You lie awake at night trying not to think about all the things you’re worried about. It’s hard to concentrate at work because your thoughts keeping going back to what might go wrong. You get irritable with people because you are constantly on edge. You start avoiding things that might make you anxious. You try deep breathing but it just makes you more anxious. You even stop drinking coffee but the anxiety just gets worse. You lie awake at night worried and then worry about how much sleep you’re losing.
From phobias to panic attacks to Obsessive Compulsive Disorder to just feeling anxious every day, people experience anxiety in many forms. There are a lot of reasons that people experience anxiety. There are certainly enough things in our lives to be worried about.
There are two types of problems. One is the stress of dealing with the day-to-day issues that everyone faces. The other problem is when the fear becomes larger than is justified or comes on at inappropriate times, such as feeling fear when there is, objectively, nothing to be afraid of.
The first problem is called “stress.” Stress can often be dealt with by learning some new techniques. This may require a session or two with a professional who can figure out what specific skills are missing and act like a personal trainer to help you learn and practice the new techniques. The second problem is what is known as “anxiety.” Anxiety is more than just a deficit in coping skills, it is something that needs to be coped with and, as such, often requires professional help.
There are many different types of anxiety. The simplest type is a phobia. This is an unrealistic or unreasonable fear of some thing, place, or situation. People also endure what is called “Generalized Anxiety Disorder” which is excessive worry about a lot of things. Some people experience Panic Attacks, which are discrete periods of anxiety that can be extremely upsetting and overwhelming. Finally, people develop Obsessive Compulsive Disorder in which rituals are used to defuse the anxiety.
Phobias are very common and may or may not be a problem for a person. For instance, most people feel anxious when asked to do public speaking. However, unless your life goal is to be a politician, most of us can avoid public appearances without it interfering with our lives. Another example would be a fear of snakes, which is not very relevant in most of our lives.
There are other phobias that can be more bothersome such as fears of heights, elevators, blood, driving, and airplanes. These kinds of fears lead people to avoid situations in which they might experience the fear. This only serves to make the fear worse. People also try medications to soothe their fears. They may carry “safety objects,” telling themselves, for example, “I know I’ll be fine because I have my cell phone.” Or they may imagine themselves in a different place, telling themselves something like “don’t think of yourself as being on the elevator, just pretend you’re on a beach somewhere.”
The problem is that we feel relief when we avoid something we are scared of. When we feel relief, that tells the brain that there must have been something to be scared of so the fear is reinforced along with the avoidance. That creates a vicious cycle where the fear gets worse and worse and can generalize to more and more things.
It is important to face the fear instead of avoiding it. The goal is, strangely enough, not to feel better, but to get better. This fear needs to be put in perspective. Yes, there is a chance that the elevator could stop, but let’s face it, the odds are against it and even if it did stop, you would probably survive.
Treatment involves looking at the fear. Fear that is faced is easier to deal with than fear that is unknown. In a gradual, gentle fashion, people can learn to face their fears. As the fears are faced, they lose their power. As we face the fear, we can evaluate the seriousness of the threat. We can also look at what to do if the worst really did happen.
Treatment for phobias is usually measured in hours, not weeks or months.
Generalized Anxiety Disorder
Generalized Anxiety Disorder involves a lot of worry about different things. It seems as soon as one thing is resolved, we’re on to the next worry without a chance to take a breath. As with phobias, a typical response is to try to ignore the worries. You can try to keep busy all day, but the worries come to haunt you in the middle of the night. You can try to tell yourself that you shouldn’t be worried, but the worries keep coming back.
Instead of trying to avoid or discount the worries, it is important to face them. This will involve a lifestyle change in which people shift to having periods of introspection where they learn to ask themselves “what am I worried about?” The next step depends on the answer to this question. Some worries need to be put in perspective such as asking what the odds are of it happening or how important it will seem when you look back at it next week. Some worries lead to action items that need to be put on to-do lists, which also need to be kept manageable. Time management is also a frequent issue.
For most of us, these techniques require a style of thinking that we have never been taught so it is frequently useful to do these exercises with someone else who can help to determine the seriousness of the anticipated event and what to do about it. As with starting an exercise program, this is not something that can be done once and you will never worry again. These are techniques that need to become as automatic as the worries so that as each worry comes, it can be evaluated and dealt with in a manner that keeps it from having too much power.
Panic Disorder may or may not overlap with Generalized Anxiety Disorder. The person with Panic Disorder experiences discrete periods of very intense anxiety. For many, there is a sense of impending doom or that something very bad is about to happen. The problem is that there is nothing “objective” to point to and say “that is what I’m afraid of.” There are a lot of physical symptoms that go along with panic, including (list taken from the DSM-IV):
- Palpitations, pounding or racing heart
- Trembling or shaking
- Sensations of shortness of breath or smothering
- Feeling of choking
- Chest pain or discomfort
- Nausea or abdominal distress
- Feeling dizzy, unsteady, lightheaded, or faint
- Feelings of unreality or feeling detached from yourself
- Fear of losing control or going crazy
- Fear of dying
- Numbing or tingling sensations
- Chills or hot flashes
These symptoms are actually a part of our body’s normal “fight or flight” system. In the event of a life-and-death situation, the brain has a mechanism that sets off an alarm that activates the body to get out of there as fast as possible. This is a very useful thing if you are standing in the middle of a street and a bus comes along or if you are in a house and the smoke alarm goes off. It is a very un-useful thing when it goes off for no apparent reason, and that is what we call a panic attack.
