What Every Therapist Needs to Know About Anxiety Disorders

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What Every Therapist Needs to Know About Anxiety Disorders is an integrated and practical approach to treating anxiety disorders for general psychotherapists. What is new and exciting is its focus on changing a patient’s relationship to anxiety in order to enable enduring recovery rather than merely offering a menu of techniques for controlling symptoms. Neither a CBT manual nor an academic text nor a self-help book, What Every Therapist Needs to Know About Anxiety Disorders offers page after page of key insights into ways to help patients suffering from phobias, panic attacks, unwanted intrusive thoughts, compulsions, and worries. The authors offer a rich array of therapist– patient vignettes, case examples, stories, and metaphors that will complement the work of trainees and experienced clinicians of every orientation. Readers will come away from the book with a new framework for understanding some of the most frustrating clinical challenges in anxiety disorders, including “reassurance junkies,” endless obsessional loops, and the paradoxical effects of effort. Martin N. Seif, PhD, ABPP, cofounded the Anxiety and Depression Association of America and was a member of its board of directors from 1977 through 1991. Dr. Seif is associate director of the Anxiety and Phobia Treatment Center at White Plains Hospital and a faculty member of New York Presbyterian Hospital/Cornell Medical School. He maintains a private practice in Manhattan and Greenwich, Connecticut, and leads Free- dom to Fly, an airport-based program for fearful ﬂ iers. Sally Winston, PsyD, cofounded the Anxiety and Stress Disorders Institute of Maryland, where she is codirector. She is the inaugural recipient of the Jerilyn Ross Award of the Anxiety and Depression Association of America and has decades of experience treating patients, training therapists, and advocating for public awareness of anxiety disorders Downloaded by [New York University] at 01:46 15 August 2016 and advances in their treatment. She has given training workshops in the US, Canada, Asia, and Africa. This page intentionally left blank Downloaded by [New York University] at 01:46 15 August 2016 What Every Therapist Needs to Know About Anxiety Disorders Key Concepts, Insights, and Interventions

Martin N. Seif and Sally Winston Downloaded by [New York University] at 01:46 15 August 2016 First published 2014 by Routledge 711 Third Avenue, New York, NY 10017 and by Routledge 27 Church Road, Hove, East Sussex BN3 2FA Routledge is an imprint of the Taylor & Francis Group, an informa business © 2014 Martin N. Seif and Sally Winston The right of Martin N. Seif and Sally Winston to be identiﬁ ed as authors of this work has been asserted by them in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. The purchase of this copyright material confers the right on the purchasing institution to photocopy pages which bear the photocopy icon and copyright line at the bottom of the page. No other parts of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice : Product or corporate names may be trademarks or registered trademarks, and are used only for identiﬁ cation and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Seif, Martin N. What every therapist needs to know about anxiety disorders : key concepts, insights, and interventions / by Martin N. Seif and Sally Winston. pages cm Includes bibliographical references and index. 1. Anxiety disorders. 2. Anxiety disorders—Treatment. 3. Anxiety— Physiological aspects. I. Winston, Sally. II. Title. RC531.S37 2014 616.85'22—dc23 2013040802

ISBN: 978-0-415-82898-7 (hbk) ISBN: 978-0-415-82899-4 (pbk) ISBN: 978-0-203-51884-7 (ebk) Typeset in Minion by Apex CoVantage, LLC Downloaded by [New York University] at 01:46 15 August 2016 To David Seif and Emily Seif To Frank and Phyllis Margolick Downloaded by [New York University] at 01:46 15 August 2016 This page intentionally left blank Downloaded by [New York University] at 01:46 15 August 2016 Contents

List of Figures and Tables xi Preface xiii Acknowledgments xvii

1 Why Details Make a Difference 1 Introduction 3 Reasonable Goals 5 Techniques Are Not the Answer 5

2 The Basics 7 Three General Characteristics of Highly Anxious People 7 Anxiety Feels Dangerous 7 How an Anxiety Disorder Differs from Plain Anxiety 8 The Three Types of Triggers 9 The Deﬁ ning Aspect of an Anxiety Disorder 13 The Basic Principle: Identify and Treat Avoidance 14

3 A Contemporary View of Anxiety Disorders 15 Sensitivity and Anxiety 15 A Discussion of Causation 15 Insight: Cause Versus Maintenance 16 Primary Versus Secondary Gains 17 Downloaded by [New York University] at 01:46 15 August 2016 Studies on Causation 17 The Dilemma of Insight 19 Consequences of Affect Intolerance 20 The Value of Talking about Anxiety Symptoms 21 A Direct Approach to Treating Anxiety Disorders 22 The Neurological Perspective: Role of the Amygdala in Sensitization 23 The Value of Exposure 28 The Fear-maintaining Cycle 29 viii Contents Avoidance, Resistance, Neutralization 30 The Phenomenology of Anxiety: Anxiety Alters Consciousness 31 With Anxiety, Common Sense Makes No Sense 34 The Paradoxical Attitude 34

4 The Therapeutic Attitude of Acceptance 37 Approaching Anxiety Mindfully 38 Embracing Anxiety 39 The Role of the Therapist 42 Teaching Metaphors 45 Essential Elements to the Therapeutic Attitude of Acceptance 47

5 Getting Started 53 The First Contact Must Instill Hope 53 Immediate Help: Embed Information in Your Questions 54 Get the Details 56 Find Out What They Have Tried 60 Introduce the New Paradigm: Offer a More Profound Change Than Techniques 61 Provide Information and Answer Questions 63

6 Techniques Your Patients Have Probably Already Tried and Misunderstood: What They Are and How to Make Them Helpful 67 The Problem with Techniques 67 How Techniques Can Be Helpful 70 Techniques Are Temporary Help, Not Goals 70 Emergency Coping 71 Techniques That Can Be Helpful: “What Is,” Not “What If?” 73 Anxiety Management Tricks That Easily Backﬁ re 81 Diaphragmatic Breathing 81 Anxiety Management in Cases of Real Danger, Not False Messages 84 Some Issues in Determining Patient Progress 84 Downloaded by [New York University] at 01:46 15 August 2016 7 Diagnoses: An Annotated Tour of the Anxiety Disorders 89 Speciﬁ c Phobias 89 Panic Disorder 92 Social Anxiety Disorder 93 Obsessive-compulsive Disorder 95 Generalized Anxiety Disorder 100 Traumatic Anxieties 101 Contents ix 8 Exposure: The Active Ingredient 105 Exposure in the History of Psychotherapy 105 Exposure Therapy Is More Than “Just Do It” 106 Role of the Therapist During Exposure: What to Say and Do 115 Exposure Can Be an Intrinsic Part of Diagnosis and Assessment 118 Exposure for Patients with Obsessive-compulsive Disorder: Exposure and Response Prevention 118 OCD with Purely Mental Obsessions and Compulsions 119 The Right Way to Practice Exposure 121

9 The Curious Case of Worry 126 Varieties of the Worry Experience 127 A Caveat: Generalized Anxiety Disorder—Rarely a Stand-alone Diagnosis 129 Worry Is Not an Affect: It Is Thinking—And Thoughts Are Not Facts 129 Productive Versus Unproductive Worry 130 An Important Insight: Some Worry Thoughts Raise Anxiety and Some Lower It 130 The Therapeutic Perspective on Worry 131 About Worry and Time: The Role of Urgency 132 Evaluating Worry 132 Rumination: A Different Kind of Worrying 133 Coping with Worry: What Doesn’t Work 134 Coping with Worry: Strategies That Work 136

10 Unwanted Intrusive Thoughts: All Bark and No Bite 144 How Unwanted Intrusive Thoughts are Maintained 144 Living with Joy Despite Unwanted Intrusive Thoughts 149 Treating Unwanted Intrusive Thoughts 150 Issues for Therapists: Varieties of Presentation 150 Issues for Therapists: Therapist Anxiety and a New Construct 153 Exposure to Unwanted Intrusive Thoughts 154 Downloaded by [New York University] at 01:46 15 August 2016

11 Classic Pitfalls: Common Mistakes Non-Specialists Make 156 Pitfall Number 1: Turning the Causation Arrow Around 156 Pitfall Number 2: Pathological Doubt OCD—Misidentifying OCD Thoughts as Issues and the Seduction of Co-compulsions 158 Pitfall Number 3: Intrusive Thoughts or Doubts about Sexual Orientation or Identity—Misdiagnosing OCD Thoughts as a Sexual Issue 160 x Contents Pitfall Number 4: Get Your Feelings Out 162 Pitfall Number 5: Mistakes in the Application of Exposure-based Treatment 164

12 Another View of Resistance: Issues that Interfere with Treatment 166 When People Come Back Without Doing Home Practice 166 Anticipatory Anxiety: When People Need Help Getting over the Hump 167 The Reassurance Junkie: When People Are Constant Callers 171

13 Some Hard to Treat Problems: A New Perspective 176 Illness Worries (Health Anxiety and Hypochondria) 176 Scrupulosity (Religious and Secular) 177 Emetophobia (Fear of Vomiting) 178 Paruresis (Shy Bladder Syndrome) 179

14 Relapse Prevention 181 Anxiety Disorders Are Chronic Intermittent Disorders: They Come Back 181 The Most Enduring Recovery Is When Symptoms Do Not Matter 182 Search and Destroy: The Role of Subtle Avoidance 183 The Role of Psychotherapy in Relapse Prevention 183 The Proper Place for Stress Management 184 Finally 186

Appendix 1 Additional Metaphors 187 Appendix 2 A Summary of the Labeling Process That Can Be Given to Patients 189 Appendix 3 How to Learn Diaphragmatic Breathing 190 Appendix 4 Anxiety Diary 192 Index 193

Downloaded by [New York University] at 01:46 15 August 2016 Figures and Tables

Figures 2.1 Three types of triggers 10 3.1 Two routes to the amygdala 24 3.2 First fear is triggered 26 3.3 The labeling decision 26 3.4 Second fear labeled danger 27 3.5 Second fear labeled anxiety 29 3.6 Fear maintaining cycle 30

Tables 8.1 Different kinds of avoidance 111 8.2 Comparison of planned and incidental practice 125 A4.1 Typical anxiety diary 192 Downloaded by [New York University] at 01:46 15 August 2016 This page intentionally left blank Downloaded by [New York University] at 01:46 15 August 2016 Preface

We are Drs. Marty Seif and Sally Winston, psychologists who specialize in treating anxiety. Since the late 1970s, we have treated thousands of people with anxiety disorders. Dr. Seif is one of the seven founders of the Anxiety and Depression Association of America, which began in 1977. Dr. Winston co-founded the Anxiety and Stress Disorders Institute of Maryland, in 1978. This was before the term “panic disorder” was in the DSM and anxiety specialization was in its infancy. We were both trained as psychodynamic and interpersonally oriented clinicians before learning about cognitive or behavioral therapies. We learned from each other, from other early pioneers, and from our patients, and we helped to create what has become the gold standard treatment for anxiety disorders. We have integrated into our work much of the extensive research done in the last 30 years to improve therapy for people with anxiety disorders. State of the art treatment of anxiety has changed rapidly and radically, and it is almost impossible for non-specialists to keep abreast of new ﬁ ndings. One author, while preparing a lecture on OCD for a Grand Rounds in 2010, realized that everything taught about OCD in the 1970s is now understood to be incorrect. Additionally, both authors have made their own clinical discoveries and developed ways to approach certain issues that could be helpful to others. Our goal is to share with psychotherapists of all backgrounds and theoretical orientations the key concepts that we, as specialists, have learned over the course of our professional lives dedicated to understanding and treating anxiety disorders.

Organization We provide information about anxiety and anxiety disorders before going into specif- Downloaded by [New York University] at 01:46 15 August 2016 ics to t reat symptoms. A guiding principle is that the more we can educate a patient about anxiety, the less bewildered and afraid he becomes. We therefore encourage specifi c guided reading, asking questions, and seeking understanding of what is happening in the brain and the body and the mind. It is our responsibility to answer questions, offer explanations, and correct misinformation. Most people with intense anxiety are concerned that there is something profoundly and irreversibly wrong with their psyche or their body. There is an enormous therapeutic benefi t in talking to someone who is knowledgeable, understands their experiences, educates them about what is happening, and also provides them with a model of what is going on in their mind that is in clear and accessible language. xiv Preface For these reasons, the fi rst parts of this book talk about anxiety from a more theoretical point of view, giving some basic facts as well as the overarching principles upon which they are anchored. Learning about something intrinsically changes our experience of it. When talking about anxiety with patients, there are often new perspectives, new realizations, and resultant therapeutic benefi ts. For example, it is not uncommon for non-psychotic patients who experience repeated panic attacks to become terrifi ed that they are losing their mind. Simply educating them that they are experiencing panic attacks, which—while profoundly uncomfortable—are treatable and have nothing to do with psychosis, often results in a marked decrease in anxiety. So it is frequently unrealistic to make a distinction between learning about anxiety, and learning how to manage it. The early chapters provide the basic information that forms the core of the assessment and psycho-education phase of treatment. In subsequent parts, we address specifi c topics related to anxiety and some interven - tions that have been shown to be effective approaches. These chapters are fi lled with practical suggestions of what to say and do, as well as numerous patient–therapist vignettes to illustrate how to apply basic principles and some of their nuances. We look at exposure-based interventions in detail and explore common misconceptions about the use of anxiety management techniques in both professional and self-help treatment. We examine intrusive thoughts and toxic worry, and some particularly challenging conditions such as anticipatory anxiety, health anxiety and hypochondriasis, scrupulosity, pathological doubt, and reassurance “junkies.” We also look at challenges that commonly plague psychodynamically trained psychotherapists. Finally, we will address relapse prevention, which, in our view, encompasses stress management, lifestyle changes, and relevant psychodynamic, psychosocial, and family therapies.

Scope Traditionally, anxiety disorders have included all those conditions in which anxious arousal, phobias, panic attacks, worry, obsessions, and compulsions are the central features. These form the focus of this book. However, despite the fact that anxiety is a prominent feature of both acute and post-traumatic stress disorders, the American Psy- chiatric Association has reorganized the structure of the Diagnostic and Statistical Man- ual (DSM-5), and removed trauma-based disorders from the classiﬁ cation of anxiety disorders. This is because most experts see the fear-based symptoms as part of a larger complex of shame, anger, guilt, grief, loss, dissociation, emotional dysregulation, numb-

Downloaded by [New York University] at 01:46 15 August 2016 ing, and moral injury. And there is emerging evidence that a different set of neurological changes occur in response to trauma (Yehuda and LeDoux, 2007) as opposed to the other types of anxiety disorders. Therefore, whenever dealing with anxiety that has been triggered by a traumatic experience, it is important to obtain a detailed description of the entire symptom picture, which includes: changes in mood and worldview; dissociative and re-experiencing phenomena such as ﬂ ashbacks and sleep disruptions. If the symptom conﬁ guration is primarily anxiety and is, for the most part, functionally no longer associated with the original trauma, then the insights and interventions in this book can be extremely helpful. How- ever, if the symptom picture presented is the full syndrome of post-traumatic stress disorder, including re-experiencing phenomena and shattered illusions of safety—acute or Preface xv enduring, simple or complex, originating in childhood or adulthood—then different approaches may apply. Concepts in this book may well help with the anxiety symptoms that have developed, but there is a larger arena for interventions that lies outside of the scope of this book. In a controversial move, DSM-5 places obsessive-compulsive disorder (OCD) and a variety of related disorders in a chapter separate from other anxiety disorders. This chapter includes OCD, body dysmorphic disorder, and hoarding disorder, as well as hair pulling and skin-picking disorders. This was based partly on emerging biological research demonstrating somewhat different fear circuitry and, possibly, separate genetic trans- mission mechanisms (Stein, Fineberg, Bienvenu, Denys, Lochner, Nestadt, … Phillips, 2010). OCD is placed immediately next to the anxiety disorders chapter because of the high co-occurrence of OCD with other anxiety disorders (Brown, Campbell, Lehman, Grisham, and Mancill, 2001). We continue to address OCD in this book, as the general principles about what maintains OCD and how best to treat it remain unchanged by this nosological decision. Both authors are psychologists who do not prescribe medication, but recognize that psychopharmacology is a legitimate treatment modality for anxiety disorders. We refer many patients for psychoactive medications, particularly if they are too depressed or overwhelmed by their symptoms to be able to make use of the approaches we offer. Despite its standing in the treatment of anxiety disorders, medication will not be addressed in this volume.

References Yehuda, R. and LeDoux, J. (2007) Response variation following trauma: A translational neuroscience approach to understanding PTSD. Neuron 56(1) 19–32. Stein, D. J., Fineberg, N. A., Bienvenu, O. J., Denys, D., Lochner, C., Nestadt, G., … Phillips, K. A. (2010) Should OCD be classiﬁ ed as an anxiety disorder in DSM-V? Depression and Anxiety 27(6) 495–506. Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, J. R., and Mancill, R. B. (2001) Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample Journal of Abnormal Psychology 110(4) 585–599. Downloaded by [New York University] at 01:46 15 August 2016 This page intentionally left blank Downloaded by [New York University] at 01:46 15 August 2016 Acknowledgments

No book is written without the support of many people, but I wish to specifi cally express my appreciation to Claire Weeks, Manny Zane, and Herbert Fensterheim, who many years ago introduced me to new perspectives on anxiety. Special thanks to Ron Doctor for his friendship and support, and for starting me out in this project. ADAA has had a tremen- dous infl uence on my professional life, and I have benefi ted much from the work of Reid Wilson and the late Jerilyn Ross. I thank Anna Kaltenboeck, Jerry Gerber, and Sigalit Levy for their editing suggestions, and Molly Winston for her graphics. I am indebted to my learned friend and colleague Carl Robbins for his reading and valuable comments, and thank Kimberly Morrow for her careful editing. My patients teach me and give me pleasure every day, and I am indeed fortunate to have them in my life. I am grateful to my collaborator Sally Winston for trusting me enough to let the world—and not just her colleagues—glimpse her gifts and sensitivity as a clinician. And I thank Laura Goulden for her confi dence, encouragement, support, and gracious acceptance of my hectic work schedule. Martin Seif

I would like to acknowledge the infl uence of a number of individuals who helped to launch my enduring interest in the anxiety disorders, including Douglas Hedlund, Zelda Milstein, and the late Jerilyn Ross whose leadership and advocacy for those suffering from anxiety disorders was of profound importance to the fi eld. My fi rst reading of Hope and Help for your Nerves by Claire Weekes was a paradigm shift for me, preceding the “third wave” of CBT innovation by several decades. For help with the manuscript: my thanks to Ruthellen Josselson for setting us on the right track and to Kimberly Morrow, for her generous editing suggestions. For constant encouragement to explore new ideas and to

Downloaded by [New York University] at 01:46 15 August 2016 think carefully about the implications of what I am saying, I am grateful to know and appreciate Carl Robbins. I never stop learning from Reid Wilson. Thanks to Molly Win- ston for her creative graphics. It would not have been possible for me to complete this work without the daily help of my co-director and closest colleague Steven Shearer. The gifted therapists of the Anxiety and Stress Disorders Institute of Maryland are my support and pleasure. Most importantly, it is my patients who have taught me almost everything about what it is like to have an anxiety disorder and what helps and what doesn’t help to transcend it and to thrive. I want to thank Marty Seif for his friendship, quiet wisdom, and his conﬁ dence in me. And to my husband Morton Winston who has been trying to get me to write for 40 years, and who has endured the process so patiently, thank you. Sally Winston This page intentionally left blank Downloaded by [New York University] at 01:46 15 August 2016 1 Why Details Make a Difference

Flight 702 from New York to Los Angeles has boarded. Six frightened ﬂ iers are seated in row 17, seats A through F. Each responds “yes” to the following.

• Are you afraid to fl y? • Are you anxious anticipating a fl ight? • Would you prefer to avoid fl ying if you can? • Are you feeling anxious right now?

In seat 17A, the passenger is thinking “I don’t know if I can stand it when the doors close. I am going to feel trapped, I won’t be able to leave, I am going to get that unbearable overwhelming rapid heart rate and I won’t be able to breathe right and I don’t know if I can control my reaction and I could just either go crazy or even cause myself a heart attack. Are there straitjackets in case I lose control? What if I lose it and open the door in the middle of the fl ight? I wonder if there is a defi brillator on the plane.” This person has panic disorder. He is terrifi ed of panicking while on the plane, and his fear of fl ying is a fear of experiencing a panic attack. Seat 17B is occupied by someone who feels sensations similar to the fi rst person— rapid heart rate, diffi culty breathing—but the cognitive focus is interpersonal rather than intrapsychic. He is thinking “I am getting anxious and I feel like I might throw up and get pale and fi dgety and the person next to me is going to turn to me and say ‘are you alright?’ and what if I can’t talk properly and by the time we get to our destination, everyone in the plane will know there is a nutcase on this plane. I don’t know if I can keep my anxiety hidden. And what if a fl ight attendant comes over to try to help me—then

Downloaded by [New York University] at 01:46 15 August 2016 everyone in this whole plane will be focusing on me and wondering what is going on. What if I start to look weird and crazy to them? What if someone thinks I am a terrorist?” This person is not primarily afraid of the anxious feelings, but of the fact that they could show and someone will judge him badly, exposing him to humiliation, inade- quacy, and shame. This person’s fear of fl ying is an aspect of his social anxiety disorder. In seat 17C is someone who is also incredibly upset with the following thoughts: “I know that they clean the planes in a deep way with antibacterial solution every two weeks and that they spray room freshener into the air when they are on the ground because I did the research, but in between fl ights, they just pick up the trash. I have really been trying to keep my arms and hands off the seat rest because you never know who was sitting here and what germs they could have—it could even be AIDS—and they are only 99% 2 Why Details Make a Difference sure that it can’t be transmitted this way and you can’t be sure that this passenger did not have an open wound on their hand anyway. And all of a sudden I am thinking that I may have inadvertently touched the armrest when I was listening to the pilot announcement and OMG what if I get sick and transmit it to my kids? And how about that virus that is going around? I’m trying not to breathe too deeply on this plane, because the inside of the cabin is just one big incubator of germs, and I don’t want them inside of me.” This person, who in former times might have been incorrectly labeled “germophobic,” suffers from obsessive-compulsive disorder (OCD). In repeated attempts to lower her anxiety, she tries to avoid exposing herself to germs, and at the same time continually reassures herself that she is overreacting. This self-talk, which comforts her only partially and only for a short time, is called cognitive compulsions. While the idea of the plane crashing (and other dangerous possibilities) may also scare her, right now she is focused on the possibility that being on this fl ight might harm herself and her children. In the next seat over, seat 17D, sits someone whose older brother went down in a plane in Vietnam when she was a child. Every time she has to fl y, she has weeks of dreams about fi ery crashes, reliving that horrible moment when her mother told her that her brother was dead. She is hyperventilating right now, feels overwhelmed with fear and grief, and would rather be anywhere else. Half of her is presently on the plane and half of her is in the past. For this person, fl ying triggers intensely painful memories of her previous trauma— memories that come alive, feel like real life, and crowd out the present when she encoun- ters triggers connected to them. This woman suffers from post-traumatic stress disorder. Seat 17E is occupied by someone worried about the plane crashing and whether or not the pilot has a hangover, and whether or not that rattling sound underneath her seat is normal. But she is also worried that she may have a scratchy throat and what if it ruins her vacation, and what if the airline loses her baggage and what if the person who is supposed to pick her up gets stuck in traffi c or forgets. And she just learned that she paid more for her ticket than the OCD person in seat 17C and does that mean she should cancel her plan to go to the expensive restaurant, and—wow—are her muscles going to be sore after sitting for six hours! This person is in an ongoing and toxic worry state, known as GAD, generalized anxiety disorder, a relentless and rambling set of “what if” worries, which is characterized by—in addition to worry—muscle tension, autonomic arousal, anxious mood, and episodes of panicky feelings. And fi nally in seat 17F is the person with aviophobia—fear of fl ying—that is a spe-

Downloaded by [New York University] at 01:46 15 August 2016 cifi c phobia (formerly called simple phobia) in which the fear is of an external thing going terribly wrong. This person does not worry as relentlessly as someone with GAD, nor does he obsessively and compulsively check on aspects of his life, like someone with OCD. This person is focused primarily on plane safety, the possibility of weather making his fl ight more dangerous, how his children might survive his death, and the horror of the image of going down during the crash. We use fear of fl ying in this example, but the same variety of experience and complexity of phenomenology is true for all anxiety presentations. All these people are “phobic” of fl ying, yet each is going through a very different experience, and will need differing types of treatment. While each may need to take a fl ight eventually for exposure to feared thoughts, sensations, memories, and emotions, the work to get there will be different Why Details Make a Difference 3 indeed. This is why details make such a difference. Similar fears may require dramatically different treatment. “Feeling anxious” can mean profoundly different things for different people, and understanding the range of experience informs accurate diagnosis and guides how to help at every step of the way.

Introduction Anxiety disorders are the most common psychological problem (Robins and Regier, 1991), and are also the most treatable (Barlow, 2004). The rise of effective therapy for these disorders is relatively new, and the media have seized on modern approaches as a panacea for anxious people. While cognitive-behavioral therapies (CBTs) have made signifi cant advances in this fi eld, most patients with an anxiety disorder cannot be fully treated with just a few simple applications of CBT principles. However, we believe that psychotherapists of all backgrounds and training can add the contributions of anxiety disorder specialists to their own repertoire. We intend to provide keys to better understand and help highly anxious patients. We present effective ways to conceptualize and treat people with overwhelming anxiety, so that their lives will no longer be run by anxiety, and there will be room for joy and emotional fl exibility. People with anxiety disorders can be extraordinarily “good” patients. Unless in the midst of an acute anxiety episode, they are usually polite, cooperative, compliant, and responsible. They are interesting to be with. Unfortunately, their anxiety symptoms often do not improve. One therapist called them annuities, in that some continue to come and pay for treatment for the rest of our professional lives. Treating a person with severe anxiety requires augmenting some of the traditional psychotherapeutic assumptions with alternative approaches that can be more helpful. Here are some key points. It is of primary importance to have a clear idea of what patients fear, since particular fears lead to differing forms of treatment. There are great benefi ts in accurately diagnosing and conceptualizing each anxiety disorder. Specifi c differential diagnoses can be essential—such as distinguishing anxiety from agitation, thoughts from impulses, obsessions from rumination—because the approach is quite different for each of these. For example, OCD can look like a multitude of different disorders— from psychosis to depression to agoraphobia—and the proper diagnosis informs how best to proceed. The popular notion that CBT involves “changing the thought in order to change the

Downloaded by [New York University] at 01:46 15 August 2016 feeling” is fallacious. A more accurate formulation of modern anxiety treatment stresses better tolerance of distressing feelings, focusing not on changing thoughts to change feelings, but on how patients tolerate and evaluate what they think and What matters most is feel. What matters most is not what they feel, but how not what they feel but they feel about what they feel. This concept— what they feel about what sometimes called “anxiety sensitivity”—is at the they feel. foreground of contemporary anxiety treatment. People with anxiety disorders are sensitive to and afraid of anxiety. The goal is to change the relationship between the patient and anxiety symptoms, reducing distress, and promoting psychological flexibility. 4 Why Details Make a Difference There are many times when responding to a highly anxious patient in a reassuring manner actually reinforces and empowers anxiety. When treating people with an anxiety disorder, once a safe therapeutic relationship has been established, their immediate comfort is not always our goal. In fact, when striving for present comfort becomes predomi- nant, it often leads to increased anxiety in the long run. There is a signiﬁ cant element of paradox when treating anxiety disorders. There is an art and skill to integrating the approach presented in this book with one that is also supportive and empathic. The goal is to relieve suffering, as opposed to just providing transitory comfort. Anxiety motivates avoidance, which in turn keeps the anxiety strong. So when dealing with highly anxious patients, the therapist sometimes needs to take a more direct approach and act like an educator or coach. Especially at the start of treatment, there is nothing more valuable than taking a teaching role and directly explaining what is happening physiologically and mentally to bewildered patients. It gives people courage and decreases shame and bewilderment when they know what is happening. Therapists who focus primarily on dynamic issues and the therapeutic dyad may doubt our stance, but it is our experience that the therapeutic process and patient–therapist relationship is strengthened, not compromised. There is a widely held view that anxiety symptoms have meanings and are manifestations of underlying causes, and that uncovering the meaning will result in the elimination of symptoms. However, intense anxiety symptoms show most reduction when the processes that maintain them, not their original causes, are addressed directly. The most effective route is to ﬁ rst help patients manage the anxiety before focusing on any uncovering processes. The best roles for the pursuit of insight and meaning in the overall treatment of an anxiety disorder will be elaborated. Finally, it is primarily avoidance of all kinds—cognitive, behavioral, and emotional— that fuels and maintains anxiety (Taylor and Asmundson, 2004). This means that exposure to the experience of anxiety is essential for effective therapy (Hayes, Wilson, Gifford, Follette, and Strosahl, 1996). We provide a framework for integrating exposure into treatment and for understanding and teaching anxiety management tools and attitudes in a way that can provide a lasting change in the patient’s quality of life. Exposure can add to the complexity of the therapeutic relationship, since patients will need to feel particularly safe within the therapy. A trusting and safe relationship forms the emotional platform upon which patients allow themselves to risk exposure to anxious triggers, and the resultant discomfort and uncertainty. Anxiety creates a sense of danger, and that danger is best tolerated within the context of a positive relationship

Downloaded by [New York University] at 01:46 15 August 2016 with the therapist. It is a challenge for any therapist to maintain a sense of safety within the therapeutic relationship while deliberately encouraging the patient to undertake feeling as if they are in danger; as therapists, our instincts push us to reassure and comfort patients whenever they are uncomfortable. Anxiety disorder therapy requires that we must frequently resist these instincts. The vast majority of time, however, treating anxiety disorders will be similar to treating patients with other problems. Anxiety disorders occur and are maintained within contexts. Most of the work identifying triggers and noticing patterns of emotional and cognitive factors is akin to teaching patients how to be aware of their inner life when anxiety is making it diffi cult for them to do so. Why Details Make a Difference 5 Reasonable Goals Patients often wish there were some magic wand that would erase their anxieties quickly. But erasing their anxiety doesn’t mean that they are recovered. Anxiety disorders are chronic intermittent disorders (Kessler, Ruscio, Shear, and Wittchen, 2010). They tend to recur because they have a strong biological underpinning (Hettema, Neale, and Kendler, 2001). If patients don’t know how to manage anxiety, if they don’t understand how to face anxious arousal and thoughts, then they will always be afraid Anxiety disorders are of their recurrence. In that case, even the complete chronic intermittent absence of symptoms would not meet our defi ni- disorders. They tend tion of recovery. Recovery requires that patients feel to recur because they confi dent in their ability to manage anxiety whenever have a strong biological it shows up, and to be willing to explore whatever underpinning. aspects of life they wish, free of the fear of anxiety. The less bothered they are by whatever anxiety occurs, the closer they come to what we mean by recovery. Recovery doesn’t mean there will be no anxiety, since that is a normal part of growth, excitement, and change. It is when anxiety gets out of hand, when it limits where one goes, interferes with relationships, identity and mood, when it causes additional suffering—that is the sort of anxiety we address in this book.

Techniques Are Not the Answer This is not a book about techniques for reducing anxiety. The following story illustrates the place that techniques hold in the overall treatment:

A man couldn’t get his furnace to work properly. He had heating experts come to his house, each would replace a part or two, and within 24 hours the furnace would always stop working. Finally, a friend recommended “a real genius.” This man came to the house and spent 20 minutes looking here, tapping there, and listening to all the sounds that came out of the heating system. He then took a hammer and struck it vigorously on the outside of the furnace. Immediately, it started working perfectly. The owner was amazed. “How much do I owe you?” he asked. The repairman replied, “Let’s make sure that takes care of it. I’ll check on you next week.” A week later the repairman called and the furnace was still purring away perfectly. Then Downloaded by [New York University] at 01:46 15 August 2016 the owner got a bill for a thousand dollars. Astonished at the price, he called up the repairman and said, “That’s ridiculous. All you did was give the furnace a bang. That isn’t worth anything like a thousand dollars!” The repairman replied, “Hold off, I’ll send you an itemized bill.” Three days later it arrived in the mail. It said: Charge for banging on your furnace to ﬁ x it: $1.00 Charge for knowing where to bang on your furnace to ﬁ x it: $999.00

Anyone can bang on a furnace, just like anyone can use anxiety management techniques. Techniques themselves are neither a help nor a hindrance, and are trivial 6 Why Details Make a Difference compared with the knowledge required to utilize them properly. A technique is merely a tool, and the real work is learning how to use it to ensure an optimal outcome. Our approach is evidence informed, but not a formula or protocol for approaching patients. It is full of ideas of things to say and do in session, and it discusses a wide range of techniques, but, more importantly, it is about attitude. It is about helping people to change their attitude, reactions, responses, and beliefs about the contents of their minds and how their bodies feel. It is about changing the relationship between patients and their anxiety. An essential point is that anxiety symptoms cannot be vanquished with effort. Anything—no matter how calming it may seem to be—if done to suppress or ﬁ ght, counteract or distract, analyze or get rid of, keep at bay or otherwise avoid these feelings will ultimately Anxiety symptoms cannot fall short of ending anxiety. Anything done with be vanquished with effort. urgency and intensity will fall prey to the paradoxical nature of the symptoms. Anxiety is best embraced and allowed. Otherwise, it will try to overpower, ﬁ ght to take over, and cause additional suffering. So we as therapists must climb on board and embrace this attitude as well: techniques are of limited help (and can be counter- productive) unless one knows the proper attitude with which to apply them. Despite the wish to comfort and contain our patients’ immediate distress, we guard against the misapplication of techniques—not only those we suggest, but also ones patients may already be using unproductively. It may take some time to demonstrate the power of this attitudinal shift, but the results can be transformative.

References Robins, L. N. and Regier, D. A. (1991) Psychiatric disorders in America: The epidemiologic catchment area study . New York, NY: Free Press. Barlow, D. H. (2004) Anxiety and its disorders: The nature and treatment of anxiety and panic. New York, NY: The Guilford Press. Taylor, S. and Asmundson, G. J. G. (2004) Treating health anxiety: A cognitive-behavioral approach. New York, NY: The Guilford Press. Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., and Strosahl, K. (1996) Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology 64(6) 1152–1168. Kessler, R. C., Ruscio, A.M., Shear, K., and Wittchen, H. U. (2010) Epidemiology of anxiety disor-

Downloaded by [New York University] at 01:46 15 August 2016 ders. Behavioral neurobiology of anxiety and its treatment. Heidelberg, Germany: Springer 21–35. Hettema, J. M., Neale, M. C., and Kendler, K. S. (2001) A review and meta-analysis of the genetic epidemiology of anxiety disorders. American Journal of Psychiatry 158 (10) 1568–1578. 2 The Basics

Three General Characteristics of Highly Anxious People The vast majority of highly anxious patients will share three characteristics. The ﬁ rst characteristic is sensitivity to certain triggers. They experience this as a whoosh of fear, and there is a characteristic physiological arousal that is triggered by the fear circuitry of the brain that includes the amygdala and is automatic and reﬂ exive. The second characteristic is their disproportionate focus on the future. They are constantly asking “what if” questions. Most highly anxious patients spend very little time focusing on the present. This is unfortunate, because the more one focuses on the present, the less one tends to experience anxiety. Anxious thoughts and feelings are almost always involved with the future, and people do best in highly anxious situations when they stay as close to the present as possible. The third characteristic is a consistent tendency to catastrophize. Patients typically imagine worst-case scenarios in sensitized situations. So, not only will they get into “what if?” future thinking, but the content of their “what if?” thoughts will be worst case, with a huge focus on the risks and almost none on the rewards. If there are a thousand possible outcomes in a future situation—mostly benign—they will spend a disproportionate amount of time and mental energy concerned with the one or two outcomes that are disastrous. So, depending on the particular sensitivity, a sore throat could be cancer, or a pain in the arm might indicate a possible tumor. If prescribed a medication, they might focus on the possibility of getting one of the worst and most serious side effects. If they are about to give a speech, they are visualizing freezing or panicking or vomiting at the podium. If they are going somewhere, getting to their destination uneventfully is rarely considered. It is their tendency to focus on what can go wrong (even if highly Downloaded by [New York University] at 01:46 15 August 2016 unlikely), than to consider any of the many possibilities of things going right.

Anxiety Feels Dangerous On the surface, there is nothing logical about anxiety disorders. If fears were based on logic, greater danger would produce greater fear. But that is not true, and patients are often fearful of situations that are very safe, yet sometimes unafraid of activities that carry a much higher risk of danger. Looking at the inner life of anxious patients, however, anxiety disorders follow impeccable internal logic. If a patient believes that light- headedness could be a stroke symptom, a rapid heart rate might signal an impending 8 The Basics cardiac event, uncertainty about turning off the gas could lead to a house ﬁ re, or social events could lead to a humiliating faux pas, then it is understandable that they feel afraid of these triggers. Anxious avoidances would follow in the same manner. If one were truly at risk of fainting (a common mistaken concern among people with panic disorder), it would be illogical not to avoid activities that require attention, such as driving. Once patients fall for these unconsciously triggered false messages, their fear makes sense. Highly anxious patients feel comforted when we inform them that their fears and avoidances are logical if they accept these false premises, but they are being fooled by anxiety, whose misleading messages are unconscious, automatic, conditioned, and—for the time being—outside of their control. Anxiety motivates avoidance by making patients feel like they are moving from danger to safety. Anxiety has the singular goal of getting patients to flee its source, because that is how it preserves itself. It accomplishes that by tricking patients into believing that feelings of anxiety indicate danger, even though that is not true. Another way to state Anxiety makes patients this is to call anxiety a bluffer, a trickster, and a believe that feeling dissembler that will always try to convince people anxious is the same as that there are good and valid reasons to avoid it, being in danger. when, in truth, no such reasons exist. Anxiety makes patients believe that feeling anxious is the same as being in danger. The goal is to erase the association between feeling anxious and being unsafe. They are not the same. But there is another aspect of avoidance that patients have probably already discovered. Avoidance keeps anxiety fresh, and intensiﬁ es its discomfort. To overcome anxiety, patients will have to move, in manageable steps, towards areas of greater discomfort. This requires exposure to anxiety and its triggers, since it is the only way the brain learns to break that connection. So following this approach takes courage, the discomfort that one is willing to experience in order to reach a goal. One patient, who was extremely afraid of heights, said that he felt as courageous for reaching the top of his stepladder as Sir Edmund Hillary must have felt upon reaching the top of Mount Everest. Anxiety is a bluffer. Overcoming anxiety involves understanding its paradoxical nature. It requires helping patients learn that the common sense steps that they take to overcome anxiety actually add to its intensity. We intend to show ways to out-bluff anxiety, and improve on common sense ways of trying to eliminate it. One key to overcoming an anxiety disorder is learning how to take manageable steps towards the source.

Downloaded by [New York University] at 01:46 15 August 2016 Not too big that one feels overwhelmed by anxiety, but large enough to make progress. That is the art of the therapy.

How an Anxiety Disorder Differs from Plain Anxiety Everyone experiences anxiety. But for most, fear and anxiety play a background role in their lives. An anxiety disorder is conceptualized as anxiety that causes either disability or extreme distress (NIMH, 2007), but there is more to the distinction. People with an anxiety disorder do not merely feel fear, they fear fear. They are frightened by their feelings of fear. They are anxious about being anxious. Being frightened of the fearful feelings is an essential component of having an anxiety disorder. It is this The Basics 9 two-step process—“fear” plus the “fear of the fear”—that turns ordinary anxiety into a disorder. This is the trait of anxiety sensitivity (Reiss, Peterson, Gursky, and McNally, 1986), a defi ning characteristic of anxiety disorders. People with anxiety sensitivity are afraid of anxiety itself. They tend to have greater anticipatory anxiety about experiencing anxiety, are more anxious about coping with fearful arousal itself, and tend to People with anxiety spend more energy—both behavioral and mental— sensitivity are afraid of avoiding feared internal sensations. Anxiety sensitiv- anxiety itself. ity is a trait that is heritable—meaning that it runs in families—and is one piece of evidence that points to genetic factors in the development of anxiety disorders (Stein, Jang, and Livesley, 2002). But let us be even more precise: people with anxiety disorders experience distress, and they try to avoid it because it seems dangerous. Highly anxious patients will understand this immediately. Virtually every patient with signifi cant anxiety will respond with relief and concurrence when the problem is conceptualized as a fear of fear. A patient’s concern about the danger of this distress and inability to handle it is what maintains and amplifi es the anxiety. He might be thinking “I’m really feeling freaked out, what if these feelings make me sick?”, which would generate additional feelings of distress. This is the anxiety-generating process at work.

The Three Types of Triggers Patients often come into therapy expressing fears of things that are “out there,” and so expend energy Triggers are what set off trying to control external events, ignoring internal the alarm, while fears are anxiety-generating processes. Triggers are what set off what happen once the the alarm, while fear is what happens once the alarm alarm is sounded. has sounded. Patients do best when they are able to focus on internal processes and become more aware of their characteristics. Apart from any speciﬁ c diagnosis, anxiety disorders can be initiated by three types of triggers—sensations, thoughts, and memories. This differentiation helps patients grasp the relationship between an external trigger and the resultant terror that characterizes the anxiety disorder. It provides a conceptual link between what patients fear “out there”

Downloaded by [New York University] at 01:46 15 August 2016 and the phenomenon of anxiety sensitivity, or fear of fear. These types of triggers are not mutually exclusive; in fact, many diagnoses fall into more than one category. But the differentiation helps discern the particular types of distress patients might be experiencing. Figure 2.1 presents a graphic representation of the three trigger types. The ﬁ rst category consists of those who are triggered by feelings or sensations they experience as dangerous, emotionally painful, or intolerable. Examples of typical feared sensations are light-headedness, tightness in the chest, and nausea. Sensations are not innately frightening; they acquire the capacity to trigger the anxiety reaction as a result of past fearful experiences. They have become conditioned, or learned reactions. So an individual who experiences light-headedness might become terriﬁ ed that this sensation indicates a dangerous medical condition. He might visit emergency rooms when the sensations start. He 10 The Basics

Figure 2.1 Three types of triggers.

might seek out medical information from the internet or medical books, searching for an explanation for his symptoms that make him feel safer or tell him how to ﬁ x them. He might start to avoid any situation that might provoke those sensations, such as exercise or high places, and particularly those which have been associated with the onset of light- headedness in the past. A more accurate perspective is that these are attempts to remove or avoid the sensations triggering the fear. Attempts to avoid the sensations will almost always make them more intense, which can trigger a cycle leading to feelings of panic. People with these sensitivities are unable to tolerate, and are therefore terriﬁ ed of, frightening sensations. We want to make sure they are aware of the role of these sensations.

PATIENT: I get this feeling in my head, sort of like things are cloudy or fuzzy. I feel almost dizzy. THERAPIST : And what happens when you get these feelings? PATIENT: I get very frightened. I feel so weird I can’t put it into words. I get terriﬁ ed that maybe I’m blacking out or maybe I’m losing control. I worry about freaking out. THERAPIST: Downloaded by [New York University] at 01:46 15 August 2016 That sounds very uncomfortable, but I notice that you are able to connect your anxiety to the sensations in your head. The pathway to feeling this way often has to do with the way we breathe when we are anxious, and has nothing to do with fainting or going crazy. In fact, later on, we are going to demonstrate how that works. So once you understand that connection, we can ﬁ nd a way to get your brain and your body to become less distressed by those sensations.

Another example of someone who is afraid of feelings and the sensations that come with them might look like this person:

PATIENT : I can’t go to the movies. They mess me up. THERAPIST : What happens in the movies? The Basics 11

PATIENT : If it is suspenseful, I start feeling like I can’t breathe and then I have to leave. I tried just to go to chick ﬂ icks but then if I get involved, I start to cry and then I can’t breathe either. I just can’t handle movies. THERAPIST : So is it the movies that mess you up? Or actually these sensations you get when you are excited or sad? If you could go to a movie with a guarantee that you wouldn’t get those sensations, would you be able to enjoy it?

This describes panic disorder. But intolerance of sensations and the resultant panic is not isolated to this single diagnosis. Those with speciﬁ c phobias, social anxiety disorder (SAD), and generalized anxiety disorder (GAD) can also be unable or unwilling to tolerate sensations because they trigger the fear of fear. Most people with obsessive-compulsive disorder (OCD) fall into the category of those who are unable to tolerate those thoughts that are experienced as threatening or predictive of catastrophe. These people might be sensitized to thoughts of illness, contamination, disorder, or impulsive and unacceptable actions. Anxiety can make thoughts feel as real as actions, and these people live through the terror of their own racing thoughts. Imagining those scenarios seems equivalent to living them, and so the terror feels dangerous and intolerable. They engage in a variety of activities—in their mind and in their behaviors—as attempts to keep those distressing thoughts at bay. They are battling the frightening thoughts inside their mind. Here is a dialogue with a person with OCD where the patient is helped to focus on the role of his frightening thoughts.

PATIENT : I keep thinking that I might have forgotten to turn off the gas and I imagine the whole place fi lling with it, and one little spark can set the whole thing off. I have to come back from work just to make sure it is off. It’s totally crazy. THERAPIST : So the thought of your house fi lling with gas creates your awful feelings. PATIENT: I keep on thinking to myself, “Did I turn it off?” or “Could I have possibly left it on?” It goes back and forth inside my head and drives me crazy until I think, “Why not just check it and be done with it?” THERAPIST: So you just told me how much power those thoughts have to make you feel anxious, and then your desire to get rid of that anxiety generates the really powerful pull to go home and check. Our goal is for you to learn how not to fear these thoughts—not to buy in and believe them as if they were realities instead of thoughts. Downloaded by [New York University] at 01:46 15 August 2016 In addition to OCD, patients with GAD and SAD fall into this category. There are also people with panic disorder and specifi c phobias who, in the midst of extremely high anxiety, also become terrifi ed of their thoughts. Here is an exchange with someone with panic disorder. She described herself as severely claustrophobic and could not close the door to any room she entered. She explained she was terrifi ed that she wouldn’t be able to open the door. One of the tasks was to restate her fears in terms of fear groups. We explained that she was terrifi ed of the thought that she wouldn’t be able to open the door, and then immediately felt sensations of heat, rapid heart rate, and light-headedness. This is an essential fi rst step in being able to switch the focus from what goes on outside the person to what is going on inside. 12 The Basics PATIENT : The closed door frightens me. THERAPIST : Okay, please tell me how the closed door frightens you. PATIENT : I’m okay when the door is opened. THERAPIST : So can you tell me how the door takes away your anxiety when it is opened? PATIENT : When it is opened I fi gure that I can run out if I start to feel anxious. THERAPIST : The “I fi gure” is the really great thing you just said. So it is the thought that you can leave, not the door itself being open, that makes you feel less anxious. PATIENT : Huh! That’s right. THERAPIST : And actually, if you think about it, it is the thought that maybe you won’t be able to run out that triggers your fears. So it is actually your thought and not the door that scares you. And that is the fi rst step, recognizing it is not actually the places but the thoughts.

Here is an example of someone with social anxiety disorder:

PATIENT : I am afraid of making an appointment with my academic advisor. I just know I will look like an idiot and he will question whether I should even be a philosophy major. He is a scary guy. THERAPIST : So is it the advisor that is making you scared or is it your thoughts of what he might think that are scaring you? Has this scene in your mind actually happened or is it what you are imagining?

Here is an example from someone with OCD:

PATIENT: I can’t go to church because every time I get in there, I feel like I am going to blurt out something horrible and I won’t be able to control myself. THERAPIST : So how many times has this happened? PATIENT: Never! But I start worrying about it even before I get there. I can’t be sure I can keep control. THERAPIST: So is it the church itself or your own thoughts and images that you are scared of?

Finally, the third general category consists of those who are unable to tolerate and therefore feel terror of a memory. They are locked onto a memory of a legitimately frightening event in the past; the memory is so intense that they are unable to distance themselves from it. It feels like they are living it all over again. Many anxiety disorders Downloaded by [New York University] at 01:46 15 August 2016 based on trauma are fears of and reactions to a memory. Most people who experience intense panic attacks have embedded the memory of those experiences. Sensations and thoughts that are associated with former panic attacks have the capacity to trigger additional fearful symptoms related to these memories. This next person has a specifi c phobic reaction to a traumatic memory. He had worked as a line cook in a restaurant near the World Trade Center on September 11, 2001. He had witnessed fi rst-hand some of the carnage of that day, and walked to safety in Brooklyn afterwards. But he never returned to his job as a cook. It made him too anxious. The phobia of stoves is created by the fear of a memory and smell memories are particularly powerful. The Basics 13 PATIENT: I haven’t been able to use the stove. I get freaked out. I can’t stand the smell. It is terrifying. THERAPIST : What is terrifying? PATIENT: The smell. There is this smell of metal on the fl ame, and I start remembering everything falling down, and big pieces of metal falling down, and someone asked me, “is this the end of the world?” and I didn’t know. I just knew I had to keep moving. And the smell. I took the train home and was coated with all that powdery stuff. THERAPIST: So you are saying that the memory of the burning smell starts the whole cycle, and it . . . PATIENT: It brings me back. I feel like my life is in danger and I get very frightened.

Here is another example:

PATIENT : Every time I put on those boots I freak out. I should throw them out. THERAPIST : What do you think is happening? PATIENT: Those were the boots I was wearing when I had that horrible panic attack in the mall that started the whole mess. It was the worst day of my life. I guess they just remind me.

Presenting three fear groups helps patients focus on the internal processes that under - lie the nature of their fears. Patients come to us believing that they are afraid of something “out there.” We want to change that. Relating all fears to these three fear trigger groups is a concrete and practical way to help patients refocus on their important inner life—what is going on inside of them—when there is a strong drive to be hypervigilant about what is going on outside of themselves.

The Defi ning Aspect of an Anxiety Disorder The inability to tolerate fearful distress—whether from sensations, thoughts, or memories—is an essential aspect of an anxiety disorder. The distress is seen as dangerous. The task is to help patients understand that discomfort and danger are separate. If we revisit the introductory comments about recovery, we mentioned that the absence of anxiety—while certainly desirable—is not suffi- Reducing anxiety cient. A better definition is being less bothered by sensitivity is a major goal anxiety, even if some remains. Another way to put of treatment. Downloaded by [New York University] at 01:46 15 August 2016 this is to say that reducing anxiety sensitivity is a major goal of treatment. The more general concept goes like this: It is not anxiety that defi nes an anxiety disorder, but the way one feels about anxiety that is essential. If a patient can say, “yes, I feel distress, but I’m not concerned that I’m in danger, and I don’t worry that this distress will harm me, and I don’t need to keep focused on it for fear that something awful is about to happen, so I can go on with my life even with this distress” (certainly this is a commendable example of Buddhist equanimity!), then this person would meet all criteria for being recovered from an anxiety disorder. He has overcome his anxiety sensitivity. 14 The Basics The Basic Principle: Identify and Treat Avoidance The basic principle for overcoming anxiety is like a story from the Talmud—books of commentary on ancient Jewish law. The Talmud tells of a man who challenged the great rabbis to teach him the Torah while standing on one foot. Legend says that he was chased away and chastised by most. But when he came to one rabbi, this man replied, “What is hateful to you, do not do to your neighbor: that is the whole Torah; all the rest is commentary.” Treating anxiety disorders can also be reduced to a principle simple enough to learn while standing on Anxiety is maintained one foot: “Anxiety is maintained by avoidance, and by avoidance and willing willing exposure is the active ingredient of recovery. exposure is the active That is essential; all the rest is commentary.” ingredient of recovery. To overcome anxiety, patients must learn to understand and identify the ways in which they avoid. In the short term, avoidances feel good. In the longer term, avoidances reinforce, empower, and energize anxiety, while at the same time disempowering the patient. The goal is to reverse that trend—to empower patients and disempower the anxiety. Sometimes avoidances are blatant and clear. For example, the claustrophobic person who avoids elevators, or the person with OCD who washes his hands repeatedly and simply refuses to touch anything that feels dirty. But most of the time, avoidances are far more subtle: the fearful fl ier who insists on a window seat; the person with panic disorder who won’t make appointments during rush hour, for fear of delays in traffi c; the person with OCD who lets himself get his hands dirty, but comforts himself by imagining how clean he will feel once he gets home and washes suffi ciently; the socially phobic person who will talk to anyone except an extremely attractive person; the worrier who won’t risk being unsure about someone’s whereabouts and needs to text them constantly. The list of avoidances is huge. Much of the work will involve helping clients to identify and change their varieties of avoidance. The basic principle is simple, but the correct way of applying it can be diffi cult. It can take persistence, discipline, effort, gentleness, and courage.

References NIMH Anxiety Disorders. (2007) June 16 2013. Retrieved from www.nimh.nih.gov/health/topics/ anxiety-disorders

Downloaded by [New York University] at 01:46 15 August 2016 Reiss, S., Peterson, R.A., Gursky, D. M., and McNally, R. J. (1986) Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behaviour Research and Therapy 24(1) 1–8. Stein, M. B., Jang, K. L., and Livesley, W. J. (2002) Heritability of social anxiety-related concerns and personality characteristics: A twin study. The Journal of Nervous and Mental Disease 190(4) 219–224. 3 A Contemporary View of Anxiety Disorders

Sensitivity and Anxiety The best way to understand an anxiety reaction is to think of it as a sensitized response (Aron, 2003). Sensitization is a general term used to describe an overall level of nervous system arousal whereby patients are likely to experience physical symptoms, such as muscle tension and increased heart rate, as well as mental symptoms, such as worrisome thoughts and hypervigilance. Sensitization varies with fatigue, degree of stress or confl ict, general health status, and mood. The triggers of any anxiety disorder provoke strong physiological and mental arousal. These triggers can be external (such as a situation viewed as confi ning), or internal (sensations—such as tightness in the chest or light-headedness, cognitions—such as an intrusive thought; or a frightening memory). Most people experience this arousal as a whoosh of fear or terror. For the moment, it might be helpful to think of these patients as allergic to these triggers, because their reaction is similar to allergic reactions. A person who has hay fever and is allergic to ragweed pollen would have a strong reaction to pollen, whereas others who do not have this allergy would have none. Similarly, sensitized people have a strong internal terror reaction to triggers that might cause almost no reaction in others. Thus, three factors interact for people with anxiety disorders. They have a high level of physiological sensitization. They have strong terror reactions to certain internal and external triggers that result in signifi cant physiological arousal. And they add a fearful appraisal to these reactions, which increases terror and motivates a desire to avoid. Treating people with anxiety disorders requires recognition of how these three factors interact. Downloaded by [New York University] at 01:46 15 August 2016 A Discussion of Causation A widely held assumption is that insight into causes is necessary for a cure (Grünbaum, 1993). It is suggested that since repressed confl icts play a role in the development of anxiety, these symptoms have a deeper meaning, and patients won’t recover until they uncover and work these through. So the traditional method for treating someone with a signifi cant anxiety disorder requires backing away from the symptom and looking instead at the underlying meaning. We understand the appeal of these assumptions, and the desire to hunt for historical causes—even hidden causes—especially because anxiety symptoms often start with 16 A Contemporary View of Anxiety Disorders such a bang. It is not uncommon for people to rapidly begin experiencing full-blown panic attacks, or start a crippling obsessive disorder, or to suddenly feel excruciatingly frightened to speak in class, or to develop some other intense anxiety symptom, often suddenly and seemingly “out of the blue.” Of course there are people who simply cannot remember when they were not anxious, such as those with a socially anxious temperament from birth or with obsessive-compulsive disorder (OCD) manifesting at a very early age. The work of traditional psychotherapies—discovering and rooting out causes of problems—is based on the tenet that insight into these causes will result in the lessen- ing or elimination of the anxiety symptoms (Paul, 1966). However, this approach has been less than effective when applied to patients with overwhelming anxiety. Here are some reasons why.

Insight: Cause Versus Maintenance We fi rst make a distinction between insights into what causes anxiety disorders as opposed to what is helpful in treating them. Personal insight into the cause of an anxiety disorder helps a patient understand the reason why he developed symptoms, and it provides him with information about the reasons he became symptomatic at a particular point in time. Insight can be essential in reducing the bewilderment and sense of overwhelming hopelessness and powerless that often accompanies intense anxiety. However, this kind of insight is almost never enough for successful treatment. Insight into origins is particularly important after symptoms are resolving, since it provides direction to avoid the stresses, situations, and coping methods that originally precipitated and continue to maintain the problem. We address this issue further in Chapter 14 (Relapse prevention). Insight has another function as well. The “aha!” experience that accompanies the understanding of how past and present interact, or the clarifi cation of an issue that appears to underlie the symptom, helps our patients to feel better. But we believe these feelings are transitory, and do not lead to real improvement. It is not enough for our patients to feel better in the moment: our aim is to reduce their ongoing suffering. But the issue of causation is different from what is needed to overcome an anxiety disorder. We view all anxiety disorders as self-maintaining. The cycle of experiencing anxious distress, and then avoiding that distress, is a self-reinforcing set of behaviors that is functionally autonomous (Allport, 1937). Once established, anxiety disorders continue to exist separately from any historical context or confl ictual issues. They can go on indefi nitely unless addressed directly.

Downloaded by [New York University] at 01:46 15 August 2016 The example of a forest fi re is sometimes used. Discovering what causes the blaze is helpful in a variety of ways. It might help to know where to fi nd fi res when they are just beginning (perhaps an area of special dryness), or to determine if some change can be made to reduce the number of fi res (perhaps campsites aren’t suffi ciently isolated from timber). But the fi re Treatment needs to itself must be extinguished directly, and the blaze burns focus on what maintains separately from any cause or set of combustion triggers. anxiety disorders, as The issue of what causes anxiety disorders is a opposed to what causes separate universe of discourse from what maintains them. them. Treatment needs to focus on what maintains anxiety disorders, as opposed to what causes them. A Contemporary View of Anxiety Disorders 17 Helping people overcome their anxiety requires that we focus less on the question of “why” and more on addressing the questions of the “how.” No amount of uncovering or working through various causes speaks to the issue of maintenance. It doesn’t scratch that itch. However, we do comfortably speak of insight into the factors that maintain anxiety symptoms. Successful therapy requires that patients develop a different perspective on their symptoms. They will need to examine anxiety triggers and their anxiety experience itself, in order to gain a fresh clarity on the sensations, thoughts, and memories that drive their anxiety. It is not the meaning of the symptoms but the way that people react to their symptoms that becomes the focus for insight. This is a radically different attitude towards their symptoms: to stay when they want to fl ee, to yield when they want to resist, and to otherwise not be fooled by the misleading messages of anxiety.

