeccable internal logic. If a patient believes that light-headedness could be a stroke symptom, a rapid heart rate might signal an impending cardiac event, uncertainty about turning off the gas could lead to a house fire, or social events could lead to a humiliating faux pas, then it is understandable that they feel afraid of these triggers. Anxious avoidances would follow in the same manner. If one were truly at risk of fainting (a common mistaken concern among people with panic disorder), it would be illogical not to avoid activities that require attention, such as driving. Once patients fall for these unconsciously triggered false messages, their fear makes sense. Highly anxious patients feel comforted when we inform them that their fears and avoidances are logical if they accept these false premises, but they are being fooled by anxiety, whose misleading messages are unconscious, automatic, conditioned, and—for the time being—outside of their control.

  Anxiety motivates avoidance by making patients feel like they are moving from danger to safety. Anxiety has the singular goal of getting patients to flee its source, because that is how it preserves itself. It accomplishes that by tricking patients into believing that feelings of anxiety indicate danger, even though that is not true. Another way to state this is to call anxiety a bluffer, a trickster, and a dissembler that will always try to convince people that there are good and valid reasons to avoid it, when, in truth, no such reasons exist. Anxiety makes patients believe that feeling anxious is the same as being in danger. The goal is to erase the association between feeling anxious and being unsafe. They are not the same.

  Anxiety makes patients believe that feeling anxious is the same as being in danger.

  But there is another aspect of avoidance that patients have probably already discovered. Avoidance keeps anxiety fresh, and intensifies its discomfort. To overcome anxiety, patients will have to move, in manageable steps, towards areas of greater discomfort.

  This requires exposure to anxiety and its triggers, since it is the only way the brain learns to break that connection. So following this approach takes courage, the discomfort that one is willing to experience in order to reach a goal. One patient, who was extremely afraid of heights, said that he felt as courageous for reaching the top of his stepladder as Sir Edmund Hillary must have felt upon reaching the top of Mount Everest.

  Anxiety is a bluffer. Overcoming anxiety involves understanding its paradoxical nature. It requires helping patients learn that the common sense steps that they take to overcome anxiety actually add to its intensity. We intend to show ways to out-bluff anxiety, and improve on common sense ways of trying to eliminate it. One key to overcoming an anxiety disorder is learning how to take manageable steps towards the source. Not too big that one feels overwhelmed by anxiety, but large enou
gh to make progress. That is the art of the therapy.

  How an Anxiety Disorder Differs from Plain Anxiety

  Everyone experiences anxiety. But for most, fear and anxiety play a background role in their lives. An anxiety disorder is conceptualized as anxiety that causes either disability or extreme distress (NIMH, 2007), but there is more to the distinction. People with an anxiety disorder do not merely feel fear, they fear fear. They are frightened by their feelings of fear. They are anxious about being anxious. Being frightened of the fearful feelings is an essential component of having an anxiety disorder. It is this two-step process—“fear” plus the “fear of the fear”—that turns ordinary anxiety into a disorder.

  This is the trait of anxiety sensitivity (Reiss, Peterson, Gursky, and McNally, 1986), a defining characteristic of anxiety disorders. People with anxiety sensitivity are afraid of anxiety itself. They tend to have greater anticipatory anxiety about experiencing anxiety, are more anxious about coping with fearful arousal itself, and tend to spend more energy—both behavioral and mental— avoiding feared internal sensations. Anxiety sensitivity is a trait that is heritable—meaning that it runs in families—and is one piece of evidence that points to genetic factors in the development of anxiety disorders (Stein, Jang, and Livesley, 2002).

  People with anxiety sensitivity are afraid of anxiety itself.

  But let us be even more precise: people with anxiety disorders experience distress, and they try to avoid it because it seems dangerous. Highly anxious patients will understand this immediately. Virtually every patient with significant anxiety will respond with relief and concurrence when the problem is conceptualized as a fear of fear. A patient’s concern about the danger of this distress and inability to handle it is what maintains and amplifies the anxiety. He might be thinking “I’m really feeling freaked out, what if these feelings make me sick?”, which would generate additional feelings of distress. This is the anxiety-generating process at work.

  The Three Types of Triggers

  Patients often come into therapy expressing fears of things that are “out there,” and so expend energy trying to control external events, ignoring internal anxiety-generating processes. Triggers are what set off the alarm, while fear is what happens once the alarm has sounded. Patients do best when they are able to focus on internal processes and become more aware of their characteristics.

  Triggers are what set off the alarm, while fears are what happen once the alarm is sounded.

  Apart from any specific diagnosis, anxiety disorders can be initiated by three types of triggers—sensations, thoughts, and memories. This differentiation helps patients grasp the relationship between an external trigger and the resultant terror that characterizes the anxiety disorder. It provides a conceptual link between what patients fear “out there” and the phenomenon of anxiety sensitivity, or fear of fear. These types of triggers are not mutually exclusive; in fact, many diagnoses fall into more than one category. But the differentiation helps discern the particular types of distress patients might be experiencing.

