What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

  Play with Worry

  Find creative ways to expose to the worry thoughts—over and over and over. The worry thought should not be followed by reassurance, or any kind of undoing, minimizing or counteracting with positive thoughts. Here are some examples: take a whole stack of Post-it notes; write, “I might fail the test” on every page. Post them everywhere—the bathroom mirror, inside the fridge, on the pillow, in the sock drawer, inside the briefcase, next to the light switch. Look at this sentence over and over until it is actually boring or silly and then look some more.

  Try these: sing your worry thought to the tune of “Happy Birthday” or “Twinkle, Twinkle, Little Star.” Write it out backwards. Translate it into other languages. Carbonell (2012) has the creative suggestion to turn it into a haiku:

  This is a tumor

  So I’ll soon be goner

  Please water my plants.

  Here is another one: speak “I have a terrible illness and have yet to be diagnosed” into an iPod and play it back before making a call or checking email. Or, worry thoughts can be spoken into a Smartphone app called Songify (Songify for iPhone, iPod touch second generation), (Songify for Android), which takes a short sentence, and turns it into a song with a rock band or orchestral back-up that is very hard to resist finding funny. Take a yellow pad and write “No one will love me, I will die alone” over and over and over, until it becomes just words. Remember that the sentence must arouse anxious feelings when first presented—and then no attempt should be made to make the anxious feelings go away. The same principles apply: expect, label, surrender the struggle, actively allow and cope with the uncertainty; do not avoid or fix or use “rational disputation” no matter how tempting.

  Face the Ultimate Fear

  This takes into account the fact that worrying blocks the direct experience of affects, and then takes the downward worry spiral all the way to its conclusion. Worriers tend to stop short of actually visualizing and facing what they are worrying about, and while they experience some degree of anxiety, worriers actually face a reduced version of their fears: they are avoiding affect with thinking (Borkovec, Ray, and Stober, 1998). A helpful technique is to follow the cascade of worries using what cognitive therapists call the vertical descent. What is the actual anticipated disaster and what does it mean about the patient, his world, and the value of worry? This is a form of exposure therapy, taking it to the “max.” Tone of voice here is important. The patient must understand you are trying to help them see how they are scaring themselves and helping them face their bottom line fears, not trying to make fun of them or make light of what is going on. Here is one example:

  PATIENT: I am afraid I will make a fool of myself at the party.

  THERAPIST: Well, let’s say that you do say the wrong thing and people know. Then what?

  PATIENT: I’ll be humiliated. I won’t be able to stand it.

  THERAPIST: And then what will happen?

  PATIENT: I would never be able to see those people again.

  THERAPIST: And then what?

  PATIENT: I would get depressed and never go anywhere.

  THERAPIST: And?

  PATIENT: Eventually I guess I would become suicidal.

  THERAPIST: And then what would happen?

  PATIENT: I would probably call my parents and they would put me in a hospital.

  THERAPIST: And then?

  PATIENT: I would never be the same again. I would kill myself.

  THERAPIST: So that would indeed be awful. Locked in the back ward of a state hospital, suicidal and suffering—no way out. Just giving up. So no wonder you get anxious about going to the party. Saying the wrong thing would ruin your life. With stakes like that, why take the risk? Why would anyone take the risk?

  Following the downward arrow to the end almost always leads to death, homelessness and humiliation, loss of family, or suicide. It is important to push the conversation to the very end, as avoidance of this imaginary scene is inadvertently helping to maintain the worry state.

  Calculate Probabilities

  This technique can easily become a form of ritualized internal reassurance, which will immediately negate its helpfulness. But it is often worth a one-time discussion simply to demonstrate the low probability of some worries occurring in fact.

  Take a look at the real likelihood of the worry thought reflecting probability instead of possibility. It can be helpful to show patients that the probability of something happening has little to do with how scary the thought feels. Remember that probabilities of multi-step events multiply, they do not add! So, for example, if one worried that the lint in the dryer could burn down the house, it would involve odds of lint being in the dryer vent, times the odds that the lint would catch on fire, times the odds that the fire would then consume the home.