Primary Versus Secondary Gains There is a distinction between the primary and secondary gains (Fishbain, Rosomoff, Cutler, and Rosomoff, 1995) with anxiety disorders. Every therapist has observed instances where patients with signiﬁ cant anxiety disorders utilize their anxiety as excuses for not engaging in a variety of activities. Sometimes they are viewed as controlling, demanding, manipulative, or rigid. Secondary gains can be realized from any psychiatric disorder, including anxiety disorders. Desperately frightened people do what they can to feel less desperate. But a secondary gain is not a cause. Certainly no one develops an anxiety disorder in order to control or manipulate a situation. Focusing on secondary gains without ﬁ rst recovering from primary symptoms will not be effective. Addressing secondary gains are part of the work of ongoing psychotherapy, and is best delayed until patients know how to manage their anxiety more effectively. The primary gain of a patient with an anxiety disorder is simply to avoid anxiety and the distress that comes with it. Unfortunately, the methods used to avoid the anxiety and their accompanying distresses are self-maintaining until they are understood and challenged.

Studies on Causation Clinical research on causation reinforces the importance of focusing on maintenance,

Downloaded by [New York University] at 01:46 15 August 2016 since causes are found to be either fi xed, or elusive, or both. First, a multitude of studies indicates that genetics plays a highly signifi cant role in determining whether someone develops overwhelming anxiety (NIMH, 2009). Anxiety disorders tend to run in families, and a genetic component exists that is independent of environmental factors (Meri- kangas and Pine, 2002). One of us sometimes tells patients—only partly in jest—that they chose the wrong parents, and that they will have to do better next time around. The other regularly asks not “whether” but “which” side of the family this comes from. Second, while environmental factors play some role in the development of the disorder, the vast majority of anxiety disorders cannot be traced to any identifi able event or series of events in our patients’ lives. Most people with anxiety disorders have histories that do not differentiate them from those without. Third—despite extensive research 18 A Contemporary View of Anxiety Disorders and many proposed and interesting ideas—there are no identifi able styles of childrearing that have been consistently linked to adult anxiety disorders. These are exhaustive studies that have spanned the past 30 years (Rosenbaum, Biederman, Bolduc-Murphy, Faraone, Chaloff, Hirshfeld, and Kagan, 1993). Finally, the set of premorbid personality characteristics that may identify some people at risk of developing anxiety disorders is likely a genetically driven temperamental predisposition that includes social withdrawal, avoidance and fear of the unfamiliar, and over arousal of certain aspects of the nervous system, a pattern called Behavioral Inhibition (Degnan and Fox, 2007) (Stemberger, Turner, Beidel, and Calhoun, 1995). In short, there is little evidence to validate that anxiety symptoms are primarily a result of underlying unresolved confl icts, and therefore have a meaning that expresses these confl icts. And the same can be said of a personality type that predicts the future development of signifi cant anxiety disorders. Some patients were fearless, precocious, and willing to take all types of risks, prior to developing overwhelming anxiety. Others were always timid and risk averse, but that these characteristics mushroomed with the development of their anxiety disorder. While it is true that being raised by an anxious parent (which includes most people with an anxiety disorder) or being subject to neglect or early loss will likely infl uence maintenance factors, they are not the cause of the disorder. Understanding the contribution of environmental experiences will not make the anxiety disorder go away. Modern understanding of the causes of anxiety disorders points to a combination of genetic and environmental factors, intertwined with a maturational process that allows different anxiety disorders to emerge at different points in patients’ lives, triggered by particular life stresses (Leonardo and Hen, 2007). Signifi cant life changes are typical stressors. These include birth, death, marriage, divorce, or graduation. Similarly, physical stresses such as surgery or childbirth and the psychological stress of events such as the death of a pet can trigger the same physiological responses. People can develop anxiety disorders in reaction to good stresses—a job promotion—or a bad stresses, such as losing a job. Our body reacts to both types of stresses in a similar manner. The maturational component is signifi cant in determining when a person might develop an anxiety disorder, and different disorders have different average onset ages. For example, panic disorder usually starts in the mid-20s, while social anxiety disorder (SAD) typically starts much earlier—around the age of 12 or 13 years. OCD can start at almost any time in a person’s life. Interestingly, boys have an earlier onset age than girls, so that prior to the age of 10, more people with OCD are male. Girls then start to catch

Downloaded by [New York University] at 01:46 15 August 2016 up, so that by the age of 17 or so, there are about as many females with OCD as males (Rapoport, Inoff-Germain, Weissman, Greenwald, Narrow, Jensen, . . . Canino, 2000). And, contrary to other anxiety disorders, the number of people with generalized anxiety disorder (GAD) increases with age (NIMH, 2009). We again emphasize that any theory of causation does not address the primary purpose of this book, Anxiety disorders are which is to understand, discover, and change the fac- rarely simply a lingering tors that keep anxiety disorders going. But there is yet result of a past fearful another point to emphasize. While arguing against event. the view that underlying meanings must be uncov- ered for successful therapy, we also advise against A Contemporary View of Anxiety Disorders 19 taking an overly simplistic view. Specifi cally, anxiety disorders are rarely simply a lingering result of a past fearful event. The vast majority of people with anxiety disorders did not develop them because of a frightening event. Critically examine the history of family anxiety disorders, age of onset, and traditional stressors for anyone who says that their anxiety disorder began as a result of a single frightening event. While this is sometimes true, it is rare, and the frightening event is often more accurately viewed as one component of a set of interacting causes. One patient fi rmly believed that her panic disorder was caused by a terrifying fl ight when she was 27 years old. She related intense turbulence for the duration of the trip, and her absolute belief that she would die on that fl ight. Prior to that time, she reported she was fearless. However, in the course of her treatment, she related that other members of her family also suffered from intense anxiety, and her fl ight was a return trip from a country where she had gone to get a quick divorce from her husband. When her age (27) was factored in, the odds were far greater that the immediate culprit was the life change, rather than the bumpy fl ight. The trigger of the bumpy fl ight was simply the topper to sensitization caused by a number of other factors. Sometimes the vulnerability to the onset of symptoms is immediately obvious—a relative is diagnosed with cancer and “what ifs” about having cancer suddenly pop up. But sometimes the sensitization is subtle, slow, or cumulative—such as a period of sleep deprivation during thesis writing, followed by too much coffee, then a cold and cold medicine with a stimulant effect. And there are times when triggers to sensitization are more complicated and subtle than that. One patient had her fi rst panic attack while giving a speech and then became unable to give speeches, tracing her sensitization to the OJ Simpson trial and becoming increasingly enraged and trans- fi xed. Her genetic predisposition was clearly traceable to her father’s family, which was dominated by anxiety disorders over three generations, but she had been unaffected until then. There was no abuse or violence in her loving, nurturing family of origin, but nearly everyone had the genetic trait of anxiety sensitivity. Her bewilderment was much reduced by understanding this—as well helping her make sense of her intensely empathic traits—but the fear of public speaking persisted until she did exposure- based treatment.

The Dilemma of Insight

Downloaded by [New York University] at 01:46 15 August 2016 We strongly support the need to focus on what maintains anxiety in contrast to searching for causes. It is The therapeutic process not that anxiety symptoms lack underlying causes, of uncovering the cause of but rather that fi nding causative factors is of limited the anxiety can increase therapeutic help. However, there is yet another rea- its intensity. son why it is rare to produce a cure by searching for causes. The therapeutic process of uncovering the cause of the anxiety can increase its intensity. Let us explain. During therapy sessions, attempts to uncover meanings involve challenging the patient to look at material that is highly charged and richly laden with affect. We can assume that there is something disturbing about those emotions, because that 20 A Contemporary View of Anxiety Disorders is why the patient is keeping it out of awareness. So we ask patients to dig deep, and can expect strong feelings to come up. And here is where the problem becomes clear. Many people with anxiety disorders have diffi culty tolerating strong emotions. Intense affect can feel uncomfortable and even dangerous, and there is an intensely felt need to distance oneself from the emotions. With many other types of patients, the emotion can be managed with proper timing, therapeutic support, reassurance, and encouragement. In general, the ability to tolerate emotions with manageable anxiety is a requirement for successful therapy. But people with overwhelming anxiety are exquisitely sensitive to emotions that trigger anxiety. We are looking at anxiety sensitivity—their inability to tolerate the experience of anxiety—from another perspective. By asking highly anxious patients to uncover the meaning of their symptoms, they have been inadvertently placed in a dilemma: in order to recover, they must tolerate the anxiety generated by the emotions they uncover. However, the essential aspect of the symptom to be addressed is the inability to tolerate anxiety. If anxiety signals the defense against emergence of repressed material, then clearly uncovering therapies initially make people more anxious. The motivation and capacity to face anxiety-producing thoughts, sensations, and memories will be greater when patients have fi rst reached the point where they no longer view strong affect as dreaded or dangerous. There is then less of a need to avoid and place limitations on addressing intense emotions. The emotions of anger, tenderness, vulnerability, etc., are no match for terror in the face of anxious arousal.

Consequences of Affect Intolerance Anxiety can also be thought of as a dump for intense and conﬂ icted emotions. People with anxiety disorders often feel anxious when they experience intense feelings. They have learned to interpret autonomic arousal in their body as anxiety, even though the same autonomic arousal can underlie a variety of legitimate emotions. For example, people with panic disorder often misinterpret excitement or anger or the tension of feeling rushed as the onset of panic, which then results in a panic attack. Thus, a patient who is watching an exciting TV show might get excited, notice the arousal, interpret it as fear, and begin to panic. This person is not afraid of TV. It is a case of misunderstanding, mislabeling, and fearing arousal . Here is a story that illustrates the underlying process. Imagine your doorbell rings, you open the door, someone presses a gun in your belly and says, “Give me your money

Downloaded by [New York University] at 01:46 15 August 2016 or you die.” You will experience intense terror. Your heart will race, you will feel lightheaded, and you will experience a full-blown alarm reaction. Now let’s rewind the tape and look at another example. Imagine your doorbell rings, you open the door, someone pushes an envelope in your direction and says, “Congratulations, you have just won the $25 million lottery!” In this case, you would also experience a rapid heart rate and light- headedness. In the ﬁ rst example, the feeling would be terror: in the second, excitement. And, if we had you hooked up to physiological measures, and could only view your reaction by those measures, we would be hard-pressed to know which was the gun and which was the lottery. Very similar physiological arousal can lead to distinctly different feelings. In addition to misinterpreting the arousal of excitement as fear, the anxious person has the tendency to focus only on impending panic, and cannot attend to the emotions A Contemporary View of Anxiety Disorders 21 initiating this process. Terror takes precedence over other emotions, initiating defenses against a danger that does not exist. When arousal is singularly experienced as fear, the patient appears alexithymic (unable to label different feelings) (Sifneos, 1996). This is particularly evident with people who have SAD. People with SAD are highly attuned to their own arousal, are hypersensitive to real or imagined criticism, and focus on how they imagine they appear to others. So the signs of physiological arousal such as slight shaking, a tremulous voice, increased sweating, etc., might be seen as looking weak, or appearing foolish or weird, and the mental indications of arousal which include blanking in the mind, or not having a snappy retort, would similarly be negatively interpreted. This would then trigger additional arousal, another round of self-criticism, and a further increase in anxiety. The original arousal—whatever the source—is soon forgotten in the maelstrom of anxiety, terror, and humiliation. It is sometimes helpful to ask patients the following question: what would you be feeling if you were not feeling anxious? This question aims to provide a way to look behind intense anxiety, and focus on the emotional underpinnings that triggered the original arousal. Sometimes this helps reveal what emotion was hijacked by anxiety.

The Value of Talking about Anxiety Symptoms Stories abound of patients being told by therapists that they are focusing too much on their symptoms during therapy, and that their preoccupation with symptoms is a defense against more important issues. One patient—a physician—with severe OCD, checked for fi ve to six hours every day. (Imagine spending 15 minutes each day just checking to make sure that a dishwasher is entirely empty!) This was in addition to his work as a doctor, and his home life responsibilities. He was constantly overwhelmed. This patient was told by his therapist that he would never make any progress with his OCD until he was able to overcome his internalized anger. It seems that much of his internalized anger was related to the stresses caused by his OCD, and not the other way around. Patients should be encouraged to speak about anxiety, because that is often the focus of their suffering. It is also the way to gain information about the stresses, triggers, and ways of reacting that defi ne the disorder. The primary reason for suggesting this approach is very simple—it works! Both authors are dynamically and interpersonally trained therapists who came to recognize the benefi ts of directly addressing the symptoms of anxiety disorders within the context of more general psychotherapy. But there is another value to this approach—one that is perhaps even more sig-

Downloaded by [New York University] at 01:46 15 August 2016 nifi cant than addressing the anxiety symptom. Anxious people have come to interpret autonomic arousal as anxiety, even though the same arousal can underlie a variety of legitimate emotions. When patients learn to manage anxiety, they learn to manage all affects. When anxiety doesn’t rule one’s life, the opportunity emerges to experience and enjoy a wider range of emotions, and patients feel more confi dent in their ability to handle life’s travails. Patients enjoy the benefi ts of greater emotional fl ex- When patients learn to ibility, and the ability to embrace life’s circumstances manage anxiety, they relatively free of neurotic suffering. learn to manage all There are times when patients with overwhelm- affects. ing anxiety are involved in realistic life situations that 22 A Contemporary View of Anxiety Disorders require realistic solutions. If these situations trigger overwhelming anxiety, the desire to reduce anxiety is so powerful that it drives actions. But taking action to reduce the anxiety is often not the best way to resolve the problem. Since the drive to avoid anxiety is so intense, it is impossible for these people to know whether they are making a decision that best solves the problem or one that provides the quickest fi x for anxiety. Here’s an example. A businessman suffers from panic disorder and GAD. He indicates that his director of sales is doing a poor job, yet this same person has asked for a raise. In his calm moments, he thinks he should fi re this person, and that he certainly does not merit a raise. However, the thought of not having a director of sales triggers panic, and his concern about the possibility of this person quitting seems intolerable. He wants to grant the raise to keep the sales director. When asked to consider whether he is acting to reduce his anxiety, or because it is the best business decision, he acknowledges that he really doesn’t know. Another frequently encountered example is women who fervently want children but are terrifi ed of the sensations, feelings, and worries they imagine they will have when pregnant. They try to avoid their anxiety by putting off the decision until they feel less anxious. This is a set-up that leads to loud ticking biological clocks. This cannot be solved until there is a better capacity to tolerate anxious thoughts and sensations. While it would be easy to interpret this situation as ambivalence about parenting, our experience is that it is about feeling unable to handle the anxiety associated with the unknown experience of pregnancy. These are happy mothers, once they can risk having anxious sensations and thoughts. Developing a way of reducing anxiety without avoidance provides additional options. When anxiety is lowered, the feeling of danger passes. Patients can focus on emotions that were blocked by anxiety. They can evaluate their situation and make a decision based on the merits of the solutions, rather than the blind need to lower anxiety. A related benefi t is that patients are now better able to handle the affect that comes up during therapy. They are now equipped with the emotional hardiness to better tolerate affect, and to cope with the anxiety generated by the uncovering process. The issue is one of timing: the fi rst task is to help the patient learn the proper attitude to cope with anxiety and work towards becoming less anxiety sensitive. As a result, anxiety lowers, and the emotions begin to emerge. By now the anxiety generated by the emotions is becoming better tolerated, and patients are more able to explore their emotional life in therapy. That, in turn, means that they are better able to make decisions about external

Downloaded by [New York University] at 01:46 15 August 2016 choices without the overwhelming need to avoid anxiety.

A Direct Approach to Treating Anxiety Disorders We propose the following path to helping patients overcome anxiety disorders. Since strong emotions can generate intolerable anxiety, start by ﬁ rst teaching patients how to better tolerate anxiety. Reaching that goal requires that they stay focused on the concept that anxiety is maintained by avoidance, and willing exposure is the active ingredient of recovery. Focus on what is maintaining the anxiety: the contemporaneous aspects of the symptom—the “what is happening?” and the “how is our patient trying to cope with it?”—rather than historical causes. A Contemporary View of Anxiety Disorders 23 Before patients will have the courage to give up their current means of dealing with anxiety symptoms, they need an explanatory model that makes sense to them. By providing that to patients—and we present such a model in this book—it helps the patient while strengthening the therapeutic bond.

The Neurological Perspective: Role of the Amygdala in Sensitization We have come a long way from the time when people with anxiety disorders were called “weak,” “lazy,” or “cowards.” It is understood that the brain has been inadvertently pro- grammed to make the body anxious, and there is knowledge about how that happens and the parts of the brain involved. Also, we know what is required in order to “rewire” the brain so that the fear-producing circuits are not so easily triggered. The “fi ght or fl ight” response is common knowledge—the brain activates an arousal system during danger. This is the stress response, which includes a series of nervous system arousals in preparation for danger. When this response is triggered, our body reacts with increased heart rate, heightened attention to possible additional dangers, release of epinephrine (adrenaline), tunnel vision, constriction of certain blood vessels, and fl ushing. We are primed to fi ght or fl ee. The amygdala is a part of the brain that triggers this arousal response, and therefore controls fear and anxiety. But fi ght or fl ight is an incomplete description of the stress response. A fi ght, fl ight, or freeze reaction, triggered by the amygdala (Bracha, 2004) provides a better description of anxiety symptoms. It accounts for the grouping of symptoms that are common to almost all anxiety reactions: rapid heartbeat, sweating, racing thoughts, and the feeling of dread that is associated with overwhelming anxiety. Much of the time they energize us to take action, to escape the situation or to fi ght harder. But there are also times when people freeze when they are anxious: the person with SAD whose mind goes blank when presenting; the white knuckle fl yer, who desperately grips the arm of their seat during fl ights; the traumatized person who hears a noise in the house but can’t move to dial 911, the agoraphobic person who freezes in crowds. People freeze because they are overwhelmed by the stimulation of competing neural circuitry (Porges, 2001). Freezing does not denote a lack of stimulation, but rather an overabundance. It is like a computer that will eventually freeze up as additional programs are utilized. It doesn’t freeze up because it is not being asked to do enough; it freezes up because too much is asked of it. The following discussion is adapted from LeDoux (1996), who reported that there

Downloaded by [New York University] at 01:46 15 August 2016 are two separate brain paths that link to the amygdala. When we perceive a possible threat, the brain’s switchboard (the thalamus) divides the signal in two and sends it along two different paths, both of which lead independently to the amygdala. One route goes directly to the amygdala, which immediately triggers the “ﬁ ght, ﬂ ight, or freeze” alarm. We become frightened and aroused, ready to defend ourselves, get out of the way, or freeze in place. This path is direct, but also fast and foggy. The amygdala gets only the gist of the signal and sounds an alarm whenever the possibility of danger exists. Better to over-react and turn off false alarms later, than to under-react and get blindsided by an actual threat. Figure 3.1 illustrates that a signal going along the “direct” route triggers the amygdala very quickly. So quickly, in fact, that the body takes action before the brain realizes what 24 A Contemporary View of Anxiety Disorders

Figure 3.1 Two routes to the amygdala.

is going on. Reactions are in the service of survival, they originate in primitive brain areas, and they are unconscious and outside of our control. But there is also a second path, a higher route: the second part of the signal takes a longer path past the more primitive brain and up to the cortex—this is the part of the brain that controls rational thought—where it determines whether an actual danger exists. This second signal arrives at the amygdala after making rounds of the cortex— about a half second later than the fi rst. Modifi ed by information provided by the cortex, this slower and wiser signal has the capacity to stop the amygdala from continuing to issue alarms, although it cannot interrupt the initial alarm which has already fi red before

Downloaded by [New York University] at 01:46 15 August 2016 full information got there. Here is a simple example to see the process at work: there is a loud sound, whose signal is sent on to the amygdala via two pathways. Via the quick route, the amygdala reacts to the sound by triggering an immediate rush of fear. About half a second later, the other part of the signal arrives after having been processed by the cortex. The cortex has determined Patients become that the loud sound is a pot crashing down and that frightened before there is no danger exists. (It could have very well been a gun- any conscious assessment shot.) Based on that information the cortex commu- of danger. nicates that a false alarm was sounded, the amygdala stops sending out its arousal signal, and, after some A Contemporary View of Anxiety Disorders 25 time passes, the physiological effects of the original alarm subside and stop. Calming happens on its own, naturally. 1 Think of a friend surprising you in your home and yelling “BOO!” when you thought you were alone. You get a jolt of fear and then realize it is harmless, even though your body might need a few minutes to calm down completely. This is the process at work. There are two essential points here. The fi rst is that patients become frightened before there is any conscious assessment of danger. Their initial fear reaction is primitive and unconscious. It precedes their conscious mind, and is not yet connected to the part of their brain that controls conscious thoughts. That is why patients The fi rst fear is automatic are unable to use willpower to stop this initial rush and unstoppable, and of anxious arousal. The fear develops before there is goes away quickly if it is any chance to intervene and gets there before the will. left alone. This fi rst fear cannot be intentionally suppressed. This should be repeated to patients. It speaks to differentiating what the patient can control from what is outside of his control, what is automatic and what is not, and focusing psychic energy where it is most helpful. The second point is that the cortex is capable of affecting subsequent reactions of the amygdala, depending on whether or not it determines that a danger exists. Fear continues to spiral when the cortex interprets signals as dangerous, and this is important indeed, since it frames the neurological basis of anxiety disorders. In Chapter 4 we discuss how these neurological facts affect clinical work.

First and Second Fear Now let’s take this process one step further: when the cortex interprets the ﬁ rst fear arousal—not the original trigger, but the arousal itself—as dangerous, then the cortex tells the amygdala that danger does indeed exist, and to continue sending out alarms. This is a neurological description of anxiety sensitivity, or fear of fear. The original alarm signal arousal (ﬁ rst fear) is perceived as dangerous, which engenders additional arousal (second fear), and so starts the anxiety cycle. A signal initially reaches the amygdala through the fast and foggy route, triggering a fearful whoosh. This whoosh occurs prior to any conscious awareness, and is the neurological representation of sensitization.

Downloaded by [New York University] at 01:46 15 August 2016 This ﬁ rst fear is automatic, unstoppable, and goes away quite quickly if left alone. Up until this point Terror caused by anxiety there is no involvement of the cortex. Figure 3.2 feels the same as terror illustrates the production of this ﬁ rst fear. caused by legitimately First fear has been triggered, and the patient is dangerous situations. experiencing a whoosh of distress. The patient must now label their terror either as “anxiety” or “danger,” because each of these is handled differently. However, terror caused by anxiety Labeling terror as anxiety feels the same as terror caused by legitimately danger- constitutes a leap of faith. ous situations—the physiological reactions and bodily 26 A Contemporary View of Anxiety Disorders

Figure 3.2 First fear is triggered.

Figure 3.3 The labeling decision. Downloaded by [New York University] at 01:46 15 August 2016

sensations are the same. To accurately label their arousal as anxiety, patients must learn to say something like, “My terror is an aspect of my anxiety, and not because I’m in danger.” Labeling terror as anxiety constitutes a leap of faith.

Whoosh and the Decision Process Since people with anxiety disorders are sensitized to certain triggers, they experience a characteristic whoosh of arousal. It can be represented as illustrated in Figure 3.3 . A Contemporary View of Anxiety Disorders 27 Creation of Second Fear For someone with panic disorder, the whoosh of ﬁ rst fear is usually a sensitized reaction to a feared sensation. This reaction is followed by the person thinking, “Oh no! What if I am starting to faint?” Then this thought—originating in the cortex—sends a signal to the amygdala to continue sounding the arousal alarm, creating more intense arousal. And when the person with panic disorder experiences additional fear symptoms, he might say to himself, “Oh no! Something terrible is really happening, my heart is starting to race, maybe I am having a heart attack?” Or, “Oh, No! What if I’m starting to freak out?” Or, “Oh, no! What if something dangerous is happening? What if I’m going to hurt myself? What if I’m going to hurt someone else? What if I am dying? What if I make a fool of myself? What if these feelings destroy me?” A panic attack is well on its way. This process is illustrated in Figure 3.4 . In the case where intrusive scary thoughts or images begin the process, (for example in OCD) there is a similar whoosh of ﬁ rst fear. In this case, however, it is the sensitized reaction to the feared thought that sets off the alarm system of the amygdala, triggering the fearful reaction, which then is interpreted by the cortex as evidence of danger. This begins the same frightening self-reinforcing feedback cycle. The pathway from scary thought to arousal by the amygdala is a lightning-fast well-conditioned pathway. This is why OCD and GAD thoughts are experienced differently from regular thoughts. They have a distinctive “jolt” or “spike” or whoosh that is attached to them. Typical second fears in OCD and GAD are “What if I am about to do something terrible?”, “What if this means I am a bad person?”, “What if this is a warning that someone is in danger?”, “Why can’t I be certain about this important thing?” Patients can readily identify such Downloaded by [New York University] at 01:46 15 August 2016

Figure 3.4 Second fear labeled danger. 28 A Contemporary View of Anxiety Disorders experiences when pointed out. This is explored more fully in Chapter 10 (Unwanted intrusive thoughts). The patient with SAD might have an initial whoosh of fear quite similar to the person with panic disorder, although the thoughts and images that escalate the process (the second fear) usually focus on the possibilities of looking foolish, doing something embarrassing, appearing anxious, and that others will think negatively of him. Sensitiv- ity to the emotions of shame and embarrassment keep these patients trying to suppress or avoid these feelings, which intensiﬁ es them and results in additional “What if I make a fool of myself ?” messages from the cortex. At the same time, the physiological aspects of arousal might cloud their thinking, redden their faces, and make their limbs and voices tremble. Frightening memories frequently add to second fear, since fear memories are stored in the amygdala, are retrieved quickly, and don’t require conscious thoughts to be triggered (Clark, 2011). This is one reason why exposure is essential to help the amygdala learn through direct experience that no danger exists.

Management of Second Fear In contrast to ﬁ rst fear, second fear is amenable to conscious and intentional intervention; it can be reduced or eliminated by retraining the cortex to stop retriggering the amygdala. Figure 3.5 shows what happens when anxious arousal is correctly labeled as anxiety. Neurologists say that circuits that ﬁ re together wire together. The brains of highly anxious patients Second fear is have become wired to keep them anxious; the goal is amenable to intentional to help them “rewire” their brain to reduce this con- interventions. It can be nection. The goal is to allow realistic information reduced or eliminated by from the cortex to stop the continual arousal of the retraining the cortex. amygdala, allowing the natural calming process to become ingrained.

The Value of Exposure The active ingredient for making these changes is exposure to anxious feelings. But this exposure must be done the right way. The right way means exposure that creates a man-

Downloaded by [New York University] at 01:46 15 August 2016 ageable level of anxiety, but is not overwhelming; it allows for very little avoidance, and encourages the patient to practice new methods of managing the anxiety that arises. And, the right way means staying with these feelings long enough for new pathways to form that overlay the old. Two important changes occur: ﬁ rst, the brain learns new responses to formerly fearful triggers, so there is less reactivity to anxious arousal, and, second, it becomes used to accessing these newly learned patterns, so that the new reaction becomes the default one. A more comprehensive explanation of how this happens is discussed in Chapter 8 . However, it is worthwhile to note that fear circuitry is never really “unlearned,” and the modern conception of recovery is learning a new set of non-fearful experiences that can inhibit and override older fearful reactions. This means that old reactions can be A Contemporary View of Anxiety Disorders 29

Figure 3.5 Second fear labeled anxiety.

retriggered under certain circumstances, and anxiety can return. Proper relapse prevention addresses this phenomenon.

The Fear-maintaining Cycle The fear-maintaining cycle (Figure 3.6) demonstrates how the misinterpretations of sensations, thoughts, or memories create a vicious cycle that maintains overwhelming anxiety. Highly anxious people have consistent tendencies, including a tendency to catastrophize and focus on worst-case outcomes. Among a thousand possible outcomes in a situation—the vast majority of them benign—they will spend an extraordinarily high percentage of their time and mental energy imagining an encounter with the one or two outcomes that are disastrous. So, for example, a sore throat brings up thoughts of cancer, light-headedness indicates a brain tumor. If prescribed a medication, the focus is on the possibility of getting one of the worst and most serious side effects. It is more

Downloaded by [New York University] at 01:46 15 August 2016 the tendency to focus on what can go wrong (even if highly unlikely) than to consider any of the many possibilities of things going right. Anxious people are also sensitized to these “what if” catastrophic thoughts. There is a real, measurable, physiological arousal to them and these thoughts crowd out others as well. They feel sticky and are difﬁ cult to chase away. The diagram is a circle because the anxiety-producing process repeats itself, maintains itself, and reinforces itself as attempts are made to evade, avoid, suppress, and push back against the feelings of anxious arousal. Let’s start with the example of someone who has panic disorder: A patient feels sensations in his chest. If he misinterprets these sensations as indications that something is wrong, as opposed to automatic and uncontrollable— but harmless—arousal from his amygdala, he understandably becomes frightened. His 30 A Contemporary View of Anxiety Disorders

Figure 3.6 Fear maintaining cycle.

attempt to avoid the arousal makes him focus even more on it. The fear and the arousal associated with it creates a new set of even more intense sensations. If once again these sensations are misinterpreted as veriﬁ cation that something is, indeed, very wrong, he would feel even greater fear. The cycle continues, his sensations and fear levels increase, and the result is often a full-blown panic attack. A similar process goes on for people with other anxiety disorders. For a person with OCD, we can start with a thought that triggers anxious arousal, such as “what if I touched something contaminated?” The arousal that follows the thought makes the thought feel like it might very well be true, as opposed to the automatic, unconscious, and terrifying—but harmless—arousal from the amygdala. So the patient tries to reassure himself that this hasn’t happened, perhaps by playing back his memories of what he touched, or deciding that his hands need to be washed ASAP. But this attempt at reassurance brings the triggering thought squarely back into focus. Notice the box labeled “Misinterpretation as Dangerous” because it includes the “what if” thinking that triggers the second fear. This is where we say to ourselves things like, “What if I am having a heart attack?”, “What if I lose control?”, “What if I sent obscene emails to my coworker?”, “What if I act on my ‘bad’ thoughts?”, “What if I start blushing when I speak to the girl and everyone thinks I’m weird and a loser?”, “What if I lose my mind and go crazy forever?”, “What if I caught AIDS when I touched that red spot?”, “What if I embarrass myself?”, “What if I begin to panic in the middle of the bridge?”

Downloaded by [New York University] at 01:46 15 August 2016 There is a huge range of “what if” catastrophic thoughts that our patients are capable of creating, the range of catastrophes limited only by the creativity of their imagination.

Avoidance, Resistance, Neutralization Avoidance plays an essential role in maintaining, reinforcing, and empowering the full spectrum of anxiety symptoms, from anxious arousal, to abhorred and frightening thoughts, to terrifying memories. The best deﬁ nition of avoidance is a very general one, and includes whatever patients do to ﬂ ee the experience of anxiety. It includes actively avoiding experiences that might cause anxiety and cognitive attempts to avoid the experience of anxiety while in the situation. We therefore include outright avoidance and a A Contemporary View of Anxiety Disorders 31 variety of mini-avoidances, rituals, superstitions, and mental reassurances—even as subtle as telling oneself Avoidance plays that it won’t be that bad (which are sometimes called an essential role in neutralizations)—or imagining who can help if things maintaining, reinforcing, get out of hand, or having an escape plan for a social and empowering the situation. In short, anything other than allowing full spectrum of anxiety anxious thoughts and feelings to continue unabated symptoms. while focusing on the task on hand is considered an avoidance, and ultimately counter-therapeutic.

The Phenomenology of Anxiety: Anxiety Alters Consciousness Anxiety produces an altered state of consciousness that tells patients they are in danger when they are safe. Usually, thinking is a safe way to imagine possible scenarios and their consequences. But as anxiety increases, thoughts become increasingly frightening. They don’t feel so much as trying things out—they feel more like living them out. Sensitiza- tion makes merely thinking about something feel frightening and dangerous. Trying to avoid thinking these frightening thoughts makes them more persistent, and the distinction between thoughts and actions starts to blur. When very anxious, thinking about something can feel as scary as it happening. Approaching panic, thoughts feel outright dangerous. They feel like facts. This is anxious thinking, and it is the altered state of consciousness that many patients will experience. Let’s take a look at these alterations in some detail, and point out how they make exposure to anxiety-producing triggers more difﬁ cult. It is important to note that overwhelming anxiety can make a person appear—and feel—like they are quite crazy. It is the altered state of consciousness that is the culprit. As clinicians, our job is to differentiate truly psychotic people from those who might appear temporarily psychotic because of intense anxiety. But the major characteristic of people with an anxiety disorder is the rapid reversibility of their symptoms, and the return to the non-altered state of consciousness when the anxiety-producing triggers are removed.

Thought–Action Fusion Ordinarily, the differences between thoughts and actions are clear. Anxious thinking

Downloaded by [New York University] at 01:46 15 August 2016 creates an altered state of consciousness where scary thoughts can feel as frightening as scary behaviors. It is as if thoughts and actions feel fused together. Thought–action fusion makes it seem that there is little difference between thinking about something and it actually happening. If a patient with a fear of Anxious thinking makes ﬂ ying worries about losing control while on the ﬂ ight, thoughts and actions feel then the anxious thinking will make that thought feel fused together. like it might really happen. Thoughts no longer feel like a safe way to rehearse actions without consequences. If a patient worries about an elevator crashing, anxious thinking makes it feel like the worries actually increase the probability—or might even be a cause—of a crash 32 A Contemporary View of Anxiety Disorders really occurring. “What ifs?” are not experienced as guesses or imaginings, they feel like envisioning the actual future. In addition, thought–action fusion makes it seem that thinking something is somehow morally equivalent to doing it—and therefore means something important about the thinker, so that bad thoughts reveal a bad person. Hav- ing a critical thought that one “shouldn’t have” about someone means that the thinker is an ungenerous, ungrateful, or unpleasant person.

All Risks Seem Unreasonable In ordinary thinking, it is understood that nothing in life is risk free, and people take reasonable risks in order to achieve a goal. In contrast, anxious thinking cannot accept any risks, because thinking about something gives it a very high probability of happening. “What if?” catastrophic thoughts seem likely to occur. Patients accept reasonable risks in many aspects of their life. One patient with OCD enjoyed skiing and bungee jumping. But he was also sensitized to the image—and therefore terriﬁ ed—that his heart medication might poison his dog, and spent hours each day checking to make sure that every pill was safely stored. Another patient, able to give speeches to large audiences without anxiety, could not leave the house without hours of make-up and hair preparation for fear of running into someone she might know in the grocery store without being perfectly presentable. When one is anxious, any risk that triggers this anxiety seems unreasonable and intolerable. Patients then want a 100% guarantee that an unpleasant or disastrous experience won’t occur. Anxiety continually asks for reassurances of safety, and demands avoidance of situations that feel dangerous. Anxious thinking makes no distinction between fears that are triggered by catastrophic images in the mind and fears that are triggered by actual danger. The feeling of how dangerous something is comes from a combination of stakes (if it happened how bad would it be?) and odds (how likely is it to happen?). As anxiety levels increase, odds fade to the background, and stakes remain at the center of attention. So, any possible danger feels likely. Even when the probabilities are understood to be very low, it still feels risky. Thus, the stakes of contracting AIDs are very high, but the odds of contracting the disease for someone not sexually active and not in contact with human blood products or needles are almost zero. Nevertheless, anxiety can make it feel like a terrible risk.

Thoughts Feel Sticky Anxious thinking makes scary thoughts hard to avoid. They seem stuck in the mind. No

Downloaded by [New York University] at 01:46 15 August 2016 matter how much one tells oneself to think of something else, catastrophic thoughts come right back to intrude themselves into consciousness. Distractions are only partially helpful in getting one’s mind onto another subject, and they sometimes are no help at all. The more one resists thinking the thoughts, the stronger and more frequently they appear (Wegner, Erber, and Zanakos, 1993). It is a little like the game you might have played when you were young. Tell someone to not think The more one resists about pink elephants for the next minute. Of course thinking the thoughts, that is impossible to do. The act of trying to keep the stronger and more something out of our mind, keeps it in the fore- frequently they appear. ground of our mind. In the same manner, attempts to get away from anxious thoughts—to keep them out A Contemporary View of Anxiety Disorders 33 of our minds—ensure that they stay. Anxiety makes anxious thoughts feel sticky at precisely the time patients would like to banish them from their awareness. It is of no help at all to ask them to stop worrying, or “just think about something else.” If anything, such distraction tends to make things worse.

Perceptual Distortions Anxiety makes the world seem different and more threatening. Anxious thinking causes over-awareness of thoughts and bodily sensations. People feel overly self-conscious. Thoughts can seem too close, and body parts can feel unusual or awkward. These feelings increase the experience of alarm when distress is triggered. Additionally, anxiety often makes people hypersensitive and hyper-aware. Sounds and other sensations can feel particularly powerful and jarring. Your patients might experience exquisite sensitivity to their bodily feelings, external movements, odors, colors, voice tone, and a host of other sensations that seem quite ordinary when they aren’t feeling anxious. The sum total of this hyper-awareness makes them feel less powerful and more vulnerable, which, in turn, adds to their overall anxiety. The experiences they report are not exaggerations or histrionic: they really are aware in a different way. Anxiety also makes one hyper-vigilant to possible threats. In order to avoid anxiety triggers, patients constantly scan to stay away from them. Attempts to avoid them paradoxically produce them. It feels dangerous not to focus on the source of distress. Other- wise, one might be blindsided by emergencies. So the awareness of threats and dangers stay centered in awareness. Anxiety increases vigilance to the reactions of others as well. Scanning for disapproval or negative reactions on the faces of others makes ambiguous or even neutral faces seem disgusted, angry, or bored.

Intolerance of Uncertainty Life is all uncertainties and no one can predict the future. In most activities, we assume that our future will be like the past. We assume people we love are okay. We learn to ﬁ ll in the gaps of uncertainty with our own experiences. We accept that nothing in life is entirely risk- free, but that there are many low-risk experiences where we can safely disregard the risk. But anxiety makes uncertainty feel threatening. Uncertainty becomes linked with the possibility of disaster. Even more disturbing, anxious thinking makes Certainty is a feeling, not a fact.

Downloaded by [New York University] at 01:46 15 August 2016 thoughts feel frightening. The most unlikely situation can feel as if it has a high probability of occurring. So, anxiety-producing triggers are perceived as extremely dangerous. Imagined catastrophic scenarios feel like they are likely to occur. People with OCD are often extraordinarily distressed by imagined events with almost no probability of occurring. One patient with OCD was terrifi ed that she might step on contaminated chicken droppings and start an epidemic of salmonella that would spread across the country. She checked the soles of her shoes for hours to protect this from happening. The point here is simple: certainty is a feeling and not a fact; a feeling incompatible with anxious arousal yet pursued by anxious people as a salve for their distress. Once patients understand that gaining certainty is not possible in the real world, they can abandon their quest for it, and begin the road to recovery. 34 A Contemporary View of Anxiety Disorders Fearful Thoughts Become Predictive One of the most distressing aspects of anxious thinking is that fearful thoughts feel like they predict future events. So, for example, if someone has a phobia of driving over bridges, anxious thinking makes that person believe that something awful will happen while attempting to drive over a bridge. As a consequence, patients will want to wait until the anxiety subsides before trying to drive over the bridge. It is not uncommon for fearful fl iers to state that they will be ready to fl y when their anxiety about the fl ight goes down. For them, increased anxiety predicts a catastrophic event, while lowered anxiety predicts a safer fl ight. The problem, of course, is that the only reliable way to lower anxiety is exposure to triggers in manageable steps, feeling the distress, and allowing the brain and body to gradually calm down. Waiting for the fear to subside before getting started is a form of avoidance that actually increases the fear.

With Anxiety, Common Sense Makes No Sense Common sense dictates that the best course is to use gut feelings to guide actions. But this is not always true, and it is never true when dealing with an anxiety disorder. Anxi- ety is an excellent trickster and bluffer, and it will make patients believe that they are in danger when perfectly safe. Since anxiety is reinforced by avoidance, gut feelings from anxiety will always tell patients to avoid. If they follow gut feelings, they will always be reinforcing their anxiety. Anxiety triggers the autonomic nervous system to create terror. The terror experienced when anxious is identical to the terror one feels when in objective danger. Both physiological reactions and bodily sensations are exactly the same. As a result, feelings are of no help at all in differentiating when one is in danger from when one is in the midst of an anxiety attack. Common-sense ways of coping are of no help when dealing with anxiety. Many feelings can be trusted to motivate us towards appropriate resolution of situations, but this Danger and anxiety feel is not true with anxiety. Patients must learn not to the same. follow what anxiety tells them to do. Anxiety is a false messenger, and the best way to avoid unintentionally reinforcing anxiety is to do the opposite of what it dictates. The solution is paradoxical: Do not do what The best way to avoid the false messenger is telling you to do, but embrace Downloaded by [New York University] at 01:46 15 August 2016 unintentionally the discomfort that this engenders. That is the thera- reinforcing anxiety is to peutic paradoxical attitude. do the opposite of what it dictates. The Paradoxical Attitude Here are some paradoxes for successfully coping with anxiety.

• When dealing with anxiety, feelings are not to be trusted. Anxiety is a great bluffer that makes a person feel in danger when perfectly safe. A Contemporary View of Anxiety Disorders 35 • When confronting anxiety, less is more. The energy used to fi ght anxiety adds to its intensity. Anxiety is a reaction with tension as an essential component. When one tenses up to fi ght anxiety, it increases the tension that is already there. The best thing to do when feeling anxiety is also the hardest thing: do nothing. Any attempt to push away or fi ght anxiety will only add to its intensity. • Attempts to avoid anxiety make it stronger. The temporary relief one feels when avoiding is actually reinforcing and empowering the distress. Resisting anxiety leads to increased persistence of anxiety. The more one is able to accept the uncomfortable reaction without engaging it, the more quickly it will start to subside. • Short-term anxiety reduction leads to increased suffering in the long run. The only way to reduce anxiety in the short term involves some sort of avoidance. Reduction of anxiety in the future requires an acceptance of increased anxiety in the present. It may not be realistic to expect to be comfortable right away, and regular exposure will increase anxiety for a period of time.

Note 1. Veenstra (2013) presents a somewhat more detailed analysis of the current neuroscience of affect that demonstrates the “bottom-up” rather than “top-down” view of fear circuitry. He makes distinctions among the higher neocortical functions (corresponding to mindfulness), neocortical functions (verbal thinking), paleocortical function (emotional responding), brain nuclei (instinctive survival reactions), and brainstem nuclei (automatic regulation/homeostasis). The amygdala—fully wired a month before birth—responds like an infant, refl exively signaling alarm reactions to the “gist” of danger and without an “off” switch. The paleocortex (developed in the fi rst year of life) supplies the non-verbal fear response to the arousal. He suggests that accepting the initial alarm response (the body arousal, the urge to fi ght or fl ee, the release of neurotransmitters) can be framed as “thanking the amygdala for doing its job”—and then one can be taught to use the higher thinking brain to assess what the problem really is instead of simply responding to automatic emotional processing. However, the circular feedback loops present in the brain make this process complex and simply expecting words to extinguish fear will not be successful. The fear extinguishing circuits respond to four signals—security (presence of a supportive other), safety (tolerating risk), tolerability (tolerating discomfort), and mastery (confi dence in skills). The latter three can be learned by practice. It should be noted that Claire Weekes (1976, Simple, effective treatment of agoraphobia. New York, NY: Hawthorn Books) developed her four-step method (face, accept, fl oat, let time pass) for dealing with panic decades before the validating neuroscience was available. Downloaded by [New York University] at 01:46 15 August 2016 References Aron, E. (2003) The highly sensitive person : How to survive and thrive when the world overwhelms you. New York, NY: HarperCollins. Grünbaum, A. (1993) The philosophical critique of Freud. In P. Robinson (ed.) Freud and his critics. Berkeley, CA: University of California Press. Retrieved from http://publishing.cdlib.org/ ucpressebooks/view?docId=ft4w10062x&chunk.id=s1.3.39&toc.id=ch3&brand=ucpress Paul, G. L. (1966). Insight vs. desensitization in psychotherapy: An experiment in anxiety reduction. Palo Alto, CA: Stanford University Press. Allport, G. W. (1937). Personality: A psychological interpretation . New York, NY. Henry Holt. 36 A Contemporary View of Anxiety Disorders Fishbain, D. A., Rosomoff, H. L., Cutler, R. B., and Rosomoff, R. S. (1995) Secondary gain concept: A review of the scientifi c evidence. The Clinical Journal of Pain 11(1) 6–21. Merikangas, K. R. and Pine, D. (2002). Genetic and other vulnerability factors for anxiety and stress disorders. Neuropsychopharmacology: The fi fth generation of progress. Brentwood, TN: American College of Neuropsychopharmacology, 867–882. Rosenbaum, J. F., Biederman, J., Bolduc-Murphy, E. A., Faraone, S. V., Chaloff, J., Hirshfeld, D. R., and Kagan, J. (1993) Behavioral inhibition in childhood: A risk factor for anxiety disorders. Harvard Review of Psychiatry 1(1) 2–16. Degnan, K. A. and Fox, N. A. (2007) Behavioral inhibition and anxiety disorders: Multiple levels of a resilience process. Development and Psychopathology 19 729–746. Stemberger, R. T., Turner, S. M., Beidel, D.C., and Calhoun, K. S. (1995) Social phobia: An analysis of possible developmental factors. Journal of Abnormal Psychology 104(3) 526. Leonardo, E. D. and Hen, R. (2007) Anxiety as a developmental disorder. Neuropsychopharmacol- ogy 33(1) 134–140. Rapoport, J.L., Inoff-Germain, G., Weissman, M. M., Greenwald, S., Narrow, W. E., Jensen, P. S., . . . Canino, G. (2000) Childhood obsessive–compulsive disorder in the NIMH MECA study: parent versus child identifi cation of cases. Journal of Anxiety Disorders 14(6) 535–548. NIMH Anxiety Disorders. (2009) 29 May 2013. Retrieved from www.nimh.nih.gov/health/ publications/anxiety-disorders Sifneos, Peter E, (1996) Alexithymia: Past and present. The American Journal of Psychiatry 153 137–142. Bracha, H. S. (2004) Freeze, fl ight, fi ght, fright, faint: Adaptationist perspectives on the acute stress response spectrum. CNS spectrums 9(9) 679–685. Porges, S, (2001) The polyvagal theory: Phylogenetic substrates of a social nervous system. Inter- national Journal of Psychophysiolog y 42 123–146. LeDoux, J. (1996) The emotional brain: The mysterious underpinnings of emotional life. New York, NY. Simon and Schuster. Clark, T. (2011) Nerve: Poise under pressure, serenity under stress, and the brave new science of fear and cool. New York, NY: Little, Brown and Company. Veenstra, G. (April 2013) Neuroscience advances for improving therapies . Unpublished paper presented at Anxiety and Depression Association Conference, La Jolla CA. Wegner, D. M., Erber, R., and Zanakos, S. (1993) Ironic processes in the mental control of mood and mood-related thought. Journal of Personality and Social Psychology 65(6) 1093–1104. Downloaded by [New York University] at 01:46 15 August 2016 4 The Therapeutic Attitude of Acceptance

We state in the introduction that this is not a book about anxiety-reducing techniques. We intend to present many ideas about what to say or do with patients, but our primary aim is to communicate that anxiety is not remedied by using techniques to make it go away. Instead we want to transmit an attitude, a perspective, and Anxiety is not remedied an understanding of how anxiety works. We help by using techniques to patients observe how they inadvertently maintain make it go away. their anxiety and, then, how to change these habitual reactions, so that anxiety can diminish. We start with the paradox: we accept anxiety in order to disengage from anxiety. This perspective can be surprising and difﬁ cult for patients to understand. They will ask lots of questions. You can provide them with information, explanations, and many metaphors to explain the approach. Many patients’ initial reaction to this We accept anxiety in idea contains a basic misunderstanding. We do not order to disengage from mean “You have to accept that this will not change, anxiety. you will always be miserable, now just get on with it.” Accepting anxiety in order to disengage from it does not mean accepting suffering and debilitation. On the contrary, there is change coming, and the change is about living a full life with far less suffering and limitations due to anxiety. We describe in detail why presenting this new attitude towards anxiety is essential, and how it can be done effectively. A very different way of communicating much the same message is that patients don’t

Downloaded by [New York University] at 01:46 15 August 2016 have to believe their anxious thoughts, nor trust their anxious feelings. Still another formulation is that patients can learn to change their relationship to anxious thoughts and feelings so that anxiety doesn’t run the show, they do. This is the basic phenomenological change in the experience of anxiety that we want them to understand: The need to avoid anxious thoughts and feelings (which, remember, keeps them going) can become less important in the process of deciding how to live one’s life, in determining what is valuable and meaningful, and in evaluating and interacting with the environment and the self. It frees the person from the miserable trap of frightening engagement with symptoms, and the sometimes frantic but ultimately futile attempts to avoid. Anxiety does not have to be obeyed or avoided or resisted: it can actually be made exciting, interesting, or just irrelevant. 38 The Therapeutic Attitude of Acceptance Patients come to treatment with a multitude of erroneous beliefs about arousal, sensations, thoughts, and their experience of anxiety that need to be addressed and corrected. If not, these beliefs drive behavior that fi ghts and runs away from anxious arousal, with the result that anxiety increases rather than decreases. We sometimes use mini-exposures to demonstrate the fallacy of these beliefs. One woman, who was afraid of heights and suffered from panic disorder, was asked to accompany the therapist to a fl oor that was above her comfort zone. She expressed high anticipatory anxiety about going to a higher fl oor, and worried that the anxiety she felt on the higher fl oor would remain high for the entire day and interfere with her demanding job. Despite her concerns, she accompanied the therapist to the higher fl oor (she chose the fl oor once entering the elevator), she experienced only a fraction of the anxiety she had anticipated, and her anxiety for the remainder of the day was unaffected by this experience. In fact, all her beliefs about this experience turned out to be unsupported by the information provided by our exposure experiment. She was certainly not recovered, but began to question some of her long-held beliefs about her anxiety. We are frequently able to create these types of “corrective learning experiences.” It is a wonder that anxious patients get things so wrong, and continue to hold onto erroneous beliefs that make their life so miserable. The culprit is the nature of anxiety and its ability to spread the false message that it needs to be avoided, and that resistance is the best way to deal with it. Resisting anxiety discourages observation of the processes that are generating anxiety, and keeps patients ignorant of what they need to know.

Approaching Anxiety Mindfully Mindfulness is an essential aspect to treating anxiety. Mindfulness is a state of open and active attention to the present, moment by moment (Kabat-Zinn, 1994). It involves the experience of observing one’s thoughts, feelings, and sensations from a distance, without judgment or evaluation. A mindful attitude implies that there is an observer that can stand back and look at present experiences with perspective, so there is a “self” and an “observer” at the same time. Mindfulness allows patients to gain an increased awareness of inner experience, and has some similarities to introspection. Both involve attending to inner life, but introspection aims to further explore causes or unconscious meanings. Mindfulness, on the other hand, aims to observe the details of the process apart from content. A mindful approach can help patients observe that much of their distress comes from avoidance of anxious thoughts and sensations, rather than the thoughts and sensa-

Downloaded by [New York University] at 01:46 15 August 2016 tions themselves. Mindfulness can be diffi cult for anxious people, since they try to avoid unpleasant sensations, and mindfulness asks to attend to all experiences. Anxious people also have an ingrained tendency to become triggered by certain mental images and bodily sensations, while mindfulness asks to focus without judgment or elaboration. But patients are sensitized, and their reaction makes certain thoughts seem loud and sticky, crowding out the rest. They are constantly checking their thoughts and bodily sensations in order to avoid them, making it harder to stay in the present. There is also the added challenge that anxious people can be extraordinarily hard on themselves, fi lling their mind with critical self-recriminations, while a mindful approach encourages one to attend to inner life non-judgmentally. The Therapeutic Attitude of Acceptance 39 Patients might feel perplexed and frustrated after explaining the importance of mindful awareness. They tend to beat themselves up for failing to stay focused on the present, which usually means getting lost in “what if?” thoughts of the future. This makes it even harder to remain non-judgmental, and this negative cycle can wreak havoc on mindful practices. We often paraphrase Jon Kabat-Zinn’s gentle guidance and say to patients something like, “And when—not if—your mind wanders away into the future or the past, as it is likely to do, each time you notice that it has, gently Change “what if?” to and non-judgmentally escort your mind back to the “what is.” present moment” (Kabat-Zinn, 1990). Change “what if?” to “what is.” Appreciate how hard it is for patients to stay mindful of anxious feelings, and that it is unrealistic to think they won’t fall off the wagon. When this does happen, ask them to follow two basic principles: the principle of discipline and the principle of gentleness. The principle of discipline addresses the diffi culty of staying connected to anxious thoughts and feelings, and our inborn desire to avoid, suppress, and run away from the task. After all, this is hard work for patients! They are staying with a painfully distressing experience in the hopes that things will improve in the future. It is not unlike the discipline that is necessary for successful dieting, exercise routines, or smoking cessation. The principle of gentleness recognizes fallibility and the near certainty that people get frustrated, curse themselves out, make mistakes, want to give up, feel sorry for themselves, and bemoan their bad luck. We do best by getting back onto the path with a gentle voice and self-forgiveness. Internal compassion does not condone or suggest giving up or being lazy, but it also does not condemn. It gives an understanding internal hug—and a gentle escort back to the task at hand. As patients learn to become more comfortable with mindfulness, they will alternate between self-discipline and self-gentleness. Both are necessary; neither is suffi cient.

Embracing Anxiety Anxiety gets worse as patients try to push anxious feelings away. Accepting anxiety is therefore the paradoxical ability to leave it alone. Techniques to relax and calm oneself will often increase anxiety if the goal of these techniques is to turn off the anxious feelings. And distractions—which can sometimes provide temporary relief—can empower the anxiety in the long term if they are utilized improperly. So right from the start, it is

Downloaded by [New York University] at 01:46 15 August 2016 important to educate your patients that anxiety is paradoxical, and that taking an entirely different approach—that of accepting and actively allowing what they previously fought and rejected—will ultimately lead to less suffering. Most patients have already discovered that trying to relax does not work for them, but they rarely understand why. Virtually any response to anxious symptoms undertaken with the express intention of controlling or eliminating these symptoms is subject to what has been called the ironic process (Wegner, Broome, and Blumberg, 1997). This describes the mechanism by which our patient’s attempt to relax is accompanied at the same time by a heightened vigilance designed to check and monitor whether the technique is working. This is a very general process that is responsible for many failed anxiety management techniques, including the fact that attempts to banish anxious thoughts tends to bring them back 40 The Therapeutic Attitude of Acceptance stronger. Forcefully attempting to use breathing as a relaxation tool tends to result in more anxious breathing, and trying to relax often does the opposite. This truism about anxiety’s paradoxical nature is one of the most diffi cult lessons for our patients to learn. Most patients are asking for methods to rid themselves of anxiety. They want the anxiety to go away. Many wonder why they can’t reason themselves out of it, or why they can’t just fi gure out what caused it so their fear will then disappear. Some are disheartened to hear that there is no magic cure, and this can easily lead to additional anxiety and disillusionment. Present this with compassion, sensitivity, and at a manageable pace that does not frighten patients away. As with every other aspect of therapy, timing is essential. Our experience is that this attitude of acceptance has to be very carefully articulated or it will simply be understood as depressing and hopeless. Patients respond initially with “You mean I am stuck like this and I had better get used to it and stop complaining?” This is not at all what acceptance means and this theme will likely need repetition and clarifi cation throughout the therapy. Acceptance means knowing what is modifi able and what is not, what is important to modify and what can be left alone, so that emotional and physical energy is not wasted on the wrong targets. This is where the notion of what is automatic—thoughts, feelings, and sensations—enters the discussion. Not only is one not able to jump in and change what is automatic, but one is not responsible for what happens automatically. That helps us determine what to change. Thus, for example, the initial rush of physical symptoms that occurs when the amygdala sounds the alarm bell (the fi rst fear) is not the target for change. This whoosh of arousal occurs before our conscious awareness, and cannot be intentionally suppressed. And—if we are brutally honest with ourselves (and believe contemporary research)—we all have a tendency to make initial snap evaluative judgments of virtually everything and everyone we see, some of them extraordinarily unfl attering! This tendency is also not amenable to change or suppression. Our anxious patients need to know that we all have sudden automatic intrusions of upsetting thoughts that seemingly come out of nowhere (“I could jump off this balcony,” “What if I suddenly yanked the steering wheel into traffi c?”, “What if I start to giggle in church?”). These initial reactions are automatic, unmodifi able by intentional means, and occur prior to and outside of conscious awareness. However, all is not lost, because what is modifi able is our reaction to these automatic events (the second fear)—we have the capacity to take them seriously or not, to differentiate between arousal as real danger

Downloaded by [New York University] at 01:46 15 August 2016 or a false message of such, to determine whether our thoughts contain useful information, or just plain noise, and—even if they do contain information—what to do with it. Most importantly, Anxiety symptoms we have the capacity to then disengage from these become less terrifying events so they do not produce misery and do not con- when the patient learns to tinue to persist. view them as automatic, Anxiety symptoms become less terrifying and conditioned, natural, more tolerable when the patient learns to view them and part of the human as automatic, conditioned, natural, and part of the experience. human experience, as opposed to signaling danger, pathology, or weakness of character. Everyone has The Therapeutic Attitude of Acceptance 41 these experiences from time to time. People who don’t have an anxiety disorder tend to notice them and then let them go. It is resistance—the frightened and sometimes desperate need to fi ght back the anxiety symptoms—that produces the greatest discomfort and disability. If these automatic experiences signal danger, it is natural to fi ght them, or—at the very least—do everything one can to keep them happening. On the other hand, if we understand them as benign—perhaps uncomfortable or even weird—but not dangerous, then acceptance is achievable. Here is an example that illustrates the central importance of valid information to help us understand arousal: In 1938, there was a dramatized radio production of HG Wells’ War of the Worlds (Koch, 1970). It was a realistic portrayal of a fi ctional alien invasion, complete with reporters describing the invasion and government spokesmen recommending evacuation. For those who tuned in from the beginning of the show and heard the introduction, it was entertaining, suspenseful, and engaging. However, for those who missed the introduction, they had no idea it was a fi ction (the show was broadcast without commercials). Many panicked, resulting in traffi c jams, overwhelmed phone lines, and real trauma. The trauma was real, but the information was false! In an analogous manner, our nervous system feeds us fi ction on a regular basis. Once we understand these signals as fi ction, we can tolerate false alarm signals in our bodies and we can even enjoy the creativity and silliness our minds can come up with. Our job is to help our patients believe that these are truly false alarms. The very same physiological state that occurs in a panic attack—acute pumping adrenalin—is present on a roller coaster, and some people happily seek out and pay for this experience! What is different is not the biology; it is the understanding and the attitude that accompanies the experience. Anxiety symptoms are thus false alarms. A rapid heartbeat does not signal an impending heart attack. A feeling of being off balance or light-headed is not a precur- sor to fainting or syncope. The derealization and depersonalization that accompanies hyperventilation are not signs of psychosis or impending loss of control. Tingling in the fi ngertips and toes and face does not imply a brain tumor. A wave of nausea does not mean vomiting is on the way, nor that the body has ingested a poison or an allergen. Blurry vision is not going to lead to blindness. In addition—and deeply important to know—bizarre intrusive thoughts are thoughts . They are not calls to action, uncontrollable impulses, or evidence of perversion, suicidality, or of being a loser. They do not mean what they may seem to mean. Patients keep the anxiety process going because they are trying to get away from the

Downloaded by [New York University] at 01:46 15 August 2016 rush of arousal, and the assessment that something is very wrong. We are addressing now the nexus of a number of processes central to anxiety disorders: The ironic process (checking frequently to make sure it isn’t there, thus making it more intrusive and alarming), the misleading message that anxious arousal is synonymous with being in danger, the stickiness of the alarming thoughts, the experience that thoughts and actions feel fused (thought–action fusion), the sensitivity to anxious arousal that is central to all people with anxiety disorders (anxiety sensitivity)—all these combine to keep anxiety going and increase its intensity. These processes underlie the functional autonomy of anxiety disorders, and account for why they continue to exist separately from any historical context or confl ictual issue, and why they can go on indefi nitely unless directly addressed. This is the attitude we aim to change. 42 The Therapeutic Attitude of Acceptance The Role of the Therapist Since it is natural for patients to misinterpret these experiences as requiring avoidance and resistance, a straightforward discussion of the biological pathways of these false alarms can be an excellent way to start. Some patients fi nd a discussion of the role of the amygdala and the A straightforward tendency for certain people to inherit the capacity to discussion of the become afraid of fear (anxiety sensitivity) particu- biological pathways of larly helpful. This can go a long way, but it is not the fear and false fear alarms complete story. Accepting anxious arousal is diffi cult can be an excellent way because it triggers the biological drive for survival. to start. The misleading messages from anxiety are saying, “You are in danger if you ignore my message—and the thoughts, feelings, and memories that are associated with it. You are putting your health, your existence, and that of others at risk if you don’t put energy into avoiding, fl eeing, and fi ghting the feelings.” Embracing anxiety therefore takes courage and effort. The anxiety-generating process is especially rapid and complicated when patients are experiencing high levels of anxiety. If they are telling you about episodes of high anxiety, or—better yet—actually experiencing those feelings in the midst of their therapist session, patients will Some patients may beg for tell you that they feel overwhelmed, they will com- reassurance and others plain of a variety of physical and mental symptoms, may avoid the therapist’s and they might use terms like panicking, losing their input. mind, freaking out, cracking up, or going insane. Some patients might cling to you and beg for reassurance, while others feel like they are on a tightrope, trying to avoid a disastrous fall, and view your input as a dangerous distraction. Most will be somewhere in between. When patients are feeling such high anxiety, it is best to stay with basics. Let them know that anxiety is uncomfortable but not dangerous. What they are experiencing is temporary—they aren’t losing their mind, they aren’t going to do the things that run through their minds. Patients need to know that Stay with them. Pay attention to your own fear of anxiety is uncomfortable, their anxiety—the less afraid we are of the patient’s temporary, and that they anxiety, the more helpful we can be. Praise them for Downloaded by [New York University] at 01:46 15 August 2016 are not “losing control.” their courage. Anxious arousal is a product of the amygdala, a primitive part of our brain that is sometimes likened to our inner infant. And, like an infant, anxiety is comforted more by a soothing attitude than by soothing words. Anxious patients can sense our own anxiety, and respond with more distress if we communicate pressure or irritation. It is important to make a very clear distinction between encouraging exposure and pressuring the patient to do it. Essential for patients feeling safe in your presence is their explicit belief that they will never be forced—or put under undue pressure—to endure anxiety when they want to stop. Patients always have the option to stop the exposure, The Therapeutic Attitude of Acceptance 43 because there might be times when words don’t make contact and they are experiencing more distress than Never trick, surprise, they chose to endure. Let them know this is an honor- or insist. It is not your able choice. Patients also need to know that they will responsibility to take never be tricked or surprised. It is not the therapist’s away your patient’s responsibility to take away the patient’s anxiety. That anxiety. only clouds the issue and turns the experience into an irrelevant test. This is practicing a new attitude, not testing the patient’s skill. Each experience of anxiety can become a learning experience. Patients should expect anxiety to return, and it is your mutual task to help them cope more effectively the next time. Even while delivering this message about anxiety, it is possible to be comforting and compassionate, as with any patient who is having a diffi cult time. The serenity prayer of the 12-step movement may be the single most infl uential bit of wisdom ever: peace comes from accepting what one cannot change and changing what one can—and most importantly discerning the difference between the two. That is the attitude we hope to instill.

