Below you will find a description of the problems that I treat in therapy and general treatment strategies for each problem.
CAUSES OF ANXIETY DISORDERS
The BioPsychoSocial model is often used to explain the development of anxiety disorders.
Biological: There may be a genetic predisposition to anxiety sensitivity, meaning that some individuals may inherit a sensitive anxiety response system in the brain. There may also be an abnormality in the neurons or the connections between neurons in the brain, and medications that increase available serotonin in the brain are thought to work by stimulating new growth within and between neurons in the brain. It is no longer thought that a lack of serotonin or a "chemical imbalance" is responsible for anxious and depressive symptoms. This new growth creates a more "plastic" or modifiable neuron, meaning more flexibility in the brain to facilitate new learning and new patterns of thoughts and behaviors. This explains why it can take several weeks for the therapeutic effects of medications are experienced, even though there are immediate side effects of the additional available serotonin.
Medical conditions can also contribute to anxiety symptoms, and therefore, all individuals with excessive anxiety symptoms should be seen by a medical professional to rule out conditions such as heart disease, diabetes, hyperthyroidism, asthma and other respiratory disorders, drug use or withdrawal, or rare tumors.
Anxiety can also be a side effect of medications or drug use or can be the result of poor sleep and nutrition. For some, physical exercise and adequate sleep can change brain and body chemistry enough to make significant changes in emotional functioning. For others, the additional assistance of medications may be beneficial.
Psychological: Certain personality factors can contribute to the general ways in which individuals think and respond (cope) when faced with stressful situations. For example, a perfectionistic personality trait can lead individuals to see anything less than perfect as a threat, or a neurotic personality can contribute to a tendency to interpret situations as negative. Another psychological factor is thinking style. Some individuals tend to overestimate the probability of threat or the occurrence of negative events while also underestimating their ability to cope with such threats. This thinking style can lead to an overactive anxiety response system.
Another psychological factor refers to the ways in which individuals think about themselves, others, their environment, and their futures. Anxiety occurs when individuals think of themselves as vulnerable or incompetent, others as threatening or uninterested, the environment as dangerous, or their future as doomed. Individuals who tend to avoid or escape from uncomfortable situations are also prone to anxiety in that those particular behaviors strengthen the fears and do not allow the individual to develop confidence in their coping skills. These psychological factors may have developed due to past experiences or there may be a biological predisposition towards these thinking styles.
Social: Anxiety responses can be learned from parents, caregivers, and other role models. By watching others, children can learn to be fearful, learn to avoid anxiety provoking situations, and generally, learn to think, feel, and behave in ways that lead to the development and maintenance of anxiety disorders. Stressors in the social environment can also contribute to anxiety, such as an unstable home environment, racism, childhood trauma, or toxic work environment while strong relationships with close family and friends can help ease the pain of anxiety.
Spiritual: Though not typically part of the BioPsychoSocial model, I believe the spiritual component is an important one that influences the entire biopsychosocial system. For some, a connection to a specific religion or a higher power can provide peace and comfort. For others, life is given meaning through nature, relationships, or acts of service to others. Identifying our purpose and values can help us to tolerate the pain we encounter in life.
TYPES OF ANXIETY DISORDERS
Social anxiety is characterized by excessive, uncontrollable fear of being embarrassed, making a bad impression, or being judged critically by others. Panic attacks related to social performance are not uncommon. Social situations such as participation in meetings or a class, answering a supervisor's questions, being at a party, meeting someone new, or eating or writing in public can become sources of extreme anxiety. Sweating excessively, blushing, stammering, heart racing, stomach distress, losing the ability to express oneself well, and feeling inferior are often associated with social situations and can lead to more discomfort in social situations. The behavior associated with social anxiety is avoidance of social situations that may trigger anxiety.
Case example: Mike, age 26, has never been able to hold a job for longer than 6 months. Supervisors make him nervous. When asked a question, he's a wreck. Even thinking about participating in a staff meeting puts him into a sweat. Mike is smart, attractive and has a sense of humor but dealing with the social nature of breaks and the lunch room is pure torture for him. He says he doesn't know how to make small talk and always worries he'll say or do the wrong thing. He is only relaxed when he is alone watching television but he feels lonely and wishes he was able to date and make friends.
