What Every Therapist Needs to Know About Anxiety Disorders
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There are two ways to make this happen. Some people count their breathing. They might breathe in to a count of “four,” and breathe out to a count of “five.” The specific numbers are less important than exhaling to a higher count than inhaling. Another way is to breathe comfortably, and pause for one or two seconds after breathing out, but before starting to take in the next breath. So, the breathing pattern would be “in … out … pause … in … out … pause …”
Here are two helpful hints. First, be sure to exhale prior to breathing in. Many people fill up their lungs, and then forget to empty them before taking another inhalation. Second, exhalation will almost take care of itself automatically if one relaxes and lets the weight of the hand on the belly help to push out the air. There is no need to force anything. It is helpful to think “allow the breath” instead of “take a breath,” and to think “slow and low.”
It is easiest to breathe diaphragmatically while lying on the back. When one is able to breathe this way lying down, gradually—over a period of several weeks—raise into a sitting position. A recliner is perfect here. Otherwise, place more and more pillows under the shoulders and aim for the goal of breathing diaphragmatically while sitting up straight. Once comfortable breathing in this position, it is easy to make the transition to standing and walking.
Do not force the breath. Allow the motion to be gentle and effortless. The goal is not to breathe deeply, but to find a comfortable rhythm that feels natural. Once diaphragmatic breathing becomes ingrained, patients will start to breathe easily, without any effort.
Appendix 4
Anxiety Diary
Here is an example of a memory aid that can be useful if patients are willing and able to record their experiences between sessions. This should be done as close as possible to real time. Each entry should be brief, and include just four elements: date and time, highest level of anxiety, anxious thought, context. Try to include one or two (but no more than three) episodes of anxiety every day. Your patients are creating an anxiety diary, not a regular one. Too much text hides the patterns of information you are trying to understand.
The anxiety diary should look something like Table A4.1.
For anxiety level, put the highest level that occurs during this episode. Encourage your patients to do their best to focus on their anxious thought—it sometimes takes a while to learn to catch them as they go through the mind. The context is just enough information to jog one’s memory when going back and remembering these anxious moments.
Table A4.1 Typical anxiety diary
Index
acceptance 37–52; approaching anxiety mindfully 38–9; embracing anxiety 39–41; essential elements 47–52; exposure 115, 116; the new paradigm 61; overview 37–8; role of the therapist 42–4; teaching metaphors 45–7
acceptance and commitment therapy (ACT) 51, 80
“accepting panic sensations” metaphor 187–8
actively allowing anxiety 51–2
addressing the relevant fears 106–7
adrenaline 23, 41
affect intolerance 20–1, 84
affirmations 70
age of onset 18, 91, 101
agitation 56, 133, 134
agoraphobia 85, 92, 103, 114
alcohol use 47, 95, 97, 148, 152
alexithymia 21, 163
Allen, Robert 105
allowing anxiety 51–2, 73–4
“allowing anxious intrusion” metaphor 187
“allow the ant” metaphor 47
amnesia 57, 86
amygdala: acceptance 40, 42, 51; characteristics of highly anxious people 7; exposure 115, 116; fear-maintaining cycle 29, 30; neuroscience of affect 35; perfectionism 78; role in sensitization 23–8; worry 129
animal phobias 89, 91
answering questions 63–6
anticipatory anxiety 113, 118, 125, 167–71, 186
