Anxiety and Its Disorders

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The information provided in this section is intended for clients as an adjunct to their treatment at Psychological Services of Pendleton, LLC. It may also provide useful information to the general public, but it should not be considered a substitute for psychotherapy with a psychologist or other qualified mental health professional.

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Terrel L. Templeman, Ph.D.

Anxiety is a psychological state that everyone feels from time to time. Like most other species humans are biologically wired to react to potential threats in their environment. Imagine a cat curled up in a room. Now imagine a door opening and a large dog entering the room, spotting the cat and charging it, teeth bared and growling. The cat reacts by leaping out of the dog’s way, or if cornered, baring its fangs and claws and hissing, the classic Flight or Fight response, which we humans label fear. Now suppose someone collars the dog, takes it away, and shuts the door. Eventually the cat calms itself and lies back down, but something inside the cat has changed. It likely will not drop into as deep a sleep as before. It becomes vigilant, looking at the door, more attentive to sounds. It may startle if the door opens, jumping away even before looking to see if there is a dog. Even if the dog is gone, it may take a while for the cat’s internal state to return to the same resting level it was in before the dog first appeared. Even though the cat can’t tell us how it’s feeling, we would likely say it has become anxious about staying in the room.

Now imagine yourself quietly sitting in a room. Imagine a door opening and a large dog charging toward you, teeth bared and growling. Your reaction in many ways will be similar to that of the cat. Your heart rate will quicken, blood pressure go up, breathing accelerate, you will look for cover or prepare to fight off the dog. Like the cat, you are now in a Flight or Fight mode. After the dog leaves it will take you a while to calm down, even with the door closed. Indeed it may be difficult for you to sit comfortably in that same room again for some time, and it is this state of anticipation that we call anxiety. Indeed, you may decide to never again go back to that room.

The example above illustrates some of the basic components of a fear response that is at the root of all anxiety. What are these components?

Physical Arousal

The physical symptoms of anxiety include faster breathing, increased heart rate, and muscle tension – reactions that prepare us to flee. Beyond this Flight or Fight response is a feeling of dread, which can produce light-headedness, dizziness, feeling flushed or hot, difficulty breathing or swallowing, and a feeling of unreality. Some people also get headaches and upset stomachs, which can lead to nausea, vomiting, or even diarrhea.

Fearful Thoughts

Although we can’t read the cat’s mind, human beings think in very predictable ways when they become anxious. Their thoughts usually take the form of either What if… or Have to… What if thoughts anticipate some threat or dreadful occurrence that might happen in the future. Have to thoughts direct us to do something to ward off the threat and make ourselves safe.

Escape and Avoidance

Just like the cat our first reaction to any perceived threat is to flee or escape. This is a natural fear response. Anxiety however goes beyond fleeing an immediate threat to focus our attention on future threats. Unlike the cat that may keep its eye on the door for a while and then go back to sleep, human beings have an enormous capacity to imagine all kinds of scenarios involving that door and what may happen to threaten or endanger us in the future. Persons with anxiety disorders don’t simply keep an eye open for danger, they actively avoid situations that might be threatening.

Anxiety Disorders

So what is an anxiety disorder? Anxiety Disorders have four essential components:

A strong sense of threat.
Physical arousal which is so intense it feels overwhelming.
Preoccupation with the perceived threat, which disrupts our thinking about anything else.
Avoidance of anything associated with the threat.
The combination of physical arousal, preoccupation with threat, and avoidance are severe enough to interfere with leading a normal, productive life.

All anxiety disorders involve the same components but in different combinations and intensities. Some persons are more prone to anxiety disorders than the general population because they experience more physical arousal than others. Others may be naturally more ruminative than the general population and when anxious engage in more fearful thoughts. Some situations would naturally make anyone anxious for a while, but those people who are more easily aroused or more ruminative are more likely to experience the disruptive effects of anxiety and thus are at greater risk for anxiety disorders. Anxiety disorders tend to run in families and clearly have a genetic component to them. They are also related to other emotional disorders, such as depression, suggesting a central role for emotional activation in both disorders. People who are anxious are more likely to become depressed.

Below is a description of common anxiety disorders using the components listed above.