God grant me the serenity to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference. Living one day at a time; Enjoying one moment at a time; Accepting hardships as the pathway to peace; Taking, as He did, this sinful world as it is, not as I would have it; Reinhold Niebuhr (1943)

Once again, here is where a mindful attitude is extremely helpful. At fi rst, the idea of observing their own thoughts and sensations may feel almost alien to patients. They may not have a notion that there is an “I,” an observer that can stand back and look at thoughts and sensations. They may not yet grasp the idea that At fi rst, the idea of it is not the thoughts and sensations that cause the observing their own Downloaded by [New York University] at 01:46 15 August 2016 ongoing anguish, but their reaction to, judgment thoughts and sensations of, and avoidance of these thoughts and sensations may feel almost alien to that is the ultimate source of the suffering. In the patients. beginning of treatment, they may benefi t from simple mindfulness exercises aimed at observing their inner experience. Here is a simple exercise to demonstrate the act of observing (speaking very slowly):

Sit comfortably in the chair and close your eyes, or if you prefer, just ﬁ nd a spot on the carpet and lightly rest your eyes there. Now try to notice how your body feels. See if you can take a little tour of your body and see where you ﬁ nd muscle 44 The Therapeutic Attitude of Acceptance tension. Not to change it, just to notice. Your scalp? Your forehead? Around your eyes? Your cheeks? Chin? Notice the tension in your neck. Front. Back. When you are ready, move to your shoulders and arms. Now your chest. Your belly (and so on . . .). Perhaps now you can focus your attention on your breath, notice in . . . and out . . . in . . . and out. Mostly your chest? Your belly? Is the air you breathe out warm? Perhaps you can notice now the places where your body touches the chair. Your thighs, the backs of your arms. Now perhaps you can turn your attention to the sounds in the room. What can you hear? (wait 30 seconds) . . . Did you hear your own heart or breath? . . . As you turn your attention to your breath—just following it—notice your mind and what it is doing. Notice your thoughts. Just notice what they are. Rest lightly there. Notice how your mind jumps from one thing to another. Notice when you stray from your breath and go forward and backward in time. Notice judgments. Liking and not liking. Self-critical thoughts. Impatient thoughts. Come back to the present moment each time you notice you are not here in time. Just watch.

The point of this exercise is not to become relaxed—although many people will spontaneously report feeling more relaxed. The point is to learn to observe in a non- judgmental way, the contents of the mind and the sensations of the body: to learn how to be an observer as well as a participant in the experience of the senses and the mind. Be sure to clarify that this is not a technique to ward off or cope with anxiety; it is an exercise in simply turning one’s attention to inner experience and embracing it. It is worthwhile to note that there are some patients who experience increased anxiety—sometimes to the point of panic—in response to relaxation (Wells, 1990). Most of these patients are chronically anxious and interpret sensations associated with letting go of muscular tension as weird or out of control. They report they don’t feel suf- ﬁ ciently vigilant, and are frightened by the lack of tension in their body. They are so used to tension in their body that it can feel scary to be without those feelings. These patients are generally vigilant, need to place strict controls on the sensations they allow, and often shun drink or medicines, because of the anxiety that can be triggered by alteration in bodily sensations. This is called panicogenic relaxation, and it is understandable when relaxation is viewed as a threat to ongoing vigilance. With patients like this, we suggest that you precede any mindfulness exercises with a message about accepting, observing, and even welcoming whatever “strange” sensations appear, and then to proceed gently, allowing your patient to set a manageable pace.

Downloaded by [New York University] at 01:46 15 August 2016 As patients become more skilled at standing back and observing their own reactions to anxiety, they begin to see and understand the ways in which they struggle to avoid it, and the distressing emotions maintained by that struggle. So the aim is to teach patients how to embrace anxiety, because this is the path that alters the fear maintaining cycle. Embracing anxiety means refusing to engage with its frightening messages and, instead, allowing the feelings to remain: not fi ghting back, not pushing back, not getting in a tug of war with them, not running away, not looking for reassurance, not checking to see whether the feelings are going up or down, not trying to stop the catastrophic “what if” thoughts, not analyzing the meaning of the anxiety, and not trying to suppress them. Embracing and disengaging from anxiety is doing what is perhaps the most diffi cult thing of all—observing and leaving it alone, while doing nothing to directly change it. The Therapeutic Attitude of Acceptance 45 Teaching Metaphors Metaphors are frequently used as a means of communicating the therapeutic attitudes of paradox and disengagement. Here is a partial list of metaphors that communicate similar ideas. Metaphors and stories can illustrate the path to a richer, more psychologically fl exible life. Many patients spontaneously create their own meaningful metaphors as they begin to grasp the basic ideas.

Bug on a Windshield Imagine you are driving on the highway and a big, fat bug smashes into your windshield. You immediately put on your windshield washer, but discover to your annoyance that you are out of washer fl uid, and all you have done is to smear the remains of the bug all over the windshield. You are on an interstate and the next exit is 28 miles down the road. How do you cope with this situation? On one hand, you can do everything you can to try to get the bug off the windshield, but each additional effort only makes the smear larger and more intrusive. You can put yourself in some danger by opening up your window, leaning forward, and trying to wipe the windshield with an old cloth you happen to have in the back seat. You can continue to use the wiper without any washer fl uid. On the other hand, you could also accept the unfortunate annoyance, and acknowledge that your task at the moment is to drive the car as safely as possible. You realize that you have a fairly clear—but annoyingly obscured—view of the road, and that you are able to safely drive the car despite that intrusion. As you drive, the wind dries up the smear and on its own, with no intervention from you, the mud begins to fl ake off and fl y away.

Headache Think of times you have a splitting headache. Then some emergency occurs, and you cope with it. It is as if the headache becomes less intense—it goes into the background. It makes no sense to say that you pushed your headache away, but the pain became much more bearable as you disengaged from the pain and engaged with the task at hand. In the same sense, anxiety can’t be pushed away, but it becomes more bearable as you disengage from the distress and become more engaged with manageable tasks in the present.

Downloaded by [New York University] at 01:46 15 August 2016 Float The best thing to do when feeling anxiety is also the hardest thing to do—do nothing. If you imagine anxiety as a huge wave that builds up intensity to a crescendo and then starts to recede, the best way to cope with that is to simply ﬂ oat on the wave. You don’t have to ﬁ ght the wave or stop the wave or modify it in any way. Instead, simply allow the wave the pick you up and then allow it to gently place you back where you were when it passes.

Watching Anxiety Pass Lie on the ground and imagine that your anxiety is in the clouds ﬂ oating in the sky. You wouldn’t think of changing the course of clouds as they ﬂ oat by, and, in the same 46 The Therapeutic Attitude of Acceptance manner, imagine that you have no control at all over the anxious arousal that you have placed into the sky. Your job is just to observe the clouds and your anxiety as you let time pass.

Picture in a Picture There are televisions with the capacity to embed a small picture of one channel while the large screen is tuned to a different channel. People often use these to follow a sports event while also watching a favorite show, and allow their attention to move from the big screen to the little square in the corner and back. Think about intrusive thoughts or unwanted sensations or anxious narratives as appearing on the “Anxiety channel” in the small picture in the corner. Imagine that the “Real life channel” is showing on the big screen. There is actually no way to turn off the little picture. It is just there. Imagine watching the big screen, and when you notice your attention has been pulled to the Anxiety channel, simply redirect your attention without judgment back to the real show.

Pop-ups on a Computer Many people can identify with this metaphor. You are working on your computer and unfortunately you keep getting pop-up ads intruding. You quickly hit the delete X and they disappear. However, one shows up with no obvious X in the corner. You try to right-click. You try to move all over the text to ﬁ nd a hidden delete button. There is none. You keep accidentally opening up the ad and have to endure a 15-second promo for something annoying. Then the pop-up shows up again. No X for delete. All you can do is reduce it slightly and drag it to the side. Your job is to keep on working on whatever you were working on—and stop trying to ﬁ nd a solution to the annoying intrusion and accidentally wasting even more time and energy. Eventually the pop-up will leave, but you just can’t know when.

Kids Fighting in the Rear Seat You are driving on the highway. There are no exits for miles and the trafﬁ c is moving fast. In the back seat are two children, safely strapped in but tired and crabby and screaming at each other and at you. There is nothing you can safely do except keep driving. You can’t turn around. They don’t listen to you trying to quiet them. You are helpless to calm them. Eventually they will probably fall asleep, but, until then, all you can do is keep on driving. Downloaded by [New York University] at 01:46 15 August 2016

The Anxiety Channel You wake up one morning and a weird event has occurred. Your house has grown an extra room. The only thing in it is a massive wall mounted fl at screen TV. It is tuned to the Anxiety channel. There is no remote. There are no controls on the TV. The plug is apparently behind it. There is no way to turn it off. Your job is to carry on your life without continuous checking to see if it is off yet—it isn’t. Sometimes you can hear it clearly—especially if you are resting or quiet. Other times it just sounds like a mumble. You have to fi gure out how to give up on getting it to turn off and still lead a good life. The Therapeutic Attitude of Acceptance 47 Anxious Arousal as a Gust of Wind When anxiety comes, try to go with it. Don’t fl ee it. Turn your sail into the anxious wind. There will be less resistance. Anxiety will have less effect on you.

Allow the Ant Imagine an ant crawling up your arm. Don’t brush it off. Observe. Notice discomfort. Notice thoughts. Notice sensations and urges. Let it happen. Do nothing. We present additional metaphors in Appendix 1.

Essential Elements to the Therapeutic Attitude of Acceptance We have distilled what we ﬁ nd to be the most important aspects of the therapeutic attitude into f ive basic elements: expecting, labeling, surrendering, actively allowing, and tolerating uncertainty. We include tolerance of uncertainty to underscore that along with each of the ﬁ rst four elements is an accompanying task: to tolerate the possibility of being mistaken—that there is at least some uncertainty inherent in each element—and that there is a leap of faith involved in acceptance.

Expect Anxiety Expecting anxiety is in direct opposition to hoping anxiety won’t happen. Such hopes, while natural, greatly undermine the attitude of acceptance. They set up a fi ght with symptoms. Dashed hopes bring shame, disappointment, and anger when conditioned responses are triggered. And surprise itself is an arousing response which sets up a struggle. Expecting anxiety acknowledges the impact of the anxiety disorder. The goal is never to be surprised or blindsided by the emergence of high anxiety. An analogy is the model of Alcoholics Anonymous: members always introduce themselves as “alcoholics,” even after decades without a drink. A member once explained why: he said that—despite 23 years of sobriety—he never again wanted to be blindsided by a sudden urge to drink. In his distant past, walking by a bar, he might notice the smell of whiskey and the next thing he knew was waking up under a bar-stool, dead drunk. He was now always ready to take action if an urge to drink should emerge. In the same way, expecting anxiety acknowledges the possibility—or more accu- Downloaded by [New York University] at 01:46 15 August 2016 rately, the inevitability—of anxious arousal in the future. This allows patients to assume the most therapeutic way to react to it. Addressing the therapeutic attitude that allows patients to accept the things they can’t change is an essential part of recovery. Anxious people have anxious bodies and conditioned anxious reactions that will re-emerge in the future. Hoping that anxiety will not happen is counter-productive. Expecting anxiety also suggests that patients remain mindful about times when they might be more sensitized. Anxiety tends to fl are during stressful times, among stages of the menstrual cycle, during times of fatigue, illness, hunger, anger, and any strongly arousing emotion. (This is the aspect of anxiety sensitivity that was addressed in C hapter 2.) Patients can become better predictors of when arousal might occur, and be more 48 The Therapeutic Attitude of Acceptance accepting when symptoms do arise. There is inherent uncertainty in predicting symptoms: anticipatory anxiety gives false messages (see Chapter 13) and confi dence that a task is mastered is a set up for great distress when unexpected symptoms occur.

Label Fearful Distress as Anxiety Anxious thinking distorts the view of the world, makes it feel unsafe, and outsmarts common sense. So it is essential to make a clear distinction between two very different types of fearful distress: distress generated by danger, and distress triggered by anxiety. They require opposite attitudes to respond well. A mindful approach helps to make this distinction because it encourages patients to observe—as it is happening—their internal fear producing process. When confronted with danger, our goal is to protect ourselves. We want to distance ourselves from the danger or neutralize the source. Here is where the “fi ght, fl ight, freeze” arousal mechanism is protective. But if one feels terror based on anxiety, attempts to avoid the source will only serve to reinforce the anxiety. The “fi ght, fl ight, freeze” arousal mechanism has been tricked, and points patients in the wrong direction. So the fi rst job is to put the label of anxiety on all fearful distress that is not caused by an objective danger. Feeling frightened is not the same as being unsafe. Labeling anxiety is the fi rst step towards breaking this connection. Here is an example of someone successfully labeling terror as anxiety.

This terror that I feel is my anxiety. I am not in danger. I do not have to avoid whatever is making me feel this way. There is no danger to confront. I just have to stay with the idea that my terror is anxiety. My anxiety makes the scary thoughts going through my mind feel like they can really happen. I therefore can’t trust my feelings when dealing with anxiety. This is an example of anxiety trying to bluff me.

This can be diffi cult to remember when patients are trying to cope with high anxiety. We sometimes suggest they write their own version of what they want to say to themselves, and put them on a card that is easily available during these times. This is a diffi cult point for your patients. Labeling anxiety is Since the feelings of fear triggered by real danger are the fi rst step towards the same as the feelings of fear that accompany anx- disabling anxiety. ious arousal, the physiology is identical. So feelings

Downloaded by [New York University] at 01:46 15 August 2016 are useless in helping make the distinction between danger and anxious arousal. This means that there is a need to rely on facts and not feelings. Labeling distress as anxiety and labeling thinking as anxious thinking requires that patients need to know the facts about anxiety. Part and parcel of labeling is coping with its inherent uncertainty. Here is an example: A 28-year-old man came into therapy because he was told by his doctor that he had panic disorder. He had several episodes of tachycardia and tightness and pains in his chest that resulted in three emergency room visits. He had been worked up by a cardiologist and told that his heart was entirely healthy, and his symptoms were a result of panic attacks. He was not still not certain what he was experiencing was anxiety, and not a dangerous medical condition. The Therapeutic Attitude of Acceptance 49

PATIENT : It seems unbelievable that there’s nothing wrong with my heart. But that’s what the doctor says. I get such pains and I feel my heart thumping. THERAPIST: It sounds like it really terrifi es you. PATIENT: Yeah, I’m hoping you can give me some techniques to make these go away. THERAPIST: Well, it sounds like you aren’t sure about what the doctor told you. I suspect you wonder that maybe there is something dangerous about your heart, and you are having trouble dealing with that uncertainty. Your doctor is saying one thing, but your body is still reacting with such intensity and such pain. PATIENT: That’s exactly right. I keep thinking that the doctor must have missed something. THERAPIST: So at this point you are having diffi culty labeling your experience as anxiety. You are uncertain whether it is anxiety—as the doctor told you—or perhaps your life is in danger because there is something wrong with your heart. You have the opinion of one highly respected expert. You probably pretty much believe him, but you aren’t sure. So we have to fi gure out what will allow you to accept the fact that no one is correct 100 percent of the time, and to grapple with the risk that you can’t be completely certain it is anxiety as opposed to a heart problem.

Here is another example: A 52-year-old man with obsessive-compulsive disorder (OCD) is terriﬁ ed that he might send out a wildly inappropriate email to a business contact. His work-day has become a hell of continually checking and rechecking all the emails he sends out. He is struggling to label his distress as anxiety when in the midst of his checking ritual.

PATIENT: I know it’s crazy, but I can’t stop worrying that maybe I’ll curse out a client, or send some sexually offensive comments on my emails. THERAPIST: So you check to make sure they are okay? PATIENT: Yeah, but not just once. Over and over again. I worry that maybe I didn’t pay attention, and so I try to read the email out loud so I can remember what I said and be more sure. THERAPIST: Do you see this as part of your OCD? PATIENT: Absolutely. At least right now I know it is. But when I’m about to press the send button, I get this terror and I have to make sure again. And then I read it over and over again and it gets out of hand and I’m losing myself because I just want to be 100 percent sure. And then I just lose it. THERAPIST: Okay, I understand what is happening. And here is what I would like you to

Downloaded by [New York University] at 01:46 15 August 2016 do: write an email and tell yourself that of course you are going to want to check. And when you start to worry about cursing someone out in the email, ask yourself if you can label this as anxiety triggered by doubting thoughts that come into your mind.

So we see that labeling the fearful distress as anxiety is often intertwined with the diffi culty of accepting uncertainty. We want to help them take that necessary leap of faith that allows them to label the next episode of chest pain or intrusive thoughts as acceptable instead of dangerous. Simply asking oneself the question, “Is this an OCD thought?” or, “Is this a false alarm in my body?” is already the beginning of perspective on the anxiety experience. This beckons the observing self to question the automatic sensitivity 50 The Therapeutic Attitude of Acceptance and the call to action or avoidance. As we will explore Anxious thoughts in some detail later on in the book, anxious thoughts are identifi ed not by are identifi ed not by their content, but by how they their content but by feel and by the accompanying urge to respond as if how they feel and the they are a real and present danger. Once there are accompanying urge to good explanations for the thoughts and sensations, respond to them. patients become increasingly aware of an inner “wise mind” that knows it is a panic attack or an obsessive thought and not a heart attack or an uncontrollable urge to do something crazy. The part that knows is just not certain, but wants to be certain. Grayson (2003) has an interesting thought experiment he proposes to help people access their wise mind without demanding certainty, which he calls the “gun test.” (See Chapter 6 on techniques for details.) How many have received anxious calls from patients complaining about cardiac symptoms, fearing they are having a heart attack? Do you wonder out loud why they called you, rather than 911 or some other emergency medical person? Your patient called because there is some part of him that is aware it is probably not a heart attack, but wants reassurance to be sure. This issue will be addressed in some detail under the topic of “The reassurance junkie” in Chapter 12 . Appendix 2 contains a summary of the labeling process that can be given to patients.

Surrender the Struggle The goal is to experience anxiety without becoming disappointed, angry, guilty, or ashamed. To neither fi ght off their symptoms, nor pretend they are not there. Both routes only exacerbate distress. Surrendering the struggle means accepting one has an anxiety disorder, That which we resist will and anxious arousal is the defi ning symptom. The tend to persist. emergence of anxious thoughts or sensations is neither a failure nor a fl aw. Symptoms are just thoughts and feelings, and feelings and thoughts are not facts. Accepting these thoughts involves the paradox of not reacting to them and not entertaining them. Surrendering the struggle means to stop actively trying to relax. Fighting the thoughts and feelings will make them more intense, intrusive, and disturbing. That which we resist will tend to persist.

Downloaded by [New York University] at 01:46 15 August 2016 It is easier to surrender the struggle when there is a clear distinction between “fi rst” and “second” fears. Help patients accept their “fi rst feelings” of anxiety, without trying to fi ght off, control, or ignore them. Patients cannot make them go away, and trying to do so will only make their anxiety more intense. It is often helpful for patients to rate their anxiety from zero (no anxiety) to 10 (panic) and observe that it fl uctuates up and down. Self-talk can help during these times. Patients can remind themselves with statements similar to these: “Accept—don’t fi ght.” “I can feel anxious and still do this.” “I will accept this anxiety and continue doing what I must.” “It is okay to be anxious. It is okay not to feel in control.” Surrendering the struggle is part and parcel of accepting the discomfort of anxious arousal, and accepting the reality of uncertainty when a patient is pleading for certainty. The Therapeutic Attitude of Acceptance 51 But certainty is a feeling, not a fact. The feeling of certainty is elusive when feeling anxious, and patients must strive to accept that nothing is risk-free or guaranteed, and that doubts may arise about anything and everything. We go on making decisions “as if” things were certain. If not, anxiety can paralyze us by denying the everyday illusions of safety and certainty. Surrendering the struggle also requires the acceptance of limited control over thoughts, sensations, and emotions. Our brains are structured so that most of those functions are outside of our awareness and our control. There are benefi ts to accepting this truism so that we are able to focus on what gives us most pleasure and satisfaction, and less distracted by messages that are irrelevant, unchangeable, or both. Carbonell (2004) suggests these words to describe what we call surrendering the struggle:

Here I accept the fact that I’m afraid at this moment. I don’t ﬁ ght the feeling; ask God to take it away; blame myself, or anybody else. I accept, as best I can, that I’m afraid in the same way I would accept a headache. I don’t like headaches, but I don’t bang my head against the wall in an effort to get rid of them, because that makes them worse. Overcoming panic attacks begins with working with, not against, my panic and anxiety symptoms (p. 146).

Acceptance and commitment therapy suggests the following metaphor—imagine you and your symptoms are involved in a tug of war, struggling back and forth for control and power. Now, instead of trying to win the war, drop the rope. Observe what happens (Forsyth and Eifert, 2007).

Actively Allow Anxiety Actively allowing is not the same thing as “putting up with.” Sometimes people accept the sensations, thoughts, and urges, but then count the minutes, wish and hope for it to stop, hold their breath until it is gone, and “white knuckle” their way through the experience. This is not the same as actively allowing it to go on as long Actively allowing is not as it happens to go on. Allowing is one step further the same thing as “putting than accepting. It entails willingness not only for up with.” the symptoms to be there, but also willingness to be

Downloaded by [New York University] at 01:46 15 August 2016 uncomfortable (Twohig, Hayes, and Masuda, 2006). It engages passivity in the face of instincts that seem to be screaming for action, since the most therapeutic way of coping with anxiety is to leave it alone. Again, it is the resistance to anxious arousal that intensiﬁ es and empowers it. So the best thing to do—which is also the hardest thing—is to do nothing. Surrender to the anxiety. Float with the feelings. Allow it to be there. Ask patients to thank their amygdala for doing its job. Actively give permission for symptoms to remain as long as they will. Again there is the additional task of tolerating uncertainty—of not knowing when the symptoms will abate, of not knowing “what to do,” of simply letting things be what they are. It is helpful to stay in the present while allowing time to pass. Patients make judgments that their fear is something to be avoided, and so devise ways to try to control it. 52 The Therapeutic Attitude of Acceptance Remind your patients that it is not their fear that is taking them out of the present and propelling them into frightening “what if” scenarios, but rather their resistance to the fear. Actively allowing anxiety also means learning to be patient. Patients sometimes need to practice the art of doing nothing. Especially when anxiety is telling them to move; that is the time to practice staying still. It is not easy, but it is a skill that can be learned. It is important to temper self-discipline with gentleness and practice the skill of letting time pass. The key is to surrender to what one cannot control. Ask your patients to feel their anxiety, feel their own resistance, and observe how they interact. Chapter 5, Getting Started, presents information that can be utilized right away— information that helps to create a safe and therapeutic connection between therapist and patient, and gives the patient information essential for beginning to counter the false messages Proper therapeutic of anxiety. Chapter 6 , Techniques Your Patients attitude is the essential Have Probably Already Tried and Misunderstood, bedrock to which reviews the range of anxiety management tech- both information and niques, and explains how they can be best utilized to technique are tethered. help patients recover. Techniques can be helpful or harmful, depending on the attitude with which they are implemented. Proper therapeutic attitude is the essential bedrock to which both information and technique are tethered.

References Kabat-Zinn, J. (1994) Wherever you go, there you are: Mindfulness meditation in everyday life. New York, NY: Hyperion. Kabat-Zinn, J. (1990) Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness . New York, NY: Delacorte. Wegner, D. M., Broome, A., and Blumberg, S.J. (1997) Ironic effects of trying to relax under stress. Behaviour Research and Therapy 35(1) 11–21. Koch, H. (1970) The panic broadcast: Portrait of an event . New York, NY: Little, Brown. Niebuhr, R. (1943) The serenity prayer. Bulletin of the Federal Council of Churches. Wells, A. (1990) Panic disorder in association with relaxation induced anxiety: An attentional training approach to treatment. Behavior Therapy 21(3) 273–280. Grayson, J. (2003) Freedom from obsessive compulsive disorder: A personalized recovery program for living with uncertainty . New York, NY: Berkley. Carbonell, D. (2004) Panic attacks workbook . Berkeley, CA: Ulysses Press. Forsyth, J. P. and Eifert, G. H. (2007) The mindfulness and acceptance workbook for anxiety. Oakland, Downloaded by [New York University] at 01:46 15 August 2016 CA. New Harbinger Publications. Twohig, M. P., Hayes, S. C., and Masuda, A. (2006) Increasing willingness to experience obsessions: Acceptance and commitment therapy as a treatment of obsessive-compulsive disorder. Behavior Therapy 37(1) 3–13. 5 Getting Started

Many of our patients have been suffering with anxiety for years. Many have been in therapy as well as on medication. Some may have been in and out of therapy over the years. They are either a little bit better but still suffering, or perhaps getting worse. They might feel fed up, demoralized, ashamed, afraid, and bewildered. They come to us understandably skep- tical about their chances for change, but still hoping that our expertise in treating anxiety disorders will offer something new and helpful. The ﬁ rst contact is often through our websites or word-of-mouth. Many are sophisticated about both anxiety and treatment, but some have avoided information because of their anxiety. Some have misinformation from sources varying from family members to popular media. Some know very little.

The First Contact Must Instill Hope The fi rst session is important for many reasons, but most important is the instillation of hope. Here are the messages to impart within the fi rst hour of seeing a new patient with signifi cant anxiety symptoms.

• What you are suffering from has a name and there is now a signiﬁ cant body of knowledge about how to help people just like you. • There are a lot of people like you. • You are not going crazy or losing control. • High anxiety—even a panic attack—is self-limiting. It will not go on forever. • You are not in danger. • It is actually quite possible to be this disabled and/or this deeply distressed and still

Downloaded by [New York University] at 01:46 15 August 2016 not be in danger. • There are very good reasons, none of which are your fault, why everything you have been trying to help yourself has not been working or stops working. • You are going to get a good explanation for how and why your mind and body are acting like this. The explanation will show you why what you have tried does not work. • There is a new way to go about relating to your anxiety experience that will make a huge difference. We are going to give you keys. We are going to ﬁ gure out together what you are doing that inadvertently keeps your anxiety going and interrupt these cycles. • Everyone who is anxious avoids, but avoidance makes anxiety worse in the long run. • It may not be obvious yet, but you are afraid of the feelings inside of you. The external object or situation just triggers the feelings inside. 54 Getting Started • Inadvertently and despite your best intentions, you are somehow maintaining this anxiety. Once you learn how you do it, you can then learn how not to do it. • You are courageous just to walk in to this appointment and this is admirable. • Working on your anxiety can be uncomfortable, but there is every reason to believe your work will result in a lot less suffering. • You are safe to say anything here. Your thoughts and feelings do not scare me. They are thoughts and feelings. Not facts or signs.

Immediate Help: Embed Information in Your Questions The initial interview of someone suffering from an anxiety disorder may depart from the typical intake or evaluation session in a number of ways. Assessment is an extended process, fi rst establishing a formal diagnosis but then continuing over a period of several sessions and often revisited in the course of therapy. The goal is to construct a theory of how this individual Be immediately helpful maintains anxiety. This requires obtaining detailed by embedding new phenomenological information about the nature of information within the the anxiety experience. initial evaluation. In the fi rst contact, the aim is to intersperse history gathering with initial psycho-education, so that the patient leaves the fi rst session already aware that there is a lot to learn and ways to approach recovery different from what they have already tried. This helps to instill hope. Here are a few examples of embedding psycho-education in the initial history-taking process.

THERAPIST: So this condition tends to run in families. Any idea which side of the family has an anxiety disorder? PATIENT : Well no one that I know has ever had a diagnosis. THERAPIST : Some of this is pretty embarrassing and hide-able with excuses. PATIENT : Well, my father hates crowds and often did not join the rest of us when we went out. But he drank. THERAPIST: Well it is not unusual for people to stumble into drinking as a way of trying to deal with anxiety. Maybe the “hating” was really “being afraid of”? Would that have been something your Dad might have been able to acknowledge? PATIENT: No way. Come to think of it, his sister had “spells” all her life and we always Downloaded by [New York University] at 01:46 15 August 2016 thought it was her nerves. And my cousin, her son, is on medication for anxiety. THERAPIST: It looks like this probably comes from your Dad’s side of the family. When they were handing out bodies, you got in the “anxiety body line” through no fault of your own, and now you are going to learn how to manage this anxiety body.

Another example:

PATIENT: So when I am driving I start getting dizzy and feel like I am going to pass out, so I won’t drive on highways where I can’t pull over safely. Bridges and tunnels I can’t do for the same reason. Getting Started 55

THERAPIST: Are there other places or situations where you feel the same? PATIENT : I always get that way in elevators and for some reason whenever I have to talk to my boss if he is standing in the doorway of my ofﬁ ce. But I stick it out and it goes away. I guess if I pass out at work or in an elevator, no one will get hurt, but I could cause not only my own death but someone else’s if I pass out while I am driving. THERAPIST: Before I go on and ask you a lot of questions about all those situations in which you feel trapped and start to feel panicky, there are a few important facts to know. Let me ask—have you ever actually passed out? PATIENT: No, not ever, but I get really close. THERAPIST : Well also, are you actually dizzy? The room spinning? Or are you lightheaded? What we call feeling “fainty” because it “feels” like it. PATIENT: I guess it is not really dizzy. But it is really strong. I can barely think. THERAPIST: So you are afraid of having a panic attack when you feel trapped. This is great news because actually panic attacks do not cause fainting. Your blood pressure is going up, not down. In fact, if you were actually about to faint for real, like from pain or malnutrition, best thing you could do would be to have a panic attack. Anxiety actually protects you from fainting.

Another example:

PATIENT: I am here because I am afraid I am going to hurt my partner. I love her and would do anything for her, but I have these terrible thoughts. I have been praying for hours every day for God to take these horrible thoughts away. I can’t tell her why I am here. But there is something wrong with me. I am a non-violent person. I grew up around violence and I swore I would never do anything to hurt someone I love. What if my childhood is catching up with me? They say abused people can become abusers. I need help. THERAPIST: This may sound like a very strange thing to say, but does OCD run in your family? Because these are “harming obsessions,” not violent impulses. PATIENT: You mean hand-washing and getting stuck with everything having to be exactly arranged? I don’t have that. THERAPIST: Well, OCD can take many forms and sometimes is pretty subtle. It can look like excessive worrying or phobias or quirky behavior—or “bad thoughts” that won’t go away. PATIENT: My grandmother never left the house. I never knew why. THERAPIST:

Downloaded by [New York University] at 01:46 15 August 2016 Well, we can take a look at where you inherited the tendency to have sticky thoughts, but for right now, I want you to know these are harmless intrusive thoughts. I have no worries for your partner’s safety. PATIENT: I was so afraid to come here. I thought you might put me in the hospital. I know in my heart that I can control this. I just want the thoughts to stop.

In the fi rst case, the biology of anxiety and genetic predisposition towards anxiety disorders is embedded in the assessment. In the second case, the unifying notion of “being trapped” as a trigger for anxiety symptoms is introduced, as well as the correction of one false message arising from sensations of arousal—the specifi c message that one is about to faint. This begins the ongoing communication that feelings of being in danger 56 Getting Started are not the same as being in danger. And in the third case, the critically important fact that intrusive thoughts are not signals of imminent loss of control is introduced. An additional point is made here. The therapist in the third case is deliberately not pursuing more information about the violent childhood at this point. This information is being stored for exploration at a later time, when the immediate terror about the thoughts has subsided. If the therapist were to launch into a search for causes stem- ming from childhood, it would provoke more affect, more anxiety, and more resistance. Fighting off the intrusive obsessive thoughts would become even more important as memories of a violent childhood were brought forward, and likely cause a worsening of symptoms. Violent thoughts are probably stuck because they are the most ego-dystonic, abhorrent, and resisted thoughts this patient could have (see Chapter 10 ). But now is not the time to do this work. That will come later. It is now time to teach the patient how to not be afraid of these thoughts, and to stop the resistance that makes them more intense. Again, the goal is to be immediately helpful by embedding bits of new information within the initial evaluation. Interactions like these make that fi rst session essential in setting the stage for further assessment and treatment. In the interest of instilling hope, we may choose not to immediately gather all the historical details. But over the next sessions, all the needed information will be obtained. It is, of course, essential to do a full psychiatric screening to rule out psychoses and suicidal or medical emergencies. It is especially important to rule out agitation with patients who present with anxiety as their major issue. Agitation—sometimes confused with anxiety—can indicate major depression, mixed bipolar, a medical condition, or other serious problems that require immediate care (see Chapter 9 ). Signifi cant psychosocial stressors also need to be assessed.

Get the Details The second goal of initial interviews is gathering detailed phenomenology to aid in diagnosis and treatment planning. The patient’s initial presentation will not be sufﬁ cient for understanding the diagnosis. For example, patients will frequently present for treatment of their “pho- The patient’s initial bias” and it will take a bit of questioning to under- presentation will stand what they are really afraid of—is it actually the not be sufﬁ cient for external object or internal sensations, feelings, mem- understanding the ories, images, or thoughts—or some combination of diagnosis. these?

Downloaded by [New York University] at 01:46 15 August 2016 Here are some typical examples:

• Someone presenting with a “germ phobia” that turns out to be classic OCD. • Someone who enters therapy because of “claustrophobia” and who describes the avoidance of places where she feels trapped because of the fear of having a panic attack. This is panic disorder. • A young man says that he feels extremely low self-esteem, when the primary issue is a fear of speaking to others or being around other people. He suffers from social anxiety disorder (SAD). • A “driving phobia” can be the presenting complaint for someone with intrusive obsessive thoughts (what if I drive the car into a pedestrian?), a fear of getting lost or Getting Started 57 making some other mistake in public, a fear of panic attacks while driving, a fear of the sensations of high speed, a fear of throwing up or losing bladder or bowel control, or fear of a variety of other triggers. • People who enter therapy for a “fear of public speaking” may fear humiliation, a panic attack, fear of acting on an intrusive obsessive thought, a memory of a bad experience, or the arousal associated with drawing positive attention. • A patient may appear self-diagnosed with OCD but their “compulsion” turns out to be an impulse-control problem such as compulsive gambling or kleptomania. This is discussed in the section on impulse control vs. anxiety disorder—differential (see Chapter 7 , on diagnosis). • A “fear of needles” can be blood–injury phobia, but it can also be panic disorder, fear of contamination secondary to OCD, anxiety from childhood medical trauma.

It is rare that a patient comes to therapy with an accurate self-diagnosis, anxiety or not. But the characteristics of anxiety disorders make this even more unlikely. Anxious patients tend to be intolerant of intense affect, and they often view their experiences through the fog of anxious arousal. In fact, many anxious patients have some retrograde amnesia of details during anxious arousal. This makes it particularly important for therapists to help patients recall details of their experience, and the best way is to ask questions, thus making it clear that addressing symptoms in detail is proper fodder for therapy. Patients almost universally appreciate an extremely detailed discussion of their experience, and can begin the process of learning how to distinguish thoughts, sensations, and beliefs from external triggers during these early discussions. However, it will usually be necessary to return to their descriptions more than once, as they become more aware of their internal anxiety generating experiences. Even while gathering details of the patient’s anxiety experience, it is possible to embed teaching points in the process. Here is an example:

PATIENT: Job interviews make me so anxious; I can’t look for a job. THERAPIST: What exactly about job interviews is it? PATIENT: I get anxious just thinking about it. THERAPIST: Please forgive me but I am an anxiety expert, so the word anxiety has so many different meanings to me. What are you referring to when you say “anxious” in this circumstance? PATIENT: Well I guess I mean that I imagine a horribly humiliating experience and rejec-

Downloaded by [New York University] at 01:46 15 August 2016 tion and I start to get upset and then I feel like I can’t breathe or think straight and it just seems like an impossibility. THERAPIST : So you scare yourself with your own vivid imagination about a possibility and then your body starts to do anxious breathing automatically and this changes how your mind and body feel. And then you get discouraged and decide not to go ahead.

Often the patient will not be able to provide such a detailed description. It is still possible to use their presenting complaint as a starting point for education. The following example shows how the therapist can obtain enough information to arrive at an initial diagnostic impression, use that diagnosis to teach the patient about the issue, and help 58 Getting Started the patient gain perspective on his symptoms. What follows is initial contact with an extremely high functioning young man from an intensely pressured and highly achieving family.

PATIENT : I get places late. I always have these last minute things to do. So I’m late. THERAPIST: Well, you came to a therapist for this. So my guess is that your lateness has caused you some distress. PATIENT : Yes, it gets worse when I’m under stress. And this year in college it got bad enough so that I got to most of my classes late. They asked me to take this year off. THERAPIST: Okay, so you are saying that your lateness gets in the way enough so that it impacted your ability to go to college? So what do you think makes you late? PATIENT: I’m not sure, but it isn’t just one thing. But often last minute things pop up. Sometimes I have to make sure my room is neat enough, and sometimes I have this messy feeling. And I have to take care of it. And lately something else started—I’m almost at class and then I’m not sure whether I forgot something and I go back to my room and check. THERAPIST: Okay, fi rst I’d like to know if you have ever heard of OCD? PATIENT: Yes, my father told me that he has it, but he has it under control. THERAPIST: Do you think it’s possible that you have OCD as well? PATIENT: It never really occurred to me. THERAPIST: Well, I think you do, and let me tell you why. [The therapist then presented some very basic information about OCD to this patient, i.e. it is an anxiety disorder. He has thoughts that feel like they can’t be ignored. Then he employs behavioral or mental ways to try to rectify the issue engendered by the thought. It is not a sign of weakness or laziness. It is treatable. He should be able to get back to school next semester. There are ways of not buying into those thoughts so much.] PATIENT: That is really interesting! I am very embarrassed about my lateness. I feel like it is a weakness or a lack of discipline. I was wondering why this was happening to me. I’m willing to work on it. [The session ended when the therapist touched the offi ce fl oor and asked him if he could do the same. He politely declined.]

By the third session, this patient had experienced a number of “aha” insights into the thoughts, sensations, beliefs, and external triggers about his OCD. He quickly developed a meta- perspective about his disorder, and became good at identifying components as they appeared.

Downloaded by [New York University] at 01:46 15 August 2016 This is an example where taking a direct psycho-educational approach and teaching the patient about the disorder, leads to rapid insight and increased therapeutic perspective. This approach is especially helpful for patients with SAD, where there is sometimes profoundly impaired insight. Anxiety is sometimes experienced as intensely exaggerated over-self-consciousness, and people with SAD get fl ooded by these sensations and thoughts as they are trying to focus on interpersonal cues. They might conceptualize their problem as one of poor self-esteem, “just being a loser,” depression, or introver- sion. Initial interviews with these patients can sometimes clarify the presence of anxious arousal, identify some of its triggers, and point towards therapeutic directions. The majority of people with SAD have normal social skills, but suffer from distorted self-perceptions. Their inability to accurately rate the feedback they receive from others Getting Started 59 can be seen as a consequence of their profound self-consciousness. But others with SAD who have been shy and avoiding social interactions from an early age may have signifi - cant defi cits in eye contact, capacity to converse naturally, or ability to ask and answer questions. So part of the assessment of SAD includes an evaluation of the patient’s actual social skills, and teaching social skills are sometimes part of the treatment plan. Social anxiety often manifests itself immediately in interactions with the therapist. The interview, by defi nition, is a social interaction and is often a trigger for anxiety. Some patients with SAD are almost unable to communicate, and their fear is palpable during session. This next patient was almost silent as he sat for the fi rst session. He made no eye contact, and remained focused on the second chair in the offi ce for the entire time. His speech was pressured, he was sweating as he spoke, and he repeatedly rubbed his forehead with his hand. People with intense SAD are often referred by other family members, because initial contact makes them so anxious. The mother of this patient made initial contact, although he came alone to the fi rst session.

PATIENT: [silent pause] THERAPIST: How can I help you? PATIENT: [silent pause] Oh, God. Wow. THERAPIST : You seem pretty frightened. Is that correct? PATIENT: Yes. THERAPIST : Can you tell me what is frightening you? PATIENT : Oh, well, I’m not good at this. My head is swimming. THERAPIST : Is there something I can do to help you be more comfortable? PATIENT: No, it’s not you. It’s me. I always get like this when I have to talk to someone. THERAPIST: Can you tell me what it is like? PATIENT : No, not really. THERAPIST: Is it worse when you have to talk to someone? Is it better when you are alone? PATIENT : Much better when I’m alone. Or with my brother or my mother. But very bad with others. And I’m doing terrible right now. THERAPIST: Actually, you are doing really well, and I wonder if you get very nervous when you are speaking to strangers. PATIEN T: Yes I do. THERAPIST: And when you are around strangers and you don’t have to speak with them? PATIENT : I’m still a wreck. THERAPIST: Are there times when you feel pretty comfortable? PATIENT : Downloaded by [New York University] at 01:46 15 August 2016 Sure, when I’m working and when I’m playing video games, and when I’m with my friend Jason. I’m fi ne then. But I freeze up with others, if I don’t know them. THERAPIST: Well, I’m wondering if you have something called social anxiety disorder, or social phobia. It’s when you get very frightened around others and you imagine in your mind that they are seeing all your fl aws. PATIENT: That is me. THERAPIST : Yes, and people with SAD can be frightened when they have to perform—like speak in front of others—and also some get frightened when they are just around people, even if nothing is expected of them. When do you get frightened? PATIENT : Defi nitely when I have to speak in front of others, but I also get these weird feelings when I walk into a room with other people. 60 Getting Started

THERAPIST: Yes, that is very common. PATIENT: It feels crazy to me. I had to drop a class because I felt so weird just walking into the lecture hall. THERAPIST: It is actually pretty common. It happens more often than you think. In fact, you might not have been the only person in the lecture who feels that way. PATIENT: Get out’a here! So I’m not the only crazy one?! THERAPIST: So you get anxious when you have to do something speciﬁ c and also when you just have to be there. . . . PATIENT : Yes, but my brother only gets frightened when he has to give a presentation. He told me he has the same fear I have. In the beginning of class, when you have to give your name, and they go around the room and it gets closer to you. My heart starts beating and my mind goes blank and—and this is so crazy—I worry that I won’t be able to remember my name! THERAPIST : I know you are having a hard time. And I know you are suffering. But, so far, what you have told me about your social anxiety disorder is commonplace. You are a unique individual, but your anxiety is a dime a dozen. PATIENT : Oh God. What a relief.

Find Out What They Have Tried There should be a discussion of why A third task in initial contact involves taking a detailed sometimes courageous inventory of everything the patient has tried to cope and persistent efforts have with, manage, or treat their anxiety. This is followed not worked. by a discussion of why these sometimes courageous and persistent efforts have not paid off.

• “I always have someone with me when I do that”. This is an avoidance of the anxious feeling. • “I take a tranquilizer whenever I feel that I can’t cope any more”. A more subtle type of avoidance.

There are also a variety of well-meaning but misguided efforts derived from self-help books, popular press, or past therapy efforts:

Downloaded by [New York University] at 01:46 15 August 2016 • “I tell myself that the thought is irrational and I substitute a positive thought for a negative one.” Chapter 9 will explain that this is actually the instillation of cognitive compulsions, which function to keep anxiety alive. • “I tried behavior therapy and it didn’t work.” The behavior therapy was relaxation training, which has been shown to be ineffective or paradoxically anxiety-raising for certain anxious patients. Or it was ﬂ awed in some other basic way, such as providing exposure to the wrong triggers (see Chapter 8), or providing breathing retraining with a counter-therapeutic attitude (see Chapter 6 ). • “I tried medication and I can’t tolerate it.” The family doctor prescribed a starting dosage that was far too high, and the patient was ﬂ ooded with intolerable side Getting Started 61 effects. He stopped taking the medication after two days, and now believes that his body doesn’t tolerate medication. • “I force myself to face my fears, but it doesn’t get any better at all. In fact, I think it is getting worse. I still dread it every day.” This person is probably using any number of mini-avoidances to push through the fear. Facing fears without any change of focus or attitude will not be helpful. See Chapter 12 for a discussion of “white knuckling.” • “My therapist and I have explored the roots of my anxiety and I understand what happened but my anxiety is still there.” Therapy has focused on the causes of the disorder, but not on what is currently maintaining the anxiety independent of the origins.

There are also thoughtful and honest attempts that fail because of misdiagnosis, attempting the wrong type of treatment (i.e., a pharmacological approach when some people react poorly to medications even when expertly prescribed), or misunderstanding of the role of coping techniques. The following example illustrates such a misunderstanding: a patient came to therapy from another cognitive behavior therapist complaining of repeated panic attacks. When asked what he had been trying, the patient stated he had been taking antipanic medication for the past four months, prescribed by a competent psychopharmacologist. In the midst of panicking, the patient obsessed that he would never get over this disorder and was doomed to be disabled for the rest of his life. The cognitive behavior therapist told this patient to correct his false beliefs by reciting to himself during each panic attack that “panics are self-limiting and will go away on their own,” and “my panic disorder will not continue indeﬁ nitely.” These statements are basically true, but in this case the information functioned to maintain the anxiety, rather than as grounding psychoeducational information. The therapist had inadvertently created a reinforcing cycle of anxiety, followed by self-reassurance—a kind of mental obsessive-compulsive reinforcement of the original panic attacks. Fortunately, this patient understood the resolution immediately, and focused attention on allowing anxious arousal and anxious thoughts to come without engaging them and without trying to reassure himself. He started feeling signiﬁ cant relief within a few weeks.

Introduce the New Paradigm: Offer a More Profound Change Than Techniques

Downloaded by [New York University] at 01:46 15 August 2016 The fourth goal of initial contact is to show that recovery involves changing one’s relationship to symptoms Goals for treatment and so that they cause no suffering or limitations in liv- a model for full recovery ing. This is the therapeutic attitude of acceptance. We belong in the ﬁ rst usually begin this discussion by talking about goals for sessions. treatment and a reasonable model for full recovery. Discussions often look like this:

PATIENT: I have to control my anxiety. It is ruining my life. I want to be rid of it once and for all. I can’t stand worrying all the time about things that ought to be easy. It takes 62 Getting Started the joy out of looking forward to anything like travel or special occasions or even everyday getting together with friends. THERAPIST: This kind of therapy is aimed at you taking back your life and its joys and freedom just as you want. However, it may surprise you that we are going to do that in a different way from what you might expect. If there really were fantastic tools we could give you that would permanently achieve those goals, we would be the ﬁ rst to be giving them out. But as we have discussed, you have a brain and body that tends to do anxiety so easily that we are going to teach you how to make anxiety not matter, whether it shows up or not. PATIENT: Are you saying that I have to accept that I will always be an anxious person? Because that is not okay with me. THERAPIST: Actually what happens when anxiety symptoms no longer matter is that you stop dreading them and you stop avoiding things, so your anticipating and worrying subside and then your conﬁ dence builds. Then you are indeed not so anxious. And your symptoms happen a lot less. But you are also inoculated so if your symptoms pop up again, they don’t shock and demoralize and take over again. They never get to take over again once you really get the learning and practicing principles you will learn here.

The following dialogue with a patient suffering from GAD tries to create a new perspective on her toxic worry, a new paradigm. Rather than looking at ways to stop or control the worrying, or to reason herself out of it, the therapist introduces the idea that worry is a series of false questions that are best ignored.

PATIENT: I’m a worry wart. It’s driving me crazy, and driving my family crazy. I worry about everything and I can’t stop it. THERAPIST: Can you give me some examples? PATIENT: Well, right now I’m worried that a mole on my arm is melanoma, and I’m waiting for the biopsy result, which the doctor told me he is doing only because I’m so worried. He says it isn’t melanoma, but how can he be sure? But I already know what I’m going to worrying about when that comes back okay. My husband got a PSA result that went from 1.4 to 2.7, and I don’t know how I could possibly survive without him. But my daughter just turned 15 ½ and wants to get her driving permit. I can’t imagine how terrifying it will be to have her on the road by herself. I just know this isn’t good for my health, and I never get any exercise because I’m always so busy, and

Downloaded by [New York University] at 01:46 15 August 2016 that is terrible for me also. With my worry and my stress I just know I am destroying my immune system. How will my children survive without me? [Patient starts to cry.] THERAPIST: I got it. You are a worry-wart, I agree. PATIENT: I try to stop worrying, I keep on telling myself to chill out or relax or think of something else, but it never works. It’s actually getting worse. I’ve always worried about melanoma, and then I found this thing on my arm. THERAPIST: Let me ask you a question that might seem very strange. What would happen if you worried in some foreign language that you didn’t speak—like Hungarian or Mandarin? Getting Started 63

PATIENT: That makes no sense. I wouldn’t understand anything going on in my head. THERAPIST: Exactly. PATIENT: I wouldn’t understand it and I couldn’t know what was going on. THERAPIST: Yes, and then you would be hearing all these foreign sounds in your head with no obvious meaning and you wouldn’t be able to respond to them. PATIENT: But then how would I know what to do? THERAPIST: Well, that is the point I want to make. Worrying like yours always starts out as a form of planning—as a way of solving problems. But then worry becomes a problem in itself. You are always asking yourself questions and then trying to answer them. But you are going into territory you have no control over. So the questions just raise your anxiety, and then you search for an answer to lower your anxiety, which engenders yet another question. But suppose you understood that the questions aren’t real questions that have real answers? You can’t stop yourself from asking the questions, but you can refrain from trying to answer them. So if you could magically think in a foreign language, it would be easy not to answer the question, because you wouldn’t understand it. PATIENT : But suppose there is a real problem that could hurt me if I didn’t solve it? THERAPIST: That is an excellent question. Part of our job is to help you differentiate worry questions, which our goal is to have you disengage from, and real questions, which require answers. Real questions are more like planning. We don’t want to interfere with your planning.

In this interview, the therapist establishes a diagnosis and then brieﬂ y outlines the content of the worried self-talk. But then a new way of coping with this is introduced: not to stop the worried thoughts, but to ﬁ gure out a method to disengage from them.

Provide Information and Answer Questions The ﬁ fth goal of initial contacts is to provide information about symptoms and what happens during anxious arousal. Sometimes facts about anxiety can be remarkably effective at reducing anxiety. When patients are afraid of the anxiety symptoms, placing the symptoms in an understandable context removes much of that added fear, reducing anxiety sensitivity.

About Anxiety in General Downloaded by [New York University] at 01:46 15 August 2016 Is anxiety/panic dangerous? No. It just feels dangerous. When we respond to initial normal arousal from anxiety by being afraid of it, it gets amplifi ed. This fear of fear is what we can help with right away. The more you understand the less afraid of it you will be. Will I go crazy? Will I lose control? Psychosis and anxiety are completely different. You have an anxiety disorder. You just “feel” crazy. A thought is not an impulse. Derealization and depersonalization are normal responses to anxious breathing and peak anxiety. Anxiety makes you believe that your terrifying thoughts 64 Getting Started are really going to happen. Anxiety is an altered state of awareness that makes thoughts feel predictive. Isn’t my chest pain a dangerous cardiac symptom? The pain in your chest is caused by tension in the intercostal muscles around your ribcage, which become tense and tight during periods of high anxiety. The pains from intense anxiety are not indications of a serious illness. It is also possible that you are having refl ux in your digestive tract, also not dangerous (but easily treatable). Why do I get so light-headed? It is the way you are breathing when you have anticipatory anxiety or panic. We can demonstrate this. Why do my hands and feet and lips get numb? This is caused by hyperventilation, which affects the acid-base balance of the blood. There is plenty of oxygen; it is just giving you harmless symptoms. You can learn how to breathe in a way to make these sensations less intense. Why does my heart race? This is the adrenalin surge preparing your body to be an effi cient fi ghter or runner. It is the fi ght, fl ight, freeze response in action. Why do I keep imagining terrible things? You must be focused on the future in order to feel anxiety. The more you are able to stay in the present—in the “here and now”—the less you will be engaged with anxiety. Try to stay with “what is” as opposed to “what if?” Switching from thinking to sensing will be helpful. You will be learning how to do this. Why do I feel like it is going to reach the point where I just won’t be able to stand it anymore? Anxiety is not an all or nothing experience. There are varying in- tensities of anxiety, and it is to your benefi t to begin to observe this. There is an illusion of unbearableness. It is actually a false message. Why doesn’t mentally reassuring myself seem to work? It is a form of avoidance, and keeps your anxiety going. This is a completely understandable habit of the mind which we will teach you how to change.

About Panic Attacks What is panic? A cardiovascular workout you did not ask for. The body’s normal emergency response system coming on when there is no real emergency. It is fear of fear. Am I going crazy? Panic attacks can make you fear you are going crazy, but people who panic do not go crazy from panic attacks, even though panic often produces strange and frightening sensations. The neurotransmitters involved in anxiety Downloaded by [New York University] at 01:46 15 August 2016 are not the same ones as those that are involved in psychosis. These are different disorders. There is nothing you have told me that I have not heard from people with anxiety disorder. Am I causing long term damage by having panic attacks? Panic attacks don’t hurt you, even though they are very uncomfortable. You won’t damage your body or make yourself sick. This is the body’s emergency response system turning on un- expectedly in a false alarm situation. Will panic attacks make me faint? No, if anything, they protect you from fainting by boosting your blood pressure. (Just a bit, not enough for a stroke!) This is why we call it “faintiness,” as it has nothing to do with fainting. In fact, if you were likely Getting Started 65 to faint from malnutrition or shock or pain, best thing you could do would be to have a panic attack.

About Obsessive-compulsive Disorder Why do I have to do things which I know don’t make any sense? People who have OCD feel like they have a nagging warning danger alarm system in one part of their mind and a second “wise mind” that realizes that the OCD is somehow not telling the truth. We are going to help your wise mind learn to scoff at and get distance from the OCD mind and not take everything you think so seriously. The things you feel compelled to do are things you are “hooked on” as ways of trying to reduce the anxiety, whether or not they make sense. You will be able to stop doing them when you understand them differently. Why am I afraid of things I never used to worry about? You are afraid of the thought that you forgot to turn off the gas. Every time you check to make sure you didn’t, you are making the thought seem more probable and more frightening. The way to reduce frightening thoughts is to stop checking their validity. Why do I doubt myself? People with OCD have a hard time with tolerating not knowing something with a sense of certainty. There is a feedback loop that is stuck in their brain. It is not your fault. You will be learning all about this. Why am I plagued by thoughts that are horrifying and disgusting to me? These are stuck thoughts called obsessions. They are harmless obsessions, and they are neither wishes nor impulses. In fact they are the opposite of wishes. They get stuck by how hard you resist them. And until you understand they are harmless, most people naturally put up a lot of resistance and make them even more stuck.

