What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

Anxious thinking makes thoughts and actions feel fused together.

  really occurring. “What ifs?” are not experienced as guesses or imaginings, they feel like envisioning the actual future. In addition, thought–action fusion makes it seem that thinking something is somehow morally equivalent to doing it—and therefore means something important about the thinker, so that bad thoughts reveal a bad person. Having a critical thought that one “shouldn’t have” about someone means that the thinker is an ungenerous, ungrateful, or unpleasant person.

  All Risks Seem Unreasonable

  In ordinary thinking, it is understood that nothing in life is risk free, and people take reasonable risks in order to achieve a goal. In contrast, anxious thinking cannot accept any risks, because thinking about something gives it a very high probability of happening. “What if?” catastrophic thoughts seem likely to occur. Patients accept reasonable risks in many aspects of their life. One patient with OCD enjoyed skiing and bungee jumping. But he was also sensitized to the image—and therefore terrified—that his heart medication might poison his dog, and spent hours each day checking to make sure that every pill was safely stored. Another patient, able to give speeches to large audiences without anxiety, could not leave the house without hours of make-up and hair preparation for fear of running into someone she might know in the grocery store without being perfectly presentable.

  When one is anxious, any risk that triggers this anxiety seems unreasonable and intolerable. Patients then want a 100% guarantee that an unpleasant or disastrous experience won’t occur. Anxiety continually asks for reassurances of safety, and demands avoidance of situations that feel dangerous. Anxious thinking makes no distinction between fears that are triggered by catastrophic images in the mind and fears that are triggered by actual danger.

  The feeling of how dangerous something is comes from a combination of stakes (if it happened how bad would it be?) and odds (how likely is it to happen?). As anxiety levels increase, odds fade to the background, and stakes remain at the center of attention. So, any possible danger feels likely. Even when the probabilities are understood to be very low, it still feels risky. Thus, the stakes of contracting AIDs are very high, but the odds of contracting the disease for someone not sexually active and not in contact with human blood products or needles are almost zero. Nevertheless, anxiety can make it feel like a terrible risk.

  Thoughts Feel Sticky

  Anxious thinking makes scary thoughts hard to avoid. They seem stuck in the mind. No matter how much one tells oneself to think of something else, catastrophic thoughts come right back to intrude themselves into consciousness. Distractions are only partially helpful in getting one’s mind onto another subject, and they sometimes are no help at all. The more one resists thinking the thoughts, the stronger and more frequently they appear (Wegner, Erber, and Zanakos, 1993).

  It is a little like the game you might have played when you were young. Tell someone to not think about pink elephants for the next minute. Of course that is impossible to do. The act of trying to keep something out of our mind, keeps it in the foreground of our mind. In the same manner, attempts to get away from anxious thoughts—to keep them out

  The more one resists thinking the thoughts, the stronger and more frequently they appear.

  of our minds—ensure that they stay. Anxiety makes anxious thoughts feel sticky at precisely the time patients would like to banish them from their awareness. It is of no help at all to ask them to stop worrying, or “just think about something else.” If anything, such distraction tends to make things worse.

  Perceptual Distortions

  Anxiety makes the world seem different and more threatening. Anxious thinking causes over-awareness of thoughts and bodily sensations. People feel overly self-conscious. Thoughts can seem too close, and body parts can feel unusual or awkward. These feelings increase the experience of alarm when distress is triggered.

  Additionally, anxiety often makes people hypersensitive and hyper-aware. Sounds and other sensations can feel particularly powerful and jarring. Your patients might experience exquisite sensitivity to their bodily feelings, external movements, odors, colors, voice tone, and a host of other sensations that seem quite ordinary when they aren’t feeling anxious. The sum total of this hyper-awareness makes them feel less powerful and more vulnerable, which, in turn, adds to their overall anxiety. The experiences they report are not exaggerations or histrionic: they really are aware in a different way.

  Anxiety also makes one hyper-vigilant to possible threats. In order to avoid anxiety triggers, patients constantly scan to stay away from them. Attempts to avoid them paradoxically produce them. It feels dangerous not to focus on the source of distress. Otherwise, one might be blindsided by emergencies. So the awareness of threats and dangers stay centered in awareness. Anxiety increases vigilance to the reactions of others as well. Scanning for disapproval or negative reactions on the faces of others makes ambiguous or even neutral faces seem disgusted, angry, or bored.