Phobias

The most common type of anxiety disorder is the simple phobia. At sometime in their lives, about 11% of the U.S. population will experience a simple phobia. Phobias consist of fears of particular objects or situations. Common phobias include fears of heights, animals, needles, and flying. Having to face these situations creates high physical arousal, but phobias are primarily maintained by avoidance. Take snakes for example. Persons who fear snakes not only avoid contacts with the slithery reptiles but also avoid going places where they might come in contact with one (e.g., the woods, the reptile house at zoos). They even avoid depictions of snakes (pictures, movies) and dislike talking about them. Avoiding snakes keeps the fear high, and when snake phobics accidentally come across one in the backyard they are likely to freak out or panic.

Social Phobia

At some point in their lifetimes about 13% of the U.S. population will fear going out in public. Few people seek treatment for this phobia because they find ways to avoid being around people. Social phobics often find occupations that allow them to avoid going out, and when they do go out they make an effort not to draw attention to themselves. In addition to just being around people, social phobics also fear being “put on the spot” and having to speak in front of others, which is sometimes called public speaking anxiety. As with other types of phobias, when having to face a social gathering social phobics experience high physical arousal, but because it is almost impossible to completely avoid interacting with other people, social phobics also spend a lot of their waking time in fearful thoughts anticipating these interactions.

Panic Disorder

Panic attacks occur when physical arousal becomes so intense the person experiencing it feels out of control. Such attacks are fairly common in the general population. Over one-third of the general population experiences at least one panic attack in any given year. Such attacks are sometimes referred to as anxiety attacks. They can occur almost anywhere. Imagine you are rushing around in a store shopping. Suddenly your heart starts pounding and you can’t catch your breath. The store starts swirling around and you have to sit down. The experience is scary, catches you off guard, and you wonder what just happened. In a few minutes you feel calm enough to go on with your shopping. You have just experienced a mild panic attack. Here’s another example. You are riding in a car on a winding road. You’re in the back seat and after a while you start to feel light headed, dizzy and even a little nauseous. You think you’re getting car sick. The feeling is so intense you can’t make it go away. You ask the driver to stop the car so you can calm down. Even after the car stops you can’t stop shaking or get your heart to slow down. In fact it may start to get worse, and you begin to feel out of control. You worry that you might pass out! Panic attack. Or how about this example: You are on a treadmill and really working hard, wanting to get a good workout. The faster you go the more you can feel your heart beating. Suddenly you feel like you’re moving too fast, your heart is really racing, and you start to feel a pain in your chest. Are you having a heart attack? No, you’re having a panic attack. Panic attacks can even occur in your sleep. They are not necessarily associated with nightmares or even dreaming – some people just wake up in a sweat and heart pounding. What does it mean? Panic attack.

If these things happen to many people, do they all have panic disorder? No. Panic disorder occurs in those people who become anxious about having panic attacks. The physical arousal of the attack leads to fearful thoughts about what is going on. Such people misinterpret the attack as something more threatening than it really is, such as a heart attack, a brain tumor, a seizure, or going crazy. Merely thinking about having one heightens the fear for such people and may lead to agoraphobia, which is the fear of going anywhere because you might have a panic attack in public. Such persons stay home to feel safe. Others are able to leave their homes but only under certain conditions that make them feel safe – they may always require someone to go with them, or they only go to certain places where they feel safe or go out at certain times of the day, or only remain away for brief periods of time to lower the chance of having a panic attack. Panic Disorder occurs in about 3.5% of the U.S. population at sometime in their lifetimes.

