What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

  What emerged was that she had OCD, and she was suffering from obsessional doubt thoughts, not marital issues. Every time she sought to reassure away or suppress or distract from or refute her doubts, the OCD retaliated with increased frequency of obsessions. The content of her doubt thoughts was, as is generally the case, the thoughts she would most not want to have—thoughts about her prior relationship—so these were vigorously fought and became more and more stuck and intrusive. Once it was clear that this was OCD and not a marital issue, and she was taught how to relate to these thoughts without horror and resistance, these melted away.

  After dealing with the cognitive compulsions which had been so disturbing, it was relatively easy to deal with the behavioral compulsions. We also were able to identify a lengthy family history of untreated OCD, which was enormously helpful in understanding some aspects of her childhood.

  OCD can also look like depression:

  A 31-year-old man was described as profoundly depressed over a breakup with his girlfriend. “I lost the girl of my dreams” he cried, and stated that he saw no reason to get up in the morning, go to work, or even continue living. The picture that quickly emerged, however, was of someone who had a long-time on and off again relationship with this woman, at times feelings intense love and a desire to marry her, and other times becoming wracked with doubt about his love and readiness to settle down. His girlfriend, frustrated to no end with this back and forth, was offered a job promotion in another city. She gave this man an ultimatum—marry her and she would stay with him and forgo the promotion, or she would move, take the new job, and cut off all ties. “It’s time for you to s*** or get off the pot,” she aptly put it. The patient, tormented by the forced choice, was unable to commit to marrying his girlfriend. She moved, and the patient immediately realized that he had “lost the girl of his dreams” and would never find someone he loved who loved him as much.

  What looks like depression is really a form of mental OCD, where the distressing trigger (the obsession) is the thought of making such an egregious mistake (I have ruined my life), and desperately figuring out ways to end his psychic pain. This is not depression, and should not be treated as depression, since the standard CBT techniques for coping with depression would actually reinforce the OCD cycle. The disorder is mental OCD, while the content of the obsessions is profoundly depressing.

  As is often the case, this person had a number of additional OCD symptoms. One was the intrusive thought that he was a closet homosexual, which added to his indecision about committing to his girlfriend (or any woman). These intrusive thoughts, however, led to behavioral restrictions. He never allowed himself to go drinking with his male buddies, since he had thoughts that he might lose control while disinhibited by alcohol and make an advance towards one of his friends. This is despite the patient’s insistence that he was unaware of any attraction to his male friends. He was unable to make a distinction between thoughts and impulses, since the triggering of anxiety made it impossible for him to distinguish between thoughts and actions (thought–action fusion).

  Fortunately, he immediately understood the reinforcing nature of his avoidances— both in behavior and thoughts. He exposed himself regularly to the script that he had lost the girl of his dreams and would never find romantic happiness in his life. His “depression” quickly abated. He focused on the theme that he was homosexual in a similar manner, and soon allowed himself to go out with male buddies and drink in a responsible manner.

  An interesting postscript: the patient was promoted and moved to the same city as his former girlfriend. They started up again, he was able to commit to marriage, and a date was finally set. At last report, he had delayed the marriage date. (We address relapse prevention in Chapter 14.)

  Purely mental OCD is common. Both the obsessions which raise anxiety and the compulsions which attempt to lower it are entirely cognitive.

  OCD is often purely mental, where both the obsession (the component of OCD that raises anxiety) and the compulsion (the component that aims to lower anxiety) are entirely cognitive. Despite any behavioral component, there is exactly the same process going on here as with the more traditional cleaners and checkers.

  A young woman with OCD had the thought that she would never get over her problems and that her life would be one long series of challenges and it seemed logical to kill herself now instead of waiting till it got so overwhelming that she could not stand it. When she let the moment pass without following the logic of her thoughts, she then had the thought that it was wrong to keep on living after having decided that it was right to die. She was unable to resolve this dilemma and remained distressed and thinking she should be hospitalized until she could decide what to do.

  In prior therapy, she had learned to conceptualize her OCD as a bully who ups the ante and screams louder until obeyed. It was pointed out that these were thoughts, not issues—even though they seemed so important—and that this is yet another manifestation of her OCD. This enabled her to treat these thoughts as she had learned to treat other OCD thoughts, which she understood to be meaningless. For example, she previously experienced intense dilemmas about which chair to sit in when she entered a room. While she was able to view trivial OCD thoughts with this attitude of “expect and allow,” thoughts about life and death seemed important messages that could not be ignored. Once she was able to label these thoughts as OCD thoughts and thoughts are only thoughts—she was able to approach these with the same therapeutic attitude.

  The key to understanding and helping people with OCD is the ability to discern what increases distress, and what lowers it. Helping people with severe OCD can feel overwhelming. Rituals can be breathtakingly complicated, with seemingly unending and nonsensical movements and required thoughts. However, there is a simple rule for making sense of OCD behaviors: all obsessions increase anxiety; all compulsions lower anxiety, but only temporarily.

