Below you will find a description of the problems that I treat in therapy and general treatment strategies for each problem.
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.
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. An individual may begin to chronically hyperventilate on a subtle level, which can lead to susceptibility to further panic attacks.
The initial 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.
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.
Annie 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.
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.
In addition, 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 everyday 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.
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 and acceptance based 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.
The cognitive behavioral treatment of insomnia may also be an important component of treatment for GAD.
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.).
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.