Obsessive Compulsive Disorder

OCD is primarily a disorder of repeated fearful thoughts (called obsessions ) and attempts to ward off the thoughts (called compulsions). Obsessions demand attention and don’t seem to go away, no matter what the person does to make them go away. They leave the sufferer in a constant state of dread and vigilance. Common obsessions focus on germs or contamination, the possibility of being harmed or harming someone else, forgetting something important, or just “doing something wrong.” These ideas are so frightening they compel action to make them go away. If the obsession is germs, the compulsion is to frequently clean, wipe, or wash whatever gets touched. If the obsession is forgetting something or doing something wrong, the compulsion is checking to make sure nothing is forgotten, left behind, or to check over one’s work repeatedly. Safety concerns often drive OCD, so one has to check doors to make sure they are locked, windows closed, plugs fastened tightly, appliances turned off, windows closed. The fear of doing something wrong may cause one to repeatedly ask for reassurance - “Did I do that OK?” or to repeat a task many times to “make sure it’s right.” The fear of not having something needed in the future leads to hoarding. OCD can also lead to superstitious behaviors, such as tapping 3 times before opening a door, counting objects in a room or counting seconds when passing cars on the highway. In such cases one may not even know what the dreaded consequence would be, but the physical arousal is still high, and the person experiences it as a Fight or Flight situation. OCD also produces avoidance of situations that are associated with the obsession. For example, an obsession about germs results in avoiding touching certain objects that might be “contaminated.”

Compulsions get locked in through a process called negative reinforcement. Any action that makes an uncomfortable feeling go away, even for a brief period, becomes a habit. Let’s say you are prone to obsessive anxiety and you have to open a door. You feel uneasy about it and for some reason think to count “1, 2, 3” before touching the knob. Something about counting to 3 makes it a little easier to open the door, so the next time you come to a closed door you are going to be more likely to repeat the count: “1,2,3.” After a few times of doing this counting “1,2,3” becomes a habit you perform each time you encounter a closed door. Once this habit gets locked in, not counting is no longer an option – counting to 3 is now a Have to.

Unfortunately compulsions don’t make the anxiety subside for very long. For example, consider the person who washes her hands right after opening a door that may have germs on it. As soon as she dries her hands and turns to leave the washroom – guess what -- another door to open! Boom – physical arousal is back to high again. If she opens that door she will be contaminated again, and so will have to wash again. Some persons with OCD try to prevent this dilemma by carrying wipes or tissues with them wherever they go, but despite these “precautions” the obsession with germs never goes away and in fact gets worse.

Thus the OCD sufferer is plagued by both types of Fearful Thoughts listed above:
What if thoughts which becomes obsessions, and
Have to thoughts which become compulsions.
Persons with OCD try to keep their Physical Arousal at bay through their compulsive behavior, but they are in such a constant state of tension that they are also prone to panic attacks. Approximately one in 45 persons in the United States will develop OCD in their lifetimes.

Generalized Anxiety Disorder

(Worry)

Worry occurs when you try to avoid an anxious thought. Here’s an example: Your son just got his driver’s license and can now drive himself to visit friends. One of these friends lives out in the country. Your son asks if he can drive out for the evening and promises to be home by 10 pm. He is a good driver and you have no logical reason to say no, so he goes off. About 9:30 pm it starts raining. You start thinking about how slick the roads can be in the rain, how visibility is poor at night, which leads to thoughts about deer that come out at night and wander onto country roads. These thoughts raise the possibility of a car accident, which causes your mind to search for examples of teenage auto accidents. You recall a bad crash several years ago that killed a young couple driving home from a party. The image of slippery road, the sound of tires screeching, the thought of his pickup being found upside down in a ----but wait! You don’t want to go there. You are now in the realm of fearful thoughts so you try to stop yourself from thinking about them, reassuring yourself that “nothing is going to happen.” You try to put your mind on something else, switch channels on the TV, pick up a magazine….. But your mind goes back to the thought, or perhaps an image of a wreck, and you begin to doubt your own reassurance. How can you be sure nothing’s going to happen? It’s happened before. You read about it “all the time,” an overturned pickup in an irrigation ditch --- “Now stop that!” you tell yourself, “Focus on something else!” So you do something to get busy, balance the checkbook, get out the ironing board, pull up Solitaire on the internet. But it’s hard to focus because your mind continues to slip back to the thought of that slippery road, an inexperienced driver, the sudden appearance of a deer on the road. You glance anxiously at the clock and realize it’s already 10 o’clock and your son is not home! Now the physical arousal begins to build, a sick feeling in the pit of your stomach, and a strong feeling of dread that something horrible has already happened. You have to do something right now! Maybe you should call his cell phone. But what if he’s driving home right now! What if your call causes him to take his hands off the wheel for just that split second and then…. Again you force yourself to think of something else, maybe call the friend’s house and see if he is still there. This thought brings momentary relief – at least you’re doing something, taking some action. You make the call, the friend answers: He tells you your son left a few minutes ago and should be home soon. You hang up and look at the clock….

