What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

  Modern understanding of the causes of anxiety disorders points to a combination of genetic and environmental factors, intertwined with a maturational process that allows different anxiety disorders to emerge at different points in patients’ lives, triggered by particular life stresses (Leonardo and Hen, 2007). Significant life changes are typical stressors. These include birth, death, marriage, divorce, or graduation. Similarly, physical stresses such as surgery or childbirth and the psychological stress of events such as the death of a pet can trigger the same physiological responses. People can develop anxiety disorders in reaction to good stresses—a job promotion—or a bad stresses, such as losing a job. Our body reacts to both types of stresses in a similar manner.

  The maturational component is significant in determining when a person might develop an anxiety disorder, and different disorders have different average onset ages. For example, panic disorder usually starts in the mid-20s, while social anxiety disorder (SAD) typically starts much earlier—around the age of 12 or 13 years. OCD can start at almost any time in a person’s life. Interestingly, boys have an earlier onset age than girls, so that prior to the age of 10, more people with OCD are male. Girls then start to catch up, so that by the age of 17 or so, there are about as many females with OCD as males (Rapoport, Inoff-Germain, Weissman, Greenwald, Narrow, Jensen, … Canino, 2000). And, contrary to other anxiety disorders, the number of people with generalized anxiety disorder (GAD) increases with age (NIMH, 2009).

  Anxiety disorders are rarely simply a lingering result of a past fearful event.

  We again emphasize that any theory of causation does not address the primary purpose of this book, which is to understand, discover, and change the factors that keep anxiety disorders going. But there is yet another point to emphasize. While arguing against the view that underlying meanings must be uncovered for successful therapy, we also advise against taking an overly simplistic view. Specifically, anxiety disorders are rarely simply a lingering result of a past fearful event.

  The vast majority of people with anxiety disorders did not develop them because of a frightening event. Critically examine the history of family anxiety disorders, age of onset, and traditional stressors for anyone who says that their anxiety disorder began as a result of a single frightening event. While this is sometimes true, it is rare, and the frightening event is often more accurately viewed as one component of a set of interacting causes.

  One patient firmly believed that her panic disorder was caused by a terrifying flight when she was 27 years old. She related intense turbulence for the duration of the trip, and her absolute belief that she would die on that flight. Prior to that time, she reported she was fearless. However, in the course of her treatment, she related that other members of her family also suffered from intense anxiety, and her flight was a return trip from a country where she had gone to get a quick divorce from her husband. When her age (27) was factored in, the odds were far greater that the immediate culprit was the life change, rather than the bumpy flight. The trigger of the bumpy flight was simply the topper to sensitization caused by a number of other factors.

  Sometimes the vulnerability to the onset of symptoms is immediately obvious—a relative is diagnosed with cancer and “what ifs” about having cancer suddenly pop up. But sometimes the sensitization is subtle, slow, or cumulative—such as a period of sleep deprivation during thesis writing, followed by too much coffee, then a cold and cold medicine with a stimulant effect. And there are times when triggers to sensitization are more complicated and subtle than that. One patient had her first panic attack while giving a speech and then became unable to give speeches, tracing her sensitization to the OJ Simpson trial and becoming increasingly enraged and transfixed. Her genetic predisposition was clearly traceable to her father’s family, which was dominated by anxiety disorders over three generations, but she had been unaffected until then. There was no abuse or violence in her loving, nurturing family of origin, but nearly everyone had the genetic trait of anxiety sensitivity. Her bewilderment was much reduced by understanding this—as well helping her make sense of her intensely empathic traits—but the fear of public speaking persisted until she did exposure-based treatment.

  The Dilemma of Insight

  We strongly support the need to focus on what maintains anxiety in contrast to searching for causes. It is not that anxiety symptoms lack underlying causes, but rather that finding causative factors is of limited therapeutic help. However, there is yet another reason why it is rare to produce a cure by searching for causes. The therapeutic process of uncovering the cause of the anxiety can increase its intensity.

  The therapeutic process of uncovering the cause of the anxiety can increase its intensity.

  Let us explain. During therapy sessions, attempts to uncover meanings involve challenging the patient to look at material that is highly charged and richly laden with affect. We can assume that there is something disturbing about those emotions, because that is why the patient is keeping it out of awareness. So we ask patients to dig deep, and can expect strong feelings to come up.

  And here is where the problem becomes clear. Many people with anxiety disorders have difficulty tolerating strong emotions. Intense affect can feel uncomfortable and even dangerous, and there is an intensely felt need to distance oneself from the emotions. With many other types of patients, the emotion can be managed with proper timing, therapeutic support, reassurance, and encouragement. In general, the ability to tolerate emotions with manageable anxiety is a requirement for successful therapy.

