As I mentioned previously, many people with anxiety try to avoid or ignore the anxiety. However, this can be counter-productive. By being aware of the anxiety, particularly the ebb and flow of the anxiety, the specifics of the anxiety, the nuances of the anxiety, you can learn greater control of it.
So often people identify success in managing anxiety as becoming anxiety free. However, this is an unreasonable goal because anxiety is a normal part of life. Anxiety provides information that we may need to act upon.
Think of it as similar to pain. If you have a sudden pain in your leg, that is information you need to assess. You may realize you just bumped your leg against something but it is nothing to worry about. Or, you may have seriously injured it and need immediate medical assistance. Without the information from pain you may not realize that a serious situation exists (there are medical conditions in which people don't have a pain response and life-threatening problems may not be noticed as a result).
Anxiety is very similar. We need the information anxiety provides so that we can assess a situation and take appropriate action. A better goal in the treatment of anxiety is to learn to pay attention to anxiety, identify the information provided by the anxiety, and to determine a course of action. To do this, however, you need to be able to identify when the anxiety is irrational or excessive. The previously described cognitive methods can help with identifying and challenging any irrational thinking that is involved.
The track and reduce method can help when anxiety is excessive. There are a number of ways this can be done and will vary depending on each individual situation. However, the idea is to track some aspect of the anxiety and see if it can be reduced over time. This creates a focus on gradually reducing the anxiety rather than an all-or-nothing focus of getting rid the anxiety.
A couple examples can illustrate how this can be done. Many people with anxiety have frequent worries. Tracking the worries can be simply counting every time a worry thought occurs. I find an easy way of doing this can be having a golf score counter in your pocket that can be clicked every time you have a worry. This can be done just during certain time periods or even over the course of the day. At the end of each day you can record the number of worries.
Another example is measuring the amount of time that a panic lasts. Again, you can use a device such as a stopwatch in your pocket that you can start and stop when the panic occurs.
The interesting thing about tracking behavior is that sometimes the tracking itself will reduce the behavior. When we become aware of behavior and are not just engaging in it automatically, we often will exert more control over it. However, even if that does not occur, the process of tracking the behavior can allow you to use other methods to see if you can reduce the chosen behavior.
One thing to keep in mind is that there can be a great deal of fluctuation in the daily count. Therefore, if you are trying to reduce the behavior, it is better to use an average to measure your progress. such as the weekly average of your daily count.
Just the term “interoceptive deconditioning” may sound pretty scary. And knowing what it means doesn't make it any more comforting. “Interoceptive” refers to the symptoms of anxiety. “Deconditioning” means to be exposed until you are no longer reactive. So this method means to be exposed directly to the symptoms of anxiety until you don't react.
Although this is a very intense method, it is one of my favorites for Panic Disorder because it can be so effective when done right. As I mentioned before, however, it is very important to work with a specialist when using the more intense methods.
With interoceptive deconditioning we usually start with an evaluation to determine if we are able to elicit the symptoms artificially. Obviously this method may not work for everyone because some people think “I know I am creating the symptoms so they don't bother me. What worries me is when I don't know what they are.” However, for those who are fearful of the symptoms no matter how they are created this method can be very useful.
A number of methods can be used to create anxiety symptoms:
1) Cardiovascular exercise. For people who are reactive to rapid heart beat and labored breathing, running in place or up and down stairs can elicit uncomfortable symptoms.
2) Hyperventilating. For those who are reactive to breathing problems combined with dizziness or light-headedness, deliberate shallow rapid breathing can bring on these symptoms.
3) Spinning around. For those who dislike feeling unsteady and dizzy, spinning around in place can create these symptoms.
Evaluation involves determining which symptoms can elicit discomfort and what degree of discomfort they might cause. An evaluation needs to start out slowly so that a starting point can be determined without creating panic symptoms initially. Therefore, if I am evaluating how someone reacts to spinning I have them start with turning around slowly once. Then I ask how they feel and if it elicits any anxiety. I then gradually increase the spinning until we find the point with which they are uncomfortable. For people who are reactive to these methods it often doesn't take much to create an uncomfortable level of anxiety. In fact, with most of the people I've used this method, one to three turns will elicit discomfort and anxiety.
If they do not react to this artificial means of creating anxiety symptoms, then interoceptive deconditioning is not a useful treatment method for them. However, for those who react during the evaluation, we now have the means to create anxiety symptoms as well as a starting point. Typically, I use this method in the office initially before I have them do it on their own. I provide explicit instructions to my client regarding what we are doing. For example, “I want you to turn around 3 times, remain standing, and tolerate the symptom for a minute. If the symptom reduces before the minute is up, spin around again. Once the minute is up, use your coping skills to reduce your anxiety symptoms.” These instructions will vary depending upon what we are trying to achieve. However, generally, the idea is to increase the intensity of the symptoms and the length of time the symptoms can be tolerated.