Let’s analyze this scenario.

This is your son’s first time driving off somewhere by himself, and it produces anxiety. Note that this initial anxiety is common for most parents.
The anxiety produces a What if thought, which heightens the anxiety.
You attempt to reduce anxiety by putting the what if thought out of your mind before it becomes too frightening.
The what if thought intrudes on the distracter thought.
You try again to avoid the what if thought.
The what if thought again intrudes, heightening anxiety by making you feel helpless.
This cycle repeats itself several times, creating more physical arousal, and making you feel more helpless.

To put it succinctly, worry is the futile attempt to avoid a scary thought. In the same way that avoiding a phobia only makes a phobia worse, avoiding scary thoughts only causes the thought to become more frightening.

Post Traumatic Stress Disorder

PTSD occurs following a traumatic event so terrifying you think you are literally going to die. It usually involves a very high degree of physical arousal and the Flight or Fight response. This reaction is most likely to occur in situations that are actually dangerous, such as natural disasters, combat, assaults, and accidents such as house fires. Auto accidents are the most common trauma associated with PTSD in the United States. PTSD was first identified in combat soldiers who were so traumatized by their war experiences that they became emotionally numb and unable to attend to events going on around them. This slipping into another world (called dissociation) is also common in other forms of PTSD and represents a kind of mental avoidance. PTSD sufferers are also constantly on the lookout for danger (called hypervigilance) and startle easily. They engage in fearful thoughts about what happened to them, sometimes believing themselves to be marked as future victims. Consequently they are always in escape mode, or in some cases fight mode.

Psychological Treatment of Anxiety Disorders

The following treatment methods are based upon those of Joseph Wolpe, Arnold Lazarus, David Barlow, Marsha Linehan, Steven Hayes, and other psychologists. The variations described below are mine.

Managing Physical Arousal

The first step to managing anxiety is learning how to physically calm yourself down. Taking a slow, deep breath (abdominal breathing), holding it briefly and letting it out slowly allows your entire body to pause and relax a bit. By continuing to breathe slowly and deeply your heart rate will also come down, as well as your blood pressure. Using that pause to be aware of muscle tension is also helpful. Where are you feeling tight? Your neck? Shoulders? Back? Guts? With each breath out, let go of the tightness in those muscles. Imagery may be helpful for some people. Such images as ocean waves, rocking in a chair, lying in a hammock on a summer day, or even just picturing yourself calming down and feeling more relaxed, may actually direct your muscles to relax. As you begin to feel more in control physically, you can direct your attention to your thoughts. These steps work best when you first begin to feel anxious. However, these steps do not work if you are already in the middle of a panic attack. (see below). Rather than waiting until you become anxious, practice slow breathing and muscle relaxation in brief moments throughout the day, beginning when you first wake up in the morning. Before getting out of bed, take a moment to pay attention to that first waking breath of the day, take it in and let it out slowly. As you get out of bed, stretch your limbs gently and experience the flow of air down deep into your lungs. If you go to work, take another slow breath when you get in the car and before you turn on the ignition. It only takes a few seconds. Do it again at random times throughout the day, stretching if you need to let out some tightness. These are brief, personal moments of calm, so momentary that no one else will even notice you doing them. Measuring your anxiety on a scale of 0 (none) to 10 (panic!) may also be helpful, as in the following example:

Anxiety scales such as the one above provide you a gauge for measuring physical arousal at various times during the day, so that you become more aware of changes from calm to anxious. On this scale 5 is the tipping point between getting back in control and slipping out of control. Once you feel yourself inching up toward a 5, it’s time to slow yourself down, take a breath, consider your thoughts and what you are doing (see Cognitive Approaches below). If you suddenly feel yourself in the upper half of the scale, again slow your breathing, and challenge your fears. Try not to leave the situation you’re in until you get yourself back down below a 5. Leaving a situation in a state of high anxiety makes it more difficult to face the same situation again.

