The caveat about such skill-enhancing is to make sure these techniques do not become safety or avoidance behaviors. If the purpose of using a map is to not get lost while practicing how to address fears of driving, this is helpful. However, if the purpose of using a map is to avoid the anxiety of getting lost, then the helpfulness is lost as well. Were that to happen, an exposure task involving deliberately losing one’s way might be added to the treatment plan.
Anxiety Management Tricks That Easily Backfire
Some of the self-help literature and popular press suggest coping techniques that can easily be applied with a counter-therapeutic attitude. This makes them particularly vulnerable to the pitfalls already discussed. These include the following techniques:
Thought-stopping: This is often described as snapping a rubber band whenever having an unwelcome thought, or yelling “stop” to oneself when an anxious thought occurs. This, of course, engages the ironic effect of increasing the frequency of feared thoughts.
Distraction: The advice is to think about something else, such as counting backwards from a hundred. This is notorious for how quickly anxiety returns.
Rational refutation: People will often refer to this as “thinking rationally” such as trying to determine how likely it is that something bad will happen, or reminding oneself that it has never happened yet. This is usually followed by “yes, but …”
Thought changing: This is sometimes combined with thought stopping. The technique is to substitute a calming thought for the frightening one. This is actually the promotion of a cognitive compulsion (see Chapter 9).
Practice stress-reducing behaviors: This suggests that immediate exercise can be used to lower anxiety or avoid the stressor. Regular exercise is enormously helpful in lowering overall levels of sensitization, but using exercise as an instant anxiety coping technique is at best a temporary measure that wears off quickly and at worst further evidence that something is seriously wrong because the exercise does not reduce anxiety as expected.
A variety of breathing techniques are suggested. The problem is that they are often are applied with a sense of urgency, thus paradoxically increasing anxiety.
Diaphragmatic Breathing
Many people believe that a proper application of regular, rhythmic, diaphragmatic breathing is a beneficial anxiety management technique. Most people change their breathing pattern when they feel tense—shallow breathing, holding one’s breath, taking big gulps of air, breathing rapidly—all of these non-rhythmic breathing patterns produce unpleasant sensations that increase anxious arousal. The majority of these sensations are attributable to hyperventilation, while some are directly related to tensions in the chest. Diaphragmatic breathing helps maintain rhythmic and regular breathing during periods of tension and anxiety. As with every other coping skill, the key is how the technique is applied. When coping with anticipatory anxiety (See Chapter 12), diaphragmatic breathing can help to reduce hyperventilation-induced sensations. In the midst of intense anxiety and panic, diaphragmatic breathing can help patients remain in the present and stay with feelings, while allowing arousal to pass. Unfortunately, it is common that many will seize on the technique as a way to combat anxiety; in that case, it can fall prey to the shortcomings of any technique, turn on the “struggle switch” (Harris, 2008), and ultimately backfire.
There Are Two Ways to Breathe
There are two distinct ways to get air into the lungs: One method involves using chest muscles to expand the rib cage; the other uses the diaphragm to expand the belly. Everyone is born breathing with their diaphragms. Take a look at newborn babies in their crib. Their belly pushes out with each inhalation, and gets smaller with each exhalation. That expansion of the belly is the unmistakable sign of diaphragmatic breathing. However, most begin breathing with the chest as we age, primarily because it looks so much more attractive to push out the chest during inhalations, as opposed to pushing out the belly. (Expanding the belly is required for diaphragmatic inhalations.)
Chest inhalations involve stretching the intercostal muscles around the ribs, expanding the rib cage, and drawing air into the lungs. As anxiety increases, this type of breathing becomes more difficult, because tension make the muscles around the ribcage relatively stiff and inflexible. People often complain that their chest feels tight during anxiety attacks, and they sometimes feel pressure around that part of the body. This is the perception of tension in these muscles. Expanding the chest during these times feels awkward and self-conscious. Inhalations feel like stretching a tight rubber-band. Rhythmic breathing becomes as difficult as chest muscles send signals of tension, pressure, and pain. When muscles are tense, belly muscles tense up into a “knot” and instinctively brace for a blow. This locks the diaphragm which rides up and down on the lower more efficient parts of the lungs and pushes the breathing into the upper chest where it is less efficient (and therefore naturally starts going faster).
Avoiding Hyperventilation
Despite feelings to the contrary, hyperventilation or “over-breathing” occurs when too much air goes into the lungs. Therefore, deep, expansive, or sighing breaths, rapid respirations, and incomplete exhalations add to its intensity. Some patients try to calm themselves by taking deep breaths when they notice symptoms, which makes hyper-ventilation worse, not better. When hyperventilation occurs, carbon dioxide levels drop while oxygen levels remain constant, and the ratio between the two changes. The relative reduction in carbon dioxide results in a set of symptoms that indude dizziness, lightheadedness, and tingling and numbness in the hands, feet, lips, and face. Some feel like they cannot take a satisfying breath and experience the symptoms of “air hunger,” making them breathe more, exhaling more carbon dioxide, and lowering its level even more. Most of these symptoms feel like anxiety, and they add to the anxiety patients are already feeling. Despite its flagrant symptomatology, there is nothing dangerous about hyperventilating, it is just uncomfortable and anxiety generating.
