What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

  PATIENT: I was so afraid to come here. I thought you might put me in the hospital. I know in my heart that I can control this. I just want the thoughts to stop.

  In the first case, the biology of anxiety and genetic predisposition towards anxiety disorders is embedded in the assessment. In the second case, the unifying notion of “being trapped” as a trigger for anxiety symptoms is introduced, as well as the correction of one false message arising from sensations of arousal—the specific message that one is about to faint. This begins the ongoing communication that feelings of being in danger are not the same as being in danger. And in the third case, the critically important fact that intrusive thoughts are not signals of imminent loss of control is introduced.

  An additional point is made here. The therapist in the third case is deliberately not pursuing more information about the violent childhood at this point. This information is being stored for exploration at a later time, when the immediate terror about the thoughts has subsided. If the therapist were to launch into a search for causes stemming from childhood, it would provoke more affect, more anxiety, and more resistance. Fighting off the intrusive obsessive thoughts would become even more important as memories of a violent childhood were brought forward, and likely cause a worsening of symptoms. Violent thoughts are probably stuck because they are the most ego-dystonic, abhorrent, and resisted thoughts this patient could have (see Chapter 10). But now is not the time to do this work. That will come later. It is now time to teach the patient how to not be afraid of these thoughts, and to stop the resistance that makes them more intense.

  Again, the goal is to be immediately helpful by embedding bits of new information within the initial evaluation. Interactions like these make that first session essential in setting the stage for further assessment and treatment. In the interest of instilling hope, we may choose not to immediately gather all the historical details. But over the next sessions, all the needed information will be obtained. It is, of course, essential to do a full psychiatric screening to rule out psychoses and suicidal or medical emergencies. It is especially important to rule out agitation with patients who present with anxiety as their major issue. Agitation—sometimes confused with anxiety—can indicate major depression, mixed bipolar, a medical condition, or other serious problems that require immediate care (see Chapter 9). Significant psychosocial stressors also need to be assessed.

  Get the Details

  The second goal of initial interviews is gathering detailed phenomenology to aid in diagnosis and treatment planning. The patient’s initial presentation will not be sufficient for understanding the diagnosis. For example, patients will frequently present for treatment of their “phobias” and it will take a bit of questioning to understand what they are really afraid of—is it actually the external object or internal sensations, feelings, memories, images, or thoughts—or some combination of these?

  The patient’s initial presentation will not be sufficient for understanding the diagnosis.

  Here are some typical examples:

  Someone presenting with a “germ phobia” that turns out to be classic OCD.

  Someone who enters therapy because of “claustrophobia” and who describes the avoidance of places where she feels trapped because of the fear of having a panic attack. This is panic disorder.

  A young man says that he feels extremely low self-esteem, when the primary issue is a fear of speaking to others or being around other people. He suffers from social anxiety disorder (SAD).

  A “driving phobia” can be the presenting complaint for someone with intrusive obsessive thoughts (what if I drive the car into a pedestrian?), a fear of getting lost or making some other mistake in public, a fear of panic attacks while driving, a fear of the sensations of high speed, a fear of throwing up or losing bladder or bowel control, or fear of a variety of other triggers.

  People who enter therapy for a “fear of public speaking” may fear humiliation, a panic attack, fear of acting on an intrusive obsessive thought, a memory of a bad experience, or the arousal associated with drawing positive attention.

  A patient may appear self-diagnosed with OCD but their “compulsion” turns out to be an impulse-control problem such as compulsive gambling or kleptomania. This is discussed in the section on impulse control vs. anxiety disorder—differential (see Chapter 7, on diagnosis).

  A “fear of needles” can be blood–injury phobia, but it can also be panic disorder, fear of contamination secondary to OCD, anxiety from childhood medical trauma.

  It is rare that a patient comes to therapy with an accurate self-diagnosis, anxiety or not. But the characteristics of anxiety disorders make this even more unlikely. Anxious patients tend to be intolerant of intense affect, and they often view their experiences through the fog of anxious arousal. In fact, many anxious patients have some retrograde amnesia of details during anxious arousal. This makes it particularly important for therapists to help patients recall details of their experience, and the best way is to ask questions, thus making it clear that addressing symptoms in detail is proper fodder for therapy. Patients almost universally appreciate an extremely detailed discussion of their experience, and can begin the process of learning how to distinguish thoughts, sensations, and beliefs from external triggers during these early discussions. However, it will usually be necessary to return to their descriptions more than once, as they become more aware of their internal anxiety generating experiences.

  Even while gathering details of the patient’s anxiety experience, it is possible to embed teaching points in the process. Here is an example:

  PATIENT: Job interviews make me so anxious; I can’t look for a job.

  THERAPIST: What exactly about job interviews is it?

  PATIENT: I get anxious just thinking about it.

  THERAPIST: Please forgive me but I am an anxiety expert, so the word anxiety has so many different meanings to me. What are you referring to when you say “anxious” in this circumstance?

