What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

  About one in three people with panic disorder develops agoraphobia, a condition in which the individual becomes afraid of being in any place or situation where escape might be difficult or help unavailable in the event of a panic attack. Agoraphobia was once defined as “fear of the Greek agora or marketplace” and then came to describe people afraid to leave the house. The modern definition changed as it was understood as a complication of panic disorder, and is now the fear of having a panic attack where one feels trapped or unable to get to safety.

  Panic disorder can become disabling. In many cases, people with agoraphobia live within a safety zone, where they feel insulated from additional panic attacks. In the most extreme cases, this safety zone can shrink to a small area of a neighborhood, home, or even just one or two rooms in one’s house. We have seen a housebound patient who lived day and night on the corner of her couch. Another patient was afraid to stand up. People with panic disorder often avoid public transportation, limited access highways, bridges and tunnels. Public transportation only stops at designated points, and they become afraid that they may start to panic between stops. So they are more likely to take local trains and buses, as opposed to express. They might fear any experience where they are unable to easily remove themselves if they begin to panic. Crowds and crowded auditoriums can trigger intense anxiety. They prefer to sit in the last row, and on the aisle. Some people with panic disorder are able to travel quite comfortably in the presence of a trusted companion, who could take over if something were to happen.

  Panic attacks are psychologically painful experiences, and patients often describe the feeling as the beginning of an endless nightmare. While in the process of panicking, patients fear going crazy, having a heart attack, having a stroke, going blind, losing control, doing something embarrassing or humiliating, or dying. Panic attacks usually run their course in less than 10 minutes, although worrying about their return can provoke additional panic attacks, so that some patients report panicking for hours. First panic attacks are often so traumatic that they are ingrained in the patient’s memory with exquisite detail.

  Many people with panic disorder are convinced that there is something physically wrong with them, undergo extensive medical workups, and are frequent visitors to emergency rooms. They find it hard to believe that their intense symptoms lack serious medical causes. These are the patients who are most bluffed by anxiety, and who have the greatest difficulty accepting that their fear of symptoms is what keeps them so intense. Once cleared medically, their inability to accept that no test can be 100% certain becomes an issue to explore.

  Social Anxiety Disorder

  SAD (formerly social phobia) is conceptualized as a hypersensitivity to real or imagined criticism. Underlying this phobia is the fear of a feeling—an exquisite sensitivity to being embarrassed or humiliated. People with SAD imagine being harshly scrutinized or judged. Some have trouble tolerating any social interaction or public performance they consider to be less than perfect. Patients may be afraid that people will think badly of them or that they won’t measure up. There is a great deal of comparing themselves with real or imagined others. Because of an intense and persistent fear of performing badly and the ensuing shame and humiliation, they often worry for days or weeks before a dreaded situation. Their fear can become severe enough to interfere with work, school, and other ordinary activities, making it hard to make and keep friends. If they manage to confront their fearful feelings and be around others, they are typically anxious beforehand, intensely uncomfortable throughout the encounter, and worry about how they were judged for hours or days afterward.

  Underlying social anxiety is an exquisite sensitivity to the feeling of embarrassment.

  In contrast to those with panic disorder, who feel relief after accomplishing something that had been fraught with anticipatory anxiety, people with SAD have a second round of “evaluation anxiety” after it is over. They may strain to recall details of their behavior and reconstruct the reactions of others. They tend to interpret neutral or ambiguous conversations with a negative outlook (Hirsch and Clark, 2004) and have negatively biased perceptions of people’s faces expressing emotion, while remembering the more negative memories (Morgan and Banerjee, 2008). Because of this, their recollections are distorted and tend to reinforce a sense of failure. And even though they realize that their fears of being judged are at least somewhat overblown, this realization doesn’t reduce their anxiety. Because embarrassment over a mistake and awkwardness or lack of social adeptness is so excruciating, people with social anxiety often hold themselves back from opportunities in relationships, work, and leisure.