Tensions in the chest caused by chest breathing and the subsequent need to stretch the intercostal muscles can cause pain and pressure, which can trigger a patient’s concerns about cardiac issues. This further increases anxiety. Another side effect of hyperventilation can be depersonalization and derealization: these are odd, difficult to describe alterations of subjective experience that frighten people and are often misunderstood as harbingers of “losing touch with reality” or loss of control. People describe such experiences as “feeling outside my body” or feeling as if everything is perceptually distorted, or foggy, clouded, unreal. Some other descriptions include odd but creative statements such as “I feel as if my head is not attached to my body,” “my voice comes out of my ears,” or “I feel as if I am driving from the back seat.”
Chronic hyperventilation can occur without conscious realization, but eventually the primitive housekeeping part of the brain (the medulla) will reduce the respiration rate to enable carbon dioxide levels to normalize. This happens automatically, but can create the frightening feeling of not breathing properly. People report “not being able to catch a breath,” become fearful of smothering, and this can trigger a panic attack. Ironically, this brain-imposed pause in breathing is the correction factor that happens automatically. Once proper carbon dioxide level is restored, the medulla steps back and people return to their normal breathing. Chronic hyperventilators start the process all over again, alternating between breathing too much and being stopped from doing so.
Because chronic hyperventilation happens outside awareness, it can be responsible for symptoms of lowered carbon dioxide levels that precede conscious anxiety. It is not uncommon for people to report tingling in hands and feet or feeling foggy while stating that “there is nothing making me anxious,” and then adding second fear to these symptoms when noticed. They experience the “uh-oh” whoosh and then associate these sensations with panic. Usually there will be no obvious external stressor, since the hyperventilation has been going on for hours or even days—often in
anticipation of some future challenge. This bewildering experience makes it seem as if there must be something medically amiss, when all that is happening is subtle effects of low-grade chronic over-breathing that has crossed the threshold of awareness.
Chronic hyperventilation is outside of awareness and its symptoms can occur before any conscious anxiety.
Diaphragmatic breathing allows people to breathe regularly and rhythmically—and therefore avoid the pitfalls of hyperventilation—even during high levels of stress and anxiety. The diaphragm muscle—as opposed to the chest muscles—is relatively insensitive to stress and anxiety. The immediate goal is to have patients breathe diaphragmatically when feeling stress. A more ambitious goal is to re-establish diaphragmatic breathing as their normal, everyday, moment-to-moment method of breathing. That will make it much easier to maintain rhythmic breathing under any circumstances, including periods of increased anxiety and stress.
Diaphragmatic breathing helps to manage anxiety by reducing symptoms of hyper-ventilation, lowering pain and pressure in the chest, and providing patients with a task (rhythmic diaphragmatic breathing) that helps them stay mindfully focused while allowing and experiencing anxious arousal. Appendix 3 provides instructions for teaching patients how to breathe diaphragmatically.
Anxiety Management in Cases of Real Danger, Not False Messages
As an expansion of the discussion of anxiety management techniques, there are cases where anxiety is comorbid with other conditions, and safety and impulsivity are a real concern. In cases involving comorbid major depression with suicidal ideation, or a personality disorder with real self-destructive impulses, it is entirely appropriate to utilize safety behaviors, anxiety management techniques, and coping skills. Emergency distress and affect tolerance techniques such as those embodied in DBT or those recommended by PTSD coach (US Department of Veterans Affairs, 2011), a mobile app developed for returning combat veterans, are entirely appropriate. These are techniques for averting real danger, not false messages. They include everything from “call a friend,” and “take a walk in nature,” to “take a shower.” Additional techniques involve calming self-talk, taking a PRN medication, getting some sleep, and other forms of psychological first aid. Early stages of crisis stabilization with these patients involve developing appropriate coping tools. Presumably, as distress tolerance improves, these coping tools will not be needed as often and can be dispensed as therapy proceeds.
These are patients who are suffering from co-occurring conditions. This is very different from patients who, despite flagrant symptoms, are in no danger but believe the false messages of anxious arousal. Examples of this include a person who—in the middle of a panic attack—wants to call 911, or the person with OCD who has touched a “contaminated” object is utterly triggered by the thought, and wants to contact poison control. Rather, this category is reserved for patients who are dealing with self-destructive impulses in actuality, such as out-of-control rage, emerging psychotic thinking, or a mixed bipolar crisis. Making this distinction requires a high level of confidence in diagnostic skills and good knowledge of the particular patient.
Some Issues in Determining Patient Progress
Patients enter therapy with varying levels of distress. Some are markedly more sensitized than others, and suffer greatly on a daily basis. Others have few triggers, react very strongly to them, but encounter them infrequently. Lifestyles also contribute significantly. Those with fears of heights or enclosed places might live comfortably in a rural environment, yet be regularly triggered and having a terrible time in a large city. Some communities and family traditions encourage living and working close to each other, so that territorial fears (panic disorder with limited agoraphobic avoidance) are rarely triggered.