Panic attacks are overwhelming and scary. They leave people wondering if they are going crazy. Most importantly, they leave people worried that they will have another panic attack and that the next one might not go away. Because of this fear, people become hypervigilant to any signs that another panic attack may be about to occur. The problem with this is that it is normal for our bodies to do weird things every so often. For instance, our heart rate goes up and down throughout the day. Sometimes, our mouths get dry. This is perfectly normal. The problem is with the interpretation of the sensation. When we start looking for these symptoms and then worry at the first sign of them because they might lead to a panic attack, the anxiety goes up. That thought is followed by another thought that this impending panic attack would be horrible, often because there is a fear that it will never end or thoughts like “I will go crazy and end up hospitalized.”
The combination of the fear and the physical sensations often leads to behavior changes. People start avoiding anything that might lead to a panic attack. This may start with the situation where the original panic attack occurred. It frequently generalizes to other situations so that there is a fear that “if I go ‘there,’ I might have a panic attack which would be overwhelming and might not stop so I better avoid the situation in the first place.” This avoidance behavior is what is known as agoraphobia. The avoidance is intensely rewarding as the anxiety immediately decreases. Unfortunately, the decrease in anxiety is only temporary and the avoidance can actually make the fear worse. Treatment focuses on all three aspects: the avoidance behavior, the fearful thoughts, and the physical sensations.
Avoidance (agoraphobia) is best treated by the technique called “exposure.” This is similar to what is used for simple phobias. First, we make a list of all the things that are being avoided. Then, we put the list in order from the least fearful thing to the most fearful thing. The goal is to push you out of your comfort zone just a little bit. Then, we work our way up the list doing exposures, which is actually going to that situation such as sitting in that car, wandering around the mall, or going in an elevator. The goal is to stay in the situation until the fear decreases and then repeat the exposure until the situation doesn’t stimulate any fear. That is the cue to move on to the next item in the list. The best part is that conquering the fear in one situation carries over to the next so it is not as anxiety-producing. This means that when you get to the most difficult item, it is no longer as difficult as it seemed when you started the process. Usually, you can make the list and together with your therapist make sure it is in small, easy to manage steps. Then, you can practice these things between sessions. Your therapist can help you if you get stuck.
While you are doing these exposures, you can also work on the fearful thoughts. This involves a two-step process. The first step is to figure out what the fearful thoughts are. These are thoughts that you really have no control over. They just go through your head really quickly and leave you feeling anxious. It is often harder than it sounds to figure out all the fearful thoughts and but there are techniques, such as thought records, that can be used to help with this. Once the thoughts are identified, they can be dealt with. For some, the energy will dissipate just by identifying them. For others, we need to look at the evidence supporting or not supporting them. For others, we need to answer the question “what if this happens?” Having a plan can often take the intensity out of the situation. The therapeutic goal is not so much to get rid of all your anxious thoughts, which would be an unrealistic goal, but to help you learn tools so that when anxious thoughts come they can be dealt with quickly, before they have a chance to get overpowering.
The final part is to deal with the physical sensations directly. The goal here is to break the association between the bodily sensations and the interpretation that they mean something bad is going to happen. Most of the sensations can be produced in the therapy session or at home. For instance, exercising can produce heart racing and sweating. Shortness of breath can be produced by deliberately breathing incorrectly such as taking short breaths in and out. The specific technique will depend on the target symptom. This becomes a type of exposure where you are exposed to the symptom in a way that is not connected to the fearful thoughts. This usually works to take the intensity out of those sensations.
Treatment for panic disorder often takes 10-12 weeks, sometimes more, sometimes less. It is effective in about 85% of the cases. Relapse is low and is usually taken care of the second time around.
Obsessive-Compulsive Disorder (OCD)
Obsessive-Compulsive Disorder (OCD) is an extreme form of anxiety. People experience anxiety, which they attempt to reduce through rituals. These rituals can be either behavioral or cognitive, such as reciting something familiar and safe. Classic rituals include hand washing, checking, and counting. Some people only experience the obsessions and don’t have any observable rituals.
Usually, there is a thought that stimulates anxiety. These thoughts can range from contamination to fear of hurting someone. Although most people have occasional random thoughts, in OCD the idea is that because the thought happened, it must be significant. Because it is significant, something must be done to neutralize the anxiety. That is where the rituals come in.
Treatment focuses on looking at the thoughts and determining their actual importance, as opposed to their perceived importance. It also involves exposure. This is done in the same way as exposure for agoraphobia. A list is made of all the problem behaviors, such as all the things that are checked. Then, the items are arranged in order of how much anxiety would be produced if the associated ritual was not performed. Treatment then consists of going forth and not doing the ritual, starting with the one that would produce the least amount of anxiety. This ritual is not done until there is no longer any anxiety about not doing it. It is important not to start any other rituals to replace it and not to do other rituals more frequently in order to reduce the anxiety. The anxiety can be endured and when it is endured, it tends to go away.
The length of treatment depends on the number of rituals, how easy it is to let go of the thoughts, and how much exposure can be done. These exposures tend to take longer than for phobias, but once conquered, the fear does tend to stay away.
Please note that this information is provided in good faith for informational purposes only. While I have attempted to make the information in this and associated document as accurate as possible, I do not assume any legal liability or responsibility for the accuracy, completeness or usefulness.