What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

  This is an essential distinction, because rumination has the potential to more fully engulf patients, with more dire consequences. The degree to which patients believe and buy into their ruminative thoughts can make a huge difference to their well-being. Let us stress that rumination is not part of anxiety—it is part of depression—despite similarities to the round and round worry cycle cognitions of anxious worry.

  Rumination is often accompanied by agitation—a biological component of a mood disorder in which physical restlessness, pacing, utter inability to relax, extreme disruptions of concentration and focus are present. Patients talk about racing thoughts and relentless tremulous “energy”; they often cannot participate in work or family life. The state is so unendurable that suicidality may become an issue. They often are also experiencing the vegetative signs of a mood disorder including disruptions in sleep, appetite, and libido. While people often describe this state as unbearable “anxiety,” an essential diagnostic step is the recognition of this syndrome as agitation. Medication— or even hospitalization—for bipolar or unipolar major depression must be considered (Surrence, Miranda, Marroquín, and Chan, 2009). When patients reach such a state of extreme agitation, discussions about thoughts and feelings may become impossible and ultimately even demoralizing.

  Coping with Worry: What Doesn’t Work

  We have all had the experience of trying to help people with their worries in ways that ultimately do not help. The patients and their loved ones have usually already tried a variety of self-help and self-improvement methods, but ultimately fail to reduce the intensity and frequency of worrying. Here is a list of interventions that offer the illusion of being helpful, but most often are not. We list the principle that each method invokes, along with intervention:

  Just relax. Don’t be nervous! (paradoxical effort)

  Stop worrying. You will make yourself sick (meta-worry)

  Everything will be okay. Trust me (reassurance)

  Don’t think about it. Think about something else (distraction)

  Think about good things and happy thoughts instead (suppression)

  Have faith. Pray about it (supplicatory ritualized prayer)

  Stay positive. Remind yourself of good things (thought substitution)

  Cut out sugar and caffeine and try this tea (lifestyle changes)

  Figure out why you are stuck on this. It will stop on its own (insight alone)

  Avoid stress. Take a vacation; take a low stress job (misunderstanding the role of stress)

  We now present these interventions in more detail, to understand why each one plays into the paradoxical nature of anxiety, and inadvertently prolongs the worrier’s suffering.

  Try to relax. The more effort one engages in trying to relax, the less relaxed one becomes. Fighting to relax never works. The effort is paradoxical because relaxation is a passive phenomenon which (like falling asleep) occurs in the absence of urgency, when it is not required or insisted upon. People with significant anxiety find themselves internally yelling “RELAX!” which quickly leads to demoralization. Many discover that vigorous exercise relaxes them temporarily, but their worries creep back, sometimes necessitating increased or more vigorous exercise.

  Stop worrying or you will make yourself sick. This injunction is akin to “stop crying or I will give you something to cry about!” It suggests a more worrisome consequence and ups the ante. This increased meta-worry may divert the patient from the content of his original worries, but introduces health anxieties, more paradoxical effort, and harsh self-recriminations. It leads to distraction, suppression, and thought substitution, all of which unwittingly continue the cycle of worrying.

  Reassurance (and self-reassurance). Asking the patient to extend trust to you as a therapist or to family and friends who try to reassure (often kindly at first and then increasingly impatiently) is a particularly hazardous route to go. This will be explored in some detail in the section on “Reassurance Junkies.” Suffice it to say here that no amount of reassurance settles the problem. Reassurance becomes a ritual with its own self-perpetuating cycle, and often extends to checking the internet for other sources of reassurance. An example might be someone who checks the weather report to calm worries about driving in bad conditions, and then finds different reports from different sources, and then is preoccupied with the forecast for hours of checking and rechecking. Patients will often seek the therapist’s opinion about how worried to be about something, as if to try to borrow a better source of risk-assessment and appraisal about danger. But this, as most therapists have experienced, rarely has any long-term effect.

  Distraction. Everyone tries “maybe if I think about something else I can stop worrying.” So they listen to music or try to formulate their shopping list or they throw themselves into their work or they start a babbly conversation with someone nearby. Keeping worries at bay this way is temporarily helpful. But the worries leak into the enjoyment of the distraction, and they come back full force, particularly when the person is driving home from work or lying in bed at night and there are no further distractions they can rely upon.

  Suppression. We all have some control over the focus of our attention, and can choose to attend to one thing while ignoring another. However, we have limited control of this kind, and at some point, the more one tries to not think about something, the stronger becomes the tendency to think about it. We have introduced this previously as the ironic process of the mind (Wegner, 1994). Thought suppression has two components—an attention focus shifter, plus an internal monitor that checks for the return of the unwanted thought. If one is trying to suppress a thought that is not very important, the monitor is relatively inactive. But if the thought is unwanted—in this case an anxiety-producing worry thought—the monitor is highly active, scans constantly to make sure the thought is not there, and so produces it. Try this—take a full three minutes to sit quietly and concentrate on not having any thoughts about your body. Observe your mind scanning for the thoughts that you are trying not to have, and observe the battle which ensues to “clear the mind” of body-related thoughts.