Treatment strategies for social anxiety: Aside from general cognitive behavioral and mindfulness techniques, the treatment of social anxiety involves behavioral experiments designed to test out fears and develop coping skills. Social skills training can also an important part of the treatment. Social anxiety groups can be highly effective as the group therapy provides a safe setting to learn to build up strength and confidence in social situations.
Click here for more information about social anxiety and its treatments from the Anxiety Disorders Association of America.
Panic attacks are sudden waves of anxiety, and the symptoms of panic attacks can include heart racing, dizziness, shortness of breath, chest pain, trembling fears of having a heart attack or going crazy, nausea, dissociation, sweating, and tingling in the fingers. Those suffering from panic disorder often develop fears about when and where their next panic attacks will occur and will restrict their activities for fear of having another panic attack. Fears might also include losing control, going crazy, or dying.
For those with panic disorder, panic attack can appear to occur "out of the blue," or for no apparent reason. More likely, an increase in background stressors along with a biological or psychological vulnerability to anxiety led to the initial panic attack, but because there were no obvious external triggers (a tiger, a test, a threat), the mind began to search for internal sources of danger such as dying, going crazy, or losing control. These unexpected physical symptoms then led to a fear of any symptom associated with a panic attack. After the initial panic attack, panic attacks can then begin to occur with higher frequency leading to panic disorder.
After the initial panic attack, an individual may begin to chronically hyperventilate on a subtle level, which can lead to susceptibility to further panic attacks. The panic attack and subsequent fear of panic attacks can lead to a heightened level of arousal and an increased level of adrenaline in the body, which can also lead to susceptibility to future panic attacks. Lastly, the fear of having a panic attack can lead to hyperscanning of the body so that an individual becomes hyperaware of normal bodily fluctuations that most people do not notice.
Physical symptoms associated with panic can lead to a fear of having a panic attack, which can lead to a the fight or flight response, which leads to the misinterpretation of physical symptoms as meaning that a heart attack is imminent, which leads to further anxiety symptoms, which leads to a fear of dying, which then leads to a full blown panic attack. Other catastrophic fears include the fear of going crazy, fear of losing control, fear of passing out, and the fear of dying.
Case example: Annie is a 20 year old student at a local community college. On several occasions recently she has found herself in absolute panic. Her heart pounds, she trembles, her mouth gets dry, and it feels like the walls are caving in on her. The feelings only last a few minutes but when they happen, the only thing that seems to relieve her fear is walking around her apartment and reminding herself that she is in control. She won't ride in cars any more unless she is driving so she is sure that she can stop if she needs to. She will only go to class if she can find an aisle seat in the back row so she can leave should she have another panic attack. She avoids any situation where she might feel out of control or where she might be embarrassed by having another panic attack.
Treatment strategies for panic disorder: Aside from general cognitive behavioral and mindfulness techniques, an important component of treatment is psychoeducation regarding the causes of panic attacks. If an individual is 100% certain that a panic attack does not indicate a serious mental or physical problem, then the anxiety response will not be as severe. A medical examination is warranted to rule out any medical issues that may be driving the anxiety.
A unique component of treatment for panic disorder is interoceptive exposure. This refers to the gradual exposure to the physical symptoms that cause fear. For example, running in place, spinning in a circle, or taking quick, shallow breaths may induce symptoms similar to those of a panic attack. Taking control over these symptoms, learning to tolerate them, and teaching the brain that the feared symptoms are uncomfortable but not dangerous are essential in the treatment of panic disorder.
Click here for a more thorough description of the treatment for panic disorder.
Panic attacks are so uncomfortable that some people attempt to avoid situations where a person might feel trapped or where help might not be readily available. People who become agoraphobic have become so afraid that they might have a panic attack that they narrow their lives down to places and experiences where they believe they won't be out of control or without the emotional supports they need to get through it. Some people become so afraid that they never leave their own homes or they require the reassurance of having a trusted person with them whenever they venture out.