About Social Anxiety Why am I so afraid of people? It is not people you fear but the feeling of humiliation or shame or embarrassment that you might have if they judge you badly or if you just think they are judging you badly. Why am I especially afraid when I eat in restaurants, or have to sign my name on the credit charge? Your body is in anxious arousal during those times, and you might be aware that your hands are shaking somewhat. You fear that others might notice that and judge you harshly. Downloaded by [New York University] at 01:46 15 August 2016 I can’t use a public restroom. It is physical but my urologist says it is due to anxiety. How can this be true? It is a fairly common condition called paruresis, and there are plenty of ways for you to overcome that limitation. Thank goodness you are brave enough to ask that question.

About Generalized Anxiety Why can’t I stop worrying? You are diligently trying to answer unanswerable questions and fi nd a way to reassure yourself about things that cannot be made certain. The strategies you are using are backfi ring. More of the same won’t help. 66 Getting Started There are different ways to handle worry thoughts than trying to solve them, no matter how intelligent you are. We will be exploring these. What is wrong with me that I can’t relax? You were born with a jumpy sensitive body and a sticky mind. Just fi ghting these predispositions is actually not productive. But there are ways to “ride” this kind of body and mind that are counterintuitive and will make a huge difference. Downloaded by [New York University] at 01:46 15 August 2016 6 Techniques Your Patients Have Probably Already Tried and Misunderstood What They Are and How to Make Them Helpful

The media is awash with techniques for managing anxiety: breathing, relaxation, thought stopping, distraction, food supplements, yoga, exercise, and aromatherapy are just a few of the techniques that are offered as antidotes to anxious arousal. Often there is confusion between managing anxiety and managing external stress. Despite all these available techniques, anxious patients continue to suffer, and anxiety disorders continue to remain the world’s most common psychological problem. So clearly there is something amiss here, and we must acknowledge that simple applications of techniques are not an effective way to banish anxiety. We stress that techniques—like any set of tools—can be evaluated only within the context and appro- priateness of their use. The value of techniques lies in the relevance of their desired function and how they address the underlying attitude towards anxiety. Techniques are not a form of non-chemical tranquilizers. They are not equivalent to popping a Xanax, and they are not anxiolytic per se, although they can Techniques are not a be helpful during anxious arousal. Techniques are not form of non-chemical “in order to” reduce anxiety, although techniques play tranquilizers. an important role in that function.

The Problem with Techniques Remember the story of Dumbo and the “Magic” feather?

Dumbo was a young circus elephant with huge ears, and his odd appearance caused

Downloaded by [New York University] at 01:46 15 August 2016 great grief in his short life. Dumbo’s only friend was a mouse named Timothy, and one day Dumbo and Timothy woke up in a tree. Bewildered by this seeming impossibility, Timothy concludes that Dumbo is capable of fl ying by using his huge ears as wings. Dumbo cannot believe this, but Timothy tells him that by holding onto a magic feather Dumbo will be able to fl y. Using this psychological trick, Timothy is able to get Dumbo to fl y by holding the feather. At the circus, Dumbo jumps from a high tower and fl ies around the tent, grasping the feather, with the mouse Timothy on his trunk. But one day, Dumbo drops the feather as he fl ies, starts to fall to the ground, and Timothy tells Dumbo that there is nothing magical about the feather at all. He can fl y on his own! Dumbo stops falling and begins to soar. 68 Techniques Tried and Misunderstood This is the problem with the misapplication of techniques. They are like Dumbo’s magic feather. Patients believe that anxiety goes down because of techniques, and ignore the most important aspect of the entire process: when techniques are applied correctly, patients react differently to anxious arousal. Dumbo was able to fl y on his own, but connected to and utilized his soaring aspects only when he held the feather. He attributed his ability to stay in the air to the power of the feather, but he fl ew on his own. In an analogous manner, patients attribute anxiety reduction to the effectiveness of techniques, and ignore that it is they who are reacting differently. There are two problems here, and they are closely inter-related. The fi rst is one of attribution. When a patient successfully utilizes anxiety management techniques, what accounts for that success? Is it the patient or the technique? Patients need to learn that techniques actually do nothing to lower anxiety, but can help them approach their symptoms in a different mindset, with an attitude that will promote new learning and change the experience to become more manageable. That, in turn, will lower anxiety. This is not just word-crafting. Techniques are counter-productive when they hide a patient’s own accomplishments. Techniques are not supposed to feel like a tranquilizer. How many of you have had highly anxious patients accomplish something that took considerable courage, yet ended their self-evaluation with “I don’t think I could have done it without the Ativan.” True or not, the goal is to allow our patients to feel empowered in relationship to their anxious symptoms, and not give one additional bit of power to their anxiety. Patients can become reliant or dependent on techniques to lower their anxiety. Whenever something is done that reduces anxious arousal, those behaviors are reinforced, and there is a natural tendency to repeat what has already been successful. But this is problematic for a number of reasons. First, it encourages rigidity, and, second, it ignores that therapists sometimes want to encourage the experience of anxiety, in order to better learn how to manage it. When someone needs a technique or coping skill “just in case,” it subtly reinforces the idea that anxiety is dangerous and must be avoided. When anxiety yells, “Emergency!” the most effective tool is to respond to that message with “I don’t actually have to do what you say.” Any technique which buys in to the emergency message will not be helpful in the long run. When patients attribute favorable outcomes to the technique, they remain vulnerable to this false message. Sometimes coping skills work only because the patient believes that anxiety won’t get out of control when the technique is used. It is these beliefs that make the technique seem to work, not the techniques themselves. This

Downloaded by [New York University] at 01:46 15 August 2016 is why a parent’s voice on the cell phone can comfort right away, even before anything calming has been said or any plan for action has been discussed. It is not the wisdom of the parent’s advice; it is the patient’s own belief that “I will be okay” that lowers anxiety. Again invoking the tranquilizer analogy, here is a patient telling his therapist why he was unable to drive over the bridge.

PATIENT : I was on the highway and I realized I forgot my Xanax. THERAPIST: You forgot to take your pill? PATIENT : No, I never take any Xanax. But I carry it with me, and I’m ﬁ ne. I was on the highway and checked my briefcase and realized I had left them home. I got really frightened and got off at the next exit. Techniques Tried and Misunderstood 69

THERAPIST: So can you explain to me how not taking a pill keeps your anxiety low, and not having the pill spikes it higher. PATIENT: It’s for just in case. THERAPIST: Yes, just in case. So here is what you are saying. If you know that you have easy access to your Xanax, then your anxiety stays low and you have no need for it. But just knowing that it’s not available, that triggers your anxiety. Our job is to ﬁ g- ure out what is different about you when you have your Xanax and when you don’t.

Similarly, the therapeutic goal is to determine what is different about our patients while using a coping technique, as opposed to when they aren’t. A patient related high anxiety during a business meeting while trying to use breathing techniques to keep it low:

PATIENT: I was using the breathing techniques to keep my anxiety down, but I started to get anxious anyway. I thought to myself, “Oh no! What if it doesn’t work anymore? What if I’m back to where I started? Maybe I’ll never get over this problem.” I was totally panicked by then. THERAPIST: The problem is that you are thinking that breathing should take away anxiety. Breathing can help you stay focused in the present. It can reduce some of your hyperventilation symptoms, and it can make it easier for you to keep with the best therapeutic attitude. But tools don’t take away anxiety. Tools can help you pass time while your symptoms subside on their own, but as soon as you check to see if they are working, you actually provoke more anxiety. And I’m truly sorry you felt so upset. But at the same time, by now you know me well enough to realize that I’m also pleased you were able to have such a great learning experience. PATIENT: Yes, I know. In fact, as I was coming here I had the thought, “Well, the doctor is really going to be happy about this!”

When anxiety returns despite techniques—as it always does—patients begin the anxiety- producing process once again. They lose hope. They drop the feather. They don’t realize that they are able to do it on their own. So, people who believe it is the technique (and not their thoughts and beliefs about the techniques) that is helping, are more vulnerable to relapse when they have a setback or unexpected return of anxiety. There is a second important overarching problem with techniques and coping skills: they often serve as neutralization or safety behaviors which inadvertently fuel the fear cycle illustrated in Chapter 3. What patients call coping techniques can negatively rein-

Downloaded by [New York University] at 01:46 15 August 2016 force anxious arousal. That is, they may immediately reduce anxiety, but anxiety returns even more intensely, and so increases the need for more anxiety reduction. In this way, misapplied coping techniques very easily become addictive, like any instant soother, such as a support person or a magic feather. By helping the anxious person avoid going through the storm of arousal to emerge on the other side, coping skills can rob him of the chance to experience the natural resilience of body and mind. They may provide instant relief but, like a drug, they are not easy to give up, and they reinforce a fear cycle with an escalating and often generalizing course. Thus, having a phobic companion come along with a patient may indeed make him less scared that one time. But the downside is that the companion acts as a negative reinforcer, and this may result in the patient experiencing anxiety in more places and situations when unaccompanied—requiring the presence of 70 Techniques Tried and Misunderstood the comfort person even more. This pattern undermines the development of a patient’s confi dence in his ability to tolerate distress and does nothing to teach him the difference between danger and discomfort. Instead, he is more likely to experience an escalating reliance on the external support. This in turn is demoralizing. Another example of a coping technique that is subtle avoidance behavior and will ultimately backfi re is often taught by well-meaning family, friends, and even therapists. It is the “think positive thoughts”—and all its variations, including affi rmations, ritualized prayer, ritualized behaviors, little positive reassurances, and mental gymnastics designed to banish anxiety by suppressing, diverting, and avoiding what are automatic conditioned negative thoughts. As will be discussed in some detail in Chapter 9 , these are actually mental compulsions and have almost no value in the ultimate goal of reducing the suffering caused by anxiety.

How Techniques Can Be Helpful Coping skills are most effective when helping patients “while” they feel anxiety, not “in order to” take it away. The anxious patient might say to herself, “While my mind is handing me crazy thoughts, or while my body is acting like there’s some emergency, I am going to try to breathe Coping skills are most in a natural way or I’m going to get my shoulders out effective for helping of my ears.” This is very different from the approach patients “while” they feel that says “I have to breathe right or relax in order to anxious, not “in order to” stop my mind from handing me anxious thoughts take the anxiety away. or to keep my body from feeling weird or having symptoms.”

Techniques Are Temporary Help, Not Goals Coping skills or anxiety management techniques often place too much importance on the content of anxious thoughts, suggesting that they need to be stopped, avoided, or ﬁ xed. This is a misunderstanding of the goal of modern anxiety treatment. As stated in the introduction, it is not true that “changing the thought will change the feeling.” Paradoxically, patients often trigger the ironic process by trying to change a thought and thereby making it more intrusive. But even more importantly, it ignores that anxious thoughts are identiﬁ ed not so much by their content, but by how dangerous they feel,

Downloaded by [New York University] at 01:46 15 August 2016 and by the accompanying urge to respond as if they warn of a real and present danger. That is why we view coping skills as temporary bridges as opposed to goals. Coping skills can also inadvertently block the new learning needed for recovery. If someone has learned to cope with cleaning the bathroom by using a new pair of rubber gloves each time, it may seem to take care of the problem. But the real problem is not about cleaning the bathroom, it is the patient’s belief that bathroom germs are dangerous and it is intolerable not to know for sure that you have avoided exposure to them. This kind of coping skill breaks down when inevitably there arise doubts about the certainty of keeping germs away—a possible hole in the gloves, or the realization that one is allowing one’s children to use the bathroom without wearing gloves. Techniques Tried and Misunderstood 71 This is why some patients repeatedly use coping techniques to get through anxious experiences without a reduction in anxiety. Here is an example:

PATIENT : I hate the Bay Bridge and I have to drive on it every weekend. I can do it, but I have to count in my mind the whole time, to keep myself distracted until I get over it. I check in with my husband before I start and ask him to say a prayer for me. One way I try to cope is to tell myself over and over that it is just like any piece of road. THERAPIST : So you are on the bridge while trying to pretend you are not on the bridge? It sounds like you believe you are practicing the bridge and it is not getting any easier, so it seems practice doesn’t seem to work. All you seem to be learning is that going over the bridge is miserable. PATIENT : Yes exactly. Practice does not help. I am using coping skills and it never gets better. THERAPIST: Well, you are actually practicing avoiding anxiety by pretending not to be on the bridge, so it is no surprise that you are not actually learning anything new. This way of “talking to yourself” is actually you giving yourself a message that it is dangerous to be anxious while driving on a bridge.

Sometimes coping skills are more subtle, but they unfortunately serve the same purpose of negatively reinforcing anxiety.

PATIENT : I’m claustrophobic. When I ﬂ y, always sit in seat 1A. It gives me the most amount of room. And I don’t have to look at the rest of the plane. So I can tell myself I’m just all by myself in this little space. Oh, and I always step into the plane with my right foot. PATIENT : I always take the upper level when I go across the George Washington Bridge. That way, I tell myself if there is a disaster and the bridge starts to collapse, there is still the lower level to hold me up. PATIENT : I used to worry about germs, so I absolutely love these antimicrobial wipes. Whenever I think that I might have gotten some germs on my hand, I just pull them out and wipe myself up. They are fantastic! PATIENT : Thank God for cell phones. Now I can text my husband and he can text me so that I don’t have to worry about his safety.

Emergency Coping Downloaded by [New York University] at 01:46 15 August 2016 There are places—and important ones—for coping skills in the successful treatment of anxiety disorders. Anxiety management techniques can be extremely helpful as temporary emergency measures, when a strategy is needed to cope with a highly anxious situation, because avoidance would have signifi cantly negative consequences. In these cases, it is better to have the patient get through the anxious experience, rather than suffer the negative consequences. Here is an example. A patient with both panic disorder and social anxiety disorder (SAD) is starting a new job. He realizes with terror that people in this job go out for lunch in groups, which is the specifi c set of triggers that he fi nds intolerable. He can tolerate—just barely—the anxiety of elevator, hallway, lobby, and restaurant, but the 72 Techniques Tried and Misunderstood addition of his peers (whom he fears will notice his anxiety) sends him into panic. In this case, he worked out a series of coping mechanisms that included reasonable excuses for a later lunch, methods of reducing the visual space of his lobby, leading his colleagues on a path that he found less triggering, methods for distracting himself when he felt too anxious, and a non-intrusive way to lead a small group of walkers closer to a wall—which he felt as comforting. Every single one of these coping mechanisms included some aspect of avoidance, and none of them helped to embrace the therapeutic attitude. But they did help him hold on to his job, and the patient was highly cognizant that this was not a long-term solution. It was an emergency fi x. He kept his job, but understood these temporary measures needed to be abandoned so that the sustainable work on his anxiety disorder could begin. The same sort of temporary emergency intervention may be needed to provide for the safety and care of children when a parent is disabled by fears and has not yet grasped the basics of treatment. Here is an example: a mother was having health anxiety fears and spending every day in the emergency room with her toddler “in case” one of them needed emergency medical care. She was aware this was not an ideal way to spend her time. Before she was able to learn a new attitude to her fearful thoughts, she was able to bring her child to her mother’s house and spend the day there. Her plan was to have her mother reassure her or babysit “in case.” This was a temporary way to better care for her child until treatment progressed to where the patient was able to do without her mother’s reassuring presence. Similarly, it might be reasonable to take a PRN benzodiazepine in order to be able to keep a promise to join a group school outing on a bus instead of disappointing the child by avoiding it. These actions allow parents to consistently place their children’s welfare front and center. These coping techniques allow “getting through” experiences, until such time as there is enough distress tolerance to undertake new learning. They should be undertaken with a conscious awareness that they are “crutches” that will be set down when the leg is stronger. Here is another example. A patient was having panic attacks and her doctor needed her to have an MRI to rule out a serious medical condition. She asked to be sedated and to have a friend come into the room with the MRI and hold her ankle and talk to her so she could have the procedure. She was simply not ready to do it on her own, and it was not reasonable to expect her to be convinced that her panic was not dangerous until the test was done. Similarly, when someone early in treatment calls in the middle of the night in a state

Downloaded by [New York University] at 01:46 15 August 2016 of acute hyperventilation and panic, they will not be able to reason because of their terror, no matter what wisdom you have to impart. Yelling “Accept!” over their gasping breath will not be helpful. A soothing tone with instructions to lie down on the fl oor on the tummy, to stop trying to “fi x” the breathing, that this is not a true emergency, and to put a pillow under the chest and simply let mechanics work and time pass will be a more effective intervention. Ultimately, lying on the fl oor is not an option for managing hyperventilation but in the immediate moment that may be the best thing to do. (Another version of this technique is to direct the patient to get onto his hands and knees—remaining on the mattress is fi ne—and continue to breathe in that position. The pressure on the arms keeps the chest in place, and gravity helps pull the diaphragm down, so that hyperventilation is temporarily allayed.) Techniques Tried and Misunderstood 73 Techniques That Can Be Helpful: “What Is,” Not “What If?” There is a general rule for the use of coping skills or anxiety management techniques: they are most effective when helping patients attain the proper therapeutic attitude. Chapter 3 stresses that patients do best when they embrace the experience of anxiety in order to disengage from it. Any coping mechanism, skill, or technique that encourages this attitude is doing its job.

Mindful Sensory Awareness: Staying in the Present Staying grounded in the present moment, sensing instead of thinking, tends to help anxious people add less second fear. When attention focuses on what can be seen, heard, felt, and experienced in the moment, there is less judgment, catastrophizing, and worrying—all of which adds up to less elaboration on the meaning of anxious arousal or intrusive anxious thoughts. The purpose is not to lower anxiety, for that will engage the paradoxical nature of the symptom, but reduced anxiety is a valued side effect. An example of such a technique would be to pay attention to sounds or smells or particular colors while walking through a mall, and being aware, at the same time, that one’s heart is beating fast and one feels off balance. It is easy to make a mistake here and instead of staying grounded, substitute unhelpful distraction: the goal of staying “in the now” is to be present while anxiety is present, not in order to make it go away. Another aspect of staying grounded in the moment is to let go of formulating an escape plan. Planning one’s escape propels patients into future thinking, trying to solve the issues created by imagined catastrophes, retriggering the ﬁ ght, ﬂ ight, or freeze response, and further elaborating on anxious arousal. When anxious, patients have the tendency to think they know what others are thinking, how they are perceived by others, and to look at themselves through the eyes of people around them. This is a sign of getting outside themselves, an indication that they are losing touch with groundedness in the present. Suggest that patients pay attention to how others look to them, what colors they are wearing, and what style of dress they are wearing. Ask them to focus on what they think of others, and less on what others might be thinking of them.

Expecting and Allowing Hoping not to be anxious is counter-productive. It is helpful to remind oneself that

Downloaded by [New York University] at 01:46 15 August 2016 symptoms are conditioned phenomena with well-worn neurological circuits, and that the discomforts of mind and body will occur. An example might be illustrated this way:

PATIENT : I know I should go to the gym but I am so self-conscious and anxious in front of all those cute athletes in little bodies. I feel like a hippo. I am trying to tell myself that I don’t really look as bad as I think, so I will have the courage to walk in. Maybe I should try to buy an outﬁ t that camouﬂ ages me better. THERAPIST: Actually what I would like to suggest is that you walk in the door saying to yourself “I feel like a hippo. There is nothing I can do about feeling this way. But I can use the treadmill while I feel this way.” PATIENT : How will that take away my anxiety? I have been doing that already. 74 Techniques Tried and Misunderstood

THERAPIST: My guess is you have been feeling like a hippo all the while telling yourself that you shouldn’t feel that way, that you should stop feeling that way, that there is something wrong with you that you feel that way. I am suggesting that you go ahead and think it on purpose. It won’t take away the feeling or the initial anxiety, but it will take away the internal battle that is keeping the anxiety going. You would at least have a chance to get used to the place.

Mindful Labeling Anxiety management techniques that encourage a more mindful approach are also helpful. Anxious people often need to be taught how to uncritically and simply observe and label their inner experiences. The vignette above illustrates another important principle. Patients routinely confuse thoughts, images, sensations, and feelings. Getting these sorted out can be of enormous value. In the example above, the statement “I feel like a hippo” is a thought, not a feeling. The feeling that accompanies the thought is shame. The sensations that arrive with the shame are fl ushing in the face and rapid heart rate. It is also helpful for a patient to understand the story of “I feel like I am having a heart attack.” It actually begins with the sensation of shortness of breath or tachycardia. Then comes the associated thought “heart attack” and then the feeling of panic or terror close behind. These distinctions help patients separate those experiences that are automatic and not modifi able, from those that can be modifi ed. And it helps them to distinguish the facts (“my heart is beating fast”) from the thoughts (“I am having a heart attack”). Similarly, “I can’t stand it anymore” is a thought. Despair is a feeling. Nausea is a sensation. And so on. Mindful labeling includes encouraging patients to rate their level of discomfort on a fear scale and become adept at watching it go up and down. They will notice the ways in which intrusive thoughts, the attempt to rid themselves of anxious feelings, and the effects of judging and evaluating instead of simply observing send anxiety up automatically. An example:

PATIENT : I am at a 4 right now. THERAPIST : OK, how about walking to the back of the store and locating the milk? PATIENT : I just shot up to a 7. THERAPIST: Well you are still in the same place. What happened that you went to a 7? PATIENT : I was imagining me getting lost and panicky when I could not see you. Can you

Downloaded by [New York University] at 01:46 15 August 2016 come with me? THERAPIST: So your imagined scene of panic made your anxiety go up to a 7. What happens if you imagine me there with you? PATIENT : It went back down to 5. THERAPIST : And the whole time we haven’t moved.

Here is another labeling technique: adding “I’m having the thought that . . .” to the beginning of a statement often helps to distinguish thoughts from facts.

PATIENT : I don’t want to interact with my neighbors. They don’t like me. THERAPIST: Could you try “I am having the thought that my neighbors don’t like me”? PATIENT : I am having the thought that my neighbors don’t like me. Techniques Tried and Misunderstood 75

THERAPIST: Any different? PATIENT : I guess I do not actually know this. But it could be true. THERAPIST: Well, yes, it could be true or not true. But I want you to see that you are treating this thought as if you already know it is a fact.

The simple mindful technique of labeling and observing thoughts is also helpful. During this ﬂ ight, notice the therapist makes no attempt to distract, refute or counter any of the patient’s “what if” thoughts.

PATIENT : I’m afraid the plane will crash. THERAPIST: That is an anxious thought, go on. PATIENT : I worry that we will hit another plane in this fog. THERAPIST: Another anxious thought. PATIENT : The computer to see other planes could break down. THERAPIST: Another anxious thought, next? PATIENT : It will be windy and foggy when we land. THERAPIST: Anxious thought. PATIENT : Yes, I’ll go on. A gust of wind could topple us over. THERAPIST: Anxious thought. PATIENT : The computer could be wrong. Anxious thought (laughs). THERAPIST: I’m not sure I’m needed here.

Increase Doubt about Anxious Messages The following person with OCD has an elaborate sleep time ritual to ensure that no germs contaminate her bed.

PATIENT : I am exhausted by the time I get into bed. The last thing I do is turn off my light with a tissue. THERAPIST: And you do this because you believe the germs can hurt you? PATIENT : Yes. My bed is the only safe place in the house. And if stuff from outside got onto my ﬂ oor, and then onto my bed, I would be dirty as well. THERAPIST: Is this an uncomfortable feeling or do you think you are really in danger? Or another way to put it, is this an OCD thought or a factual representation? PATIENT : I don’t know. If I knew it was OCD, I wouldn’t be driving myself crazy. It seems

Downloaded by [New York University] at 01:46 15 August 2016 real. It feels real. I don’t know. I can’t know. THERAPIST: I agree you can’t know for sure. But let’s try to see your very best guess. Imag- ine this: “I have a gun. I will shoot you if you guess wrong. You only get one guess. I want you to tell me if this is an OCD thought or a real danger.” PATIENT : That way. If I must choose, and if I die if I’m wrong, then I’ll say it is OCD. THERAPIST: So you are at least 50.00001% sure it is OCD. So you need to treat it as an OCD thought.

This is an example of the Gun Test proposed by Grayson (2003). The patient suspects OCD thoughts, but isn’t sure, and wants to be sure. The Gun Test allows for uncertainty even while labeling the thought as anxiety. Grayson says that “Thoughts are just guesses about reality.” 76 Techniques Tried and Misunderstood Psycho-education plays a role in increasing doubt about anxious thoughts. One patient had a lightheaded feeling that triggered terror and the fear of a brain tumor. She was able to hold onto the information that lightheaded “faintiness” is a common symptom of anxiety. Sometimes these feelings were reduced during diaphragmatic breathing. Together, this enabled the labeling of feelings as anxiety rather than a dangerous neurological condition. It gave her courage to allow the feelings and dispense with her usual reassurance behaviors. It allowed the anxiety to reduce on its own. The following patient with SAD was able to use information modeled by his therapist. The patient feared leading weekly team meetings at work. He worried about losing his concentration; just standing in front of the room awkwardly paused, with everyone thinking of him as a weird, incompetent team leader.

PATIENT : And the worst part is that I get so anxious that I actually lose my place. I stand there saying nothing while looking for my notes. Everyone sees how weird I look, and that makes it worse. THERAPIST: You think standing there without saying anything makes you look weird? How long do you stand there? PATIENT : Certainly. And even if it isn’t long in an objective sense, it still feels like eternity to me. THERAPIST: Well, let me tell you a story about one of the great orators. He would speak to thousands of people. And here . . . is . . . one . . . secret . . . to . . . what [the therapist’s speech slows signiﬁ cantly] . . . this person . . . knew. . . . Here it is . . . [a pause of 10 seconds]. It is that [resuming normal speaking speed] putting pauses in talks actually engrosses the audience. Now, what was your experience as I was pausing my speech? PATIENT : I was waiting for you to continue. I started to lean forward. THERAPIST: Did you think I looked weird? PATIENT : No, but I hoped you were okay. THERAPIST: There is a lesson here for you. PATIENT : I got it.

Encourage the Paradoxical Approach Anxiety is a relentless bluffer, and following its directions will prolong anxious arousal. The general rule is to do the opposite of what anxiety is telling one to do, or, more often,

Downloaded by [New York University] at 01:46 15 August 2016 to move in the direction that anxiety is telling the patient not to go. Carbonell (2004) calls this the rule of opposites. A patient with panic disorder must attend a beneﬁ t concert for work.

PATIENT : I am having nightmares about the concert. What if I panic in the middle of the performance? I haven’t been able to buy my tickets, because I just don’t want to think about it. THERAPIST: Buy your ticket; it will actually lower your anxiety. You are currently going through an internal “should I or shouldn’t I?” debate that is keeping your anxiety level higher. There is nothing more anxiety-producing than staying on the fence. Make a commitment, and see what happens. Techniques Tried and Misunderstood 77 This next patient suffers from SAD and fears dining with others in restaurants. He fears the embarrassment of having to leave the table to use the bathroom. More speciﬁ cally (and this is an example of why details make a difference), he fears having to use the men’s room a second time, since he imagines that will put him under great scrutiny. For that reason, he tells himself, he must “save” his ﬁ rst bathroom visit, because once he uses it he is vulnerable to the humiliation of going a second time.

PATIENT : I was in the restaurant and my stomach was hurting and I knew I had to hold on. But then I wondered if people are noticing that something is wrong, and maybe they are thinking I’m looking odd. And all of a sudden I had this urge to pee. But I wanted to wait. It was too close to the beginning of the meal. THERAPIST: I’d like you to do the opposite. Walk into the restaurant and use the men’s room. Sit down at the table and use it again, whether you feel the urge to pee or not. PATIENT : But I’ll worry they’ll think I’m weird. THERAPIST: Perhaps, but your worry will be less than if you follow what your anxiety is telling you to do.

Here is another example:

PATIENT : When the plane takes off I put my head between my legs, close my eyes, and pray that everything will work out okay. THERAPIST: Why do you put your head down that way and close your eyes? PATIENT : I hate the feelings of acceleration and turning, and I hope that with my head down, I won’t feel them. THERAPIST : Those actions are making you more sensitive to the sensations. The next time you take off, do your best to sit up, look around with your eyes open, and focus on what is happening in the present. There is a good chance you will feel much less anxious.

Here is another example:

PATIENT : Whenever I go to a party, I am dreading that no one will talk to me. I feel like a loser. THERAPIST: Here is a suggestion: Spot the person who looks the most lonely and miserable and make it your goal that that person has a great night.

Downloaded by [New York University] at 01:46 15 August 2016 And another:

PATIENT : I text my kids several times a day. I just want to make sure they are OK. THERAPIST : You are obeying your OCD thoughts. I wonder what would happen if you turned off your phone and dealt with your “what ifs” as thoughts instead of messages.

Anything Worth Doing Is Worth Doing Badly (WordPoints, 2011) The pursuit of perfection raises anxious arousal, increases anticipatory anxiety, and indicates an unwillingness to allow feelings of awkwardness that accompany new activities. The need for immediate excellence initiates a self-evaluative process that takes patients 78 Techniques Tried and Misunderstood away from present experience into a world of “what ifs?” Patients can generally function well with high levels of anxiety, although not so efﬁ ciently. They are certainly unlikely to scream, faint, or do the embarrassing, outrageous, or dangerous things they sometimes picture in their mind. The need to be “the best” makes necessary uncertainties intolerable, and that is why perfectionism often paralyzes. Suggest to patients that their task is to do “well enough,” without precisely deﬁ ning what “enough” means. Remind them that the only way to surely avoid making mistakes is to do nothing, and that is why the pursuit of perfection often leads to immobility and paralysis. The need for perfection is a bit like hot-wiring the amygdala, and so it leads to increased anxiety, writer’s block, and a more generalized freeze response. People cling to perfectionism for many reasons involving critical judgments about themselves as well as expected (and often projected) judgments by others. But most frequently they fear that if they give up the effort to be absolutely perfect, they will slide into mediocrity, apathy, and failure. In fact, releasing oneself from perfectionism allows for the achievement of excellence, in part because one learns best from mistakes, and resilience following mistakes is a genuine mark of excellence required in all performance. Perfectionism can also be conceptualized as a form of OCD—with the constant checking for mistakes and inadequacies as a compulsive way of avoiding the uncertainty of possibly not measuring up or being good enough. There is also the attempt to make certain that success will occur now and in all future endeavors. Thus, deliberately making mistakes—or even better—allowing the possibility of having made a mistake, and deliberately not checking—can be an excellent technique for dealing with perfectionism.

Slow Down and Let Time Pass Patients frequently rush through anxious experiences in an effort to minimize their misery. They attempt to get home before the panic hits, get over the dreaded speech, or gobble down food to shorten a socially anxious interaction. Patients often believe that they were about to Slow down and let time panic and would have surely lost control if they had pass. stayed a moment longer, thereby feeding the illusion that danger was indeed averted. Some patients ﬁ ght with time. Many believe that rushing makes them more productive, but rushing has little effect on productivity. Rushing is arousing to the autonomic nervous system, and adds to fear feedback loops. Additionally, rushing

Downloaded by [New York University] at 01:46 15 August 2016 through experiences validates the belief that there is something wrong with slowing down, and makes it more diffi cult for patients to practice the valuable skills of mindful awareness and allowing time to pass. Some patients acknowledge this with the promise that they will slow down “as soon as I have fi nished what I need to do.” However, experience shows that most of these patients never fi nish what they need to do. If patients wait until their work is done to slow down, most never will. A better way of managing anxiety-producing situations is to slow down, pay attention, and consciously allow the unfolding of what is happening. A helpful metaphor is to imagine walking in a swimming pool where the water is chest high. The eventual goal is to get to the other side. It is impossible to go fast, each step must be deliberate, and Techniques Tried and Misunderstood 79 the goal will be reached, one step at a time. Slowing down is a prerequisite to mindful awareness.

Reminders to Take Care of Oneself and Not Everything Else Patients need reminders to defi ne and limit their job and to try not to manage the whole world. That tendency increases “what if” thoughts, leading to feelings of being overwhelmed and increased anxiety. Ask your patients if they can let the pilot take care of the plane, let the driver take care of the bus, and let the others do their Let the pilot take care of own job. Carbonell, describing the most therapeutic the plane. attitude to cope with fear of fl ying, tells patient that they are only “Baggage that breathes” (2004, p. 136). The patient’s job is to take care of himself, monitor his own anxiety level, and do manageable things in the present. Similarly, it is common for anxious parents to feel as if they are the only ones making decisions about their children: actual shared responsibility for both decisions and outcomes is often a vague concept. People with OCD frequently have an infl ated sense of responsibility. Here is an example:

PATIENT : I am compelled to pick up every bit of trash I see. THERAPIST: What is the thought that drives that? PATIENT : Well, if I see something on the street and I don’t do anything about it, then if someone trips over it and breaks a hip, it is my fault. I can’t stand that idea. THERAPIST: Do you think I would be a bad person if I walked past a piece of trash? PATIENT : No, I wish I were like you. THERAPIST: Well if it is not my job, why is it yours?

I Am Bigger Than my Thoughts Anything that encourages a different ﬁ gure/ground relationship between anxious thoughts and sensations, and ordinary present experience can be helpful. This would include creating metaphors to understand how to passively observe thoughts, images, and sensations while pursuing behavioral goals. Watching dispas- I am bigger than my thoughts. Downloaded by [New York University] at 01:46 15 August 2016 sionately what is happening in the mind and body allows one to move anxious arousal from the overwhelming foreground to the less consuming background, thereby creating a larger perspective. Many psychological paradigms describe this phenomenon of becoming aware of and operating from an internal stance of “I am bigger than my thoughts.” A simple illustration of this perspective is to add the words “I am having the thought that . . . ” in front of an anxiety-producing thought. Thus, “I am losing control” becomes “I am having the thought that I am losing control.” This immediately draws attention to the larger “I” which is observing the “I” having the thought. Another simple application is the question “What is my mind telling me now?” 80 Techniques Tried and Misunderstood This same change of perspective is akin to Gestalt principles of ﬁ gure/ground (Rock and Palmer, 1990), the concepts of defusion and expansion derived from acceptance and commitment therapy (ACT) (Hayes, 2004; Harris, 2008), the mindful stance central to dialectical behavior therapy (DBT) (Robins, Ivanoff, and Linehan, 2001), and mindfulness based stress reduction (MBSR) (Miller, Fletcher, and Kabat-Zinn, 1995). Reid Wilson’s (2009) concept of “the observer” was an early description of consciously promoting this kind of disengaged awareness during anxious arousal. Wilson also describes shifting anxiety symptoms from “signal” (meaningful or important intrusions) to “noise” (background annoying but unimportant static).

Increase Willingness to Experience Discomfort This is a variant of motivational interviewing, but in this case the patient is taught to interview himself. The approach addresses an oft-observed phenomenon: in the throes of anxious arousal, the patient might not be able to remember why—or believe that—therapeutic goals Ask: Why are you willing are worth the discomfort. Anxiety has the capac- to experience discomfort? ity to wash out other emotions: an intense desire to face fears and expand one’s life can be lost to anxious arousal. The therapist can query the patient and remind him about his reasons for persevering through the anxious storm to the other side. Questions include:

• What have you paid in terms of quality of life and restrictions on freedom to keep your avoidances intact? Are these payments costing you more than you can afford? • Who else are you hurting (family? friends? employer?) by giving in to the false messages of your anxiety? • What values important to you personally do you betray by being unwilling to undergo this discomfort? Will you ultimately feel worse or better if you undergo this discomfort?

There is an art to these motivational pep talks, and they can be counter-productive if turned into non-compassionate self-bullying. But if compassionately delivered, these reminders can increase motivation to stay with discomfort. They spell out concrete reasons to experience short term discomfort for a future with less suffering. Downloaded by [New York University] at 01:46 15 August 2016 Competence-enhancing Skills Sometimes anxious anticipation is a reasonable response to poor skills or competencies, as opposed to a fear of arousal. In these cases, it is helpful to practice new techniques, learn new competencies, and generally increase skills for coping with practical require- ments. One example of this would involve social skills training and role-playing practice for exceedingly shy people who lack social interactions skills. Another would be that of a musician practicing to the point of trusting one’s “automatic pilot” to form the backdrop for treating performance anxiety. Similarly, if someone’s anxiety over driving is fuelled Techniques Tried and Misunderstood 81 by a poor sense of direction, then learning to read a map or consulting a GPS would be helpful. The caveat about such skill-enhancing is to make sure these techniques do not become safety or avoidance behaviors. If the purpose of using a map is to not get lost while practicing how to address fears of driving, this is helpful. However, if the purpose of using a map is to avoid the anxiety of getting lost, then the helpfulness is lost as well. Were that to happen, an exposure task involving deliberately losing one’s way might be added to the treatment plan.

Anxiety Management Tricks That Easily Backﬁ re Some of the self-help literature and popular press suggest coping techniques that can easily be applied with a counter-therapeutic attitude. This makes them particularly vulnerable to the pitfalls already discussed. These include the following techniques:

• Thought-stopping: This is often described as snapping a rubber band whenever having an unwelcome thought, or yelling “stop” to oneself when an anxious thought occurs. This, of course, engages the ironic effect of increasing the frequency of feared thoughts. • Distraction: The advice is to think about something else, such as counting backwards from a hundred. This is notorious for how quickly anxiety returns. • Rational refutation: People will often refer to this as “thinking rationally” such as trying to determine how likely it is that something bad will happen, or reminding oneself that it has never happened yet. This is usually followed by “yes, but . . .” • Thought changing: This is sometimes combined with thought stopping. The technique is to substitute a calming thought for the frightening one. This is actually the promotion of a cognitive compulsion (see Chapter 9 ). • Practice stress-reducing behaviors: This suggests that immediate exercise can be used to lower anxiety or avoid the stressor. Regular exercise is enormously helpful in lowering overall levels of sensitization, but using exercise as an instant anxiety coping technique is at best a temporary measure that wears off quickly and at worst further evidence that something is seriously wrong because the exercise does not reduce anxiety as expected. • A variety of breathing techniques are suggested. The problem is that they are often are applied with a sense of urgency, thus paradoxically increasing anxiety. Downloaded by [New York University] at 01:46 15 August 2016 Diaphragmatic Breathing Many people believe that a proper application of regular, rhythmic, diaphragmatic breathing is a beneﬁ cial anxiety management technique. Most people change their breathing pattern when they feel tense—shallow breathing, holding one’s breath, taking big gulps of air, breathing rapidly—all of these non-rhythmic breathing patterns produce unpleasant sensations that increase anxious arousal. The majority of these sensations are attributable to hyperventilation, while some are directly related to tensions in the chest. Diaphragmatic breathing helps maintain rhythmic and regular breathing 82 Techniques Tried and Misunderstood during periods of tension and anxiety. As with every other coping skill, the key is how the technique is applied. When coping with anticipatory anxiety (See Chapter 12), diaphragmatic breathing can help to reduce hyperventilation-induced sensations. In the midst of intense anxiety and panic, diaphragmatic breathing can help patients remain in the present and stay with feelings, while allowing arousal to pass. Unfortunately, it is common that many will seize on the technique as a way to combat anxiety; in that case, it can fall prey to the shortcomings of any technique, turn on the “struggle switch” (Harris, 2008), and ultimately backﬁ re.

There Are Two Ways to Breathe There are two distinct ways to get air into the lungs: One method involves using chest muscles to expand the rib cage; the other uses the diaphragm to expand the belly. Everyone is born breathing with their diaphragms. Take a look at newborn babies in their crib. Their belly pushes out with each inhalation, and gets smaller with each exhalation. That expansion of the belly is the unmistakable sign of diaphragmatic breathing. However, most begin breathing with the chest as we age, primarily because it looks so much more attractive to push out the chest during inhalations, as opposed to pushing out the belly. (Expanding the belly is required for diaphragmatic inhalations.) Chest inhalations involve stretching the intercostal muscles around the ribs, expanding the rib cage, and drawing air into the lungs. As anxiety increases, this type of breathing becomes more diffi cult, because tension make the muscles around the ribcage relatively stiff and infl exible. People often complain that their chest feels tight during anxiety attacks, and they sometimes feel pressure around that part of the body. This is the perception of tension in these muscles. Expanding the chest during these times feels awkward and self-conscious. Inhalations feel like stretching a tight rubber-band. Rhyth- mic breathing becomes as diffi cult as chest muscles send signals of tension, pressure, and pain. When muscles are tense, belly muscles tense up into a “knot” and instinctively brace for a blow. This locks the diaphragm which rides up and down on the lower more effi cient parts of the lungs and pushes the breathing into the upper chest where it is less effi cient (and therefore naturally starts going faster).

Avoiding Hyperventilation

Downloaded by [New York University] at 01:46 15 August 2016 Despite feelings to the contrary, hyperventilation or “over-breathing” occurs when too much air goes into the lungs. Therefore, deep, expansive, or sighing breaths, rapid respirations, and incomplete exhalations add to its intensity. Some patients try to calm themselves by taking deep breaths when they notice symptoms, which makes hyperventilation worse, not better. When hyperventilation occurs, carbon dioxide levels drop while oxygen levels remain constant, and the ratio between the two changes. The relative reduction in carbon dioxide results in a set of symptoms that indude dizziness, lightheadedness, and tingling and numbness in the hands, feet, lips, and face. Some feel like they cannot take a satisfying breath and experience the symptoms of “air hunger,” making them breathe more, exhaling more carbon dioxide, and lowering its level even more. Most of these symptoms feel like anxiety, and they add to the anxiety patients are Techniques Tried and Misunderstood 83 already feeling. Despite its ﬂ agrant symptomatology, there is nothing dangerous about hyperventilating, it is just uncomfortable and anxiety generating. Tensions in the chest caused by chest breathing and the subsequent need to stretch the intercostal muscles can cause pain and pressure, which can trigger a patient’s concerns about cardiac issues. This further increases anxiety. Another side effect of hyperventilation can be depersonalization and derealization: these are odd, difﬁ cult to describe alterations of subjective experience that frighten people and are often misunderstood as harbingers of “losing touch with reality” or loss of control. People describe such experiences as “feeling outside my body” or feeling as if everything is perceptually distorted, or foggy, clouded, unreal. Some other descriptions include odd but creative statements such as “I feel as if my head is not attached to my body,” “my voice comes out of my ears,” or “I feel as if I am driving from the back seat.” Chronic hyperventilation can occur without conscious realization, but eventually the primitive housekeeping part of the brain (the medulla) will reduce the respiration rate to enable carbon dioxide levels to normalize. This happens automatically, but can create the frightening feeling of not breathing properly. People report “not being able to catch a breath,” become fearful of smothering, and this can trigger a panic attack. Ironically, this brain-imposed pause in breathing is the correction factor that happens automatically. Once proper carbon dioxide level is restored, the medulla steps back and people return to their normal breathing. Chronic hyperventilators start the process all over again, alternating between breathing too much and being stopped from doing so. Because chronic hyperventilation happens outside awareness, it can be responsible for symptoms of lowered carbon dioxide levels that precede conscious anxiety. It is not uncommon for people to report tingling in hands and feet or feeling foggy while stating that “there is nothing making me anxious,” and then adding sec- Chronic hyperventilation ond fear to these symptoms when noticed. They is outside of awareness experience the “uh-oh” whoosh and then associate and its symptoms these sensations with panic. Usually there will be no can occur before any obvious external stressor, since the hyperventilation conscious anxiety. has been going on for hours or even days—often in anticipation of some future challenge. This bewildering experience makes it seem as if there must be something medically amiss, when all that is happening is subtle effects of low-grade chronic over-breathing that has crossed the threshold of awareness.

Downloaded by [New York University] at 01:46 15 August 2016 Diaphragmatic breathing allows people to breathe regularly and rhythmically—and therefore avoid the pitfalls of hyperventilation—even during high levels of stress and anxiety. The diaphragm muscle—as opposed to the chest muscles—is relatively insen- sitive to stress and anxiety. The immediate goal is to have patients breathe diaphragmatically when feeling stress. A more ambitious goal is to re-establish diaphragmatic breathing as their normal, everyday, moment-to-moment method of breathing. That will make it much easier to maintain rhythmic breathing under any circumstances, including periods of increased anxiety and stress. Diaphragmatic breathing helps to manage anxiety by reducing symptoms of hyperventilation, lowering pain and pressure in the chest, and providing patients with a task (rhythmic diaphragmatic breathing) that helps them stay mindfully focused while 84 Techniques Tried and Misunderstood allowing and experiencing anxious arousal. Appendix 3 provides instructions for teaching patients how to breathe diaphragmatically.

Anxiety Management in Cases of Real Danger, Not False Messages As an expansion of the discussion of anxiety management techniques, there are cases where anxiety is comorbid with other conditions, and safety and impulsivity are a real concern. In cases involving comorbid major depression with suicidal ideation, or a personality disorder with real self-destructive impulses, it is entirely appropriate to utilize safety behaviors, anxiety management techniques, and coping skills. Emergency distress and affect tolerance techniques such as those embodied in DBT or those recommended by PTSD coach (US Department of Veterans Affairs, 2011), a mobile app developed for returning combat veterans, are entirely appropriate. These are techniques for averting real danger, not false messages. They include everything from “call a friend,” and “take a walk in nature,” to “take a shower.” Additional techniques involve calming self-talk, taking a PRN medication, getting some sleep, and other forms of psychological fi rst aid. Early stages of crisis stabilization with these patients involve developing appropriate coping tools. Presumably, as distress tolerance improves, these coping tools will not be needed as often and can be dispensed as therapy proceeds. These are patients who are suffering from co-occurring conditions. This is very different from patients who, despite fl agrant symptoms, are in no danger but believe the false messages of anxious arousal. Examples of this include a person who—in the middle of a panic attack—wants to call 911, or the person with OCD who has touched a “contaminated” object is utterly triggered by the thought, and wants to contact poison control. Rather, this category is reserved for patients who are dealing with self-destructive impulses in actuality, such as out-of-control rage, emerging psychotic thinking, or a mixed bipolar crisis. Making this distinction requires a high level of confi dence in diagnostic skills and good knowledge of the particular patient.

Some Issues in Determining Patient Progress Patients enter therapy with varying levels of distress. Some are markedly more sensitized than others, and suffer greatly on a daily basis. Others have few triggers, react very strongly to them, but encounter them infrequently. Lifestyles also contribute signiﬁ - cantly. Those with fears of heights or enclosed places might live comfortably in a rural

Downloaded by [New York University] at 01:46 15 August 2016 environment, yet be regularly triggered and having a terrible time in a large city. Some communities and family traditions encourage living and working close to each other, so that territorial fears (panic disorder with limited agoraphobic avoidance) are rarely triggered. Patients most frequently enter therapy when acutely distressed. New fears pop up, old fears re-emerge, or something occurs in their lives that forces them to address anxieties that they had been avoiding. A family moves from a city to the suburb, so that the mother can no longer use public transportation and must address her fears of driving. A job promotion requires fl ying, giving team presentations, taking elevators, coping in an effi cient way that has no room for compulsive rituals, and so the individual experiences intense consequences of an anxiety disorder that has been present, but kept at bay. Techniques Tried and Misunderstood 85 And a percentage of biologically predisposed patients develop an anxiety disorder while they are in treatment, usually because of the intersection of maturational and stressful factors. It can be distressing, bewildering, and frustrating to the therapist, who might sense that things are going in the wrong direction, or, conversely, that the emergence of the symptom must be a defense against the issues being addressed in therapy. With these inevitable ups and downs in symptomatology, how does one determine the progress patients are making in therapy? What are the criteria, and whose report- ing (the patient, the family, or the therapist) is given priority? Reasonable standards might include intensity of anxiety, amount of avoidance, willingness to tolerate anxious arousal, ability to label anxieties as misleading messages best ignored, or the overall ability to disengage from anxious arousal. One might also focus on overall quality of life, a subjective sense of well-being, or a growth in fl exibility leading to wider choices. Also important is the degree to which anxiety symptoms or other relevant variables like mood and the use of substances create functional impairment or disability. While priority must be given to patient reports, there are also times when patients’ own assessment of progress appears highly unreliable. For example, it is not uncommon for a patient with severe OCD—or some other crippling anxiety disorder—to be unmis- takably progressing while complaining that therapy isn’t helping. This is partly because memory is a poor tool to assess progress. A few low anxiety days can brighten a dismal week, and two or three days of unusually high anxiety can make people feel like they are seriously slipping backwards. But the issue is more complicated. Anxiety symptoms will increase—at least temporarily—when avoidance is reduced, and decrease—also temporarily—with increased avoidance. Reduction of symptoms by itself gives little information about how the patient is coping with anxiety, what they are learning in treatment, and to what extent anxiety sensitivity is being reduced. On the contrary, if a patient feels empowered to expose himself more frequently to anxiety-producing triggers, then an increase in anxiety might be a welcome sign of progress. This is why a housebound agoraphobia patient who never goes out will frequently report that they have not had a panic attack in years and their overall level of sensitization is low. Conversely, someone who refuses to completely avoid, but “white knuckles” their way through every challenging experience will have chronically high levels of sensitization and anticipatory anxiety but will be less functionally impaired. Anxiety levels are also exacerbated by stressors. There is a complex relationship between anxiety and stress that is rife for misunderstandings. Anxiety disorders are not caused by increased stress, just as they cannot be cured by decreasing it. However,

Downloaded by [New York University] at 01:46 15 August 2016 stress is frequently an essential component of the tri- fecta interactions of genetic predisposition, maturational progression, and stressful change that appears Anxiety tends to increase to trigger the emergence of many anxiety disorders. when feeling HALT Life stresses such as ﬁ nancial concerns, housing and (hungry, angry, lonely, health issues almost always increase anxiety symp- and tired) and IFS (ill, toms, regardless of how well anxiety treatment may fatigued, stressed). be proceeding. In the short term, anxiety tends to increase when feeling hungry, angry, lonely, and tired—the 12-step acronym H.A.L.T. To this, we add I.F.S. (Ill, Fatigued, and Stressed). (See Chapter 14 on relapse prevention for a further discussion of stress and anxiety.) 86 Techniques Tried and Misunderstood These factors highlight a most important point: regardless of desires to relieve distress, it is not always in the patient’s best interest to focus on lowering anxiety. In the long run, even more important than symptom remission is the patient’s development of a mindful awareness of the anxiety generating process, and ability to adopt the therapeutic attitude. As described in Chapter 3, this requires the moment-to-moment awareness of anxious thoughts, sensations, and memories, and the patient’s efforts to distance himself from distress—the process that paradoxically keeps anxiety alive.

Memory Aids for the Patient Patients who report anxious episodes often have a very poor memory of them—and are therefore poor reporters—even if they occurred just a few days prior. The distress of high anxiety is a chaotic experience resulting in a fog of fear. Patients report a form of retrograde amnesia trying to recall details of very high anxiety. However, when patients are asked about their experience immediately after it occurred, they are much better reporters. Observation of this led to two concrete changes in treatment. The ﬁ rst change was the introduction of supported exposure, in which therapists accompanied patients into the anxiety-producing situation, observing and interacting with them while they felt anxiety. Therapists spoke with patients before, during, and immediately after exposure, obtaining all the relevant details. Under these circumstances, patients provide far more accurate and detailed narratives of their experience, and are therefore more able to focus on the moment to moment details of their anxious experience. The second change was to seek any opportunity to retain freshly obtained information, even when symptomatic episodes occurred days (or weeks) prior to a scheduled session. Home practice assignments were given to patients to journal or record anxious experiences right after they occurred. Just as recording a dream upon awakening can keep the dream memory fresh, writing down the details of an anxious experience can keep those details in memory, despite the tendency to develop amnesia. This meant that patients and therapists had much better information during sessions to understand each anxiety episode. Here is an example where a memory aid helped a patient turn an unpleasant anxiety episode into a positive learning experience.

A woman with OCD became terriﬁ ed that she had inadvertently poisoned the Jell-O mold she had brought to dinner at a friend’s house. Initially, she could not remember any further details, but remembered that she had jotted down some details

Downloaded by [New York University] at 01:46 15 August 2016 soon afterwards. After looking at her notes (smart phones are perfect for this), she remembered feeling tense and insecure about being invited to dinner for the ﬁ rst time, her concerns that her children might misbehave, and the sudden intrusion of the terrifying thought that she might have inadvertently mixed poison with the Jell-O. (This was a not uncommon symptom of her OCD.) She also remembered that she was able to label her distress as OCD, but was angry at herself for not adequately checking that her ingredients were pure while she made the Jell-O—her usual OCD checking ritual. She was encouraged to celebrate her ability to cut down on the checking ritual, even though it resulted in greater anxiety afterwards, and that she was able to successfully label the distress as OCD. She acknowledged her difﬁ culty accepting the feeling of distress, instead of getting angry at herself for what felt like Techniques Tried and Misunderstood 87 inadequate checking. And that her self-anger might have contributed to her intensity of distress. She agreed to be on the lookout for this next time, while making an effort to accept the feelings with greater equanimity.

With the aid of a journal or diary, patients can describe the anxiety episode in detail and the therapist helps the patient identify all the triggers, thoughts, images, sensations, and memories that contribute to the anxiety episode. Additionally, there is opportunity to help the patient set the emotional and physical contexts that trigger initial anxiety reactions. What was happening? What were the thoughts and images running through the patient’s mind? Ideally, each anxious episode can be a learning experience that makes it easier to tolerate the next one. One popular form of obtaining information is to have patients keep an anxiety diary systematically, as a record of anxious episodes occurring between sessions. There are many variations of this concept, and one such version is described in detail in Appendix 4 . The most helpful information of all can often be obtained by directly observing the patient while deliberately attempting to induce anxiety in the offi ce or during an out-of-offi ce exposure. There is enormous value for patients to experience manageable levels of anxiety while the therapist helps focus on contemporaneous Deliberate attempts to triggers, images, thoughts, sensations, and memories. induce anxiety in the The focus here is less on anxiety management, and offi ce or outside can more on increased meta-awareness of the moment provide very helpful to moment internal processes—reactions to triggers, direct observations. sensations, thoughts, and memories—that create and maintain anxiety. There are simple ways to accomplish this. Patients who are afraid of sensations can spin round—either standing and twirling or sitting on a revolving chair. (It is surprising how many patients will initially refuse a request of this type.) Or they can over-breathe by taking 10 deep breathes, experience the effects of hyperventilation, and then run in place while the mild exercise replenishes carbon dioxide levels. Patients with OCD can be asked to touch the fl oor, pick up coins dropped on the fl oor, touch the fl oor and rub their face, mess up your offi ce desk, and any other task that triggers anxious arousal. Those with SAD might be asked to stand and recite a speech or a poem in your offi ce. Or sing a song. It is immediately interesting to observe and talk with a generalized anxiety disorder patient about what is happening when they typically refuse to write the sen-

Downloaded by [New York University] at 01:46 15 August 2016 tence “I wish my child would die” on a blank piece of paper.

References Grayson, J. (2003) Freedom from obsessive compulsive disorder: A personalized recovery program for living with uncertainty . New York, NY: Berkley. Carbonell, D. (2004) Panic attacks workbook . Berkeley, CA: Ulysses Press. WordPoints. (2011) “Anything worth doing is worth doing badly.” Chesterton G. K. Retrieved from http://wordpoints.com/brasstacks/articles/periodicals/Art0018%20-%20Worth%20Doing%20 Badly.pdf Rock, I. and Palmer S. (1990) The legacy of Gestalt psychology. Scientiﬁ c American 263(6) 48–61. 88 Techniques Tried and Misunderstood Hayes, S. C. (2004) Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behavior Therapy 35(4) 639–665. Harris, R. (2008) The happiness trap . Boston, MA: Shambhala Publications. Robins, C. J., Ivanoff, A.M., and Linehan, M. M. (2001) Dialectical behavior therapy. In W. J. Lives- ley (ed.) Handbook of personality disorders: Theory, research, and treatment . New York, NY: Guil- ford Press 437–459. Miller, J. J., Fletcher, K., and Kabat-Zinn, J. (1995) Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. General hospital psychiatry 17(3) 192–200. Wilson, R. (2009) Don’t panic, 3rd edition. New York, NY: HarperCollins. Harris, R. (2008) The happiness trap . Boston, MA: Shambhala Publications. US Department of Veterans Affairs (2011) PTSD coach (Version 1.0.1) [Mobile application software] Retrieved from http://itunes.apple.com Downloaded by [New York University] at 01:46 15 August 2016 7 Diagnoses An Annotated Tour of the Anxiety Disorders

The DSM-5 contains a complete and detailed description of every disorder presented in the following pages. So why do we include a diagnostic chapter here? The answer is that knowledge of criteria for an anxiety disorder may not be suffi cient to make an accurate and useful diagnosis, and so we supplement readily available information with our own clinical observations. For example, we present the fact that many “specifi c phobias” are not specifi c at all, nor are they phobias! We also explain why much of generalized anxiety disorder (GAD) is best conceptualized as a form of “OCD Lite,” how obsessive- compulsive disorder (OCD) can masquerade as any number of disorders, and what to do if your patient presents with a fi rst panic attack after the age of 40. Understanding ways in which anxiety disorders differ and yet appear similar is essential for guiding treatment. Patients often present initially with symptoms which may not fi t the DSM. We therefore share additional information about people with anxiety disorders to assist in diagnosis and treatment planning.

