What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

  Pitfall Number 2: Pathological Doubt OCD—Misidentifying OCD Thoughts as Issues and the Seduction of Co-compulsions

  There is a particular presentation of intrusive thought that, if not understood to be a form of ego-dystonic OCD, can lead to additional suffering and negative therapeutic results. This form of OCD, called pathological doubt, can focus on any topic for which there is no definitive certainty. It masquerades as a serious issue that demands exploration and screams for resolution. In French, OCD has been referred to as “le malade de doute,” and, indeed, as discussed previously, intolerance of uncertainty forms the core of the experience of anxiety. In pathological doubt, a question arises in the mind of the patient and is accompanied by a sudden jolt of doubt, along with an overwhelming driven need to resolve the doubt. This can happen in childhood as early as children can formulate a question. It frequently jumps into awareness out of the blue, although sometimes people are able to identify the trigger for the intrusive thought. Some of these issues may seem to be philosophical quandaries, religious musings, or relationship issues. Religious and non-religious scrupulosity (overblown conscience) falls in this category. But philosophy as an activity is a pleasurable discourse and an intellectually intriguing inquiry; religion as practiced in its true form provides peace, comfort, and connectedness; and relationship issues can be resolved. These doubts are tortuous mental activity which returns again and again no matter how much mental and emotional energy is dedicated to their resolution. They are maintained by cognitive compulsions, the efforts undertaken to solve, analyze, explore, understand, research, discuss, refute, and rationalize. Here is a list of the most common topics that masquerade as issues and become the foci for obsessional (and compulsive) preoccupation.

  How does one live happily all the while knowing you are going to die?

  How can I be sure there is a God?

  How can I know that I have chosen the right life partner?

  What is the meaning of life?

  Am I possibly not straight (or gay)? Could I be attracted to the wrong person?

  Is my partner faithful in his/her heart and mind as well as behavior?

  Am I going to heaven?

  Could I survive the loss of my (parent/child/partner)?

  Am I healthy?

  Have I done everything I could to be good?

  Once it is understood that these preoccupying “issues,” no matter how important they may seem to be, are actually symptoms of an exquisite intolerance of uncertainty and part of OCD, then the patient is able to cease unproductive and tortuous internal and external conversations, and may begin the road to recovery. Here are some examples of pathological doubt OCD.

  A young man was self-referred after refusing to take antipsychotic medication that had been prescribed by a psychiatrist. The psychiatrist informed him that he was having an “incipient break” and he needed to take the medication to prevent himself from having the delusions and hallucinations that were gradually “taking over his mind.” What the patient described was that he was having flashes of the scenes in the movie “The Matrix” which represented a reality in which humans were trapped in vats, while they collectively imagined a false computer-generated world where everything seemed normal but was entirely fictitious. Accompanying these flashes, was the thought “What if this is actually the Matrix or something like it, and I am the only one asking questions, and I will never be able to prove this reality is not real and I will be labeled as crazy?” He was so afraid of this idea that he did everything he could to not think about it. This, of course, had the predictable effect of increasing the frequency and intensity of these intrusive images and thoughts. He became avoidant of other people for fear he might blurt out something that would sound crazy and get himself in trouble. His isolation was rapidly creating depression and feelings of hopelessness.

  Once this “issue” is understood as OCD intolerance of uncertainty, the tortuous internal dialogue and unproductive conversations can stop.

  A second patient had been in therapy for years to talk about his “commitment phobia.” Every time he became close to a woman he was dating and started to consider making the relationship exclusive, he began to imagine the rest of his life with her, and would have a series of doubts such as “I wonder if she has the best temperament to be a mother,” “I am afraid I will grow tired of her voice,” “What if my sexual attraction to her does not last?”, “What if she gets fat—her parents are fat—could I still love her?”, and “I don’t know if she will support me in my career enough.” He would then feel compelled to break up with the woman so as to not treat her unfairly by raising her hopes of a future with him. Once the problem was reframed as OCD and intolerance of uncertainty and unanswerable questions, the therapist created an entirely new framework to approach the problem.

  The Phenomenon of Co-compulsing: It Is Never Helpful

  Co-compulsing by friends, family, and therapists is enticing and seductive and is always unproductive.

  There is also the tendency for highly insightful and introspective patients to become involved in what we term “co-compulsing.” We define co-compulsing as the anxious equivalent of co-rumination (Rose, 2002; Stone, Hankin, Gibb, and Abela 2011), which addresses the tendency of certain people (most often adolescent girls) to talk extensively and repeatedly about their problems, focusing on their negative feelings, and thereby reinforcing depression. We define co-compulsing as joining in with the patient as he attempts to use cognitive compulsions to lower his distress. There is a natural tendency for anxious patients to engage family, friends, and therapists in mutual attempts to lower anxiety by suggesting apparent solutions to obsessive concerns. It can be enticing and seductive, and is always unproductive.

