Anxiety Disorders and Therapy
Overview
This page covers the following topics related to anxiety:
Anxiety as a stress response
Anxiety Disorder Symptoms
DSM 5 Criteria for Anxiety Disorders
How I work with anxiety as a therapist
How do you know if you have anxiety?
You might be wondering if feeling anxious is a problem for you or if it's just normal. At this point in time, there are a lot of unpredictable and terrifying world events happening in our country and across the world. The future feels uncertain and some of us are feeling scared and unsafe. We lived through a pandemic not too long ago and are still recovering from its effects. There's a lot more I could say, but the point is we are living through tumultuous times and an anxiety reaction is expected right now.
Anxiety as a stress response is usually fleeting. It comes when you're reacting to a stressor and then it resolves in some way. It's also a reasonable response when you're dealing with uncertainty or making a big change. It's short term and resolves on its own and doesn't stop you from doing most things that matter. Anxiety is normal in small doses and part of our survival system. If we didn't have anxiety, we'd all be in a lot of danger. In fact anxiety at a low level is what makes us feel alert, focused and motivated to take action.
What makes anxiety disordered?
Anxiety disorders are persistent and pervasive. People with anxiety disorders, like generalized anxiety for example, usually feel it almost daily and not always in response to a stressor. You could just wake up and notice that your heart is racing, you feel keyed up, you can't go back to sleep and you start to have racing thoughts. If the anxiety is provoked by something stressful, you're more likely to worry or ruminate about it. Rumination is like rewinding an upsetting scene in a horror movie and just watching it over and over again, each time re-experiencing the fear and disgust.
Anxiety disorders cause you to exaggerate the potential for danger and minimize your ability to manage it. A key element of an anxiety disorder is avoidance. For example, you start to drive your car on the side streets instead of the freeway or you tell yourself "I'm better off staying home and not going to noisy, crowded places". It makes sense because you feel better when you just don't do those things that scare you.
Everyday things start to feel overwhelming and impossible. Things that made you feel a little uneasy before can start to feel impossible. Perhaps you always felt uneasy shopping at the grocery store, but you were able to get to the checkout. Now just the thought of shopping at the store makes you feel exposed and uneasy. You may even try to shop and then have a panic attack in the process, forcing you to abruptly abandon your cart and get out of there.
You start to miss out on experiences and then you feel anxious or even depressed about that. Maybe you want to do something like travel or go to a concert, but the days leading up to it you're filled with dread. You don't understand because this is something you've always loved, so you start beating yourself up and feeling sad.
Anxiety disorders over time create a vicious cycle that looks like this:
being afraid → avoiding that thing → short term relief → low self confidence → depression → being even more afraid
What are anxiety disorder symptoms?
I'm including parts of the DSM 5 or DSM V criteria for several anxiety disorders. This isn't the full criteria in the DSM, as it can get lengthy and repetitive. The following information is intended to help you learn about anxiety disorders versus just anxiety reactions but should not be used to self diagnose.
Generalized Anxiety Disorder or GAD
Generalized anxiety disorder is excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities. The worry is difficult to control and comes with at least three of the following symptoms:
Restlessness or feeling on edge
Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Problems with sleep
The anxiety, worry and physical symptoms must cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
What does generalized anxiety disorder feel like?
GAD is one of the most common mental health disorders and yet most people that have it suffer in silence. People with GAD can usually function in their day to day lives, but there's a persistent feeling of stress and discomfort. Worrying about every day events can look like:
What if I screw up at work? I just know I'm going to get fired.
My husband was quiet this morning. He must be mad at me.
My chest feels heavy…there's something seriously wrong with my heart.
What if my friends don't actually like me and they're just pretending?
What if I make the wrong decision and hate my life?
The anxiety and lack of control over it creates a lot of shame. There are often feelings of frustration because you understand that your thinking isn't completely logical but you can't stop worrying. Generalized anxiety disorder also creates physical discomfort similar to panic disorder at a less intense level but symptoms like pounding heart, chest pain, sweating, etc., can go on for much longer and disrupt things like sleep and relaxation. The anxiety can get so bad that you stop doing things because they're too stressful.
Panic Disorder or Panic Attacks
According to the DSM 5, Panic Disorder is defined by recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four or more of the following occur:
Palpitations, pounding heart, or accelerated heart rate
Sweating
Trembling or Shaking
Sensations of shortness of breath or smothering
Feelings of choking
Chest pain or heaviness
Nausea/diarrhea
Feeling dizzy, lightheaded, faint or unsteady
Chills or heat
Numbness/tingling sensations
Derealization or depersonalization (a sense of not being attached to your body or that things aren't real)
Fear of losing control
Fear of dying
In addition to these symptoms, they must also be followed by one month or more of:
Persistent concern or worry about additional panic attacks or their consequences.
