Exposure Treatments for Anxiety Disorders

A Practitioner's Guide to Concepts, Methods, and Evidence-Based Practice

Johan Rosqvist

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136915772
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Exposure Treatments for Anxiety Disorder s is a unique volume, as it draws together the latest research on the rapidly-expanding field of anxiety disorders and illuminates how to correctly apply the proven methodology of behavioral therapy techniques to the variety of situations that face today's mental health professional. That said, cognitive therapy has in the last 10 years gotten increased attention as an alternative to behavior therapy in the treatment of anxiety disorders. But while it is gaining acceptance among practitioners, cognitive therapy has yet to illustrate substantial benefits above those that behavior therapy can already provide. In light of the aforementioned, coupled with the pressure many practitioners feel from managed care paradigms and shrinking healthcare coverage, this book will be a welcome resource allowing for increased clarity of action, accountability, and ultimately, positive client outcome. Each chapter is designed to address pivotal aspects in the assessment, formulation and diagnosis, and treatment of anxiety disorders, to a sufficient depth that the generalist practitioner will be comfortable using this book as a guide when working with the anxiety disordered client.

CHAPTER 1

The Anxiety Phenomenon:
Nature and Disorder

Therefore, do not be anxious about tomorrow,
for tomorrow will be anxious for itself.
Let the day's own trouble be sufficient for the day.

—Matthew 6:24

DESCRIPTION OF ANXIETY AS A NORMAL
PHENOMENON AND IN ANXIETY DISORDERS

Anxiety is a normal and naturally occurring universal phenomenon that plays an ongoing role in people's daily life. In foundation, it is a primitive biophysiological process meant to protect the person experiencing it during times of danger through preparing and priming the person to act in self-preserving ways. Indeed, in the face of threat, this biophysiological process should activate to increase pure odds of physical survival. This process works in a predictable fashion, and has, over evolution, served to protect species of all sorts, including people. In fact, people have successfully survived to procreate and have consequently furthered the human species in the face of much ecological adversity because of their capacity to react with anxiety. In this vein, anxiety is good and normal (e.g., Darwin, 1872/1965; Skinner, 1963).

Anxiety, in short, is adaptive in that it holds great survival value. In times of danger, anxiety can be a person's “best friend.” Yet, few people who experience anxiety in modern times proclaim much fondness for the response. Anxiety, for all its greatness and utility, can be perceived and experienced as physically and emotionally quite uncomfortable and disturbing. Some people are even frightened by anxiety, especially when they do not understand what it is and why it occurs. In this sense, people might become anxious about anxiety or fearful of fear (e.g., Barlow & Craske, 2000; Craske & Barlow, 2000; Craske, Barlow, & Meadows, 2000; Otto, Jones, Craske, & Barlow, 1996; Otto, Pollack, & Barlow, 1995). Just how frightened or uncomfortable a person feels when experiencing anxiety is directly related to the presence and immediacy of threat; the closer in proximity, both in space and time, threat is, the less uncomfortable the anxiety will seem, because it then makes common sense and has an obvious source and inherent value (Barlow, 2002; Craske, 1999; McLean & Woody, 2001). When threat is further away, however, or is perhaps even theoretical or abstract, experienced discomforts are more negatively viewed as the anxiety response, which is then less useful in the immediate moment. Under such conditions, it just feels bad. Unfortunately, people are not terribly accurate about what constitutes threat or danger; in fact, so long as the person perceives or believes there to be danger (i.e., whether real, imagined, or misconstrued), his or her body will predictably react as if it is genuinely being threatened, and begins activating the self-preserving survival mode. The brain is in essence a loyal listener, but may not necessarily be an accurate judge of what is real and what is not real.

Most people experience an anxiety reaction, or the activation response, in presence of true threat. This action should work this way and is highly desirable. For instance, if a person crossing a street glances over and sees a car heading straight toward him or her, giving no signs of slowing down, there is a perceived danger of being hit by the car if some action is not taken to avoid being hit. The anxiety response then, almost instantaneously, kicks in, reacting to the estimated threat of potentially being killed or being seriously injured or maimed if he or she does not get out of the way.

