Psychotherapy and Training Collective of New York



Dread and Worry 101



By Laura Impert, LCSW

How much worrying is too much? Like many mental health issues, anxiety is on a broad spectrum ranging from "normal" worry to dysfunctional anxiety that interferes with everyday life. The piece that follows is about the experiential aspect of worrying, (Footnote 1) specifically the inner experience of the "somewhere in–­between" worrier who struggles to curb everyday worrying but often lacks the necessary tools to stop.

For anybody who has suffered from chronic worry, anxiety is an awful experience. Sometimes even going outside and talking to a neighbor is avoided or the thought of sitting in a meeting and speaking is overwhelming. Many of us hear our patients say, "How do I stop this? I know my thoughts are irrational but my mind gets stuck." Perhaps not coincidentally, therapists themselves often feel powerless to offer more immediate relief and struggle to find what will help their patient. Will this patient benefit from more support, concrete guidance, use of specific techniques or just more time in the office working together? But patients presenting with anxiety symptoms are often suffering acutely and more than willing to put in the time.

What Happens When Context is Lost

Think of a powerful camera zooming in on an image. The anxiety sufferer not only zooms in on small details but ascribes meaning to them. The larger context of the situation fades from view. Triggers might include an upsetting situation at work, a social interaction or a health concern. Small details consume the field of focus: "My rash looks redder today. Or, what if I speak up at the meeting later and say something stupid and people think I don't belong." When flooded with anxiety, alternative perspectives or explanations are dismissed or disregarded.

This way of thinking is often referred to by cognitive behaviorists as "faulty appraisal thinking". On the one hand, the anxiety sufferer pays too much attention to the world around them and on the other hand, instinctively avoids situations that might help them shift perspective.

Pattern Recognition

Social researchers suggest that we would not have survived as a species if we didn't know how to worry. Our ancestors were clever enough to make sure that someone was listening for predators at night. We seem designed to worry­ to be on the lookout for changes in details that might indicate danger. We are perceiving and assessing constantly. Anyone who has had a close call driving on the highway knows how the surge of adrenaline slows down time. Important details jump out automatically, guiding the driver to avert disaster. Pattern recognition is wired into our brains in order to deal with acute danger.

Anxious Worrying vs. Pattern Recognition

The anxious worrier has great difficulty switching off the useful kind of pattern recognition when flooded with anxiety symptoms. One patient of mine constantly worked to keep her worrying under control and commented, "It's like a sorting problem. I can't stop going through all the details. I keep trying to figure out which ones are important and which ones aren't." Another patient felt sure that a recurring rash on her elbow was a melanoma in spite of negative lab reports. She looked for reassurance constantly from doctors to friends to the Internet. Convinced that no one really understood the genuine threat of a skin cancer, she felt dismissed by friends and family and became more isolated.

Reassurance Seeking Behaviors and Magic

Anxiety sufferers find it difficult to trust the accuracy of their perceptions and comment that they wish they had clearer gut feelings that could guide them. Reassurance seeking behaviors, coined by cognitive therapists, are common for patients with anxiety disorders. Behaviorists have classified three types of general reassurance—self­reassurance: (checking a door to see if it's locked or anxiously replaying a work call in one's mind). The second category is reassurance seeking from others: (asking a friend to confirm that their partner looked angry). The third is research seeking behaviors to magically relieve a chronic worry (maybe this last article will give me the information I need to calm down). I've had patients tell me that they feel compelled to keep worrying because of the feeling that the missed a clue. Reassurance becomes equated with the magic fantasy that the right person or the right article or the right solution will clear up feelings of dread and provide the truth.

Feelings vs. Thoughts

Paradoxically, though anxiety sufferers are often highly sensitive individuals, the ability to name or identify strong emotions is often underdeveloped. For instance, one patient was upset about several mistakes she made during a musical performance. Instead of noticing her feelings ("I'm really disappointed after all the practicing that I did"), she quickly got stuck on the thought ("I'll always be a mediocre professional"). Often these thoughts and feelings are incongruent and don't line up.

As part of therapy, it's important to help patients become aware of the emotions that link up with the corresponding anxious thoughts. Cognitive therapists teach patients to disassemble their internal distress by asking key questions: What is the evidence for this assumption? Am I having unnamed feelings like sadness, loneliness or anger? How are they linked if at all?