  Here is an example of such an exchange:

  PATIENT: I think I might have left the toaster on. I could burn down the house. My dog is there.

  THERAPIST: And what do you think the chances are that this thought means you actually did leave the toaster on?

  PATIENT: Well I might have. Maybe one in three chances that I did.

  THERAPIST: OK. Well let’s say you actually did. What are the chances that the automatic shut off is broken and the toaster has overheated?

  PATIENT: Not likely but you never know.

  THERAPIST: Well give it a probability. An absurdly high one. One in 10?

  PATIENT: OK.

  THERAPIST: So now the chances that the toaster has overheated is one in 30. What happens if a toaster overheats?

  PATIENT: It could melt the counter.

  THERAPIST: Is it granite or wood or plastic? Chances it would melt the counter?

  PATIENT: One in 50.

  THERAPIST: OK. One in 50. That comes to one in 1,500. And what is the chance that a melting counter would catch the wall or the tile floor on fire?

  PATIENT: How about one in 20.

  THERAPIST: Ridiculous, but let’s go along. So that makes one in 30,000. And if the wall catches on fire? Then the house burns to the ground?

  PATIENT: Well the fire alarm would go off. And my dog would bark.

  THERAPIST: And the chance that no one would call the fire department?

  PATIENT: One in three. It is an apartment building.

  THERAPIST: OK now we are up to one in 90,000 chance. And if the fire department comes, then …

  PATIENT: OK I get it.

  Reduce Avoidance

  Identify and stop coping behaviors that serve to avoid and therefore ultimately increase worry. Examples of typical ways that people try to cope with worrying are procrastination, distraction, internet checking for reassurance or information, ritualistic prayer, magical coping, and “as needed” medications. Seeking perfection, checking for mistakes, and overworking are other ways that people attempt to avoid worrying. Some people carry around what we like to call the “what if bag”: a set of objects that represent safety behaviors and attempts to avoid worrying by being prepared. The “what if bag” may contain the cell phone to call for help “in case,” a dose of PRN Xanax, a banana or crackers, a bottle of water, hygienic wipes, a list of medications and illnesses (in case of incoherence or coma). Some people seek reassurance from others on such a regular basis that they get hooked on it (See “The reassurance junkie” in Chapter 12 for more on this).

  Behavioral Activation

  Increase pleasurable activity without demanding the absence of negative thoughts or the presence of positive ones. Go to the gym even while thinking “I am fat and ugly and embarrassed.” Go to the movies even while you are thinking, “What if I panic or don’t enjoy myself?” Pet the cat and listen to music and take a walk no matter what repetitive activity is going on in one portion of the mind. Acceptance of the automatic nature of unwanted worry thoughts is key. This means actively allowing them to be there but not allowing them to run the show. Imagine that you are driving on the highway and the traffic requires your full attention to stay safe. Now in
the back seat, safely strapped in, are two whining and nagging children, one is provoking the other and they are making an unpleasant racket. Your job is to keep on driving. There is nothing you can do to make them stop. So you embrace the reality you are in, and drive. Worries are like the kids in the back seat: they can make a racket and be unpleasant, but they do not run the show, they cannot actually do much of anything if they are strapped in—but they can keep it up for hours.

  References

  Leahy, R. (2005) The worry cure: Seven steps to stop worrying from stopping you. New York, NY: Three Rivers Press.

  Judd, L. L., Kessler, R. C., PauIus, M. P., Zeller, P. V., Wittchen, H.-U., and Kunovac, J. L.(1998) Comorbidity as a fundamental feature of generalized anxiety disorders: Results from the National Comorbidity Study (NCS). Acta Psychiatrica Scandinavica 98(s393) 6–11.

  Noyes, R. (2001) Comorbidity in generalized anxiety disorder. Psychiatric Clinics of North America 24(1) 41–55.