  Here is an example of therapy that did not work because it was actually cocompulsing. A graduate student in philosophy presented for treatment because he was haunted by a conundrum he simply could not get out of his mind. He had had the thought that “we all know we will die” and then thought “how can I go on unless I know the reason I am here and pursue that purpose before I die?” This disturbed him deeply, and he began a search for the meaning of life which took him on a journey through major philosophical and theological literature. Still he was losing sleep because every bit of research was flawed and every answer he sought created more doubts and more questions. He felt driven to work on this “issue” night and day and was unable to fulfill his teaching responsibilities. He was aware that others were increasingly concerned about him. He was articulate and bright. His therapist then engaged with him in deep discussions about the meaning of life, why he believed he was on earth, what his parents had taught him about God, and how he felt about that. She attempted to explore what might be behind his drive to find these answers. She wondered with him if he was avoiding relationships and why. He got worse. He became demoralized and depressed. He described himself as trapped in an abyss and the only way out was to find “the answer.” After 18 months, his therapist moved to another state. His former girlfriend said he should seek an expert in “obsessions” as this was how she viewed him. This man was diagnosed with OCD in the form of pathological doubt. He needed an entirely different relationship to his thoughts.

  Pitfall Number 3: Intrusive Thoughts or Doubts about Sexual Orientation or Identity—Misdiagnosing OCD Thoughts as a Sexual Issue

  As anxiety specialists, patients sometimes come to us for help with issues they believe may be real, but cause them extreme anxious distress. A woman was seeing a therapist she admired and liked, but sensed that something important was missing. She presented to this therapist with confusion over sexual orientation. The thought that perhaps she was gay created great anxiety, and her therapist framed the issue as one of lifestyle choice: the patient was very sexual, and very sexual people can feel attracted to and can be sexually fulfilled by people of either sex. This patient, however, was dogged by anxiety from an early age. She researched her concerns and came up with the possibility that this was an
aspect of OCD, showing references to her therapist, who discounted the possibility.

  The following email is from this patient, and comprised the only introductory information relayed prior to an initial interview.

  I have had bouts of anxiety since I was young. After college it started again when I started to have phobias of the underground transit, then trains in general, flying and then tunnels. I also always worried that my boyfriend would leave me for someone else. These thoughts would occupy my mind. I started having thoughts that I didn’t love him which were all consuming and anxiety provoking. Then during an anxious time the thought that maybe I’m a lesbian popped in my head and that has been the most distressing. I was able to get rid of it for short periods of time but now it’s stuck. Please let me know if you think you can help me.

  The wording of the email screams out a diagnosis of OCD with intrusive thoughts and pathological doubt. The phrases “having thoughts that I didn’t love him which were all consuming and anxiety provoking” and “the thought that maybe I’m a lesbian popped in my head … but now it’s stuck” are pathognomonic of mental OCD. Additionally, the patient related an exchange with another therapist she had been seeing years previously: she wondered if her jealousy concerns and worries that her boyfriend would leave her for another person was another aspect of OCD. Again, this therapist assured the patient that it was not—it was an indication of her insecurity and—this time—her lack of sexual confidence.

  So how did these two therapists get things so wrong? It concerns a misunderstanding of the nature of OCD and compulsions—that OCD is often entirely mental and that compulsions can take myriad different forms. So therapists fail to explore the anxiety maintaining cycle from a meta-level, and focus attention on the misleading content of the sexual orientation issue.

  When patients like this present for therapy, they rarely provide an accurate diagnosis. Rather, this patient might have told her therapist the following:

  PATIENT: I think I’m a lesbian, and I’m married and about to try to get pregnant, and I’m afraid I’m making the biggest mistake in my life.

  THERAPIST: What makes you think you are a lesbian?

  PATIENT: I get turned on by women. I notice attractive women when they are around. I can feel myself getting sexually aroused by certain women, and I fantasize about women when I’m making love with my husband.

  Although this sounds like solid evidence for an exploration of orientation issues, careful questioning would elicit the following information. Prior to her concerns about orientation, she enjoyed erotica with both male–male and female–female themes. The thought that she might be a lesbian popped into her head one day, causing intense anxiety, along with a desperate desire to believe she is straight. Whenever she sees an attractive woman she thinks “maybe I want to be with her,” gets a whoosh of anxiety, and then checks her body for signs of arousal—to make sure she doesn’t feel attraction. But the thought has created anxious arousal, the patient checks and finds sensations in her genitals, and that awareness confirms her worst fear—that she is indeed a lesbian. And so the patient works harder to keep these thoughts from her mind, reinforcing the stuck thought phenomenon. What has been communicated as feeling aroused by people of the same sex turns out to be an ongoing cycle of anxious arousal and compulsive checking.

  The patient emphasized that she had no concerns about enjoying lesbian porn prior to having intrusive thoughts of being gay. And her fantasies of women while in bed with her husband turned out to be intrusive thoughts that frightened her and began turning her off of sex, which reinforced her fears that she might be gay. She looked at naked pictures of men and women, trying to judge which images cause greater arousal. Her history indicates a lifelong struggle with anxiety, and a family history of OCD on her father’s side.

  Here are some examples of the same phenomenon.