The Plasticity of Change

Brain research is everywhere these days from the genetics of psychiatric disorders to the neuroscience of therapy. Much of this research suggests that brains are more "plastic" than previously understood. Though much of this research is still in its infancy, new science suggests that the brain has the potential to re­learn new responses to toxic stress and anxiety in more adaptive ways. This has implications for many therapies ranging from new approaches for stroke victims to using novel therapeutic approaches to psychiatric issues like anxiety. In the field of mental health, cognitive researchers have theorized that controlled exposure to danger or to anxiety has the potential to re­set the brain's response to fear. Exposure therapy is designed around this theory. Many of the trauma therapies are designed to take advantage of the mind/brain connection as well. New studies are testing out how certain treatments, including medication and short term therapies have the potential to fundamentally "change" the brain's response to toxic triggers. (Footnote 2)

Treatment Approaches: Bearing Anxiety and Building Tolerance For Uncertainty

Patients will frequently ask, "but what can I do now?" One young man learned that the sensation of placing his fingers on the strings of his guitar helped him to regain his equilibrium when flooded by anxiety. During the course of a successful therapy, patients develop and internalize their own crib sheets of meaningful phrases to guide them when regulating distress. Change is hard work. Whether the array of techniques employed by the therapist is Buddhist, psychoanalytic, cognitive, bodily/somatic or relational to name a few, the treatment goals are the same­ for patients to build a higher threshold for tolerating uncertainty and ambiguity and to live more present, full and vivid lives.

Laura Impert, LCSW is a New York City based psychotherapist. She is interested in the integration of relational psychotherapy with other approaches in the mental health field. She has also published in professional journals on nostalgia and mourning.
Laura Impert, LCSW
www.lauraimpert.com
lauraimpert@gmail.com

Footnotes

1. Anxiety disorders in the most recent DSM V include Generalized Anxiety Disorder, Agoraphobia, Social Anxiety Disorder, Panic Disorder, Separation Anxiety and Phobia. OCD, including its specific subset of disorders, is now a separate category from anxiety disorders after the most recent DSM V reclassification. However, most practitioners in the field see an overlap, similar but distinctive. A list of resources with more general information on anxiety and OCD can be found at the end of this article.
2. Several types of short term therapy have been rigorously researched for their success in treating anxiety disorders, including panic disorder, social phobia as well as OCD disorders. The Evidence Based Therapies include CBT, Dialectical Behavioral Therapy, Exposure Therapy and Mindfulness therapy.


Publications:

1. Impert, L. (1999). The body held hostage: The paradox of self­ sufficiency. Contemporary Psychoanalysis, 35, 647­671.
2. Impert, L.& Rubin, M. (2011). The Mother at the glen: The relationship between mourning and nostalgia. Psychoanalytic Dialogues, 21: 691­706.
3. Impert, L.& Rubin, M. (2011). Revitalizing the self through mourning: Reply to commentaries. Psychoanalytic Dialogues: 21: 736­741.

Online Resources for Patients:

1. National Institute of Mental Health. Information is available on-line for Generalized anxiety disorder and all anxiety disorders. www.nimh.nih.gov/health/topics/generalized-anxiety-disorder
2. On line information is available also through NIMH for OCD. 3.Science News about brain research and anxiety. www.nimh.nih.gov/news/science-news/science-news-about-anxiety-disorders
4. In New York City: www.cognitivebehavioralconsultants.com/
5.There are numerous websites with information on anxiety and OCD. One helpful website is: http://ocdla.com

Books on anxiety and related topics:

1.The Man who Couldn't Stop: OCD and The True story of Life Lost in Thought by David Adam (www.amazon.com/Man-Who-Couldnt-Stop-Thought)
2. Anxiety Disorders and Phobias by Aaron Beck (www.amazon.com/dp/046500587X/ref=rdr_ext_tmb
3. The Imp of the Mind: Exploring the Silent Epidemic of Obsessive Bad Thoughts by Lee Baer, Ph.D. (Imp-Mind-Exploring-Epidemic-Obsessive
4. Brain Lock: Free Yourself From Obsessive Compulsive Behavior by Jeffrey Schwartz, M.D. (Brain-Lock-Yourself-Obsessive-Compulsive-Behavior
5. The Synaptic Self: How Our Brains Become Who We Are by Joseph LeDoux (Synaptic-Self-How-Brains-Become