Case example: Debbie is 36 and lives with her ailing mother. Over the years, her life has become more and more centered on the house and her mother. After having a few panic attacks, she became so afraid to leave the house that she was unable to keep her job. She can only go out now if her mother or sister go with her. In her efforts to avoid panic attacks, Debbie has developed agoraphobia.
Treatment strategies for Agoraphobia: Aside from general cognitive behavioral and mindfulness techniques for the treatment of anxiety, treatment for agoraphobia would include the gradual exposure to feared situations that are avoided.
Chronic worrying/Generalized Anxiety Disorder
Generalized Anxiety Disorder (GAD) is characterized by 6 months or more of chronic, exaggerated worry and tension that is much more severe than the normal range of anxiety most people experience. People with this disorder usually expect the worst and worry excessively even when there may be no signs of trouble. Though panic disorder is about fear of present moment symptoms, worry is typically anxious anticipation of feared future outcomes. In addition, panic attacks are characterized by an abrupt onset of intense fear, whereas worry involves a gradual increase in anxiety.
Stress associated with worrying can produce uncomfortable physical symptoms such as headaches, muscle tension, insomnia, or stomach distress. Stress can compromise your immune system functioning leaving you vulnerable to illness and infection. Stress can also lead to high blood pressure which can lead to heart problems. Stress can lead to unhealthy behaviors such as not eating or sleeping well or increased alcohol or cigarette use. Difficulty concentrating, restlessness, fatigue, and difficulty with sleep are also often part of the picture. Managing the normal demands of a job, relationships, and every day life can then become more and more difficult.
What external situations cause stress? People often become aware of stress when they begin to experience the physical symptoms associated with excessive stress such as muscle tension, headaches, insomnia, or high blood pressure. Certain situations can make people vulnerable to stress such as major life events (death of family member, marriage, retirement, pregnancy, loss of job, divorce, etc.) and daily hassles (traffic, bad weather, relationship conflict, job stress). There is some research evidence that suggests that the cumulative effect of minor daily hassles can have a greater impact on our physical and emotional well-being than even major life events.
What internal situations cause stress? Though external situations can leave us vulnerable to stress, it is ultimately our interpretations of events that create the experience of stress. For example, when confronted with an abrasive co-worker, Jim might think to himself, "I can't handle this. This always happens to me. Nobody understands me," whereas Sally might think to herself, "Developing a way to work with abrasive co-workers is a good interpersonal challenge. How should I approach this situation? At least I know it's only that one co-worker and that most of my other co-workers are fun and supportive. I'll talk to my friend Kerry and see what she thinks would be a good approach."
What's the difference? Sally feels a sense of challenge from this even whereas Jim feels a sense of threat. Sally also has a sense of having control over effecting change in this situation, is optimistic about her ability to confront this challenge, puts the event into perspective, sees it as a specific event rather than a global situation, and feels a sense of social support. These factors are just some examples of how our interpretations of events can affect how much stress we experience.
Case example: Amy, age 38, is a worrier, She is restless, irritable, and has difficulty concentrating. She doesn't like that she worries so much and isn't always sure what it is that she is worried about. She can't let her husband or children leave the house without making them call her regularly to reassure her that they are okay. Her husband is growing weary of her fretting, and her children can't understand what the fuss is all about. Their impatience with her only makes her worry more.
Treatment strategies for GAD: Mindfulness strategies have been found to be a powerful adjunct to general cognitive behavioral therapy. Scheduling worrying has also been found to be an effective strategy where you set aside time each day to write down and give attention to your nagging worries. During the day when worrisome thoughts pop up, you make a decision to set aside those worries until your scheduled worrying time. This helps train your mind to set aside worries rather than being consumed by them all day long. This also allows you to give your worries focused attention so that they do not have to nag you for attention all day long.
Click here for more information regarding GAD from the Anxiety Disorders Association of America.
Obsessive Compulsive Disorder (see section on OCD)
Specific phobias refer to intense fears about particular objects or situations where the fear is so great that it interferes with an individual's life functioning. For example, a fear of airplanes is not a problem unless you are compromising your own happiness or your job functioning because of this fear. Common fears include fears of natural environment (storms, high cliffs, ocean), animals (dogs, insects, horses, etc.), blood and injections (usually triggered by seeing blood or an injury or thought about getting an injection or having a medical procedure), or situations (tunnels, bridges, elevators, flying, enclosed places, etc.).
