What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

  Here is an example where a memory aid helped a patient turn an unpleasant anxiety episode into a positive learning experience.

  A woman with OCD became terrified that she had inadvertently poisoned the Jell-O mold she had brought to dinner at a friend’s house. Initially, she could not remember any further details, but remembered that she had jotted down some details soon afterwards. After looking at her notes (smart phones are perfect for this), she remembered feeling tense and insecure about being invited to dinner for the first time, her concerns that her children might misbehave, and the sudden intrusion of the terrifying thought that she might have inadvertently mixed poison with the Jell-O. (This was a not uncommon symptom of her OCD.) She also remembered that she was able to label her distress as OCD, but was angry at herself for not adequately checking that her ingredients were pure while she made the Jell-O—her usual OCD checking ritual. She was encouraged to celebrate her ability to cut down on the checking ritual, even though it resulted in greater anxiety afterwards, and that she was able to successfully label the distress as OCD. She acknowledged her difficulty accepting the feeling of distress, instead of getting angry at herself for what felt like inadequate checking. And that her self-anger might have contributed to her intensity of distress. She agreed to be on the lookout for this next time, while making an effort to accept the feelings with greater equanimity.

  With the aid of a journal or diary, patients can describe the anxiety episode in detail and the therapist helps the patient identify all the triggers, thoughts, images, sensations, and memories that contribute to the anxiety episode. Additionally, there is opportunity to help the patient set the emotional and physical contexts that trigger initial anxiety reactions. What was happening? What were the thoughts and images running through the patient’s mind? Ideally, each anxious episode can be a learning experience that makes it easier to tolerate the next one. One popular form of obtaining information is to have patients keep an anxiety diary systematically, as a record of anxious episodes occurring between sessions. There are many variations of this concept, and one such version is described in detail in Appendix 4.

  The most helpful information of all can often be obtained by directly observing the patient while deliberately attempting to induce anxiety in the office or during an out-of-office exposure. There is enormous value for patients to experience manageable levels of anxiety while the therapist helps focus on contemporaneous triggers, images, thoughts, sensations, and memories. The focus here is less on anxiety management, and more on increased meta-awareness of the moment to moment internal processes—reactions to triggers, sensations, thoughts, and memories—that create and maintain anxiety.

  Deliberate attempts to induce anxiety in the office or outside can provide very helpful direct observations.

  There are simple ways to accomplish this. Patients who are afraid of sensations can spin round—either standing and twirling or sitting on a revolving chair. (It is surprising how many patients will initially refuse a request of this type.) Or they can over-breathe by taking 10 deep breathes, experience the effects of hyperventilation, and then run in place while the mild exercise replenishes carbon dioxide levels. Patients with OCD can be asked to touch the floor, pick up coins dropped on the floor, touch the floor and rub their face, mess up your office desk, and any other task that triggers anxious arousal. Those with SAD might be asked to stand and recite a speech or a poem in your office. Or sing a song. It is immediately interesting to observe and talk with a generalized anxiety disorder patient about what is happening when they typically refuse to write the sentence “I wish my child would die” on a blank piece of paper.

  References

  Grayson, J. (2003) Freedom from obsessive compulsive disorder: A personalized recovery program for living with uncertainty. New York, NY: Berkley.

  Carbonell, D. (2004) Panic attacks workbook. Berkeley, CA: Ulysses Press.

  WordPoints. (2011) “Anything worth doing is worth doing badly.” Chesterton G. K. Retrieved from http://wordpoints.com/brasstacks/articles/periodicals/Art0018%20-%20Worth%20Doing%20Badly.pdf

  Rock, I. and Palmer S. (1990) The legacy of Gestalt psychology. Scientific American 263(6) 48–61.

  Hayes, S. C. (2004) Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behavior Therapy 35(4) 639–665.

  Harris, R. (2008) The happiness trap. Boston, MA: Shambhala Publications.

  Robins, C. J., Ivanoff, A.M., and Linehan, M. M. (2001) Dialectical behavior therapy. In W. J. Lives-ley (ed.) Handbook of personality disorders: Theory, research, and treatment. New York, NY: Guilford Press 437–459.

  Miller, J. J., Fletcher, K., and Kabat-Zinn, J. (1995) Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. General hospital psychiatry 17(3) 192–200.

  Wilson, R. (2009) Don’t panic, 3rd edition. New York, NY: HarperCollins.

  Harris, R. (2008) The happiness trap. Boston, MA: Shambhala Publications.

  US Department of Veterans Affairs (2011) PTSD coach (Version 1.0.1) [Mobile application software] Retrieved from http://itunes.apple.com

  7

  Diagnoses

  An Annotated Tour of the Anxiety Disorders

  The DSM-5 contains a complete and detailed description of every disorder presented in the following pages. So why do we include a diagnostic chapter here? The answer is that knowledge of criteria for an anxiety disorder may not be sufficient to make an accurate and useful diagnosis, and so we supplement readily available information with our own clinical observations. For example, we present the fact that many “specific phobias” are not specific at all, nor are they phobias! We also explain why much of generalized anxiety disorder (GAD) is best conceptualized as a form of “OCD Lite,” how obsessive-compulsive disorder (OCD) can masquerade as any number of disorders, and what to do if your patient presents with a first panic attack after the age of 40.