  SAD can be limited to one situation (such as talking to people, introducing oneself, making a phone call, or writing on a blackboard in front of others) or may be so broad that the person experiences anxiety around almost anyone other than the family. One patient suffered from social anxiety so severe that he could not ask for someone to pass a dish at his own dinner table and preferred to eat in another room in front of the TV. Patients can feel anxious in situations that put them in the spotlight like asking for directions—or in situations that require no specific performance, such as entering a room with other people, or eating a meal in public. One subtype of social anxiety is called performance anxiety, and is particularly relevant to those who are triggered by public speaking, test taking, and by musical or theatrical performance. A patient who refused to get a driver’s license and was presumed to have a fear of driving was too embarrassed to admit to her family that the real problem was her inability to imagine tolerating the humiliation of failing the written pre-test, since she had a master’s degree. She felt she would never be able to live it down and instead was willing to have others believe she was afraid to drive, which she was not.

  Paruresis, or shy bladder, is a specific social anxiety in which people are unable to urinate in situations where others might hear or be aware. Most often these people cannot use public restrooms, and this leads to additional social limitation. Some people with paruresis cannot use any restroom at work, limit their fluid intake severely, and commute home during their lunch hour in order to urinate. Long airplane trips are impossible and dating can be out of the question. Paruresis is often so embarrassing that the sufferer tells no one about the problem.

  People with SAD are frightened of sensations (racing heart, shaking hands, dry mouth, flushed face), and also of the thoughts that they are making fools of themselves, failing in a task, or having their anxiety noticed by others. Frequently they are focused on the physical symptoms that actually show and can be noticed by others such as blushing, profuse sweating (hyperhidrosis) (Davidson, Foa, Connor, and Churchill, 2002), trembling, nausea, and difficulty talking. When these symptoms occur, people with social anxiety feel like all eyes are focused on them. They often describe their distress as a form of unbearable over-self-consciousness. Anxiety can often reach the intensity of episodes of panic attacks, but doesn’t necessarily escalate to that point. People with severe social anxiety may describe themselves as “paranoid,” although they are not psychotic.

  Social anxiety has an early onset—age 12 or 13 is not uncommon—and since the average onset age is so young, many people who develop SAD are overwhelmed, perplexed, and unable to articulate the sudden appearance of their fears. It is not uncommon for them to just drop out, stop going to classes, leave their social groups, and spend more and more time by themselves. Sometimes parents first learn of the development of SAD when they receive a notice from school that their child—some of whom were fine students prior to the development of SAD—has failed a class. Parents might suspect substance abuse, hanging out with the wrong crowd, depression, or plain laziness.

  Because their fears are triggered by social interaction, there is a subgroup of people with SAD who avoid relationships with peers, and keep their social interaction to a minimum. And there is also a subgroup of socially anxious people who have been severely shy since childhood. For these patients, extens
ive avoidance of social interactions means that they often fall behind in social skills and peer relationships, never developing the requisite set of social interactional skills. So the anxiety itself, as well as the reduced social skill capacity, must be addressed in therapy.

  While some people with social anxiety are temperamentally shy, most are not. Many people with SAD have managed to develop excellent social skills, either despite their anxiety or because their social anxiety is specific enough so that it doesn’t interfere with the majority of interpersonal interaction. So, for example, there are plenty of people with SAD who have no problem interacting one on one or in small groups, but panic in classes, work-related presentations, PTA meetings, or any gathering that they consider to be larger than their limit.

  There is high comorbidity between SAD and depression (Stein, Fuetsch, Müller, Höfler, Lieb, and Wittchen, 2001), as well as the substance abuse disorders, most especially alcohol (Grant, Stinson, Dawson, Chou, Dufour, Compton,…. Kaplan, 2004). SAD can look like dysthymia, “low self-esteem,” or “poor self-confidence” upon initial presentation, or it can be entirely submerged under alcohol dependence and its complexities.

