What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

  Another patient believes her worry about whether her children are eating a healthy diet is why she feeds them well, and that worry keeps impulses to feed them badly in check. Without worry, people would misbehave. For her, people who do not worry about dangers will get in trouble out of casual neglect or ignorance or impulses that should be controlled. Another patient has to stay alert and worry during airplane flights, as if worry will somehow magically keep the plane in the air. Similarly, another patient feels compelled to worry about his academic achievement every day, because he believes this will keep him turning in outstanding work. If he were to stop worrying, he would, he firmly believes, get too casual about studying and ruin his future.

  There is a Russian proverb that states, “If you think about bad things, good things will come on their own.” It conveys the idea that worry brings better luck, better consequences, and a better future. And the converse—which is to ignore worry, to think too positively—invites bad happenings.

  One patient who worries chronically to prevent bad things from happening, but is practicing giving up the need to worry, emailed her therapist “I took a pelvic ultrasound yesterday. Follow-up on a cyst. I really wasn’t worried, but always allow room for unexpected results. I totally forgot about it today. I only remembered because the doctor left me a message. All ok. Literally forgot!!! So now I’m worried I’m getting Alzheimer’s.” This woman, like many, believes that worry keeps her sharp, and keeps her from being blindsided by an unexpected negative occurrence. She also believes that worrying about these things proves that she has good control of her memory and other mental faculties. The belief that worry protects someone from the bad occurrence—that is, actually reduces the probability of something like that happening—is non-logical, but still fairly common. People like this feel that worry gives them protection. One patient stated, “Worry is my emotional body armor.”

  Other people believe that worrying is “just my personality” and is not something that can change. They may also believe that people who do not worry are actually naive and will be less prepared to meet the challenges of life if they have not rehearsed them ahead of time. The fact that the truly bad things in life are almost always unpredicted, arrive out of left field, and are almost never the things we worry about has no impact. So, although people are miserable with how much they worry and want to stop, they arrive for help with the attitude either that “I am a worrywart and can’t really change” or they hold some unconscious beliefs about worrying which maintain their worrying—and their worry about worrying.

  A Caveat: Generalized Anxiety Disorder—Rarely a Stand-alone Diagnosis

  Anxiety disorders rarely come in pure form and often co-occur with other psychiatric and/or medical disorders. This, of course, speaks to the issue of comorbidity. In fact, GAD is almost never present without a significant co-occurring disorder. Epidemiological research suggests that over 90% of patients with generalized anxiety have another medical or psychological diagnosis in their lifetime (Judd, Kessler, Paulus, Zeller, Wittchen, and Kunovac, 1998). If GAD is all you are attending to in an individual’s therapy, you are likely missing something important. Almost 70% of people with GAD have a mood disorder during their lifetime, most often depression (Noyes, 2001). Substance use and abuse may be implicated and unacknowledged (Grant, Hasin, Stinson, Dawson, Ruan, Goldstein,… Huang, 2005). There are also high levels of co-occurring social anxiety, panic disorder, and obsessive-compulsive disorder (OCD). Many medical conditions such as thyroid or endocrine dysfunction, pulmonary, cardiac problems, and autoimmune disorders may have worry and irritability as presenting symptoms. And, since patients use the term “anxiety” to describe everything from mild worries to outright agitation signaling a slide into a major depressive or bipolar episode, determining and clarifying the context of the worrying will be essential in deciding treatment priorities.

  Worry Is Not an Affect: It Is Thinking—And Thoughts Are Not Facts

  It is often not obvious to anxious patients that worry is a thinking activity, and not a feeling. Patients often say “I feel like I will fail” or “I feel like he is going to dump me for someone prettier,” when these are actually thoughts. Modern brain imaging studies show that worry takes place in prefrontal lobes of the brain (Damsa, Kosel, and Moussally, 2009), where cognition takes place. Whenever worrying is provoked, the pathways of the amygdala (where emotional reactions occur, and where the “fight, flight, freeze” reaction is triggered) show reduced activity. Much as it seems counterintuitive, worry itself—round and round thinking—apparently blocks the direct experience of affect (Hirsch, Hayes, Mathews, Perman, and Borkovec, 2012).

  Worry is not an affect—it is thinking. And thoughts are not facts.

  There is another important point that is not always obvious to patients: Just because a worry thought crosses a mind does not make it any more likely to be true, important, or worthy of further examination. Chronic worriers have a great deal of difficulty with this truism: for them, having a thought somehow increases the probability of it occurring! We sometimes try this little exercise with a patient who is prone to worry, but first they must be prepared about the misleading messages that worry carries. Ask them to write the sentence “I hope my child will die a miserable death this year.” Most recoil in shock and many simply cannot bring themselves to write down such a thought. Some will get annoyed and angry with you for even suggesting such an awful thing. Your task is to turn this into a learning experience about their ideas and beliefs about thoughts. Exploring their resistances—what their beliefs are about the power and meaning of thoughts and words can be essential here. Just because a horrible thought is present in the mind does not make it any more likely or true. Make it one of the goals to practice with patients having horrible thoughts on purpose—sometimes in the form of a light-hearted contest— see who can come up with a more horrible thought. Playing with thoughts, exaggerating them to absurdity, singing them to “happy birthday,” saying them backwards—all help to gradually convince the worried patient that thoughts are actually just thoughts—not facts, messages, predictions, or demands.

