What Every Therapist Needs to Know About Anxiety Disorders
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THERAPIST: So can you tell me how the door takes away your anxiety when it is opened?
PATIENT: When it is opened I figure that I can run out if I start to feel anxious.
THERAPIST: The “I figure” is the really great thing you just said. So it is the thought that you can leave, not the door itself being open, that makes you feel less anxious.
PATIENT: Huh! That’s right.
THERAPIST: And actually, if you think about it, it is the thought that maybe you won’t be able to run out that triggers your fears. So it is actually your thought and not the door that scares you. And that is the first step, recognizing it is not actually the places but the thoughts.
Here is an example of someone with social anxiety disorder:
PATIENT: I am afraid of making an appointment with my academic advisor. I just know I will look like an idiot and he will question whether I should even be a philosophy major. He is a scary guy.
THERAPIST: So is it the advisor that is making you scared or is it your thoughts of what he might think that are scaring you? Has this scene in your mind actually happened or is it what you are imagining?
Here is an example from someone with OCD:
PATIENT: I can’t go to church because every time I get in there, I feel like I am going to blurt out something horrible and I won’t be able to control myself.
THERAPIST: So how many times has this happened?
PATIENT: Never! But I start worrying about it even before I get there. I can’t be sure I can keep control.
THERAPIST: So is it the church itself or your own thoughts and images that you are scared of?
Finally, the third general category consists of those who are unable to tolerate and therefore feel terror of a memory. They are locked onto a memory of a legitimately frightening event in the past; the memory is so intense that they are unable to distance themselves from it. It feels like they are living it all over again. Many anxiety disorders based on trauma are fears of and reactions to a memory. Most people who experience intense panic attacks have embedded the memory of those experiences. Sensations and thoughts that are associated with former panic attacks have the capacity to trigger additional fearful symptoms related to these memories.
This next person has a specific phobic reaction to a traumatic memory. He had worked as a line cook in a restaurant near the World Trade Center on September 11, 2001. He had witnessed first-hand some of the carnage of that day, and walked to safety in Brooklyn afterwards. But he never returned to his job as a cook. It made him too anxious. The phobia of stoves is created by the fear of a memory and smell memories are particularly powerful.
PATIENT: I haven’t been able to use the stove. I get freaked out. I can’t stand the smell. It is terrifying.
THERAPIST: What is terrifying?
PATIENT: The smell. There is this smell of metal on the flame, and I start remembering everything falling down, and big pieces of metal falling down, and someone asked me, “is this the end of the world?” and I didn’t know. I just knew I had to keep moving. And the smell. I took the train home and was coated with all that powdery stuff.
THERAPIST: So you are saying that the memory of the burning smell starts the whole cycle, and it …
PATIENT: It brings me back. I feel like my life is in danger and I get very frightened.
Here is another example:
PATIENT: Every time I put on those boots I freak out. I should throw them out.
THERAPIST: What do you think is happening?
PATIENT: Those were the boots I was wearing when I had that horrible panic attack in the mall that started the whole mess. It was the worst day of my life. I guess they just remind me.
Presenting three fear groups helps patients focus on the internal processes that underlie the nature of their fears. Patients come to us believing that they are afraid of something “out there.” We want to change that. Relating all fears to these three fear trigger groups is a concrete and practical way to help patients refocus on their important inner life—what is going on inside of them—when there is a strong drive to be hypervigilant about what is going on outside of themselves.
The Defining Aspect of an Anxiety Disorder
The inability to tolerate fearful distress—whether from sensations, thoughts, or memories—is an essential aspect of an anxiety disorder. The distress is seen as dangerous. The task is to help patients understand that discomfort and danger are separate. If we revisit the introductory comments about recovery, we mentioned that the absence of anxiety—while certainly desirable—is not sufficient. A better definition is being less bothered by anxiety, even if some remains. Another way to put this is to say that reducing anxiety sensitivity is a major goal of treatment.
Reducing anxiety sensitivity is a major goal of treatment.
The more general concept goes like this: It is not anxiety that defines an anxiety disorder, but the way one feels about anxiety that is essential. If a patient can say, “yes, I feel distress, but I’m not concerned that I’m in danger, and I don’t worry that this distress will harm me, and I don’t need to keep focused on it for fear that something awful is about to happen, so I can go on with my life even with this distress” (certainly this is a commendable example of Buddhist equanimity!), then this person would meet all criteria for being recovered from an anxiety disorder. He has overcome his anxiety sensitivity.
The Basic Principle: Identify and Treat Avoidance
The basic principle for overcoming anxiety is like a story from the Talmud—books of commentary on ancient Jewish law. The Talmud tells of a man who challenged the great rabbis to teach him the Torah while standing on one foot. Legend says that he was chased away and chastised by most. But when he came to one rabbi, this man replied, “What is hateful to you, do not do to your neighbor: that is the whole Torah; all the rest is commentary.”
Treating anxiety disorders can also be reduced to a principle simple enough to learn while standing on one foot: “Anxiety is maintained by avoidance, and willing exposure is the active ingredient of recovery. That is essential; all the rest is commentary.”