Specifi c Phobias Specifi c phobias are special types of fear. They are fears that are out of proportion to the danger, and intense enough so that the person consistently strives to avoid the source. Some people with specifi c phobias panic when they are in contact with the phobic trigger. Others feel intense anxiety and the need to avoid even though they do not experience actual panic episodes. Animal phobias are the most common specifi c phobia, and can include phobias of dogs, snakes, insects, or mice. The other main groups are situational phobias (such as

Downloaded by [New York University] at 01:46 15 August 2016 fl ying, driving over a bridge or through a tunnel, or of taking elevators), environmental phobias (fear of water or storms), blood-injury phobias (defi ned as fears of being injured, seeing blood or invasive medical tests or procedures), plus a list of other phobias that don’t easily fi t into other categories (such as phobias of clowns, loud sounds, falling down). Helping people with specifi c phobias requires an understanding of the thoughts, experiences, emotions, and sensations with which they are grappling. Some dog phobics are terrifi ed that a dog will harm them, and have great reactivity to that image. Other animal phobics report their distress as an extreme disgust reaction—one that feels intol- erably intense. Some have actually had a traumatic experience with a dog in the past, but, surprisingly, most have not. 90 Diagnoses: An Annotated Tour Situational phobias require careful consideration. As an example, the specifi c phobia “elevator phobia” is a fear of an elevator not functioning and crashing to the ground. But many different anxiety disorders can manifest as an intense fear of elevators; most common (and far more common than the specifi c phobia) are fears of feeling trapped, where the elevator acts as a trigger for panic attacks. So a fear of elevators could be an aspect of panic disorder. People may also be afraid of elevators because of social anxiety, where the person fears the elevator stopping, others notice this fear, and the patient feels humiliated. Still others with social anxiety disorder (SAD) might become terrifi ed by people looking at them when the elevator gets crowded. And a person with OCD can also fear elevators for a variety of reasons (“I need to go up and down a certain number of times or something terrible might happen,” or “I can only get out on even numbered fl oors,” or, “It can be crowded and if someone coughs or sneezes, I’ll be exposed to all those germs”). Similarly, a “fear of public restrooms” can range from a fear of being attacked, of contaminants and germs, of panic attacks which happen when enclosed in a stall, or paruresis (“shy bladder syndrome”), a SAD described below. Others are afraid they will encounter fi lth or smells and be unbearably disgusted. One patient did have a bona fi de public restroom specifi c phobia which consisted of an acute anxious reaction if the toilet seats were black. While the possibility of a traumatic experience with a black toilet seat as a child could not be ruled out, the origin of this specifi c phobia was never determined. Another phobia that looks initially like a specifi c phobia almost never is: emetophobia— the fear of vomiting. This is encountered frequently in clinical practice, and can represent a fear of the sensations of panic attacks or acute anticipatory states, and can include fear of the loss of control represented by vomiting. This is frequently an aspect of panic disorder. Emetophobia can also be the bottom line fear in an elaborate avoidance of germs and contaminants, with the fear of becoming ill that is a variant of OCD. Alterna- tively, it may be a memory of a parent’s panicky reaction to childhood vomiting, or it can have a social anxiety focus in which the primary fear is the social humiliation of being seen to vomit or smell like vomit. A “bridge phobia” can sometimes be a specifi c phobia and in other cases, not. Few people afraid of bridges fear the bridge collapsing. Most are afraid of having an anxiety attack or an intrusive scary thought while on the bridge. The fear isn’t of the bridge, but rather the feelings they might experience while driving over it. A person with a specifi c bridge phobia will remain anxious anywhere on the bridge, while someone who fears their thoughts or sensations usually Few people afraid of starts to feel better after having passed the halfway point. bridges fear the bridge

Downloaded by [New York University] at 01:46 15 August 2016 Similarly, claustrophobia is rarely just a specifi c phobia collapsing. Most are or fear of being in an enclosed space. It is most often afraid of panicking on the an aspect of panic disorder—fearing a panic attack in an bridge. elevator, an MRI machine, the backseat of a car, or some other “trapped” place. Occasionally, a post-traumatic fear fueled by a memory of being trapped and experiencing danger can underlie claustrophobia. If many “phobias” are identifi ed, they are best treated for panic disorder, OCD, SAD—or whatever common factor shows up in the variety of circumstances. Treatment for multiple specifi c phobias will be ineffi cient and fail to target the relevant overarching triggers, which is necessary in order for the patient to stop developing new “phobias.” Diagnoses: An Annotated Tour 91 Blood and injury phobias can be particularly misleading. For many, a blood and injury “phobia” isn’t a phobia at all. Rather, it is a triggered vasovagal reaction, resulting in a sudden drop in heart rate and blood pressure, and is a common cause of syncope (fainting). There are a few moments of rapid heart rate when confronted with actual or imagined blood or injury, which is then followed by a slowing of the heart and plum- meting blood pressure. There are a small percentage of people whose bodies react to the sight of blood in this manner, sometimes despite a lack of fear. Most have a parent with the same tendency. Blood and injury phobias start in childhood, and it is rare to develop them in middle age. Usual treatment consists of teaching patients how to keep blood pressure stable during exposures to triggers, techniques which can include using arousing or exciting imagery, increasing muscle tension, biofeedback, or the “bearing down” refl ex (which raises blood pressure). These patients need to learn the opposite of relaxation in the presence of a trigger. Other people with blood and injury phobias can have extreme fears of any invasive medical procedure, but would not be classifi ed as true blood and injury phobics, because they do not have this specifi c vasovagal syncope and therefore do not faint. It is essential to fi nd out the nature of their discomfort, and the mental images, sensations, and memories they fear. Some people fear pain, others fear the possibility of getting ill from contaminated equipment; others are terrifi ed by the possible side effects of the procedures themselves. Others are afraid they will have a panic attack and either embarrass themselves or lose control. Still others know someone who does faint in these circumstances, and lack the information that anxiety raises blood pressure and heart rate, protecting them against fainting. Specifi c phobias tend to start early in life. When they appear later (after the age of 12 or so), look closely for the possibility that an anxiety that looks like simple phobia is really another type of anxiety disorder. Here is an example. Dog phobias start early in life and a good percentage of children under the age of 6 will be frightened of dogs. How- ever, almost all of them outgrow their fear by the age of 9 or 10, but a small percentage will not, and it will intensify to phobic proportions. One patient reported an intense fear of dogs, which started in her mid-20s. (She was perplexed by her fear, because she had loved and played with dogs in her teens.) How- ever, it became apparent that her fear of dogs was not a simple phobia. Instead, it was an obsessive fear of getting rabies, and was more accurately conceptualized and treated as a form of OCD. She was certainly terrifi ed of dogs, but also obsessively worried that she had been bitten by a rabid dog, even when there was no apparent contact with a dog in

Downloaded by [New York University] at 01:46 15 August 2016 her vicinity. She would then compulsively check her body for possible bite marks. There are signifi cant differences in therapeutic approaches between specifi c phobia and OCD. In fact, OCD can masquerade as a variety of disorders—anxiety and otherwise. The essential point, however, remains the same: understanding the phenomenology of the anxiety experience is essential. Whatever the specifi c phobia, many phobic people do recognize that their distress resides inside themselves. They recognize their fear as irrational or at least “out of proportion.” Treatment begins with learning the difference between external triggers (dogs, bees, heights, elevators, bridges, tunnels, airplanes), internal triggers (sensations, thoughts, and memories), and their phobic reactions, or terrors. 92 Diagnoses: An Annotated Tour Panic Disorder Panic disorder starts with a single panic attack, followed by anticipation and fear of the next panic attack, and then often a cluster following in close succession. Panic attacks are intensely and unbearably uncomfortable discrete episodes of terror, which mount rapidly and reach a crescendo in minutes. People with panic disorder fear the recurrence of attacks and they often limit their activities to avoid situations that might trigger additional episodes. This is described as panic disorder with agoraphobic avoidance. Panic disorder ordinarily starts between adolescence and early 30s, and it is highly unusual for someone to have a fi rst panic attack after the age of 40. Onset of true panic disorder in late life with no prior episodes is so rare that it is essential to pursue an excellent medical workup whenever this occurs, to rule out other causes, including major depression and cardiac, endocrine, respiratory, and neurological conditions. Initial panic attacks typically are described as coming “out of the blue.” While there is no such thing as an event with no cause, the experience of that fi rst attack is of no immediate or obvious cause or trigger. Some people call this an “uncued” or “spontane- ous” panic attack. While fi rst panic attacks are unexpected, it is not uncommon for an interesting change in insight to occur as therapy progresses. Patients often retroactively recover memories of anxious episodes that they were trying to ignore prior to the emergence of severe symptoms. First panic attacks sometimes occur in highly stimulating fl uorescently over-lit environments like supermarkets or in situations without easy exits like public transportation, traffi c jams, or family events. Fear of sensations is a primary concern for people with panic disorder. They fear lightheadedness, arousal sensations involving their heart, head, or gastrointestinal tract, and “dizziness.” Many fear the odd experiences of depersonalization and derealization. They typically avoid roller coasters, and a good percentage of them are exercise intolerant (they don’t want to feel too out of breath). Those who hyperventilate fear associated feelings, including that of smothering, being unable to “get a deep breath,” feeling cog- nitively impaired or “foggy.” Others are frightened by the sensations they experience (or imagine they will experience) from prescription and OTC medications, or of drinking alcohol. Most have already stopped all use of caffeine. Some have had panic attacks in the dentist chair after a Novocain shot increased the heart rate. There are reports of fi rst panic attacks occurring after smoking marijuana, and these people thereafter avoid all similar sensations. The ultimate fears are of a panic attack progressing to the point that they “can’t stand it,” and they will lose control or go crazy, or that the symptoms will cause a physical overload, causing a heart attack or other catastrophic medical event. Downloaded by [New York University] at 01:46 15 August 2016 About one in three people with panic disorder develops agoraphobia, a condition in which the individual becomes afraid of being in any place or situation where escape might be diffi cult or help unavailable in the event of a panic attack. Agoraphobia was once defi ned as “fear of the Greek agora or marketplace” and then came to describe people afraid to leave the house. The modern defi nition changed as it was understood as a complication of panic disorder, and is now the fear of having a panic attack where one feels trapped or unable to get to safety. Panic disorder can become disabling. In many cases, people with agoraphobia live within a safety zone, where they feel insulated from additional panic attacks. In the most extreme cases, this safety zone can shrink to a small area of a neighborhood, home, or Diagnoses: An Annotated Tour 93 even just one or two rooms in one’s house. We have seen a housebound patient who lived day and night on the corner of her couch. Another patient was afraid to stand up. People with panic disorder often avoid public transportation, limited access highways, bridges and tunnels. Public transportation only stops at designated points, and they become afraid that they may start to panic between stops. So they are more likely to take local trains and buses, as opposed to express. They might fear any experience where they are unable to easily remove themselves if they begin to panic. Crowds and crowded audi- toriums can trigger intense anxiety. They prefer to sit in the last row, and on the aisle. Some people with panic disorder are able to travel quite comfortably in the presence of a trusted companion, who could take over if something were to happen. Panic attacks are psychologically painful experiences, and patients often describe the feeling as the beginning of an endless nightmare. While in the process of panicking, patients fear going crazy, having a heart attack, having a stroke, going blind, losing control, doing something embarrassing or humiliating, or dying. Panic attacks usually run their course in less than 10 minutes, although worrying about their return can provoke additional panic attacks, so that some patients report panicking for hours. First panic attacks are often so traumatic that they are ingrained in the patient’s memory with exquisite detail. Many people with panic disorder are convinced that there is something physically wrong with them, undergo extensive medical workups, and are frequent visitors to emergency rooms. They fi nd it hard to believe that their intense symptoms lack serious medical causes. These are the patients who are most bluffed by anxiety, and who have the greatest diffi culty accepting that their fear of symptoms is what keeps them so intense. Once cleared medically, their inability to accept that no test can be 100% certain becomes an issue to explore.

Social Anxiety Disorder SAD (formerly social phobia) is conceptualized as a hypersensitivity to real or imagined criticism. Underlying this phobia is the fear of a feeling—an exquisite sensitivity to being embarrassed or humiliated. People with SAD imagine being harshly scrutinized or judged. Some have trouble tolerating any social interaction or public perfor- Underlying social mance they consider to be less than perfect. Patients anxiety is an exquisite may be afraid that people will think badly of them or sensitivity to the feeling that they won’t measure up. There is a great deal of of embarrassment. Downloaded by [New York University] at 01:46 15 August 2016 comparing themselves with real or imagined others. Because of an intense and persistent fear of performing badly and the ensuing shame and humiliation, they often worry for days or weeks before a dreaded situation. Their fear can become severe enough to interfere with work, school, and other ordinary activities, making it hard to make and keep friends. If they manage to confront their fearful feelings and be around others, they are typically anxious beforehand, intensely uncomfortable throughout the encounter, and worry about how they were judged for hours or days afterward. In contrast to those with panic disorder, who feel relief after accomplishing something that had been fraught with anticipatory anxiety, people with SAD have a second round 94 Diagnoses: An Annotated Tour of “evaluation anxiety” after it is over. They may strain to recall details of their behavior and reconstruct the reactions of others. They tend to interpret neutral or ambiguous conversations with a negative outlook (Hirsch and Clark, 2004) and have negatively biased perceptions of people’s faces expressing emotion, while remembering the more negative memories (Morgan and Banerjee, 2008). Because of this, their recollections are distorted and tend to reinforce a sense of failure. And even though they realize that their fears of being judged are at least somewhat overblown, this realization doesn’t reduce their anxiety. Because embarrassment over a mistake and awkwardness or lack of social adeptness is so excruciating, people with social anxiety often hold themselves back from opportunities in relationships, work, and leisure. SAD can be limited to one situation (such as talking to people, introducing oneself, making a phone call, or writing on a blackboard in front of others) or may be so broad that the person experiences anxiety around almost anyone other than the family. One patient suffered from social anxiety so severe that he could not ask for someone to pass a dish at his own dinner table and preferred to eat in another room in front of the TV. Patients can feel anxious in situations that put them in the spotlight like asking for directions—or in situations that require no specifi c performance, such as entering a room with other people, or eating a meal in public. One subtype of social anxiety is called performance anxiety, and is particularly relevant to those who are triggered by public speaking, test taking, and by musical or theatrical performance. A patient who refused to get a driver’s license and was presumed to have a fear of driving was too embarrassed to admit to her family that the real problem was her inability to imagine tolerating the humiliation of failing the written pre-test, since she had a master’s degree. She felt she would never be able to live it down and instead was willing to have others believe she was afraid to drive, which she was not. Paruresis, or shy bladder, is a specifi c social anxiety in which people are unable to urinate in situations where others might hear or be aware. Most often these people cannot use public restrooms, and this leads to additional social limitation. Some people with paruresis cannot use any restroom at work, limit their fl uid intake severely, and com- mute home during their lunch hour in order to urinate. Long airplane trips are impossible and dating can be out of the question. Paruresis is often so embarrassing that the sufferer tells no one about the problem. People with SAD are frightened of sensations (racing heart, shaking hands, dry mouth, fl ushed face), and also of the thoughts that they are making fools of themselves, failing in a task, or having their anxiety noticed by others. Frequently they are focused on

Downloaded by [New York University] at 01:46 15 August 2016 the physical symptoms that actually show and can be noticed by others such as blushing, profuse sweating (hyperhidrosis) (Davidson, Foa, Connor, and Churchill, 2002), trem- bling, nausea, and diffi culty talking. When these symptoms occur, people with social anxiety feel like all eyes are focused on them. They often describe their distress as a form of unbearable over-self-consciousness. Anxiety can often reach the intensity of episodes of panic attacks, but doesn’t necessarily escalate to that point. People with severe social anxiety may describe themselves as “paranoid,” although they are not psychotic. Social anxiety has an early onset—age 12 or 13 is not uncommon—and since the average onset age is so young, many people who develop SAD are overwhelmed, perplexed, and unable to articulate the sudden appearance of their fears. It is not uncommon for them to just drop out, stop going to classes, leave their social groups, and spend Diagnoses: An Annotated Tour 95 more and more time by themselves. Sometimes parents fi rst learn of the development of SAD when they receive a notice from school that their child—some of whom were fi ne students prior to the development of SAD—has failed a class. Parents might suspect substance abuse, hanging out with the wrong crowd, depression, or plain laziness. Because their fears are triggered by social interaction, there is a subgroup of people with SAD who avoid relationships with peers, and keep their social interaction to a mini- mum. And there is also a subgroup of socially anxious people who have been severely shy since childhood. For these patients, extensive avoidance of social interactions means that they often fall behind in social skills and peer relationships, never developing the requisite set of social interactional skills. So the anxiety itself, as well as the reduced social skill capacity, must be addressed in therapy. While some people with social anxiety are temperamentally shy, most are not. Many people with SAD have managed to develop excellent social skills, either despite their anxiety or because their social anxiety is specifi c enough so that it doesn’t interfere with the majority of interpersonal interaction. So, for example, there are plenty of people with SAD who have no problem interacting one on one or in small groups, but panic in classes, work-related presentations, PTA meetings, or any gathering that they consider to be larger than their limit. There is high comorbidity between SAD and depression (Stein, Fuetsch, Müller, Höfl er, Lieb, and Wittchen, 2001), as well as the substance abuse disorders, most especially alcohol (Grant, Stinson, Dawson, Chou, Dufour, Compton,. . . . Kaplan, 2004). SAD can look like dysthymia, “low self-esteem,” or “poor self-confi dence” upon initial presentation, or it can be entirely submerged under alcohol dependence and its complexities.

Obsessive-compulsive Disorder OCD is a complicated and sometimes profoundly disabling disorder. It consists of two components: the ﬁ rst is obsessions , which are repetitive thoughts, or images that feel uncontrollable, threatening, repulsive, or shocking, that arrive with a “whoosh,” and contain a strong urge to avoid or get rid of the thoughts or images. Obses- Obsessions and sions increase anxious distress. The other component compulsions are deﬁ ned is compulsions, which are actions or thoughts whose not by their content but by function is to lower anxiety. Compulsions can consist their relationship to each of the commonly known checking or cleaning ritu- other.

Downloaded by [New York University] at 01:46 15 August 2016 als, but mental compulsions, which attempt to lower anxiety with thoughts, are also common, and probably far more common than generally recognized. Repetitive reassurance-seeking efforts are also classifi ed as compulsions (see “The reassurance junkie” Chapter 12 ). Obsessions and compulsions are defi ned not by their content but by their relationship to each other. It is common but incorrect to think that obsessions are thoughts and compulsions are behaviors. The most common type of OCD with behavioral components concerns those who are afraid of contamination (cleaners and avoiders) and those who are afraid of overlook- ing something that may be harmful or embarrassing to them or others (checkers). But these easily identifi able people are only a small part of the picture. Also very common 96 Diagnoses: An Annotated Tour are people with unwanted intrusive thoughts and images of causing harm, violence, and suicide, an aspect of OCD which is extensively covered in Chapter 10 (Unwanted intrusive thoughts). People whose lives are ruled by “overblown conscience,” also known as religious and secular forms of scrupulosity, are classifi ed as OCD as well (see Chapter 7 , and a more complete discussion in Chapter 13 ). A variant of this involves those with an excessive sense of responsibility, and fear of triggers that provoke guilt. Because OCD is often perceived as out of control, irrational, and “crazy” by the patient, the full symptom picture is often not initially volunteered for fear of stigma, ridicule, or even hospitalization. It is therefore not uncommon for someone to present for treatment with a complaint that seems more socially acceptable (like a driving phobia) and only later is it revealed that the central problem is OCD. Sometimes the physical symptoms that result from OCD are the path to discovering the disorder. For example, studies have looked at people presenting at dermatology clinics for hand rashes. The initial diagnosis was usually non-specifi c contact dermatitis. But a closer look at these same people revealed that almost one-third of them suffered from the cleaning type of OCD, and repeated washing made their hands raw (Fineberg, O’Doherty, Rajagopal, Reddy, Banks, and Gale, 2003; Hatch, Paradis, Friedman, Popkin, and Shalita, 1992). The nature of the distress in OCD can feel more guilt-like than fearful. It is not uncommon for people with OCD to feel even more concerned about others than themselves. Concern with the welfare of others, as opposed to singular concern with oneself, is often a clue towards dis- OCD can be about guilt, tinguishing OCD from, for example, panic disorder. disgust, or incompleteness Some people with OCD have disgust-based rather as well as fear. than fear-based avoidances and rituals. These are the cleaners who are not worried about getting sick but rather recoil from “icky-sticky” experiences. Another sub-group of people with OCD has what is sometimes called “just right OCD,” where symmetry, order, arranging, and repetitions are prominent features. So, for example, someone might touch one side of a hallway, and then need to touch the other side. In the same manner, he might touch one arm and then need to “even it out” by touching the other. Personal grooming can become a nightmare, where sideburns, facial hair, makeup, etc. can take up hours of time getting it just right. People with “just right OCD” are usually not preventing bad things from happening with their rituals. They are trying to prevent the feeling of discomfort that comes with being unfi nished, uneven, or

Downloaded by [New York University] at 01:46 15 August 2016 incomplete. Most people have a sense of a “click” that comes to tell us when something is arranged or ordered or done in a “good enough” way, and we just stop when we get that sense. People with this kind of OCD seem not to experience this internal sense of “done” and feel compelled to keep going.

Some Comments on “Compulsivity” In everyday English, the word “compulsive” describes the experiences of “I can’t help it,” “I do it against my better judgment,” “I can’t stop,” or “I feel driven.” There are a number of conditions where people engage in behaviors experienced as out of control that share some characteristics of “compulsivity,” but these are not OCD. In the DSM-5, these disorders include impulse-control disorders such as kleptomania (impulsive stealing) and Diagnoses: An Annotated Tour 97 compulsive gambling; tic disorders (classifi ed as neurodevelopmental disorders); and the addictions such as alcohol use disorder. Hoarding disorder is now no longer conceptualized as a subcategory of OCD, but is classifi ed as a separate “related” disorder. Body dysmorphic disorder is placed within the OCD family of conditions. On the other hand, eating disorders, which incorporate many “I can’t help it” behaviors, merit a separate chapter in the DSM-5. It is helpful to understand distinctions between varieties of the “compulsive” experience, to stay focused on what maintains the compulsivity and therefore how to treat it. Unlike OCD—which is a disorder of over-control —kleptomania and compulsive gambling are disorders of under - control . The acquisition phase of hoarding disorder can be conceptualized this way as well. These three disorders clearly share some important characteristics in common with the addictions, including the impaired ability to resist short-term pleasures despite their anticipated long-term consequences. The repeated behaviors are intrinsically pleasurable: patients “get high” off these activities, and then regret them later. It is the consequences of these behaviors—such as getting caught, being punished, or losing money—that are not pleasurable. In contrast, true compulsions in OCD are not pleasurable. A person spending hours hand washing is distressed, agitated, exhausted, and often in pain while performing compulsions, unlike the gambler who is having a lot of fun until she loses. Between these two opposites are the tic-like disorders of excoriation (skin-picking) and trichotillomania (hair-pulling) (often called BFRBs—body-focused repetitive behaviors) (Keuthen, Siev, and Reese, 2012), which are characterized by compulsions not triggered by mental obsessions, but in response to body-focused intrusive sensations or urges. These behaviors provide relief from urges that do not seem connected to conscious mental obsessions, and they are self-reinforcing because of the brief experience of a mixture of pleasure and pain at the moment of pulling off a scab or pulling out a hair. Some aspects of body dysmorphic disorder and even some of the eating disorders are closely related in phenomenology and structure to OCD and require very similar exposure-based treatments, in addition to other specifi c interventions. The treatment of these complex disorders is beyond the scope of this book. Hoarding disorder, now classifi ed in its own right as an obsessive-compulsive related disorder, is a particularly refractory condition whose treatment requires specialized interventions. Some excellent resources are now available for guiding treatment of both the acquisition and discarding phases (Steketee and Frost, 2006; Tolin, Frost, and Steketee, 2007).

Downloaded by [New York University] at 01:46 15 August 2016 OCD Can Masquerade as Other Disorders and “Issues” OCD frequently looks like another disorder. People with OCD are often misdiagnosed as depressed, agoraphobic, relationship-phobic, paranoid, and a host of other conditions. In Chapter 11 (“Classic Pitfalls”), we will examine some of the more common syndromes—such as pathological doubt—that have signiﬁ cant OCD components. Here is an example of OCD looking like a relationship issue.

A young woman was referred for therapy for her “anxiety” by her marriage counselor who had had a most frustrating experience attempting to help a young couple work out an issue in their marriage. It was clear to the counselor that the couple 98 Diagnoses: An Annotated Tour were well matched and loved each other, but about once a week they were up all night in long painful discussions trying to decide whether or not to separate. What distressed this young woman was that on a quite regular basis, she found herself thinking about a past boyfriend and wondering how her life would have been had she married him. She recognized that he was mean to her, she had felt relief after breaking up with him, and he had recent legal problems, but nevertheless his image popped into her head and thoughts of him arose while lovemaking with her husband, and at random other times. The more she rejected these thoughts and images, the more often they arose. Both she and her husband tearfully interpreted this to mean that she had serious doubts about the marriage despite the fact that neither could identify any problems between them. After all, why would she be struggling with these thoughts? The only other issue the husband could identify was that she spent too much time cleaning the kitchen. Upon closer questioning, it became clear that she had a “thing” about raw chicken and if she thought or suspected or imagined that raw chicken had touched the counter, she had to wash down the whole counter, and then the ﬂ oor and sometimes all the dishes that could have come into contact with the counter.

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

Downloaded by [New York University] at 01:46 15 August 2016 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 fi nd someone he loved who loved him as much. Diagnoses: An Annotated Tour 99 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 fi guring 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 fi nd 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 Purely mental OCD to marriage, and a date was fi nally set. At last report, is common. Both the he had delayed the marriage date. (We address relapse obsessions which prevention in Chapter 14 .) raise anxiety and the OCD is often purely mental, where both the obses- compulsions which sion (the component of OCD that raises anxiety) and attempt to lower it are the compulsion (the component that aims to lower entirely cognitive. 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

Downloaded by [New York University] at 01:46 15 August 2016 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 100 Diagnoses: An Annotated Tour 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 An extremely odd seems extremely odd (we have seen people who “phobia” should raise came to therapy because of fear of wind chimes, the consideration of OCD as a letter “s,” or the name “Estee Lauder”), look at their possibility. internal experience and wonder about the possibility of OCD.

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

Downloaded by [New York University] at 01:46 15 August 2016 with daily functioning, including work, school, social activities, and relationships. Worries seem to fl oat 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 specifi c episodes of panic. GAD is intimately involved with a person’s cognitive process, but the constant vigilant arousal can lead to physical symptoms as well. In addition to increased heart rate and blood pressure, symptoms of GAD can include diffi culty 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, Diagnoses: An Annotated Tour 101 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 signifi cant 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.

Downloaded by [New York University] at 01:46 15 August 2016 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 offi ce-based supply offi cer and, once home, had the sudden thought that perhaps she 102 Diagnoses: An Annotated Tour 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 signifi cantly and they do develop Only a small percentage a psychiatric disorder in response to the trauma, of people exposed to a depression and substance abuse are more common traumatic experience than PTSD. And also more common is the onset of develop the full PTSD anxiety symptoms which are triggered by the high syndrome. impact event. These fi t 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. Here is an example of someone who experienced trauma, developed a signifi cant anxiety reaction to those triggers, yet did not develop PTSD. She avoided fl ying 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 bomb- ing. Although other family members avoided fl ying after the death of her father, she continued to fl y, 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 fl own since.” While these

Downloaded by [New York University] at 01:46 15 August 2016 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 fore- casts but these soon subsided after she was able to identify the triggers and be prepared Diagnoses: An Annotated Tour 103 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 ﬂ ashbacks 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 later 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 Psy- chology Review 24(7) 799–825. Morgan, J. and Banerjee, R. (2008) Post-event processing and autobiographical memory in social anxiety: The inﬂ uence 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., Höﬂ er, 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. Grant, B. F., Stinson, F. S., Dawson, D. A., Chou, S. P., Dufour, M. C., Compton, W.,. . . . Kaplan, K. (2004) Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Con- ditions . Archives of general psychiatry 61(8) 807–816. Fineberg, N. A., O’Doherty, C., Rajagopal, S., Reddy, K., Banks, A., and Gale, T. M. (2003) How Downloaded by [New York University] at 01:46 15 August 2016 common is obsessive-compulsive disorder in a dermatology outpatient clinic? The Journal of Clinical Psychiatry 64(2) 152–155. Hatch, M. L., Paradis, C., Friedman, S., Popkin, M., and Shalita, A. R. (1992) Obsessive-compulsive disorder in patients with chronic pruritic conditions: Case studies and discussion. Journal of the American Academy of Dermatology 26(4) 549–551. Keuthen, N. J., Siev, J., and Reese, H. (2012) Assessment of trichotillomania, pathological skin picking, and stereotypic movement disorder. In J. E. Grant, D. J. Stein, D. W. Woods, and N. J. Keuthen (eds) Trichotillomania, skin picking, and other body-focused repetitive behaviors. Arling- ton, VA: American Psychiatric Association 129–152. Steketee, G. and Frost, R. O. (2006) Compulsive hoarding and acquiring: Therapist guide (treatments that work) . New York, NY: Oxford University Press. 104 Diagnoses: An Annotated Tour Tolin, D. F., Frost, R. O., and Steketee, G. (2007) Buried in treasures: Help for compulsive acquiring, saving, and hoarding . New York, NY: Oxford University Press. Lydiard, R. B. (2001) Irritable bowel syndrome, anxiety, and depression: What are the links? Jour- nal of Clinical Psychiatry 62(8) 38–45. Wittchen, H. U. and Hoyer, J. (2001) Generalized anxiety disorder: Nature and course. Journal of Clinical Psychiatry 62 15–21. Downloaded by [New York University] at 01:46 15 August 2016 8 Exposure The Active Ingredient

I believe that anyone can conquer fear by doing the things he fears to do, provided he keeps doing them until he gets a record of successful experiences behind him. Eleanor Roosevelt

There is no failure. Only feedback. Robert Allen

All exposure therapy is guided by the principle that anxiety is maintained by avoidance and intentional exposure is the active ingredient of recovery. If one moves towards the source of anxiety and willingly experiences the discomfort that arises, the anxiety will diminish. Patients begin to learn that they can cope with anxious feelings—that what is distressing is not dangerous—and so need not spend so much energy avoiding distress. When people pay less attention to avoiding anxiety—when they disengage themselves from anxiety’s false and frightening messages, anxiety becomes less intense, overall arousal reduces, and symptoms remit quite naturally. Equally therapeutic is a patient’s realization that they need not distance themselves from the source of their anxiety in order to feel better. They can experience anxiety and recover while still in contact with the anxiety triggers—an elevator for the claus- trophobe, a crowded room for the social phobic, a dirty hand for the person with obsessive-compulsive disorder (OCD). This realization—that they can feel anxiety and then recover while still in the anxiety-producing situation—is a concrete step towards overcoming their anxiety disorder. It means that avoidance and escape are not the only means to feel less anxious. Downloaded by [New York University] at 01:46 15 August 2016

Exposure in the History of Psychotherapy It can be difﬁ cult to encourage patients to expose themselves to anxiety before they say they are ready. But anxiety will always tell patients they aren’t yet ready to face their fears, so imagine how this analyst felt when he wrote the about pushing limits to help severe agoraphobics.

But the phobias have made it necessary for us to go beyond our former limits. One can hardly master a phobia if one waits till the patient lets the analysis inﬂ uence him 106 Exposure: The Active Ingredient to give it up. [Certain agoraphobic patients] protect themselves from the anxiety by altogether ceasing to go about alone. … [With these patients], one succeeds only when one can induce them … to go into the street and to struggle with their anxiety while they make the attempt. One starts, therefore, by moderating the phobia so far; and it is only when that has been achieved at the physician’s demand that the associations and memories come into the patient’s mind which enable the phobia to be resolved. (Italics added) (Freud, 1955)

Freud understood that avoidance can be the ultimate defense, and treatment for chronic avoiders must include inducements to approach anxiety triggers. He was willing to make modiﬁ cations to his technique as needed to treat the patient. We differ on the purpose of exposure, but agree on its necessity.

Exposure Therapy Is More Than “Just Do It” In order for exposure to work, it has to be done the right way. Otherwise, it is just repeating the miserable and demoralizing experience that brought the patient into treatment in the fi rst place. “Just do it” is not exposure therapy. The right way includes six essential elements: fi rst, exposure must address the underlying relevant fears; second, it should reframe anxiety as a “Just do it” is not positive learning experience; third, it should break exposure therapy. exposure down to manageable steps; fourth, it must reduce or eliminate avoidances; fi fth, each exposure session should be of suffi cient duration for new learning about the feared stimulus to occur and, sixth, it must focus on the right side of the street. These elements, all derived from evidence-based research protocols, encompass a huge degree of subjectivity, and address the art of treatment.

1. Address the Relevant Fears Anxious people have differing sensitivities. Although there are variations among the diagnostic categories, and many patients have more than one anxiety disorder, here are some general rules. Because people with panic disorder are afraid of the sensations of arousal, exposure should be directly to those sensations by deliberately provoking them. This is called interoceptive exposure and includes such exercises as deliberately hyper- Downloaded by [New York University] at 01:46 15 August 2016 ventilating to provoke all its sensations, breathing through a straw to simulate shortness of breath, spinning to create dizziness, running in place or up and down stairs to raise the heart rate. People with panic disorder require exposure not only to the sensations but also to the thoughts associated with their experience of panic. People with social phobia are sensitive to, and therefore require exposure to, feelings of embarrassment. Their hypersensitivity to real or imagined criticism is based on this fear. Exercises in which people deliberately undertake situations which would make anyone feel embarrassed are part of exposure therapy for social anxiety. Examples would be deliberately mispronouncing a word, or knocking over a display in a store, or wearing one blue and one brown sock all day. Exposure: The Active Ingredient 107 People with OCD are exquisitely sensitive to obsessive thoughts and images—often with a combination of panicky and guilty feelings. The content of these thoughts and images are what defi ne the underlying fears. These can be invoked by exposure to the particular triggers that provoke them, such as touching dirty things or walking through a hospital waiting room or whatever invokes the relevant thoughts and images. Traumatic anxieties require exposure to relevant memories and the associated emotions. Specifi c phobia exposures are to the external phobic objects as well as the internal sensations and thoughts that they trigger. People who worry too much (GAD) need exposure to worry thoughts, tolerating uncertainty, and their physiological arousal. Careful assessment becomes essential. Here is an example of someone who presented as typical panic disorder. She was afraid to drive over the Tappan Zee Bridge, and her stated concern was fear of losing control and driving off the bridge. This is a commonly expressed fear, and the typical sequence goes like this: someone starts to drive across the bridge, experiences a whoosh of anxious arousal, and fi ghts the feelings, which makes them more intense. Then starts a series of “what if?” catastrophic thoughts, further escalating anxiety. Feeling out of control and enmeshed in anxious thinking, the thought arises, “what if I lose control and drive the car over the guardrail and into the water?” further adding to the terror. The altered state of anxious thinking makes the thought seem like it could really happen. Since exposure is the active therapeutic ingredient, one would expect this patient to feel much less anxiety after repeatedly driving over the bridge in the presence of her therapist. However, there was no change after over 50 crossings! The problem here is that the therapist misdiagnosed the anxiety disorder, and therefore failed to expose the patient to the relevant underlying fears. In panic disorder, the initial fear is almost always the fear of sensations. This fear increases until the patient reaches panic, or near panic. The “what if?” thoughts come about as a result of the initial anxious arousal. They are part of the second fear. However, this woman suffered from OCD, not panic disorder. With OCD, the primary fear is often a fear of the thought, in this case, “What if I drive the car off the bridge?” This obsessive thought increased anxiety, and the resultant attempts to lower anxiety (the compulsions) are in the form of self-reassurances and avoidances. In panic disorder, the “what if?” thought follows the emergence of fi rst fear. In OCD, the “what if?” thought triggers the fi rst fear. The relevant fear is the obsessive thought, and that is what needs to be addressed. Exposure to the bridge is not suffi cient: exposure must be to the thought while she is driving on the bridge. Because of the misdiagnosis, the anxiety

Downloaded by [New York University] at 01:46 15 August 2016 management techniques she was using were working in reverse. She thought it kept her anchored in the present, but it functioned instead to avoid the anxious-making obsessive thought of driving off the bridge. The technique prolonged the anxiety, rather than reducing it. What was needed was to drive over the bridge while deliberately thinking— “ I could yank the wheel and drive off the bridge .” Here is a similar case where addressing the relevant fear is shown to be essential. A patient afraid to leave the house was unproductively practicing tolerating rapid heart rate and gastrointestinal distress while standing in the door and on the front porch. It was then discovered that what he was actually avoiding was encountering the gaze of other people who made him instantly self-conscious and anxious. Tolerating eye contact and his embarrassment was the needed exposure task. 108 Exposure: The Active Ingredient 2. Reframe Anxiety as a Positive Learning Experience Anxiety feels dangerous and there is a built-in desire to avoid its source. Encourage patients to seek out and embrace anxiety as part of the therapeutic process. This is a challenge to anxiety’s ability to trick people into thinking they are in danger. Remind patients that they are safe even while experiencing fearful distress. No amount of reasoning can think No amount of reasoning away an anxiety disorder. can think away an anxiety Experiencing anxiety is the only way for patients to disorder. learn how to better handle it. Despite its discomfort, an anxiety-laden day is a “good” day, and a non-anxiety day is a missed opportunity to practice and learn. Suggest that they welcome the anxious feelings with open arms. Experiencing anxiety Patients need to believe that experiencing anxiety is not is not a failure; it is an a failure. (Lots of patients see it that way.) In contrast, let opportunity to learn. It is them understand that feeling anxiety is a positive step in a necessary positive step the therapeutic process, and there are great beneﬁ ts to in the therapeutic process. feeling manageable anxiety. Having symptoms and learning to experience them as less aversive changes patients’ relationship to anxiety, so that it no longer runs their lives. Overcoming an anxiety disorder is a learning process that requires practice. As an analogy, imagine learning a foreign language without speaking the new language. In both cases, the brain needs to create new circuitry. Speaking a new language is uncomfortable and frustrating at ﬁ rst, but the speed that one learns a language is directly related to one’s willingness to dive into awkward conversations. There is also the need for patients to accept and actively allow their anxious feelings. Any time a patient feels disappointed, angry, or let down because of their anxiety, the process of avoidance, resistance, and neutralization is triggered. This, in turn, will increase and prolong the anxious feelings.

3. Manageable Steps Most highly anxious people will tell you that they have repeatedly tried—and repeatedly failed—to overcome their anxieties. Failure often comes from not understanding the importance of taking manageable steps. When patients try to expose themselves

Downloaded by [New York University] at 01:46 15 August 2016 to overly anxiety-intensive situations, they run the risk of resensitizing themselves and learning only that it really is a good idea to stay away from the source. It is common to teach patients to subjectively quantify their levels of anxiety as they are going through the experience. Many use a 0–10 scale, where a higher number corresponds to greater anxiety. So one might say to a patient, “I’d like you to start quantifying your anxiety on a 0–10 scale, where a higher number means greater anxiety: 0 means no anxiety—you may have felt that for a brief time a few years back—and 10 is the highest level you can imagine, a no holds barred absolute panic. Now remember, this is very subjective. If you think about that, at what anxiety level would you rate yourself right now?” If the patient responds with “5,” one might continue: “Okay, great. Remember this Exposure: The Active Ingredient 109 is subjective, and there is no way to know whether your ‘5’ corresponds to mine. But we do want internal consistency, so that your 6 is more anxious than your 4, and your 5 is less anxious than your 7 or 8. Is that clear?” Most patients have no trouble with this concept. Working in manageable steps usually involves working with anxiety levels at a moderate 4–6 level. However, as patients learn about anxiety and gain confi dence in their ability and willingness to manage those feelings, manageable steps can involve much higher levels. And eventually, when it is clear that anxiety is no longer feared but embraced, the steps themselves often become unnecessary. Here are examples of manageable steps. For the person with panic disorder who panics in a shopping mall, sometimes even parking in an indoor garage is too large a step. Patients can park their car outside the mall, and then slowly approach the mall. You can work out ways so that they can stay in control of their location, which helps to keep anxiety levels manageable. An elevator phobic might work on merely approaching an elevator, and get in and out before the door closes. For some, having the door actually close increases anxiety beyond a manageable step. Patients need help understanding manageable steps to avoid getting frustrated and trying for unrealistic goals. Encourage exposure while keeping anxiety levels low enough so that patients begin to feel confi dence in their own abilities. On the other hand, the steps cannot be so small that no anxiety is experienced, as this will not result in any helpful learning. Often they keep their eye on the goal as opposed to the process. We will discuss this in much more detail later in this chapter under “The right way to practice exposure.” For a person with OCD who is a cleaner, manageable steps might include modify- ing or shortening the cleaning compulsion, but still keeping levels of anxiety in middle ranges. Specifi cally, if the patient washes the soap (or soap bottle) before washing himself, you might ask him to try to stop doing that one step in his ritual. The result is that he exposes himself to moderate levels of anxiety while continuing with a partial ritual. Similarly, ask cleaners to stop washing before all their anxiety goes down—they usually interpret that as before they feel clean—and ask them to then wait with their anxious feeling until the feeling goes away, or the exposure time has expired. But the patient needs to understand that the primary criterion for manageable steps is manageable levels of anxiety, not a predetermined set of tasks marching towards a goal. The identical exposure may bring on differing levels of anxiety on different days. Your patient might feel more or less willing to tolerate anxious feelings on certain days. This is all part of the process, which is anything but linear. Once a patient grasps that it is not

Downloaded by [New York University] at 01:46 15 August 2016 the external situation but his own appraisal and tolerance of anxiety that he is addressing, formal “hierarchies” of triggers tend to collapse. The external situations are simply ways of invoking the anxious thoughts, feelings, sensations, and memories so that new learning can occur.

4. Reduce Avoidances Since anxiety is maintained by avoidance, reducing avoidances during exposure is essential. Most highly anxious people put themselves in a diffi cult position. They expose themselves and—at the same time—they look for ways to avoid feeling the uncomfortable 110 Exposure: The Active Ingredient feelings. Unfortunately, they learn to become better avoiders, not how to better manage their anxious feelings. Here are some examples: the elevator phobic who only goes in certain elevators during certain times; the fearful fl yer, who insists on certain seats, will not fl y at night, over water, or on fl ights longer than a certain length; the bridge phobic, who avoids driving on certain lanes, levels, or times of the day; the cleanser who, under group pressure, will dirty his hands but then focus on how good he will feel once he is able to have a good, long, hand wash; the social phobic who must pitch a project and makes sure that most of the pitch is delivered by a subordinate. And there is the worrier who is engaged in a constant internal conversation in which he poses worry questions and then tries to reassure himself that his worry is irrational. Create an ongoing line of communication between you and your patient, especially when he is feeling high levels of anxiety. You are identifying triggers as well as focusing on the patient’s internal dialogue between the misleading messages of anxiety, and the ways your patient responds to them. Sometimes it is helpful to tell patients that they are both the patient and also the co-therapist. They go through the experience as the patient, but also observe and relate to you what is happening. Our defi nition of avoidance is a very general one, and includes everything that patients do to fi ght anxiety. We have articulated this in some detail in Chapter 2 but the concept warrants further discussion. Avoidance includes both behavioral and cognitive avoidances. It includes physically avoiding experiences that cause anxiety, as well as all cognitive mechanisms to avoid the experience of anxiety while in the anxiety arousing situation. These include outright avoidance as well as mini-avoidances (shortening exposure, counting down the time until one can escape, taking a less-anxious path), covert avoidances (attempts to reduce or avoid the anxious feelings while staying in contact with triggers), rituals and superstitions (needing to wear the “right” shirt, stepping into the elevator with the right foot fi rst), mental reassurances—even as subtle as telling oneself that it won’t be that bad (which are sometimes called neutralizations)—imagining who can help, who is available, where the closest medical facility is located, any escape or avoidance plans, or the thoughts “I can get help whenever I need it,” “this isn’t that dirty because they vacuum the room every night.” In short, anything other than allowing anxious thoughts and feelings to continue unabated while focusing on the task on hand is considered an avoidance and ultimately counter-therapeutic. Table 8.1 presents a listing of avoidances, grouping them in a manner that makes it easy to identify their variations.

Downloaded by [New York University] at 01:46 15 August 2016 Anxiety management techniques are helpful ways to allow time to pass while the anxious brain does its thing. When used in this manner, they are therapeutic. But if these same techniques are used to evade or block anxiety, then they will ultimately maintain and reinforce anxious feelings . This subtle distinction will be need to be revisited again and again—before, during, and after exposure tasks—whether they occur as intended practice or in the course of daily life. Whenever a patient remains fearful of something they do frequently—ﬂ ying is a good example—look for covert avoidances. Covert avoidances give patients the worst of both worlds. They experience anxiety that is potentially therapeutic, but the avoidances negate those beneﬁ ts. What we note as covert avoidances are often called “coping Exposure: The Active Ingredient 111 Table 8.1 Different kinds of avoidance

Complete avoidance • Just don’t go or don’t do it

• Shorten the exposure • Sit in a particular place • Avoid rush hour Mini-avoidance • Go, but only with a companion • Avoid certain triggers within the exposure • Talk only to old or unattractive people • Wear sunglasses

• Map out safe places (e.g., hospitals) or people (friends or family) just “in case” Cognitive avoidance • Plan escape • Countdown until escape • Remind self you can undo it or check on it later

• Wear the “right” shirt, step into elevator with “right” foot • Affirming or repeating comforting phrases or facts: “God is Cognitive rituals and superstitions good and he wouldn’t hurt me” • Remind yourself you can always take your Xanax® • Repeat over and over “this is just anxiety, I will be okay”

• Always bring water...or your dog...or your cell phone • Imagine who can help • Relaxation techniques Coping skills • Pretend you are somewhere else • Talk about anything for distraction • Wear gloves or wash later

skills” by the patient—and it will take considerable explanation and discussion for them to see how Look for and let go these so-called “anxiety reducing techniques” actually of covert avoidance maintain the anxiety and undermine recovery, reduc- (sometimes called “coping ing, and sometimes eliminating, the therapeutic ben- skills” by the patient). eﬁ ts of exposure. Coping skills of this sort are not only unhelpful, they are often the reason the patient is not making progress. Unfortunately, many people who are engaged in self-help or uninformed counseling will be encouraged to use these sorts of covert avoidances. It is important to explore what the patient is doing behaviorally and mentally to cope with

Downloaded by [New York University] at 01:46 15 August 2016 anxiety: this is a key concept, something not at all obvious to most patients, and a huge breakthrough when it is grasped.

5. Suffi cient Duration Ideally, each exposure session should last long enough for anxiety levels to start lowering. If the exposure is just long enough to feel a jolt of anxiety, and the patient then leaves the situation, nothing therapeutic has happened. On the contrary, fear-generating reactions have been reinforced and the patient may conclude that, in fact, he can’t handle the situation and ought to stay away. 112 Exposure: The Active Ingredient There is controversy about the curative processes that occur during exposure. The more traditional view is that fear is extinguished through the process of habituation, where ongoing exposure reduces sensitized reactivity and the brain learns a new connection to anxiety triggers. Exposure continues until the fear is gone, or nearly gone, and the brain learns to substitute “I’m not afraid” circuitry for the old “I am afraid” circuits (Foa, Hembree, and Rothbaum, 2007; Foa and Kozak, 1991). Unlearning a fear response is something of a misnomer. Neurologists know that old circuitry is never really lost, but new “non-fearful” circuits are learned and these new neural pathways can inhibit and take the place of older, less used circuitry. So a more accurate way of describing successful desensitization is that default circuitry switches from “automatic terror” to “no fear.” The “automatic terror” circuits still exist in the brain, but are not accessed by the old triggers. More recent fi ndings by Craske, Liao, Brown, and Vervliet (2012) indicate that exposure need not progress to where the patient feels little or no anxiety. In this inhibitory model of exposure, the essential point is for patients to learn they can experience anxiety and develop a tolerance for the discomfort. The original fear circuitry remains, but is inhibited by what is learned during exposure. In this case, the default circuitry would switch from “I’m afraid and I can’t tolerate it” to “I’m afraid but I am able to cope with these feelings.” The goal is then to foster anxiety tolerance as opposed to anxiety elimination. Research suggests that this approach eventually leads to greater symptom remission. The therapeutic benefi ts of exposure require that anxiety be triggered as part of the process, and learning new brain pathways is dependent upon anxious arousal. The term “exposure plus activation” describes exposure to underlying relevant fears, and the triggering of the anxious reaction. Ideally, each exposure session should continue long enough for new learning to take place. For people with panic disorder, this can be within 15 or 20 minutes. Patients with OCD often take considerably longer. In practical terms, one almost never has ongoing contact with anxiety triggers, and there is great subjectivity in the exposure process. Ask patients to try to remain in the situation until they feel their anxiety starting to decrease or experience some subjective change in the tolerability of their distress. Another technique is to ask someone to practice until they start to feel bored, since boredom is anathema to anxiety. A key is to practice in many different situations and variations over time, in as many contexts as possible. The goal is to both create the new neural circuits, and also to make them as accessible as possible. A helpful metaphor

Downloaded by [New York University] at 01:46 15 August 2016 might be to imagine that a new roadway is being Practice in many different built, the old one still remains, and the new roadway situations and variations will only be used if many entrance and exit ramps are over time. also constructed. It is impossible to overemphasize the importance of repeated practice under a variety of circumstances, so there are variations to practice sessions. We regularly supervise therapists who ask what is wrong—their patients are not progressing. Often the answer is that nothing is wrong, but that patients need to practice more often, more consistently, and under more varied situations. Choosing when to end an intentional exposure is also a critical part of the learning process. Exposure practice decisions are made by mutual agreement with the patient, Exposure: The Active Ingredient 113 based on willingness to experience anxiety during any particular task. If anticipation of the experience is too high (even though anticipatory anxiety is not an actual predictor of symptomatic response—see Chapter 12), then the exposure plan needs to be reduced until it is a challenge but not overwhelming to the patient. On the other hand, once a specifi c goal is set and the willing attitude is in place, then the end of the exposure task needs to be considered and planned as well. The most unhelpful way to do this is to keep going indefi nitely—and to stop only when the symptoms have begun to escalate to the point where it feels like “too much.” This will reinforce escape as a solution to anxiety, and give the patient the impression that he might not have been able to make it a moment more. It also produces a constant anxious monitoring of symptoms for when to leave—with the notion of “Is it more than I can stand?”, “Should I stop now?”, or “Is this really worth doing?”—all of which are counterproductive in maintaining the attitude of acceptance. A positive example would be to drive three exits on the highway and then exit, whether feeling relaxed or anxious or anywhere in between. Another would be to spend 15 minutes talking with a stranger, and then end the conversation, even if there is an unanticipated willing attitude to continue. Or to fi nish a shower at a specifi c time limit, whether or not the compulsive washing has reduced anxiety to its lowest level—and to continue the shower for its limit in the unlikely case that anxiety is reduced more quickly than anticipated. It is also the case that forcing oneself to remain in an exposure task by adopting a white knuckling, grim determination is almost never helpful. Should this be occurring, stopping exposure assignments temporarily and reviewing the purpose of exposure and the attitudes needed for new learning is advised.

6. “Stay on the Right Side of the Street” The aim is to identify an internal process—that of adding fear to sensations, memories, and thoughts—and to have patients change that process. An aspect of this is focusing on what is relevant. The right side of the street is what goes on inside the patient. The wrong side of the street is the external triggers. Here is a story that illustrates this point:

A man comes out of a bar one night to ﬁ nd a group of people huddled by the ground under a streetlight. He goes to one of the people and asks what is happening. “A woman lost a contact lens, and we are trying to ﬁ nd it,” is the response he

Downloaded by [New York University] at 01:46 15 August 2016 gets. So the man joins in. But after a few minutes, he realizes that contact lenses are small, and the grass on the ground makes for good camoufl age. So he decides to ask the person who dropped the contact lens if she could tell him—to the best of her ability—precisely where she believes it was dropped. That way, he thinks, everyone could start at that point and search more systematically, in concentric circles from where it was last seen. He asks the woman, “Please—to the best of your ability— point to where you think it was dropped.” The woman stretches out her hand and says, “Oh, I dropped it on the other side of the street,” while pointing in the distance. The man is astounded, and asks, “Why look here if you know that you dropped it across the street?” To which the woman responds, “Because the light is much better here.” 114 Exposure: The Active Ingredient During exposure, it is easy to focus on the wrong side of the street, because it is easier to focus on external triggers, as opposed to internal processes. Patients forget that they will never fi nd the source of their anxiety by looking at the externals—just like the woman looking for the contact lens will never fi nd it under the streetlight. Here are some illustrations: A patient with moderate agoraphobia manages to travel outside of his safety zone, feeling little or no anxiety, and might feel proud of this achievement, believing he has made real progress. While this might seems like a commendable achievement, it is an example of looking on the wrong side of the street. It is focusing on achieving external goals—in this case traveling outside of one’s safety zone. If no anxiety is generated, there is no opportunity to better understand and change his fears. Looking at the right side of the street pays less attention to where the patient trav- els, or even how much anxiety is experienced. Instead, the primary focus is on how the person manages and relates to the anxious feelings that arise. The patient is encouraged to focus on the internal fear-generating processes, while learning the skills to feel less frightened by the emergence of these thoughts, sensation and images. In this instance— where the client has traveled outside of a safety zone with little or no anxiety—there has been little or no therapeutic exposure. Alternatively, let’s suppose that this same person forges outside their safety zone and experiences considerable anxiety, but manages to stay by gritting their teeth, powering through, and counting down the minutes until getting back to comfortable surround- ings. This is yet another example of focusing on the wrong side of the street. The important point is not where the person goes, or how much anxiety he endures. The right side of the street focuses on the internal anxiety-generating processes, and how the person inadvertently maintains anxiety by trying to avoid it, as well as observing what happens when he stops avoiding. Similarly, let’s look at someone with OCD who is a cleaner who triumphantly reports that he managed to put his hands on the carpet at work and not wash for 20 minutes. But further questioning reveals he counted down the 20 minutes, refused to touch anything else during that wait, and checked out the carpet, deciding that it really wasn’t all that dirty. We can congratulate this person for the courage to face his fear, but the exposure was moderated by a number of avoidances and neutralizations, and this is another example of focusing on the wrong side of the street. It is the willingness to actually connect with the anxious experience that is the right side of the street. Sometimes these differences are subtle, and we accidently join our patient on the

Downloaded by [New York University] at 01:46 15 August 2016 wrong side of the street. A patient with OCD might ask, “What if I poison my child by inadvertently mixing cleaner in the lemonade?” or, “What if I left the gas on?” The person with panic disorder might fear panicking and screaming during a theater performance. The person with social anxiety disorder (SAD) might fear blushing during an introduction. Sometimes the fears are so absolutely preposterous that we start to reassure the patient. When one patient with OCD reported fears of stepping in chicken feces and starting an epidemic over the east coast of the United States, it was diffi cult not to challenge the probabilities. In the same manner, if one tells an aviophobe that fl ying is really very safe, that starts to cross onto the wrong side of the street. Avoid getting into a discussion about the chances of these things happening, or reassuring patients that they won’t. Talking about what goes on “out there” is looking on the wrong side of the street. Exposure: The Active Ingredient 115 There are times, however, when it makes sense to restate facts that are also reassuring. This is part of psycho-education that encourages patients to know the facts about their fears. Correcting misinformation is not the same thing as attempting to provide reassurance. The distinction can be hard to make at times, but good general rules are (1) repeating the same facts again and again is not helpful and (2) trying to provide a sense of certainty about an unanswerable question will backfi re. For example, teaching patients the fact that airplane accident rates during turbulence are the same as without turbulence can be helpful to patients who fear bumpy fl ights. The primary purpose is education, and it would be proper to provide the correct information even if turbulence increased accident rates. Repeating these facts over and over in an attempt to calm anxiety while on the plane will not be helpful. There is a need to face and accept that no one can guarantee that bad stuff won’t happen. Staying on the right side of the street is about tolerating uncertainty and allowing for a new way to respond to “what if?” thoughts. Patients often say, “I could easily drive over the bridge if I knew that there wouldn’t be any traffi c delays,” or, “I wouldn’t worry about my child taking the school bus if I could drive the bus,” or, “I wouldn’t fear stepping on red spots on the ground if someone would guarantee that the spots aren’t AIDS-infected blood.” But peo- The realities of traffi c, ple usually have little control over external triggers. dirt, delays, and mistakes The realities of traffi c, dirt, delays, crowds, speeches, are impossible to control. and mistakes (to name just a few external factors) are impossible to control. The most effective therapeutic exposures pay less attention to external triggers, hierarchies, and external goals realized, and focus more on the patient’s internal world. Patients react to sensations and feelings, frightening thoughts, and distressing memories. These fears are what need to be worked on. That is the right side of the street. A work by Sisemore (2012) contains a comprehensive listing of ideas for exposure tasks arranged by diagnosis. They can help to generate ideas to be discussed while planning individualized exposure tasks with patients.

Role of the Therapist During Exposure: What to Say and Do Dealing with a patient when experiencing high anxiety is akin to dealing with a terriﬁ ed infant or a frightened pet. The part of the brain triggering anxious arousal is among the most primitive—the amygdala. Like an infant or a pet, the amygdala does not com-

Downloaded by [New York University] at 01:46 15 August 2016 municate with words, but responds to body language, quality of sounds, and general attitude. When an infant becomes frightened, it does no good to explain that his reaction is inappropriate, or to tell him to calm down or get over it. A frustrated tone only makes it worse. Similarly with an anxious patient, any sense of urgency, tension, or anxiety will be projected, transmitted, and amplifi ed. If the therapist is anxious about the patient’s anxiety, the patient will feel that anxiety. If the therapist feels pressure or urgency to make patients feel better, the major message transmitted is pressure, which undermines the attitude of acceptance and models a fear of fear. When communicating to a patient to “accept and allow,” it does best to promote a general attitude towards anxiety itself— discomfort not danger—and not be just a verbal message. Soothing speech and a relaxed and patient attitude promote calm far more effi ciently than any other methods. This can 116 Exposure: The Active Ingredient be shown in the accepting, empathic, and confi dent manner of supporting the patient during anxious times. When patients experience anxiety in your presence, remind them that this is anxiety, that they are safe, that anxiety is painful and uncomfortable but not dangerous, and that the courage they show in exposing themselves to this distress will be rewarded by less suffering in the future. When to stop exposure is a clinical decision, looking for the optimum point between too long and not long enough. Patients often express initial hesitation about exposure, so we recommend encouragement when they desire to stop. But waiting until they insist and anxiety approaches panic is probably too late. Remind them that exposure is not a test but practice, an experiment with the purpose of gaining more information about the anxious experience. Finally, go over rules and expectations for physical contact and closeness before exposure commences. Some patients prefer to be left entirely alone, and given a wide physical space. Others appreciate proximity. Some patients are comforted when the therapist taps their arm or makes some other physical contact. But these preferences must be discussed when the patient is feeling comfortable and able to communicate without pressure.

Expect Them to Feel Anxious: Embrace the Therapeutic Attitude Together Anxiety is never a welcome visitor, but patients should never feel surprised, blindsided, or disappointed by their anxious whoosh. Deliberate exposure practice in which no anxiety occurs is not particularly useful, so symptoms are not only expected, they are desired. It is a conditioned response outside their control. Patients do best when they understand that sensitivity is not their fault, and they can expect reactions to anxiety- producing triggers. Embracing the therapeutic attitude of acceptance will be revisited throughout the experience as you talk through what is happening in the patient’s mind and body. There will be times when it is important to explore while not trying to relax, ﬁ x, ﬁ ght, get rid of, deny, or resist. This is all part of learning to surrender the struggle and just let time pass.