  Figure 2.1 presents a graphic representation of the three trigger types. The first category consists of those who are triggered by feelings or sensations they experience as dangerous, emotionally painful, or intolerable. Examples of typical feared sensations are light-headedness, tightness in the chest, and nausea. Sensations are not innately frightening; they acquire the capacity to trigger the anxiety reaction as a result of past fearful experiences. They have become conditioned, or learned reactions. So an individual who experiences light-headedness might become terrified that this sensation indicates a dangerous medical condition. He might visit emergency rooms when the sensations start. He might seek out medical information from the internet or medical books, searching for an explanation for his symptoms that make him feel safer or tell him how to fix them. He might start to avoid any situation that might provoke those sensations, such as exercise or high places, and particularly those which have been associated with the onset of light-headedness in the past. A more accurate perspective is that these are attempts to remove or avoid the sensations triggering the fear. Attempts to avoid the sensations will almost always make them more intense, which can trigger a cycle leading to feelings of panic. People with these sensitivities are unable to tolerate, and are therefore terrified of, frightening sensations. We want to make sure they are aware of the role of these sensations.

  Figure 2.1 Three types of triggers.

  PATIENT: I get this feeling in my head, sort of like things are cloudy or fuzzy. I feel almost dizzy.

  THERAPIST: And what happens when you get these feelings?

  PATIENT: I get very frightened. I feel so weird I can’t put it into words. I get terrified that maybe I’m blacking out or maybe I’m losing control. I worry about freaking out.

  THERAPIST: That sounds very uncomfortable, but I notice that you are able to connect your anxiety to the sensations in your head. The pathway to feeling this way often has to do with the way we breathe when we are anxious, and has nothing to do with fainting or going crazy. In fact, later on, we are going to demonstrate how that works. So once you understand that connection, we can find a way to get your brain and your body to become less distressed by those sensations.

  Another example of someone who is afraid of feelings and the sensations that come with them might look like this person:

  PATIENT: I can’t go to the movies. They mess me up.

  THERAPIST: What happens in the movies?

  PATIENT: If it is suspenseful, I start feeling like I can’t breathe and then I have to leave. I tried just to go to chick flicks but then if I get involved, I start to cry and then I can’t breathe either. I just can’t handle movies.

  THERAPIST: So is it the movies that mess you up? Or actually these sensations you get when you are excited or sad? If you could go to a movie with a guarantee that you wouldn’t get those sensations, would you be able to enjoy it?

  This describes panic disorder. But intolerance of sensations and the resultant panic is not isolated to this single diagnosis. Those with specific phobias, social anxiety disorder (SAD), and generalized anxiety disorder (GAD) can also be unable or unwilling to tolerate sensations because they trigger the fear of fear.

  Most people with obsessive-compulsive disorder (OCD) fall into the category of those who are unable to tolerate those thoughts that are experienced as threatening or predictive of catastrophe. These people might be sensitized to thoughts of illness, contamination, disorder, or impulsive and unacceptable actions. Anxiety can make thoughts feel as real as actions, and these people live through the terror of their own racing thoughts. Imagining those scenarios seems equivalent to living them, and so the terror feels dangerous and intolerable. They engage in a variety of activities—in their mind and in their behaviors—as attempts to keep those distressing thoughts at bay. They are battling the frightening thoughts inside their mind.

  Here is a dialogue with a person with OCD where the patient is helped to focus on the role of his frightening thoughts.

  PATIENT: I keep thinking that I might have forgotten to turn off the gas and I imagine the whole place filling with it, and one little spark can set the whole thing off. I have to come back from work just to make sure it is off. It’s totally crazy.

  THERAPIST: So the thought of your house filling with gas creates your awful feelings.

  PATIENT: I keep on thinking to myself, “Did I turn it off?” or “Could I have possibly left it on?” It goes back and forth inside my head and drives me crazy until I think, “Why not just check it and be done with it?”

  THERAPIST: So you just told me how much power those thoughts have to make you feel anxious, and then your desire to get rid of that anxiety generates the really powerful pull to go home and check. Our goal is for you to learn how not to fear these thoughts—not to buy in and believe them as if they were realities instead of thoughts.

  In addition to OCD, patients with GAD and SAD fall into this category. There a
re also people with panic disorder and specific phobias who, in the midst of extremely high anxiety, also become terrified of their thoughts.

  Here is an exchange with someone with panic disorder. She described herself as severely claustrophobic and could not close the door to any room she entered. She explained she was terrified that she wouldn’t be able to open the door. One of the tasks was to restate her fears in terms of fear groups. We explained that she was terrified of the thought that she wouldn’t be able to open the door, and then immediately felt sensations of heat, rapid heart rate, and light-headedness. This is an essential first step in being able to switch the focus from what goes on outside the person to what is going on inside.

  PATIENT: The closed door frightens me.

  THERAPIST: Okay, please tell me how the closed door frightens you.

  PATIENT: I’m okay when the door is opened.