Anxiety is maintained by avoidance and willing exposure is the active ingredient of recovery.
To overcome anxiety, patients must learn to understand and identify the ways in which they avoid. In the short term, avoidances feel good. In the longer term, avoidances reinforce, empower, and energize anxiety, while at the same time disempowering the patient. The goal is to reverse that trend—to empower patients and disempower the anxiety.
Sometimes avoidances are blatant and clear. For example, the claustrophobic person who avoids elevators, or the person with OCD who washes his hands repeatedly and simply refuses to touch anything that feels dirty. But most of the time, avoidances are far more subtle: the fearful flier who insists on a window seat; the person with panic disorder who won’t make appointments during rush hour, for fear of delays in traffic; the person with OCD who lets himself get his hands dirty, but comforts himself by imagining how clean he will feel once he gets home and washes sufficiently; the socially phobic person who will talk to anyone except an extremely attractive person; the worrier who won’t risk being unsure about someone’s whereabouts and needs to text them constantly. The list of avoidances is huge. Much of the work will involve helping clients to identify and change their varieties of avoidance. The basic principle is simple, but the correct way of applying it can be difficult. It can take persistence, discipline, effort, gentleness, and courage.
References
NIMH Anxiety Disorders. (2007) June 16 2013. Retrieved from www.nimh.nih.gov/health/topics/anxiety-disorders
Reiss, S., Peterson, R.A., Gursky, D. M., and McNally, R. J. (1986) Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behaviour Research and Therapy 24(1) 1–8.
Stein, M. B., Jang, K. L., and Livesley, W. J. (2002) Heritability of social anxiety-related concerns and personality characteristics: A twin study. The Journal of Nervous and Mental Diseas
e 190(4) 219–224.
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A Contemporary View of Anxiety Disorders
Sensitivity and Anxiety
The best way to understand an anxiety reaction is to think of it as a sensitized response (Aron, 2003). Sensitization is a general term used to describe an overall level of nervous system arousal whereby patients are likely to experience physical symptoms, such as muscle tension and increased heart rate, as well as mental symptoms, such as worrisome thoughts and hypervigilance. Sensitization varies with fatigue, degree of stress or conflict, general health status, and mood. The triggers of any anxiety disorder provoke strong physiological and mental arousal. These triggers can be external (such as a situation viewed as confining), or internal (sensations—such as tightness in the chest or light-headedness, cognitions—such as an intrusive thought; or a frightening memory). Most people experience this arousal as a whoosh of fear or terror. For the moment, it might be helpful to think of these patients as allergic to these triggers, because their reaction is similar to allergic reactions. A person who has hay fever and is allergic to ragweed pollen would have a strong reaction to pollen, whereas others who do not have this allergy would have none. Similarly, sensitized people have a strong internal terror reaction to triggers that might cause almost no reaction in others.
Thus, three factors interact for people with anxiety disorders. They have a high level of physiological sensitization. They have strong terror reactions to certain internal and external triggers that result in significant physiological arousal. And they add a fearful appraisal to these reactions, which increases terror and motivates a desire to avoid. Treating people with anxiety disorders requires recognition of how these three factors interact.
A Discussion of Causation
A widely held assumption is that insight into causes is necessary for a cure (Grünbaum, 1993). It is suggested that since repressed conflicts play a role in the development of anxiety, these symptoms have a deeper meaning, and patients won’t recover until they uncover and work these through. So the traditional method for treating someone with a significant anxiety disorder requires backing away from the symptom and looking instead at the underlying meaning.
We understand the appeal of these assumptions, and the desire to hunt for historical causes—even hidden causes—especially because anxiety symptoms often start with such a bang. It is not uncommon for people to rapidly begin experiencing full-blown panic attacks, or start a crippling obsessive disorder, or to suddenly feel excruciatingly frightened to speak in class, or to develop some other intense anxiety symptom, often suddenly and seemingly “out of the blue.” Of course there are people who simply cannot remember when they were not anxious, such as those with a socially anxious temperament from birth or with obsessive-compulsive disorder (OCD) manifesting at a very early age. The work of traditional psychotherapies—discovering and rooting out causes of problems—is based on the tenet that insight into these causes will result in the lessening or elimination of the anxiety symptoms (Paul, 1966). However, this approach has been less than effective when applied to patients with overwhelming anxiety. Here are some reasons why.
Insight: Cause Versus Maintenance
We first make a distinction between insights into what causes anxiety disorders as opposed to what is helpful in treating them. Personal insight into the cause of an anxiety disorder helps a patient understand the reason why he developed symptoms, and it provides him with information about the reasons he became symptomatic at a particular point in time. Insight can be essential in reducing the bewilderment and sense of overwhelming hopelessness and powerless that often accompanies intense anxiety. However, this kind of insight is almost never enough for successful treatment. Insight into origins is particularly important after symptoms are resolving, since it provides direction to avoid the stresses, situations, and coping methods that originally precipitated and continue to maintain the problem. We address this issue further in Chapter 14 (Relapse prevention).
