What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

  Note that we are addressing an issue that differs from teaching patients how to make distinctions between the arousing emotions that they do feel. The alexithymia (poor labeling of emotions) that occurs from experiencing arousal as uncomfortable (and thus mislabeled as anxiety) is part of learning to accept and allow arousal. The external expression of these emotions is a separate issue.

  Many therapists find themselves telling patients to feel more, to express their emotions, and perhaps even to be more assertive. This latter suggestion often stems from confusing the expression of a feeling with the experience of it. Most of the time, well-meaning therapists report telling patients to be more emotionally expressive out of their own frustration, when typical coping and anxiety management techniques fail to provide relief. But the suggestion often creates more problems than it solves.

  Pitfall Number 5: Mistakes in the Application of Exposure-based Treatment

  A detailed explanation of exposure-based treatment appears in Chapter 8. It is easy for both experienced therapists and patients following self-help manuals to “almost” get it right. Following is a list of some of the most common mistakes we see.

  Inadvertent Reassurance While Doing or Discussing Exposure Tasks

  Example: Driving around in car with “hit and run” OCD patient. Patient hears a noise, says “probably I did not hit anyone, right?” Therapist says “yes, not a body in sight” instead of “I don’t actually know for sure, but let’s keep driving and just let that thought be there.” (Trying to suppress anxiety instead of encouraging it to happen.)

  Exposing with the Wrong Attitude

  Example: Patient with social anxiety is assigned to talk to a cashier while pretending to appear calm. A better approach is to deliberately drop something off the counter for exposure to feelings of embarrassment. (Prescribing white knuckling instead of acceptance.)

  “Just Do It!” Posing as Exposure Therapy

  Example: Patient is assigned to go back and forth through the tunnel until it no longer scares him. But he is still afraid of his thought that he will yank the wheel into the oncoming flow of traffic and spends his time trying to suppress the thought and hold the wheel rigidly. A better approach is to have the thought deliberately while driving in easier places and then in the tunnel itself.

  Choosing an Assignment That Is Unrealistic

  Example: housebound patient asked to go for a walk around the block when actually just sitting on the front porch is terrifying. (Too overwhelming.)

  Exposure to the Inadequate Triggers

  Example: Patient afraid of germs is asked to read a book about how our immune systems work. Better assignment would be to walk through a hospital waiting room and then allow “not knowing” if he has contracted an illness (exposure to external trigger instead of uncertainty.)

  Exposure to the Wrong Trigger

  Example: Patient with panic disorder who is afraid of rapid heart rate while on a bus, asked to ride the bus daily. Better assignment: run up and down the stairs to get heart rate up. (Exposure to external trigger before interoceptive exposure to feared sensations.)

  Expansion of Safe Boundaries Instead of Learning to Tolerate Anxiety

  Example: Patient inches his way around his neighborhood hoping to not panic and gradually develops confidence that he can shop, work, and visit his children’s school without symptoms. He would never consider leaving the state or taking public transportation instead of driving himself. (Better assignment: Go “collect” panic symptoms in your neighborhood and then beyond—it is not the place that matters, it is the thoughts and sensations one is learning not to fear.)

  Patient Has Met All His Behavioral Goals and Is Discharged as “Cured”

  There needs to be a clear expectation of the return of symptoms and a plan for how to respond to this likely occurrence.

  References

  Rose, A. J. (2002) Co-rumination in the friendships of girls and boys. Child Development 73(6) 1830–1843.

  Stone, L. B., Hankin, B. L., Gibb, B. E., and Abela, J. R. Z.(2011) Co-rumination predicts the onset of depressive disorders during adolescence. Journal of abnormal psychology 120(3) 752–757.

  Freud, S. (1962) Three essays on the theory of sexuality. New York, NY: Basic Books.

  Freud, S. (1959) Address to the society of B’nai B’rith. The standard edition of the complete psychological works of Sigmund Freud, Volume XX (1925–1926): An autobiographical study, Inhibitions, symptoms and anxiety, the question of lay analysis and other works. Toronto: Hogarth Press 271–274.

  12

  Another View of Resistance

  Issues That Interfere with Treatment

  We now examine three specific issues that regularly arise, each of which interferes with progress. The use of the term resistance is purposeful, since we want to emphasize that many apparently self-defeating behaviors are more accurately conceptualized and treated as anxiety avoidances. They stem from fear, not from oppositionalism or an attempt to sabotage treatment. In these cases, it is the role of therapist to make that explicit to the patient, and to work out manageable steps towards the goal. The assumption is that resistance is never the patient’s fault, any more than having an anxiety disorder is the patient’s fault. And it is our responsibility to observe it, point it out to the patient, conceptualize it as a meta-problem, and suggest concrete steps to overcome it. Resistance as a response to unmanageable anxiety will typically emerge repeatedly during the course of treatment. The sources of anxiety can be varied, from exposure assignments that are too difficult, to more subtle triggers such as the patient’s difficulty coping with skepticism or uncertainty, alternate belief systems, or the anticipation that changes will bring a clash in lifestyles. Family issues may well emerge as forces afraid of change. And a patient’s demoralization (and its partner depression) may sap him of the energy, enthusiasm, and hope required for this kind of active approach.