  Intolerance of Uncertainty

  Life is all uncertainties and no one can predict the future. In most activities, we assume that our future will be like the past. We assume people we love are okay. We learn to fill in the gaps of uncertainty with our own experiences. We accept that nothing in life is entirely risk-free, but that there are many low-risk experiences where we can safely disregard the risk.

  But anxiety makes uncertainty feel threatening. Uncertainty becomes linked with the possibility of disaster. Even more disturbing, anxious thinking makes thoughts feel frightening. The most unlikely situation can feel as if it has a high probability of occurring. So, anxiety-producing triggers are perceived as extremely dangerous. Imagined catastrophic scenarios feel like they are likely to occur.

  Certainty is a feeling, not a fact.

  People with OCD are often extraordinarily distressed by imagined events with almost no probability of occurring. One patient with OCD was terrified that she might step on contaminated chicken droppings and start an epidemic of salmonella that would spread across the country. She checked the soles of her shoes for hours to protect this from happening.

  The point here is simple: certainty is a feeling and not a fact; a feeling incompatible with anxious arousal yet pursued by anxious people as a salve for their distress. Once patients understand that gaining certainty is not possible in the real world, they can abandon their quest for it, and begin the road to recovery.

  Fearful Thoughts Become Predictive

  One of the most distressing aspects of anxious thinking is that fearful thoughts feel like they predict future events. So, for example, if someone has a phobia of driving over bridges, anxious thinking makes that person believe that something awful will happen while attempting to drive over a bridge. As a consequence, patients will want to wait until the anxiety subsides before trying to drive over the bridge. It is not uncommon for fearful fliers to state that they will be ready to fly when their anxiety about the flight goes down. For them, increased anxiety predicts a catastrophic event, while lowered anxiety predicts a safer flight. The problem, of course, is that the only reliable way to lower anxiety is exposure to triggers in manageable steps, feeling the distress, and allowing the brain and body to gradually calm down. Waiting for the fear to subside before getting started is a form of avoidance that actually increases the fear.

  With Anxiety, Common Sense Makes No Sense

  Common sense dictates that the best course is to use gut feelings to guide actions. But this is not always true, and it is never true when dealing with an anxiety disorder. Anxiety is an excellent trickster and bluffer, and it will make patients believe that they are in danger when perfectly safe. Since anxiety is reinforced by avoidance, gut feelings from anxiety will always tell patients to avoid. If they follow gut feelings, they will always be reinforcing their anxiety.

  Anxiety triggers the autonomic nervous system to create terror. The terror experienced when anxious is identical to the terror one feels when in objective
danger. Both physiological reactions and bodily sensations are exactly the same. As a result, feelings are of no help at all in differentiating when one is in danger from when one is in the midst of an anxiety attack. Common-sense ways of coping are of no help when dealing with anxiety.

  Many feelings can be trusted to motivate us towards appropriate resolution of situations, but this is not true with anxiety. Patients must learn not to follow what anxiety tells them to do. Anxiety is a false messenger, and the best way to avoid unintentionally reinforcing anxiety is to do the opposite of what it dictates. The solution is paradoxical: Do not do what the false messenger is telling you to do, but embrace the discomfort that this engenders. That is the therapeutic paradoxical attitude.

  Danger and anxiety feel the same.

  The best way to avoid unintentionally reinforcing anxiety is to do the opposite of what it dictates.

  The Paradoxical Attitude

  Here are some paradoxes for successfully coping with anxiety.

  When dealing with anxiety, feelings are not to be trusted. Anxiety is a great bluffer that makes a person feel in danger when perfectly safe.

  When confronting anxiety, less is more. The energy used to fight anxiety adds to its intensity. Anxiety is a reaction with tension as an essential component. When one tenses up to fight anxiety, it increases the tension that is already there. The best thing to do when feeling anxiety is also the hardest thing: do nothing. Any attempt to push away or fight anxiety will only add to its intensity.

  Attempts to avoid anxiety make it stronger. The temporary relief one feels when avoiding is actually reinforcing and empowering the distress. Resisting anxiety leads to increased persistence of anxiety. The more one is able to accept the uncomfortable reaction without engaging it, the more quickly it will start to subside.

  Short-term anxiety reduction leads to increased suffering in the long run. The only way to reduce anxiety in the short term involves some sort of avoidance. Reduction of anxiety in the future requires an acceptance of increased anxiety in the present. It may not be realistic to expect to be comfortable right away, and regular exposure will increase anxiety for a period of time.