  Supplicatory prayer. Many people will pray to God to remove the worry thoughts from their minds. Some people believe that if they pray hard and long and sincerely enough, God will answer their prayers and take away their worries. Rather than ask for the strength and comfort they need to learn how to live with their anxious minds with less suffering, they ask for the worries to be removed. Then they check to see if the prayers have worked—thereby bringing up their doubts and worries, including now additional worries that they are not in God’s grace, or not praying with enough sincerity, or perhaps even doubting their religious beliefs. Repeated prayer can serve as distraction or suppression or attempts at reassurance: it can become ritualized attempts to avoid worrying that are disappointing and demoralizing.

  Thought substitution. Stay positive, remind yourself of all the good things in your life, and whenever you have a negative thought, substitute a positive one instead. This technique combines distraction and thought suppression with possible self-recrimination for causing one’s own suffering by being negative, especially when there are so many aspects of life that are quite good. In reality, worry thoughts become quite automatic after a time: they just seem to “pop up” faster than they can be intercepted. When worriers try this method, they invariably find that they become more self-critical. They begin a worry pattern along the lines of “Why can’t I do this? What is wrong with me, this is supposed to work?”

  Change your lifestyle. Soothing teas, change of diet, healthy sleeping habits may all be enjoyable, and may reduce the overall level of sensitization or general arousal. But if this were the key to toxic worrying, our services would not be needed. Every health magazine, stress-reduction blog, exercise club newsletter, and news outlet has articles about lifestyle changes that can “reduce stress.” Virtually every patient has tried this route—or some aspect of this route—on his own. Some have exceedingly “healthy”
lives, having long ago discovered that caffeine made them jittery. Then they begin to worry about lifestyle stressors they cannot avoid, such as out gassing chemicals from furniture and undisclosed hormones in food, and whether or not the weather will permit their daily run. Excessive worry may well be exacerbated by an unhealthy lifestyle: poor sleeping habits and 42-ounce cola drinks will not be helpful—but they are not the ultimate cause or drivers of worry.

  Figure it out. Try to figure out what lies underneath getting stuck on worry thoughts. Search for hidden meanings, unconscious causes, past events, and— when you finally come to an understanding—that insight will enable you to stop worrying. What happens in real life, however, is that no definitive understanding will emerge and the search is prolonged indefinitely. The constant exploration maintains the OCD “lite” nature of worrying: asking a question that increases anxious distress, finding an answer that temporarily lowers it, another question emerges (usually in the form “Yes, but what if?”) that again raises anxiety levels and requires an answer, then searching for another answer. And the cycle continues. The “Why am I worrying?” questions are particularly prone to turning into obsessive and compulsive thought processes, particularly if the worrier is seeking to end his worries, as opposed to gaining a dispassionate understanding of them.

  Avoid stress and a stressful lifestyle. This is a misunderstanding of the role stress plays in the development of anxiety disorder. Stress does not cause worry, nor can lack of stress cure it. Stress management can be helpful in reducing overall level of sensitization and thus the intensity of worry—as can a healthy lifestyle, regular exercise, and good eating and sleeping habits. But stress management is not an effective way to cope with chronic worry, and usually patients become more stressed because their stress management isn’t working the way it is supposed to!

  Coping with Worry: Strategies That Work

  In keeping with our overall theme, all techniques for managing worry address the larger context of an attitude of acceptance, mindful non-judgment, and a lack of effort or urgency. Otherwise, their effect will be paradoxical, and ultimately of limited help. Once again, techniques are to use while one has worry thoughts, not in order to stop them.

  Correcting Basic Misinformation: Once Only

  In those rare situations where the patient is worrying about something without proper information, it can be illuminating just to provide it. A middle-aged man worried about the tingling he felt intermittently in both hands and on his face around his lips. He had spent hours on the internet researching this symptom, and asked if he should first see a neurologist about possible neuralgia or tumor on his spine, or a cardiologist about circulatory problems, or a rheumatologist about Raynaud’s disease. He already had a full medical work-up and had been dismissed as “healthy and anxious.” When informed this was a classic symptom of hyperventilation, he was able to stand back from his worrying long enough to abandon his focus on the symptom itself. What ensued was a discussion about tolerating the truth that we can never be absolutely sure that we are healthy and how one is to handle this with less suffering and preoccupation.

  Another example. A 46-year-old woman experienced depersonalization and derealization whenever she entered a situation with significant anticipatory anxiety. She worried these symptoms signaled the onset of psychosis and that she needed to hide this experience from everyone to avoid being hospitalized, and that eventually she would lose her mind in the battle to stay sane. She worried about this constantly. Informing her that she was far too old for a first episode of schizophrenia, and explaining these symptoms as benign artifacts of hyperventilation (and demonstrating this by intentionally hyper-ventilating together until we both felt the symptoms) was reassuring in a profound and helpful way. The result was that her question “Am I going crazy?” was answered—and laid to rest. It is those worry thoughts that are not laid to rest with simple information that constitute the more challenging problem. It becomes clear that the patient is being “hooked” by a rigged game, and that any more attempts to answer the question will produce only more questions and fuel the cycle of worry.

