What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

  This kind of practice is often called “white knuckling.” The task is accomplished, but what is learned, yet again, is that taking elevators (or driving on highways, or going into hospitals, or giving presentations at work) is a miserable experience and there are good reasons to avoid it. The patient also often has the sense that he just made it, that a moment longer would have broken him, that he was about to turn around and go home the whole time and five more minutes would have produced a failure—that he almost fainted, threw up, drove off the road, went out of control, lost control of his bowels, humiliated himself, or ran out of the room. The moment the task is accomplished, the escape from the situation provides such huge relief that it reinforces avoidance of anxiety. It is therefore not an effective way to practice coping with anxiety.

  Planned Practice

  Let’s contrast this with planned practice. In planned practice, the goal is to practice exposure to the anxious feelings themselves. The triggers (such as the elevator) are important in that they cause levels of anxiety, but the goal has nothing to do with how many of these triggers one can tolerate. With planned practice, there is no need to go anywhere specific, or even do anything specific. The goal is to experience anxiety for a planned period of time.

  What is the optimal planned amount of time? While there are individual differences, almost all studies suggest that ongoing exposure for 30 minutes to an hour is most effective, and to try to stay in the situation until anxiety starts to significantly decrease, although there are many exceptions to this general rule.

  The principle behind planned practice is that the patient decides how much distress he is willing to tolerate during exposure, and then keeps distress within that range. So, for example, if a patient is afraid of driving, have him set a maximum distress level, and drive until he approaches that level, no matter how quickly that level arises. It doesn’t matter if that distress is reached in his driveway, down the block, the next town over, or on an interstate hundreds of miles away. The goal is to keep anxiety at or near the level chosen for the practice that day. Sometimes the patient will expand his “safety zone” while doing this, sometimes not. That is not important. He is moving only to adjust his anxiety level as it changes up and down.

  Patients need regular reminders that they are practicing to expose themselves to the anxious feelings independent of how far they travel, and the most important aspect is for them to decide, each time they practice, their own intended level of anxious distress.

  Planned practice encourages new learning, and the creation of new neural pathways which function to interfere with or inhibit the former fear-producing pathways. As introduced in Chapter 3, contemporary learning theory and current research on exposure (Craske, Kircanski, Zelikowsky, Mystkowski, Chowdhury, and Baker, 2008) show that inhibitory neural pathways that reduce fearful arousal are created during exposure, but the original fear circuits are not removed. Patients are sometimes disappointed or upset when informed of this, but this also explains why symptoms can suddenly reappear during stress, when encountering the feared triggers in a new or different context, or over a period of time without exposure practice (Bouton, 2004) (see Chapter 14). These inhibitory pathways are maximized with repeated exposure to triggers in a variety of circumstances. During the exposure process, the variety of exposures is much more important than elimination of fear in the therapeutic process. Patients who learn that they can tolerate fearful distress (as opposed to eliminate it) are helped the most (Bouton, 2002).

  Planned practice creates new neural pathways which inhibit or interfere with former fear-producing pathways.

  Reality constraints make planned practice a goal that is sometimes elusive. If one ventures into a mall, for example, one may encounter anxiety levels not previously willingly anticipated or planned. It might take some time to end the practice and involve going past an area of the mall that triggers additional anxiety. In these situations, it makes sense for patients to set a task based on their anticipation and expectation of anxiety levels, and to practice willingness to tolerate whatever levels of anxiety they actually experience. Practices can be based on expectations (do something that feels likely to be a stretch but not overwhelming), but real life has many unplanned experiences both during treatment and after. Patients can and should use the situations they encounter in the course of each day (like an elevator) to practice. They can choose in the moment to use their old ways of white knuckled breath-holding struggle, or they can decide to practice distress tolerance, even if the practice was not planned in advance.

  Benefits of Planned Practice

  There are significant advantages to encouraging your patient to practice in this manner. A major advantage is that it provides a systematic and manageable method to maximize exposure to the feared situation, and this discourages the multitude of avoidances that can occur during exposure. Planned practice also helps cope with the common phenomenon called “raising the bar.” Raising the bar syndrome occurs after managing to reach a specific behavioral target during practice sessions. This can happen when patients practice exposure in a way that is not consistent with the principles of planned practice. As soon as a behavioral goal is reached, patients feel pressure to at least reach that target in subsequent practice sessions. That pressure raises anxiety, and makes it harder to reach the same goal the next time. In effect, each time a goal is accomplished, subsequent attainment can be more difficult if the bar is raised. So practice can make for more perplexity.

  PATIENT: I finally used the elevator to visit my sister on the 11th floor.

  THERAPIST: What was that like?

  PATIENT: Great! I felt like this was really working. I hardly had any anxiety. But …

  THERAPIST: But what?

  PATIENT: But then when we left her apartment after dinner I got this spike of anxiety, and I thought to myself, “How can this be?” I’m not even in the elevator and I should be able to do it. I just went into the elevator and now I’m scared just after pushing the button. It should have been easier, and I couldn’t even do it. I walked down. Felt like a real loser.