anxiety: acceptance 47–52; actively allowing anxiety 51–2; anxiety and anxiety disorders 8–9; anxiety-raising and anxiety-lowering thoughts 130–1; and danger 4, 7–8, 117; defining aspects of anxiety disorders 13; expecting anxiety 47–8, 73–4; exposure 108, 117; identifying and treating avoidance 14; labeling anxiety 48–50; out-bluffing 8; paradoxical nature of 34–5, 37, 40; phenomenology of 31–4; as a positive learning experience 108; providing information and answering questions 63–4; role of amygdala in sensitization 25, 26; and sensitivity 15
Anxiety and Depression Association of America (ADAA) 180
“Anxiety channel” metaphor 46
anxiety diary 87, 192
anxiety disorders: advances in treatment 3; anxiety and anxiety disorders 8–9; anxiety feels dangerous 7–8; avoidance, resistance, neutralization 30–1; the basics 7–14; causation 15–16; cause versus maintenance 16–17; characteristics of highly anxious people 7; common sense makes no sense 34; consequences of affect intolerance 20–1; contemporary view 15–36; defining aspects 13; diagnoses 89–104; dilemma of insight 19–20; direct approach to treatment 22–3; fear-maintaining cycle 29–30; getting started 53–66; identifying and treating avoidance 14; illness worries 176–7; overview 3–4; the paradoxical attitude 34–5; phenomenology of anxiety 31–4; primary and secondary gains 17; relapse prevention 181–6; role of amygdala in sensitization 23–8; role of techniques 5–6; scrupulosity 177–8; sensitivity and anxiety 15; studies on causation 17–19; symptoms 4; techniques 67–88; therapeutic attitude of acceptance 37–52; types of triggers 9–13; value of exposure 28–9; value of talking about symptoms 21–2; why details make a difference 1–6
anxiety sensitivity: acceptance 41, 42, 47; anxiety and anxiety disorders 3, 9, 13; dilemma of insight 20; first and second fear 25; getting your feelings out 163; hypersensitivity 33; sensitivity and anxiety 15; unwanted intrusive thoughts 147
“anxious arousal as a gust of wind” metaphor 47
appraisal of thoughts 145–6
arousal: acceptance 38, 40; autonomic arousal 20, 21; fear-maintaining cycle 29, 30; role of amygdala in sensitization 23, 25, 26, 28; value of talking about symptoms 21
assessment 54–6, 118
autonomic arousal 20, 21
autonomic nervous system 34
aviophobia (fear of flying) 2, 102, 114
avoidance: anxiety and danger 8; anxiety maintenance 4; avoidance, resistance, neutralization 30–1; depression 100; determining patient progress 85; direct approach to treatment 22; emotional and behavioral avoidance 146–7; exposure 105, 106, 109–11, 114, 121; identifying and treating 14; phenomenology of anxiety 34; previous coping skills 60; reducing 141; relapse prevention 183, 185
behavioral activation 142
Behavioral Inhibition 18
behavior therapy 60
beliefs about thoughts 147
benzodiazepines 72, 168
BFRBs (body-focused repetitive behaviors) 97
biological fear pathways 23–8, 42, 112, 122
bipolar disorder 84, 133
blood–injury phobias 57, 89, 91
body dysmorphic disorder 97
body-focused repetitive behaviors (BFRBs) 97
Borkovec, T.D. 138
breathing techniques: diaphragmatic breathing 81–4, 190–1; embracing anxiety 40; home practice 167; problems 69, 81
bridge phobia 90, 107, 110, 168–9
“bug on a windshield” metaphor 45
caffeine 92, 124, 136, 148
calculating probabilities 140–1
Carbonell, D. 51, 76, 79, 139
catastrophic thoughts 7, 29, 30, 32, 133
catharsis 156, 162
causation: anxiety disorders 15–16; cause versus maintenance 16–17; studies on causation 17–19; turning the causation arrow around 156–8
CBT see cognitive-behavioral therapies
chest breathing 82, 83
chest pain 49, 64, 176
childrearing 18, 72
“Chinese finger trap” metaphor 187
circadian rhythm 148
Clark, D.A. 144
&nbs
p; classic pitfalls 156–65; getting your feelings out 162–3; misdiagnosing OCD thoughts as a sexual issue 160–2; mistakes in exposure-based treatment 164–5; pathological doubt OCD 158–60; turning the causation arrow around 156–8
claustrophobia 11, 14, 56, 90, 167
cleaning rituals: diagnoses 95, 96, 100; exposure 109, 110, 114, 118, 119; illness worries 176–7
co-compulsing 132, 159–60