  Understanding ways in which anxiety disorders differ and yet appear similar is essential for guiding treatment. Patients often present initially with symptoms which may not fit the DSM. We therefore share additional information about people with anxiety disorders to assist in diagnosis and treatment planning.

  Specific Phobias

  Specific phobias are special types of fear. They are fears that are out of proportion to the danger, and intense enough so that the person consistently strives to avoid the source. Some people with specific phobias panic when they are in contact with the phobic trigger. Others feel intense anxiety and the need to avoid even though they do not experience actual panic episodes.

  Animal phobias are the most common specific phobia, and can include phobias of dogs, snakes, insects, or mice. The other main groups are situational phobias (such as flying, driving over a bridge or through a tunnel, or of taking elevators), environmental phobias (fear of water or storms), blood-injury phobias (defined as fears of being injured, seeing blood or invasive medical tests or procedures), plus a list of other phobias that don’t easily fit into other categories (such as phobias of clowns, loud sounds, falling down).

  Helping people with specific phobias requires an understanding of the thoughts, experiences, emotions, and sensations with which they are grappling. Some dog phobics are terrified that a dog will harm them, and have great reactivity to that image. Other animal phobics report their distress as an extreme disgust reaction—one that feels intolerably intense. Some have actually had a traumatic experience with a dog in the past, but, surprisingly, most have not.

  Situational phobias require careful consideration. As an example, the specific phobia “elevator phobia” is a fear of an elevator not functioning and crashing to the ground. But many different anxiety disorders can manifest as an intense fear of elevators; most common (and far more common than the specific phobia) are fears of feeling trapped, where the elevator acts as a trigger for panic attacks. So a fear of eleva
tors could be an aspect of panic disorder. People may also be afraid of elevators because of social anxiety, where the person fears the elevator stopping, others notice this fear, and the patient feels humiliated. Still others with social anxiety disorder (SAD) might become terrified by people looking at them when the elevator gets crowded. And a person with OCD can also fear elevators for a variety of reasons (“I need to go up and down a certain number of times or something terrible might happen,” or “I can only get out on even numbered floors,” or, “It can be crowded and if someone coughs or sneezes, I’ll be exposed to all those germs”).

  Similarly, a “fear of public restrooms” can range from a fear of being attacked, of contaminants and germs, of panic attacks which happen when enclosed in a stall, or paruresis (“shy bladder syndrome”), a SAD described below. Others are afraid they will encounter filth or smells and be unbearably disgusted. One patient did have a bona fide public restroom specific phobia which consisted of an acute anxious reaction if the toilet seats were black. While the possibility of a traumatic experience with a black toilet seat as a child could not be ruled out, the origin of this specific phobia was never determined.

  Another phobia that looks initially like a specific phobia almost never is: emetophobia— the fear of vomiting. This is encountered frequently in clinical practice, and can represent a fear of the sensations of panic attacks or acute anticipatory states, and can include fear of the loss of control represented by vomiting. This is frequently an aspect of panic disorder. Emetophobia can also be the bottom line fear in an elaborate avoidance of germs and contaminants, with the fear of becoming ill that is a variant of OCD. Alternatively, it may be a memory of a parent’s panicky reaction to childhood vomiting, or it can have a social anxiety focus in which the primary fear is the social humiliation of being seen to vomit or smell like vomit.

  A “bridge phobia” can sometimes be a specific phobia and in other cases, not. Few people afraid of bridges fear the bridge collapsing. Most are afraid of having an anxiety attack or an intrusive scary thought while on the bridge. The fear isn’t of the bridge, but rather the feelings they might experience while driving over it. A person with a specific bridge phobia will remain anxious anywhere on the bridge, while someone who fears their thoughts or sensations usually starts to feel better after having passed the halfway point. Similarly, claustrophobia is rarely just a specific phobia or fear of being in an enclosed space. It is most often an aspect of panic disorder—fearing a panic attack in an elevator, an MRI machine, the backseat of a car, or some other “trapped” place. Occasionally, a post-traumatic fear fueled by a memory of being trapped and experiencing danger can underlie claustrophobia. If many “phobias” are identified, they are best treated for panic disorder, OCD, SAD—or whatever common factor shows up in the variety of circumstances. Treatment for multiple specific phobias will be inefficient and fail to target the relevant overarching triggers, which is necessary in order for the patient to stop developing new “phobias.”

  Few people afraid of bridges fear the bridge collapsing. Most are afraid of panicking on the bridge.