  A general rule of thumb: one good explanation of the best available information is permitted. If the question keeps coming back, then the content of the worry should no longer be the focus, and exploration of meta-worry issues such as intolerance of uncertainty and treating intrusive thoughts as messages should become the therapy work. (See Chapter 12 for more discussion of reassurance junkies and Chapter 11 for pathological doubt.)

  Changing the Paradigm: Teach the Patient Not to Answer the Question because the Game Is Rigged (Wilson, 2010)

  Imagine this: the President is having a press conference; a reporter stands up and yells out “Is it true you are sleeping with your secretary of state?” The President now faces a choice: he can say “No I am not sleeping with my secretary of state,” thereby facing headlines “President Denies Sleeping with Cabinet Member.” Or, he might have the reporter ejected from the press conference, thereby facing headlines “President Defensive about Sex Accusation; Investigative Reporter Ejected.” Or, he can look straight at the reporter, making it clear he heard the question and simply say, “Next question please.” He cannot undo that the question was raised, but he can quietly not get entangled with it; not engage with the content of the question (A. Papantonio, personal communication, March 6, 2013).

  The paradigm change is to understand that worry thoughts are not real questions—they are just masquerading as such.

  Worries are like provocative reporters. They raise questions, usually based on fearful imagination, sometimes based on memories, sometimes on images that wander into awareness. Most of them will not settle down with any response—they escalate and fight back and elaborate if they are given the honor of a response—whether it is denial, reassurance, outrage, rational disputation, or attempts at ejection. Patients who worry know this, and yet they repeatedly get caught again with the illusion that they can overpower or analyze or “rationalize away” their provocative worry questions. They treat them as if they are real messages that deserve attention and problem solving. And even as they do so, their hearts are sinking because they know they are starting on a miserable internal debate that will get them nowhere. The paradigm change is to help our patients understand that worry thoughts aren’t real questions—they are just masquerading as such.

  Begin by having your patients ask the right labeling questions. Not “Am I worrying too much, irrationally, or out of control?” But rather:

  Is this thinking productive or helpful? Or is it unproductive and unhelpful? Is there a do-able action plan that would lay this worry aside? Am I believing there is an answer in a rigged game—am I looking for certainty or answers or a guaranteed solution where there cannot be one? Am I somehow keeping the worry going by valuing it as loyalty or concern or refusal to be naive? Am I sensing urgency where there really is none? Am I making something seem important or likely only because it crossed my mind?

  And most importantly—“Will I allow myself the risk to let the thought happen and simply not honor it with any further engagement? Can I allow myself to treat a thought as a thought, not a warning or a message about my life, my world, or me? Can I simply let it be there until it goes away on its own, whenever that may be?”

  There is also an important urgency issue to be addressed: “Is this urgent or does it just feel urgent? How will this play 10 years from now? Can I move from “what if?” to “what is?” and stay in the present, which is real and concrete, instead of the future, which is not? Can I treat this alarm I feel as a false alarm?”

  Worry as Noise

  In order to disengage from the content of anxious worry, it is helpful to think of worry thoughts as noise, a concept first promoted by Reid Wilson (2006). This is a concrete way of conceptualizing that the most therapeutic way of approaching worry thoughts is to allow their emergence and then refrain from engaging with them. Noise has no content, and therefore carries no message.


  A similar helpful approach is to ask worry patients to imagine they are worrying in a foreign language, and the worries going round and round in their mind are unintelligible. This simple idea is startlingly effective with some patients, who then immediately understand the need and benefits of disengaging from a rigged game.

  Worry Exposure

  Schedule Worry Time

  Borkovec (Borkovec, Alcaine, and Behar, 2004) was one of the first to propose the scheduling of worry. Have the patient concentrate on worrying a specific amount of time every day, preferably the same time and place. During that time—which can be as short as 15 minutes and as long as an hour—the goal is to do nothing except worry intensely. Patients will need to save up worries all day and defer them to worry time, or they will run out. When they get bored, ask them to increase the urgency and intensity of the worry. The rest of the day is a worry-free zone. On the surface, this is an absurd injunction, and the paradoxical nature of the assignment will emerge as the patient practices.

  The therapeutic mechanism of worry time is not entirely clear. When first proposed, it was viewed as a form of repeated exposure that allowed for complete emotional processing of worry thoughts, with the elimination of fear through habituation (Foa and Kozak, 1986). More recently, the model of fear reduction is focused on fear management rather than outright elimination (Craske, Kircanski, Zelikowsky, Mystkowski, Chowdhury, and Baker, 2008).

  We find that perhaps the greatest value of worry time is the practice of mindful awareness of worry thoughts. Specifically, this means allowing a thought, acknowledging it as a worry thought, accepting the anxious arousal, and then not engaging the thought by answering, disputing, or avoiding, and then bringing up the next worry thought. This helps the patient grasp which is the question and which is the attempt to answer the question. Another effect of this intervention stems from the sheer absurdity of the notion of worry time and worry-free zones. There is no way to miss noticing that worries are actually thoughts, not urgent issues requiring immediate attention.