Help Them Label the Experience as Anxiety in the Moment This can be a difﬁ cult step for patients to embrace, and it directly addresses the decision process outlined in Figure 3.3. Patients need to be able to relabel their distressing and frightening thoughts, feelings, and memories as symptoms of their anxiety. Remind them about this often, since it is the nature of anxiety to bluff, trick, and mislead, and anxiety

Downloaded by [New York University] at 01:46 15 August 2016 will continually be triggering doubt and uncertainty. We have addressed some of these issues in Chapter 4 . If patients can remember to ask themselves the question “Is this an anxiety reaction?” or “Is this an OCD thought?” while this is happening, we are helping the patient widen his psychological fi eld of vision and thereby gain useful perspective on his experience. It does not eliminate the experience— and there is no need to—but rather helps to integrate that experience into a larger and more realistic contest. The automatic arousal and call to active avoidance triggered by the amygdala can now be viewed with less urgency. As our perspective expands, each individual element takes up less emotional space. The snarling tiger at our face is far more compelling than the one on the horizon. Remember that anxious thoughts are identifi ed less by their content, and more by how they feel and by the accompanying urge Exposure: The Active Ingredient 117 to respond as if they are a real and present danger. Once patients have found alternative explanations for these feelings, they will become increasingly aware of an inner “wise mind” that really knows it is a panic attack or an obsessive thought and not a heart attack or an uncontrollable urge to do something crazy. Patients are not clueless about this. It is more that the part of their mind that knows is not absolutely certain, but wants to feel that way. Grayson’s (2003) thought experiment, the “gun test,” helps patients to distinguish what they know intellectually and logically from what they are feeling. There are two parts: In the fi rst part, ask the patient to imagine that someone has a gun to his head, knows the answer to this question, and forces him to make a choice between danger and anxiety. If he doesn’t make a choice, or if he makes the wrong choice, he will be shot. This experiment bypasses certainty, forces a person to go along with his best guess and helps him get in contact with his “wise mind.” In the second part of the gun test, patients are asked if they could proceed with exposure if someone put a gun to their head, and would be sure to pull the trigger if they refuse. This speaks to issues of motivation as well as certainty. Anxiety is remarkably persistent. Repeatedly frame the truism that feeling anxious is not the same as being unsafe, and that anxiety will continually attempt to mislead by mistaking anxious feelings for danger. Patients will “get it” and then lose it, and then “get it” once again. They are coping with their uncertainty, which is inevitable while feeling anxious.

Stay as Close to the Present as Possible Anxiety cannot exist without a future-oriented reference. (People can feel physiological arousal in the present, but the labeling of that arousal as anxiety requires a future reference.) Encourage patients to stay with “what is” as opposed to “what if?” Remind them when they get ahead of themselves, or otherwise stuck in the future. Help them to focus on the “here and now.” The most helpful thing for patients to do when they are coping with anxiety is also the most difﬁ cult thing: nothing. Help them to ﬂ oat with their feelings. Use metaphors. Stay with them as they learn to allow time to pass.

Label the Level of Distress From 0 to 10 Anxiety is not an all or nothing experience, nor does it remain static. Observing anxiety levels go up and down, and to experience—as it happens—the correlations between

Downloaded by [New York University] at 01:46 15 August 2016 thoughts, feelings, and memories, on one hand, and anxiety levels, on the other.

Distress in the Present Will be Rewarded with Less Suffering in the Future Congratulate them. Celebrate their courage. There is nothing easy about exposure. They have been facing fear and its terror—not just dirt or the subway or speaking to a clerk. Check for ways in which they tend to minimize or undermine their accomplishments (“I could not have done this without you or without my medication”; “So what if I went in a store, anyone can do that”). In fact, it is not uncommon for patients to become discouraged and say things like, “I work so hard and I put so much effort into this—and where do I end up? Right where other people start out!” 118 Exposure: The Active Ingredient Exposure Can Be an Intrinsic Part of Diagnosis and Assessment Sometimes exposure is the ideal way to get a clear idea of the nature of the patient’s anxious reaction. Standardized assessment tools cannot provide the moment-to-moment information that being with the patient during exposure can provide. One of us has an offi ce in Manhattan, and when patients indicate a fear of the subway, the suggestion might be made to approach a subway station next meeting. Making it extremely and explicitly clear that nothing too frightening will be attempted—perhaps not even getting past the subway entrance—the patient often arrives next session with intense anticipatory anxiety (see “Anticipatory anxiety” in Chapter 12 ). Patients must trust that they will never be tricked, or put in an anxiety-producing situation without their consent. Equally important is the attitude that this is not a test or contest, and whatever the patient is willing to do is enough. The goal only is to interact with the patient as she begins to experience the anxiety she would like to overcome. Other times, there is no need to wait for an additional appointment. If an offi ce is close to coffee shops, ask patients with SAD to accompany you and order a coffee for you, to observe their anxiety fi rst hand. Some will refuse this request, saying it makes them too anxious. Right here is an opportunity to discuss the details of their frightening thoughts, feelings, and memories triggered by the request. Other social phobics might say there is no need—it wouldn’t trigger any anxiety. So you might ask them to go outside with you and ask a stranger for directions to some landmark. The point is to observe how they cope with such situations. The process is similar for many people with OCD. Because of inexplicable and sometimes embarrassing symptoms, people with OCD often downplay its severity. If someone talks about being a cleaner, one suggestion is for you to put your hand on the offi ce fl oor, and then rub your face with your hands. Ask the patient if they can do the same. Or, drop some loose change on the fl oor, pick it up, and ask the patient to repeat that. Patients will sometimes refuse, and sometimes comply, but the more important point is to ask them what is going on in their mind and body and memories as they respond to the request. If a patient has compulsions involving symmetry and order, shred a tissue and leave it on the fl oor—it will be informative to discuss the patient’s reactions. Here are some questions to ask: Does it matter if it is my offi ce or your home? Would it make a difference if you knew I would pick it up before you leave? How much of your attention is on the tissue and how much on our conversation? How diffi cult is it for you to refrain from picking this up? Would you fi nd it easier to leave it on the fl oor if I paid you $1,000? It is also important for you to get a very clear idea of the triggers that set off your Downloaded by [New York University] at 01:46 15 August 2016 patient. So, for example, is your patient frightened of standing in line at the cashier? Or perhaps the patient is frightened of going into the rear of the store, which might feel claustrophobic. Or, perhaps there are some items in the store that frighten your patient.

Exposure for Patients with Obsessive-compulsive Disorder: Exposure and Response Prevention For people with OCD, exposure techniques require some modifi cation. People with OCD get a distressing thought that hits them with a jolt. This is the obsession . There is a rapid spike of anxiety, and the person then searches for ways to reduce this anxiety and Exposure: The Active Ingredient 119 provide relief. This is the compulsion , which can be extremely varied. Compulsions can consist of overt behaviors, mental rituals, and combinations of both. Obsessions raise anxiety, while compulsions—whether they are mental or behavioral—always attempt to lower anxiety. Exposing a patient with OCD involves putting him in contact with a trigger, encouraging the obsession (along with the whoosh of fear and distress) to remain, and then helping him to not engage in his habitual method of reducing the anxiety (the compulsion). Staying with the anxious feelings, refraining from running away from them, not fi ghting them off, accepting and allowing them—this is the attitude that you are trying to teach, so that anxiety can lower on its own, and new brain circuitry can be created. Exposure work with OCD patients is called exposure and response prevention, or ERP for short. The therapist is deliberately evoking a distress-producing thought or image, while helping the patient to refrain from any kind of avoidance. The patient needs help allowing time to pass, not pushing away the obsessions (that is technically a compulsion), accepting and allowing the arousal, and staying focused on manageable and relevant tasks in the present. The distress triggered by compulsions can be extremely persistent, and you will almost certainly need to repeat these exposures a number of times. Patients will almost invariably look to you for reassurance, and you will need to provide as little as possible. Sometimes this is more diffi cult than expected. For example, a patient who is afraid of radioactivity was standing with his therapist near the smoke detector section of a hardware store. He asked, “Are you sure I won’t get cancer from the radioactivity in the smoke detector?” From an exposure point of view, the very best answer is something like, “No, I’m not at all sure. As a matter of fact, you might possibly get cancer from the radioactivity you are subjecting yourself to right now.” This response helps focus the patient on the most relevant anxiety-arousing thoughts and images, even to the point of overstating the (practically) null chance of cancer from these smoke detectors. More supportive statements invariably reduce anxiety. If the response is, “Well, I’m not sure, but I’m willing to risk my life with you,” an element of reassurance is provided: the distress of exposure is reduced, but also its effectiveness. What the patient wants—and what our initial instincts tell us to say (and what well-meaning friends and family do say)— “Of course not,”—will be completely counter-productive. The more general rule is not to distract during exposure, and—within manageable anxiety levels—to arouse anxiety. Work at a level that is a stretch, but not overwhelming. You can model exposure behaviors. If your patient is a cleaner, place the palm of

Downloaded by [New York University] at 01:46 15 August 2016 your hand on the fl oor, touch your hand to your face, and ask your patient if she will do the same. It is possible to vary the exposure intensity. Placing a fi nger on the fl oor and touching your ear might be modeling a less diffi cult exposure than rubbing your hand on the bottom on your shoe and then rubbing your face.

OCD with Purely Mental Obsessions and Compulsions We conceptualize OCD as a disorder with two distinct components that are deﬁ ned by their relationship to each other. One component increases anxiety while the other lowers it, and, of course, it is this relationship that creates the self-maintaining cycle. With unwanted intrusive thoughts, the obsession is the unwanted thought, the patient 120 Exposure: The Active Ingredient engages in an attempt to reason, rationalize, or deny the content of the thought, and these mental gymnastics constitute compulsions. Unwanted intrusive thoughts that relate to harming, sexual orientation, unnoticed offensiveness, and unintended aggres- siveness are all examples of OCD with purely mental obsessions and compulsions. A similar process occurs with ego-syntonic worry—a “what if?” thought that increases distress like an obsession, and an urgent attempt to answer that question, which is entirely mental and lowers distress temporarily like a compulsion. There is no functional distinction between these two phenomena. The challenge is to maintain exposure to the thought that raises anxiety (the obsession) without setting off the thought that lowers it (the compulsion). Mental compulsions require some methodological changes. Since it is impossible for anyone to simply not think of calming thoughts, techniques aim to keep the patient focused on anxiety raising obsessions (Phillipson, 1991). The general rule is to let the frightening thoughts remain and to help the patient give himself permission to have the thoughts. One approach is to take responsibility for the imagined consequences, once the thought is labeled as an OCD thought. So, for example, if a person has a thought that her mother will die if she doesn’t count backwards from 100 three times, then she might respond, “Perhaps she will, and I will do my best to accept that risk and the consequences if she does die.” The uncertainty is allowed. Deliberate evocation of the thoughts can be part of the treatment. Here is an illustration:

PATIENT: I keep having thoughts that my dog is going to die. I try to tell myself these are just thoughts and it doesn’t mean he is going to die. THERAPIST: Well indeed they are thoughts. They don’t tell us anything about what will happen—either that he will or won’t die. PATIENT: I guess you are right. But I keep thinking that my negative thoughts will somehow manifest themselves in reality. So I have to stop them or at least argue with them. THERAPIST: Let’s try something. See that ﬁ sh tank? Let’s see if we can kill the ﬁ sh with our thoughts. PATIENT : Are you serious? That is ridiculous. THERAPIST: OK then, are you willing to imagine with me a scene in which your dog dies a miserable death? PATIENT : I see what you mean. That scares me. But we can try.

Another technique speciﬁ es times to do nothing but mentally obsess and there are many

Downloaded by [New York University] at 01:46 15 August 2016 variations of the approach (Foa and Wilson, 2009). Making a “worst-case” scenario script and reading it repeatedly. Recording an audiotape of the obsessions and listening to it for speciﬁ ed lengths of time. Or by making the obsessions even worse, for example, “what if I hit a person with my car on the way to work?” Instead of compulsively going over the memory of driving that morning making sure that couldn’t have happened, respond with “I may have hit many people, there might be a line of bodies lying in the street on my route to work. I’ll probably hear from the police any minute. I could be a murderer” (Grayson, 2003). Sometimes the cognitive compulsion (the self-reassurance) happens so quickly and automatically that patients get frustrated trying to do deliberate exposure to obsessive thoughts. They will notice that they have supplied a habitual refutation or analysis or Exposure: The Active Ingredient 121 reassurance before they could stop themselves. Rather than berate themselves for such an automatic habit of the mind, the objective is to notice what has happened and then slowly, deliberately, and mindfully reintroduce the obsessive thought in its clearest form. This slowed-down and deliberate re-exposure will allow the patient to refrain from the automatic cognitive compulsion. Patients who understand the two-part nature of worry (see Chapter 9 ) will be able to see the alternating obsessive question and its accompanying attempt at neutralization. The rule of thumb is to always try to end such a sequence with the anxiety-raising thought. Many of these methods are addressed in Chapter 6 and ampliﬁ ed in Chapter 9 .

The Right Way to Practice Exposure Intentional exposure is the active ingredient of the treatment and there are methods of practice that maximize its beneﬁ ts. We illustrate this by describing two types of practice—incidental and planned. Only planned practice maximizes the therapeutic aspects of exposure.

Incidental Practice Incidental practice occurs when the primary task is to achieve a particular goal. It is a “grin and bear it” method. If someone afraid of driving must drive to pick up his kids, he will do whatever is needed to accomplish that. If someone is afraid of public speaking, but must make a presentation to keep a job, she will do what is needed to make the presentation. And if someone is terrifi ed of germs, but feels intensely obligated to visit an ill family member in the hospital, he might do whatever is needed to make that visit. Completing the task is the primary goal—not learning how to better manage anxiety. So the anxiety practice is incidental to the primary task of goal completion. Here is another example of incidental practice. A patient is afraid of taking elevators and must attend a meeting in an offi ce that requires that he use one. So he screws up his courage, grins and bears it, and—anxiety be damned—puts himself on the elevator and presses the button for the correct fl oor. He does whatever is needed to make it through that elevator ride, and then scoot out the door as soon it opens. He has taken an elevator ride, but it probably won’t be any easier next time. Exposure to anxiety was incidental to the larger goal. The true goal was to get to the meeting. The patient probably engaged in lots of little avoidance tricks to get through the ordeal. He breathed a sigh of relief when

Downloaded by [New York University] at 01:46 15 August 2016 the ride was over. But he has not gained many therapeutic benefi ts. This kind of practice is often called “white knuckling.” The task is accomplished, but what is learned, yet again, is that taking elevators (or driving on highways, or going into hospitals, or giving presentations at work) is a miserable experience and there are good reasons to avoid it. The patient also often has the sense that he just made it, that a moment longer would have broken him, that he was about to turn around and go home the whole time and fi ve more minutes would have produced a failure—that he almost fainted, threw up, drove off the road, went out of control, lost control of his bowels, humiliated himself, or ran out of the room. The moment the task is accomplished, the escape from the situation provides such huge relief that it reinforces avoidance of anxiety. It is therefore not an effective way to practice coping with anxiety. 122 Exposure: The Active Ingredient Planned Practice Let’s contrast this with planned practice. In planned practice, the goal is to practice exposure to the anxious feelings themselves. The triggers (such as the elevator) are important in that they cause levels of anxiety, but the goal has nothing to do with how many of these triggers one can tolerate. With planned practice, there is no need to go anywhere specifi c, or even do anything specifi c. The goal is to experience anxiety for a planned period of time. What is the optimal planned amount of time? While there are individual differences, almost all studies suggest that ongoing exposure for 30 minutes to an hour is most effective, and to try to stay in the situation until anxiety starts to signifi cantly decrease, although there are many exceptions to this general rule. The principle behind planned practice is that the patient decides how much distress he is willing to tolerate during exposure, and then keeps distress within that range. So, for example, if a patient is afraid of driving, have him set a maximum distress level, and drive until he approaches that level, no matter how quickly that level arises. It doesn’t matter if that distress is reached in his driveway, down the block, the next town over, or on an interstate hundreds of miles away. The goal is to keep anxiety at or near the level chosen for the practice that day. Sometimes the patient will expand his “safety zone” while doing this, sometimes not. That is not important. He is moving only to adjust his anxiety level as it changes up and down. Patients need regular reminders that they are practicing to expose themselves to the anxious feelings independent of how far they travel, and the most important aspect is for them to decide, each time they practice, their own intended level of anxious distress. Planned practice encourages new learning, and the creation of new neural pathways which function to interfere with or inhibit the former fear-producing pathways. As introduced in Chapter 3, contemporary learning theory and current research on exposure (Craske, Planned practice creates Kircanski, Zelikowsky, Mystkowski, Chowdhury, and new neural pathways Baker, 2008) show that inhibitory neural pathways which inhibit or interfere that reduce fearful arousal are created during expo- with former fear- sure, but the original fear circuits are not removed. producing pathways. Patients are sometimes disappointed or upset when informed of this, but this also explains why symptoms can suddenly reappear during stress, when encoun- Downloaded by [New York University] at 01:46 15 August 2016 tering the feared triggers in a new or different context, or over a period of time without exposure practice (Bouton, 2004) (see Chapter 14). These inhibitory pathways are maximized with repeated exposure to triggers in a variety of circumstances. During the exposure process, the variety of exposures is much more important than elimination of fear in the therapeutic process. Patients who learn that they can tolerate fearful distress (as opposed to eliminate it) are helped the most (Bouton, 2002). Reality constraints make planned practice a goal that is sometimes elusive. If one ven- tures into a mall, for example, one may encounter anxiety levels not previously willingly anticipated or planned. It might take some time to end the practice and involve going past an area of the mall that triggers additional anxiety. In these situations, it makes Exposure: The Active Ingredient 123 sense for patients to set a task based on their anticipation and expectation of anxiety levels, and to practice willingness to tolerate whatever levels of anxiety they actually experience. Practices can be based on expectations (do something that feels likely to be a stretch but not overwhelming), but real life has many unplanned experiences both during treatment and after. Patients can and should use the situations they encounter in the course of each day (like an elevator) to practice. They can choose in the moment to use their old ways of white knuckled breath-holding struggle, or they can decide to practice distress tolerance, even if the practice was not planned in advance.

Benefi ts of Planned Practice There are signifi cant advantages to encouraging your patient to practice in this manner. A major advantage is that it provides a systematic and manageable method to maximize exposure to the feared situation, and this discourages the multitude of avoidances that can occur during exposure. Planned practice also helps cope with the common phenomenon called “raising the bar.” Raising the bar syndrome occurs after managing to reach a specifi c behavioral target during practice sessions. This can happen when patients practice exposure in a way that is not consistent with the principles of planned practice. As soon as a behavioral goal is reached, patients feel pressure to at least reach that target in subsequent practice sessions. That pressure raises anxiety, and makes it harder to reach the same goal the next time. In effect, each time a goal is accomplished, subsequent attainment can be more diffi cult if the bar is raised. So practice can make for more perplexity.

PATIENT : I fi nally used the elevator to visit my sister on the 11th fl oor. THERAPIST: What was that like? PATIENT : Great! I felt like this was really working. I hardly had any anxiety. But … THERAPIST: But what? PATIENT : But then when we left her apartment after dinner I got this spike of anxiety, and I thought to myself, “How can this be?” I’m not even in the elevator and I should be able to do it. I just went into the elevator and now I’m scared just after pushing the button. It should have been easier, and I couldn’t even do it. I walked down. Felt like a real loser. THERAPIST: Sounds like you sort of psyched yourself out. You fi gured it should be easier, but there was this pressure on you to do it again. Downloaded by [New York University] at 01:46 15 August 2016 PATIENT : Exactly! TH ERAPIST: And maybe do it better this time. Less anxiety. PATIENT : You are exactly right! THERAPIST: Doesn’t leave much room for expect and allow . . .

Planned practice also helps patients keep their eye on the goal. The goal of practice is willing exposure, and if the focus is on a behavioral goal (such as a location or a distance or a type of transportation), then it is natural to do what is needed to get there. Patients will be strongly tempted to look for avoidances, safeties, and reassurances in order to reach that goal, reducing the effectiveness of the practice. 124 Exposure: The Active Ingredient Additionally, without planned practices, exposures can turn into a test. People who practice are hoping to reach their goal with lower anxiety, and are testing themselves to see how much they will react in the practice situation. If anxiety is low, they feel positive about the practice, and look at that as passing the test; if it is high, there is a tendency to feel disappointment, to wonder what is wrong, and to give themselves a low or failing grade on this test. The interesting point here is that people grade themselves in a way that values getting lower levels of anxiety. This is exactly the opposite of what we want: to maximize exposure to anxious stimuli. Finally, planned practice changes the deﬁ nitions of success and failure. In general, people feel like they have successfully practiced when they are able to reach their target with little or no anxiety. They feel like a failure when they have extremely high levels of anxiety, or when they are unable to reach their goal. This is precisely the opposite of what is most therapeutic. The object of practice is to allow exposure to anxiety to learn better ways of coping with it, to develop an attitude of disengagement, to accept the feelings as they are, and to allow oneself to desensitize and habituate to triggers. However, with planned practice, there is only one way to fail: one fails a planned practice when one does Anxiety is the mark of a not experience anxiety. Any practice that creates anxi- successful practice. ety, no matter where that anxiety occurs, counts as a success. Anxiety is the mark of a successful practice. A successful planned practice maximizes the therapeutic beneﬁ ts of exposure.

PATIENT : I went to the store and got in and out in ﬁ ve minutes with no anxiety at all, isn’t that great? THERAPIST: Well I am delighted you got your shopping done, but of course, that turned out not to be much of a practice, right? So I am hoping you have thought about what you could do to make you more anxious in the store so you could get some practice. Would it be a chance to get anxious if you stayed longer? Or if you had a cup of coffee before you went shopping? Or if you left the car keys and cell phone with me while you went in the store? PATIENT : There is no way I could do that without my cell phone. I am anxious even imagining it. But I think I could probably give myself some anxiety if I knew I had to stay for ten minutes. THERAPIST: OK why don’t you go back tomorrow and stay for 10 minutes. Let’s hope you

Downloaded by [New York University] at 01:46 15 August 2016 get anxious, at least a four, ok? PATIENT : I thought coffee was bad for anxiety. THERAPIST: Well, that is the point, isn’t it? To deliberately and willingly bring on symptoms and then let time pass. Coffee or a Jolt Cola is sometimes a helpful way of achieving that. Wouldn’t you like to get to the point where you don’t care how it makes you feel? PATIENT : Well maybe I can try coffee at home but I am not ready for coffee in a store. THERAPIST: Sounds good. Exposure: The Active Ingredient 125 Table 8.2 summarizes the cogent differences between planned versus incidental practice.

Table 8.2 Comparison of planned and incidental practice Planned Practice Incidental Practice

Object is to expose oneself to a Object is to go into the anxiety - predetermined level of anxiety producing situation Reduces the desire to engage in Encourages mini-avoidances mini-avoidances Reduces anticipatory anxiety Tends to increase anticipatory anxiety Eliminates the “raise the bar” syndrome Creates the “raise the bar” syndrome Encourages prolonged exposure to Encourages exposure to situations, anxiety in manageable steps and not on the feeling of anxiety Makes failure impossible so Makes success or failure dependent long as practice takes place on behavioral goals

References Freud, S. (1955) Advances in psychoanalytic therapy. The standard edition of the complete psychological works of Sigmund Freud, Vol. XVII (1917–1919). London: Hogarth Press 165–166. Foa, E., Hembree, E., and Rothbaum, B. O. (2007) Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences. Therapist guide . New York, NY. Oxford University Press. Foa, E. B. and Kozak, M. J.(1991) Emotional processing: Theory, research, and clinical implications for anxiety disorders. In Jeremy D. Safran and Leslie S. Greenberg (eds) Emotion, psychotherapy, and change . New York, NY: The Guilford Press 21–49. Craske, M. G., Liao, B., Brown, L, and Vervliet, B. (2012) Role of inhibition in exposure therapy. Journal of Experimental Psychopathology 3(3) 322–345. Sisemore, T (2012. The clinician’s guide to exposure therapies for anxiety spectrum disorders: Integrating techniques and applications from CBT, DBT, and ACT. Oakland, CA. New Harbinger Publications. Grayson, J. (2003) Freedom from obsessive compulsive disorder: A personalized recovery program for living with uncertainty . New York, NY: Berkley Press. Phillipson, S. (1991) Thinking the unthinkable. Obsessive-compulsive Newsletter 5, 1–4. Foa, E. B. and Wilson, R. (2009) Stop obsessing! How to overcome your obsessions and compulsions. New York, NY: Bantam Press. Grayson, J. (2003) Freedom from obsessive compulsive disorder: A personalized recovery program for

Downloaded by [New York University] at 01:46 15 August 2016 living with uncertainty . New York, NY: Berkley. Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., and Baker, A. (2008) Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy 46(1) 5–27. Bouton, M. E. (2004) Context and behavioral processes in extinction. Learning and Memory 11(5) 485–494. Bouton, M. E. (2002) Context, ambiguity, and unlearning: Sources of relapse after behavioral extinction. Biological psychiatry 5(10) 976–986. 9 The Curious Case of Worry

Worry is part of the human condition. We are granted the gift of imagination and the ability to think about and visualize possible futures. Worry begins as a means of planning, and can serve a helpful function in preparation and problem solving. The planning part of worry can save time, energy, and emotional discomfort, enabling us to make better decisions. Sometimes, however, worry becomes a problem in itself. Worry can become overwhelming, preoccupying, paralyzing, and toxic. Some people worry about relatively unimportant things, and others realize that they worry about situations that are completely out of their control, so that no useful purpose is accomplished by their worrying. But these people continue to worry all the same. People who worry more than they want to will often then start worrying about how much they worry, and how out of control and worrisome it is not to feel in charge of their own minds. They worry that their worry will hurt their relationships, result in a heart attack, or raise their cancer vulnerability, cause their children to disrespect them or their boy- Meta-worry is often friend to leave them. Some believe their worrying the reason for seeking indicates that they are neurotic and weak, and that treatment. it will make them sick, dysfunctional, or insomniac. They do not know how to stop worrying and they come to us to ﬁ gure out how to get it to stop. This meta-worry (worry about their own worrying) is often the reason for seeking treatment. Worry about worry sounds like this: “I can’t stand all this worrying,” “What is wrong with me that I can’t stop worrying?”, “Why am I such a downer/loser/neurotic?” These are not productive questions to explore: they are merely additional examples of

Downloaded by [New York University] at 01:46 15 August 2016 worrying. Worry occurs in all anxiety conditions and is a central feature of generalized anxiety disorder (GAD). Patients often express their treatment goals to include controlling or stopping worry. Prior to seeking professional help, most have already tried distraction, self-reassurance, exercise, and lifestyle changes, as well as internal attempts at self- control. Frequently they have already researched their worries in great detail and know more about the topic than most. It is easy to get caught up in debating the facts of their worries, but they already have answers for every point. The Curious Case of Worry 127 Varieties of the Worry Experience There are important distinctions about worry that we need to understand in order to develop useful directions for treatment. Worry can be ego-syntonic or ego-dystonic. Worry can be anxiety raising or anxiety lowering. Worry can be depressive or anxious in content. Worry can be stuck on one thing or it can be wide-ranging and ﬂ uid. Worry thoughts can be helpful (in which case addressing them can be productive) or unhelpful (in which case addressing the content will ultimately be unproductive). Let’s look at each of these distinctions, as they determine how to plan and go carry out treatment.

Ego- syntonic versus Ego-dystonic Worry Some worries seem perfectly reasonable to the worrier. These reasonable worries might be of the sort “Will I have enough money to pay the rent this month?”, “What if my aging parent gets ill?”, “What if I upset my friend in our last conversation?”, “What if I fail this test and can’t get into college because of it?”, or “What if my children don’t get good jobs?” These are the sorts of events that anyone could worry about, and they cover the gamut of happenings carrying a reasonable chance that something could become amiss. The problem with these ego-syntonic worries is that they take up so much time, interfere with sleep, take the fun out of life, seem to be unsolvable, unanswerable, and ongoing, and the worrier feels dread, preoccupation, helplessness, and above all—worried—about how much they worry and what consequences this might have for health, relationships, and quality of life. On the other hand, there are worries that are ego-dystonic. They feel “crazy” or out of proportion or irrational to the worrier himself. Examples might be “What if I contract AIDS even though I have no contact with blood products and am not sexually active?” or “ What if I suddenly become suicidal and jump off a balcony, against my own wishes?” or “What if I left the iron on even though I checked it and I inadvertently burn down the house?” or “What if I am gay even though I know I am not and I could accept it if I were?” Ego-dystonic worries can range from the mundane—“What if I insulted someone and do not remember?” or “What if I do not get the absolute best deal on this purchase?”—to the bizarre “What if I locked a child in the refrigerator?” or “What if my therapist is really Satan?” Ego-dystonic worries will be covered in considerable detail in Chapter 10 on intrusive thoughts. Here we focus on ego-syntonic worry, what maintains it, and how to treat it. Downloaded by [New York University] at 01:46 15 August 2016

False Beliefs about Ego-syntonic Worry: Patients Are Uneasy about Not Worrying Most people do not realize that they value the same worry that they fi nd so distressing. In fact, many worriers are afraid or unwilling to risk not worrying (Leahy, 2005). This is because they hold false beliefs about worry. Many patients look at worry as an expression of love and loyalty, and believe that worry is an essential aspect of concern. Some incorrectly believe that planning for the future involves worry, and others believe that worry allows them to rehearse responses to real-life crises and “be prepared.” But the 128 The Curious Case of Worry rehearsals lack the specifi c details of the actual event, and so what is rehearsed is almost always inappropriate to a crisis. Here is an illustration. One author was talking with a patient about her need to know exactly where every member of her family was at all times, and how annoying this constant worrying was to both her and her family. She would insist they call or text her many times a day, and if someone did not, she would become overwhelmed by thoughts of catastrophic events. The author told the patient that her husband was overseas on a complex itinerary, and that she was not sure in what country he was or when he would be taking his next fl ight. The patient was astonished—and blurted out “don’t you care about him?” To her, constant worry was an expression of love and loyalty. If you don’t worry, then you must not care. Another patient believes her worry about whether her children are eating a healthy diet is why she feeds them well, and that worry keeps impulses to feed them badly in check. Without worry, people would misbehave. For her, people who do not worry about dangers will get in trouble out of casual neglect or ignorance or impulses that should be controlled. Another patient has to stay alert and worry during airplane fl ights, as if worry will somehow magically keep the plane in the air. Similarly, another patient feels compelled to worry about his academic achievement every day, because he believes this will keep him turning in outstanding work. If he were to stop worrying, he would, he fi rmly believes, get too casual about studying and ruin his future. There is a Russian proverb that states, “If you think about bad things, good things will come on their own.” It conveys the idea that worry brings better luck, better consequences, and a better future. And the converse—which is to ignore worry, to think too positively—invites bad happenings. One patient who worries chronically to prevent bad things from happening, but is practicing giving up the need to worry, emailed her therapist “I took a pelvic ultrasound yesterday. Follow-up on a cyst. I really wasn’t worried, but always allow room for unexpected results. I totally forgot about it today. I only remembered because the doctor left me a message. All ok. Literally forgot!!! So now I’m worried I’m getting Alzheim- er’s.” This woman, like many, believes that worry keeps her sharp, and keeps her from being blindsided by an unexpected negative occurrence. She also believes that worrying about these things proves that she has good control of her memory and other mental faculties . The belief that worry protects someone from the bad occurrence—that is, actually reduces the probability of something like that happening—is non-logical, but still fairly common. People like this feel that worry gives them protection. One patient

Downloaded by [New York University] at 01:46 15 August 2016 stated, “Worry is my emotional body armor.” Other people believe that worrying is “just my personality” and is not something that can change. They may also believe that people who do not worry are actually naive and will be less prepared to meet the challenges of life if they have not rehearsed them ahead of time. The fact that the truly bad things in life are almost always unpredicted, arrive out of left ﬁ eld, and are almost never the things we worry about has no impact. So, although people are miserable with how much they worry and want to stop, they arrive for help with the attitude either that “I am a worrywart and can’t really change” or they hold some unconscious beliefs about worrying which maintain their worrying—and their worry about worrying. The Curious Case of Worry 129 A Caveat: Generalized Anxiety Disorder—Rarely a Stand-alone Diagnosis Anxiety disorders rarely come in pure form and often co-occur with other psychiatric and/or medical disorders. This, of course, speaks to the issue of comorbidity. In fact, GAD is almost never present without a signiﬁ cant co-occurring disorder. Epidemiological research suggests that over 90% of patients with generalized anxiety have another medical or psychological diagnosis in their lifetime (Judd, Kessler, Paulus, Zeller, Wittchen, and Kunovac, 1998). If GAD is all you are attending to in an individual’s therapy, you are likely missing something important. Almost 70% of people with GAD have a mood disorder during their lifetime, most often depression (Noyes, 2001). Substance use and abuse may be implicated and unacknowledged (Grant, Hasin, Stinson, Dawson, Ruan, Goldstein,. . . Huang, 2005). There are also high levels of co-occurring social anxiety, panic disorder, and obsessive-compulsive disorder (OCD). Many medical conditions such as thyroid or endocrine dysfunction, pulmonary, cardiac problems, and autoim- mune disorders may have worry and irritability as presenting symptoms. And, since patients use the term “anxiety” to describe everything from mild worries to outright agitation signaling a slide into a major depressive or bipolar episode, determining and clarifying the context of the worrying will be essential in deciding treatment priorities.

Worry Is Not an Affect: It Is Thinking—And Thoughts Are Not Facts It is often not obvious to anxious patients that worry is a thinking activity, and not a feeling. Patients often say “I feel like I will fail” or “I feel like he is going to dump me for someone prettier,” when these are actually thoughts. Modern brain imaging studies show that worry takes place in prefrontal lobes of the brain (Damsa, Kosel, Worry is not an affect—it and Moussally, 2009), where cognition takes place. is thinking. And thoughts Whenever worrying is provoked, the pathways of are not facts. the amygdala (where emotional reactions occur, and where the “fi ght, fl ight, freeze” reaction is triggered) show reduced activity. Much as it seems counterintuitive, worry itself—round and round thinking—apparently blocks the direct experience of affect (Hirsch, Hayes, Mathews, Perman, and Borkovec, 2012). There is another important point that is not always obvious to patients: Just because a worry thought crosses a mind does not make it any more likely to be true, important, or worthy of further examination. Chronic worriers have a great deal of diffi culty with this Downloaded by [New York University] at 01:46 15 August 2016 truism: for them, having a thought somehow increases the probability of it occurring! We sometimes try this little exercise with a patient who is prone to worry, but fi rst they must be prepared about the misleading messages that worry carries. Ask them to write the sentence “I hope my child will die a miserable death this year.” Most recoil in shock and many simply cannot bring themselves to write down such a thought. Some will get annoyed and angry with you for even suggesting such an awful thing. Your task is to turn this into a learning experience about their ideas and beliefs about thoughts. Exploring their resistances—what their beliefs are about the power and meaning of thoughts and words can be essential here. Just because a horrible thought is present in the mind does 130 The Curious Case of Worry not make it any more likely or true. Make it one of the goals to practice with patients having horrible thoughts on purpose—sometimes in the form of a light-hearted contest— see who can come up with a more horrible thought. Playing with thoughts, exaggerating them to absurdity, singing them to “happy birthday,” saying them backwards—all help to gradually convince the worried patient that thoughts are actually just thoughts—not facts, messages, predictions, or demands. Most worriers initially believe that worries stem directly from fact—from the events going on in their lives—and they do not see their own contribution in creating worry. As explained in Chapter 8 on exposure, these people are looking at the wrong side of the street. They are paying attention to what is going on “out there,” and not focusing on their own internal processes. They do not see that it is their own personal internal appraisal of situations—not the situations—that make for anxious thinking. They have extreme diffi culty accepting the fact that tolerating anxious thoughts is not the same as inviting danger. They are falling for anxiety’s ubiquitous trap that equates feeling anxious with being in danger. The job of the therapist is to point out, for example, that just because one worries about the safety of a medication does not make the medication unsafe. One can have the worry thought (“anaphylaxis could happen”), take the medication even while thinking that thought, become anxious, and still remain safe.

Productive Versus Unproductive Worry Leahy (2004) presents the concept of productive and unproductive worry. Some worries are reasonable by most people’s standards. They can be looked at as a form of planning. They result in a do-able action plan and they are put to rest either when a decision to enact a plan is made, or the plan is enacted. An example would be “That ladder looks rickety; I am worried I might fall.” This worry is “solved” when you ask someone to hold the ladder or you get a better ladder or you decide to defer the climb until the conditions are safer. This is a productive worry. Another kind of productive worry would be like this: “I am worried that I might have a fever,” which is followed by using a thermometer and believing it when the thermometer registers a normal temperature. Unproductive worries are those that are unanswerable (“I worry that my children might not lead happy lives”; “I worry that I am not a good enough person in the eyes of God”; “I worry that I might not have the best spouse I could have found if I had waited”). Or they have illusory answers (“Even if I had a stress test yesterday, how can I be sure that my heart is ok today?” “Will my boyfriend keep his promise to be faithful?”

Downloaded by [New York University] at 01:46 15 August 2016 or “How can I know that I can drive across the bridge?” or “Will I ﬁ nd a job tomorrow?”). Some worries are about bad things that will indeed happen but there is nothing to be done about them and more and more thinking about them in the same way will not change a thing. (“I worry that I will not be able to handle it when my mother dies”).

An Important Insight: Some Worry Thoughts Raise Anxiety and Some Lower It What is called by the single word “worry” is actually a process with two distinct components that are defi ned and identifi ed by their relationship to each other. One component of worry increases anxiety while the other component lowers it. It is this relationship that creates the self-maintaining cycle of ongoing worry. The Curious Case of Worry 131 In OCD, these components are referred to as obsessions and compulsions, where compulsions can be “Worry” is actually behavioral or mental. In GAD (which we are label- a process with two ing as ego-syntonic worry), the same components are distinct components present, but only in a cognitive, or mental form. Let’s that are defi ned by their be specifi c: worry starts with a worried thought—a relationship to each other. “what if?” which is a leap into the future addressing a potential problem, confl ict, disaster, or mistake. It is posed in the form of a question that patients easily identify as a “what if?” This question raises anxiety. The The fi rst component of patient then launches into an effort to make the anxi- worry asks the question, ety go away by more thinking—to solve the problem, the second attempts to to make a plan, to get prepared, to answer the ques- answer it. tion, to reassure themselves, or to analyze the meaning. Sometimes the reaction to the thought is to try to control it, to distract, suppress or stop the anxiety raising thought from happening again. Responses to “what if” thoughts are often misidentifi ed as problem-solving or planning. This is because many “what if” thoughts do solve problems in that they come up with a reasonable action plan and then go away. However, worry thoughts behave differently—they do not go away. Most of the time, the barrage of thinking is not really planning, it is the second component of worrying. Patients describe this as “round- and-round,” “gerbil in a wheel,” and uncontrollable and excessive. They sometimes come into therapy with the request to turn off their minds, or at least turn down the volume. They often (and mistakenly) say that they can’t stop “obsessing.” Technically, they are suffering from cognitive “compulsing.” A cognitive compulsion—the component of worry that attempts to lower anxiety—is yet another form of avoidance. Worriers mistakenly treat their worry question as if it is an urgent, important, factual issue that must be solved or fi xed right now. In fact—just like people with other types of anxiety disorders—they are looking at the wrong side of the street, ignoring their own internal reactions, and inadvertently empowering and energizing the ongoing cycle of worry. Cognitive compulsions are not only unproductive, they keep the worry cycle going and they escalate it. They drown the worrier in a sea of useless attempts to either make the worry thought go away or to fi nd certainty, safety, or calm. Patients erroneously call this activity “rationalizing.” It is not. It is cognitive compulsion.

Downloaded by [New York University] at 01:46 15 August 2016 The Therapeutic Perspective on Worry We, as therapists, must resist the temptation to participate in this second component of worry, no We, as therapists, must matter what the content of the worry thoughts might resist the temptation to be. Remember that this second component tempo- participate in the second rarily reduces anxiety, but maintains suffering in component of worry–no the long run. Staying away from this is sometimes matter what the content of tricky, because the content of the thoughts may be the worry. psychodynamically very interesting and may seem to signify issues that could be fertile grounds for exploration and personal introspection. Usually we begin 132 The Curious Case of Worry to co-ruminate or co-compulse as we are seduced by the content in exactly the same way the patient has been worrying. (We deﬁ ne and discuss co-compulsion in Chapter 11 , Pitfall number 2.) We either try to help the patient solve the problem or make the best choice, or we delve in and try to uncover the hidden issues. However, very quickly it becomes clear that this is not helpful, that the very same “issues” arise again and again, perhaps in slightly camouﬂ aged form or with a little twist to make them more interesting or escalated in the form of “Yes, I know but what if . . . ” It is therefore not the content of the worry thoughts that needs changing, but rather one’s rela- It is the relationship to the tionship to the thoughts—one’s appraisal of the thoughts, the appraisal thoughts—and the aim is to reduce the power that is of the thoughts, not their granted to the thoughts. This is something new and content, which needs a radical idea for many people. The task is not to try changing. to solve the problems posed by anxious worry, but rather to learn how to disregard them. The origin and meaning of worry thoughts may be interesting and something to explore in the future, when worrying is no longer making the patient miserable and anxiety sensitivity has been reduced. But exploring the content of worry will almost universally fail to provide relief. On the contrary, when insights occur—but the expected cessation of worries does not follow—further worries emerge of the meta-worry variety—for example, “What is wrong with me that even understanding my worries does not help me?” or, “I must be even worse off since I know where this came from and that does not help.”

About Worry and Time: The Role of Urgency There are certain “negative” thoughts that we seem The feeling of urgency is to have and then be able to let go of, and others that what drives worrying. seem to get stuck and turn into worry. We are able to say “so what?” or “I will consider this later” about some thoughts but not others. A worry thought is one that is accompanied by a feeling of urgency—it carries a message that it must now be addressed—now, and not later. This feeling of urgency is what drives worrying. If something is a threat, it is an immediate threat requiring an immediate solution. If something is unclear or uncertain, it must be cleared up now. But a feeling of urgency is not a fact; it is a feeling, most often having little or nothing to do with true emergency. Downloaded by [New York University] at 01:46 15 August 2016 This complex relationship between worry thoughts and time leads people with excessive worrying to feel irritable and impatient. Wasting time may be seen as very bad indeed—so relaxing, doing nothing, enjoying the moment, just whiling away the time are not valued or allowed. Every moment must be used to solve problems or prevent future problems. Multitasking is valued; over-scheduling is common; the passage of time itself is worrisome and problematic.

Evaluating Worry Here are some questions to ask diagnostically when worrying is a prominent feature of a presentation. Does it feel out of control, disproportionate, intrusive to the patient? Do the concerns and themes feel valid (ego-syntonic) or invalid (ego-dystonic)? What is the The Curious Case of Worry 133 content and are there simple bits of information that might lay the worry to rest that have not yet been offered at least one time? How much meta-worry (worry about worry) is feeding the ﬁ res and promoting provocative attempts at over control, suppression, and distraction? How caught up is the patient in forms of so called “problem-solving” or “planning” which is actually maintaining the worrying? And, is this worrying part of a depressive voice (worthless, hopeless, guilty, and self-recriminating) or an anxious voice (warning of dangers, what ifs, or a quest for knowing something unknowable)? Or both? And most importantly, is it productive or unproductive mental activity? Does it lead to an action plan or to additional round and round thinking?

Rumination: A Different Kind of Worrying When a patient is signifi cantly depressed, two types of repetitive thoughts can occur: anxious worry and depressive rumination (Fresco, Frankel, Mennin, Turk, and Heim- berg, 2002). Catastrophic thoughts occur in all anxiety disorders. In anxious worry, the focus is on the future (“what if?”) and the issue is often how to manage perceived threats that might be looming. Patients are concerned about issues regarding safety or morality, and their uncertainty about how to best react to these issues—which are often imagined, exaggerated, or out of proportion—results in increased vigilance, arousal, urgency, and anxiety (McLaughlin, Borkovec, and Sibrava, 2007). When signifi cant depression is also present, something different occurs, which is called rumination. Rumination is repeated, miserable, self-referential criticism and hopelessness. The voice of rumination is about hopelessness, guilt, worthlessness, futil- ity of effort, and shame. The content of ruminative thoughts is experienced as true, as if the depressed person has fi nally grasped the awful facts of his existence. There is often an internal debate about whether it is worth it to carry on. The typical thoughts of rumination include the following: “others would be better off without me,” “I can’t stand myself,” “I am a hopeless loser,” “I have tried everything to improve my life and nothing works,” “no one can ever love me,” and “I have made irreparable mistakes.” Rumination may persist throughout the waking day and consist of continually repeated rounds of thinking hopeless thoughts. It is not ego-dystonic. It overtakes the psyche. It can be shat- tering and feels true. Patients may describe it as “anxiety” or “obsession,” but this kind of preoccupation is dangerously different (Smith, Alloy, and Abramson, 2006). 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

Downloaded by [New York University] at 01:46 15 August 2016 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 134 The Curious Case of Worry (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.

1 . 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 signiﬁ cant anxiety ﬁ nd 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.

Downloaded by [New York University] at 01:46 15 August 2016 2 . 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. 3 . 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 fi rst and then increasingly impatiently) is a particularly hazardous route to go. This will be explored in some detail in the section on “Reassurance Junkies.” Suffi ce it to say here that no amount of reassurance settles the problem. Reassurance becomes a ritual The Curious Case of Worry 135 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 fi nds 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. 4 . 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. 5 . 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 en- sues to “clear the mind” of body-related thoughts. 6 . 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

Downloaded by [New York University] at 01:46 15 August 2016 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. 7 . 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 fi nd that they 136 The Curious Case of Worry 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?” 8 . 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. 9 . Figure it out. Try to fi gure out what lies underneath getting stuck on worry thoughts. Search for hidden meanings, unconscious causes, past events, and— when you fi nally come to an understanding—that insight will enable you to stop worrying. What happens in real life, however, is that no defi nitive understanding will emerge and the search is prolonged indefi nitely. The constant exploration maintains the OCD “lite” nature of worrying: asking a question that increases anxious distress, fi nding 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. 10. 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 Downloaded by [New York University] at 01:46 15 August 2016 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 The Curious Case of Worry 137 spent hours on the internet researching this symptom, and asked if he should fi rst 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 signifi cant 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 fi rst episode of schizophrenia, and explaining these symptoms as benign artifacts of hyperventilation (and demonstrating this by intentionally hyperventilating 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

Downloaded by [New York University] at 01:46 15 August 2016 from the press conference, thereby facing headlines “President Defensive about Sex Accu- sation; 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). 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 ﬁ ght 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 138 The Curious Case of Worry analyze or “rationalize away” their provocative worry The paradigm change is questions. They treat them as if they are real messages to understand that worry that deserve attention and problem solving. And even thoughts are not real as they do so, their hearts are sinking because they know questions—they are just they are starting on a miserable internal debate that will masquerading as such. 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 ﬁ rst 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 Downloaded by [New York University] at 01:46 15 August 2016 a foreign language, and the worries going round and round in their mind are unintel- ligible. This simple idea is startlingly effective with some patients, who then immediately understand the need and beneﬁ ts of disengaging from a rigged game.

Worry Exposure

Schedule Worry Time Borkovec (Borkovec, Alcaine, and Behar, 2004) was one of the fi rst to propose the scheduling of worry. Have the patient concentrate on worrying a specifi c amount of time every day, preferably the same time and place. During that time—which can be as short The Curious Case of Worry 139 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 fi rst 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, Chowd- hury, and Baker, 2008). We fi nd that perhaps the greatest value of worry time is the practice of mindful awareness of worry thoughts. Specifi cally, 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.

Play with Worry Find creative ways to expose to the worry thoughts—over and over and over. The worry thought should not be followed by reassurance, or any kind of undoing, minimizing or counteracting with positive thoughts. Here are some examples: take a whole stack of Post-it notes; write, “I might fail the test” on every page. Post them everywhere—the bathroom mirror, inside the fridge, on the pillow, in the sock drawer, inside the briefcase, next to the light switch. Look at this sentence over and over until it is actually boring or silly and then look some more. Try these: sing your worry thought to the tune of “Happy Birthday” or “Twinkle, Twinkle, Little Star.” Write it out backwards. Translate it into other languages. Carbonell (2012) has the creative suggestion to turn it into a haiku:

This is a tumor So I’ll soon be goner Please water my plants. Downloaded by [New York University] at 01:46 15 August 2016

Here is another one: speak “I have a terrible illness and have yet to be diagnosed” into an iPod and play it back before making a call or checking email. Or, worry thoughts can be spoken into a Smartphone app called Songify (Songify for iPhone, iPod touch second generation), (Songify for Android), which takes a short sentence, and turns it into a song with a rock band or orchestral back-up that is very hard to resist fi nding funny. Take a yellow pad and write “No one will love me, I will die alone” over and over and over, until it becomes just words. Remember that the sentence must arouse anxious feelings when fi rst presented—and then no attempt should be made to make the anxious feelings go away. The same principles apply: expect, label, surrender the struggle, actively allow and cope with the uncertainty; do not avoid or fi x or use “rational disputation” no matter how tempting. 140 The Curious Case of Worry Face the Ultimate Fear This takes into account the fact that worrying blocks the direct experience of affects, and then takes the downward worry spiral all the way to its conclusion. Worriers tend to stop short of actually visualizing and facing what they are worrying about, and while they experience some degree of anxiety, worriers actually face a reduced version of their fears: they are avoiding affect with thinking (Borkovec, Ray, and Stober, 1998). A helpful technique is to follow the cascade of worries using what cognitive therapists call the vertical descent. What is the actual anticipated disaster and what does it mean about the patient, his world, and the value of worry? This is a form of exposure therapy, taking it to the “max.” Tone of voice here is important. The patient must understand you are trying to help them see how they are scaring themselves and helping them face their bottom line fears, not trying to make fun of them or make light of what is going on. Here is one example:

PATIENT : I am afraid I will make a fool of myself at the party. THERAPIST : Well, let’s say that you do say the wrong thing and people know. Then what? PATIENT : I’ll be humiliated. I won’t be able to stand it. THERAPIST : And then what will happen? PATIENT : I would never be able to see those people again. THERAPIST : And then what? PATIENT : I would get depressed and never go anywhere. THERAPIST: And? PATIENT : Eventually I guess I would become suicidal. THERAPIST : And then what would happen? PATIENT : I would probably call my parents and they would put me in a hospital. THERAPIST : And then? PATIENT : I would never be the same again. I would kill myself. THERAPIST: So that would indeed be awful. Locked in the back ward of a state hospital, suicidal and suffering—no way out. Just giving up. So no wonder you get anxious about going to the party. Saying the wrong thing would ruin your life. With stakes like that, why take the risk? Why would anyone take the risk?

Following the downward arrow to the end almost always leads to death, homelessness and humiliation, loss of family, or suicide. It is important to push the conversation to the very end, as avoidance of this imaginary scene is inadvertently helping to maintain the worry state. Downloaded by [New York University] at 01:46 15 August 2016

Calculate Probabilities This technique can easily become a form of ritualized internal reassurance, which will immediately negate its helpfulness. But it is often worth a one-time discussion simply to demonstrate the low probability of some worries occurring in fact. Take a look at the real likelihood of the worry thought refl ecting probability instead of possibility. It can be helpful to show patients that the probability of something happening has little to do with how scary the thought feels. Remember that probabilities of multi-step events multiply, they do not add! So, for example, if one worried that the lint The Curious Case of Worry 141 in the dryer could burn down the house, it would involve odds of lint being in the dryer vent, times the odds that the lint would catch on fi re, times the odds that the fi re would then consume the home. Here is an example of such an exchange:

PATIENT : I think I might have left the toaster on. I could burn down the house. My dog is there. THERAPIST: And what do you think the chances are that this thought means you actually did leave the toaster on? PATIENT : Well I might have. Maybe one in three chances that I did. THERAPIST: OK. Well let’s say you actually did. What are the chances that the automatic shut off is broken and the toaster has overheated? PATIENT : Not likely but you never know. THERAPIST: Well give it a probability. An absurdly high one. One in 10? PATIENT : OK. THERAPIST: So now the chances that the toaster has overheated is one in 30. What happens if a toaster overheats? PATIENT : It could melt the counter. THERAPIST: Is it granite or wood or plastic? Chances it would melt the counter? PATIENT : One in 50. THERAPIST: OK. One in 50. That comes to one in 1,500. And what is the chance that a melting counter would catch the wall or the tile fl oor on fi re? PATIENT : How about one in 20. THERAPIST: Ridiculous, but let’s go along. So that makes one in 30,000. And if the wall catches on fi re? Then the house burns to the ground? PATIENT : Well the fi re alarm would go off. And my dog would bark. THERAPIST: And the chance that no one would call the fi re department? PATIENT : One in three. It is an apartment building. THERAPIST: OK now we are up to one in 90,000 chance. And if the fi re department comes, then . . . PATIENT : OK I get it.

Reduce Avoidance Identify and stop coping behaviors that serve to avoid and therefore ultimately increase

Downloaded by [New York University] at 01:46 15 August 2016 worry. Examples of typical ways that people try to cope with worrying are procrasti- nation, distraction, internet checking for reassurance or information, ritualistic prayer, magical coping, and “as needed” medications. Seeking perfection, checking for mistakes, and overworking are other ways that people attempt to avoid worrying. Some people carry around what we like to call the “what if bag”: a set of objects that represent safety behaviors and attempts to avoid worrying by being prepared. The “what if bag” may contain the cell phone to call for help “in case,” a dose of PRN Xanax, a banana or crackers, a bottle of water, hygienic wipes, a list of medications and illnesses (in case of incoherence or coma). Some people seek reassurance from others on such a regular basis that they get hooked on it (See “The reassurance junkie” in Chapter 12 for more on this). 142 The Curious Case of Worry Behavioral Activation Increase pleasurable activity without demanding the absence of negative thoughts or the presence of positive ones. Go to the gym even while thinking “I am fat and ugly and embarrassed.” Go to the movies even while you are thinking, “What if I panic or don’t enjoy myself ?” Pet the cat and listen to music and take a walk no matter what repetitive activity is going on in one portion of the mind. Acceptance of the automatic nature of unwanted worry thoughts is key. This means actively allowing them to be there but not allowing them to run the show. Imagine that you are driving on the highway and the trafﬁ c requires your full attention to stay safe. Now in the back seat, safely strapped in, are two whining and nagging children, one is provoking the other and they are making an unpleasant racket. Your job is to keep on driving. There is nothing you can do to make them stop. So you embrace the reality you are in, and drive. Worries are like the kids in the back seat: they can make a racket and be unpleasant, but they do not run the show, they cannot actually do much of anything if they are strapped in—but they can keep it up for hours.

References Leahy, R. (2005) The worry cure: Seven steps to stop worrying from stopping you. New York, NY: Three Rivers Press. Judd, L. L., Kessler, R. C., PauIus, M. P., Zeller, P. V., Wittchen, H.-U., and Kunovac, J. L.(1998) Comorbidity as a fundamental feature of generalized anxiety disorders: Results from the National Comorbidity Study (NCS). Acta Psychiatrica Scandinavica 98(s393) 6–11. Noyes, R. (2001) Comorbidity in generalized anxiety disorder. Psychiatric Clinics of North America 24(1) 41–55. Grant, B. F., Hasin, D. S., Stinson, F. S., Dawson, D. A., Ruan, W. J., Goldstein, R. B., . . . Huang, B. (2005) Prevalence, correlates, co-morbidity, and comparative disability of DSM-IV generalized anxiety disorder in the USA: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Psychological Medicine 35(12) 1747–1759. Damsa, C., Kosel, M., and Moussally, J. (2009) Current status of brain imaging in anxiety disorders. Current Opinion in Psychiatry 22(1) 96–110. Hirsch, C. R., Hayes, S., Mathews, A., Perman, G., and Borkovec, T. (2012) The extent and nature of imagery during worry and positive thinking in generalized anxiety disorder. Journal of Ab- normal Psychology 121(1) 238–243. Leahy, R. L. (2004) Cognitive-behavioral therapy. In R.G. Heimberg, C. L. Turk, and D. Mennin (eds) Generalized Anxiety disorder: advances in research and practice . New York, NY: Guilford Press 265–292. Downloaded by [New York University] at 01:46 15 August 2016 Fresco, D. M., Frankel, A. N., Mennin, D. S., Turk, C. L., and Heimberg, R. G. (2002) Distinct and overlapping features of rumination and worry: The relationship of cognitive production to negative affective states. Cognitive Therapy and Research 26(2) 179–188. McLaughlin, K. A, Borkovec, T. D., and Sibrava, N. J. (2007) The effects of worry and rumination on affect states and cognitive activity. Behavior Therapy 38(1) 23–38. Smith, J. M, Alloy, L. B., and Abramson, L. Y. (2006) Cognitive vulnerability to depression, rumination, hopelessness, and suicidal ideation: multiple pathways to self-injurious thinking. Suicide and Life-threatening Behavior 36(4) 443–454. Surrence, K., Miranda, R., Marroquín, B. M., and Chan, S. (2009) Brooding and reﬂ ective rumination among suicide attempters: Cognitive vulnerability to suicidal ideation. Behaviour Research and Therapy 47(9) 803–808. The Curious Case of Worry 143 Wegner, D. M. (1994) Ironic processes of mental control. Psychological Review 10 (1) 34–52. Wilson, R. (2013) The Anxiety Game, Psychotherapy Networker. Retrieved from www.psychotherapy networker.org/magazine/recentissues/2013-januaryfebruary/item/1996-the-anxiety-game Wilson, R. (2006) “Trumping anxiety: The game, cont’d” Unpublished paper presented at the 26th annual Anxiety and Depression Association Conference, March 24, 2006, Miami, FL. Wilson, R. (2010) Brief Strategic Treatment of the Anxiety Disorders, Unpublished paper presented at the Brief Therapy Conference, Orlando, FL. Retrieved from http://brieftherapyconference. com/BT2010/handouts/brief-strategic-treatment-for-the-anxiety-disorders.pdf Borkovec, T. D., Alcaine, O. and Behar, E. (2004 ) Avoidance theory of worry and generalized anxiety disorder. In R. G. Heimberg, C. L. Turk, and D. S. Mennin (eds) Generalized anxiety disorder: Advances in research and practice . New York, NY: Guilford Press 77–108. Foa, E. B. and Kozak, M. J. (1986) Emotional processing of fear: Exposure to corrective information. Psychological Bulletin 99(1) 20–35. Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., and Baker, A. (2008) Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy 46(1) 5–27. Carbonell, D. (2012) Anxiety: Treatment Techniques that Really Work. Online presentation by CMI premier education solutions. Retrieved from http://shop.pesi.com/product/anxiety treatmenttechniquesthatreallywork(8345) Songify for iPhone by Smule (2013) Songify (Version 2.1.1) [Mobile Application Software] Retrieved from https://itunes.apple.com/us/app/songify/id438735719?mt=8 Borkovec, T. D., Ray, W. J., and Stober, J. (1998) Worry: A cognitive phenomenon intimately linked to affective, physiological, and interpersonal behavioral processes. Cognitive Therapy and R e s e a r c h 22(6) 561–576. Downloaded by [New York University] at 01:46 15 August 2016 10 Unwanted Intrusive Thoughts All Bark and No Bite

We all have them (Clark and Rhyno, 2005). They are thoughts, images, impulses that seem to emerge suddenly from our own minds, unbidden and unwanted. They are unacceptable, they can be weird and violent or improper, and sometimes they create a bit of hidden perverse pleasure. (How many points for hitting a nun crossing the street? A pregnant woman? A baby stroller?) For most, these experiences are ﬂ eeting and unimportant. They can even be funny, especially the bizarre ones. We have all had the thought of suddenly yanking the wheel wildly while driving and causing an accident or death. Nearly everyone has had a sudden weird thought—of jumping, being pushed, or even pushing someone else onto the tracks—while waiting for a subway train. Many have reached for the phone to call a dead relative or “saw” a deceased pet scoot by the periphery of their vision. We have suddenly recalled a dream fragment in the middle of a business meeting. We have had a vivid intrusive image of a social catastrophe—a wardrobe malfunction, or a sudden attack of amnesia, mutism, or imbecility. We have had the completely alien thought of stabbing a child or poking a dog with a pin. We have been “about to” blurt out something rude or mean. For most of us these experiences are short and meaningless; we forget about them almost as they happen and they are over. We don’t care about them because our minds are not sticky and we are not worried about our minds or our behavior. For others, however, these experiences become terrifying, out of control, and imbued with meaning (Clark and Purdon, 1995). These are people with anxiety disorders or depression. Unwanted intrusive thoughts can also be a contributing factor to insomnia, prolonged grief, and traumatized states. How is it that these universal phenomena turn into horrible suffering? Studies of mental processes have taught us a great deal about how it is that unwanted intrusive thoughts become problematic (Salkovskis, 1989)—and

Downloaded by [New York University] at 01:46 15 August 2016 have opened the door for treatment approaches that are truly effective.