Case example: Hannah, age 55, has had a phobia of spiders since she was a young child. She remembers her uncle chasing her around with spiders to scare her. Her fear has increased to the point that she avoids major sections of her home that she fears may contain a spider and will have her husband check a room before she enters it. The last time she saw a spider, she began hyperventilating and crying until her husband returned home.
Treatment strategies for specific phobias: Aside from general cognitive behavioral and mindfulness techniques, the treatment of specific phobias involves exposure to anxiety provoking objects or situations in a graduated and controlled manner to learn to tolerate the anxiety, to learn how to handle the situation, and to teach the brain that the feared object or situation may generate discomfort but is not necessarily dangerous.
What to call it exactly? Some people come into therapy, not because of specific problems or specific disorders, but because they are seeking to understand themselves better, perhaps so that they can lead a more meaningful life, build healthier relationships, feel better about themselves, or make better choices in their future. For some clients, they start therapy for specific problems or specific disorders, but once those issues are manageable and since we've already developed a therapeutic relationship, we agree to shift the focus of therapy to more global issues such as self-development, self-esteem, self-understanding, self-identity, self-improvement....call it what you will. This often entails a more thorough understanding of family dynamics past and present, family patterns passed on through generations, childhood experiences, the impact of cultural values that are imposed on us, clarification of goals and values, or prioritizing commitments to create a more meaningful life. The process and goals for therapy are mutually determined by both client and therapist.
Habit change refers to changing any maladaptive, intrusive habit such as nail biting, skin picking, hair pulling, overspending, procrastination, unhealthy eating, or other unhealthy habits. Habits to be changed are those habits that interfere with your emotional and physical well-being or cause problems in your relationships, school, or work.
Cognitive-therapy can be an effective way to change a habit. The cognitive component entails identifying the thoughts and emotions that often precede an episode of nail biting, skin picking, hair pulling, etc. By managing these thoughts and emotions in a more effective way, the need to engage in the habit decreases. A typical thoughts might be, "I just NEED to pick at my skin," or sometimes people are not even aware of having any thoughts at all and only become aware of their thoughts afterwards ("Why did I do this again? I'm so ashamed of myself.") Becoming aware of the thoughts and emotions that actually come before the habit takes much time and practice.
Behaviors might include learning to tolerate that feeling of discomfort or distress that comes with wanting to engage in the habit and not being able to. Other behaviors may include limiting contact with triggers that seem to precipitate the habit or rewarding oneself for not engaging in the habit.
Another strategy that is often important are stress management techniques. Stress is a common trigger for many different habits, and therefore, lowering overall levels of stress can help decrease the need to engage in the habit. As with any program for change, combating long-standing habits, becoming aware of automatic thoughts and emotions, and implementing an effective program of change takes time and effort. Therapy does not provide magical solutions but rather provides practical solutions that you may already be aware of but have been unable to put into practice. Therapy can also support you as you embark on this challenge, help you deal with the emotions related to the habit, and motivate you to change.
Perfectionism refers to having excessively, unreasonably high standards that, when not met, lead to harsh self-criticism and feelings of failure. Those suffering from perfectionism find that their perfectionistic standards lead to significant distress leading to stress, anxiety, physical symptoms (ulcers, headaches, aches and pains, etc.), or depression. In addition, perfectionistic standards tend to be debilitating, discouraging, or counterproductive. Perfectionism is markedly different from having healthy high standards. With healthy high standards, an individual does not feel distress but rather feels a sense of challenge or excitement because reasonable standards are set and the probability of meeting those standards are pretty good. In addition, with healthy high standards, an individual feels motivated to achieve their best rather than debilitated by the pressure to be perfect.
How does perfectionism develop?
Perfectionism is not necessarily bad, but rather, it is a strategy often developed early in life that was once effective but eventually begins to cause too much distress and impairment. Some theorists believe that perfectionistic standards are developed via harsh and critical standards set by parents that are then internalized by the children. Perfectionistic behaviors may also be modeled by parents and picked up by children. In addition, our society rewards those who strive for perfection while criticizing those who feel that good enough is good enough. Perfectionistic behaviors are maintained because sometimes it can lead to powerful rewards such as the admiration of others, high scores on exams, landing a business contract, or more money.