  Obsessive-compulsive Disorder

  OCD is a complicated and sometimes profoundly disabling disorder. It consists of two components: the first is obsessions, which are repetitive thoughts, or images that feel uncontrollable, threatening, repulsive, or shocking, that arrive with a “whoosh,” and contain a strong urge to avoid or get rid of the thoughts or images. Obsessions increase anxious distress. The other component is compulsions, which are actions or thoughts whose function is to lower anxiety. Compulsions can consist of the commonly known checking or cleaning rituals, but mental compulsions, which attempt to lower anxiety with thoughts, are also common, and probably far more common than generally recognized. Repetitive reassurance-seeking efforts are also classified as compulsions (see “The reassurance junkie” Chapter 12). Obsessions and compulsions are defined not by their content but by their relationship to each other. It is common but incorrect to think that obsessions are thoughts and compulsions are behaviors.

  Obsessions and compulsions are defined not by their content but by their relationship to each other.

  The most common type of OCD with behavioral components concerns those who are afraid of contamination (cleaners and avoiders) and those who are afraid of overlooking something that may be harmful or embarrassing to them or others (checkers). But these easily identifiable people are only a small part of the picture. Also very common are people with unwanted intrusive thoughts and images of causing harm, violence, and suicide, an aspect of OCD which is extensively covered in Chapter 10 (Unwanted intrusive thoughts). People whose lives are ruled by “overblown conscience,” also known as religious and secular forms of scrupulosity, are classified as OCD as well (see Chapter 7, and a more complete discussion in Chapter 13). A variant of this involves those with an excessive sense of responsibility, and fear of triggers that provoke guilt.

  Because OCD is often perceived as out of control, irrational, and “crazy” by the patient, the full symptom picture is often not initially volunteered for fear of stigma, ridicule, or even hospitalization. It is therefore not uncommon for someone to present for treatment with a complaint that seems more socially acceptable (like a driving phobia) and only later is it revealed that the central problem is OCD.

  Sometimes the physical symptoms that result from OCD are the path to discovering the disorder. For example, studies have looked at people presenting at dermatology clinics for hand rashes. The initial diagnosis was usually non-specific contact dermatitis. But a closer look at these same people revealed that almost one-third of them suffered from the cleaning type of OCD, and repeated washing made their hands raw (Fineberg, O’Doherty, Rajagopal, Reddy, Banks, and Gale, 2003; Hatch, Paradis, Friedman, Popkin, and Shalita, 1992).

  The nature of the distress in OCD can feel more guilt-like than fearful. It is not uncommon for people with OCD to feel even more concerned about others than themselves. Concern with the welfare of others, as opposed to singular concern with oneself, is often a clue towards distinguishing OCD from, for example, panic disorder. Some people with OCD have disgust-based rather than fear-based avoidances and rituals. These are the cleaners who are not worried about getting sick but rather recoil from “icky-sticky” experiences.

  OCD can be about guilt, disgust, or incompleteness as well as fear.

  Another sub-group of people with OCD has what is sometimes called “just right OCD,” where symmetry, order, arranging, and repetitions are prominent features. So, for example, someone might touch one side of a hallway, and then need to touch the other side. In the same manner, he might touch one arm and then need to “even it out” by touching the other. Personal grooming can become a nightmare, where sideburns, facial hair, makeup, etc. can take up hours of time getting it just right. People with “just right OCD” are usually not preventing bad things from happening with their rituals. They are trying to prevent the feeling of discomfort that comes with being unfinished, uneven, or incomplete. Most people have a sense of a “click” that comes to tell us when something is arranged or ordered or done in a “good enough” way, and we just stop when we get that sense. People with this kind of OCD seem not to experience this internal sense of “done” and feel compelled to keep going.