  Note

  1. Veenstra (2013) presents a somewhat more detailed analysis of the current neuroscience of affect that demonstrates the “bottom-up” rather than “top-down” view of fear circuitry. He makes distinctions among the higher neocortical functions (corresponding to mindfulness), neocortical functions (verbal thinking), paleocortical function (emotional responding), brain nuclei (instinctive survival reactions), and brainstem nuclei (automatic regulation/homeostasis). The amygdala—fully wired a month before birth—responds like an infant, reflexively signaling alarm reactions to the “gist” of danger and without an “off” switch. The paleocortex (developed in the first year of life) supplies the non-verbal fear response to the arousal. He suggests that accepting the initial alarm response (the body arousal, the urge to fight or flee, the release of neurotransmitters) can be framed as “thanking the amygdala for doing its job”—and then one can be taught to use the higher thinking brain to assess what the problem really is instead of simply responding to automatic emotional processing. However, the circular feedback loops present in the brain make this process complex and simply expecting words to extinguish fear will not be successful.

  The fear extinguishing circuits respond to four signals—security (presence of a supportive other), safety (tolerating risk), tolerability (tolerating discomfort), and mastery (confidence in skills). The latter three can be learned by practice.

  It should be noted that Claire Weekes (1976, Simple, effective treatment of agoraphobia. New York, NY: Hawthorn Books) developed her four-step method (face, accept, float, let time pass) for dealing with panic decades before the validating neuroscience was available.

  References

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  Paul, G. L. (1966). Insight vs. desensitization in psychotherapy: An experiment in anxiety reduction. Palo Alto, CA: Stanford University Press.

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  Merikangas, K. R. and Pine, D. (2002). Genetic and other vulnerability factors for anxiety and stress disorders. Neuropsychopharmacology: The fifth generation of progress. Brentwood, TN: American College of Neuropsychopharmacology, 867–882.

  Rosenbaum, J. F., Biederman, J., Bolduc-Murphy, E. A., Faraone, S. V., Chaloff, J., Hirshfeld, D. R., and Kagan, J. (1993) Behavioral inhibition in childhood: A risk factor for anxiety disorders. Harvard Review of Psychiatry 1(1) 2–16.

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  4

  The Therapeutic Attitude of Acceptance

  We state in the introduction that this is not a book about anxiety-reducing techniques. We intend to present many ideas about what to say or do with patients, but our primary aim is to communicate that anxiety is not remedied by using techniques to make it go away. Instead we want to transmit an attitude, a perspective, and an understanding of how anxiety works. We help patients observe how they inadvertently maintain their anxiety and, then, how to change these habitual reactions, so that anxiety can diminish.

  Anxiety is not remedied by using techniques to make it go away.

  We start with the paradox: we accept anxiety in order to disengage from anxiety. This perspective can be surprising and difficult for patients to understand. They will ask lots of questions. You can provide them with informa tion, explanations, and many metaphors to explain the approach. Many patients’ initial reaction to this idea contains a basic misunderstanding. We do not mean “You have to accept tha
t this will not change, you will always be miserable, now just get on with it.” Accepting anxiety in order to disengage from it does not mean accepting suffering and debilitation. On the contrary, there is change coming, and the change is about living a full life with far less suffering and limitations due to anxiety. We describe in detail why presenting this new attitude towards anxiety is essential, and how it can be done effectively.

  We accept anxiety in order to disengage from anxiety.

  A very different way of communicating much the same message is that patients don’t have to believe their anxious thoughts, nor trust their anxious feelings. Still another formulation is that patients can learn to change their relationship to anxious thoughts and feelings so that anxiety doesn’t run the show, they do. This is the basic phenomenological change in the experience of anxiety that we want them to understand: The need to avoid anxious thoughts and feelings (which, remember, keeps them going) can become less important in the process of deciding how to live one’s life, in determining what is valuable and meaningful, and in evaluating and interacting with the environment and the self. It frees the person from the miserable trap of frightening engagement with symptoms, and the sometimes frantic but ultimately futile attempts to avoid. Anxiety does not have to be obeyed or avoided or resisted: it can actually be made exciting, interesting, or just irrelevant.

  Patients come to treatment with a multitude of erroneous beliefs about arousal, sensations, thoughts, and their experience of anxiety that need to be addressed and corrected. If not, these beliefs drive behavior that fights and runs away from anxious arousal, with the result that anxiety increases rather than decreases.