  THERAPIST: Sounds like you sort of psyched yourself out. You figured it should be easier, but there was this pressure on you to do it again.

  PATIENT: Exactly!

  THERAPIST: And maybe do it better this time. Less anxiety.

  PATIENT: You are exactly right!

  THERAPIST: Doesn’t leave much room for expect and allow …

  Planned practice also helps patients keep their eye on the goal. The goal of practice is willing exposure, and if the focus is on a behavioral goal (such as a location or a distance or a type of transportation), then it is natural to do what is needed to get there. Patients will be strongly tempted to look for avoidances, safeties, and reassurances in order to reach that goal, reducing the effectiveness of the practice.

  Additionally, without planned practices, exposures can turn into a test. People who practice are hoping to reach their goal with lower anxiety, and are testing themselves to see how much they will react in the practice situation. If anxiety is low, they feel positive about the practice, and look at that as passing the test; if it is high, there is a tendency to feel disappointment, to wonder what is wrong, and to give themselves a low or failing grade on this test. The interesting point here is that people grade themselves in a way that values getting lower levels of anxiety. This is exactly the opposite of what we want: to maximize exposure to anxious stimuli.

  Finally, planned practice changes the definitions of success and failure. In general, people feel like they have successfully practiced when they are able to reach their target with little or no anxiety. They feel like a failure when they have extremely high levels of anxiety, or when they are unable to reach their goal. This is precisely the opposite of what is most therapeutic. The object of practice is to allow exposure to anxiety to learn better ways of coping with it, to develop an attitude of disengagement, to accept the feelings as they are, and to allow oneself to desensitize an
d habituate to triggers.

  However, with planned practice, there is only one way to fail: one fails a planned practice when one does not experience anxiety. Any practice that creates anxiety, no matter where that anxiety occurs, counts as a success. Anxiety is the mark of a successful practice. A successful planned practice maximizes the therapeutic benefits of exposure.

  Anxiety is the mark of a successful practice.

  PATIENT: I went to the store and got in and out in five minutes with no anxiety at all, isn’t that great?

  THERAPIST: Well I am delighted you got your shopping done, but of course, that turned out not to be much of a practice, right? So I am hoping you have thought about what you could do to make you more anxious in the store so you could get some practice. Would it be a chance to get anxious if you stayed longer? Or if you had a cup of coffee before you went shopping? Or if you left the car keys and cell phone with me while you went in the store?

  PATIENT: There is no way I could do that without my cell phone. I am anxious even imagining it. But I think I could probably give myself some anxiety if I knew I had to stay for ten minutes.

  THERAPIST: OK why don’t you go back tomorrow and stay for 10 minutes. Let’s hope you get anxious, at least a four, ok?

  PATIENT: I thought coffee was bad for anxiety.

  THERAPIST: Well, that is the point, isn’t it? To deliberately and willingly bring on symptoms and then let time pass. Coffee or a Jolt Cola is sometimes a helpful way of achieving that. Wouldn’t you like to get to the point where you don’t care how it makes you feel?

  PATIENT: Well maybe I can try coffee at home but I am not ready for coffee in a store.

  THERAPIST: Sounds good.

  Table 8.2 Comparison of planned and incidental practice

  References

  Freud, S. (1955) Advances in psychoanalytic therapy. The standard edition of the complete psychological works of Sigmund Freud, Vol. XVII (1917–1919). London: Hogarth Press 165–166.

  Foa, E., Hembree, E., and Rothbaum, B. O. (2007) Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences. Therapist guide. New York, NY. Oxford University Press.

  Foa, E. B. and Kozak, M. J.(1991) Emotional processing: Theory, research, and clinical implications for anxiety disorders. In Jeremy D. Safran and Leslie S. Greenberg (eds) Emotion, psychotherapy, and change. New York, NY: The Guilford Press 21–49.

  Craske, M. G., Liao, B., Brown, L, and Vervliet, B. (2012) Role of inhibition in exposure therapy. Journal of Experimental Psychopathology 3(3) 322–345.

  Sisemore, T (2012. The clinician’s guide to exposure therapies for anxiety spectrum disorders: Integrating techniques and applications from CBT, DBT, and ACT. Oakland, CA. New Harbinger Publications.

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

  Phillipson, S. (1991) Thinking the unthinkable. Obsessive-compulsive Newsletter 5, 1–4.

  Foa, E. B. and Wilson, R. (2009) Stop obsessing! How to overcome your obsessions and compulsions. New York, NY: Bantam Press.

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

  Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., and Baker, A. (2008) Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy 46(1) 5–27.

  Bouton, M. E. (2004) Context and behavioral processes in extinction. Learning and Memory 11(5) 485–494.

  Bouton, M. E. (2002) Context, ambiguity, and unlearning: Sources of relapse after behavioral extinction. Biological psychiatry 5(10) 976–986.

