What Every Therapist Needs to Know About Anxiety Disorders
What Every Therapist Needs to Know About Anxiety Disorders is an integrated and practical approach to treating anxiety disorders for general psychotherapists. What is new and exciting is its focus on changing a patient’s relationship to anxiety in order to enable enduring recovery rather than merely offering a menu of techniques for controlling symptoms. Neither a CBT manual nor an academic text nor a self-help book, What Every Therapist Needs to Know About Anxiety Disorders offers page after page of key insights into ways to help patients suffering from phobias, panic attacks, unwanted intrusive thoughts, compulsions, and worries. The authors offer a rich array of therapist– patient vignettes, case examples, stories, and metaphors that will complement the work of trainees and experienced clinicians of every orientation. Readers will come away from the book with a new framework for understanding some of the most frustrating clinical challenges in anxiety disorders, including “reassurance junkies,” endless obsessional loops, and the paradoxical effects of effort.
Martin N. Seif, PhD, ABPP, cofounded the Anxiety and Depression Association of America and was a member of its board of directors from 1977 through 1991. Dr. Seif is associate director of the Anxiety and Phobia Treatment Center at White Plains Hospital and a faculty member of New York Presbyterian Hospital/Cornell Medical School. He maintains a private practice in Manhattan and Greenwich, Connecticut, and leads Freedom to Fly, an airport-based program for fearful fliers.
Sally Winston, PsyD, cofounded the Anxiety and Stress Disorders Institute of Maryland, where she is codirector. She is the inaugural recipient of the Jerilyn Ross Award of the Anxiety and Depression Association of America and has decades of experience treating patients, training therapists, and advocating for public awareness of anxiety disorders and advances in their treatment. She has given training workshops in the US, Canada, Asia, and Africa.
What Every Therapist Needs to Know About Anxiety Disorders
Key Concepts, Insights, and Interventions
Martin N. Seif and Sally Winston
First published 2014
by Routledge
711 Third Avenue, New York, NY 10017
and by Routledge
27 Church Road, Hove, East Sussex BN3 2FA
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2014 Martin N. Seif and Sally Winston
The right of Martin N. Seif and Sally Winston to be identified as authors of this work has been asserted by them in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
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Library of Congress Cataloging-in-Publication Data
Seif, Martin N.
What every therapist needs to know about anxiety disorders : key concepts, insights,
and interventions / by Martin N. Seif and Sally Winston.
pages cm
Includes bibliographical references and index.
1. Anxiety disorders. 2. Anxiety disorders—Treatment. 3. Anxiety—
Physiological aspects. I. Winston, Sally. II. Title.
RC531.S37 2014
616.85’22—dc23 2013040802
ISBN: 978-0-415-82898-7 (hbk)
ISBN: 978-0-415-82899-4 (pbk)
ISBN: 978-0-203-51884-7 (ebk)
Typeset in Minion
by Apex CoVantage, LLC
To David Seif and Emily Seif
To Frank and Phyllis Margolick
Contents
List of Figures and Tables
Preface
Acknowledgments
1 Why Details Make a Difference
Introduction
Reasonable Goals
Techniques Are Not the Answer
2 The Basics
Three General Characteristics of Highly Anxious People
Anxiety Feels Dangerous
How an Anxiety Disorder Differs from Plain Anxiety
The Three Types of Triggers
The Defining Aspect of an Anxiety Disorder
The Basic Principle: Identify and Treat Avoidance
3 A Contemporary View of Anxiety Disorders
Sensitivity and Anxiety
A Discussion of Causation
Insight: Cause Versus Maintenance
Primary Versus Secondary Gains
Studies on Causation
The Dilemma of Insight
Consequences of Affect Intolerance
The Value of Talking about Anxiety Symptoms
A Direct Approach to Treating Anxiety Disorders
The Neurological Perspective: Role of the Amygdala in Sensitization
The Value of Exposure
The Fear-maintaining Cycle
Avoidance, Resistance, Neutralization
The Phenomenology of Anxiety: Anxiety Alters Consciousness
With Anxiety, Common Sense Makes No Sense
The Paradoxical Attitude
4 The Therapeutic Attitude of Acceptance
Approaching Anxiety Mindfully
Embracing Anxiety
The Role of the Therapist
Teaching Metaphors
Essential Elements to the Therapeutic Attitude of Acceptance
5 Getting Started
The First Contact Must Instill Hope
Immediate Help: Embed Information in Your Questions
Get the Details
Find Out What They Have Tried
Introduce the New Paradigm: Offer a More Profound Change Than Techniques
Provide Information and Answer Questions
6 Techniques Your Patients Have Probably Already Tried and Misunderstood: What They Are and How to Make Them Helpful
The Problem with Techniques
How Techniques Can Be Helpful
Techniques Are Temporary Help, Not Goals
Emergency Coping
Techniques That Can Be Helpful: “What Is,” Not “What If?”