The problem is that perfectionism may begin to interfere with life happiness, social relationships, educational attaintment, or job performance. With perfectionism, people inevitably hit a wall where their perfectionistic standards become more debiltating than facilitating. A common phenomenon associatied with perfectionism is procrastination. The pressure to be perfect generates so much anxiety that people often choose to avoid the situation rather than confront the possibility of failure. At this point, people begin to recognize that their healthy high standards have somewhere along the way turned into debilitating or distressing perfectionism.
Treatment strategies: Perfectionism can be seen as a habit. In therapy, we can begin to generate an understanding of how this habit developed and how it can be both helpful and harmful and decide which components to keep and which to change. In addition, cognitive therapy techniques have been found to be helpful in shifting perfectionistic attitudes. This entails monitoring perfectionistic thoughts and then developing alternative perspectives.
For example, a typical perfectionistic thought might be, "I have to get this proposal right before I present it at the meeting tomorrow," which is followed by the behavior of writing and re-writing the proposal over and over again throughout the night. A strategy may be to develop an alternative thought such as, "I've been working on this proposal in some form over the last week. I'm sure I've done a pretty good job. If there's any mistake, I'm certain there won't be any serious consequence. I've done propsoals like this before and they were well recieved."
Changing perfectionistic attitudes may also require changing one's priority, for example, prioritizing your physical health and happiness over a perfect proposal. This all may sound easy enough, but if you suffer from perfectionism, you probably already can tell that change will take much effort and time. Therapy may not offer you anything magical or new, but it may offer you support, motivation, and a systematic program for change.
One of the most wonderful aspects of living in Southern California is the cultural diversity. Many people from countries around the world immigrate and settle in the area so that by now some ethnic communities have been firmly established in California for several generations. Many people from ethnic minority groups, at some time or another, go through a process of ethnic identity development. This process is characterized by thoughts, feelings, and behaviors related to the question, "Who am I?" For individuals from ethnic minority groups, this question often involves how they feel about their own ethnic identity.
There are many different reasons why one might start thinking about their ethnic identity. Perhaps it was a racial comment another person made, perhaps it is a gradual understanding that ethnicity and how you look may at times impact how others react to you (whether positive or negative or neutral), or perhaps it is triggered by life changes such as separating from parents, starting a family, or moving to a community with a different ethnic composition than one you're used to. Ethnic identity development does not necessarily have to be a confusing or torturous process and there is no one right way of feeling about your ethnic identity. Instead, it is a process of understanding more fully who you are and what that means to you.
Cross-cultural issues do not necessarily have to be the focus of one's thinking but can still impact one's life decisions and psychological functioning. For example, general life issues (transitioning to college, changing jobs, getting married, raising children, etc.) may be influenced by cultural factors such as cultural values, parental values and expectations, expectations of the ethnic community, balancing your needs and values with the family's needs and values.
Treatment strategies: Therapy can help you develop a better understanding of yourself, the influences in your life, and how that impacts your future choices. Therapy can also help you through experiences related to racism and discrimination by providing a place of support and by also helping you to develop strategies to be able to make decisions and attain life goals without feeling constrained.
For some individuals, value conflicts contribute to distress around life decisions. Parents may have been raised with different cultural values, they may want their children to follow their values, and the children may be torn because a part of them wants to follow the cultural values of their traditional ethnic group and another part of them wants to follow the cultural values they developed as Americans or American residents. Therapy can help clarify these issues so that these individuals feel they are making more informed decisions about your life.
Even if cultural issues are not the focus of therapy, it will be important to have a counselor with cultural sensitivty. Cultural sensitivity has been identified as an important component of effective psychotherapy. According the the U.S. Department of Education, a culturally sensitive individual is one who understands each individual has unique value system based on upbringing and culture, values diversity (in ethnicity, sexual orientation, religions, etc.), is aware of her own cultural biases, can work effectively in different cultural contexts, and does not assign values (better or worse/right or wrong) to cultural differences. For ethnic minority or international clients, these qualities can be quite important.