  But people with overwhelming anxiety are exquisitely sensitive to emotions that trigger anxiety. We are looking at anxiety sensitivity—their inability to tolerate the experience of anxiety—from another perspective. By asking highly anxious patients to uncover the meaning of their symptoms, they have been inadvertently placed in a dilemma: in order to recover, they must tolerate the anxiety generated by the emotions they uncover. However, the essential aspect of the symptom to be addressed is the inability to tolerate anxiety. If anxiety signals the defense against emergence of repressed material, then clearly uncovering therapies initially make people more anxious. The motivation and capacity to face anxiety-producing thoughts, sensations, and memories will be greater when patients have first reached the point where they no longer view strong affect as dreaded or dangerous. There is then less of a need to avoid and place limitations on addressing intense emotions. The emotions of anger, tenderness, vulnerability, etc., are no match for terror in the face of anxious arousal.

  Consequences of Affect Intolerance

  Anxiety can also be thought of as a dump for intense and conflicted emotions. People with anxiety disorders often feel anxious when they experience intense feelings. They have learned to interpret autonomic arousal in their body as anxiety, even though the same autonomic arousal can underlie a variety of legitimate emotions. For example, people with panic disorder often misinterpret excitement or anger or the tension of feeling rushed as the onset of panic, which then results in a panic attack. Thus, a patient who is watching an exciting TV show might get excited, notice the arousal, interpret it as fear, and begin to panic. This person is not afraid of TV. It is a case of misunderstanding, mislabeling, and fearing arousal.

  Here is a story that illustrates the underlying process. Imagine your doorbell rings, you open the door, someone presses a gun in your belly and says, “Give me your money or you die.” You will experience intense terror. Your heart will race, you will feel light-headed, and you will experience a full-blown alarm reaction. Now let’s rewind the tape and look at another example. Imagine your doorbell rings, you open the door, someone pushes an envelope in your direction and says, “Congratulations, you have just won the $25 million lottery!” In this case, you would also experience a rapid heart rate and light-headedness. In the first example, the feeling would be terror: in the second, excitement. And, if we had you hooked up to physiological measures, and could only view your reaction by those measure
s, we would be hard-pressed to know which was the gun and which was the lottery. Very similar physiological arousal can lead to distinctly different feelings.

  In addition to misinterpreting the arousal of excitement as fear, the anxious person has the tendency to focus only on impending panic, and cannot attend to the emotions initiating this process. Terror takes precedence over other emotions, initiating defenses against a danger that does not exist. When arousal is singularly experienced as fear, the patient appears alexithymic (unable to label different feelings) (Sifneos, 1996).

  This is particularly evident with people who have SAD. People with SAD are highly attuned to their own arousal, are hypersensitive to real or imagined criticism, and focus on how they imagine they appear to others. So the signs of physiological arousal such as slight shaking, a tremulous voice, increased sweating, etc., might be seen as looking weak, or appearing foolish or weird, and the mental indications of arousal which include blanking in the mind, or not having a snappy retort, would similarly be negatively interpreted. This would then trigger additional arousal, another round of self-criticism, and a further increase in anxiety. The original arousal—whatever the source—is soon forgotten in the maelstrom of anxiety, terror, and humiliation.

  It is sometimes helpful to ask patients the following question: what would you be feeling if you were not feeling anxious? This question aims to provide a way to look behind intense anxiety, and focus on the emotional underpinnings that triggered the original arousal. Sometimes this helps reveal what emotion was hijacked by anxiety.

  The Value of Talking about Anxiety Symptoms

  Stories abound of patients being told by therapists that they are focusing too much on their symptoms during therapy, and that their preoccupation with symptoms is a defense against more important issues. One patient—a physician—with severe OCD, checked for five to six hours every day. (Imagine spending 15 minutes each day just checking to make sure that a dishwasher is entirely empty!) This was in addition to his work as a doctor, and his home life responsibilities. He was constantly overwhelmed. This patient was told by his therapist that he would never make any progress with his OCD until he was able to overcome his internalized anger. It seems that much of his internalized anger was related to the stresses caused by his OCD, and not the other way around. Patients should be encouraged to speak about anxiety, because that is often the focus of their suffering. It is also the way to gain information about the stresses, triggers, and ways of reacting that define the disorder. The primary reason for suggesting this approach is very simple—it works! Both authors are dynamically and interpersonally trained therapists who came to recognize the benefits of directly addressing the symptoms of anxiety disorders within the context of more general psychotherapy.

  But there is another value to this approach—one that is perhaps even more significant than addressing the anxiety symptom. Anxious people have come to interpret autonomic arousal as anxiety, even though the same arousal can underlie a variety of legitimate emotions. When patients learn to manage anxiety, they learn to manage all affects. When anxiety doesn’t rule one’s life, the opportunity emerges to experience and enjoy a wider range of emotions, and patients feel more confident in their ability to handle life’s travails. Patients enjoy the benefits of greater emotional flexibility, and the ability to embrace life’s circumstances relatively free of neurotic suffering.

  When patients learn to manage anxiety, they learn to manage all affects.

