Dr. Levy's CBT Blog
Insights on Well-Being, Contentment, and Cognitive Behavioral Therapy
Psychiatric conditions are classified in accordance with a manual published by the American Psychiatric Association call the “Diagnostic and Statistical Manual of Mental Disorders.” This thick tome is in its fifth edition, so it is currently referred to as the DSM-5. There is a section in the DSM dedicated exclusively to Anxiety Disorders, and among them we’ll find Generalized Anxiety Disorder (GAD).
In clinical terms, GAD is characterized by excessive anxiety and worry about several domains of life that last for at least six months and is clearly excessive. That is accompanied by physical symptoms such as fatigue, difficulty concentrating, restlessness, muscle pain, difficulty sleeping or irritability. Together, these symptoms make life more difficult to live and enjoy. In everyday terms, GAD is that nagging, annoying, and relentless nasty voice in your head reminding you of everything that can possibly go wrong if you stop trying to control it. It’s exhausting - and no fun.
In the US, GAD affects approximately 8 in every 100 adults in their lifetime. Single (unmarried or previously married) females under 60 appear to be diagnosed with GAD more frequently than other demographic groups. That said, GAD affects all ages, genders, and socioeconomic strata, with 25% of all cases onsetting by age 25, 50% by age 39, and 75% by 53 years. Unfortunately, GAD is often recurrent and presenting with other mental health issues such as depression.
Interestingly, data from around the world shows us that GAD is more prevalent in high-income, industrialized countries than in developing ones. For example, while the 8% lifetime prevalence applies to the US, Australia and New Zealand, that figure is close to 1% for the population of Nigeria, While we don’t know exactly why that happens, one interesting hypothesis articulated in a large global study is that “individual differences in the propensity to worry may be more evident under conditions of relative wealth and stability, such as those found in high-income countries, than under conditions of relative scarcity and instability, where worry may be expected and widespread.”
Despite its high prevalence, GAD is often untreated. Research shows that less than 50% of individuals affected by GAD at the time of the survey had sought mental health treatment in the previous 12 months. That’s too bad, because psychotherapy, and particularly Cognitive Behavioral Therapy (CBT), have been proven effective to treat GAD, with no side effects! If you want to determine if you have GAD and whether CBT may help, talk to a therapist.
This article in the New York Times describes the author's struggles with Obsessive Compulsive Disorder (OCD) and how he managed to overcome it after years of struggles. OCD is a mental health illness that encompasses obsessions, compulsions, or both.
Obsessions are repeated thoughts, urges, or mental images that cause anxiety. Common forms of obsessions include:
Compulsions are behaviors that an individual suffering from OCD feels the urge to do in response to an obsessive thought. The function of the compulsion is to alleviate the tension, anxiety, and nervousness that comes with the obsessive thought. Common forms of compulsions include:
The author of the article above was able to overcome his OCD on his own, using a form of interpersonal exposure that we call in TEAM-CBT "self-disclosure." He slowly started sharing his deepest fears with his loved ones and learned, over time, that he got support and acceptance in return. That reduced his anxiety and allowed him to manage his OCD.
When motivation and self-disclosure alone are not enough to kick OCD, exposure therapy (exposing patients to their feared stimuli) combined with a technique called response prevention can help. It is a scientifically proven intervention to help most individuals suffering from OCD to learn how to better manage their compulsions, tolerate the obsessions, and quickly overcome both of those.
Anxiety and fear are quite different. To illustrate the difference I normally share a concrete example. Let's say I open my front door and there is a wild tiger right there. I will be terribly afraid. There is a clear and imminent danger I can pinpoint, thus leading to the fear. However, if I step out of my front door, hear a noise or see some movement in the grass, and think that there might be a tiger in there somewhere, odds are I will be feeling quite anxious. I think there might be a threat somewhere, only I cannot see it. I can imagine it.
Anxiety is a response to perceived threats that come to us either in the form of thoughts (a story) or images. Because we don’t like the feeling of anxiety, we often avoid thinking about those threats and try to block out the troublesome images. This helps reduce the anxiety in the immediate short-term. But long-term, it is still there. That pesky feeling of foreboding, a tightness in your chest, a lump in your throat. If it’s in your head and it has a negative emotional valence, it will come back at some point. That makes sense, right? I’s your brain trying to keep you safe by reminding you often of the dangers around you.
How can you conquer that anxiety? There are several methods in cognitive behavioral therapy (CBT) for anxiety treatment. The most effective one is exposure therapy. This is an approach where, figuratively, you get out of the house, go to where the noises and movement in the grass are, look behind the bushes, and find out that there isn’t a tiger there after all – it’s a kitty cat. To get to this liberating a-ha moment, we do need the courage to be willing to face the tiger.
For some types of anxiety such as driving or public speaking, we can actually go out there and do exposure exercises in real life relatively simply. But other times, if our fears involve imagined situations and outcomes that we can’t replicate in the real world, then we have to use the tool of ‘imaginal exposure.’ Imaginal exposure, as the name suggests, involves immersing ourselves in this worst-case scenario fear of how things can turn out badly. For example, if I am constantly anxious about having a deadly disease, I can enter a mental world where that actually happens. If I am concerned about my children having a terrible accident, I can make that true in my head.