  Compulsions can include rituals (common ones are washing and checking), reassurances, mental games, fact checking, internal debate, self-affirmations, prayers, and much, much more. However, all compulsions are a form of avoidance, and therefore decrease distress in the short term, but maintain and reinforce the anxiety disorder in the long term. In treatment, the goal is to find ways to encourage patients to trigger and maintain manageable levels of anxiety, while discouraging them from using normal compulsions to lower anxiety.

  Finally, if a patient presents with a “phobia” that seems extremely odd (we have seen people who came to therapy because of fear of wind chimes, the letter “s,” or the name “Estee Lauder”), look at their internal experience and wonder about the possibility of OCD.

  An extremely odd “phobia” should raise consideration of OCD as a possibility.

  Generalized Anxiety Disorder

  GAD is characterized by excessive, exaggerated anxiety, and worry about a variety of things, including common life events such as ordinary daily activities, school and work challenges, relationships, and concerns over health. Many of the issues that people with GAD worry about are not obvious reasons for worry. (For example, a patient with GAD reported that she worried about which exit she should use to get out of a parking lot.) Patients sometimes worry about how much they worry, and whether the act of worrying itself could be harmful to themselves or a loved one. This worry (and meta-worry—worry about worrying) can so dominate a person’s thinking that it interferes with daily functioning, including work, school, social activities, and relationships.

  Worries seem to float from one problem to another, such as family or relationship, work issues, school, money, health, and other potential problems. Patients with GAD tend to always expect disaster and can’t stop worrying about that possibility. People with GAD sometimes have full-blown panic attacks along with their worries, and other times they remain extremely anxious, but without specific episodes of panic.

  GAD is intimately involved with a person’s cognitive process, but the constant vigilant arousal can lead to physical sym
ptoms as well. In addition to increased heart rate and blood pressure, symptoms of GAD can include difficulty concentrating, feeling edgy, fatigue, irritability, problems falling or staying asleep, sleep that is often restless and unsatisfying, and a hyper-startle reaction. There can also be increased muscle tension, sweating, and additional self-consciousness because of these signs. Patients also describe tension headaches and shakiness, as well as gastrointestinal issues, such as ongoing nausea and diarrhea, and a frequent need to use the bathroom. Many people with irritable bowel syndrome have GAD (Lydiard, 2001).

  From an objective perspective, a lot of what they worry about seems quite minor, such as daily activities and ordinary events in the future. However, anxious thinking makes their concerns feel real, dangerous, and “sticky.” Their thoughts carry enormous emotional impact. Some people with GAD worry constantly, and will tell you that they start to worry about one thing as soon as the previous one is resolved. Worry, which starts out as a means of solving problems, becomes a problem in itself. Some people with GAD worry continuously and worry that their worry will damage them in some way—that they will become ill under the stress of all their worry, or that they will pass on their worry ways to other family members, and still others worry about the fact that they worry so much. These issues will be discussed in Chapter 9.

  Importantly, worry is both a trigger of anxiety—it raises levels of anxiety—and also a means of avoiding or reducing anxiety. People with GAD often say that worrying makes them very anxious, but not worrying feels even more threatening. Worry sometimes feels like it protects them from getting blindsided by catastrophe. One patient said that eliminating worry frightened her, making her feel like she was facing the world without her emotional body armor.

  Worrying is actually a two-step process: one aspect of worry increases anxiety (a “what if?” thought) while the other lowers it (a search for a solution). The decrease in anxiety generates additional anxiety-generating thoughts, and the worry cycle continues. In OCD, these are called obsessions and compulsions, where compulsions can be behavioral or mental. In GAD, they are present only mentally. That is why GAD is sometimes referred to as OCD lite.

  Anyone—even children—can develop GAD, although there are a considerable percentage of people who develop GAD after the age of 40 (Wittchen and Hoyer, 2001). Patients who report a significant increase in worry after the age of 35 or 40 will often report an incident or sudden realization that bad things can happen in their life, and they respond with a markedly increased feeling of vulnerability and inability to cope with life’s uncertainties. They can sometimes acknowledge their worry as a means of trying to protect themselves from these uncertainties. Still, many people with the disorder report that they have been anxious for as long as they can remember.

  Traumatic Anxieties

  As mentioned, post-traumatic stress disorder (PTSD) is not to be considered as an anxiety disorder in DSM-5, since additional consideration is given to the PTSD symptoms that include shame, anger, guilt, grief, loss, dissociation, numbing, and moral injury. However, for those individuals who are biologically and psychologically predisposed, virtually any anxiety disorder can be precipitated by a traumatic experience. Thus, it is not uncommon for obsessive-compulsive symptoms, or panic attacks, or phobic avoidance patterns to begin shortly after a high impact or traumatic experience.