Insight has another function as well. The “aha!” experience that accompanies the understanding of how past and present interact, or the clarification of an issue that appears to underlie the symptom, helps our patients to feel better. But we believe these feelings are transitory, and do not lead to real improvement. It is not enough for our patients to feel better in the moment: our aim is to reduce their ongoing suffering.
But the issue of causation is different from what is needed to overcome an anxiety disorder. We view all anxiety disorders as self-maintaining. The cycle of experiencing anxious distress, and then avoiding that distress, is a self-reinforcing set of behaviors that is functionally autonomous (Allport, 1937). Once established, anxiety disorders continue to exist separately from any historical context or conflictual issues. They can go on indefinitely unless addressed directly.
The example of a forest fire is sometimes used. Discovering what causes the blaze is helpful in a variety of ways. It might help to know where to find fires when they are just beginning (perhaps an area of special dryness), or to determine if some change can be made to reduce the number of fires (perhaps campsites aren’t sufficiently isolated from timber). But the fire itself must be extinguished directly, and the blaze burns separately from any cause or set of combustion triggers.
Treatment needs to focus on what maintains anxiety disorders, as opposed to what causes them.
The issue of what causes anxiety disorders is a separate universe of discourse from what maintains them. Treatment needs to focus on what maintains anxiety disorders, as opposed to what causes them. Helping people overcome their anxiety requires that we focus less on the question of “why” and more on addressing the questions of the “how.” No amount of uncovering or working through various causes speaks to the issue of maintenance. It doesn’t scratch that itch.
However, we do comfortably speak of insight into the factors that maintain anxiety symptoms. Successful therapy requires that patients develop a different perspective on their symptoms. They will need to examine anxiety triggers and their anxiety experience itself, in order to gain a fresh clarity on the sensations, thoughts, and memories that drive their anxiety. It is not the meaning of the symptoms but the way that people react to their symptoms that becomes the focus for insight. This is a radically different attitude towards their symptoms: to stay when they want to flee, to yield when they want to resist, and to otherwise not be fooled by the misleading messages of anxiety.
Primary Versus Secondary Gains
There is a distinction between the primary and secondary gains (Fishbain, Rosomoff, Cutler, and Rosomoff, 1995) with anxiety disorders. Every therapist has observed instances where patients with significant anxiety disorders utilize their anxiety as excuses for not engaging in a variety of activities. Sometimes they are viewed as controlling, demanding, manipulative, or rigid. Secondary gains can be realized from any psychiatric disorder, including anxiety disorders. Desperately frightened people do what they can to feel less desperate. But a secondary gain is not a cause. Certainly no one develops an anxiety disorder in order to control or manipulate a situation. Focusing on secondary gains without first recovering from primary symptoms will not be effective. Addressing secondary gains are part of the work of ongoing psychotherapy, and is best delayed until patients know how to manage their anxiety more effectively.
The primary gain of a patient with an anxiety disorder is simply to avoid anxiety and the distress that comes with it. Unfortunately, the methods used to avoid the anxiety and their accompanying distresses are self-maintaining until they are understood and challenged.
Studies on Causation
Clinical research on causation reinforces the importance of focusing on maintenance, since causes are found to be either fixed, or elusive, or both. First, a multitude of studies indicates that genetics plays a highly significant role in determining whether someone develops overwhelming anxiety (NIMH, 2009). Anxiety disorders tend to run in families, and a genetic component exists that is independent of e
nvironmental factors (Merikangas and Pine, 2002). One of us sometimes tells patients—only partly in jest—that they chose the wrong parents, and that they will have to do better next time around. The other regularly asks not “whether” but “which” side of the family this comes from. Second, while environmental factors play some role in the development of the disorder, the vast majority of anxiety disorders cannot be traced to any identifiable event or series of events in our patients’ lives. Most people with anxiety disorders have histories that do not differentiate them from those without. Third—despite extensive research and many proposed and interesting ideas—there are no identifiable styles of childrearing that have been consistently linked to adult anxiety disorders. These are exhaustive studies that have spanned the past 30 years (Rosenbaum, Biederman, Bolduc-Murphy, Faraone, Chaloff, Hirshfeld, and Kagan, 1993). Finally, the set of premorbid personality characteristics that may identify some people at risk of developing anxiety disorders is likely a genetically driven temperamental predisposition that includes social withdrawal, avoidance and fear of the unfamiliar, and over arousal of certain aspects of the nervous system, a pattern called Behavioral Inhibition (Degnan and Fox, 2007) (Stemberger, Turner, Beidel, and Calhoun, 1995).
In short, there is little evidence to validate that anxiety symptoms are primarily a result of underlying unresolved conflicts, and therefore have a meaning that expresses these conflicts. And the same can be said of a personality type that predicts the future development of significant anxiety disorders. Some patients were fearless, precocious, and willing to take all types of risks, prior to developing overwhelming anxiety. Others were always timid and risk averse, but that these characteristics mushroomed with the development of their anxiety disorder. While it is true that being raised by an anxious parent (which includes most people with an anxiety disorder) or being subject to neglect or early loss will likely influence maintenance factors, they are not the cause of the disorder. Understanding the contribution of environmental experiences will not make the anxiety disorder go away.