This reaction of anxiety to the presence of true threat constitutes a normal type of one-way reasoning and reactivity that all people have the capacity for. Again, for purposes of survival, this is a desirable and preferred way of responding. Most people who have jumped out of the way of oncoming cars, and the like, are indeed probably thankful and happy this capacity exists. Although the circumstance could have been experienced as frightening—as almost being hit by a car can be—the activating response is probably not viewed negatively, and the person who survived the experience typically reasons he or she responded as he or she should have. Given the situation, that person responded as needed (with anxiety and fear) and survived it. Fanselow (1984) suggested that fear is a motivational system that organizes an organism's response at many different levels (e.g., overt behavior, autonomic functioning) so that the response is coordinated toward the function of protecting against environmental threats—more precisely, predation. This coordination restricts responses to a behavioral response set consistent with an evolutionary history of thwarting predation; in lab rats, for example, the dominant response is freezing, usually next to a wall, in a corner, or in a darkened area, because doing so optimizes antidetection properties of freezing. When it freezes, the lab rat exhibits a number of interesting and useful responses; for instance, its heart-rate decelerates and its breathing becomes shallow and rapid, helping it to become less perceptible to the eye and perhaps contributing to a decreased likelihood of the animal being overlooked by a visually scanning predator. Freezing is also associated with increased attention and decreased reaction times, allowing prey to become increasingly vigilant and ready to spring into action (i.e., flight or fight). Additionally, the lab rat becomes analgesic, activating the endogenous opioid system; this response reduces recuperative behavior (e.g., wound licking), because it would disrupt responses needed for immediate survival. Putting all of these normal, natural responses together increases sheer odds of survival, and are controlled by a system chiefly concerned with protecting the organism from predation. At times of threat, this system should “fire.”

Although this one-way (i.e., in the presence of danger, react with anxiety) reasoning is normal, Arntz, Rauner, and Van den Hout (1995) eloquently described a second type of reasoning—bidirectional reasoning—that leads to undesirable, abnormal anxiety reactions. They reported that ex-consequentia (read as bidirectional or emotional) reasoning makes the person reason in a backward fashion. As with other people, those who suffer with anxiety disorders also respond with anxiety to truly dangerous situations, such as almost being run over by a car. That kind of response is still advantageous. On the other hand, anxiety-disordered people often also reason in this other, unique way. That is, when they feel anxious, they emotionally reason, or infer, there must be danger. After all, as most people recognize, anxiety should occur within the context or situation of threat and danger. So, when the anxiety-disordered person feels anxious, he or she understands or interprets that it signals the presence of such negative contexts, and, not surprisingly, the person responds as if in such situations. In essence, the person sometimes emotionally responds with anxiety when there is no car coming, and he or she may indeed respond like this to a variety of circumstances devoid of actual threat, or may represent benign or imagined (misperceived) dangers. These people are reacting in this bidirectional way because it feels like there should be danger around. Ironically, if the body and brain cannot tell the difference between actual, benign, and imagined, then it will respond to them equally.

Arntz et al. (1995) argued that ex-consequentia, or emotional reasoning, plays a central role in the development and maintenance of pathological anxiety and fear. They reported that when patients are questioned about the specific danger in specific situations, the patient might very well present the argument that the experienced anxiety and fear is sufficient “proof” that there must be danger. They cite Beck and Emery (1985) as describing this type of emotional reasoning when suggesting patients use their feelings to validate their thoughts and that such behavior starts the vicious, self-sustaining circle of reasoning that there must be something to fear if one feels anxious. Collectively, this reasoning anomaly portrays itself in the following fashion: “If there is danger, I feel anxious” implies or infers “if I feel anxious, there must be danger.” In their description of this bidirectional reasoning phenomenon, Arntz et al. hinted at a particularly compelling example of how to illustrate the fallacious nature of this way of reasoning, namely the “cow example.” I have adapted this example and incorporated it as a standard story/metaphor for explaining emotional reasoning in a fashion to enhance information processing and integration. Otto (2000) suggested that the use of stories and metaphors in cognitive-behavioral therapy (CBT) provides a method for transforming therapeutic information, sometimes quite technical and dry therapeutic information, into a more palatable and easily understandable format. Such a modified format makes it much easier for patients to readily remember the information and apply it in real-life situations. Most patients I have treated tell me that there is no way to forget the cow illustration and find that it helps them notice “cow moments” when they are happening in their daily life. This is of central value, because emotional reasoning appears to be otherwise largely responsible for maintaining abnormal anxiety and fear. The metaphor/story, as I tell it in my own work with anxiety disordered patients, follows.

People are interesting creatures, in that we are very adept at surviving. I have spent a fair amount of time investigating just how people “survive,” and what I have found is that how we reason is quite influential in how people decide what is dangerous and not. After all, to survive we have to escape from or avoid danger altogether. As it turns out, as you well know, life has its dangers, so reasoning plays an important role in how well we do or fare in life. Unfortunately, in the reasoning department, there are some ways in which we tend to get ourselves into more trouble than is good for us. That is, sometimes when we reason that there is danger or threat, there really isn't, or we grossly overestimate just how dangerous some situation or circumstance really is, and as a result we feel anxious or at least quite uncomfortable when we really don't have to be. In the absence of such real situations, anxiety doesn't seem to help much, and if anything it tends to make life pretty miserable.