  PATIENT: Well I guess I mean that I imagine a horribly humiliating experience and rejection and I start to get upset and then I feel like I can’t breathe or think straight and it just seems like an impossibility.

  THERAPIST: So you scare yourself with your own vivid imagination about a possibility and then your body starts to do anxious breathing automatically and this changes how your mind and body feel. And then you get discouraged and decide not to go ahead.

  Often the patient will not be able to provide such a detailed description. It is still possible to use their presenting complaint as a starting point for education. The following example shows how the therapist can obtain enough information to arrive at an initial diagnostic impression, use that diagnosis to teach the patient about the issue, and help the patient gain perspective on his symptoms. What follows is initial contact with an extremely high functioning young man from an intensely pressured and highly achieving family.

  PATIENT: I get places late. I always have these last minute things to do. So I’m late.

  THERAPIST: Well, you came to a therapist for this. So my guess is that your lateness has caused you some distress.

  PATIENT: Yes, it gets worse when I’m under stress. And this year in college it got bad enough so that I got to most of my classes late. They asked me to take this year off.

  THERAPIST: Okay, so you are saying that your lateness gets in the way enough so that it impacted your ability to go to college? So what do you think makes you late?

  PATIENT: I’m not sure, but it isn’t just one thing. But often last minute things pop up. Sometimes I have to make sure my room is neat enough, and sometimes I have this messy feeling. And I have to take care of it. And lately something else started—I’m almost at class and then I’m not sure whether I forgot something and I go back to my room and check.

  THERAPIST: Okay, first I’d like to know if you have ever heard of OCD?

  PATIENT: Yes, my father told me that he has it, but he has it under control.

  THERAPIS
T: Do you think it’s possible that you have OCD as well?

  PATIENT: It never really occurred to me.

  THERAPIST: Well, I think you do, and let me tell you why. [The therapist then presented some very basic information about OCD to this patient, i.e. it is an anxiety disorder. He has thoughts that feel like they can’t be ignored. Then he employs behavioral or mental ways to try to rectify the issue engendered by the thought. It is not a sign of weakness or laziness. It is treatable. He should be able to get back to school next semester. There are ways of not buying into those thoughts so much.]

  PATIENT: That is really interesting! I am very embarrassed about my lateness. I feel like it is a weakness or a lack of discipline. I was wondering why this was happening to me. I’m willing to work on it.

  [The session ended when the therapist touched the office floor and asked him if he could do the same. He politely declined.]

  By the third session, this patient had experienced a number of “aha” insights into the thoughts, sensations, beliefs, and external triggers about his OCD. He quickly developed a meta-perspective about his disorder, and became good at identifying components as they appeared. This is an example where taking a direct psycho-educational approach and teaching the patient about the disorder, leads to rapid insight and increased therapeutic perspective.

  This approach is especially helpful for patients with SAD, where there is sometimes profoundly impaired insight. Anxiety is sometimes experienced as intensely exaggerated over-self-consciousness, and people with SAD get flooded by these sensations and thoughts as they are trying to focus on interpersonal cues. They might conceptualize their problem as one of poor self-esteem, “just being a loser,” depression, or introversion. Initial interviews with these patients can sometimes clarify the presence of anxious arousal, identify some of its triggers, and point towards therapeutic directions.

  The majority of people with SAD have normal social skills, but suffer from distorted self-perceptions. Their inability to accurately rate the feedback they receive from others can be seen as a consequence of their profound self-consciousness. But others with SAD who have been shy and avoiding social interactions from an early age may have significant deficits in eye contact, capacity to converse naturally, or ability to ask and answer questions. So part of the assessment of SAD includes an evaluation of the patient’s actual social skills, and teaching social skills are sometimes part of the treatment plan.

  Social anxiety often manifests itself immediately in interactions with the therapist. The interview, by definition, is a social interaction and is often a trigger for anxiety. Some patients with SAD are almost unable to communicate, and their fear is palpable during session. This next patient was almost silent as he sat for the first session. He made no eye contact, and remained focused on the second chair in the office for the entire time. His speech was pressured, he was sweating as he spoke, and he repeatedly rubbed his forehead with his hand. People with intense SAD are often referred by other family members, because initial contact makes them so anxious. The mother of this patient made initial contact, although he came alone to the first session.

  PATIENT: [silent pause]

  THERAPIST: How can I help you?

  PATIENT: [silent pause] Oh, God. Wow.

  THERAPIST: You seem pretty frightened. Is that correct?

  PATIENT: Yes.

  THERAPIST: Can you tell me what is frightening you?

  PATIENT: Oh, well, I’m not good at this. My head is swimming.

  THERAPIST: Is there something I can do to help you be more comfortable?

  PATIENT: No, it’s not you. It’s me. I always get like this when I have to talk to someone.

  THERAPIST: Can you tell me what it is like?

  PATIENT: No, not really.

  THERAPIST: Is it worse when you have to talk to someone? Is it better when you are alone?

  PATIENT: Much better when I’m alone. Or with my brother or my mother. But very bad with others. And I’m doing terrible right now.