Coelho, Paolo 167
coffee 19, 124
cognitive avoidance 110, 111
cognitive-behavioral therapies (CBTs) 3, 99, 180
cognitive compulsions 2, 60, 81, 98, 120–1, 131, 158
cognitive rituals 111
common sense 34
competence-enhancing skills 80–1
complete avoidance 111
compulsions: diagnoses 95, 96–7, 100; exposure 119, 120; getting the details 57; reassurance junkies 173; unwanted intrusive thoughts 153; worry 131
compulsive gambling 57, 97
consciousness 31–4
constricted affect 163
contamination, fear of 11, 57, 95, 176–7
contemporary view of anxiety disorders 15–36; avoidance, resistance, neutralization 30–1; causation 15–16; cause versus maintenance 16–17; common sense makes no sense 34; consequences of affect intolerance 20–1; dilemma of insight 19–20; direct approach to treatment 22–3; fear-maintaining cycle 29–30; the paradoxical attitude 34–5; phenomenology of anxiety 31–4; primary and secondary gains 17; role of amygdala in sensitization 23–8; sensitivity and anxiety 15; studies on causation 17–19; value of exposure 28–9; value of talking about symptoms 21–2
coping techniques: cases of real danger 84; determining patient progress 84–7; diaphragmatic breathing 81–4; effectiveness of techniques 70; emergency coping 71–2; helpful techniques 73–81; previous coping skills 60–1; problems 68, 69, 81; reducing avoidances 110–11; relapse prevention 182, 183; techniques as temporary help 70–1; worry strategies that don’t work 134–6; worry strategies that do work 136–42
correcting basic misinformation 136–7
cortex 24, 25, 26, 27, 28, 35
co-rumination 132, 159
covert avoidances 110–11
Craske, M.G. 112
crisis stabilization 84
danger: and anxiety 4, 7–8, 117; cases of real danger 84; first and second fear 25, 26, 27; labeling anxiety 48; phenomenology of anxiety 32, 34; unwanted intrusive thoughts 145
DBT see dialectical behavior therapy
demoralization 166, 181, 185
depersonalization 41, 63, 83, 92, 137, 187
depression: cases of real danger 84; diagnoses 95, 98, 99, 102; resistance 166; unwanted intrusive thoughts 148; worry 129, 133
derealization 41, 63, 83, 92, 137
desensitization 112, 124
determining patient progress 84–7
diagnoses 89–104; classic pitfalls 156; exposure in diagnosis and assessment 118; generalized anxiety disorder 100–1; obsessive-compulsive disorder 95–100; panic disorder 92–3; social anxiety disorder 93–5; specific phobias 89–91; traumatic anxieties 101–3
Diagnostic and Statistical Manual (DSM-5) xv, xiv, 89, 96
dialectical behavior therapy (DBT) 80, 84
diaphragmatic breathing 81–4, 190–1
diaries 87, 192
diet 39, 128, 134, 136
discipline principle 39
distractions 32–3, 39, 81, 134–5, 141, 146
distress tolerance 72, 84, 123, 166
diurnal cycle 148
dog phobia 89, 91
doubts 98, 158–60
driving, fear of 56, 81, 84, 94, 113, 121, 122
DSM-5 (Diagnostic and Statistical Manual) xiv, xv, 89, 96
eating disorders 97
ego-dystonic worry 127, 132, 150, 151, 153
ego-syntonic worry 120, 127–8, 131, 132, 150
elevator phobia 89, 90, 109, 110, 121, 123, 167
embarrassment 28, 93, 94, 106, 107
emergency coping 71–2, 84
emetophobia (fear of vomiting) 90, 170, 178–9
emotions 19–20, 21, 162–3
empty reassurance 173–4
environmental factors 17, 18
environmental phobias 89
epinephrine (adrenaline) 23, 41
ERP (exposure and response prevention) 118–19
evaluation anxiety 94
excoriation (skin-picking) 97
exercise 81, 134, 185
expecting anxiety 47–8, 73–4
exposure 105–25; acceptance 42; addressing the relevant fears 106–7; anticipatory anxiety 170; anxiety and danger 8; in diagnosis and assessment 118; direct approach to treatment 22; essential elements 106–15; first and second fear 28; in history of psychotherapy 105–6; identifying and treating avoidance 14; incidental practice 121; manageable steps 108–9; memory aids 86, 87; mistakes in exposure-based treatment 164–5; obsessive-compulsive disorder 118–21; the paradoxical attitude 35; planned practice 122–5; reducing avoidances 109–11; reframing anxiety as a positive learning experience 108; the right way to practice 121–5; role of the therapist 115–17; staying on the “right side of the street” 113–15; sufficient duration 111–13; supported exposure 86; unwanted intrusive thoughts 154–5; value of 4, 28–9; worry strategies 138–9, 140