Because you are sitting here with me today, I imagine you might also have some difficulties with feeling anxious a lot of the time, even when there isn't a directly discernible threat around; is that right? [Patient typically responds in the affirmative because he or she is seeking help for some anxiety condition.] OK, well, anxiety is an interesting phenomenon, in that it is supposed to prepare us to act in the presence of some bad situation; that is, it typically prepares us to run like the wind or fight like a mad person when we are faced with some real danger. That way, we have a better chance of surviving. It isn't really that fancy, but it works like a charm when the chips are down. By surviving, we live to tell the tale another day, too, and, ultimately, to pass on our genes. Survival, then, is the actual goal of anxiety. People have in essence survived because we have the capacity to respond with anxiety. So, how does this reasoning business come into it all then? Well, it turns out that in the presence of threat and danger we all respond with anxiety, as it should be, so we can run away from—or avoid—the dangerous circumstance. So, imagine that danger triggers anxiety [I typically will draw on a whiteboard the relationship DANGER → ANXIETY]. Again, it should work like this, and it is good for survival in that anxiety will help you run or fight. The problem is this: many people who struggle with anxiety tend to reason the other way, too. That is, if they feel anxious, they reason there must be something to be feared around. [I typically draw the relationship DANGER ← ANXIETY.] Fortunately, danger isn't lurking around most corners these days, so a lot of the distress experienced, unfortunately, is really unnecessary. After all, who really wants to feel anxious when it isn't necessary? It feels bad! Make sense so far? Understand? [Here I am eliciting whether the patient has followed me to this point because I am about to launch into the metaphor (cow) part.]

OK, well, let's talk about something quite different for a little bit, but I think you'll find it really isn't so different after all. Let's talk about cows. [Here it is normal and expected that the patient initially looks puzzled, and if he or she looks too perturbed I usually ask him or her to bear with me.] Cows, unless something dramatic or strange has happened to them, have four legs, correct? [Patient usually agrees, even if puzzled by the line of discussion.] Well, let's look at a particular relationship then. If you have a cow, you have four legs, right? [Again, patient will commonly agree, and I draw the relationship COWS → FOUR LEGS.] Kind of like if you have danger, you have anxiety [pointing to the relationship DANGER → ANXIETY]. Well, let me then ask you the million dollar question. [Pause, to make the patient focus and expect that something important is coming.] If you have four legs, do you always have a cow? [Here I pause again for important effect, and allowing time for the patient to begin to form a beginning, naturally occurring insight (“ah-ha” moment) into the problematic relationship.] What else could you have if you had four legs? [Pause; patient might contribute something.] How about a horse? How about a dog? A cat? A table? A chair? How about anything which has four legs? [Pause.]

So, is it really true then, that when you have four legs you always have cow? [I typically draw COWS ← FOUR LEGS.] Why do four legs have to be a cow? [Pause.] I'll tell you why. It's because it feels like a cow. Four legs feel like a cow, much like anxiety feels like there's danger. If something feels bad, it unfortunately often becomes, or is reified into being bad, whether that's true or not, unless you question it. [Here I am making sure to illustrate the problematic connection between feelings and feelings that reify situations into being “true.”] So, the next time you feel anxious, ask yourself “where's the cow?” to begin to question whether you might be engaging in emotional reasoning, or reasoning with how it feels. If that turns out to be true about what you are doing, then you might be feeling anxious when it's really not needed. After all, if you look around and can't see a cow, why should you behave like you're about to run for your life?

A vast majority of patients report, during follow-up assessments and interviews, that the multitude of stories and metaphors I use in my work with them stick. Some of them even go so far as to create metaphorical reminders for themselves to highlight the main themes discovered and lessons learned during treatment (e.g., some former patients have reported carrying around a picture of a cow [or cows] on a 3 × 5 note card as a consistent reminder that they may be prone to emotional reasoning and its effects if they stop paying attention to such processes).

It is quite understandable why anxiety-disordered people and people in general really feel so bad much of the time if they do not regularly question what they feel or believe. Emotion theorists have long portrayed certain basic emotions as adaptive response sets meant to protect against danger (e.g., Ekman, 1992, 1994; Izard, 1992; Panksepp, 1992). Without questioning them, these emotions and beliefs might as well be true, or absolute, because the person will most likely act on them as if they were true if he or she does not consider their veracity. When a person acts on something as if that situation is true, it by default becomes “reality.”