What to do if you are in a panic attack. Remember, panic attacks involve very high physical arousal, often pounding heart rate, rapid or choked up breathing, lightheadedness, and even chest pain. Believe it or not, the best response to a panic attack that has already started is to just let it happen….. Slow breathing is not effective once a panic attack really gets going, and if you try to fight it you will actually make it worse, mainly because your efforts will tighten muscles and speed up your breathing, which only contributes to the sensations you are already feeling. If you just ride with it the panic will begin to subside all by itself. Some people ride it out by moving around to use up the adrenaline that is surging through their bodies. Jogging in place, jumping up and down, or just pacing the floor will burn up some of the energy. However, such activity is impractical in certain situations. If you are in a crowded auditorium, attending a funeral, or in a closed door meeting it is best to just sit through it and work on your fears. Despite feeling nauseous, it is unlikely you will actually vomit. Likewise in most cases you are not going to soil yourself, faint, or have a heart attack (see Cognitive Approaches below). The main thing to remember about physical arousal during a panic attack is that it always subsides by itself if you don’t fight it. It does so because panic attacks are very exhausting and can’t sustain themselves for long periods of time. They are like running a race or climbing a mountain – they wear you out. In fact panic attacks are so exhausting you may fall asleep after it’s over.

Managing Frightening Thoughts

It should be clear by now that where we direct our attention and how we think about something are key to how we feel at any given moment. As a demonstration try this little exercise: Think about your seat right now. Are you sitting on a soft couch or a hard 9 chair? How comfortable is it? How long have you been sitting here? Think about the muscles in your bottom, pressed against that surface, how uncomfortable they feel. Focus on the aching feeling in your back from sitting in this posture. Keep your attention focused on your bottom and your back, especially on the discomfort. How is your posture? Think about what all that sitting is doing to your joints, the discs in your back, especially those low down. Now focus on your breathing. Is it starting to pick up? How is your heart right now? Can you feel it beating? Is it fast or slow or arrhythmic? Is it all right? Notice that where and how you focus your attention directly affects how you feel, even if you are doing nothing in particular.

Here’s another experiment: Take a moment and think about what else you could be doing right now, or maybe what you should be doing right now. Were you planning to do something else before you started reading this? Is there something you need to get done today? Why aren’t you doing it now? When are you going to get around to it? What if it doesn’t get done? Are you forgetting something important? Is someone counting on you? Continue your focus on these questions and then check your anxiety level on the 1-10 scale above. Notice how your attention to your thoughts heightens the feelings that go along with them.. Anxious people pay a lot of attention to disturbing thoughts, which makes these thoughts more frightening. Such thinking intimidates the person who harbors them. There are several approaches to counter such intimidation:

The Rational Approach. Anxiety disorders tend to produce fears that are not rational; i.e., they are not likely to happen, and if they do, the experience isn’t likely to be as horrible as imagined. Take the social phobic fear of saying something wrong or saying something badly. When you actually do speak to someone is your speech really as bad as you thought it would be? And if you make a blooper – pause too long, mispronounce someone‘s name – is it really the end of the world? Or take the obsessive-compulsive fear of accidentally leaving a light on when leaving the house, which could somehow cause the house to burn down. While not impossible, the odds of an electric lamp burning down the house when no one’s home are low to zero. Or take the snake phobic fear of stepping on a snake in the woods. Most snakes hear you coming and are long gone before you cross their path, but even if you came across one it would not likely harm you. Or take the fear of panic in which you believe you will throw up in the middle of Wal-Mart if you don’t get out of the store fast enough. In fact if you just stay in the store and let the panic attack run its course you are not likely to toss your cookies, but even if you hurled all the way down Aisle 8 it wouldn’t be the end of the world, and you might feel physical relief afterward. Or take the worrier’s fear that her son will be in a car wreck if he is late coming home. Of all the possible reasons for him to be late, an auto accident is one of the least likely. Consider more likely possibilities (e.g., forgot the time and hasn’t even left yet, stopped somewhere on the way to see someone else, gave someone else a ride home, etc.)