A significant maladaptive change in behavior related to the attacks.
What does panic disorder feel like?
People with panic disorder are often living in fear of making a panic attack happen. Many will seek emergency care when they experience a panic attack for the first time because they believe it's a heart attack. Panic attacks can happen unexpectedly, out of nowhere or they can be tied to an event that you experienced. You may have anxiety prior to the panic attack, but not necessarily. Panic attacks can be debilitating, disruptive, and you may go to great lengths to avoid them. Whatever environment you were in during your first panic attack can become such a significant source of distress that it turns into a phobia on its own. For example, you had a panic attack while driving in your car and now you fear having another one, so now you can't be in a car without feeling significant anxiety. Panic disorder can often lead to other concerning issues such as substance abuse, depression, suicidal thoughts, and/or agoraphobia.
Agoraphobia
The DSM 5 criteria for Agoraphobia includes
Marked fear or anxiety about two (or more) of the following five situations:
Using public transportation
Being in open spaces
Being in enclosed spaces
Standing in line or being in a crowd
Being outside of the home alone
The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms, incapacitating or embarrassing symptoms
The agoraphobic situations almost always provoke fear or anxiety.
The agoraphobic situations are effectively avoided, require the presence of a companion, or are endured with intense anxiety or fear.
The fear, anxiety or avoidance is persistent, typically lasting for 6 months or more.
What does agoraphobia feel like?
People's experiences with agoraphobia can vary from slight to extreme. Some may be able to leave the house and do some activities while some design their lives to limit contact with the outside world as much as possible. In slight cases of agoraphobia, people may push themselves to do things and then have to leave abruptly due to fear or panic. In more severe cases, people believe they are better off staying at home and will design their lives to limit contact with the outside world as much as possible. They may adapt to their fears by becoming overly dependent on others for services or assistance. Many with agoraphobia have a history of trauma and/or panic attacks. Traumatic experiences can lead to beliefs that the world is unsafe and unstable. They also can pair environmental cues with the traumatic event in your brain, causing an exaggerated startle response when you're in that environment again (i.e. re-experiencing, hyperarousal, hypervigilance). People with agoraphobia are at risk of becoming depressed or completely disabled. According to the DSM 5, more than one-third of individuals with agoraphobia are completely homebound and unable to work.
Social Anxiety Disorder (SAD)
The DSM 5 criteria for Social Anxiety Disorder is
Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social situations, being observed and performing in front of others.
The individual fears they will act in a way or show anxiety symptoms that will be negatively evaluated
The social situations almost always provoke fear or anxiety.
The social situations are avoided or endured with intense fear or anxiety.
The fear or anxiety is out of proportion to the actual threat posed by the social situation.
The fear, anxiety or avoidance is persistent lasting for 6 months or more.
What does social anxiety disorder feel like?
People with social anxiety are quite skilled at keeping it hidden. They may socialize well and appear totally normal in social situations. The anxiety can come up prior to a social event, during, or after in the form of worrying, over planning, ruminating, or avoiding. People with social anxiety are highly critical of themselves and fear being disliked or embarrassed. Before a social event they become anxious and may overplan and strategize on how they're going to perform. Afterwards they are likely to revisit their "performance" and criticize what they said and did. People with SAD may use excessive alcohol or drugs to help them relax and feel more at ease in social situations. On the other hand, SAD can lead to avoiding social situations all together and lead to intense isolation and loneliness. People with SAD often have a history of bullying, social rejection, or some kind of humiliation trauma.
Social anxiety disorder is quite common, affecting about 12% of adults according to the National Institute of Mental Health (NIMH), however people with social anxiety disorder feel ashamed of their symptoms and are reluctant to admit to them. Most people don't seek therapy for social anxiety disorder alone and it can be confused with generalized anxiety disorder.
Phobias
The DSM 5 criteria for phobias is:
Marked fear or anxiety about a specific object or situation. Common examples include: flying, heights, animals, receiving an injection or seeing blood.
The phobic object or situation almost always provokes immediate fear of anxiety.
The phobic object or situation is actively avoided or endured with intense fear or anxiety.
The fear, anxiety, or avoidance is persistent, lasting typically 6 months or more.
What do phobias feel like?
According to the DSM 5, specific phobias can develop as a result of a traumatic experience, but most people are unable to recall a specific reason for their phobia. Phobias are more common in children, with the median age of onset being before age 10 years old. Phobias that do not resolve during childhood or adolescence are more difficult to resolve once they reach adulthood. Older adults are more likely to develop phobias as well due to fears of falling or becoming disabled.