Indeed, some emotion theorists (e.g., Russell, 1980; Russell & Mehrabian, 1977) have found combinations of emotions that, as a conglomerate, look in action and effect much like the two most common byproducts of anxiety and fear, namely withdrawal (i.e., escape) and avoidance. Specifically, they consider combinations of activation (arousal), pleasure (valence), and dominance (control) in portraying a system for how to formulate what happens in anxiety and fear experiences. Fear, according to their system, would be demonstrative of a combination of high arousal, low enjoyment, and low control; combined, because of the aversive nature of the combination, these often produce the behaviors of escape and avoidance. Again, people generally do not like feeling bad and generally act to reduce negative states.

Mowrer (1939, 1960) suggested, in his two-factor theory of fear acquisition and maintenance, that the autonomic response reactivity must be regulated to reduce escape and avoidance behaviors to a meaningful degree. So long as situations feel bad, whether true or not, such problematic behaviors will continue. Therefore, autonomic arousal and reactivity must be reduced to eliminate anxiety and fear to a meaningful degree and to improve overall individual functioning. A more complete discussion of the role of negative reinforcement in the acquisition and maintenance of anxiety reactions and fear responses will follow. Nonetheless, escape and avoidance behaviors, including safety behaviors and reliance on safety signals, are central contributors to the maintenance of anxiety and fear (Craske et al., 2000).

Although most people who experience anxiety to any great extent can clearly say that something is (obviously) happening within their bodies, few can adequately explain the phenomenon or know exactly what does happen when they are exposed to a perceived or actual threat. A general lack of knowledge about processes of anxiety often contributes to irrational, fear-based reasoning about meaning of symptoms. Appreciating the predominantly fallacious nature of anxiety and the misconception that it occurs in the presence of danger (only) readily affords the practitioner insight into how easily people can give meaning to their symptoms that simply cannot be supported by facts.

In working to normalize the experience of anxiety with patients, it is often useful to provide detailed scientific explanations about the bio-physiological processes involved. It is often the component bit within bio-psychosocial formulations that patients know least about, and struggle most with understanding because it involves biology, neurology, and other highly complex chemistry issues typically outside many laypersons’ educational backgrounds. Lacking such detailed knowledge and insight leaves many patients reporting that they fear the symptoms they are experiencing are demonstrative of being “crazy” or are precursors to going insane. Many are quite relieved to hear this is a common fear, but then also often go on to have questions about what exactly their bodies are doing and why they are doing it, if the experience is not indicative of impending major mental health problems. Depending on the sophistication of the patient, information can be tailored both for amount and depth. As a basic orientation, patients benefit universally from knowing that the response sets are adaptive, in that anxiety allows people to learn more quickly and perform better motorically and intellectually in preparing to meet challenge and adversity (Barlow, 1991a, 1991b).

When a more complex explanation is required, it is often most useful to explain what survival value each symptom experienced holds, and how that symptom is created, much like what is commonly done in the psycho-educational component of panic control treatment (e.g., Barlow & Craske, 2000; Barlow, Craske, Cerny, & Klosko, 1989). It is commonly most helpful and easier (more tolerable) for patients to start such a discussion by focusing on several specific symptoms more commonly experienced during anxiety. For instance, because an increased heart rate commonly occurs during stress and adversity, it makes a good starting point. It is important to explain that a pounding heart is related to a quickening heart rate, which allows the heart to pump blood more quickly to the major muscle groups engaged when one is running or fighting. More blood is needed for those high-demand activities, so the heart has to work harder to support such behaviors. If the heart rate goes up, the respiration rate likely follows in increasing quickness, often producing rapid, shallow (panting) breathing. This allows for more oxygen in the blood. This is important because many “fuels” are transported on oxygen molecules. Indeed, more fuels are typically required for running “like the wind” or fighting “like a mad person,” so the liver dumps increasing amounts of glucose into the bloodstream for transport to major muscle groups. Because the major muscles need more fuel, the blood vessels in such groups expand, whereas blood vessels in extremities contract. Shunting blood away from extremities also serves the purpose of preventing excessive bleeding from points of contact initially most likely to face danger (i.e., hands, arms, feet, legs, and skin surfaces). Not only is blood drawn away from extremities and the skin, but also away from digestion (i.e., it does not serve an immediate survival value). Essentially, lots of responses occur that prepare a person to be best able to fight off an attack (become aggressive) or run away from such a threat.

For some patients who become more intere...