Anxiety Management Tricks That Easily Backfire
Diaphragmatic Breathing
Anxiety Management in Cases of Real Danger, Not False Messages
Some Issues in Determining Patient Progress
7 Diagnoses: An Annotated Tour of the Anxiety Disorders
Specific Phobias
Panic Disorder
Social Anxiety Disorder
Obsessive-compulsive Disorder
Generalized Anxiety Disorder
Traumatic Anxieties
8 Exposure: The Active Ingredient
Exposure in the History of Psychotherapy
Exposure Therapy Is More Than “Just Do It”
Role of the Therapist During Exposure: What to Say and Do
Exposure Can Be an Intrinsic Part of Diagnosis and Assessment
Exposure for Patients with Obsessive-compulsive Disorder: Exposure and Response Prevention
OCD with Purely Mental Obsessions and Compulsions
The Right Way to Practice Exposure
9
The Curious Case of Worry
Varieties of the Worry Experience
A Caveat: Generalized Anxiety Disorder—Rarely a Stand-alone Diagnosis
Worry Is Not an Affect: It Is Thinking—And Thoughts Are Not Facts
Productive Versus Unproductive Worry
An Important Insight: Some Worry Thoughts Raise Anxiety and Some Lower It
The Therapeutic Perspective on Worry
About Worry and Time: The Role of Urgency
Evaluating Worry
Rumination: A Different Kind of Worrying
Coping with Worry: What Doesn’t Work
Coping with Worry: Strategies That Work
10 Unwanted Intrusive Thoughts: All Bark and No Bite
How Unwanted Intrusive Thoughts are Maintained
Living with Joy Despite Unwanted Intrusive Thoughts
Treating Unwanted Intrusive Thoughts
Issues for Therapists: Varieties of Presentation
Issues for Therapists: Therapist Anxiety and a New Construct
Exposure to Unwanted Intrusive Thoughts
11 Classic Pitfalls: Common Mistakes Non-Specialists Make
Pitfall Number 1: Turning the Causation Arrow Around
Pitfall Number 2: Pathological Doubt OCD—Misidentifying OCD Thoughts as Issues and the Seduction of Co-compulsions
Pitfall Number 3: Intrusive Thoughts or Doubts about Sexual Orientation or Identity—Misdiagnosing OCD Thoughts as a Sexual Issue
Pitfall Number 4: Get Your Feelings Out
Pitfall Number 5: Mistakes in the Application of Exposure-based Treatment
12 Another View of Resistance: Issues that Interfere with Treatment
When People Come Back Without Doing Home Practice
Anticipatory Anxiety: When People Need Help Getting over the Hump
The Reassurance Junkie: When People Are Constant Callers
13 Some Hard to Treat Problems: A New Perspective
Illness Worries (Health Anxiety and Hypochondria)
Scrupulosity (Religious and Secular)
Emetophobia (Fear of Vomiting)
Paruresis (Shy Bladder Syndrome)
14 Relapse Prevention
Anxiety Disorders Are Chronic Intermittent Disorders: They Come Back
The Most Enduring Recovery Is When Symptoms Do Not Matter
Search and Destroy: The Role of Subtle Avoidance
The Role of Psychotherapy in Relapse Prevention
The Proper Place for Stress Management
Finally
Appendix 1 Additional Metaphors
Appendix 2 A Summary of the Labeling Process That Can Be Given to Patients
Appendix 3 How to Learn Diaphragmatic Breathing
Appendix 4 Anxiety Diary
Index
Figures and Tables
Figures
2.1 Three types of triggers
3.1 Two routes to the amygdala
3.2 First fear is triggered
3.3 The labeling decision
3.4 Second fear labeled danger
3.5 Second fear labeled anxiety
3.6 Fear maintaining cycle
Tables
8.1 Different kinds of avoidance
8.2 Comparison of planned and incidental practice
A4.1 Typical anxiety diary
Preface
We are Drs. Marty Seif and Sally Winston, psychologists who specialize in treating anxiety. Since the late 1970s, we have treated thousands of people with anxiety disorders. Dr. Seif is one of the seven founders of the Anxiety and Depression Association of America, which began in 1977. Dr. Winston co-founded the Anxiety and Stress Disorders Institute of Maryland, in 1978. This was before the term “panic disorder” was in the DSM and anxiety specialization was in its infancy. We were both trained as psychodynamic and interpersonally oriented clinicians before learning about cognitive or behavioral therapies. We learned from each other, from other early pioneers, and from our patients, and we helped to create what has become the gold standard treatment for anxiety disorders. We have integrated into our work much of the extensive research done in the last 30 years to improve therapy for people with anxiety disorders.
State of the art treatment of anxiety has changed rapidly and radically, and it is almost impossible for non-specialists to keep abreast of new findings. One author, while preparing a lecture on OCD for a Grand Rounds in 2010, realized that everything taught about OCD in the 1970s is now understood to be incorrect. Additionally, both authors have made their own clinical discoveries and developed ways to approach certain issues that could be helpful to others. Our goal is to share with psychotherapists of all backgrounds and theoretical orientations the key concepts that we, as specialists, have learned over the course of our professional lives dedicated to understanding and treating anxiety disorders.