exposure and response prevention (ERP) 118–19
external triggers 15, 91, 113, 114, 115
“faintiness” 64, 76
fear: addressing the relevant fears 106–7; anxiety and anxiety disorders 8–9; anxiety and danger 4, 7–8, 117; autonomic arousal 20, 21; biological fear pathways 23–8, 42, 112, 122; characteristics of highly anxious people 7; diagnosis 3; facing the ultimate fear 140; fear-extinguishing circuits 35; fearful thoughts as predictive 34; fear-maintaining cycle 29–30, 69; first fear 25–6; role of amygdala in sensitization 24–8; second fear 26–8; types of triggers 9, 11
fear of fear 9, 11, 25, 63–4, 115, 156, 184
feelings: acceptance 37, 50; common sense 34; dilemma of insight 19–20; getting your feelings out 162–3; mindful labeling 74; types of triggers 9–11
fight, flight, or freeze reaction 23, 48, 73
figure/ground relationship 79–80
figuring it out 134, 136
first fear 25–6, 40, 50, 107
“float” metaphor 45
flying, fear of: diagnoses 1–2, 89; exposure 110, 114–15; phenomenology of anxiety 31, 34; resistance 168, 171; traumatic anxieties 102
freeze reaction 23, 78
Freud, Sigmund 106, 153, 162
future thinking 7, 73 see also “what if” thoughts
gambling 57, 97
generalized anxiety disorder (GAD): addressing the relevant fears 107; age of onset 18; diagnoses 89, 100–1, 156; fear of flying 2; first and second fear 27; hard-to-treat problems 180; introducing the new paradigm 62; observations 87; providing information and answering questions 65–6; types of triggers 11; worry 126, 129, 131
genetics 9, 17, 18, 19, 55
gentleness principle 39
germs, fear of 1–2, 56, 70, 75, 90, 121, 176–7
Gestalt principles 80
“getting better” 182
getting the details 56–60
getting your feelings out 162–3
goals 5, 61, 122, 123
Grayson, J. 50, 75, 117
guilt 96, 133, 156–7
“gun test” 50, 75, 117
gut feelings 34
habituation 112, 124, 139
hair-pulling (trichotillomania) 97
HALT (hungry, angry, lonely, tired) 85
hand washing 14, 96, 97
harming obsessions 150–3, 157, 158
“headache” metaphor 45
health anxiety 72, 134, 176, 179
heights, fear of 8, 38, 84, 169
history-taking 54
hoarding disorder 97
home practice 166–7
homosexuality 99,
161–2
hope 53–4
hormones 148
hypersensitivity 33
hyperventilation 72, 81, 82, 83, 87, 137, 167
hypervigilance of the mind 148
hypochondria 177
“I am bigger than my thoughts” technique 79–80
IFS (ill, fatigued, stressed) 85
illness worries 176–7
impulse-control disorders 57, 96, 151
incidental practice 121, 125
indecision 169
information, providing 63–6
inhibitory model of exposure 112, 122
initial interview 54–60
injury phobia 57, 89, 91
insight 16–17, 19–20, 58, 132, 134, 136, 156
internal triggers 15, 91, 113, 114, 115
interoceptive exposure 106
interview, initial 54–60
intolerance of uncertainty 33, 158, 159, 177
introspection 38, 147
intrusive thoughts see unwanted intrusive thoughts
ironic process of the mind 39, 41, 70, 135, 148
irritable bowel syndrome 101
journals 86, 87
“just right OCD” (obsessive compulsive disorder) 96
Kabat-Zinn, Jon 39
“kids fighting in the rear seat” metaphor 46
kleptomania (impulsive stealing) 57, 96, 97
Klonopin 168
labeling anxiety: acceptance 47, 48–50; exposure 116–17; first and second fear 25–6, 27, 28, 29; labeling level of distress 117; mindful labeling 74–5; summary of labeling process 189; worry strategies 138
lateness 58
Leahy, R. 130
“lean with the motorcycle” metaphor 187
life stresses 18, 102
lifestyle change 134, 136, 181–2
“magic feather” 67–8
maintenance of anxiety disorders 16–17
major depression 84, 133, 148
marijuana 92
marriage counselling 97–8
MBSR (mindfulness-based stress reduction) 80