  There are times when patients with overwhelming anxiety are involved in realistic life situations that require realistic solutions. If these situations trigger overwhelming anxiety, the desire to reduce anxiety is so powerful that it drives actions. But taking action to reduce the anxiety is often not the best way to resolve the problem. Since the drive to avoid anxiety is so intense, it is impossible for these people to know whether they are making a decision that best solves the problem or one that provides the quickest fix for anxiety.

  Here’s an example. A businessman suffers from panic disorder and GAD. He indicates that his director of sales is doing a poor job, yet this same person has asked for a raise. In his calm moments, he thinks he should fire this person, and that he certainly does not merit a raise. However, the thought of not having a director of sales triggers panic, and his concern about the possibility of this person quitting seems intolerable. He wants to grant the raise to keep the sales director. When asked to consider whether he is acting to reduce his anxiety, or because it is the best business decision, he acknowledges that he really doesn’t know.

  Another frequently encountered example is women who fervently want children but are terrified of the sensations, feelings, and worries they imagine they will have when pregnant. They try to avoid their anxiety by putting off the decision until they feel less anxious. This is a set-up that leads to loud ticking biological clocks. This cannot be solved until there is a better capacity to tolerate anxious thoughts and sensations. While it would be easy to interpret this situation as ambivalence about parenting, our experience is that it is about feeling unable to handle the anxiety associated with the unknown experience of pregnancy. These are happy mothers, once they can risk having anxious sensations and thoughts.

  Developing a way of reducing anxiety without avoidance provides additional options. When anxiety is lowered, the feeling of danger passes. Patients can focus on emotions that were blocked by anxiety. They can evaluate their situation and make a decision based on the merits of the solutions, rather than the blind need to lower anxiety.

  A related benefit is that patients are now better able to handle the affect that comes up during therapy. They are now equipped with the emotional hardiness to better tolerate affect, and to cope with the anxiety generated by the uncovering process. The issue is one of timing: the first task is to help the patient learn the proper attitude to cope with anxiety and work towards becoming less anxiety sensitive. As a result, anxiety lowers, and the emotions begin to emerge. By now the anxiety generated by the emotions is becoming better tolerated, and patients are more able to explore their emotional life in therapy. That, in turn, means that they are better able to make decisions about external choices without the overwhelming need to avoid anxiety.

  A Direct Approach to Treating Anxiety Disorders

  We propose the following path to helping patients overcome anxiety disorders. Since strong emotions can generate intolerable anxiety, start by first teaching patients how to better tolerate anxiety. Reaching that goal requires that they stay focused on the concept that anxiety is maintained by avoidance, and willing exposure is the active ingredient of recovery. Focus on what is maintaining the anxiety: the contemporaneous aspects of the symptom—the “what is happening?” and the “how is our patient trying to cope with it?”—rather than historical causes.

  Before patients will have the courage to give up their current means of dealing with anxiety symptoms, they need an explanatory model that makes sense to them. By providing that to patients—and we present such a model in this book—it helps the patient while strengthening the therapeutic bond.

  The Neurological Perspective: Role of the Amygdala in Sensitization

  We have come a long way from the time when people with anxiety disorders were called “weak,” “lazy,” or “cowards.” It is understood that the brain has been inadvertently programmed to make the body anxious, and there is knowledge about how that happens and the parts of the brain involved. Also, we know what is required in order to “rewire” the brain so that the fear-producing circuits are not so easily triggered.

  The “fight or flight” response is common knowledge—the brain activates an arousal system during danger. This is the stress response, which includes a series of nervous system arousals in preparation for danger. When this response is triggered, our body reacts with increased heart rate, heightened attention to possible additional dangers, release of epinephrine (adrenaline), tunnel vision, constriction of certain blood vessels, and flushing. We a
re primed to fight or flee. The amygdala is a part of the brain that triggers this arousal response, and therefore controls fear and anxiety. But fight or flight is an incomplete description of the stress response.

  A fight, flight, or freeze reaction, triggered by the amygdala (Bracha, 2004) provides a better description of anxiety symptoms. It accounts for the grouping of symptoms that are common to almost all anxiety reactions: rapid heartbeat, sweating, racing thoughts, and the feeling of dread that is associated with overwhelming anxiety. Much of the time they energize us to take action, to escape the situation or to fight harder. But there are also times when people freeze when they are anxious: the person with SAD whose mind goes blank when presenting; the white knuckle flyer, who desperately grips the arm of their seat during flights; the traumatized person who hears a noise in the house but can’t move to dial 911, the agoraphobic person who freezes in crowds. People freeze because they are overwhelmed by the stimulation of competing neural circuitry (Porges, 2001). Freezing does not denote a lack of stimulation, but rather an overabundance. It is like a computer that will eventually freeze up as additional programs are utilized. It doesn’t freeze up because it is not being asked to do enough; it freezes up because too much is asked of it.