  A man in his early 20s presents for treatment with a “compulsion” that he wants to be rid of. He is spending hours upon hours every night viewing homosexual porn and checking to see if he is aroused. He then compares his sexual responses to heterosexual porn, and goes back and forth in a frenzy, often causing himself penile bruising, sleep deprivation, and daytime regrets. He has gone to gay bars to see how he feels. He has even participated in a single anonymous sex encounter in order to find out “for sure” if he is attracted to men. This experience left him even more embroiled in doubts. He is very clear that he is not against homosexuality: all he wants is to know with certainty whether or not he is gay or even bisexual. Any answer would be okay with him. He just wants to settle the question so he can go about his life. He can’t stop.

  A teenage girl presents for treatment to help her to stop “un-Christian” thoughts. She has prayed for God to take away these thoughts but they are actually increasing in frequency and intensity. She has an exhausting intense gaze, focused into the eyes of whomever she is talking to or walking past, because she fears that she will look at breasts of women or what she refers to as the “laps” of men. This urge is understood by her as punishment for having sexual thoughts she should not have. She is worried that she is hopelessly “perverted.” She is terrified that she is actually gay. She has never had any sexual activity with anyone. She went through a period of time as a child in which she was fearful of bad thoughts about her parents, but these went away, she believes, because she prayed for God to remove them.

  A teenage girl comes in for a consultation to see whether she might be a “secret trans-sexual.” She is being bombarded by a train of thought that she describes as “my mind is trying to convince me that I might really be a boy.” She had read an article about trans-sexuality and suddenly became panicky with thoughts such as “I like pants and hate skirts,” “I enjoy team sports,” “I might like to have a penis,” and “my parents could never handle this if I told them I was thinking about it.” She told her parents she was having panic attacks so she could see a therapist. It turned out that she had a prior history of panicky responses when she was very young: fears about her parents dying; worry that she might grow up to be a pedophile when warned about them in first grade; and—a few years previously—had badgered her parents for proof she was not adopted.

  Pitfall Number 4: Get Your Feelings Out

  There are certain assumptions about psychotherapy that seem so obvious, so commonsensical, that there seems no need to question their validity. One of these assumptions is that getting in touch with one’s feelings—becoming more emotionally expressive, more assertive, feeling more deeply—will help a patient overcome or lower anxiety. This assumption may stem from the popular idea that catharsis, or some form of emotional venting, is inherently therapeutic, and this extends to the area of anxiety disorders as well. And there are analytic underpinnings that originate with Freud, who at one time viewed anxiety as a consequence of repression and employed abreaction as a method of treatment (Freud, 1962). Later, he changed his theory to include anxiety as both a signal and a symptom (Freud, 1959), and turned the causation arrow around so that anxiety became the instigator of repression, and not the other way around. Interestingly, Freud’s final theory of anxiety shares similarities with contemporary conceptualizations.

  The problem with the assumption that it is good to express one’s anger is twofold. First, there is no evidence that a lack of expression of emotionality has any relationship to anxiety disorders, and those suggestions can pressure patients to express emotions they truly don’t feel. People with anxiety disorders—like the rest of the population—fall into three general categories: some experience a full range of affect, and are emotionally expressive and assertive; some experience emotions but are limited in their ability to express those feelings, and others who profess to feel very few emotions, and so have little to express. Some patients who consider themselves rather cerebral and less emotional, report being told by therapists that if they could just feel their feelings more intensely, they would become less anxious. The potential result is a feeling that the
y are doing something wrong, failing at a task, responsible for their own anxiety, and must change their style of relating to the world in order to suffer less. After being told this by a therapist, one patient reported:

  PATIENT: She (referring to the therapist) said that I needed to let my feelings out to feel less anxiety.

  THERAPIST: What did you do?

  PATIENT: I tried to feel more. I tried to make myself cry. But I wondered if I was trying too hard. Sometimes I did cry, and I felt better. But I have always thought of myself more like my father. He’s the anxious one, and he’s into his head. I’m the cerebral one also; my sister is the emotional one. I wish I could be more like her.

  So the suggestion to feel and express more emotions can become a measure of how well one is doing in therapy, a source of unsupported guilt and overblown responsibility, and may add to the patient’s bewilderment and frustration.

  The second problem is that this premise turns the causation arrow around: constricted affect does not cause anxiety; it is anxiety that can cause constricted affect. This issue was initially addressed in Chapter 3, under the heading “Consequences of Affect Intolerance,” although the primary focus in that section was explaining the difficulties in coping with affect triggered when searching for hidden causes. But a similar issue arises when the suggestion is made to be more emotional.

  Constricted affect does not cause anxiety; it is anxiety that can cause constricted affect.

  Many patients with anxiety disorders fear arousal, and its associated sensations, memories, and thoughts, and can have difficulty tolerating strong emotions. Again, we are addressing anxiety sensitivity—an inability to tolerate the experience of anxiety—from the perspective of affect intolerance. Intense affect can feel uncomfortable and even dangerous, and there is a felt need to distance oneself from the emotions. Asking some patients to be more emotional— or to let their feelings out—can trigger anxiety that makes it more difficult to do so.