  Many self-defeating behaviors are more accurately conceptualized and treated as anxiety avoidance.

  Resistance is never the patient’s fault.

  When People Come Back Without Doing Home Practice

  It is often best to start with very small home practice assignments because the concept of home practice is often surprising to patients. Since it is not a traditional strategy to ask a patient to do home practice between sessions, there are a wide range of responses. Frequently patients agree to practice schedules and exposure tasks that are actually far beyond their abilities to tolerate—out of wanting to please, hoping that their new knowledge can counteract years of conditioned responses, bravado, or simple miscalculation. They will need assistance in setting their behavioral goals for the week in realistic ways that take into account their time management, their readiness to adopt a therapeutic attitude of acceptance and distress tolerance, and their grasp of the basic principles they are being taught.

  Non-compliance can come from a multitude of reasons: too much anxiety might be triggered; it could indicate a chaotic lifestyle that has little structure; it can also point to personality or transferential issues. It is always best not to become embroiled in a power struggle over an assignment. Rather, there should be an attitude of curiosity about what has happened: Was the assignment or goal just too ambitious and should we cut it in half for this week? Or, are you having trouble believing that you can manage the anxiety you expect to experience? Or is there something else in your life—your family or job, perhaps—that is in the way of your practicing between sessions? Or do you “forget”— and how might we do something about that? Sometimes the problem is simply that the patient is struggling through their practices trying to “stay calm” and so learning nothing and rapidly becoming disillusioned. More subtle cognitive avoidance behaviors can stymie progress and build resistance to home practice because the exposure tasks do not get any easier over time.

  In a similar vein, home practice assignments can be misunderstood or practiced in such a way as to make anxiety worse. Typical examples occur
with breathing exercises as well as any technique that is designed to induce relaxation, which is one reason why they are rarely assigned as home practice for most patients. Patients are frequently so sensitized and their musculature and central nervous systems so “cranked up” that a sudden induction of relaxation, whatever the technique, can trigger a panic attack or significant anxiety. Feeling relaxed is so alien to them that it feels “out of control,” strange, or even dissociated. Patients can become obsessed with sensations, so that the first attempt at a relaxation exercise may well be the last. As discussed in Chapter 6, breathing retraining can paradoxically result in further hyperventilation and heightened anxiety when practiced with a sense of urgency or need to control.

  Other potential causes of resistance are covert alcohol or substance abuse, or intense shame about being anxious so that therapy is hidden from the family and home practice is not possible in secret. Such secrecy will very likely lead to treatment failure and must be addressed before any other work can proceed productively.

  Anticipatory Anxiety: When People Need Help Getting over the Hump

  Tell your heart that the fear of suffering is worse than the suffering itself.

  Paulo Coelho

  Anticipatory anxiety is the anxiety that one experiences in anticipation of exposure to frightening triggers. When claustrophobic people worry about taking an elevator later in the day—that is anticipatory anxiety. For people fearful of contamination who worry about having to sit in a dirty seat tomorrow—that is anticipatory anxiety. And if a patient with a fear of public speaking worries that his anxiety will ruin his presentation next week—that is yet another example of anticipatory anxiety.

  This simple phenomenon plays an enormous role in creating and maintaining virtually all anxiety disorders. Anticipatory anxiety drives the desire to avoid contact with sources of anxiety, thereby generating attempts to avoid phobic situations, worries, and obsessions. It is extremely powerful and difficult to eradicate. Anticipatory anxiety is natural and automatic, and often the first and most persistent manifestation of an escalating problem with anxiety. Even when formerly anxiety-producing situations have become routine, there is often a brief “hump” of anticipatory anxiety that persists, sometimes for years. The irony here is that, like every aspect of anxiety, anticipatory anxiety is entirely paradoxical. Since attempts to avoid the anxiety make it stronger, patients feel like they are avoiding in order to reduce anxiety, but the truth is that anticipatory anxiety generates additional anxiety.

  Anticipatory anxiety is often the first and most persistent manifestation of an escalating problem with anxiety.

  Anticipatory anxiety is not a true predictor of how much anxiety someone feels in the actual situation. This fact flies in the face of common sense (as many other aspects of anxiety do). Here is how anticipatory anxiety may be experienced: a patient afraid of overnight travel is scheduled to take an overnight business trip. He becomes intensely anxious when imagining it and might think to himself, “Here I am just thinking about the trip in the comfort of my living room and my anxiety is up to a level 8. If I am that anxious just thinking about it, imagine how panicked I am going to be when I am actually in the hotel, away from home, and can’t return when I want to. I have to cancel the trip.”

  But anticipatory anxiety gives false messages, and patients encounter the majority of their anxiety before and at the very beginning of their contact with anxiety-producing triggers. Remaining in contact with those triggers past that initial surge of anxiety most often yields relative calm if the attitude of acceptance is embraced. Flying is a good example of this phenomenon, because there is no way to avoid anticipatory anxiety. In the case of flying, we tell patients that—if they have a good understanding of the anxiety-producing process and practice applying the therapeutic attitude—then by the time the plane has reached level flight, they will have experienced 80% or more of all their anxiety. By that time, anticipatory anxiety will have largely passed, and they will begin to benefit from the therapeutic effects of exposure.