Organization
We provide information about anxiety and anxiety disorders before going into specifics to treat symptoms. A guiding principle is that the more we can educate a patient about anxiety, the less bewildered and afraid he becomes. We therefore encourage specific guided reading, asking questions, and seeking understanding of what is happening in the brain and the body and the mind. It is our responsibility to answer questions, offer explanations, and correct misinformation. Most people with intense anxiety are concerned that there is something profoundly and irreversibly wrong with their psyche or their body. There is an enormous therapeutic benefit in talking to someone who is knowledgeable, understands their experiences, educates them about what is happening, and also provides them with a model of what is going on in their mind that is in clear and accessible language.
For these reasons, the first parts of this book talk about anxiety from a more theoretical point of view, giving some basic facts as well as the overarching principles upon which they are anchored. Learning about something intrinsically changes our experience of it. When talking about anxiety with patients, there are often new perspectives, new realizations, and resultant therapeutic benefits. For example, it is not uncommon for non-psychotic patients who experience repeated panic attacks to become terrified that they are losing their mind. Simply educating them that they are experiencing panic attacks, which—while profoundly uncomfortable—are treatable and have nothing to do with psychosis, often results in a marked decrease in anxiety. So it is frequently unrealistic to make a distinction between learning about anxiety, and learning how to manage it. The early chapters provide the basic information that forms the core of the assessment and psycho-education phase of treatment.
In subsequent parts, we address specific topics related to anxiety and some interventions that have been shown to be effective approaches. These chapters are filled with practical suggestions of what to say and do, as well as numerous patient–therapist vignettes to illustrate how to apply basic principles and some of their nuances. We look at exposure-based interventions in detail and explore common misconceptions about the use of anxiety management techniques in both professional and self-help treatment. We examine intrusive thoughts and toxic worry, and some particularly challenging conditions such as anticipatory anxiety, health anxiety and hypochondriasis, scrupulosity, pathological doubt, and reassurance “junkies.” We also look at challenges that commonly plague psychodynamically trained psychotherapists. Finally, we will address relapse prevention, which, in our view, encompasses stress management, lifestyle changes, and relevant psychodynamic, psychosocial, and family therapies.
Scope
Traditionally, anxiety disorders have included all those conditions in which anxious arousal, phobias, panic attacks, worry, obsessions, and compulsions are the central features. These form the focus of this book. However, despite the fact that anxiety is a prominent feature of both acute and post-traumatic stress disorders, the American Psychiatric Association has reorganized the structure of the Diagnostic and Statistical Manual (DSM-5), and removed trauma-based disorders from the classification of anxiety disorders. This is because most experts see the fear-ba
sed symptoms as part of a larger complex of shame, anger, guilt, grief, loss, dissociation, emotional dysregulation, numbing, and moral injury. And there is emerging evidence that a different set of neurological changes occur in response to trauma (Yehuda and LeDoux, 2007) as opposed to the other types of anxiety disorders.
Therefore, whenever dealing with anxiety that has been triggered by a traumatic experience, it is important to obtain a detailed description of the entire symptom picture, which includes: changes in mood and worldview; dissociative and re-experiencing phenomena such as flashbacks and sleep disruptions. If the symptom configuration is primarily anxiety and is, for the most part, functionally no longer associated with the original trauma, then the insights and interventions in this book can be extremely helpful. However, if the symptom picture presented is the full syndrome of post-traumatic stress disorder, including re-experiencing phenomena and shattered illusions of safety—acute or enduring, simple or complex, originating in childhood or adulthood—then different approaches may apply. Concepts in this book may well help with the anxiety symptoms that have developed, but there is a larger arena for interventions that lies outside of the scope of this book.
In a controversial move, DSM-5 places obsessive-compulsive disorder (OCD) and a variety of related disorders in a chapter separate from other anxiety disorders. This chapter includes OCD, body dysmorphic disorder, and hoarding disorder, as well as hair pulling and skin-picking disorders. This was based partly on emerging biological research demonstrating somewhat different fear circuitry and, possibly, separate genetic transmission mechanisms (Stein, Fineberg, Bienvenu, Denys, Lochner, Nestadt, … Phillips, 2010). OCD is placed immediately next to the anxiety disorders chapter because of the high co-occurrence of OCD with other anxiety disorders (Brown, Campbell, Lehman, Grisham, and Mancill, 2001). We continue to address OCD in this book, as the general principles about what maintains OCD and how best to treat it remain unchanged by this nosological decision.
Both authors are psychologists who do not prescribe medication, but recognize that psychopharmacology is a legitimate treatment modality for anxiety disorders. We refer many patients for psychoactive medications, particularly if they are too depressed or overwhelmed by their symptoms to be able to make use of the approaches we offer. Despite its standing in the treatment of anxiety disorders, medication will not be addressed in this volume.
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