The Rational Approach asks you to examine your thoughts more closely to determine their likelihood. Research has shown that people tend to overestimate risk when something primes them to think about risk. A common example is people who fear flying. Suppose you have booked a flight for the day after tomorrow and in today’s paper you read about an airplane going down somewhere, killing everybody on board. Although the crash may be all over the news, the odds of any given flight getting into trouble the very next day are just as low as they were the day before the crash. We overestimate risk because the news story primes us to think about the risk.

Sometimes our fears do come true. People do sometimes become tongue-tied when speaking in front of an audience, sometimes we say the wrong things and people get mad at us, we forget something important when we leave the house, we make mistakes at school or work, the car runs out of gas because we forgot to fill up, the dog gets run over, the list goes on and on. When a feared event occurs, most of the time the outcome is not as catastrophic as we imagined it to be. The Rational Approach works to decatastrophize such fears by walking through each one of them and evaluating each step in terms of its catastrophic value. Take the social phobic who fears saying the wrong thing at an important social gathering. One way to test the notion that such a blooper would be catastrophic is to make the blooper on purpose and then observe the reactions of other people. This little experiment, called a shame attack exercise, allows the social phobic to see whether the dreaded outcome really occurs.

The Rational Approach acknowledges that sometimes terrible events do occur. If you are on an airliner that is blown up the odds of dying right then are excellent. But the same could be said about being struck by lightning. Do you avoid going outside because of the possibility you will be struck by lightning? No, you go outside because the odds of being struck by lightning are actually very very low. Comparing the odds of various lethal events can itself be therapeutic, but it requires some familiarity with probabilities. It also helps you face the fact that you are mortal, which leads us to….

The Existential Approach. This approach acknowledges that we are mortal and will die of something or other at some time or other. Since we can’t know for sure when or how, the existentialist suggests we focus on what we actually do while we’re alive. Taking action gives us purpose and also gets our minds off our worries. We can only accomplish what we do, not what we think about. Or, as the philosopher Jean Paul Sartre once said, “There is only one day left, always starting over; it is given to us at dawn and taken away from us at dusk.”

The Faith Based Approach. Faith in God is one of the most powerful antidotes to anxiety. Numerous studies have demonstrated that believers are more likely to take risks than are non-believers. There are numerous scriptures from the Abrahamic faiths (Judaism, Christianity, Islam) illustrating how faith in God was sometimes the only thing that helped a person get through a crisis without fear. The 23 rd Psalm is a good example of facing fear knowing God is with you. Jesus’s comments in Luke’s Gospel (Chapter 22) put daily worries in the broader context of what is really important. Of course religion can sometimes produce its own brand of anxiety, usually about right and wrong, whether you are a good person or a bad person, doing God’s will or not, which brings on fears of sinning or even going to hell. Here the notion of forgiveness is helpful. Is God going to punish you for a particular thought? If not, why do you punish yourself? Religious persons with OCD are often beset with such obsessions, to the point where experiencing a “bad thought” translates into being a “bad person.” Unfortunately turning to scripture does not always help this dilemma, and the Mindfulness Approach may be more helpful.

Mindfulness Strategies take a more Zen-like approach to fear thoughts through a series of exercises designed to put some distance between you and your thoughts. Think of a bad thought as a kind of mental hiccup. You didn’t do anything to cause it – it just happened. The thought is not directly related to reality or the outside world or even to your personhood. It’s just a thought. Like a hiccup, you can’t make it go away. In fact, if you try to rid your mind of it you only make it worse. Mindfulness involves observing the fearful thought, as if it you were watching it on a screen, more like an observer than a participant. There may be a stream of such thoughts, like a movie with clips of this and that strung together randomly. The point is, you don’t have to do anything about them. Even if they are frightening or disgusting, just let them float on by – they are not a part of you. Let’s go back to that religious OCD person. She is sitting in church during the pastoral prayer and suddenly an obscene word pops into her mind. What if she were to blurt out that word! That would be horrible! As her fear builds she feels an urge now to actually say it, maybe even shout the word! She tries to put her mind on something else but can’t focus – the word is stuck in her mind. What should she do, get up and leave? No. Stay seated, take a slow breath, and let the word pass. Observe the word, how many letters does it have, what does it look like spelled backward. Imagine the letters of the word on a Scrabble board. Mix them up, make a different word. Or rapidly repeat the word to yourself over and over until it no longer makes sense. Like an anxiety attack, the word will eventually lose its energy and fade. Like a hiccup, it will disappear as quickly as it came.