  Grant, B. F., Hasin, D. S., Stinson, F. S., Dawson, D. A., Ruan, W. J., Goldstein, R. B., … Huang, B. (2005) Prevalence, correlates, co-morbidity, and comparative disability of DSM-IV generalized anxiety disorder in the USA: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Psychological Medicine 35(12) 1747–1759.

  Damsa, C., Kosel, M., and Moussally, J. (2009) Current status of brain imaging in anxiety disorders. Current Opinion in Psychiatry 22(1) 96–110.

  Hirsch, C. R., Hayes, S., Mathews, A., Perman, G., and Borkovec, T. (2012) The extent and nature of imagery during worry and positive thinking in generalized anxiety disorder. Journal of Abnormal Psychology 121(1) 238–243.

  Leahy, R. L. (2004) Cognitive-behavioral therapy. In R.G. Heimberg, C. L. Turk, and D. Mennin (eds) Generalized Anxiety disorder: advances in research and practice. New York, NY: Guilford Press 265–292.

  Fresco, D. M., Frankel, A. N., Mennin, D. S., Turk, C. L., and Heimberg, R. G. (2002) Distinct and overlapping features of rumination and worry: The relationship of cognitive production to negative affective states. Cognitive Therapy and Research 26(2) 179–188.

  McLaughlin, K. A, Borkovec, T. D., and Sibrava, N. J. (2007) The effects of worry and rumination on affect states and cognitive activity. Behavior Therapy 38(1) 23–38.

  Smith, J. M, Alloy, L. B., and Abramson, L. Y. (2006) Cognitive vulnerability to depression, rumination, hopelessness, and suicidal ideation: multiple pathways to self-injurious thinking. Suicide and Life-threatening Behavior 36(4) 443–454.

  Surrence, K., Miranda, R., Marroquín, B. M., and Chan, S. (2009) Brooding and reflective rumination among suicide attempters: Cognitive vulnerability to suicidal ideation. Behaviour Research and Therapy 47(9) 803–808.

  Wegner, D. M. (1994) Ironic processes of mental control. Psychological Review 10 (1) 34–52.

  Wilson, R. (2013) The Anxiety Game, Psychotherapy Networker. Retrieved from www.psychotherapynetworker.org/magazine/recentissues/2013-januaryfebruary/item/1996-the-anxiety-game

  Wilson, R. (2006) “Trumping anxiety: The game, cont’d” Unpublished paper presented at the 26th annual Anxiety and Depression Association Conference, March 24, 2006, Miami, FL.

  Wilson, R. (2010) Brief Strategic Treatment of the Anxiety Disorders, Unpublished paper presented at the Brief Therapy Conference, Orlando, FL. Retrieved from http://brieftherapyconference.com/BT2010/handouts/brief-strategic-treatment-for-the-anxiety-disorders.pdf

  Borkovec, T. D., Alcaine, O. and Behar, E. (2004) Avoidance theory of worry and generalized anxiety disorder. In R. G. Heimberg, C. L. Turk, and D. S. Mennin (eds) Generalized anxiety disorder: Advances in research and practice. New York, NY: Guilford Press 77–108.

  Foa, E. B. and Kozak, M. J. (1986) Emotional processing of fear: Exposure to corrective information. Psychological Bulletin 99(1) 20–35.

  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.

  Carbonell, D. (2012) Anxiety: Treatment Techniques that Really Work. Online presentation by CMI premier education solutions. Retrieved from http://shop.pesi.com/product/anxietytreatmenttechniquesthatreallywork(8345)

  Songify for iPhone by Smule (2013) Songify (Version 2.1.1) [Mobile Application Software] Retrieved from https://itunes.apple.com/us/app/songify/id438735719?mt=8

  Borkovec, T. D., Ray, W. J., and Stober, J. (1998) Worry: A cognitive phenomenon intimately linked to affective, physiological, and interpersonal behavioral processes. Cognitive Therapy and Research 22(6) 561–576.