After the interoceptive exposure, I obtain specific information regarding the exposure experience such as the highest the anxiety level reached and how tolerable it was. This information is used to decide how to proceed with the next exposure. Exposures during the therapy session often allows us to do numerous exposures during each session. Typically, we will see an improvement even over the period of one session. However, the entire process may take several sessions.
In addition, because many people are reassured with the presence of the therapist, once the client is able to tolerate the in-session exposures, they are assigned interoceptive exposures to complete on their own. These exposures will also involve a gradual desensitization process.
As I have said, this method can be very effective. I have seen people elicit panic symptoms, tolerate the symptoms for a period of time, and then reduce the symptoms at will using their coping skills. When a person learns to do this, their cognitions about panic will likely change. They are more likely to believe “I can handle panic. I'm not afraid of it.”
A flooding exposure is engaging in a situation that will elicit panic and staying in the situation until the anxiety decreases. This is a very intense type of treatment and should never be used without a skilled professional as it can cause increased sensitization and fear if not done correctly.
Most importantly, when a flooding exposure is used in treatment, it is necessary to remain in the exposure situation until the anxiety is reduced. This can be difficult to do in the typical therapeutic hour because the therapist cannot say “I'm sorry, but our time is up” while the person is still experiencing a high level of anxiety. Otherwise, an increase in fear may occur. Often it is best to do flooding exposures under very controlled circumstances such as in a day treatment program.
Another problem with flooding exposures is a high drop-out rate. Many clients will refuse to continue with therapy because the exposure is too frightening for them. This is also likely to lead to increased fearfulness as well as hopelessness.
Fortunately, I find that most people can be assisted with gradual desensitization exposures and do not require flooding types of exposures. However, there are several circumstances where flooding might be the treatment of choice:
1) Time. Flooding takes less time—it can be rapidly effective. If someone has a time limit such as they need to be able to travel by a certain time because of a work demand, then flooding might be the quickest method.
2) All situations create high anxiety. For systematic desensitization it is necessary to develop a hierarchy that includes lower level exposures. For some people, everything, including exposures with therapist support, may elicit high levels of anxiety. In this case, there may not be an option for systematic exposures and flooding is the only way to proceed.
3) Other methods have failed. If the other methods have been tried but were ineffective, then flooding may be worth trying.
If it is decided to use a flooding method, the process needs to be carefully structured by the therapist to ensure a high level of success. The specific goal needs to be determined. The method of exposure to achieve that goal needs to be described specifically. How to keep the client in the exposure until the desensitization has occurred needs to be addressed.
It should go without saying that the client should be fully involved and informed during this process. No one should ever deliberately expose a person with an anxiety disorder to a high level exposure without a careful plan and full disclosure. Unfortunately, however, I have known of family members and even a few health professionals who have placed a person in a high level exposure without their consent. It usually has disastrous results due to increasing their fear as well as lowering their trust of others.
A paradox is a statement or situation that seems to be illogical or contradictory to the goal although in reality it is not. In the situation of an anxiety disorder, the person with anxiety wants to get rid of the anxiety. Therefore, it would seem to be illogical to try and create anxiety. However, that is exactly the purpose of this type of exposure.
You may realize after reading the previous suggestions that the goal of CBT is not to get rid of anxiety but to learn how to tolerate it and manage it. The less fearful you become of the anxiety, the less control it has over your life.
Paradoxically creating anxiety teaches you that you can tolerate the anxiety. In addition, it helps you to recognize your control over the anxiety. In particular, if you are able to create anxiety, you also may realize that you have the ability to reduce anxiety. To create anxiety you need to think in certain ways. Therefore, to reduce anxiety you can change those ways of thinking.
Sometimes that can occur automatically in the process of trying to create anxiety. For instance, I once treated a client who had a fear of having a panic attack while flying. We used other methods to prepare for a practice flight including imaginal coping exposure methods. However, my final instructions were to fully experience the anxiety on the trip to Chicago and to use the coping methods on the way back.
I wanted him to realize that he could have a panic while flying and be able to tolerate it. The goal was to paradoxically create a high level of anxiety and ask for assistance from the flight attendant. However, when the person reported back after the trip he said “I really tried to be anxious but I just couldn't.” He was so prepared to tolerate the anxiety that he was unable to create it.
This can sometimes be an outcome of trying to create the anxiety. Just the process of attempting to create the anxiety makes you aware of your control over it and your ability to tolerate it. As I previously stated, when you can believe “So what if I have anxiety?” you are likely to experience less intense and less frequent anxiety because it is the FEAR of anxiety that empowers it.
However, this type of exposure can't be for the purpose of failing to create anxiety. It needs to be with the full belief that anxiety will occur and the attitude of being able to tolerate it no matter what. “So what if I have anxiety?”
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