  Some Comments on “Compulsivity”

  In everyday English, the word “compulsive” describes the experiences of “I can’t help it,” “I do it against my better judgment,” “I can’t stop,” or “I feel driven.” There are a number of conditions where people engage in behaviors experienced as out of control that share some characteristics of “compulsivity,” but these are not OCD. In the DSM-5, these disorders include impulse-control disorders such as kleptomania (impulsive stealing) and compulsive gambling; tic disorders (classified as neurodevelopmental disorders); and the addictions such as alcohol use disorder. Hoarding disorder is now no longer conceptualized as a subcategory of OCD, but is classified as a separate “related” disorder. Body dysmorphic disorder is placed within the OCD family of conditions. On the other hand, eating disorders, which incorporate many “I can’t help it” behaviors, merit a separate chapter in the DSM-5.

  It is helpful to understand distinctions between varieties of the “compulsive” experience, to stay focused on what maintains the compulsivity and therefore how to treat it. Unlike OCD—which is a disorder of over-control—kleptomania and compulsive gambling are disorders of undercontrol. The acquisition phase of hoarding disorder can be conceptualized this way as well. These three disorders clearly share some important characteristics in common with the addictions, including the impaired ability to resist short-term pleasures despite their anticipated long-term consequences. The repeated behaviors are intrinsically pleasurable: patients “get high” off these activities, and then regret them later. It is the consequences of these behaviors—such as getting caught, being punished, or losing money—that are not pleasurable. In contrast, true compulsions in OCD are not pleasurable. A person spending hours hand washing is distressed, agitated, exhausted, and often in pain while performing compulsions, unlike the gambler who is having a lot of fun until she loses.

  Between these two opposites are the tic-like disorders of excoriation (skin-picking) and trichotillomania (hair-pulling) (often called BFRBs—body-focused repetitive behaviors) (Keuthen, Siev, and Reese, 2012), which are characterized by compulsions not triggered by mental obsessions, but in response to body-focused intrusive sensations or urges. These behaviors provide relief from urges that do not seem connected to conscious mental obsessions, and they are self-reinforcing because of the brief experience of a mixture of pleasure and pain at the moment of pulling off a scab or pulling out a hair. Some aspects of body dysmorphic disorder and even some of the eating disorders are closely related in phenomenology and structure to OCD and require very similar exposure-based treatments, in addition to other specific intervention
s. The treatment of these complex disorders is beyond the scope of this book. Hoarding disorder, now classified in its own right as an obsessive-compulsive related disorder, is a particularly refractory condition whose treatment requires specialized interventions. Some excellent resources are now available for guiding treatment of both the acquisition and discarding phases (Steketee and Frost, 2006; Tolin, Frost, and Steketee, 2007).

  OCD Can Masquerade as Other Disorders and “Issues”

  OCD frequently looks like another disorder. People with OCD are often misdiagnosed as depressed, agoraphobic, relationship-phobic, paranoid, and a host of other conditions. In Chapter 11 (“Classic Pitfalls”), we will examine some of the more common syndromes—such as pathological doubt—that have significant OCD components.

  Here is an example of OCD looking like a relationship issue.

  A young woman was referred for therapy for her “anxiety” by her marriage counselor who had had a most frustrating experience attempting to help a young couple work out an issue in their marriage. It was clear to the counselor that the couple were well matched and loved each other, but about once a week they were up all night in long painful discussions trying to decide whether or not to separate. What distressed this young woman was that on a quite regular basis, she found herself thinking about a past boyfriend and wondering how her life would have been had she married him. She recognized that he was mean to her, she had felt relief after breaking up with him, and he had recent legal problems, but nevertheless his image popped into her head and thoughts of him arose while lovemaking with her husband, and at random other times. The more she rejected these thoughts and images, the more often they arose. Both she and her husband tearfully interpreted this to mean that she had serious doubts about the marriage despite the fact that neither could identify any problems between them. After all, why would she be struggling with these thoughts? The only other issue the husband could identify was that she spent too much time cleaning the kitchen. Upon closer questioning, it became clear that she had a “thing” about raw chicken and if she thought or suspected or imagined that raw chicken had touched the counter, she had to wash down the whole counter, and then the floor and sometimes all the dishes that could have come into contact with the counter.