  Anticipatory anxiety gives false messages.

  Anticipatory anxiety is real anxiety, but very different from panic experienced in the triggering situation (Gray and McNaughton, 2000). There is evidence that anticipatory anxiety and situational anxiety are generated in different parts of our brain, since different classes of medications have different effects on these types of anxiety. SSRIs (selective serotonin reuptake inhibitors) significantly reduce panic, phobic, and obsessional anxiety, but have little effect on anticipatory anxiety. Conversely, the benzodiazepine class of medications (Valium, Xanax, Klonopin, etc.) can reduce anticipatory anxiety, but have relatively little impact (except at impractically high dosages) on panic, phobias, and obsessional disorders (Rosenbaum, Pollock, Jordan, and Pollack, 1996). Anticipatory anxiety is also quick to appear and slow to go away. There are many people who have improved to the point that they no longer feel anxiety when in contact with their feared triggers. Yet these same people can feel considerable fear when anticipating contact with the same triggers.

  Here is an excellent example.

  A man feared getting stuck in traffic while driving over a bridge, feeling trapped, becoming panicky and then doing something impulsive or dangerous, like jumping out of his car or causing a motor accident. We practiced by repeatedly driving across a major bridge that connects Manhattan to other parts of New York City. The traffic on the bridge was literally bumper to bumper in both directions, we could see a sea of red brake lights ahead of us. In keeping with the principle of re-framing anxiety as a positive experience during practice, the patient said, “Well, you may be happy, I’m freaking out here.”

  The span of this particular bridge is curved in such a way so that one can see the entire row of cars coming at us. As we crawled over the bridge span looking at the sea of red brake lights in front of us, by simply shifting the view a little to the left, we simultaneously witnessed the mass of bright headlights coming over the bridge towards us: Red brake lights ahead of us. Headlights to the left of us. In the middle of the span, the patient said, “I’m shocked. This stop and go traffic is my worst nightmare. I thought I would be panicked, but my anxiety really isn’t that bad—maybe a 2 or a 3. I can’t believe it.” Then there was a silence and he continued; “Now you’re going to think I’m really crazy. I told you when I look at the traffic ahead of us, my level is maybe a 2 or a 3. But—listen to this—when I look at the traffic coming back into Manhattan, and I think to myself that pretty soon I’ll be part of that line of cars, my anxiety level goes up to a 7 or an 8. How weird is it that? I’m much more frightened of thinking about what I have to do, even though I’m doing that exact same thing right this minute!”

  This particular situation allowed the patient to “switch” quickly between situational anxiety and anticipatory anxiety. When he looked at the line of cars in front of him, he exposed himself to situational anxiety. When he looked a little to the left and noticed the cars coming back into Manhattan, he experienced anticipatory anxiety. By switching back and forth that way, he was able to isolate and clarify the difference between these two.

  Anticipatory anxiety also increases with indecision. Anticipatory anxiety becomes more pervasive as patients get closer to the feared activity, as they find it harder to just “put off” thinking about it. The anxiety they feel makes them waver in their determination to pursue the activity. So, for example, a patient who is afraid of heights must go to a meeting on the 43rd story of a building. As the day of the meeting nears, he will become ever more aware of his anticipatory anxiety, and he might start to waver about attending the meeting. Can he reschedule the meeting to an office on a lower floor? Should he call in sick that day? Could a colleague take his place in the meeting? This sort of “should I or shouldn’t I?” wavering will continue to increase his anticipatory anxiety. The temptation to avoid the meeting grows, because there will be immediate relief if he cancels, but reinforcing his fear in the long run. On the othe
r hand, a firm commitment to attend the meeting will also produce immediate relief (often to the patient’s surprise) because indecision itself is enormously sensitizing.

  Anticipatory anxiety increases with indecision and proximity.

  The internal debate that drives up anticipatory anxiety will be turned off, and by freeing himself of the “should I or shouldn’t I?” internal conflict, he is more able to stay connected to the present and focus on manageable tasks. It is easier to be on this side of the fence (“I am choosing to avoid”) or on that side of the fence (“I am going to do this no matter how I feel”) than to be on top of the fence trying to decide what to do. The problem is that very few patients believe this until they try it out.

  Suggestions for Managing Anticipatory Anxiety

  Help the patient to label anticipatory anxiety as just that—anticipatory anxiety. It is real anxiety, but it is different from the anxiety experienced when he makes contact with what frightens him. Remind him that anticipatory anxiety is not an accurate indicator of how anxious he will be when encountering anxiety triggers. Perhaps he can recall past instances of this phenomenon. The important issue is to commit to the task no matter how he feels, and not to use anticipatory anxiety as a measure for deciding whether it is worth the risk. Practicing exposure with a willingness to ride out anticipatory anxiety will produce a gradual emerging pattern in which the patient will notice how frequently anxiety during the actual exposure is less than anticipated. In addition, he will notice, to his own surprise, that commitment stops the escalating agitation of the internal debate.