  10

  Unwanted Intrusive Thoughts

  All Bark and No Bite

  We all have them (Clark and Rhyno, 2005). They are thoughts, images, impulses that seem to emerge suddenly from our own minds, unbidden and unwanted. They are unacceptable, they can be weird and violent or improper, and sometimes they create a bit of hidden perverse pleasure. (How many points for hitting a nun crossing the street? A pregnant woman? A baby stroller?) For most, these experiences are fleeting and unimportant. They can even be funny, especially the bizarre ones. We have all had the thought of suddenly yanking the wheel wildly while driving and causing an accident or death. Nearly everyone has had a sudden weird thought—of jumping, being pushed, or even pushing someone else onto the tracks—while waiting for a subway train. Many have reached for the phone to call a dead relative or “saw” a deceased pet scoot by the periphery of their vision. We have suddenly recalled a dream fragment in the middle of a business meeting. We have had a vivid intrusive image of a social catastrophe—a wardrobe malfunction, or a sudden attack of amnesia, mutism, or imbecility. We have had the completely alien thought of stabbing a child or poking a dog with a pin. We have been “about to” blurt out something rude or mean. For most of us these experiences are short and meaningless; we forget about them almost as they happen and they are over. We don’t care about them because our minds are not sticky and we are not worried about our minds or our behavior.

  For others, however, these experiences become terrifying, out of control, and imbued with meaning (Clark and Purdon, 1995). These are people with anxiety disorders or depression. Unwanted intrusive thoughts can also be a contributing factor to insomnia, prolonged grief, and traumatized states. How is it that these universal phenomena turn into horrible suffering? Studies of mental processes have taught us a great deal about how it is that unwanted intrusive thoughts become problematic (Salkovskis, 1989)—and have opened the door for treatment approaches that are truly effective.

  How Unwanted Intrusive Thoughts Are Maintained

  Clark and Rhyno (2005) introduce the principle that that it is not the thoughts themselves that are problematic but how the individual reacts to them. Here are the factors that determine whether or not unwanted thoughts loom large and create misery, or remain fleeting meaningless experiences. Each of these factors will be discussed.

  (1) How the thoughts are appraised

  (2) Control strategies that fail

  (3) Behavioral and emotional avoidance

  (4) Meta-cognitive beliefs (beliefs about thoughts)

  (5) Physiological factors that make the mind sticky

  How the Thoughts Are Appraised

  People who are anxious or depressed or worried become more self-focused and vigilant about the contents of their minds (Tallis and Eysenck, 1994), as if they need to monitor their thoughts to keep themselves in check, or protect their mental health, or guard against danger. We all have many parallel streams of thought upon which we can focus our attention and mental energy or not. (Our brains are broadband!)

  To illustrate, we all simultaneously have streams of awareness that are monitoring our internal sensations:

  How comfortable is this chair?

  How full is my bladder?

  How hungry am I?

  We are also monitoring social cues:

  How is what I am saying impacting you?

  Do you like me?

>   Do I agree with you?

  Did I just say something dumb?

  Plus, we are all monitoring the passage of time:

  Will I get to my meeting on time if I encounter traffic?

  How much longer till I get to go to sleep?

  Is this book I am reading a waste of time?

  We keep track remotely of the people we love. We calculate carbohydrate intake. We wonder if it will rain. We check on our scratchy throat. And the list goes on.

  When we are at peace, we allow and embrace this natural shifting of our thoughts. Some of these thoughts seem intentional, others seem out of the blue or even intrusive, but we don’t worry about them. We expect not to be in full control of our minds. We gently refocus ourselves if we need to, and the intrusion is over in a few moments.

  A sensitized mind is hypervigilant: it scans thoughts for danger and evaluates them for significance. An unintended thought which reaches awareness gets examined, judged, and appraised. The centrality of appraisal is discussed by Purdon (2005). The anxious mind questions what this means about reality, or danger or factual correctness, and wonders if this thought is a warning or a sign about the self. It questions what it means that it thought it. It anxiously

  The anxious mind questions an intrusive thought—what does this mean about reality or danger or me? Is it a warning?