Patients most frequently enter therapy when acutely distressed. New fears pop up, old fears re-emerge, or something occurs in their lives that forces them to address anxieties that they had been avoiding. A family moves from a city to the suburb, so that the mother can no longer use public transportation and must address her fears of driving. A job promotion requires flying, giving team presentations, taking elevators, coping in an efficient way that has no room for compulsive rituals, and so the individual experiences intense consequences of an anxiety disorder that has been present, but kept at bay.
And a percentage of biologically predisposed patients develop an anxiety disorder while they are in treatment, usually because of the intersection of maturational and stressful factors. It can be distressing, bewildering, and frustrating to the therapist, who might sense that things are going in the wrong direction, or, conversely, that the emergence of the symptom must be a defense against the issues being addressed in therapy.
With these inevitable ups and downs in symptomatology, how does one determine the progress patients are making in therapy? What are the criteria, and whose reporting (the patient, the family, or the therapist) is given priority? Reasonable standards might include intensity of anxiety, amount of avoidance, willingness to tolerate anxious arousal, ability to label anxieties as misleading messages best ignored, or the overall ability to disengage from anxious arousal. One might also focus on overall quality of life, a subjective sense of well-being, or a growth in flexibility leading to wider choices. Also important is the degree to which anxiety symptoms or other relevant variables like mood and the use of substances create functional impairment or disability.
While priority must be given to patient reports, there are also times when patients’ own assessment of progress appears highly unreliable. For example, it is not uncommon for a patient with severe OCD—or some other crippling anxiety disorder—to be unmistakably progressing while complaining that therapy isn’t helping. This is partly because memory is a poor tool to assess progress. A few low anxiety days can brighten a dismal week, and two or three days of unusually high anxiety can make people feel like they are seriously slipping backwards.
But the issue is more complicated. Anxiety symptoms will increase—at least temporarily—when avoidance is reduced, and decrease—also temporarily—with increased avoidance. Reduction of symptoms by itself gives little information about how the patient is coping with anxiety, what they are learning in treatment, and to what extent anxiety sensitivity is being reduced. On the contrary, if a patient feels empowered to expose himself more frequently to anxiety-producing triggers, then an increase in anxiety might be a welcome sign of progress. This is why a housebound agoraphobia patient who never goes out will frequently report that they have not had a panic attack in years and their overall level of sensitization is low. Conversely, someone who refuses to completely avoid, but “white knuckles” their way through every challenging experience will have chronically high levels of sensitization and anticipatory anxiety but will be less functionally impaired.
Anxiety levels are also exacerbated by stressors. There is a complex relationship between anxiety and stress that is rife for misunderstandings. Anxiety disorders are not caused by increased stress, just as they cannot be cured by decreasing it. However, stress is frequently an essential component of the trifecta interactions of genetic predisposition, maturational progression, and stressful change that appears to trigger the emergence of many anxiety disorders. Life stresses such as financial concerns, housing and health issues almost always increase anxiety symptoms, regardless of how well anxiety treatment may be proceeding. In the short term, anxiety tends to increase when feeling hungry, angry, lonely, and tired—the 12-step acronym H.A.L.T. To this, we add I.F.S. (Ill, Fatigued, and Stressed). (See Chapter 14 on relapse prevention for a further discussion of stress and anxiety.)
Anxiety tends to increase when feeling HALT (hungry, angry, lonely, and tired) and IFS (ill, fatigued, stressed).
These factors highlight a most important point: regardless of desires to relieve distress, it is not always in the patient’s best interest to focus on lowering anxiety. In the long run, even more important than symptom remission is the patient’s development of a min
dful awareness of the anxiety generating process, and ability to adopt the therapeutic attitude. As described in Chapter 3, this requires the moment-to-moment awareness of anxious thoughts, sensations, and memories, and the patient’s efforts to distance himself from distress—the process that paradoxically keeps anxiety alive.
Memory Aids for the Patient
Patients who report anxious episodes often have a very poor memory of them—and are therefore poor reporters—even if they occurred just a few days prior. The distress of high anxiety is a chaotic experience resulting in a fog of fear. Patients report a form of retrograde amnesia trying to recall details of very high anxiety. However, when patients are asked about their experience immediately after it occurred, they are much better reporters. Observation of this led to two concrete changes in treatment.
The first change was the introduction of supported exposure, in which therapists accompanied patients into the anxiety-producing situation, observing and interacting with them while they felt anxiety. Therapists spoke with patients before, during, and immediately after exposure, obtaining all the relevant details. Under these circumstances, patients provide far more accurate and detailed narratives of their experience, and are therefore more able to focus on the moment to moment details of their anxious experience. The second change was to seek any opportunity to retain freshly obtained information, even when symptomatic episodes occurred days (or weeks) prior to a scheduled session. Home practice assignments were given to patients to journal or record anxious experiences right after they occurred. Just as recording a dream upon awakening can keep the dream memory fresh, writing down the details of an anxious experience can keep those details in memory, despite the tendency to develop amnesia. This meant that patients and therapists had much better information during sessions to understand each anxiety episode.
What Every Therapist Needs to Know About Anxiety Disorders Page 15