Acceptance and Commitment therapy utilizes mindfulness techniques but also like the Existentialists emphasizes commitment to a goal or activity that not only gives your life meaning but also keeps your mind from wandering to anxious thoughts. This notion is supported by research showing that people experience more positive emotions when they are paying attention to what they are doing (see the What’s New in Psychology article, "The Dangers of the Wandering Mind"). For example, musicians sometimes speak of a “groove” they get into when playing music that allows them to tune out everything else and just “get into the music.” Writers talk about a “flow of words” when writing that allows them to do the same thing. Artists, athletes, and even mathematicians sometimes experience the same phenomenon, losing themselves in what they are doing.

Do you have to be good at something to experience flow? Not at all. Some people can get into a flow just cleaning house or working in the garden. It discharges energy, gives you something specific to focus on, and produces concrete results. There may even be a driven quality to it, but such activity is not a compulsion. Activity driven by a sense of purpose is different from activity driven by a sense of dread in at least two ways: First, while doing something purposeful your mind is focused on the task. You are literally living in the moment. In contrast, an anxious compulsion keeps you focused on how the task will turn out (remember, anxiety always focuses on the future), so you can’t really get into a groove or experience a sense of flow. Second, purposeful activity leads to a sense of accomplishment. Once you’re done, you can look back at it and feel good about it. In contrast, compulsions driven by anxiety often result in a sense of failure – no matter how hard you worked at it, it wasn’t good enough, you missed something, it could have been better. In fact anxious compulsions feel like they’re never done.

Behaviorist Approach (Face your fears)

Perhaps the most challenging aspect of anxiety is the avoidance of activities it causes. Behavioral strategies are designed to move anxious persons back into activities they have been avoiding. The most common strategy is the Approach Hierarchy, which is described in more detail in the Therapy Helper “Facing Fears”. This is basically a list of situations that you have been avoiding, with the most frightening one at the top (usually rated 100) and the easiest ones to face at the bottom (rated somewhere between 1 and 10). It helps to have a therapist create these hierarchies so that they are behaviorally specified and arranged in such a way that you can gain more confidence in yourself as you move up the scale. The following example describes a typical example for agoraphobia, which is a fear of leaving the house.

Example of Agoraphobia Hierarchy

100: Driving alone to a distant city, spending the night, and returning alone.
90: Driving to a distant city, spending the night, and returning with a friend.
80: Driving alone to a city within 100 miles, spending the day shopping, and returning.
75: Driving alone to a city within 50 miles, getting gas, and returning.
70: Riding with a friend to a distant city, spending the night and returning.
60: Riding with a friend to a city within 100 miles, spending the day shopping and returning.
55: Driving alone to the grocery store when it’s busy, buying groceries, and returning home.
50: Driving yourself to church.
45: Driving alone to the grocery store when it’s not busy, buying groceries, and returning home.
40: Walking downtown alone, entering a couple stores, and returning home.
35: Going for a drive alone for an hour.
33: Going for a ride with a friend for a couple hours.
30: Driving to a restaurant and meeting a friend for lunch.
20: Walking downtown with a friend and going shopping.
17: Making a phone call.
15: Answering the telephone.
12: Stepping outside to say Hi to your neighbor.
10: Walking around the block.
5: Going outside to the mailbox.

Hierarchies are best created by designating your worst fear at the top, the least anxious situation at the bottom, and a midway activity (rated 50) that divides the hierarchy into top and bottom halves. Note that these hierarchies are very personalized and must be tailored to your individual needs. For example, in the example above driving to church (rated 50) is considered more anxiety provoking than going for a drive alone for an hour. Note also that slightly altering the situation may make it more anxiety provoking. Some agoraphobics are also socially phobic and restrict their shopping to times of the day when there are few other shoppers in the store. Thus in the example above going to the grocery store when it’s not busy is rated lower (45) than when it is busy (55). Such attempts to make yourself feel safe when going out are called safety behaviors.