How Unwanted Intrusive Thoughts Are Maintained Clark and Rhyno (2005) introduce the principle that that it is not the thoughts themselves that are problematic but how the individual reacts to them. Here are the factors that determine whether or not unwanted thoughts loom large and create misery, or remain ﬂ eeting meaningless experiences. Each of these factors will be discussed.

(1) How the thoughts are appraised (2) Control strategies that fail Unwanted Intrusive Thoughts 145 (3) Behavioral and emotional avoidance (4) Meta-cognitive beliefs (beliefs about thoughts) (5) Physiological factors that make the mind sticky

How the Thoughts Are Appraised People who are anxious or depressed or worried become more self-focused and vigilant about the contents of their minds (Tallis and Eysenck, 1994), as if they need to monitor their thoughts to keep themselves in check, or protect their mental health, or guard against danger. We all have many parallel streams of thought upon which we can focus our attention and mental energy or not. (Our brains are broadband!) To illustrate, we all simultaneously have streams of awareness that are monitoring our internal sensations:

• How comfortable is this chair? • How full is my bladder? • How hungry am I?

We are also monitoring social cues:

• How is what I am saying impacting you? • Do you like me? • Do I agree with you? • Did I just say something dumb?

Plus, we are all monitoring the passage of time:

• Will I get to my meeting on time if I encounter trafﬁ c? • How much longer till I get to go to sleep? • Is this book I am reading a waste of time?

We keep track remotely of the people we love. We calculate carbohydrate intake. We wonder if it will rain. We check on our scratchy throat. And the list goes on. When we are at peace, we allow and embrace this natural shifting of our thoughts. Some of these thoughts seem intentional, others seem out of the blue or even intrusive,

Downloaded by [New York University] at 01:46 15 August 2016 but we don’t worry about them. We expect not to be in full control of our minds. We gently refocus ourselves if we need to, and the intrusion is over in a few moments. A sensitized mind is hypervigilant: it scans thoughts for danger and evaluates them for signiﬁ - cance. An unintended thought which reaches aware- The anxious mind ness gets examined, judged, and appraised. The questions an intrusive centrality of appraisal is discussed by Purdon (2005). thought—what does The anxious mind questions what this means about this mean about reality reality, or danger or factual correctness, and wonders or danger or me? Is it a if this thought is a warning or a sign about the self. It warning? questions what it means that it thought it. It anxiously 146 Unwanted Intrusive Thoughts 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. Typi-

Downloaded by [New York University] at 01:46 15 August 2016 cal 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 backﬁ res. 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 Unwanted Intrusive Thoughts 147 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 camouﬂ aged 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.

Downloaded by [New York University] at 01:46 15 August 2016 • 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 148 Unwanted Intrusive Thoughts 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 fl ow 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 fl uctuations—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 fi ght 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 fi rst 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 infl uence on stickiness is mood. Depression is a potent risk factor for increased stickiness. Another is hormonal fl uctuations 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 fl uctuations in stickiness due to mood variations are even more pronounced in people with anxiety disorders. And the onset of an episode of major depression is very frequently preceded by a period of severe mind- stickiness and increased worry (Watkins, 2008). We fi nd 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.

Downloaded by [New York University] at 01:46 15 August 2016 It is most important to know that physiological factors can infl uence the intensity, frequency, and persistence of unwanted intrusive thoughts and images, along with certain medications. When disturbing thoughts are intensifi ed because of modifi able 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 modifi able. 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 terrifi c way of producing increased frequency and intensity of thoughts for Unwanted Intrusive Thoughts 149 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 con- A thought is merely trol disorder, as different as chalk and cheese. Patients a thought. It is not a will ask for reassurance, and that must be sparingly message. distributed, because reassurance ultimately makes the thought louder, more frequent, and stickier. 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” Most people need help or reassuring or calculating probabilities every time disengaging from the the thought comes back or intrudes into awareness. loud, repetitive voice It means actively allowing the thought to be there and to actively allow the but depriving it of its power to inﬂ uence by remain- thought to be there. ing 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:

A young woman had moved into a new apartment building that was only partly occupied. The fi rst night, while she was taking a shower the fi re 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 fi re was evident anywhere. She looked outside and no one was exiting the building. She called the front desk and they said

Downloaded by [New York University] at 01:46 15 August 2016 there was no fi re they knew of. She anxiously returned to fi nish 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 fi nd there was no fi re. She returned and fi nished her shower. The third night, the alarm went off again while she was in the shower. This time, she fi nished 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. 150 Unwanted Intrusive Thoughts Our point is that patients can live a good life while If one deprives these leaving room for unwanted thoughts of all kinds. If thoughts of power, it is one deprives these thoughts of power by rendering possible to live well. 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 ofﬁ ce, 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 terriﬁ ed 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

Downloaded by [New York University] at 01:46 15 August 2016 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! Unwanted Intrusive Thoughts 151

THERAPIST: But I’m not concerned about you hurting your child—or yourself. The thoughts are stuck because you are ﬁ ghting 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 fi lled with th e 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 hal- lucination, 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 confi dent 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 Misdiagnosis of post- common and a very costly diagnostic error. There is partum OCD as psychosis nothing psychotic about this individual, and treating is a common costly error. her as having a psychotic break would damage her self-esteem, confi dence, and social relationships, in addition to leading to less effective treatment. 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: Downloaded by [New York University] at 01:46 15 August 2016 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 ? PATIENT : I do not want you to call the police. I will bring shame on my family. THERAPIST: Well that certainly sounds scary. Are these things you actually want to do? PATIENT : Oh NO! Never! I would never want to hurt any living being. THERAPIST: You can’t go to jail just for thoughts. Tell me what is going on so I can see if you need a hospital. 152 Unwanted Intrusive Thoughts

PATIENT : I keep thinking that I am going to lose control and shoot up a school or a movie theater or a mall. THERAPIST: Do you have a gun? PATIENT : I hate guns. I would have to buy one. THERAPIST: Are you angry? Do you have a message or an agenda? Do you have any reason why you might do this? PATIENT : No. It just keeps jumping into my head that I could. THERAPIST: But why you? PATIENT : Well I have these thoughts. They used to be about “what if I give someone AIDS?” but that went away. This is worse. THERAPIST: Do you have AIDS or HIV? PATIENT : Not that I know of. I have never done needles and only have sex with my wife.

This dialogue continued until it was very clear that the thoughts of shooting up a public venue constituted harmless unwanted intrusive thoughts and that the patient had a long series of harming obsessions whose topics morphed over his lifetime. This man—who turned out to be a kind and gentle soul—had a hypervigilant and over-controlling relationship with his mind. He was tortured by his mental OCD, and seeking the relief of someone else to contain him, as if it was only by his extreme effort that he had not suc- cumbed to his horrible thoughts. Another patient presented with the dilemma, as she described it, that her “unconscious was punishing her.” She was in a long-term committed relationship in which she and her partner had both stopped drinking in the past six months. Suddenly while they were making love, she had an intrusive image of strangling her partner, terrifying her. Now, every time they became amorous, she would have the same image pop into her head. And, even worse, she was starting to see pictures in her mind of poking in the eye, stabbing, and shooting her partner. The patient had profoundly non-violent values, and concluded that she must be angry and not know it; she was also worried that perhaps she was losing control now that she was not “numbed out” with alcohol. Another presentation:

PATIENT : My wife said I have to see you. THERAPIST: Why is that? PATIENT : I am driving her crazy by talking about suicide. I have these thoughts. I feel as if I have to tell her about them so I won’t act on them. I am scaring both of us. THERAPIST: Downloaded by [New York University] at 01:46 15 August 2016 What are these thoughts? PATIENT : Well, they are actually sort of fantasies or maybe images in my mind. I keep on seeing myself stepping into trafﬁ c or jumping off a building or buying a gun and shooting myself. I was on a cyanide kick for a while. When someone mentions something planned for next year, I quickly think “I won’t be here.” Then I have to tell her about it. THERAPIST: Do you actually want to die? How is your life going? PATIENT : That is what is so weird. I love my wife and my job is okay and I think I am healthy. I have no reason to commit suicide. But telling myself that does not stop it. THERAPIST: So these are thoughts and images that seem ridiculous to you? Unwanted Intrusive Thoughts 153 PATIENT : Yes, and also scary. But why can’t I stop them? THERAPIST: Because the really good news here is that this is OCD, not suicidality, and it is really treatable!

This patient was attempting to cope with his unwanted intrusive thoughts by “confess- ing” them to his wife. These types of thoughts followed by a ritualized attempt to make them go away are signs of classic OCD: the thought (obsession) followed by the confes- sion (compulsion) in an escalating cycle.

Issues for Therapists: Therapist Anxiety and a New Construct This can be an extraordinarily diffi cult concept for traditionally trained therapists to accept, and it brings up two sets of issues. First, it generates therapist anxiety about the intent of these people. It is implicit in dynamic therapy that the wish is father to the fear (Freud, 1961). The theoretical assumption that a frightening intrusive thought refers to an impulse—even if unconscious—creates doubts about the safety of patients with violent and sexually charged mental images. Second, the idea that content can be irrelevant, and that these symptoms are just hiccups of the brain can seem shocking. It is helpful to realize that the content of the thoughts may be irrelevant but not random. Thoughts get stuck by virtue of how much energy is expended to get rid of them, so they are actually the exact oppo- The assumption that a site of a wish. One never sees an atheist horrifi ed by frightening intrusive the intrusive thought of standing up in church and thought refers to an cursing: it is always a religious person. Such thoughts unconscious impulse matter to someone who is religious and the intrusion creates doubts about is given power and repetitiveness by the force used to the safety of patients resist it. Similarly, it is people who love their children with violent or sexually for whom the thought of the worst possible thing they charged images. could do is to harm their child. This is anathema and thus they give it energy by trying to get it to go away. People who have ego-dystonic intrusive thoughts of suicide (“what if, against my wishes, I suddenly lose Thoughts get stuck by my mind and jump off this bridge impulsively?”) are virtue of how much people who love life and want more of it. energy is expended to get Lots of well-meaning therapists fi nd these par-

Downloaded by [New York University] at 01:46 15 August 2016 rid of them. ticular symptoms ripe for analysis. Unfortunately, traditional psychotherapeutic uncovering of these particular images adds to their intensity, since analysis reinforces the idea that the thought means something important and forbidden (after all, why else would it be repressed?), and needs to be made understandable. It is just one more example of the paradoxical nature of anxiety. The point to take away is that intrusive obsessive thoughts are thoughts, and not impulses or wishes. Incorrectly interpreting a harming obsession (e.g., the thought that one could poke a loved one in the eye during lovemaking) as anger is a huge clinical error that will escalate attempts to suppress the thoughts, resulting in more repetitive, 154 Unwanted Intrusive Thoughts louder, and more intense thoughts of the same vari- Intrusive obsessive ety. Similarly incorrectly interpreting a bizarre obses- thoughts are thoughts, not sive intrusive thought (e.g., the thought that one impulses or wishes. locked a child in the refrigerator, or that one’s mother is actually possessed by Satan)—which the patient knows is nuts but can’t help thinking it—as a psychotic process can lead to antipsychotic medication, Intrusive thoughts are hospitalization, and other radical changes to stave not random, but are off decompensation. This will again provoke panic, usually not meaningful increase resistance to the intrusive thoughts, and or important. Exploration result in increased frequency and intensity. can dramatically increase We agree that what comes to mind is not necessar- symptoms and suffering. ily random, but we also assert that much is not meaningful, important, or worth exploring. And there are times when exploration dramatically increases symptoms and suffering. Since unwanted intrusive thoughts gain power by the effort enjoined to uncover and resist them, traditional analysis provokes more persistent, frequent, and intense symptomatology. As Robbins has stated:

The art of therapy has a lot to do with knowing when to go into content, and when to step out of content. For example, it is almost never helpful to go into the content of an obsession when treating OCD. The same is often true with worry. (C. Robbins, personal communication, June 21, 2013)

Exposure to Unwanted Intrusive Thoughts Once the patient understands that these thoughts are neither messages, nor facts, nor meaningful outcroppings of the unconscious mind that must be suppressed, confessed or “dealt with,” exposure tasks can be undertaken. These will involve deliberately inducing the thoughts by means of writing, singing, watching videos, and making recordings of the thoughts and playing them back. They can be translated into other languages. They can be played with and exaggerated. Or record it onto Songify, the App that turns a sentence into a song and plays it back (Songify for iPhone and Android). Here is an example of an exposure session with a patient who has unwanted intrusive thoughts concerning the safety of her children. Downloaded by [New York University] at 01:46 15 August 2016 PATIENT: Whenever my kids are out of my sight, even if I am busy at work, I start imagining that they are in danger or already dead or injured. I try not to think about it but my imagination keeps zinging me. THERAPIST: Are you clear that this is an intrusive thought and not a fact? PATIENT: I know what you are saying but it feels so real at the time that I want to call and check on them to be sure. THERAPIST: Would you be willing to write a sentence on a piece of paper right now? The sentence is “My daughter is injured and will die if I don’t do something right away.” PATIENT: (upset) I just can’t do that. I can’t stand thinking that. THERAPIST: Do these words become true if you write them down? Unwanted Intrusive Thoughts 155 PATIENT: I guess they don’t but it makes me so scared, like I am tempting fate. THERAPIST : How about if I write them and just show them to you. PATIENT: OK (cries but agrees, and does read the sentence). This is silly isn’t it? I know it is just a bunch of words. I can read them. It isn’t true. THERAPIST: I hate to be contrary, but actually, we just don’t know with absolute certainty if it is true or not. You have to deal with that. PATIENT: I am not good with not knowing for sure. THERAPIST: Would you be willing to fold this piece of paper up and carry it in your purse all week? PATIENT: As long as no one else sees it, I can do this.

References Clark, D. A. and Rhyno, S. (2005) Unwanted intrusive thoughts in nonclinical individuals. In D. A. Clark (ed.) Intrusive thoughts in clinical disorders: Theory, research, and treatment. New York, NY: Guilford Press 1–29. Clark, D. A. and Purdon, C. L. (1995) The assessment of unwanted intrusive thoughts: A review and critique of the literature. Behaviour Research and Therapy 33(8) 967–976. Salkovskis, P.M. (1989) Cognitive-behavioural factors and the persistence of intrusive thoughts in obsessional problems. Behaviour Research and Therapy 27(6) 677–682. Tallis, F. and Eysenck, M. W. (1994) Worry: Mechanisms and modulating inﬂ uences. Behavioural and Cognitive Psychotherapy 22(1) 37–56. Purdon, C. (2005) Unwanted Intrusive thoughts: Present status and future directions. In D. A. Clark (ed.) Intrusive thoughts in clinical disorders: Theory, research and treatment. New York, NY: Guilford Press 226–245. Taylor, S. (1999) Anxiety Sensitivity: Theory, research, and treatment of the fear of anxiety. Person- ality & Clinical Psychology . Mahwah, NJ: Lawrence Erlbaum. Watkins, E. R. (2008) Constructive and unconstructive repetitive thought. Psychological Bulletin 13(2) 163–206. Wegner, D. M. (1994) Ironic processes of mental control. Psychological Review 101(1) 34–52. Freud, S. (1961) “Dostoevsky and parricide. The Standard edition of the complete psychological works of Sigmund Freud, Volume XXI (1927–1931). London: Hogarth Press 173–194. Songify for iPhone by Smule (2013) Songify (Version 2.1.1) [Mobile Application Software] Retrieved from https://itunes.apple.com/us/app/songify/id438735719?mt=8 Songify for Android by Smule (2012) Songify (Version 1.0.9) [Mobile Application Software] Retrieved from https://play.google.com/store/apps/details?id=com.smule.songify&hl=en Downloaded by [New York University] at 01:46 15 August 2016 11 Classic Pitfalls Common Mistakes Non-Specialists Make

Therapists with limited experience treating highly anxious patients can easily fall prey to a number of understandable pitfalls which are unproductive and even harmful. These fall into several categories. First, misdiagnoses can lead to unhelpful (although often quite interesting) exploration of “issues,” when the therapy work that needs to Traditional concepts be done is at a meta-level involving the patient’s rela- such as insight and tionship to his own thoughts, sensations, memories, catharsis can lead to and imagination. Second, traditional concepts such as causal explanations and insight and catharsis can lead to causal explanations interventions that are less and interventions that are less than helpful with this than helpful with this group of patients. We provide a number of examples. group of patients. Third, there are typical mistakes in the application of exposure-based practice that we illustrate. Common “under-diagnosis” errors include recognizing general anxiety disorder (GAD) but missing the underlying obsessive-compulsive disorder (OCD), treating social anxiety disorder as “low self-esteem,” and conceptualizing a phobia as fear of the external trigger (e.g., claustrophobia) without treating the panic disorder (fear of fear, or anxiety sensitivity) component. “Over-diagnosis” includes being waylaid by the bizarre nature of some unwanted ego-dystonic intrusive thoughts into concluding they are psychotic or dangerous intrusion of impulses. This can be particularly problematic in postpartum OCD, for example. Over-diagnosis can also occur in readily diagnosing Axis II traits such as lying, controlling, dependency, and manipulation prior to treatment of the anxiety. Often, these supposedly enduring traits will abate or disappear when they are no longer needed in the service of avoiding anxiety symptoms. Downloaded by [New York University] at 01:46 15 August 2016

Pitfall Number 1: Turning the Causation Arrow Around Patients can have signifi cant intrusive anxious thoughts from childhood, and many of them spend time in psychodynamic therapy before fi nding specialized help. Here are a few examples of turning the causation arrow around that created massive relief and helped to reframe problems that had plagued patients for years. One patient believed that her lifelong struggle with anxiety was derived from irrational childhood guilt over having caused the premature death of her father. She had misbehaved when she was 10 years old, and on that very day he had died of a heart attack Classic Pitfalls, Common Mistakes 157 on the front lawn. The patient had worked in therapy trying to acknowledge that she had only been a child doing what children do, that her father had an undetected heart condition, that she needed to have more compassion for herself, as well as a variety of other means of assuaging the guilt that caused her anxiety. However, when the original events were examined more closely, it became apparent that she had exhibited OCD symptoms for several years prior to her father’s death and it was therefore not possible that the “cause” was her irrational guilt. The intrusive OCD thought “what if I caused his death?” had not emerged until several years after he died. Her “misbehavior” on the day of his death had been a refusal to wear a certain piece of clothing which had been “contaminated” by “icky thoughts.” So the intrusive guilty thought that she had caused her father’s death was “caused” by her pre-existing OCD and was yet another OCD symptom. The best ways to handle such a thought was not to refute it but to get it labeled properly and disengage from it. Her previous therapy had inadvertently maintained her “guilty” thoughts. A second and very similar example: an elderly woman came to talk about her lifelong struggle with “infi delity” thoughts. She was still plagued by the belief that she had “lusted in her mind” for men other than her husband. She had been widowed many years earlier after what had seemed to the outside world an ideal marriage. During her 40s, she had gone to a therapist to try to banish these thoughts. What resulted was an escalation of doubting thoughts about her marriage, so she fl ed therapy and tried to get rid of the thoughts on her own. She remained convinced that she had deceived her husband by keeping these thoughts private and felt guilty about this to the present. She believed that her private struggles indicated that she must not have really loved him. In fact, when she understood that all that was happening was OCD obsessions—that these were ego-dystonic intrusive thoughts rather than secret wishes—she began sob- bing in relief. What good news to understand she had OCD! She realized that her choice to spare her husband knowledge of her struggles with these thoughts was a true act of love—and sharing her thoughts would only have caused him pain and further ener- gized her struggle. The thoughts were not caused by not loving her husband enough; they were “caused” by refusing to allow any doubts about loving him to pass through her mind. A fi nal illustration: a young woman came to therapy in acute distress after her family doctor had sent her to a therapist one month after giving birth to her fi rst child. The therapist had listened to her confessions of having thoughts of harming her baby, sometimes a fear of suddenly dropping him, sometimes “unspeakable” thoughts while changing his

Downloaded by [New York University] at 01:46 15 August 2016 diaper. She had employed a full-time baby nurse because she was afraid she would act on these thoughts. The initial diagnosis was “postpartum depression” but she did not seem depressed—she was eating and sleeping well, and when someone else was taking care of her son, she seemed far more relaxed. The therapist suggested that she might be ambivalent about having a child and began to explore this theme, including her fears of being trapped with this husband now that she had a child with him. Perhaps, the therapist suggested, she was also ambivalent about her husband, and this was the “cause” of such thoughts. She became upset and argued vehemently that this was not so. Then, fortunately, the therapist wondered if this was “postpartum OCD” and referred her to a specialist, feeling unequipped to diagnose and treat OCD. This young mother resumed care of her child within weeks of an accurate diagnosis and attitude towards these thoughts. 158 Classic Pitfalls, Common Mistakes The meaning of harming obsessions is that these are the most resisted thoughts; it is not strange that a hormonally challenged and stressed young mother with a genetic predisposition towards “stickiness of the mind” would ﬁ nd passing thoughts of hurting her baby disturbing and would launch an internal compulsive campaign to rid herself of these thoughts. The avoidance of caring for the child was due to loving and “protecting” him and not due to ambivalence.

Pitfall Number 2: Pathological Doubt OCD—Misidentifying OCD Thoughts as Issues and the Seduction of Co-compulsions There is a particular presentation of intrusive thought that, if not understood to be a form of ego-dystonic OCD, can lead to additional suffering and negative therapeutic results. This form of OCD, called pathological doubt, can focus on any topic for which there is no deﬁ nitive certainty. It masquerades as a serious issue that demands exploration and screams for resolution. In French, OCD has been referred to as “le malade de doute,” and, indeed, as discussed previously, intolerance of uncertainty forms the core of the experience of anxiety. In pathological doubt, a question arises in the mind of the patient and is accompanied by a sudden jolt of doubt, along with an overwhelming driven need to resolve the doubt. This can happen in childhood as early as children can formulate a question. It frequently jumps into awareness out of the blue, although sometimes people are able to identify the trigger for the intrusive thought. Some of these issues may seem to be philosophical quandaries, religious musings, or relationship issues. Religious and non-religious scrupulosity (overblown conscience) falls in this category. But philosophy as an activity is a pleasurable discourse and an intellectually intriguing inquiry; religion as practiced in its true form provides peace, comfort, and connectedness; and relationship issues can be resolved. These doubts are tortuous mental activity which returns again and again no matter how much mental and emotional energy is dedicated to their resolution. They are maintained by cognitive compulsions, the efforts undertaken to solve, analyze, explore, understand, research, discuss, refute, and rationalize. Here is a list of the most common topics that masquerade as issues and become the foci for obsessional (and compulsive) preoccupation.

1. How does one live happily all the while knowing you are going to die? 2. How can I be sure there is a God? 3. How can I know that I have chosen the right life partner?

Downloaded by [New York University] at 01:46 15 August 2016 4. What is the meaning of life? 5 Am I possibly not straight (or gay)? Could I be attracted to the wrong person? 6. Is my partner faithful in his/her heart and mind as well as behavior? 7. Am I going to heaven? 8. Could I survive the loss of my (parent/child/partner)? 9. Am I healthy? 10. Have I done everything I could to be good?

Once it is understood that these preoccupying “issues,” no matter how important they may seem to be, are actually symptoms of an exquisite intolerance of uncertainty and part of OCD, then the patient is able to cease unproductive and tortuous internal and Classic Pitfalls, Common Mistakes 159 external conversations, and may begin the road to recovery. Here are some examples of pathological doubt OCD. A young man was self-referred after refusing to take antipsychotic medication that had been prescribed by a psychiatrist. The psychiatrist informed him that he was having an “incipient break” and he needed to take the medication to prevent himself from having the delu- sions and hallucinations that were gradually “taking Once this “issue” over his mind.” What the patient described was that is understood as he was having fl ashes of the scenes in the movie “The OCD intolerance of Matrix” which represented a reality in which humans uncertainty, the tortuous were trapped in vats, while they collectively imagined internal dialogue a false computer-generated world where everything and unproductive seemed normal but was entirely fi ctitious. Accom- conversations can stop. panying these fl ashes, was the thought “What if this is actually the Matrix or something like it, and I am the only one asking questions, and I will never be able to prove this reality is not real and I will be labeled as crazy?” He was so afraid of this idea that he did everything he could to not think about it. This, of course, had the predictable effect of increasing the frequency and intensity of these intrusive images and thoughts. He became avoidant of other people for fear he might blurt out something that would sound crazy and get himself in trouble. His isolation was rapidly creating depression and feelings of hopelessness. A second patient had been in therapy for years to talk about his “commitment phobia.” Every time he became close to a woman he was dating and started to consider making the relationship exclusive, he began to imagine the rest of his life with her, and would have a series of doubts such as “I wonder if she has the best temperament to be a mother,” “I am afraid I will grow tired of her voice,” “What if my sexual attraction to her does not last?”, “What if she gets fat—her parents are fat—could I still love her?”, and “I don’t know if she will support me in my career enough.” He would then feel compelled to break up with the woman so as to not treat her unfairly by raising her hopes of a future with him. Once the problem was reframed as OCD and intolerance of uncertainty and unanswerable questions, the therapist created an entirely new framework to approach the problem.

The Phenomenon of Co-compulsing: It Is Never Helpful

Downloaded by [New York University] at 01:46 15 August 2016 There is also the tendency for highly insightful and introspective patients to become involved in what we term “ co-compulsing. ” We defi ne co-compulsing as the anxious equivalent of co-rumination (Rose, 2002; Stone, Hankin, Gibb, and Abela 2011), which addresses the tendency of certain people (most often adolescent girls) to talk extensively and repeatedly about their problems, focusing on their negative Co-compulsing by feelings, and thereby reinforcing depression. We friends, family, and defi ne co-compulsing as joining in with the patient therapists is enticing and as he attempts to use cognitive compulsions to lower seductive and is always his distress. There is a natural tendency for anxious unproductive. patients to engage family, friends, and therapists 160 Classic Pitfalls, Common Mistakes in mutual attempts to lower anxiety by suggesting apparent solutions to obsessive concerns. It can be enticing and seductive, and is always unproductive. Here is an example of therapy that did not work because it was actually co- compulsing. A graduate student in philosophy presented for treatment because he was haunted by a conundrum he simply could not get out of his mind. He had had the thought that “we all know we will die” and then thought “how can I go on unless I know the reason I am here and pursue that purpose before I die?” This disturbed him deeply, and he began a search for the meaning of life which took him on a journey through major philosophical and theological literature. Still he was losing sleep because every bit of research was fl awed and every answer he sought created more doubts and more questions. He felt driven to work on this “issue” night and day and was unable to ful- fi ll his teaching responsibilities. He was aware that others were increasingly concerned about him. He was articulate and bright. His therapist then engaged with him in deep discussions about the meaning of life, why he believed he was on earth, what his parents had taught him about God, and how he felt about that. She attempted to explore what might be behind his drive to fi nd these answers. She wondered with him if he was avoiding relationships and why. He got worse. He became demoralized and depressed. He described himself as trapped in an abyss and the only way out was to fi nd “the answer.” After 18 months, his therapist moved to another state. His former girlfriend said he should seek an expert in “obsessions” as this was how she viewed him. This man was diagnosed with OCD in the form of pathological doubt. He needed an entirely different relationship to his thoughts.

Pitfall Number 3: Intrusive Thoughts or Doubts about Sexual Orientation or Identity—Misdiagnosing OCD Thoughts as a Sexual Issue As anxiety specialists, patients sometimes come to us for help with issues they believe may be real, but cause them extreme anxious distress. A woman was seeing a therapist she admired and liked, but sensed that something important was missing. She presented to this therapist with confusion over sexual orientation. The thought that perhaps she was gay created great anxiety, and her therapist framed the issue as one of lifestyle choice: the patient was very sexual, and very sexual people can feel attracted to and can be sexually fulﬁ lled by people of either sex. This patient, however, was dogged by anxiety from an early age. She researched her concerns and came up with the possibility that this was an aspect of OCD, showing references to her therapist, who discounted the possibility.

Downloaded by [New York University] at 01:46 15 August 2016 The following email is from this patient, and comprised the only introductory information relayed prior to an initial interview.

I have had bouts of anxiety since I was young. After college it started again when I started to have phobias of the underground transit, then trains in general, ﬂ ying and then tunnels. I also always worried that my boyfriend would leave me for someone else. These thoughts would occupy my mind. I started having thoughts that I didn’t love him which were all consuming and anxiety provoking. Then during an anxious time the thought that maybe I’m a lesbian popped in my head and that has been the most distressing. I was able to get rid of it for short periods of time but now it’s stuck. Please let me know if you think you can help me. Classic Pitfalls, Common Mistakes 161 The wording of the email screams out a diagnosis of OCD with intrusive thoughts and pathological doubt. The phrases “having thoughts that I didn’t love him which were all consuming and anxiety provoking” and “the thought that maybe I’m a lesbian popped in my head . . . but now it’s stuck” are pathognomonic of mental OCD. Additionally, the patient related an exchange with another therapist she had been seeing years previously: she wondered if her jealousy concerns and worries that her boyfriend would leave her for another person was another aspect of OCD. Again, this therapist assured the patient that it was not—it was an indication of her insecurity and—this time—her lack of sexual conﬁ dence. So how did these two therapists get things so wrong? It concerns a misunderstanding of the nature of OCD and compulsions—that OCD is often entirely mental and that compulsions can take myriad different forms. So therapists fail to explore the anxiety maintaining cycle from a meta-level, and focus attention on the misleading content of the sexual orientation issue. When patients like this present for therapy, they rarely provide an accurate diagnosis. Rather, this patient might have told her therapist the following:

PATIENT: I think I’m a lesbian, and I’m married and about to try to get pregnant, and I’m afraid I’m making the biggest mistake in my life. THERAPIST: What makes you think you are a lesbian? PATIENT: I get turned on by women. I notice attractive women when they are around. I can feel myself getting sexually aroused by certain women, and I fantasize about women when I’m making love with my husband.

Although this sounds like solid evidence for an exploration of orientation issues, careful questioning would elicit the following information. Prior to her concerns about orientation, she enjoyed erotica with both male–male and female–female themes. The thought that she might be a lesbian popped into her head one day, causing intense anxiety, along with a desperate desire to believe she is straight. Whenever she sees an attractive woman she thinks “maybe I want to be with her,” gets a whoosh of anxiety, and then checks her body for signs of arousal—to make sure she doesn’t feel attraction. But the thought has created anxious arousal, the patient checks and ﬁ nds sensations in her genitals, and that awareness conﬁ rms her worst fear—that she is indeed a lesbian. And so the patient works harder to keep these thoughts from her mind, reinforcing the stuck thought phenomenon. What has been communicated as feeling aroused by people of the same sex

Downloaded by [New York University] at 01:46 15 August 2016 turns out to be an ongoing cycle of anxious arousal and compulsive checking. The patient emphasized that she had no concerns about enjoying lesbian porn prior to having intrusive thoughts of being gay. And her fantasies of women while in bed with her husband turned out to be intrusive thoughts that frightened her and began turning her off of sex, which reinforced her fears that she might be gay. She looked at naked pictures of men and women, trying to judge which images cause greater arousal. Her history indicates a lifelong struggle with anxiety, and a family history of OCD on her father’s side. Here are some examples of the same phenomenon. A man in his early 20s presents for treatment with a “compulsion” that he wants to be rid of. He is spending hours upon hours every night viewing homosexual porn and 162 Classic Pitfalls, Common Mistakes checking to see if he is aroused. He then compares his sexual responses to heterosexual porn, and goes back and forth in a frenzy, often causing himself penile bruising, sleep deprivation, and daytime regrets. He has gone to gay bars to see how he feels. He has even participated in a single anonymous sex encounter in order to fi nd out “for sure” if he is attracted to men. This experience left him even more embroiled in doubts. He is very clear that he is not against homosexuality: all he wants is to know with certainty whether or not he is gay or even bisexual. Any answer would be okay with him. He just wants to settle the question so he can go about his life. He can’t stop. A teenage girl presents for treatment to help her to stop “un-Christian” thoughts. She has prayed for God to take away these thoughts but they are actually increasing in frequency and intensity. She has an exhausting intense gaze, focused into the eyes of whomever she is talking to or walking past, because she fears that she will look at breasts of women or what she refers to as the “laps” of men. This urge is understood by her as punishment for having sexual thoughts she should not have. She is worried that she is hopelessly “perverted.” She is terrifi ed that she is actually gay. She has never had any sexual activity with anyone. She went through a period of time as a child in which she was fearful of bad thoughts about her parents, but these went away, she believes, because she prayed for God to remove them. A teenage girl comes in for a consultation to see whether she might be a “secret trans- sexual.” She is being bombarded by a train of thought that she describes as “my mind is trying to convince me that I might really be a boy.” She had read an article about transsexuality and suddenly became panicky with thoughts such as “I like pants and hate skirts,” “I enjoy team sports,” “I might like to have a penis,” and “my parents could never handle this if I told them I was thinking about it.” She told her parents she was having panic attacks so she could see a therapist. It turned out that she had a prior history of panicky responses when she was very young: fears about her parents dying; worry that she might grow up to be a pedophile when warned about them in fi rst grade; and—a few years previously—had badgered her parents for proof she was not adopted.

Pitfall Number 4: Get Your Feelings Out There are certain assumptions about psychotherapy that seem so obvious, so common- sensical, that there seems no need to question their validity. One of these assumptions is that getting in touch with one’s feelings—becoming more emotionally expressive, more assertive, feeling more deeply—will help a patient overcome or lower anxiety. This

Downloaded by [New York University] at 01:46 15 August 2016 assumption may stem from the popular idea that catharsis, or some form of emotional venting, is inherently therapeutic, and this extends to the area of anxiety disorders as well. And there are analytic underpinnings that originate with Freud, who at one time viewed anxiety as a consequence of repression and employed abreaction as a method of treatment (Freud, 1962). Later, he changed his theory to include anxiety as both a signal and a symptom (Freud, 1959), and turned the causation arrow around so that anxiety became the instigator of repression, and not the other way around. Interestingly, Freud’s ﬁ nal theory of anxiety shares similarities with contemporary conceptualizations. The problem with the assumption that it is good to express one’s anger is twofold. First, there is no evidence that a lack of expression of emotionality has any relationship to anxiety disorders, and those suggestions can pressure patients to express emotions they truly don’t feel. People with anxiety disorders—like the rest of the population—fall Classic Pitfalls, Common Mistakes 163 into three general categories: some experience a full range of affect, and are emotionally expressive and assertive; some experience emotions but are limited in their ability to express those feelings, and others who profess to feel very few emotions, and so have little to express. Some patients who consider themselves rather cerebral and less emotional, report being told by therapists that if they could just feel their feelings more intensely, they would become less anxious. The potential result is a feeling that they are doing something wrong, failing at a task, responsible for their own anxiety, and must change their style of relating to the world in order to suffer less. After being told this by a therapist, one patient reported:

PATIENT: She (referring to the therapist) said that I needed to let my feelings out to feel less anxiety. THERAPIST: What did you do? PATIENT: I tried to feel more. I tried to make myself cry. But I wondered if I was trying too hard. Sometimes I did cry, and I felt better. But I have always thought of myself more like my father. He’s the anxious one, and he’s into his head. I’m the cerebral one also; my sister is the emotional one. I wish I could be more like her.

So the suggestion to feel and express more emotions can become a measure of how well one is doing in therapy, a source of unsupported guilt and overblown responsibility, and may add to the patient’s bewilderment and frustration. The second problem is that this premise turns the causation arrow around: constricted affect does not cause anxiety; it is anxiety that can cause constricted affect. This issue was initially addressed in Chapter 3, under the heading “Consequences of Affect Intolerance,” although the primary focus in that section was explaining the difﬁ - Constricted affect does culties in coping with affect triggered when searching not cause anxiety; it is for hidden causes. But a similar issue arises when the anxiety that can cause suggestion is made to be more emotional. constricted affect. Many patients with anxiety disorders fear arousal, and its associated sensations, memories, and thoughts, and can have difﬁ culty tolerating strong emotions. Again, we are addressing anxiety sensitivity—an inability to tolerate the experience of anxiety—from the perspective of affect intolerance. Intense affect can feel uncomfortable and even dangerous, and there is a felt need to distance oneself from the emotions. Asking some patients to be more emotional—

Downloaded by [New York University] at 01:46 15 August 2016 or to let their feelings out—can trigger anxiety that makes it more difﬁ cult to do so. 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 ﬁ nd 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. 164 Classic Pitfalls, Common Mistakes 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 ﬂ ow of trafﬁ c 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 Downloaded by [New York University] at 01:46 15 August 2016 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.) Classic Pitfalls, Common Mistakes 165 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 conﬁ dence 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, Inhibi- tions, symptoms and anxiety, the question of lay analysis and other works. Toronto: Hogarth Press 271–274. Downloaded by [New York University] at 01:46 15 August 2016 12 Another View of Resistance Issues That Interfere with Treatment

We now examine three specifi c 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 Many self-defeating avoidances. They stem from fear, not from oppo- behaviors are more sitionalism or an attempt to sabotage treatment. In accurately conceptualized these cases, it is the role of therapist to make that and treated as anxiety explicit to the patient, and to work out manageable avoidance. 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, Resistance is never the conceptualize it as a meta-problem, and suggest con- patient’s fault. crete 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 diffi cult, to more subtle triggers such as the patient’s diffi culty 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.

Downloaded by [New York University] at 01:46 15 August 2016 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. Fre- quently 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. Another View of Resistance 167 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 signiﬁ cant 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 ﬁ rst 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

Downloaded by [New York University] at 01:46 15 August 2016 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 diffi cult to eradicate. Anticipatory anxiety is natural and automatic, and often the fi rst and most persistent manifestation of an escalating problem with anxiety. Even when formerly anxiety-producing situations 168 Another View of Resistance have become routine, there is often a brief “hump” of anticipatory anxiety that per- sists, 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 Anticipatory anxiety is they are avoiding in order to reduce anxiety, but the often the fi rst and most truth is that anticipatory anxiety generates additional persistent manifestation anxiety. of an escalating problem Anticipatory anxiety is not a true predictor of with anxiety. how much anxiety someone feels in the actual situation. This fact fl ies 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 fl ying, we Anticipatory anxiety gives tell patients that—if they have a good understand- false messages. ing of the anxiety-producing process and practice applying the therapeutic attitude—then by the time the plane has reached level fl ight, 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 benefi t from the therapeutic effects of exposure. 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) signifi cantly reduce panic, phobic, and obsessional anxiety, but have little effect on anticipatory anxiety. Conversely, the benzodiazepine class of medica-

Downloaded by [New York University] at 01:46 15 August 2016 tions (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 traffi c 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 traffi c Another View of Resistance 169 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 traffi c 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 traffi c ahead of us, my level is maybe a 2 or a 3. But—listen to this—when I look at the traffi c 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 fi nd 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. Anticipatory anxiety As the day of the meeting nears, he will become ever increases with indecision more aware of his anticipatory anxiety, and he might and proximity. start to waver about attending the meeting. Can he reschedule the meeting to an offi ce on a lower fl oor?

Downloaded by [New York University] at 01:46 15 August 2016 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 other hand, a fi rm commitment to attend the meeting will also produce immediate relief (often to the patient’s surprise) because indecision itself is enormously sensitizing. 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 confl ict, 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. 170 Another View of Resistance 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 indi- cator 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. Next, frame anticipatory anxiety as a learning experience about the power of the brain to affect feelings. While anticipatory anxiety is real anxiety, it a type of anxiety that is generated by mental images, independent of external causes. Closely observing instead of trying to suppress anticipatory anxiety will help to grasp the power of the mind to create its own version of reality. Suggest changing “what if” to “what is,” thereby redirecting the patient’s attention to the present moment when he fi nds himself stuck in images of the future. We repeatedly remind patients to stay in the “now.” Again, this is best accomplished by redirecting attention from cognition and thinking to the senses (“What do you hear, see, smell? Notice the fl oor under your feet. Pay attention to the coolness of air you breathe in compared with the warmth of the air you breathe out, etc.”).

Here is a particularly vivid example. A patient had a severe phobia of vomiting (emetophobia), and was so terrifi ed about it that she limited her life enormously. She avoided anyone whom she believed might be ill, since that person might pass on a stomach virus and cause her to throw up. She lived in an apartment with a roommate with whom she was friendly, but not very close. Each had their own bedroom and bathroom. One morning she and her roommate lingered over breakfast, and both went to work at the same time. That evening she returned home to fi nd that her roommate’s door was shut and she could hear defi nite signs that her roommate was coughing, retching, and throwing up. “What if,” she thought, “she caught her roommate’s stomach virus and would soon start getting nauseous and vomiting herself?” That night was a horror. She was afraid to knock on the door Downloaded by [New York University] at 01:46 15 August 2016 and contact her roommate. She couldn’t sleep, and spent most of the night with intense anticipatory anxiety, waiting for her own nausea and vomiting to begin. Finally, out of exhaustion, she fell asleep until the morning. When she awoke, she saw her roommate walking around the apartment, smiling pleasantly, sipping coffee, eating breakfast, and reading the paper. “But I thought you were sick last night?” my patient asked, “How did you recover so quickly?” Her roommate looked a little surprised, then laughed a bit, and said that she had been fi ne all night, but saw the movie “Detroit Rock City” on a DVD before going to bed. There was an explicit scene in the movie where someone throws up, and she guessed that my patient had overheard that scene. Another View of Resistance 171 This woman immediately realized that her roommate had never been ill, and that there had never been a danger of catching her stomach virus. The entire experience was based on misinformation, and was entirely generated in the mind of the patient. It was the beginning of a profound realization that her fear was triggered by images in her brain, and not by the external reality. Weekes (1976) notes that anticipatory anxiety is always the last to go because patients need to build up a new set of less distressful experiences in order to override memories of intense situational fear. The best way to overcome anticipatory anxiety is to relate to it for what it is: an automatic misleading message that is best allowed and ignored. The result is that anticipatory anxiety has the opportunity to become increasingly relegated to the background of awareness. That way, it no longer matters.

The Reassurance Junkie: When People Are Constant Callers Some patients spend an extraordinary amount of energy looking for reassurance. Here are some examples. A 25-year-old female hates it whenever she believes a friend or colleague might be angry at her.

PATIENT : So I text them and tell them I hope I didn’t offend them. THERAPIST: Do you think you did? Offend them? PATIENT : Most of the time, “no.” but I can’t really be sure. I go over in my mind what I said, and I hope they didn’t take it the wrong way. But the worst part is that I text them and apologize even when they treat me poorly.

A 55-year-old male repeatedly calls his doctor because of a feared symptom.

PATIENT: I have this burning in my throat that makes me very nervous that I might have cancer. And I feel so stupid calling the doctor about it. THERAPIST: Why is that? PATIENT : Because I called him last month about it. And I got an upper endoscopy and he said I’m ﬁ ne. But now I’m having this burning again. So I called his ofﬁ ce and spoke with the doctor again. He is very nice, and he said there is nothing wrong with my throat. But as soon as I got off the phone, I worried that maybe he had mixed me up with another patient, but I was too embarrassed to call him again.

Downloaded by [New York University] at 01:46 15 August 2016 THERAPIST: So what did you do? PATIENT: I made an appointment with another doctor.

A 47-year-old female continually asks to be calmed down during an airplane ﬂ ight.

PATIENT : During the fl ight I’m a basket case. I look at the fl ight attendants to make sure they look relaxed and not frightened. I use the call button all the time, and ask about sounds that I hear that seem unusual. I make my husband tell me that the fl ight will go well. I need to know everything is okay or else I start to panic. When the turbulence starts I beg the fl ight attendant to stay with me. 172 Another View of Resistance This 37-year-old female wants to know exactly where her husband is every single minute.

PATIENT : I get very nervous when he is away. I worry a lot that something awful might happen to him. I have all these crazy ideas that he’ll be hurt or get into an accident and I can’t get them out of my mind. THERAPIST: So what do you do? PATIENT : I have him call me when he gets into his offi ce. And then I relax a bit. And then I like to know where he goes for lunch, if he goes out for lunch. And when he gets back to the offi ce he calls to let me know he is back safe and sound. And then my husband has to call me when he leaves the offi ce, so I know when I should start worrying if he is late. THERAPIST: And what happens if he is late? PATIENT : First I call and ask where he is. If I can’t get him, I get really scared, and start checking the news to see if there are any accidents.

The list is long and varied: the dependent employee who calls the supervisor for approval before even the most trivial decision. The spouse who asks her husband to reassure her each bedtime that she won’t go crazy during the night. The driver who wants her mother to guarantee that she won’t freak out while driving over a bridge. The mother who puts her child on the school bus, then calls her friends to tell her she is not being irresponsi- ble. The person who combs the internet for websites and chat groups compulsively, often re-reading the same information to reassure himself that he does not have some medical or psychological problem. One patient with panic disorder was afraid to go into the park for fear she would panic and rip off her clothes. She repeatedly asked for guarantees that she wouldn’t do that. A caring and competent therapist mentioned a patient who had developed an unusual and intense “dependency”: he called her regularly, told her about colored spots he saw on the ground, and asked if she thought that the spots could be blood. She would answer “no” about any spots that weren’t red, and the patient would hang up, seemingly satis- ﬁ ed. The therapist was concerned that these phone calls were increasing in frequency, and indicated an attempt to expand treatment outside of the ofﬁ ce. These patients often contact the therapist for reassurance as well. Their calls are different from the occasional calls that patients may make during genuine crises. They may be for approval of a decision, assurance that they did something correctly, a guarantee

Downloaded by [New York University] at 01:46 15 August 2016 that they aren’t having a heart attack or a stroke, conﬁ rmation of an appointment time, clariﬁ cation of an issue discussed in session, a discussion of a new anxiety or returning symptom, permission that it is all right to call between sessions, apologizing over something said in session or for calling too much, or a seemingly endless list of “issues” that pop up and need urgent soothing.

What These Patients Have in Common While some might describe these people as dependent or manipulative, they all suffer from intense anxiety, and—while their specifi c diagnoses may be different—they all share a similar and unsuccessful method of coping with their anxiety: they require other people to reassure them that their fears are unjustifi ed. There is a place for reassurance Another View of Resistance 173 in therapy. Most people benefi t from empathic and realistic reassurance when they are coping with the normal anxiety associated with change—trying out new ways of coping, making hard life decisions, confronting diffi cult people. The majority of the time, reassuring patients helps them over hurdles, and leads to greater confi dence and decreased anxiety. Sometimes a patient will say, “This is new to me. I have no perspective. Does it seem like I’m handling this in a way that makes good sense?” And you will—when you think it appropriate—use reassurance as a means to keep anxiety manageable. But for certain anxious patients, reassurance has the opposite effect. While it decreases anxiety for a short period of time, the anxiety soon returns with a vengeance. This surge of anxiety is followed by an increased need for further reassurance. And the cycle continues. The cycle of behavior is analogous to the heroin addict, who temporarily feels beatifi c after a fi x, but then has an increased craving for the drug when it wears off. The reassurance “fi x” keeps anxiety manageable for a time, but anxiety reappears when it wears off, necessitating yet another reassurance. These people are reassurance junkies! We have emphasized that a very powerful way of temporarily keeping anxiety at bay is to gain assurance there is nothing to worry about—that there is no basis for concern. For certain patients, whenever anxiety is triggered, the quest for reassurance becomes driven and compulsive, and we view this obsessive need for reassurance as OCD, independent of any additional issues. Reassurance compulsions function exactly the same way as hand washing and checking compulsions. Sometimes reassurance junkies directly ask for reassurance. Here are examples:

Please guarantee me that I won’t lose my mind from anxiety. I’m ﬂ ying tomorrow. Please tell me that I’ll be safe. Are you sure I won’t catch AIDS from that red spot?

Other times, patients will ask for reassurance in a less direct manner.

The individual with an obsessive fear of illness might ask, “Do you think I should talk to the doctor about my sore throat?” The person with GAD and worries about her child’s safety asks, “Do you think I did the right thing by letting my child go on the school trip?” The person with social anxiety asks “Do I look nervous when you come get me in the waiting room?”

Downloaded by [New York University] at 01:46 15 August 2016 Empty Reassurance: The Sign of the Reassurance Junkie One sure sign of a reassurance junkie is their tendency to ask for guarantees about facts that can’t possibly be Reassurance “junkies” ask provided. Another sign is the tendency to repeatedly for guarantees about facts ask for the same or similar reassurances. These simi- that cannot possibly be lar questions can be quite creative—and they often provided. feel like they are different (and urgent) questions to the person who is asking them. Here are examples:

One patient coughed in the ofﬁ ce and asked if she had lung cancer. Another continually asked for assurances that the elevator wouldn’t get stuck. 174 Another View of Resistance A young woman periodically felt compelled to look at herself in the mirror and ask her mother whether she was fat. If her mother wasn’t around, she would text the same question to her boyfriend. Another patient constantly asked if her son was going to get a job and be able to keep it. Another felt susceptible to head injuries, and, every time she bumped her head— even a bump that she could acknowledge was insigniﬁ cant from a health point of view—would ask for reassurance from trusted companions that she was okay and didn’t need medical attention.

Asking for reassurance is sometimes subtle. Patients can ask outright, but they also judge the other’s reaction and look for signs of uncertainty in answers. It is easy for the therapist to get caught off guard by a sharp-eyed patient who ﬁ rst asks for empty reassurance, and then questions your response. Every answer is scrutinized, and minor differences or contradictions between answers are often seized upon. Excessive fact checking is another way that highly anxious people look for reassurance. The therapist’s job is twofold. First, to recognize the varieties of reassurance— patients don’t always overtly ask if they will be okay—and, second, to ﬁ nd the right level of support in the moment, while keeping an eye on the longer range goal of helping your patient get over their anxiety disorder. Make the distinction explicitly to the patient between reassurances that are informational, and those that are empty. A general rule is to provide information that is comforting once or twice, but, no more. After that, treatment should focus on the process more than content. A therapist can say something like, “There’s that ‘what if?’ thought again. Quite amazing how persistent it is, isn’t it?” Withholding reassurance gently, explicitly, and supportively teaches the patient in the moment how they are attempting to avoid facing their own internal anxious experience.

Helping a Reassurance Junkie The most effective way to proceed is to provide a meta-analysis of the compulsive need for reassurance. An aspect of this approach is to explain to patients the double-edged nature of reassurance, and ask them how many of their behaviors qualify as empty reassurance. Almost every patient can identify the reassuring nature of these interactions. Most realize that they are ridiculous and readily accept that they are reassurance junkies, but feel powerless to stop.

Downloaded by [New York University] at 01:46 15 August 2016 Patients also readily acknowledge that their demands for reassurance are driving family and friends away. It is very valuable to devise a way to alert the home-based reassurers—who are just trying to help—that their reactions are an aspect of what maintains the problem, and to teach them alternative ways of responding. This can be a conjoint session or two, or it can be the patient’s responsibility to explain the rationale for asking to be Provide the patient with deprived of reassurance even when he might be plead- a meta-analysis of the ing for it—and to try to do this in a compassionate compulsive need for (or humorous) manner. One patient explained to his reassurance. wife that his requests for reassurance were just quack questions, and they both decided that she would honk Another View of Resistance 175 a silly quacking toy if the question “quacked like a duck,” since they were both ready for this route out of reassurance addiction. Other ideas for family: “May I hug you instead of answer that question? This must be awful for you.” Or “I love you too much to get started with that ‘what if?’ stuff.” It is sometimes helpful to issue patients reassurance coupons that can be used between sessions. Patients receive a limited supply that be budgeted as they desire. With children, any remaining coupons can be traded in for a reward. Both children and adults love stickers! (C. Robbins, personal communication, August 13, 2013). It is helpful to let patients determine how much reassurance they are going to get— or as sometimes stated in session—to let them decide the speed of their detox regime. Sometimes it is surprisingly easy. The patient who texted everyone immediately after any disagreement to apologize in case she upset them, agreed to wait one hour before texting. The next session she triumphantly reported that it was far easier than expected, several times she forgot about texting, and, one time, someone actually texted her to apologize—something that she couldn’t remember ever happening!

References Gray, J. A. and McNaughton, N. (2003) The neuropsychology of anxiety. An enquiry into the functions of the septo-hippocampal system . New York, NY: Oxford University Press. Rosenbaum, J. F., Pollock, R. A., Jordan, S. K., and Pollack, M. H. (1996) The pharmacotherapy of panic disorder. Bulletin of the Menninger Clinic 60(2 Suppl. A) A54–75. Weekes, C. (1976) Simple, effective treatment of agoraphobia . New York, NY: Hawthorne Books. Downloaded by [New York University] at 01:46 15 August 2016 13 Some Hard to Treat Problems A New Perspective

Illness Worries (Health Anxiety and Hypochondria) Many anxious people focus their anxiety on their There are three distinct health. As with other situations in which there can be kinds of illness worries no guarantees or certainty, having something wrong requiring three different with their own (or a loved one’s) body can become treatment approaches. a full-time preoccupation. There are three distinct kinds of illness worries requiring three different treatment approaches.

Undiagnosed Panic Disorder In undiagnosed panic disorder, patients worry that their dramatic physical symptoms cannot possibly just be due to anxiety and they turn up in emergency rooms (ERs) while hyperventilating, with chest pain, and fearing they are in the middle of a heart attack, stroke, or some other catastrophic medical event. The fact that they had a recent medical work-up following a previous ER visit does little to convince them that this time it really is not an emergency. Unfortunately, these patients are often discharged from the hospital with many dire illnesses ruled out, but nothing specifi c ruled in. Sometimes an exotic (and highly unlikely) medical condition is mentioned, thereby starting another round of anxieties, panic attacks, and emergency room visits. What is most problematic is that often they receive no guidance as to how to seek specifi c help: they are diagnosed with “atypical chest pain” or “anxiety,” but no positive diagnosis in a helpful form, e.g., “You have panic disorder, which is not dangerous, mimics heart attacks and is highly treat- Downloaded by [New York University] at 01:46 15 August 2016 able,” along with a referral to a specialist. Otherwise, the patient is likely to be back to an ER, and may very well engage in the “million dollar workup” designed to rule everything out without necessarily coming up with a defi nitive diagnosis. 1

Obsessive-compulsive Disorder In obsessive-compulsive disorder (OCD), patients with what has been called “health anxiety” may become overwhelmed with the responsibility to keep themselves or loved ones healthy. These people are often mistakenly called “germophobic,” although this is actually OCD rather than a simple phobia. In this case, the patient tries to avoid all Some Hard to Treat Problems 177 possible contaminants, exposure to germs, and people who might be ill. These are the people who develop washing and cleaning compulsions, who use paper towels to open restroom doors and won’t sit down on toilets, who avoid friends with colds, who carry around antibacterial wipes and lotions, and who keep their children from touching rail- ings in public places. These are the people who see the world as full of danger to their health: they avidly follow the news of possible toxic substances such as outgassing furniture and X-ray dangers in airports. They are likely to eat only organic foods. They worry about and try to avoid anything that has the slightest chance of causing illness. Even when the science is poor and the sources of information are questionable or incorrect (i.e., the dangers of childhood vaccinations), these patients prefer avoidance to taking any risks with health issues. They are often phobic of medication side effects. They may see themselves as living a holistic or natural lifestyle, but beneath the surface is the larger problem of being unable to assess health risks rationally. They might ﬁ nd themselves cleaning the kitchen for a second time after having had a “doubt” about whether or not the sponge itself was clean enough; they might be stuck in the bathroom washing themselves; they develop food allergy fears and food avoidances because they had a mildly runny nose after a meal; they don’t shake hands because it is unsanitary. This is about preventing illness and the impossible quest of being certain that one has done everything possible to protect one’s own and loved ones’ health.

Hypochondria In hypochondria, the issue is a conviction that one is or might be ill, and there is an endless search to afﬁ rm, diagnose, and treat that illness. Intolerance of uncertainty is the issue here. People say things like “I would rather know I have cancer than be told I might have cancer.” These patients are vigilantly looking for signs and symptoms of illness: “Can this spot be cancer?”, “Does this funny sensation in my chest indicate heart disease?”, “Is this a lump that needs to be biopsied?” They often check their blood pressure and pulse regularly; they ask for blood and imaging tests frequently; they check the internet on multiple sites about a variety of illnesses no matter how esoteric; they bring articles from magazines and websites to their doctors; they join online support groups of patients with questionable conditions; they own their own medical books. Frequently the sensations they have are quite real but the error is in thinking they are important. For example, everyone has minor aches and pains which, if left to benign neglect, go away on their own or wax and wane with the passage of time. They are not indications of a more serious problem. Some-

Downloaded by [New York University] at 01:46 15 August 2016 times there are sensory obsessions (“Do I have too much or too little saliva?”, “Does my swallowing feel right?”, “Is my erection weaker?”). The illusion here is that checking will eventually provide an answer to settle the question and remove uncertainty. In fact, checking invariably raises new questions, and works only very temporarily to provide any relief. And, of course, it is possible for one to be both hypochondriacal and also actually sick.