  Blood and injury phobias can be particularly misleading. For many, a blood and injury “phobia” isn’t a phobia at all. Rather, it is a triggered vasovagal reaction, resulting in a sudden drop in heart rate and blood pressure, and is a common cause of syncope (fainting). There are a few moments of rapid heart rate when confronted with actual or imagined blood or injury, which is then followed by a slowing of the heart and plummeting blood pressure. There are a small percentage of people whose bodies react to the sight of blood in this manner, sometimes despite a lack of fear. Most have a parent with the same tendency. Blood and injury phobias start in childhood, and it is rare to develop them in middle age. Usual treatment consists of teaching patients how to keep blood pressure stable during exposures to triggers, techniques which can include using arousing or exciting imagery, increasing muscle tension, biofeedback, or the “bearing down” reflex (which raises blood pressure). These patients need to learn the opposite of relaxation in the presence of a trigger.

  Other people with blood and injury phobias can have extreme fears of any invasive medical procedure, but would not be classified as true blood and injury phobics, because they do not have this specific vasovagal syncope and therefore do not faint. It is essential to find out the nature of their discomfort, and the mental images, sensations, and memories they fear. Some people fear pain, others fear the possibility of getting ill from contaminated equipment; others are terrified by the possible side effects of the procedures themselves. Others are afraid they will have a panic attack and either embarrass themselves or lose control. Still others know someone who does faint in these circumstances, and lack the information that anxiety raises blood pressure and heart rate, protecting them against fainting.

  Specific phobias tend to start early in life. When they appear later (after the age of 12 or so), look closely for the possibility that an anxiety that looks like simple phobia is really another type of anxiety disorder. Here is an example. Dog phobias start early in life and a good percentage of children under the age of 6 will be frightened of dogs. However, almost all of them outgrow their fear by the age of 9 or 10, but a small percentage will not, and it will intensify to phobic proportions.

  One patient reported an intense fear of dogs, which started in her mid-20s. (She was perplexed by her fear, because she had loved and played with dogs in her teens.) However, it became apparent that her fear of dogs was not a simple phobia. Instead, it was an obsessive fear of getting rabies, and was more accurately conceptualized and treated as a form of OCD. She was certainly terrified of dogs, but also obsessively worried that she had been bitten by a rabid dog, even when there was no apparent contact with a dog in her vicinity. She would then compulsively check her body for possible bite marks. There are significant differences in therapeutic approaches between specific phobia and OCD. In fact, OCD can masquerade as a variety of disorders—anxiety and otherwise. The essential point, however, remains the same: understanding the phenomenology of the anxiety experience is essential.

  Whatever the specific phobia, many phobic people do recognize that their distress resides inside themselves. They recognize their fear as irrational or at least “out of proportion.” Treatment begins with learning the difference between external triggers (dogs, bees, heights, elevators, bridges, tunnels, airplanes), internal triggers (sensations, thoughts, and memories), and their phobic reactions, or terrors.

  Panic Disorder

  Panic disorder starts with a single panic attack, followed by anticipation and fear of the next panic attack, and then often a cluster following in close succession. Panic attacks are intensely and unbearably uncomfortable discrete episodes of terror, which mount rapidly and reach a crescendo in minutes. People with panic disorder fear the recurrence of attacks and they often limit their activities to avoid situations that might trigger additional episodes. This is described as panic disorder with agoraphobic avoidance.

  Panic disorder ordinarily starts between adolescence and early 30s, and it is highly unusual for someone to have a first panic attack after the age of 40. Onset of true panic disorder in late life with no prior episodes is so rare that it is essential to pursue an excellent medical workup whenever this occurs, to rule out other causes, including major depression and cardiac, endocrine, respiratory, and neurological conditions.

  Initial panic attacks typically are described as coming “out of the blue.” While there is no such thing as an event with no cause, the experience of that first attack is of no immediate or obvious cause or trigger. Some people call this an “uncued” or “spontaneous” panic attack. While first panic attacks are unexpected, it is not uncommon for an interesting change in insight to occur as therapy progresses. Patients often retroactively recover memories of anxious episodes that they were trying to ignore prior to the emergence of severe symptoms. First panic attacks sometimes occur in highly stimulating fluorescently over-lit envi
ronments like supermarkets or in situations without easy exits like public transportation, traffic jams, or family events.

  Fear of sensations is a primary concern for people with panic disorder. They fear lightheadedness, arousal sensations involving their heart, head, or gastrointestinal tract, and “dizziness.” Many fear the odd experiences of depersonalization and derealization. They typically avoid roller coasters, and a good percentage of them are exercise intolerant (they don’t want to feel too out of breath). Those who hyperventilate fear associated feelings, including that of smothering, being unable to “get a deep breath,” feeling cognitively impaired or “foggy.” Others are frightened by the sensations they experience (or imagine they will experience) from prescription and OTC medications, or of drinking alcohol. Most have already stopped all use of caffeine. Some have had panic attacks in the dentist chair after a Novocain shot increased the heart rate. There are reports of first panic attacks occurring after smoking marijuana, and these people thereafter avoid all similar sensations. The ultimate fears are of a panic attack progressing to the point that they “can’t stand it,” and they will lose control or go crazy, or that the symptoms will cause a physical overload, causing a heart attack or other catastrophic medical event.