Safety behaviors are somewhat like crutches in that they help you face frightening situations, but unlike crutches you never get rid of them because they actually keep your fear of these situations alive. Although they provide a sense of overcoming fear, you come to depend upon them to feel safe when facing these situations. Without them you will feel even more anxious. Examples include

Going out only at certain times of the day
Going to a party only if certain people are going to be there
Always carrying a cell phone “in case of emergency”
Wearing a special garment when you go out, regardless of the weather
Carrying a lucky charm
Keeping a dose of anti-anxiety medicine on your person at all times
Taking a specific route to a destination even if it’s not direct or efficient
Waiting at least six rings before answering the phone

Examples like these usually come into play through negative reinforcement. That is, the first time you engage in them in an anxious situation you feel more at ease, so you are more likely to do the same thing the next time you’re in the same situation. Feeling at ease reinforces the safety behavior in the same way that the famous psychologist B. F. Skinner trained pigeons to develop little rituals when pressing a key for food. He noted the similarity between these little rituals the superstitious behaviors of people.

In contrast to safety behaviors, approach behaviors more directly expose one to the fearful situation. Examples of approach behaviors are as follows:

Leave the house at all times of the day
Go to the party without your friends
Leave the house without your cell phone, medicine, lucky charm, special coat, etc.
Take a different route to your destination every time you go out
Answer the phone on the first ring

Getting rid of safety behaviors is difficult because when you try to stop doing them your anxiety initially gets worse! Talking yourself through them with directives like, “Just do it!” and “I can do this!” sometimes helps. Breaking these habits may require someone to walk you through the approach behavior so that you actually do it. But watch out! Sticking too close to your helper could become your next safety behavior.

A behaviorist approach to reducing fear of physical arousal involves exposing yourself to bodily cues that promote the anxiety. This technique is called interoceptive exposure. Common internal sensations during panic include rapid heart rate, difficulty breathing or swallowing, hyperventilation and light-headedness or a sense of unreality, caused by an increase in carbon dioxide. Some people are very sensitive to internal sensations, from their lungs to their muscles, heart rate, bowels or bladder. They are on “high alert” for any slight alteration in the functioning of these organs, and they become anxious when something “feels wrong,” which leads to the fear of losing control. This fear focuses attention on these sensations, which escalate and become more worrisome. One way to reduce this fear is to make the sensation happen on purpose, or expose yourself to it as an exercise. For example, practice breathing rapidly for 60 seconds to bring on the internal sensation of hyperventilation. When you stop, see how long it takes for the woozy feeling to subside. Time yourself if you like. Instead of fighting the feeling, go with it. Let it roll over you. Let your breathing slow back down by itself. Don’t try to make it happen, just let it follow its own course. Here’s another exercise: Run in place until you get your heart rate up to 150 beats per minute. Don’t stop just because you feel faint or dizzy. After about a minute, stop or walk slowly around the room. Continue walking or just breathing normally until your heart rate subsides. There are many different interoceptive exposure exercises. (See Chapter 10 of the book, An End to Panic published by New Harbinger Press.) The key is to practice them once or twice a day until the sensations they create no longer frighten you. Practice experiencing the sensations not only gives you more confidence in dealing with them but also desensitizes you to them when they occur spontaneously.

Behavioral practice helps you face other stresses besides internal sensations. Even the most experienced actors and public speakers rehearse what they are going to say before they perform in public. Rehearsal helps you get comfortable with your own words and gives you an opportunity to try out different approaches. Rehearsal also helps you get comfortable with making mistakes. Practice your flub-ups at home. However, it’s important to remember that rehearsal doe not eliminate mistakes. Everyone makes mistakes. Rehearsal desensitizes you to making mistakes. Thus rehearsal is a prelude to exposure, not an avoidance strategy.

Ready for Treatment?

Now that you have read over the types of Anxiety Disorders, make some notes about your own symptoms, noting

Your physical symptoms
Your thoughts
Situations you are avoiding
Behaviors that get in the way of facing your fears

Review the treatment approaches listed above and decide which ones you would like to try. Therapy for anxiety disorders works best with a therapist to help you identify your target symptoms and coordinate your treatment strategies.