  9

  The Curious Case of Worry

  Worry is part of the human condition. We are granted the gift of imagination and the ability to think about and visualize possible futures. Worry begins as a means of planning, and can serve a helpful function in preparation and problem solving. The planning part of worry can save time, energy, and emotional discomfort, enabling us to make better decisions. Sometimes, however, worry becomes a problem in itself. Worry can become overwhelming, preoccupying, paralyzing, and toxic. Some people worry about relatively unimportant things, and others realize that they worry about situations that are completely out of their control, so that no useful purpose is accomplished by their worrying. But these people continue to worry all the same.

  People who worry more than they want to will often then start worrying about how much they worry, and how out of control and worrisome it is not to feel in charge of their own minds. They worry that their worry will hurt their relationships, result in a heart attack, or raise their cancer vulnerability, cause their children to disrespect them or their boyfriend to leave them. Some believe their worrying indicates that they are neurotic and weak, and that it will make them sick, dysfunctional, or insomniac. They do not know how to stop worrying and they come to us to figure out how to get it to stop. This meta-worry (worry about their own worrying) is often the reason for seeking treatment. Worry about worry sounds like this: “I can’t stand all this worrying,” “What is wrong with me that I can’t stop worrying?”, “Why am I such a downer/loser/neurotic?” These are not productive questions to explore: they are merely additional examples of worrying.

  Meta-worry is often the reason for seeking treatment.

  Worry occurs in all anxiety conditions and is a central feature of generalized anxiety disorder (GAD). Patients often express their treatment goals to include controlling or stopping worry. Prior to seeking professional help, most have already tried distraction, self-reassurance, exercise, and lifestyle changes, as well as internal attempts at self-control. Frequently they have already researched their worries in great detail and know more about the topic than most. It is easy to get caught up in debating the facts of their worries, but they already have answers for every point.

  Varieties of the Worry Experience

  There are important distinctions about worry that we need to understand in order to develop useful directions for treatment. Worry can be ego-syntonic or ego-dystonic. Worry can be anxiety raising or anxiety lowering. Worry can be depressive or anxious in content. Worry can be stuck on one thing or it can be wide-ranging and fluid. Worry thoughts can be helpful (in which case addressing them can be productive) or unhelpful (in which case addressing the content will ultimately be unproductive). Let’s look at each of these distinctions, as they determine how to plan and go carry out treatment.

  Ego-syntonic versus Ego-dystonic Worry

  Some worries seem perfectly reasonable to the worrier. These reasonable worries might be of the sort “Will I have enough money to pay the rent this month?”, “What if my aging parent gets ill?”, “What if I upset my friend in our last conversation?”, “What if I fail this test and can’t get into college because of it?”, or “What if my children don’t get good jobs?” These are the sorts of events that anyone could worry about, and they cover the gamut of happenings carrying a reasonable chance that something could become amiss. The problem with these ego-syntonic worries is that they take up so much time, interfere with sleep, take the fun out of life, seem to be unsolvable, unanswerable, and ongoing, and the worrier feels dread, preoccupation, helplessness, and above all— worried—about how much they worry and what consequences this might have for health, relationships, and quality of life.

  On the other hand, there are worries that are ego-dystonic. They feel “crazy” or out of proportion or irrational to the worrier himself. Examples might be “What if I contract AIDS even though I have no contact with blood products and am not sexually active?” or “What if I suddenly become suicidal and jump off a balcony, against my own wishes?” or “What if I left the iron on even though I checked it and I inadvertently burn down the house?” or “What if I am gay even though I know I am not and I could accept it if I were?” Ego-dystonic worries can range from the mundane—“What if I insu
lted someone and do not remember?” or “What if I do not get the absolute best deal on this purchase?”—to the bizarre “What if I locked a child in the refrigerator?” or “What if my therapist is really Satan?”

  Ego-dystonic worries will be covered in considerable detail in Chapter 10 on intrusive thoughts. Here we focus on ego-syntonic worry, what maintains it, and how to treat it.

  False Beliefs about Ego-syntonic Worry: Patients Are Uneasy about Not Worrying

  Most people do not realize that they value the same worry that they find so distressing. In fact, many worriers are afraid or unwilling to risk not worrying (Leahy, 2005). This is because they hold false beliefs about worry. Many patients look at worry as an expression of love and loyalty, and believe that worry is an essential aspect of concern. Some incorrectly believe that planning for the future involves worry, and others believe that worry allows them to rehearse responses to real-life crises and “be prepared.” But the rehearsals lack the specific details of the actual event, and so what is rehearsed is almost always inappropriate to a crisis.

  Here is an illustration. One author was talking with a patient about her need to know exactly where every member of her family was at all times, and how annoying this constant worrying was to both her and her family. She would insist they call or text her many times a day, and if someone did not, she would become overwhelmed by thoughts of catastrophic events. The author told the patient that her husband was overseas on a complex itinerary, and that she was not sure in what country he was or when he would be taking his next flight. The patient was astonished—and blurted out “don’t you care about him?” To her, constant worry was an expression of love and loyalty. If you don’t worry, then you must not care.