  For example, a patient returned from military duty where she had served as an office-based supply officer and, once home, had the sudden thought that perhaps she had committed an atrocity she did not remember. She proceeded to become entangled in memory-checking compulsions which eventually escalated to continuously attempting to reconstruct every moment she had spent in Iraq. It was discovered that this patient experienced a brief period of constantly apologizing to her parents for having bad thoughts when in elementary school, and she had a sister with full-blown contamination-based OCD. The patient’s nervous system responded to the stress of military duty not by developing PTSD, but by precipitating the OCD that was brewing underneath the surface.

  In fact, only a small percentage of people who are exposed to traumatic experiences develop the full PTSD syndrome. More commonly, people are surprisingly resilient and their initial reactions resolve naturally. If they are impacted more significantly and they do develop a psychiatric disorder in response to the trauma, depression and substance abuse are more common than PTSD. And also more common is the onset of anxiety symptoms which are triggered by the high impact event. These fit the general criteria of anxiety disorders resulting from an unfolding of genetic and maturational factors, triggered by a particular life stress. In these cases, the life stresses are particularly intense, but still the anxiety disorder comes about from the combination of factors. Eventually, it becomes functionally autonomous and is best understood and treated as an anxiety disorder that exists independently of any previous trauma. In this case, the military veteran was treated for her OCD quite successfully. If she had been mistakenly treated for PTSD, the attempt to reconstruct the narrative of her stressful experiences—and the exploration of the meaning of her initial fearful thought—would have seriously exacerbated her symptoms.

  Only a small percentage of people exposed to a traumatic experience develop the full PTSD syndrome.

  Here is an example of someone who experienced trauma, developed a significant anxiety reaction to those triggers, yet did not develop PTSD. She avoided flying after watching the aftermath of 9/11 from her downtown Manhattan apartment and had previously lived through the trauma of losing her father in the Lockerbie terror bombing. Although other family members avoided flying after the death of her father, she continued to fly, citing a strong, almost stubborn, “I’m not going to let that stop me” motivation. When 9/11 occurred, she lived close to the World Trade Center, and was close to the panic of that morning as well as the aftermath. Ten years later, she wrote, “My response to the attacks was fast and furious—I have not flown since.” While these conditions might suggest a trauma-based disorder, the combination of age (she was about 30 when the World Trade Center was destroyed), current life stresses apart from trauma (she had been recently married and was about to become a new mother), and family history pointed to a less complicated disorder—aviophobia—which responded well to exposure treatment.

  Here is another example in which a traumatic experience precipitated an anxiety disorder, but not PTSD. A patient had a serious motor vehicle accident in which several people in the other car were injured. The accident had been weather related and unavoidable and neither driver could be considered at fault. Shortly after the accident, the patient had a series of panic attacks which seemed to be precipitated by weather forecasts but these soon subsided after she was able to identify the triggers and be prepared for what she called “excessive imagination attacks” which followed hearing the forecast. On the other hand, she began to fear panic attacks, and began avoiding time alone in case she had an attack. She began to curtail and avoid activities in which she felt trapped and unable to get to her husband, who became the source of comfort whenever she had anticipatory anxiety. She went to her pastoral counselor who misunderstood her terror as flashbacks and began to review her beliefs and meanings about the accident. Panic attacks began to appear more and more frequently and agoraphobia ensued. It turned out that her fear was that a panic attack would stress her heart too much. She was not re-experiencing the accident, she was anticipating dying of a heart attack. The original car accident was no longer even relevant. In fact, she was happy to drive as it meant she could drive to a hospital emergency room if she needed to, or to her husband’s place of work if she needed him. As it turned out, the patient recognized the pattern in her mother’s older sister, who was virtually housebound for many years. It was the fear of turning into her aunt that brought the patient to treatment. It is easy to see that the original trauma was just the tipping point in a nervous system prone to panic. While her feelings about the accident were meaningfully explored during the l
ater sessions of her treatment, what she needed immediately was an understanding of what panic attacks were, and how she was inadvertently making them worse, as well as a systematic way to deal with her developing phobic pattern.

  References

  Hirsch, C. R. and Clark, D. M. (2004) Information-processing bias in social phobia. Clinical Psychology Review 24(7) 799–825.

  Morgan, J. and Banerjee, R. (2008) Post-event processing and autobiographical memory in social anxiety: The influence of negative feedback and rumination. Journal of anxiety disorders 22(7) 1190–1204.

  Davidson, J. R. T., Foa, E. B., Connor, K. M., and Churchill, L. E. (2002) Hyperhidrosis in social anxiety disorder. Progress in Neuro-Psychopharmacology and Biological Psychiatry 26(7) 1327–1331.

  Stein, M. B., Fuetsch, M., Müller, N., Höfler, M., Lieb, R., and Wittchen, H. U. (2001) Social anxiety disorder and the risk of depression: a prospective community study of adolescents and young adults . Archives of General Psychiatry 58(3) 251–256.