What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

  wonders if it is out of control, or immoral, or a loser. It might wonder what actions should be taken to stop the thoughts, or to analyze what the meaning might be. This appraisal immediately produces an emotional reaction ranging from anxious arousal to fear, shame, or anger at oneself or others. If a new mom notices the typical intrusive thought “you could drop/abuse/not enjoy/shake” your baby, and she is tired and anxious, she might appraise this as (1) you are not safe to take care of this baby alone or (2) you don’t really love being a mom, or even (3) what if I have postpartum psychosis and I kill my child? Most new mothers who have this reaction to such a thought (a common thought among moms at some point) will then start a regime of thought control or behavioral avoidance that paradoxically hastens the thought’s return. The thought control strategy makes the thought stronger and more repetitive, giving it more importance and meaning. The stronger the thought, the more dangerous and likely it feels.

  One patient, struggling with unwanted intrusive thoughts, said to her therapist soon after the massacre of schoolchildren in Sandy Hook, Connecticut:

  PATIENT: I’m such a terrible person. I don’t deserve to have my children. They should be taken away from me.

  THERAPIST: Why is that?

  PATIENT: I was looking at the TV about those poor children who were killed, and I thought to myself—this tells you what kind of person I am—I thought to myself I wish my son was one. [With pressured speech] But Doctor, you have to believe me, I’m not that type of person, I would never do that, I love my children. I don’t know what I would do if my son were killed. Do you hate me? How can I stop this?

  In a single sentence we see here the admission of an unwanted intrusive thought, the rise of anxious arousal, and the plea for understanding and forgiveness that gives temporary relief, but energizes the next intrusive thought.

  Control Strategies That Fail

  Because intrusive thoughts are accompanied by a jolt of alarm, they seem dangerous. The ones that get stuck are the ones most abhorrent and most resisted. It makes sense that if an intrusive thought is appraised as dangerous or morally reprehensible, it is natural to try to do something to get rid of it. But efforts to banish thoughts have the paradoxical effect of strengthening them, increasing their volume, frequency, and believability. Typical control strategies include self-reassurance (“you would never do that, you love your child”), distraction (think about something else, get involved in something else), and refutation (“that doesn’t make sense, I will substitute rational or positive thoughts”). Each attempt to banish or neutralize the thoughts backfires. The patient checks to see if the thought might return—and indeed it does.

  Emotional and Behavioral Avoidance

  Because the appearance of unwanted thoughts can be so disturbing, patients will begin to avoid any triggers that they perceive as likely to provoke the thoughts. And if they believe these thoughts indicate an imminent loss of control, an immoral idea, or a risk of psychological collapse, they avoid situations where those thoughts might be risky. So our new mom with an intrusive thought of harming her baby might avoid being alone with her child, not pick up the baby, or bring her child to her own mother’s for long visits—which are camouflaged as family time. But she is really trying to avoid being alone and handling her child, which is seen as dangerous. And—as an example—if her thoughts engender the belief she is developing an underlying “anger problem,” she might pray to God to help her overcome her anger and then start ritualized counting to try to keep from feeling frustrated and become distressed and worried if she is unable to keep herself in a state of emotional equilibrium at all times.

  Metacognitive Beliefs (Beliefs about Thoughts)

  Metacognition consists of the cognitive factors that appraise, control, and monitor thinking. These are often unconsciously held ideas about thoughts. Beliefs about thoughts have nothing to do with the content of particular thoughts; they have to do with our relationship to our thinking minds: It has to do with how we feel about our thoughts. Most people rarely examine their metacognitions, but this process becomes important if faulty beliefs about thoughts are actually serving to maintain, reinforce, amplify, and over-analyze intrusive thoughts that cause suffering.

  Here are some examples of beliefs about thoughts that our patients may not realize they believe, but which nevertheless feed the misery. Treating intrusive thoughts must include addressing the false underlying beliefs about thoughts which give them power they do not deserve.

  Every thought is worth thinking about.

  Every thought has implication or meaning.

  I am responsible for my thoughts.

  If I can’t keep “bad thoughts” away, there is something terribly wrong with me.

  Not feeling certain about something signals danger.

  Not remembering clearly signals dangers and an urgent need to know.

  I must be free of unwanted thoughts or I cannot be happy or a good person.

  Thinking about doing something makes it more likely or is morally equivalent to doing it.

  Replace negative thoughts with positive ones and you will feel better.

  If a thought brings a feeling with it, it becomes an urgent matter.

  Ignoring thoughts is unhealthy.

  Introspection is always helpful and leads to a deeper more meaningful life.

  Physiological Factors That Make the Mind Sticky

  We have stated that the trait that forms the genetic predisposition to anxiety is called anxiety sensitivity (Taylor, 1999), a tendency to be afraid of fear. Additionally we have found virtually every anxious patient to have a tendency towards stickiness of the mind, an aspect of anxious thinking addressed in Chapter 3. Patients identify with this idea immediately—they know that other people do not suffer with repetitive thoughts, the sense of thoughts being out of control, and an inability to let go or forget about something that has entered their minds with an alarm bell jolt. It helps to understand the inherited and shared aspects of this issue, as patients often blame themselves for being so challenged when it comes to managing the flow of their thoughts.