  Most worriers initially believe that worries stem directly from fact—from the events going on in their lives—and they do not see their own contribution in creating worry. As explained in Chapter 8 on exposure, these people are looking at the wrong side of the street. They are paying attention to what is going on “out there,” and not focusing on their own internal processes. They do not see that it is their own personal internal appraisal of situations—not the situations—that make for anxious thinking. They have extreme difficulty accepting the fact that tolerating anxious thoughts is not the same as inviting danger. They are falling for anxiety’s ubiquitous trap that equates feeling anxious with being in danger. The job of the therapist is to point out, for example, that just because one worries about the safety of a medication does not make the medication unsafe. One can have the worry thought (“anaphylaxis could happen”), take the medication even while thinking that thought, become anxious, and still remain safe.

  Productive Versus Unproductive Worry

  Leahy (2004) presents the concept of productive and unproductive worry. Some worries are reasonable by most people’s standards. They can be looked at as a form of planning. They result in a do-able action plan and they are put to rest either when a decision to enact a plan is made, or the plan is enacted. An example would be “That ladder looks rickety; I am worried I might fall.” This worry is “solved” when you ask someone to hold the ladder or you get a better ladder or you decide to defer the climb until the conditions are safer. This is a productive worry. Another kind of productive worry would be like this: “I am worried that I might have a fever,” which is followed by using a thermometer and believing it when the thermometer registers a normal temperature.

  Unproductive worries are those that are unanswerable (“I worry that my children might not lead happy lives”; “I worry that I am not a good enough person in the e
yes of God”; “I worry that I might not have the best spouse I could have found if I had waited”). Or they have illusory answers (“Even if I had a stress test yesterday, how can I be sure that my heart is ok today?” “Will my boyfriend keep his promise to be faithful?” or “How can I know that I can drive across the bridge?” or “Will I find a job tomorrow?”). Some worries are about bad things that will indeed happen but there is nothing to be done about them and more and more thinking about them in the same way will not change a thing. (“I worry that I will not be able to handle it when my mother dies”).

  An Important Insight: Some Worry Thoughts Raise Anxiety and Some Lower It

  What is called by the single word “worry” is actually a process with two distinct components that are defined and identified by their relationship to each other. One component of worry increases anxiety while the other component lowers it. It is this relationship that creates the self-maintaining cycle of ongoing worry.

  In OCD, these components are referred to as obsessions and compulsions, where compulsions can be behavioral or mental. In GAD (which we are labeling as ego-syntonic worry), the same components are present, but only in a cognitive, or mental form. Let’s be specific: worry starts with a worried thought—a “what if?” which is a leap into the future addressing a potential problem, conflict, disaster, or mistake. It is posed in the form of a question that patients easily identify as a “what if?” This question raises anxiety. The patient then launches into an effort to make the anxiety go away by more thinking—to solve the problem, to make a plan, to get prepared, to answer the question, to reassure themselves, or to analyze the meaning. Sometimes the reaction to the thought is to try to control it, to distract, suppress or stop the anxiety raising thought from happening again.

  “Worry” is actually a process with two distinct components that are defined by their relationship to each other.

  The first component of worry asks the question, the second attempts to answer it.

  Responses to “what if” thoughts are often misidentified as problem-solving or planning. This is because many “what if” thoughts do solve problems in that they come up with a reasonable action plan and then go away. However, worry thoughts behave differently—they do not go away. Most of the time, the barrage of thinking is not really planning, it is the second component of worrying. Patients describe this as “round and-round,” “gerbil in a wheel,” and uncontrollable and excessive. They sometimes come into therapy with the request to turn off their minds, or at least turn down the volume. They often (and mistakenly) say that they can’t stop “obsessing.” Technically, they are suffering from cognitive “compulsing.” A cognitive compulsion—the component of worry that attempts to lower anxiety—is yet another form of avoidance. Worriers mistakenly treat their worry question as if it is an urgent, important, factual issue that must be solved or fixed right now. In fact—just like people with other types of anxiety disorders—they are looking at the wrong side of the street, ignoring their own internal reactions, and inadvertently empowering and energizing the ongoing cycle of worry. Cognitive compulsions are not only unproductive, they keep the worry cycle going and they escalate it. They drown the worrier in a sea of useless attempts to either make the worry thought go away or to find certainty, safety, or calm. Patients erroneously call this activity “rationalizing.” It is not. It is cognitive compulsion.

  The Therapeutic Perspective on Worry

  We, as therapists, must resist the temptation to participate in the second component of worry–no matter what the content of the worry.