Scrupulosity (Religious and Secular) The Catholic Church has recognized scrupulosity (Abata, 1976) for centuries. It is a form of excessive religious observance that is pathological and destructive, and is based on a fundamental misunderstanding of what religious practice is intended to be (Ciarrocchi, 178 Some Hard to Treat Problems 1995). Scrupulosity is a form of OCD that is expressed in religious or secular versions (often described as “overblown conscience”). The sufferer becomes obsessed with unanswerable questions about life, death, God, morality, right and wrong, and trying to be a “good person.” This is fi ltered through a perfectionistic, thought–action fusion, all-or-nothing context in which being good is never being good enough, being holy is never perfectly holy, being observant is not being done with the right thoughts and feelings, and altruism is impossible because it gives pleasure. There is a frightening and hopeless quest for certainty about going to heaven rather than hell, or pleasing God, or never harming another soul—even inadvertently—that dominates their life and overwhelms the patient. People with scrupulosity are horrifi ed by uncertainty about their own motives, beliefs, and actions. They may be stuck in praying compulsions, frozen in place by unwillingness to inadvertently do something bad or wrong. They may ask a thousand questions that sound philosophical but are actually a compulsive attempt to “nail down the answers” to inherently complex and unanswerable questions. Examples of secular scrupulosity include (1) the patient who must travel back throughout his day to every place he visited to fi nd out where to return the pencil he accidentally stole, (2) the patient who spends many hours each day looking for homeless people to give money, and is constantly haunted by thoughts that he did not give enough and he might have missed someone, (3) the patient who cannot say no to anyone who makes any request because it would be wrong to refuse a favor if it is within her power to grant it. Religious scrupulosity is not just profound religion. It is an obsessive-compulsive distortion of religious teachings. It gives none of the peace and joy that true religious observance provides. It is not about following a good life guided by good values. People with scrupulosity Religious scrupulosity is do not feel closer to God, they are constantly ques- not just profound religion. tioning whether they have displeased, disobeyed, or It is an OCD distortion of become alienated from God. Treatment may need to religious teachings and involve a well-informed member of the clergy to help gives none of the peace the patient see the difference between scrupulosity and joy that true religious and true religion. Interestingly, more and more clergy observance provides. are becoming aware of this issue, and make appropriate referrals to treatment specialists.

Emetophobia (Fear of Vomiting)

Downloaded by [New York University] at 01:46 15 August 2016 Emetophobia (Boschen, 2007) is the term given to fear of vomiting. While it would appear on the surface to be a relatively straightforward speciﬁ c phobia, in reality this is not the case. Fear of vomiting can result from a number of different underlying fears: for some, the loss of control—and the physical sensations of vomiting—provides the horror. For others, the fears are primarily in the interpersonal sphere and involve humiliation and enduring the disgust or pity of others. For some there are intrusive memories of traumatic experiences involving vomiting or feelings of nausea. While early sexual abuse has been reported, data suggest it is much more common to have been raised by an anxious parent who was also afraid of vomiting (Christie, 2011). For others, there are no memories in particular, and there may not have been an actual episode of vomiting for many, many years. A great many of these people avoid crowds, friends, or family who Some Hard to Treat Problems 179 might be sick, avoid shaking hands, and can look very much like health anxiety sufferers. Others simply become panicky when they themselves feel nausea or have anticipatory anxiety with vague gastrointestinal sensations. Female sufferers often put off having children because of the fear of morning sickness. Treating emetophobia effectively requires an exposure-based regimen with considerable repetition—and a willingness on the part of the patient to risk nausea and possibly vomiting along the way. Deliberately inducing vomiting by using ipecac has been suggested by some but is deﬁ nitely not recommended, and can be a dangerous route. In fact, it is far more important to experience Emetophobics need to the risk of possibly vomiting than vomiting itself, and experience the risk of learn how to tolerate this risk, rather than force vom- possibly vomiting more iting in the hope of making it less awful. Motivational than vomiting itself. discussion (“what do you have to pay in order to not confront your fear?”) may need to be revisited often. Creative exposure tasks include a wide variety of YouTube videos, as well as making or purchasing and smelling fake vomit (there are some recipes involving over-ripe cheese that are readily available online). For those with interpersonally oriented fears, exposure tasks might involve going into a public bathroom stall and making vomiting noises when someone else is on the bathroom, as just one example.

Paruresis (Shy Bladder Syndrome) Shy bladder syndrome is defi ned as the inability to urinate in situations where one might be seen or heard doing so. It occurs in both men and women, but it is far more prevalent in men, likely due—at least to some extent—to the way public bathrooms in western cultures are designed and the differences in male and female anatomy. People with paruresis are not afraid of public bathrooms, they simply cannot use them. The requisite relaxation of musculature required to urinate does not occur. This sets up signifi cant avoidance behaviors and anticipatory anxiety surrounding activities with no accessible “safe” bathrooms. Trying harder to let go results in the paradoxical exacerbation of the problem (Soifer, Zgourides, Himle, and Pickerling, 2001). Paruresis can be mild—and handled with such “coping skills” as minor fl uid restric- tion, using stalls instead of urinals and what we classify as avoidances—e.g., going home from work at lunchtime to urinate. Or it can

Downloaded by [New York University] at 01:46 15 August 2016 be severely debilitating, resulting in highly restricted lives verging on being housebound. People with paru- Paruresis can be severely resis cannot take jobs where there is urine testing as debilitating. part of the application process. They suffer agonies in the military, prisons, and boarding schools. Long airplane ﬂ ights are sometimes impossible. Paruresis is usually accompanied by feelings of shame and secrecy, and patients may avoid dating and telling family members about their problem and why they are avoiding certain activities. Some have taught themselves how to self-catheterize to forestall medically dangerous situations. Until recently, most with shy bladder believed they were the only ones with such a problem. Fortunately, the IPA (International Paruresis Association) has a presence on the internet and is dedicated 180 Some Hard to Treat Problems to disseminating the latest information available about research, advocacy, and treatment options, the most effective of which is specialized cognitive behavior therapy. Currently, shy bladder syndrome is classiﬁ ed as a social anxiety disorder. It is common that people with paruresis do have a searing memory of a traumatic incident involving urination, and most frequently the disorder begins during the childhood or teenage years. Sometimes there are other aspects of social anxiety, but frequently the symptoms of the disorder stand alone. The exact physiological mechanisms involved in the disorder are not well understood.

Note

1 . The Anxiety and Depression Association of America (ADAA) produced a white paper on GAD (ADAA White Paper (2004) Improving the Diagnosis and Treatment of Generalized Anxiety Disorder: A Dialogue between Mental Health Professionals and Primary Care Physicians—Produced by Anxiety Disorders As- sociation of America, retrieved from www.adaa.org/sites/default/ﬁ les/FinalADAGADPaper.pdf ) with the recommendation that anxiety not be listed as a “rule out” diagnosis. That is, the recommendation was to change the current protocol of ﬁ rst investigating physical reasons for symptoms, and coming to the diagnosis of anxiety disorder only when every other cause is ruled out. The ADAA recommended that anxiety be ascertained in the same manner as other presenting problems.

References Abata, R. M. (1976) Helps for the scrupulous. Liguori, MO: Liguori Publications. Ciarrocchi, J. W. (1995) The doubting disease: Help for scrupulosity and religious compulsions. Mah- wah, NJ: Paulist Press. Boschen, M. J. (2007) Reconceptualizing emetophobia: A cognitive–behavioral formulation and research agenda Journal of Anxiety Disorders 21(3) 407–419. Christie, A. (2011) Emetophobia: Fear of Vomiting. Information for Professionals, Sufferers and their Families. Emetophobiahelp.org. Retrieved from www.emetophobiahelp.org/fact-sheet. html Soifer, S., Zgourides,G. D., Himle, J., and Pickerling, N.L. (2001) Shy bladder syndrome: Your step-by-step guide to overcoming paruresis . Oakland, CA: New Harbinger. Downloaded by [New York University] at 01:46 15 August 2016 14 Relapse Prevention

This chapter focuses on steps to ensure that recovery is enduring and that patients walk away from regular therapy appointments with what they need. We again address our deﬁ - nition of recovery, and the preventive work that should be done to identify leftover avoidance behaviors which can undermine the positive effects of treatment. Finally we answer the questions about the roles of exploratory psychotherapy and stress management.

Anxiety Disorders Are Chronic Intermittent Disorders: They Come Back Unless a person lives an unrealistically limited life in which no physical or emotional stressors occur—as well as any excitement or novelty or challenges or boredom—it is highly likely that symptoms of anxious arousal will recur at some point. Sometimes that is two weeks after stopping formal therapy, sometimes after two or even 20 years. When an intrusive unwanted bizarre We talk about not “if” but thought or a whoosh of panic or an urge to avoid sud- “when” symptoms come denly appears, it is most important that the patient back, and what to do and be prepared for and even expect such an event. Oth- how to embrace it when erwise, there may ensue terrible demoralization (“I that happens. thought I was better!”) or shame (“I guess I am just a loser”) or anger (“I was sold a bill of goods, this stuff does not work!”). This is why we talk about not “if” symptoms return, but “when,” and what to do and how to embrace it when that happens. This form of inoculation will be invaluable in the future. We also look at relapse prevention as a lifestyle effort. It makes no sense at all for Downloaded by [New York University] at 01:46 15 August 2016 people to say “I have learned to exercise so being sedentary is no longer a problem for me,” unless they include what they learn into their day to day life. The same can be said with weight control. Knowing healthy eating has little beneﬁ t unless people integrate what they know into everyday life. This is especially relevant for people with a history of substance abuse. It accounts for the remarkable popularity—and relatively high success rates—of the 12-step method groups. If we take this argument to a more explicitly medical context, diabetes is a chronic disorder that requires lifestyle changes and ongoing maintenance and attention to delay the progression of associated medical issues. Lifestyle change in the context of anxiety disorders does not mean to avoid stress: it means pay regular attention to those physical and emotional factors which tend to make one sensitized and vulnerable to setbacks and re-emergence of symptoms. However, 182 Relapse Prevention even if one is diligent about lifestyle changes, there will be times when symptoms return and the attitude towards this occurrence will be of utmost importance, determining whether the return of symptoms is short-lived and simple—or plummets into relapse, avoidance behavior, and feelings of demoralization.

The Most Enduring Recovery Is When Symptoms Do Not Matter There are two different kinds of “getting better” which are distinctly different in their resilience in the face of ongoing stressors. The fi rst is a state of relief in which symptoms are “controlled” or “managed” or “limited” by expanded territorial boundaries, “coping skills,” sub- Anxiety “managed” tle avoidance behaviors, or compromises and “set- or “controlled” is an tling” for some limitations. These are people who incomplete recovery. can go “anywhere” within the state now, but could not imagine taking a trip overseas, or people who can now touch the handles on the taps in a public toilet but could “never” touch the bottom of their shoes, or who can manage to speak at a small meeting at work but refuse promotions that involve public speaking because that would be too much. Often these incomplete recoveries are huge improvements in the lives of these patients—and frequently they want to stop when the essentials of their lives are do-able without signifi cant distress. They are willing to forgo unessential challenges in order not to experience the dread and misery and self-doubts involved in expanding beyond their current limitations. They are so happy to be able to grocery shop on their own in the neighborhood that they cannot imagine why it is important to shop anywhere else. Even though they are afraid to enter the subway, there are buses and cars they can ride now, so why, they ask, should they even worry about the subway? The answer is that, although their lives are much improved, what has happened is that they have gained confi dence not in their ability to handle, live with, or embrace anxiety but only the confi dence that anxiety is no longer likely to occur in that particular situation or circumstance. This kind of confi dence is likely to shatter when anxiety does happen to occur “Confi dence” that in a previously deemed “safe” circumstance or while anxiety won’t happen is doing something previously mastered. shattered when it occurs What is missing is that the relationship to anxi- in a previously “mastered” ety itself has not changed. Anxiety is still dreaded and

Downloaded by [New York University] at 01:46 15 August 2016 circumstance. avoided and feared. Effort is still being expended in arranging circumstances to minimize anxiety and there is still a concept that there is something like “too much” anxiety or unacceptable levels of anxiety. What is missing is that In the long run, if the occurrence of anxiety symp- the relationship to anxiety toms is not acknowledged as one of the natural con- has not changed. sequences of living in a human body with mental and physical manifestations of arousal, then the vulnerability to relapse is increased. If the attitudinal shift we have been addressing has not occurred—even if the patient is currently signifi cantly less anxious—than the next time they are sensitized and an anxious symptom pops up, there will not be acceptance or curiosity, but fear. Relapse Prevention 183 Search and Destroy: The Role of Subtle Avoidance If we return to the basic concept that anxiety is maintained by avoidance, it makes sense to examine the role of avoidance throughout the entire process of therapy, including the patient’s avoidances when ready to end regular appointments. Let’s look at our fi rst type of recovery, where symptoms are managed and controlled, and the patient has made undeniable progress in expanding safety zones and reducing suffering. Still, there is signifi cant avoidance, either because these patients lack the means or the motivation to continue with gains, or because they relish the opportunity to live with less anxiety in their day to day life. But they have not yet gained the most essential aspect to overcoming an anxiety disorder—the ability and willingness to embrace anxious feelings and so become less fearful of them. People who leave therapy with this type of recovery have a higher probability of relapsing. But sometimes avoidance is not so obvious, and the assumption is that a patient leaves therapy with an altered attitude towards symptoms. But we can be wrong, because our patient has learned to control and avoid anxious feelings with numerous small, subtle, and often hidden, methods of avoidance. And we won’t know about them unless we ask direct specifi c questions about the patient’s experience during these times. Sometimes patients themselves aren’t aware that they are avoiding, and sometimes they are aware but consider them trivial. As discussed in Chapter 6, some of these subtle avoidances are conceptualized as “coping skills” by patients and they are loathe to give them up. Some are rationalized, like the always present bottle of water or the light-hearted distracting conversation designed to keep from noticing any signs of anxiety. All of them, however, prolong the experience of anxiety and create vulnerability to relapse. This is a process we call “search and destroy,” because the goal is to help the patient focus on methods of avoidance and then systematically eliminate them. Ask a patient to make a list of any avoidant thoughts, behaviors, or rituals in which he fi nds himself engaging. One patient, who had previously avoided elevators, found that he systematically looked up at the display whenever he walked into the elevator, stood at “Search and destroy” the front near the elevator buttons, and turned his keys focuses on eliminating around in his hand as he rode. He reported that he felt avoidances that remain. no anxiety, but experienced some unpleasant emotions when he intentionally stopped these activities. Another patient with social anxiety disorder, who formerly was unable to speak to groups of people larger than two or three, comfortably presented to groups of 20 or more Downloaded by [New York University] at 01:46 15 August 2016 on a regular—almost daily—basis. Yet she said that she was never able to look into the eyes of men who were listening to her (as opposed to women), nor at much younger women. Her “search and destroy” avoidances were numerous and fi lled three sheets of yellow paper.

The Role of Psychotherapy in Relapse Prevention Sensitization describes an overall level of nervous system arousal that makes it more likely to experience both physical arousal symptoms—such as muscle tension and increased heart rate, and mental symptoms—such as worry thoughts and hypervigilance. It can take considerable exploration and observation for each person to fi gure out their particular sensitivities—over and above the ordinary stressors that affect all of us, 184 Relapse Prevention which include sleep deprivation, over-caffeinating, the day after alcohol intake, and feeling stuck in a quandary about something important. Here is where exploratory psychotherapy fi ts: it is an opportunity to discover and work on the patient’s Exploratory sensitizing issues and vulnerabilities. Some typical psychotherapy is an sensitizers are often found in anxious patients, and opportunity to discover here we are probably venturing on familiar territory. and work on the patient’s So, for example, patients with poor assertiveness sensitizing issues and skills and fears of anger, confrontation, or interper- vulnerabilities. It is sonal confl ict may learn that the reappearance of relapse prevention. anxiety may indicate a need to address an interpersonal confl ict—either internally facing how they feel or actually confronting the issue behaviorally. Other typical anxiety-sensitizing issues include an over-valuation of stoicism, for example. Patients often attribute acting strong, independent, or mature with being unemotional and may try to suppress or avoid their emotional experiences, because they are ashamed of them as well as fear them. Thus, feeling sad, helpless, or humiliated may be avoided, leading to patterns of behavior which may be interpersonally destructive, life-limiting, or sensitizing in and of themselves. It is common for people to have early memories of separation anxiety (or separation guilt) and many anxious people are at the least ambivalent about being alone, both alone at any given time, and also alone in the world. Most people with anxiety disorders were raised by people with anxiety disorders. It is therefore often fruitful to explore the messages about the world that were taught and demonstrated by one or both anxious parents. It is often illuminating for patients at this phase of treatment to re-examine long-held beliefs about risk, relationships, safety, morality, and emotions. How they view the contents of their minds and how they make decisions about proceeding in the world may well have vestiges of anxious teachings by anxious parents. These are all well worth examining. It is also the case that people with a lot of generalized anxiety and worry tend to be caretakers, overly nurturing, and have trouble with over-empathic permeable interpersonal boundaries. These issues identifi ed as sensitizing can be addressed and explored with whatever psychotherapy interventions you fi nd effective. We wish to be clear: it may well be that exploration of childhood schema, or gestalt two-chair techniques, or internal family system therapies will be enormously helpful at this phase of treatment. By now, the patient has developed the capacity to tolerate feelings that may be evoked by

Downloaded by [New York University] at 01:46 15 August 2016 such work. He is less afraid to be uncomfortable, and he is no longer basing his decisions about what to do and what not to do based primarily on how anxious he feels. He is no longer ruled by a fear of fear, and is ready to approach the triggers and issues which set him up for periods of increased arousal. He is ready to approach living freely according to his values.

The Proper Place for Stress Management Sensitized bodies and minds can certainly benefi t from efforts aimed at directly reducing the overall level of arousal. The problem with stress management strategies as presented in health magazines and popular press is that they are not suffi cient for dealing with Relapse Prevention 185 full-fl edged anxiety disorder symptoms. Anxiety disorders are stress-sensitive disorders: they are not caused by stress. They are not conquered by effortful attempts to banish stress. It is not uncommon to fi nd someone with generalized anxiety and constant worrying to be exercising for hours each day, eating “healthy” in every possible way, following advice to take “me-time” away from the kids, putting aromatherapy products in the bath and sleeping on a magnetic mattress—and nothing seems to help. All that effort at stress management only serves to prove that the situation is hopeless or more serious or unfi xable. It can be extraordinarily demoralizing. Proper stress management requires that we address the two issues of timing and attitude. Introducing stress management at the beginning of treatment before the patient has understood the limits of what to expect will be counter-productive. If, every time a panic-disordered patient begins to feel anxious, she goes out for a run in order to calm down, she will be using exercise as a fi ghting tool that will eventually backfi re. If, on the other hand, a patient learns that going for a run every morning lowers the overall tendency of his obsessive-compulsive disorder to rapid-fi re intrusive doubt thoughts at him, that can be helpful. If stress-reducing changes in lifestyle are to be undertaken in a helpful way, they should be regular, unlinked to how a person feels at the time, and routine. They should be aimed at reducing overall levels of sensitization, not at getting rid of particular symptoms at a particular time. They are a long-term project, not a quick fi x. In the same way, any other healthy living endeavors—whether it be engaging in a hobby, going to church, or learning to say “no” to excessive requests from others—these If stress-reducing changes changes in lifestyle, these kinds of stress management, in lifestyle are undertaken should not be constantly evaluated to see if they are in a helpful way, they working to eliminate symptoms of arousal. It can also should be regular and be helpful to take a look at time management issues routine, unlinked to how a as part of stress management strategies, since anxious person feels at the time. people tend to have a diffi cult relationship with time in general. It can be helpful to pay attention to sleep hygiene and exercise routines and spiritual practice and the nurturing of healthy relationships. It can be helpful to resolve any ongoing issues which tend to arouse anger or frustration—or to make peace with unresolvable ongoing frustrations. However, a very important point needs to be made regarding what stress management is and is not. It cannot be emphasized enough that proper stress management does not mean “avoid stress” so that every time one feels stressed, back away. People

Downloaded by [New York University] at 01:46 15 August 2016 often confuse the term stress with the appearance of anxious thoughts or sensations. Stress management most certainly does not mean “stay away from situations that feel stressful.” This is a formula for avoidance behavior and for devel- Stress management opment of generalizing phobic patterns. It is exactly certainly does not mean the wrong message. We are trying to convey that it “stay away from situations is okay—not dangerous—but helpful to expect and that feel stressful.” allow anxiety and to approach situations and internal experiences which produce anxiety. So it is easy to see why stress management suggestions at the very beginning of treatment can contain very confusing messages, and why they belong in the relapse prevention phase of treatment. 186 Relapse Prevention Finally Even if you do everything right, sensitized bodies take some time to wind down. Long after panic attacks have become rare, anticipatory anxiety will launch itself. There is no protection against random uninvited thoughts. The world will contain reminders and challenges and novel situations and triggers. When the anxious person has managed to overcome his fear, shame, and aversion to doubts, memories, sensations, and thoughts— when anxiety symptoms no longer mean anything bad, no longer carry a danger message, and no longer determine how to act—that is the best inoculation against relapse prevention. There will always be issues to explore and curiosity about oneself, and these are legitimate and meaningful activities whenever someone wants to pursue ways to grow and change, including the self-examination of dynamic psychotherapy. So long as insight- oriented therapy is not framed as getting rid of anxiety by analyzing it away, then by all means, proceed! Downloaded by [New York University] at 01:46 15 August 2016 Appendix 1

Additional Metaphors

Chinese Finger Trap We have all seen the children’s “trick” toy. It is a cylinder made of woven bamboo with holes at both ends just big enough to insert a ﬁ nger into each. Once you do, however, as you try to pull them out, the tube elongates and traps your ﬁ ngers. The harder you pull, the more stuck you get. The key is to do the opposite of what seems right—push in, the tube expands, and pops off. That is same with anxiety. Do the opposite of what seems right.

Lean with the Motorcycle Have you ever been on the back of a motorcycle? You may have had the experience of going around a corner. As it does, it leans. The driver leans with the bike. He does not try to compensate for the natural tilt. You need to do that too, or you will fall off or topple the bike. It is counter-intuitive to lean with the leaning, but when you are anxious, go ahead and lean into your anxiety: lean into, not away from, your discomfort.

On Allowing Anxious Intrusion One patient found a wonderful way to deal with depersonalization, which she frequently experienced when shopping in ﬂ uorescent-lit stores. She imagined a baseball cap stuck to her head with a rubber ball on an elastic hanging from the brim. While she could easily see around the bouncing ball, it was always somewhere visible. She learned to shop while aware of the ball but doing nothing at all to try to remove the cap. In fact, she Downloaded by [New York University] at 01:46 15 August 2016 began to welcome the arrival of the imagined cap as it reminded her to accept the presence of her anxiety symptom and go about her shopping anyway.

On Accepting Panic Sensations You are driving in a car which is rather strange because it is constructed like the human body. It has a gas pedal but no brakes. You are on a straightaway in the middle of the country on a fl at road with no traffi c and no ditches. You are going 55 mph. You decide you want to stop and rest for a while. You reach for the brakes and can’t fi nd them. You then get frantic, scrambling all over the car trying everything to see if it might be 188 Appendix 1: Additional Metaphors the brakes. Accidentally, you keep hitting the gas while you panic. Then you realize the only thing you can do is just take your foot off the gas and the car drifts to a stop—not immediately, but when it runs out of fuel. Meanwhile you just have to let time pass and coast to a stop with it.

The Whack -a-mole Game This refers to the carnival game whack-a-mole. When the game starts, fake-fur “moles” pop up and down in a random pattern from an array of holes in the game board. Your job is to whack the moles with a large soft bat before they disappear. The more you whack, the more points you get. And if you do it better than everyone else, you get a huge stuffed animal. You are competitive. You are good at this, and your reaction time is really fast. This time however, the game starts, you pick up your bat—and realize to your dismay that it is tied to the board with a two-inch cord, and there is no way to reach the moles. All you can do it watch them pop up and down until the round is over. You score zero. You can struggle and curse and complain, or you can laugh. It is your choice. It can be unfair and your dollar was wasted, or it can be absurd. Once again, it is your choice. You can choose how you react to the situation, but the length of the cord is out of your control. Downloaded by [New York University] at 01:46 15 August 2016 Appendix 2 A Summary of the Labeling Process That Can Be Given to Patients

1. With feelings of terror, the fi rst task is to try to label the feeling as anxiety, as opposed to danger. This labeling is very important, because anxiety is addressed in a totally different manner than danger. 2. The decision is diffi cult because there is no way to use feelings to help make a decision. Remember that the terror associated with real danger is exactly the same as the terror felt when experiencing anxiety. Feelings cannot help with this decision. It requires thinking, and relying on facts about anxious arousal. 3. Anxiety makes the thoughts feel like they are very likely to happen. This is the distortion caused by anxious thinking. Demanding certainty eliminates the possibility of progress, because certainty is not possible. Remember that certainty is a feeling and not a fact. So it might feel risky to label these feelings as discomfort and not true danger. This will be a leap of faith. 4. Even if the choice is to follow what anxious thoughts are saying, and you fl ee to avoid the feelings, they can still be labeled as anxiety. The eventual goal is to label the distress as anxiety, not to dignify it with a response, and therefore disengage from it. That is the beginning of de-fusion from anxious triggers. Downloaded by [New York University] at 01:46 15 August 2016 Appendix 3 How to Learn Diaphragmatic Breathing

Like any skill, learning to breathe with the diaphragm takes practice. Good times to practice are before going to sleep and upon waking up, although any time when patients have a few minutes and a place to lie down will work. Each practice should be only a few minutes in length, so it is best to practice several times a day. Wear clothing that won’t constrict waist movements. Lie down on the back. Start by placing the right hand on the abdomen, so that the palm of the hand is right over the belly button. Place the left hand on the chest. While breathing in, imagine that the air is bypassing the chest and moving directly into the abdomen, fi lling the stomach with breath. The right hand should rise with the inhalation and fall with the exhalation. Ask patients to try to make it so that their left hand hardly moves at all. It is best to breathe in through the nose and out through the mouth. While breathing in, some people are helped with image of turning the belly into an infl ating and defl ating balloon. If patients are having diffi culty getting air into their belly, it often helps to place a rolled- up towel under the small of the back.

Make Exhalations Longer Than Inhalations Relaxations are encouraged if exhalations are slightly longer than inhalations. There is a physiological reason for this. Inhalations stimulate the sympathetic nervous system, which is the part of the nervous system that speeds things up. Exhaling, on the other hand, stimulates the parasympathetic nervous system, the portion of the nervous system that slows things down. So spending more time breathing out than in tends to slow things down.

Downloaded by [New York University] at 01:46 15 August 2016 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 “fi ve.” The specifi c 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 fi ll 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 Appendix 3: How to Learn Diaphragmatic Breathing 191 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 fi nd a comfortable rhythm that feels natural. Once diaphragmatic breathing becomes ingrained, patients will start to breathe easily, without any effort. Downloaded by [New York University] at 01:46 15 August 2016 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 Date and Time Anxiety level (0–10) Anxious thought(s) Context Downloaded by [New York University] at 01:46 15 August 2016

Index

acceptance 37 – 52 ; approaching anxiety 14 ; labeling anxiety 48 – 50; out-bluffi ng mindfully 38 – 9; embracing anxiety 39 – 41; 8 ; paradoxical nature of 34 – 5 , 37 , 40 ; essential elements 47 – 52; exposure 115 , phenomenology of 31 – 4 ; as a positive 116 ; the new paradigm 61 ; overview learning experience 108; providing 37 – 8; role of the therapist 42 – 4; teaching information and answering questions 63 – 4 ; metaphors 45 – 7 role of amygdala in sensitization 25 , 26 ; and acceptance and commitment therapy (ACT) sensitivity 15 51 , 80 Anxiety and Depression Association of “accepting panic sensations” metaphor 187 – 8 America (ADAA) 180 actively allowing anxiety 51 – 2 “Anxiety channel” metaphor 46 addressing the relevant fears 106 – 7 anxiety diary 87 , 192 adrenaline 23 , 41 anxiety disorders: advances in treatment 3 ; affect intolerance 20 – 1, 84 anxiety and anxiety disorders 8 – 9; anxiety affi rmations 70 feels dangerous 7 – 8; avoidance, resistance, age of onset 18 , 91 , 101 neutralization 30 – 1; the basics 7 – 14; agitation 56 , 133 , 134 causation 15 – 16; cause versus maintenance agoraphobia 85 , 92 , 103 , 114 16 – 17; characteristics of highly anxious alcohol use 47 , 95 , 97 , 148 , 152 people 7 ; common sense makes no sense alexithymia 21 , 163 34 ; consequences of affect intolerance Allen, Robert 105 20 – 1; contemporary view 15 – 36; defi ning allowing anxiety 51 – 2 , 73 – 4 aspects 13 ; diagnoses 89 – 104 ; dilemma of “allowing anxious intrusion” metaphor 187 insight 19 – 20 ; direct approach to treatment “allow the ant” metaphor 47 22 – 3; fear-maintaining cycle 29 – 30; getting amnesia 57 , 86 started 53 – 66; identifying and treating amygdala: acceptance 40 , 42 , 51 ; characteristics avoidance 14 ; illness worries 176 – 7 ; of highly anxious people 7 ; exposure overview 3 – 4 ; the paradoxical attitude 115 , 116 ; fear-maintaining cycle 29 , 30 ; 34 – 5 ; phenomenology of anxiety 31 – 4 ; neuroscience of affect 35 ; perfectionism 78 ; primary and secondary gains 17 ; relapse

Downloaded by [New York University] at 01:46 15 August 2016 role in sensitization 23 – 8; worry 129 prevention 181 – 6 ; role of amygdala in animal phobias 89 , 91 sensitization 23 – 8; role of techniques 5 – 6; answering questions 63 – 6 scrupulosity 177 – 8 ; sensitivity and anxiety anticipatory anxiety 113 , 118 , 125 , 167 – 71, 15 ; studies on causation 17 – 19; symptoms 186 4 ; techniques 67 – 88 ; therapeutic attitude of anxiety: acceptance 47 – 52 ; actively allowing acceptance 37 – 52; types of triggers 9 – 13; anxiety 51 – 2 ; anxiety and anxiety disorders value of exposure 28 – 9 ; value of talking 8 – 9 ; anxiety-raising and anxiety-lowering about symptoms 21 – 2; why details make a thoughts 130 – 1; and danger 4 , 7 – 8, 117 ; difference 1 – 6 defi ning aspects of anxiety disorders 13 ; anxiety sensitivity: acceptance 41 , 42 , 47 ; expecting anxiety 47 – 8 , 73 – 4 ; exposure anxiety and anxiety disorders 3 , 9 , 13 ; 108 , 117 ; identifying and treating avoidance dilemma of insight 20 ; fi rst and second 194 Index fear 25 ; getting your feelings out 163 ; childrearing 18 , 72 hypersensitivity 33 ; sensitivity and anxiety “Chinese fi nger trap” metaphor 187 15 ; unwanted intrusive thoughts 147 circadian rhythm 148 “anxious arousal as a gust of wind” metaphor Clark, D.A. 144 47 classic pitfalls 156 – 65; getting your feelings appraisal of thoughts 145 – 6 out 162 – 3 ; misdiagnosing OCD thoughts as arousal: acceptance 38 , 40 ; autonomic arousal a sexual issue 160 – 2 ; mistakes in exposure- 20 , 21 ; fear-maintaining cycle 29 , 30 ; role based treatment 164 – 5; pathological doubt of amygdala in sensitization 23 , 25 , 26 , 28 ; OCD 158 – 60 ; turning the causation arrow value of talking about symptoms 21 around 156 – 8 assessment 54 – 6, 118 claustrophobia 11 , 14 , 56 , 90 , 167 autonomic arousal 20 , 21 cleaning rituals: diagnoses 95 , 96 , 100 ; autonomic nervous system 34 exposure 109 , 110 , 114 , 118 , 119 ; illness aviophobia (fear of fl ying) 2 , 102 , 114 worries 176 – 7 avoidance: anxiety and danger 8 ; anxiety co-compulsing 132 , 159 – 60 maintenance 4 ; avoidance, resistance, Coelho, Paolo 167 neutralization 30 – 1; depression 100 ; coffee 19 , 124 determining patient progress 85 ; direct cognitive avoidance 110 , 111 approach to treatment 22 ; emotional and cognitive-behavioral therapies (CBTs) 3 , 99 , behavioral avoidance 146 – 7; exposure 180 105 , 106 , 109 – 11, 114 , 121 ; identifying and cognitive compulsions 2 , 60 , 81 , 98 , 120 – 1, treating 14 ; phenomenology of anxiety 34; 131 , 158 previous coping skills 60 ; reducing 141 ; cognitive rituals 111 relapse prevention 183 , 185 common sense 34 competence-enhancing skills 80 – 1 behavioral activation 142 complete avoidance 111 Behavioral Inhibition 18 compulsions: diagnoses 95 , 96 – 7, 100 ; behavior therapy 60 exposure 119 , 120 ; getting the details 57 ; beliefs about thoughts 147 reassurance junkies 173; unwanted intrusive benzodiazepines 72 , 168 thoughts 153 ; worry 131 BFRBs (body-focused repetitive behaviors) 97 compulsive gambling 57 , 97 biological fear pathways 23 – 8, 42 , 112 , 122 consciousness 31 – 4 bipolar disorder 84 , 133 constricted affect 163 blood – injury phobias 57 , 89 , 91 contamination, fear of 11 , 57 , 95 , 176 – 7 body dysmorphic disorder 97 contemporary view of anxiety disorders body-focused repetitive behaviors (BFRBs) 97 15 – 36 ; avoidance, resistance, neutralization Borkovec, T.D. 138 30 – 1; causation 15 – 16; cause versus breathing techniques: diaphragmatic breathing maintenance 16 – 17 ; common sense 81 – 4, 190 – 1; embracing anxiety 40 ; home makes no sense 34 ; consequences of affect practice 167 ; problems 69 , 81 intolerance 20 – 1 ; dilemma of insight bridge phobia 90 , 107 , 110 , 168 – 9 19 – 20; direct approach to treatment “bug on a windshield” metaphor 45 22 – 3; fear-maintaining cycle 29 – 30; the

Downloaded by [New York University] at 01:46 15 August 2016 paradoxical attitude 34 – 5 ; phenomenology caffeine 92 , 124 , 136 , 148 of anxiety 31 – 4 ; primary and secondary calculating probabilities 140 – 1 gains 17 ; role of amygdala in sensitization Carbonell, D. 51 , 76 , 79 , 139 23 – 8; sensitivity and anxiety 15 ; studies on catastrophic thoughts 7 , 29 , 30 , 32 , 133 causation 17 – 19 ; value of exposure 28 – 9 ; catharsis 156 , 162 value of talking about symptoms 21 – 2 causation: anxiety disorders 15 – 16; cause coping techniques: cases of real danger versus maintenance 16 – 17 ; studies on 84 ; determining patient progress 84 – 7; causation 17 – 19; turning the causation diaphragmatic breathing 81 – 4; effectiveness arrow around 156 – 8 of techniques 70 ; emergency coping 71 – 2 ; CBT see cognitive-behavioral therapies helpful techniques 73 – 81 ; previous coping chest breathing 82 , 83 skills 60 – 1 ; problems 68 , 69 , 81 ; reducing chest pain 49 , 64 , 176 avoidances 110 – 11 ; relapse prevention 182 , Index 195 183 ; techniques as temporary help 70 – 1; empty reassurance 173 – 4 worry strategies that don’t work 134 – 6 ; environmental factors 17 , 18 worry strategies that do work 136 – 42 environmental phobias 89 correcting basic misinformation 136 – 7 epinephrine (adrenaline) 23 , 41 cortex 24 , 25 , 26 , 27 , 28 , 35 ERP (exposure and response prevention) co-rumination 132 , 159 118 – 19 covert avoidances 110 – 11 evaluation anxiety 94 Craske, M.G. 112 excoriation (skin-picking) 97 crisis stabilization 84 exercise 81 , 134 , 185 expecting anxiety 47 – 8 , 73 – 4 danger: and anxiety 4 , 7 – 8 , 117 ; cases of real exposure 105 – 25 ; acceptance 42 ; addressing danger 84 ; fi rst and second fear 25 , 26 , 27 ; the relevant fears 106 – 7; anticipatory labeling anxiety 48 ; phenomenology of anxiety 170 ; anxiety and danger 8 ; in anxiety 32 , 34 ; unwanted intrusive thoughts diagnosis and assessment 118 ; direct 145 approach to treatment 22 ; essential elements DBT see dialectical behavior therapy 106 – 15; fi rst and second fear 28 ; in history demoralization 166 , 181 , 185 of psychotherapy 105 – 6 ; identifying and depersonalization 41 , 63 , 83 , 92 , 137 , 187 treating avoidance 14 ; incidental practice depression: cases of real danger 84 ; diagnoses 121 ; manageable steps 108 – 9 ; memory 95 , 98 , 99 , 102 ; resistance 166 ; unwanted aids 86 , 87 ; mistakes in exposure-based intrusive thoughts 148 ; worry 129 , 133 treatment 164 – 5; obsessive-compulsive derealization 41 , 63 , 83 , 92 , 137 disorder 118 – 21 ; the paradoxical attitude desensitization 112 , 124 35 ; planned practice 122 – 5; reducing determining patient progress 84 – 7 avoidances 109 – 11 ; reframing anxiety as a diagnoses 89 – 104; classic pitfalls 156 ; positive learning experience 108 ; the right exposure in diagnosis and assessment way to practice 121 – 5 ; role of the therapist 118 ; generalized anxiety disorder 100 – 1 ; 115 – 17 ; staying on the “right side of the obsessive-compulsive disorder 95 – 100 ; street” 113 – 15 ; suffi cient duration 111 – 13 ; panic disorder 92 – 3; social anxiety disorder supported exposure 86 ; unwanted intrusive 93 – 5 ; specifi c phobias 89 – 91; traumatic thoughts 154 – 5 ; value of 4 , 28 – 9 ; worry anxieties 101 – 3 strategies 138 – 9, 140 Diagnostic and Statistical Manual (DSM-5) xv, exposure and response prevention (ERP) xiv, 89 , 96 118 – 19 dialectical behavior therapy (DBT) 80 , 84 external triggers 15 , 91 , 113 , 114 , 115 diaphragmatic breathing 81 – 4, 190 – 1 diaries 87 , 192 “faintiness” 64 , 76 diet 39 , 128 , 134 , 136 fear: addressing the relevant fears 106 – 7 ; discipline principle 39 anxiety and anxiety disorders 8 – 9 ; anxiety distractions 32 – 3, 39 , 81 , 134 – 5, 141 , 146 and danger 4 , 7 – 8 , 117 ; autonomic arousal distress tolerance 72 , 84 , 123 , 166 20 , 21 ; biological fear pathways 23 – 8, 42 , diurnal cycle 148 112 , 122 ; characteristics of highly anxious dog phobia 89 , 91 people 7 ; diagnosis 3 ; facing the ultimate

Downloaded by [New York University] at 01:46 15 August 2016 doubts 98 , 158 – 60 fear 140 ; fear-extinguishing circuits 35 ; driving, fear of 56 , 81 , 84 , 94 , 113 , 121 , 122 fearful thoughts as predictive 34 ; fear- DSM-5 (Diagnostic and Statistical Manual) maintaining cycle 29 – 30, 69 ; fi rst fear 25 – 6 ; xiv, xv, 89 , 96 role of amygdala in sensitization 24 – 8 ; second fear 26 – 8; types of triggers 9 , 11 eating disorders 97 fear of fear 9 , 11 , 25 , 63 – 4 , 115 , 156 , 184 ego-dystonic worry 127 , 132 , 150 , 151 , 153 feelings: acceptance 37 , 50 ; common sense ego-syntonic worry 120 , 127 – 8, 131 , 132 , 150 34 ; dilemma of insight 19 – 20; getting your elevator phobia 89 , 90 , 109 , 110 , 121 , 123 , 167 feelings out 162 – 3; mindful labeling 74 ; embarrassment 28 , 93 , 94 , 106 , 107 types of triggers 9 – 11 emergency coping 71 – 2 , 84 fi ght, fl ight, or freeze reaction 23 , 48 , 73 emetophobia (fear of vomiting) 90 , 170 , 178 – 9 fi gure/ground relationship 79 – 80 emotions 19 – 20, 21 , 162 – 3 fi guring it out 134 , 136 196 Index fi rst fear 25 – 6, 40 , 50 , 107 illness worries 176 – 7 “fl oat” metaphor 45 impulse-control disorders 57 , 96 , 151 fl ying, fear of: diagnoses 1 – 2, 89 ; exposure incidental practice 121 , 125 110 , 114 – 15 ; phenomenology of anxiety 31 , indecision 169 34 ; resistance 168 , 171 ; traumatic anxieties information, providing 63 – 6 102 inhibitory model of exposure 112 , 122 freeze reaction 23 , 78 initial interview 54 – 60 Freud, Sigmund 106 , 153 , 162 injury phobia 57 , 89 , 91 future thinking 7 , 73 see also “what if” insight 16 – 17, 19 – 20, 58 , 132 , 134 , 136 , 156 thoughts internal triggers 15 , 91 , 113 , 114 , 115 interoceptive exposure 106 gambling 57 , 97 interview, initial 54 – 60 generalized anxiety disorder (GAD): intolerance of uncertainty 33 , 158 , 159 , 177 addressing the relevant fears 107; age of introspection 38 , 147 onset 18 ; diagnoses 89 , 100 – 1, 156 ; fear of intrusive thoughts see unwanted intrusive fl ying 2 ; fi rst and second fear 27; hard-to- thoughts treat problems 180 ; introducing the new ironic process of the mind 39 , 41 , 70 , 135 , 148 paradigm 62 ; observations 87 ; providing irritable bowel syndrome 101 information and answering questions 65 – 6 ; types of triggers 11 ; worry 126 , 129 , 131 journals 86 , 87 genetics 9 , 17 , 18 , 19 , 55 “just right OCD” (obsessive compulsive gentleness principle 39 disorder) 96 germs, fear of 1 – 2 , 56 , 70 , 75 , 90 , 121 , 176 – 7 Gestalt principles 80 Kabat-Zinn, Jon 39 “getting better” 182 “kids fi ghting in the rear seat” metaphor 46 getting the details 56 – 60 kleptomania (impulsive stealing) 57 , 96 , 97 getting your feelings out 162 – 3 Klonopin 168 goals 5 , 61 , 122 , 123 Grayson, J. 50 , 75 , 117 labeling anxiety: acceptance 47 , 48 – 50 ; guilt 96 , 133 , 156 – 7 exposure 116 – 17; fi rst and second fear “gun test” 50 , 75 , 117 25 – 6, 27 , 28 , 29 ; labeling level of distress gut feelings 34 117 ; mindful labeling 74 – 5; summary of labeling process 189 ; worry strategies 138 habituation 112 , 124 , 139 lateness 58 hair-pulling (trichotillomania) 97 Leahy, R. 130 HALT (hungry, angry, lonely, tired) 85 “lean with the motorcycle” metaphor 187 hand washing 14 , 96 , 97 life stresses 18 , 102 harming obsessions 150 – 3, 157 , 158 lifestyle change 134 , 136 , 181 – 2 “headache” metaphor 45 health anxiety 72 , 134 , 176 , 179 “magic feather” 67 – 8 heights, fear of 8 , 38 , 84 , 169 maintenance of anxiety disorders 16 – 17 history-taking 54 major depression 84 , 133 , 148

Downloaded by [New York University] at 01:46 15 August 2016 hoarding disorder 97 marijuana 92 home practice 166 – 7 marriage counselling 97 – 8 homosexuality 99 , 161 – 2 MBSR (mindfulness-based stress reduction) hope 53 – 4 80 hormones 148 medical procedures, fear of 91 hypersensitivity 33 medication 60 – 1, 130 , 141 , 148 hyperventilation 72 , 81 , 82 , 83 , 87 , 137 , 167 medulla 83 hypervigilance of the mind 148 memories 9 , 12 – 13, 28 , 29 – 30 hypochondria 177 memory aids 86 – 7 , 192 mental compulsions 95 , 120 “I am bigger than my thoughts” technique mental OCD (obsessive compulsive disorder) 79 – 80 99 , 119 – 21, 150 , 152 , 161 IFS (ill, fatigued, stressed) 85 mental reassurances 110 Index 197 metacognitive beliefs (beliefs about thoughts) paleocortex 35 147 panic attacks: acceptance 41 ; diagnoses 92 – 3, metaphors 45 – 7, 149 , 187 – 8 102 , 103 ; diaphragmatic breathing 83 ; fi rst meta-worry (worry about worry) 126 , 132 – 4 , and second fear 26 ; panic disorder 92 – 3 ; 137 providing information and answering mindfulness: acceptance 38 – 9, 43 , 44 , 48 ; “I questions 64 – 5; traumatic anxieties 102 , am bigger than my thoughts” technique 80 ; 103 ; types of triggers 12 , 13 mindful labeling 74 – 5; mindful sensory panic disorder: autonomic arousal 20 ; awareness 73 ; stress 86 ; worry exposure 139 causation studies 18 , 19 ; diagnoses 90 , mindfulness-based stress reduction (MBSR) 80 92 – 3, 156 ; exposure 106 , 107 , 109 , 114 ; fear- mini-avoidances 110 , 111 , 125 maintaining cycle 29 ; fear of fl ying 1 ; fi rst misdiagnoses 156 and second fear 26 ; getting the details 56, monitoring of the mind 148 57 ; illness worries 176 ; labeling anxiety 48 ; mood 148 types of triggers 10 , 11 motivation 117 panicogenic relaxation 44 motivational interviewing 80 paradoxical nature of anxiety 34 – 5, 37 , 76 – 7, muscular tension 43 – 4 134 parasympathetic nervous system 190 needles, fear of 57 parenting 17 , 18 , 22 , 184 nervous system 41 , 190 paruresis (“shy bladder syndrome”) 65 , 90 , 94 , neural pathways 23 – 8, 35 , 42 , 112 , 122 179 – 80 neutralization 30 – 1 , 69 , 110 , 114 , 121 pathological doubt OCD (obsessive new mothers 146 , 147 , 150 – 1, 157 , 158 compulsive disorder) 158 – 60 Niebuhr, Reinhold 43 patient progress 84 – 7 perceptual distortions 33 “the observer” 80 perfectionism 77 – 8 observing 43 – 4, 87 performance anxiety 80 , 94 obsessions: anxiety-raising and anxiety- personality disorder 84 lowering thoughts 131 ; diagnoses 95 , 98 , personality type 18 100 ; exposure 118 , 119 , 120 ; OCD 95 , 100 , phenomenology of anxiety 31 – 4 119 , 120 ; unwanted intrusive thoughts 153 , phobias: agoraphobia 85 , 92 , 103 , 114 ; animal 154 phobias 89 , 91 ; aviophobia (fear of fl ying) 2 , obsessive-compulsive disorder (OCD): age 102 , 114 ; blood – injury phobias 57 , 89 , 91 ; of onset 18 ; anxiety-raising and anxiety- claustrophobia 11 , 14 , 56 , 90 , 167 ; diagnoses lowering thoughts 131 ; causation of 89 – 91 , 100 , 156 ; emetophobia (fear of anxiety disorders 16 ; classic pitfalls 156 , vomiting) 90 , 170 , 178 – 9; exposure 105 – 6; 157 , 158 – 62; determining patient progress getting the details 56 ; phenomenology of 85 , 86 , 87 ; diagnoses 3 , 89 , 90 , 91 , 95 – 100, anxiety 34 ; specifi c phobias 89 – 91 , 107 ; 101 , 102 ; DSM-5 xv; exposure 107 , 109 , types of triggers 11, 12 114 , 118 – 21; fear-maintaining cycle 30 ; physical contact 116 fear of fl ying 2 ; fi rst and second fear 27; “picture in a picture” metaphor 46 getting started 56 , 57 , 58 , 65 ; helpful pitfalls 156 – 65

Downloaded by [New York University] at 01:46 15 August 2016 techniques 75 , 78 , 79 ; identifying and planned practice 122 – 5 treating avoidance 14 ; illness worries 176 – 7 ; playing with worry 139 intolerance of uncertainty 33 ; labeling “pop-ups on a computer” metaphor 46 anxiety 49 ; mental OCD 99 , 119 – 21, 150 , positive thoughts 70 , 134 , 135 152 , 161 ; misdiagnosing OCD thoughts as postpartum OCD (obsessive compulsive a sexual issue 160 – 2 ; pathological doubt disorder) 151 , 156 , 157 OCD 158 – 60; reassurance junkies 173 ; post-traumatic stress disorder (PTSD) 2, 101 , scrupulosity 178 ; types of triggers 11 , 12 ; 102 unwanted intrusive thoughts 152 , 153 , 154 ; prayer 135 , 141 value of talking about symptoms 21 pregnancy 22 onset age 18 , 91 , 101 premenstrual women 148 , 149 overblown conscience 96 , 158 , 178 primary gains 17 over-diagnosis 156 probabilities 140 – 1 198 Index productive worry 130 SAD see social anxiety disorder providing information 63 – 6 scheduling worry time 138 – 9 pseudoephedrine 148 scrupulosity 96 , 158 , 177 – 8 psycho-education 54 , 76 , 115 “search and destroy” process 183 psychosis xiv, 56 , 63 , 64 , 151 secondary gains 17 psychotherapy 16 , 21 , 105 – 6, 162 , 183 – 4, 186 second fear 26 – 8, 30 , 40 , 50 PTSD see post-traumatic stress disorder secular scrupulosity 96 , 158 , 177 – 8 PTSD coach 84 selective serotonin reuptake inhibitors (SSRIs) public restrooms, fear of 65 , 90 , 94 , 179 168 public speaking, fear of 19 , 57 , 121 , 167 self-discipline 39 Purdon, C. 145 self-gentleness 39 purely mental OCD (obsessive compulsive self-help 60 , 111 , 134 , 164 disorder) 99 , 119 – 21 , 150 , 152 , 161 self-reassurance 120 , 134 , 146 sensations: acceptance 38 , 43 , 44 ; determining questions, answering 63 – 6 patient progress 87 ; fear-maintaining cycle 29 – 30 ; fear of 92 , 94 ; mindful approach “raising the bar” syndrome 123 , 125 43 , 74 ; perceptual distortions 33 ; types of rational refutation 81 triggers 9 – 11 reasonable risks 32 sensitivity see anxiety sensitivity reassurance: acceptance 50 ; exposure 110 , sensitization: phenomenology of anxiety 119 , 164 ; OCD 95 , 119 ; reassurance junkies 31 ; relapse prevention 183 – 4 , 186 ; role of 171 – 5; unwanted intrusive thoughts 149 ; amygdala 23 – 8; sensitivity and anxiety 15 ; worry strategies 134 – 5, 141 studies on causation 19 recovery: goals for treatment 5 ; identifying separation anxiety 184 and treating avoidance 14 ; introducing serenity prayer 43 the new paradigm 61 ; relapse prevention sexuality 160 – 2 181 – 6 ; value of exposure 28 “shy bladder syndrome” (paruresis) 65 , 90 , 94 , reducing avoidance 141 179 – 80 reframing anxiety as a positive learning Sisemore, T. 115 experience 108 situational anxiety 168 , 169 refutation 146 situational phobias 89 , 90 relapse prevention 181 – 6 ; chronic intermittent skin-picking (excoriation) 97 disorders 181 – 2; overview 186 ; proper sleep 75 , 148 , 185 place for stress management 184 – 5 ; role slowing down to let time pass 78 – 9 of psychotherapy 183 – 4 ; role of subtle smartphones 86 , 139 avoidance 183 ; when symptoms do not social anxiety disorder (SAD): age of onset matter 182 18 ; autonomic arousal 21 ; determining relaxation 40 , 44 , 60 , 134 , 167 , 190 patient progress 87 ; diagnoses 90 , 93 – 5, religious scrupulosity 96 , 158 , 177 – 8 156 ; exposure 106 , 114 , 118 ; fear of ﬂ ying repression 162 1 ; ﬁ rst and second fear 28 ; getting started resilience 78 56 , 58 – 60, 65 ; helpful techniques 76 , 77 ; shy resistance 166 – 75; acceptance 38 , 41 , 51 ; bladder syndrome (paruresis) 180 ; types of

Downloaded by [New York University] at 01:46 15 August 2016 anticipatory anxiety 167 – 71; avoidance, triggers 11 , 12 resistance, neutralization 30 – 1 ; to home social skills 58 – 9 , 80 , 95 practice 166 – 7; reassurance junkies 171 – 5 Songify 139 , 154 retrograde amnesia 57 , 86 specifi c phobias 89 – 91 , 107 Rhyno, S. 144 SSRIs (selective serotonin reuptake inhibitors) risks 32 , 33 168 rituals: avoidance, resistance, neutralization staying in the present 51 – 2, 73 , 117 , 170 31 ; diagnoses 95 , 96 , 100 ; exposure 109 , 110 , stealing 57 , 96 , 97 111 ; OCD 95 , 96 , 100 steroids 148 Robbins, C. 154 , 175 stickiness of the mind 32 – 3, 38 , 147 – 9, 150 Roosevelt, Eleanor 105 stress: determining patient progress 85 ; relapse rule of opposites 76 prevention 184 – 5 ; stress response 23 ; rumination 133 – 4 studies on causation 18 ; traumatic anxieties Index 199 102 ; tricks that can backfi re 81 ; worry thought substitution 134 , 135 strategies 134 , 136 thought suppression 81 , 134 , 135 “struggle switch” 82 tic disorders 97 substance abuse 95 , 102 , 129 , 181 time 78 – 9 , 132 , 185 suicidality 56 , 84 , 133 , 152 , 153 tranquilizers 60 , 67 , 68 , 69 superstitions 110 , 111 transsexuality 162 supplicatory ritualized prayer 134 , 135 traumatic anxieties 101 – 3 , 107 supported exposure 86 treatment: cause versus maintenance 16 – 17 ; suppression 134 , 135 direct approach to treatment 22 – 3 ; fi rst surrendering the struggle 50 – 1 contact 53 – 4 ; getting started 53 – 66 ; getting sympathetic nervous system 190 the details 56 – 60 ; goals for treatment 5 ; symptoms: meaning of 4 ; surrendering the initial interview 54 – 6; introducing the struggle 50 ; value of talking about 21 – 2 ; new paradigm 61 – 3 ; previous coping skills when symptoms do not matter 182 60 – 1 ; providing information and answering questions 63 – 6 ; role of techniques 5 – 6 Talmud 14 trichotillomania (hair-pulling) 97 teaching metaphors 45 – 7 triggers: characteristics of highly anxious techniques 67 – 88 ; anxiety management people 7 ; exposure 8 , 118 , 164 ; sensitivity in cases of real danger 84 ; competence- and anxiety 15 ; specifi c phobias 91 ; types enhancing skills 80 – 1; determining patient 9 – 13 progress 84 – 7; diaphragmatic breathing trust 134 81 – 4 ; effectiveness of 70 ; emergency coping “tug of war” metaphor 51 71 – 2; encourage the paradoxical approach Twain, Mark 186 76 – 7 ; expecting and allowing 73 – 4 ; helpful 12-step method 43 , 85 , 181 techniques 73 – 81 ; “I am bigger than my thoughts” technique 79 – 80; increasing uncertainty: acceptance 48 , 49 , 50 – 1; doubt doubt about anxious messages 75 – 6 ; about anxious messages 75 ; exposure 115 , mindful labeling 74 – 5; mindful sensory 117 , 120 ; illness worries 177 ; intolerance of awareness 73 ; perfectionism 77 – 8; problem 33 , 158 , 159 , 177 ; pathological doubt OCD with 67 – 70 ; reminders to take care of 158 , 159 oneself 79 ; role of techniques in treatment unconscious reactions 24 , 25 , 40 5 – 6; slowing down to let time pass 78 – 9; under-diagnosis 156 as temporary help 70 – 1 ; tricks that can unipolar major depression 133 backfi re 81 ; willingness to experience unproductive worry 130 discomfort 80 unwanted intrusive thoughts 144 – 55; control terror 15 , 20 , 21 , 25 , 26 , 34 , 48 strategies that fail 146 ; diagnoses 96, 98 , thalamus 23 , 24 99 ; embracing anxiety 41 ; emotional and therapeutic attitude of acceptance see behavioral avoidance 146 – 7; exposure acceptance 119 , 120 , 154 – 5; getting started 55 , 56 ; therapist role: acceptance 42 – 4; exposure how thoughts are appraised 145 – 6 ; how 115 – 17 ; therapist anxiety and a new thoughts are maintained 144 – 9; living with construct 153 – 4 ; unwanted intrusive joy despite thoughts 149 – 50; metacognitive

Downloaded by [New York University] at 01:46 15 August 2016 thoughts 150 – 4 beliefs 147 ; OCD 96 , 98 , 99 , 119 , 120 , thought – action fusion 31 – 2, 41 , 99 158 – 60; pathological doubt OCD 158 – 60; thoughts: acceptance 37 , 38 , 41 , 43 , 50 ; physiological factors that make the mind anxiety-raising and anxiety-lowering sticky 147 – 9 ; therapist anxiety and a new thoughts 130 – 1 ; depression 99 , 100 ; fear- construct 153 – 4 ; treating 150 ; turning the maintaining cycle 29 – 30; helpful techniques causation arrow around 156 , 157 ; varieties 74 , 79 – 80; “I am bigger than my thoughts” of presentation 150 – 3 technique 79 – 80; living with joy despite urgency 132 , 138 thoughts 149 – 50; mindful labeling 74 ; phenomenology of anxiety 31 , 32 – 3 , 34 ; Valium 168 types of triggers 9 , 10 , 11 – 12; see also Veenstra, G. 35 unwanted intrusive thoughts; “what if” vertical descent 140 thoughts violent thoughts 55 , 56 , 96 200 Index

vomiting, fear of (emetophobia) 90 , 170 , willingness to experience discomfort 80 178 – 9 Wilson, Reid 80 , 137 , 138 wise mind 50 , 65 , 117 War of the Worlds 41 worry 126 – 43 ; anxiety-raising and anxiety- washing rituals 100 , 113 lowering thoughts 130 – 1; ego-syntonic “watching anxiety pass” metaphor 45 – 6 vs ego-dystonic worry 127 – 8 ; evaluating Weekes, Claire 35 , 171 worry 132 – 3; exposure 110 , 120 , 121 ; Wells, HG 41 generalized anxiety disorder 65 – 6 , 100 – 1 , “whack-a-mole game” metaphor 188 129 ; introducing the new paradigm 62 – 3; “what if bag” 141 meta-worry 126 , 132 – 4, 137 ; productive “what if” thoughts: approaching anxiety versus unproductive worry 130 ; rumination mindfully 39 ; characteristics of highly 133 – 4 ; strategies that don’t work 134 – 6 ; anxious people 7 ; exposure 107 , 115 , strategies that do work 136 – 42 ; therapeutic 117 , 120 ; fear-maintaining cycle 29 , 30 ; perspective 131 – 2 ; thoughts are not facts generalized anxiety disorder 101 ; studies 129 – 30; time and urgency 132 ; varieties of on causation 19 ; thought – action fusion 32; the worry experience 127 – 8 ; worry time worry 131 , 133 138 – 9 white knuckling 61 , 85 , 113 , 121 , 123 , 164 “whoosh” of arousal 25 – 6, 27 , 28 , 40 Xanax 67 , 68 , 69 , 141 , 168 Downloaded by [New York University] at 01:46 15 August 2016