  It is also the case that minds get more or less sticky through the course of a day, weeks, months, or even years. We help patients observe these fluctuations—not necessarily in order to avoid the factors that cause them (such as stress), but to provide insight into what has happened when people notice that they are stickier (or more sensitized in general). The more people understand what is happening and what is to be expected, the more they are willing to experience discomfort and not launch into a counter-productive attempt to fight off symptoms. Less bewilderment leads to informed, less fearful applications of the relevant principles. Thus, it is helpful to know the relationship between thought “stickiness” and sleep. People who are sleep deprived, or fatigued, or who sleep poorly, tend to have stickier thoughts. Similarly, the day after drinking alcohol tends to make people more symptomatic. Lots of caffeine can do it. So can the side effects of various OTC medications like pseudoephedrine. Asthma medications and steroids are notorious stimulants which increase stickiness in those prone to it. Any illness, in fact, can have that effect. There is also a natural circadian rhythm/diurnal cycle which most patients will recognize: stickier upon first awakening, gradually better during the day, a great evening, and then a return of stickiness for some as soon as the head hits the pillow and anticipation of tomorrow—or of insomnia—begins.

  Another potent physiological influence on stickiness is mood. Depression is a potent risk factor for increased stickiness. Another is hormonal fluctuations in women: premenstrual and postpartum women tend to have increases in the frequency, intensity, and stickiness of unwanted thoughts. Most women have had the experience of something really bothering them that seems insistently important the day prior to their period, only to forget about it the following day. These fluctuations in stickiness due to mood variations are even more pronounced in people with anxiety disorders. And the onset of an episode of major depressio
n is very frequently preceded by a period of severe mind-stickiness and increased worry (Watkins, 2008).

  We find that the factor which most affects mind stickiness, however, is hypervigilance or monitoring of the mind. The constant checking and judging of the acceptability of the content of the mind has a most pronounced effect. This ironic process (Wegner, 1994) referenced in Chapter 4 is so completely automatic in most patients that even noticing it can be a revelation.

  It is most important to know that physiological factors can influence the intensity, frequency, and persistence of unwanted intrusive thoughts and images, along with certain medications. When disturbing thoughts are intensified because of modifiable physiological factors, then these can be addressed. As an example, if one is sleep deprived, sleep can help. On the other hand, sometimes the physiological drivers of mind-stickiness are not easily modifiable. If steroids, for example, are a required medication, they should be taken, despite their effect on unwanted intrusive thoughts. It reduces a patient’s bewilderment—and therefore distress—to know a particular medication is what is causing increased symptomatology. In fact, some of these factors can be used to provide techniques for exposure. Deliberately increasing caffeine and skipping a night of sleep can be a terrific way of producing increased frequency and intensity of thoughts for practice at accepting, allowing, and gently disengaging from them. Predicting increased unwanted intrusive thoughts premenstrually can allow a patient to deliberately and consciously practice expecting, allowing, and not engaging.

  Living with Joy Despite Unwanted Intrusive Thoughts

  Here is the key to what our patients need to learn: a thought is a thought. It is not a message. It is not an impulse. Even a very scary thought that arrives with a jolt is not an impulse. The content is not meaningful. It implies only that the person has a mind that is sticky. These patients have an anxiety disorder not an impulse control disorder, as different as chalk and cheese. Patients will ask for reassurance, and that must be sparingly distributed, because reassurance ultimately makes the thought louder, more frequent, and stickier.

  A thought is merely a thought. It is not a message.

  Treating the thought as “just a thought” is easier said than done. Most people will need a lot of help and practice at disengaging from the loud and repetitive voice. Disengaging does not mean ignoring in the sense of pretending it is not there or forcefully trying to think something else. It certainly does not mean arguing or “rationalizing” or reassuring or calculating probabilities every time the thought comes back or intrudes into awareness. It means actively allowing the thought to be there but depriving it of its power to influence by remaining neutral, unimpressed, uninvolved, disinterested, maybe even bored or amused. It means doing nothing at all: not an easy thing to do when something is yelling “Danger! Danger! Craziness is coming,” into the patient’s ear. Often stories and metaphors are helpful in illustrating what this attitude of accepting and allowing means in a real sense. Here is one:

  Most people need help disengaging from the loud, repetitive voice and to actively allow the thought to be there.

  A young woman had moved into a new apartment building that was only partly occupied. The first night, while she was taking a shower the fire alarm went off. She jumped out of the shower, heart beating fast, grabbed a towel and ran out into the hallway. No one else was there. No smoke or fire was evident anywhere. She looked outside and no one was exiting the building. She called the front desk and they said there was no fire they knew of. She anxiously returned to finish her shower. The very next evening, she was in the shower and the alarm went off again! This time she took a few moments to dress, went into the hallway and downstairs to find there was no fire. She returned and finished her shower. The third night, the alarm went off again while she was in the shower. This time, she finished her shower, got curious after she was dressed and dry—and discovered that the heat-sensitive alarm was too close to the bathroom door. The steam from the shower was setting off the alarm. It was months before the situation could be corrected, so she just got used to showering with the alarm beeping. So it will be when your patient can understand that the unwanted intrusive thought is a just a glitch of the mind that sets off a false alarm.