  We, as therapists, must resist the temptation to participate in this second component of worry, no matter what the content of the worry thoughts might be. Remember that this second component temporarily reduces anxiety, but maintains suffering in the long run. Staying away from this is sometimes tricky, because the content of the thoughts may be psychodynamically very interesting and may seem to signify issues that could be fertile grounds for exploration and personal introspection. Usually we begin to co-ruminate or co-compulse as we are seduced by the content in exactly the same way the patient has been worrying. (We define and discuss co-compulsion in Chapter 11, Pitfall number 2.) We either try to help the patient solve the problem or make the best choice, or we delve in and try to uncover the hidden issues. However, very quickly it becomes clear that this is not helpful, that the very same “issues” arise again and again, perhaps in slightly camouflaged form or with a little twist to make them more interesting or escalated in the form of “Yes, I know but what if …”

  It is therefore not the content of the worry thoughts that needs changing, but rather one’s relationship to the thoughts—one’s appraisal of the thoughts—and the aim is to reduce the power that is granted to the thoughts. This is something new and a radical idea for many people. The task is not to try to solve the problems posed by anxious worry, but rather to learn how to disregard them.

  It is the relationship to the thoughts, the appraisal of the thoughts, not their content, which needs changing.

  The origin and meaning of worry thoughts may be interesting and something to explore in the future, when worrying is no longer making the patient miserable and anxiety sensitivity has been reduced. But exploring the content of worry will almost universally fail to provide relief. On the contrary, when insights occur—but the expected cessation of worries does not follow—further worries emerge of the meta-worry variety—for example, “What is wrong with me that even understanding my worries does not help me?” or, “I must be even worse off since I know where this came from and that does not help.”

  About Worry and Time: The Role of Urgency

  There are certain “negative” thoughts that we seem to have and then be able to let go of, and others that seem to get stuck and turn into worry. We are able to say “so what?” or “I will consider this later” about some thoughts but not others. A worry thought is one that is accompanied by a feeling of urgency—it carries a message that it must now be addressed—now, and not later. This feeling of urgency is what drives worrying. If something is a threat, it is an immediate threat requiring an immediate solution. If something is unclear or uncertain, it must be cleared up now. But a feeling of urgency is not a fact; it is a feeling, most often having little or nothing to do with true emergency.

  The feeling of urgency is what drives worrying.

  This complex relationship between worry thoughts and time leads people with excessive worrying to feel irritable and impatient. Wasting time may be seen as very bad indeed—so relaxing, doing nothing, enjoying the moment, just whiling away the time are not valued or allowed. Every moment must be used to solve problems or prevent future problems. Multitasking is valued; over-scheduling is common; the passage of time itself is worrisome and problematic.

  Evaluating Worry

  Here are some questions to ask diagnostically when worrying is a prominent feature of a presentation. Does it feel out of control, disproportionate, intrusive to the patient? Do the concerns and themes feel valid (ego-syntonic) or invalid (ego-dystonic)? What is the content and are there simple bits of information that might lay the worry to rest that have not yet been offered at least one time? How much meta-worry (worry about worry) is feeding the fires and promoting provocative attempts at over control, suppression, and distraction? How caught up is the patient in forms of so called “problem-solving” or “planning” which is actually maintaining the worrying? And, is this worrying part of a depressive voice (worthless, hopeless, guilty, and self-recriminating) or an anxious voice (warning of dangers, what ifs, or a quest for knowing something unknowable)? Or both? And most importantly, is it productive or unproductive mental activity? Does it lead to an action plan or to additional round and round thinking?

  Rumination: A Different Kind of Worrying

  When a patient is significantly depressed, two types of repetitive thoughts can occur: anxious worry and depressive rumination (Fresco, Frankel, Mennin, Turk, and Heimberg, 2002)
. Catastrophic thoughts occur in all anxiety disorders. In anxious worry, the focus is on the future (“what if?”) and the issue is often how to manage perceived threats that might be looming. Patients are concerned about issues regarding safety or morality, and their uncertainty about how to best react to these issues—which are often imagined, exaggerated, or out of proportion—results in increased vigilance, arousal, urgency, and anxiety (McLaughlin, Borkovec, and Sibrava, 2007).

  When significant depression is also present, something different occurs, which is called rumination. Rumination is repeated, miserable, self-referential criticism and hopelessness. The voice of rumination is about hopelessness, guilt, worthlessness, futility of effort, and shame. The content of ruminative thoughts is experienced as true, as if the depressed person has finally grasped the awful facts of his existence. There is often an internal debate about whether it is worth it to carry on. The typical thoughts of rumination include the following: “others would be better off without me,” “I can’t stand myself,” “I am a hopeless loser,” “I have tried everything to improve my life and nothing works,” “no one can ever love me,” and “I have made irreparable mistakes.” Rumination may persist throughout the waking day and consist of continually repeated rounds of thinking hopeless thoughts. It is not ego-dystonic. It overtakes the psyche. It can be shattering and feels true. Patients may describe it as “anxiety” or “obsession,” but this kind of preoccupation is dangerously different (Smith, Alloy, and Abramson, 2006).