The fear of the object or situation must be intense or severe. The individual becomes fearful when they are exposed to the object or situation almost every single time and the fear experienced is out of proportion to the threat. They may experience panic attacks in response to exposure and may avoid the situation as much as possible.
Is OCD or obsessive compulsive disorder an anxiety disorder?
It's common to think of obsessive compulsive disorder as an anxiety disorder since it shares so many similarities, however OCD is in a separate category titled "Obsessive Compulsive and Related Disorders". According to the DSM 5, there is strong evidence that OCD, body dysmorphic disorder, hoarding disorder, trichotillomania, and a few other conditions have similar diagnostic features and presentations, therefore were placed into their own category.
It's important to differentiate between OCD from anxiety disorders because the way it's treated is different. Anxiety disorders respond to cognitive behavioral and compassion focused approaches while OCD may actually get worse.
How does therapy help anxiety?
I get it – living with anxiety is distressing and debilitating at times. If you read my about me section, you know that I have an anxiety disorder too. I understand the discomfort so well, but my goal is not to get rid of it or make it go away - that's not possible. We can't cut out unpleasant emotions no matter how much distress they cause. But we can help you build a better relationship with your anxiety and here are some ways that I do that with my clients. I use a combination of these approaches with most people.
Trauma Informed Therapy
It's common for anxiety disorders to have an underlying trauma attached to them. This doesn't always mean it's related to a major trauma, like abuse or neglect, but it can be. Painful experiences can feel traumatic, especially when they occurred as children when we didn't have the resources to understand or cope with them. These experiences can show up in the form of beliefs we hold about ourselves, others and our environment. They can also relate to feelings we have in certain anxiety provoking situations that may be subconscious or even unconscious.
The goal of trauma informed therapies is to help you access and process upsetting events, healing the damage that was done. Therapy moves at a gradual pace, careful not to overwhelm you beyond your capacities and includes multiple theories and styles of treatment. Theories that inform my practice, as well as therapies I have experience with include Internal Family Systems or IFS, Attachment, Trauma Focused Cognitive Behavioral Therapy, Family Systems, Epigenetics, and Cognitive Processing Therapy. I see clients benefit and grow when they understand the root causes of their suffering and give themselves what they truly need.
Cognitive Behavioral Therapy or CBT
Anxiety disorders often involve deeply entrenched patterns of thinking that influence the way you feel and your behavior. Anxious people tend to have lots of automatic thoughts that are extreme, usually focused on warning you of danger or endlessly calculating the odds of something terrible happening. They can also be highly critical of you in an effort to protect you from doing something foolish or careless.
I listen closely for extreme patterns of thinking and bring them to your awareness. I will also listen for destructive behaviors or intense feelings and try to help you identify the underlying patterns of thinking connected to them. In therapy we explore the origins of these beliefs – Where did you first learn this? Who told you that? How has this belief helped you in the past? Is it still serving you now? I can tell CBT is working when my clients start to notice their thinking patterns in real time and either change their thoughts to be more helpful or learn to observe their thoughts and not buy into them too much.
Family and Relationship Systems
Anxiety can be exacerbated by stressful relationships we have in our lives. We are constantly juggling the needs we have with the needs and expectations of others, which inevitably leads to conflict. Anxious people often struggle in relationships. Anxiety can make conflict more difficult, causing the anxious person to shut down and have trouble communicating. They may struggle to set boundaries with people or be overbearing in relationships, usually in an effort to avoid some kind of threat. They also might not want to do many things because of their anxiety, which can leave a partner feeling frustrated and bored in the relationship.
Using a systems approach, I want to understand your relationship network and how it operates. I'm looking for breakdowns in the "system" that lead to dysfunction. Breakdowns can be things like poor communication, lack of closeness, controlling behavior, isolation, or having a healthy separation from yourself and others. When clients start to understand what healthy boundaries look like and let go of whatever fear they're holding onto, they usually find relief.
Behavior Modification
It's important if you have an anxiety disorder to start confronting patterns of avoidance. It's completely understandable that you've developed these patterns to protect yourself, but it's not sustainable and only makes you more anxious over time. Avoidance can work similarly to an addiction, creating short term relief but making the initial problem even worse than it was to begin with.
We work together to start to identify those behaviors and discuss strategies for overcoming them. This may involve a little bit of gradual exposure, where you slowly expose yourself to mildly distressing activities and work on increasing your tolerance over time to more meaningful activities. Over time, you build up your confidence and the anxiety will become more tolerable.