  If one deprives these thoughts of power, it is possible to live well.

  Our point is that patients can live a good life while leaving room for unwanted thoughts of all kinds. If one deprives these thoughts of power by rendering them irrelevant, it is possible to live well. Expanding the scope of the mind to include these experiences— but not be controlled, harassed, or made fearful by them is how to accept oneself as a human being with a sticky mind.

  Treating Unwanted Intrusive Thoughts

  There is great similarity in the treatment of purely mental obsessive-compulsive disorder (OCD) (see “OCD with purely mental obsessions and compulsions” in Chapter 8), unwanted intrusive thoughts (which we conceptualize as both a subgroup of mental OCD and ego-dystonic worry), and ego-syntonic worry (see “Coping with worry” in Chapter 9). We provide many suggestions in Chapters 9 and 10. Once the thought is labeled as such and the beliefs which reinforce engagement with the thoughts are challenged, the key is to allow the thoughts, stay with the distress, actively disengage from the content, and practice the attitude of acceptance so new brain circuitry can be created.

  Issues for Therapists: Varieties of Presentation

  A 31-year-old female presented in the following manner. She came into the office, clearly agitated, holding back tears, speaking with a barely audible voice:

  PATIENT: (almost whispering) I’m going to kill myself. I’m going to kill my baby.

  THERAPIST: How would you do it?

  PATIENT: (starting to cry) How can you ask me that? I’m terrified I could do it. I can’t think about that, but that is what I keep thinking about. You have to help me doctor! My mother is staying with me. I can’t trust myself.

  THERAPIST: Are these thoughts of killing? Are these voices in your head about killing?

  PATIENT: OMG! You think I’m crazy. Maybe I am. I’m not trustable.

  THERAPIST: Voices or thoughts?

  PATIENT: Thoughts, but very powerful ones. They panic me. I think they mean having a baby is the biggest mistake in my life!

  THERAPIST: I think they mean that you are having intrusive thoughts, and that your thoughts are scaring the heck out of you. Is there a history of anxiety disorders in your past?

  PATIENT: I had panic attacks for a while when I started college. They were bad, but nothing like this.

  THERAPIST: And anxiety in your family?

  PATIENT: My mother doesn’t have a nerve in her. My father died when I was young, but I know he was nervous and high strung.

  THERAPIST: Well I think you have a form of anxiety that I call intrusive obsessive thoughts. They are awful thoughts …

  PATIENT: … and they are so real!

  THERAPIST: But I’m not concerned about you hurting your child—or yourself. The thoughts are stuck because you are fighting them—because they are the opposite of what you want to be thinking

  Patients with unwanted intrusive thoughts can present in the midst of panic and anguish. They are filled with the terror of revealing the experience, and realize that talking about the thoughts makes them come more often, so they can sometimes initially appear impulsive or even psychotic.

  In the situation above, the therapist looked for the possibility that this person was hearing voices, and whether the phrase “I’m going to kill …” was a command hallucination, a statement of intention, or an intrusive thought. The therapist also asked about a possible plan. When the patient responded to those questions with additional upset, and gave the typical “thoughts that seem different from regular thoughts” answer, the therapist already felt confident that these were intrusive thoughts. She was a new mother (these types of thoughts are not uncommon during this time), and had a previous history of panic disorder with a notably anxious father (family history).
When this information was factored in, it became quite clear that this was a terrifying, but typical, example of unwanted intrusive thoughts of the harming type—commonly called harming obsessions.

  An important note here is that misdiagnosis of postpartum OCD as postpartum psychosis is quite common and a very costly diagnostic error. There is nothing psychotic about this individual, and treating her as having a psychotic break would damage her self-esteem, confidence, and social relationships, in addition to leading to less effective treatment.

  Misdiagnosis of postpartum OCD as psychosis is a common costly error.

  The topic of intrusive obsessive thoughts always come up when teaching psychiatry residents, since people with intrusive thoughts often come to the Emergency Room with frantic concerns of harming themselves or others. Therapists, especially those in the Emergency Room with the power to immediately hospitalize people, need to differentiate between an anxiety disorder and an impulse disorder. There is a huge difference between “I am having the thought that I want to kill myself which is a totally horrible thing. What if it means I am suicidal?” and “I want to die.” This “not-me” ego-dystonic quality to the intrusive thought or image is critical.

  Here are some typical presentations:

  PATIENT: I am going crazy. Put me in the hospital before I do something crazy.

  THERAPIST: What is making you think you are going crazy?

  PATIENT: I can’t tell you. Just give me medication or put me in the hospital.

  THERAPIST: Why can’t you tell me?