  THERAPIST: Actually, you are doing really well, and I wonder if you get very nervous when you are speaking to strangers.

  PATIENT: Yes I do.

  THERAPIST: And when you are around strangers and you don’t have to speak with them?

  PATIENT: I’m still a wreck.

  THERAPIST: Are there times when you feel pretty comfortable?

  PATIENT: Sure, when I’m working and when I’m playing video games, and when I’m with my friend Jason. I’m fine then. But I freeze up with others, if I don’t know them.

  THERAPIST: Well, I’m wondering if you have something called social anxiety disorder, or social phobia. It’s when you get very frightened around others and you imagine in your mind that they are seeing all your flaws.

  PATIENT: That is me.

  THERAPIST: Yes, and people with SAD can be frightened when they have to perform—like speak in front of others—and also some get frightened when they are just around people, even if nothing is expected of them. When do you get frightened?

  PATIENT: Definitely when I have to speak in front of others, but I also get these weird feelings when I walk into a room with other people.

  THERAPIST: Yes, that is very common.

  PATIENT: It feels crazy to me. I had to drop a class because I felt so weird just walking into the lecture hall.

  THERAPIST: It is actually pretty common. It happens more often than you think. In fact, you might not have been the only person in the lecture who feels that way.

  PATIENT: Get out’a here! So I’m not the only crazy one?!

  THERAPIST: So you get anxious when you have to do something specific and also when you just have to be there….

  PATIENT: Yes, but my brother only gets frightened when he has to give a presentation. He told me he has the same fear I have. In the beginning of class, when you have to give your name, and they go around the room and it gets closer to you. My heart starts beating and my mind goes blank and—and this is so crazy—I worry that I won’t be able to remember my name!

  THERAPIST: I know you are having a hard time. And I know you are suffering. But, so far, what you have told me about your social anxiety disorder is commonplace. You are a unique individual, but your anxiety is a dime a dozen.

  PATIENT: Oh God. What a relief.

  Find Out What They Have Tried

  A third task in initial contact involves taking a detailed inventory of everything the patient has tried to cope with, manage, or treat their anxiety. This is followed by a discussion of why these sometimes courageous and persistent efforts have not paid off.

  There should be a discussion of why sometimes courageous and persistent efforts have not worked.

  “I always have someone with me when I do that”. This is an avoidance of the anxious feeling.

  “I take a tranquilizer whenever I feel that I can’t cope any more”. A more subtle type of avoidance.

  There are also a variety of well-meaning but misguided efforts derived from self-help books, popular press, or past therapy efforts:

  “I tell myself that the thought is irrational and I substitute a positive thought for a negative one.” Chapter 9 will explain that this is actually the instillation of cognitive compulsions, which function to keep anxiety alive.

  “I tried behavior therapy and it didn’t work.” The behavior therapy was relaxation training, which has been shown to be ineffective or paradoxically anxiety-raising for certain anxious patients. Or it was flawed in some other basic way, such as providing exposure to the wrong triggers (see Chapter 8), or providing breathing retraining with a counter-therapeutic attitude (see Chapter 6).

  “I tried medication and I can’t tolerate it.” The family doctor prescribed a starting dosage that was far too high, and the patient was flooded with intolerable side effects. He stopped taking the medication after two days, and now believes that his body doesn’t tolerate medication.

  “I force myself to face my fears, but it doesn’t get any better at all. In fact,
I think it is getting worse. I still dread it every day.” This person is probably using any number of mini-avoidances to push through the fear. Facing fears without any change of focus or attitude will not be helpful. See Chapter 12 for a discussion of “white knuckling.”

  “My therapist and I have explored the roots of my anxiety and I understand what happened but my anxiety is still there.” Therapy has focused on the causes of the disorder, but not on what is currently maintaining the anxiety independent of the origins.

  There are also thoughtful and honest attempts that fail because of misdiagnosis, attempting the wrong type of treatment (i.e., a pharmacological approach when some people react poorly to medications even when expertly prescribed), or misunderstanding of the role of coping techniques.

  The following example illustrates such a misunderstanding: a patient came to therapy from another cognitive behavior therapist complaining of repeated panic attacks. When asked what he had been trying, the patient stated he had been taking antipanic medication for the past four months, prescribed by a competent psychopharmacologist. In the midst of panicking, the patient obsessed that he would never get over this disorder and was doomed to be disabled for the rest of his life. The cognitive behavior therapist told this patient to correct his false beliefs by reciting to himself during each panic attack that “panics are self-limiting and will go away on their own,” and “my panic disorder will not continue indefinitely.” These statements are basically true, but in this case the information functioned to maintain the anxiety, rather than as grounding psychoeducational information. The therapist had inadvertently created a reinforcing cycle of anxiety, followed by self-reassurance—a kind of mental obsessive-compulsive reinforcement of the original panic attacks. Fortunately, this patient understood the resolution immediately, and focused attention on allowing anxious arousal and anxious thoughts to come without engaging them and without trying to reassure himself. He started feeling significant relief within a few weeks.