Imaginal exposure scripts are short stories that we can write laying out what would happen if our worst fears came true. We add what happens in the immediate aftermath and what happens over the long run. These scripts are usually sad and dark because, well, our anxieties are sad and dark. Once an anxiety-provoking imaginal exposure script is written, exposure therapy involves reading that script over and over and over, several times a day for several days, recording the level of distress that it brings up. The objective is to get you habituated to the facts and feelings in the script. After reading a story a few hundred times, it gets boring. Boring is the opposite of anxiety-provoking. Boring is good.
Of course, you’ll be well served to have a therapist support you through this unpleasant but highly effective and necessary process. Any well-trained CBT therapist should be able to hold your hand and help you feel safe and cared for as you go face your tigers. Happy hunting!
Anxiety is a natural affective and somatic response to a perception of threat. As I mentioned before, it is our body's natural "alarm system" informing us that a potentially dangerous situation lies ahead. It is an uncomfortable feeling - on purpose! It encourages us to get ready, protect ourselves, or run away. A good amount of anxiety can gets us moving. Too much can paralyze us!
So, if you are dealing with "too much" kind of anxiety, how can therapy help? Evidence-based treatment for anxiety can take several forms. In TEAM-CBT, we categorize anxiety interventions in four groups:
1) Cognitive Treatment for Anxiety: Cognitive treatment of anxiety looks at the precise thoughts that are triggering the distressing emotion. In the case of panic disorder, it is usually a flavor of "I am going to die." For social anxiety disorder, it can be along the lines of "I am going to make a fool of myself." For generalized anxiety disorder, it can be "all sorts of impossible-to-solve problems will come up!" The therapist assists the client in pinpoint those thoughts, analyzing their validity, pinpointing distortions, and generating alternatives. With more balanced, realistic, and helpful thoughts, the anxiety can easily subside.
2) Behavioral Treatment for Anxiety: This is the gold standard for anxiety treatment. Individuals suffering from anxiety have an ingrained habit of avoiding things and situations that trigger their anxiety. Paradoxically, this has the effect of perpetuating excessive anxiety and worrying, rather than alleviate it. The antidote to that is to face one's fears. The most indicated behavioral intervention for anxiety is exposure therapy. In exposure, the client, with support of the therapist, will learn to face their fears head on (through use of images and in real life!).
3) Motivational Enhancement: Just reading the above, it is easy to see that many anxious clients will not be eager to jump into treatment that elicits that more anxiety-provoking thoughts and requires that they finally face their worst fears. In TEAM-CBT, we honor this very valid trepidation. Therapist and client partner up to identify reasons for changing vs. embracing the status quo and analyze whether the client is willing to pay the cost of getting better (not only in terms of treatment costs, but including homework, follow up, and getting in front of scary stuff!). The simple act of articulating and honoring the resistance to change can, most times, melt it away!
4) Hidden Emotion Model: This is an adaptation of the psychodynamic principle that anxiety is often a shield against more powerful - and difficult to embrace - emotions that the client may be struggling with. Another possible treatment for anxiety is to create the safe and warm space where the client can candidly acknowledge the emotions behind the anxiety. By verbalizing and sharing them, they lose their power and the anxiety subsides.
It is likely that you'll need to try all of these approaches to find the best way to conquer your anxiety. But conquer it you can!
Everyone has a sleepless night every now and then. What we do - and don't do - during the day, how we eat, what we drink, how much we exercise, our environment, our mental health, and how much stress vs. pleasurable activities we have in a typical day all influence the quality of our sleep. When insomnia hits for a night or two, it is easy to catch up. But when it becomes a chronic issue, it needs to be addressed before your health starts to suffer. One of the most effective and widely recommended treatments for insomnia is cognitive behavioral therapy (CBT).
There are two models of understanding and treating insomnia in CBT. The first approaches insomnia as the main focus of treatment. It starts by addressing behavioral modification, i.e., how long you stay in bed, and then moves on to address your beliefs about sleep. This line of treatment is often referred to as CBT-I, or cognitive-behavioral therapy for insomnia. CBT-I is shown to work better than sleeping pills, with no side effects! There are several self-help apps and websites for CBT-I. Personally, I recommend cbtforinsomnia.com, a five-week online intervention with some clinical oversight.
A second model of looking at insomnia is to view it as a symptom of another, bigger emotional health problem. Often times, insomnia is a consequence of depression or anxiety. For example, patients with excessive anxiety and worry may have trouble falling asleep as their mind starts racing - worrying about tomorrow's to-dos or ruminating about past events - the minute they lay their heads on the pillow. In this case, treating the underlying disorder (anxiety) with an approach such as TEAM-CBT will lead to the insomnia resolving itself short-term.
In either case, a well trained CBT therapist may be able to guide you on your path to a good night of restful sleep!
A client recently shared with me a video of actor Will Smith talking about the fear that he felt before he was scheduled to go on a skydiving trip. That prompted a discussion around the difference between fear and anxiety.
To my way of thinking, fear is to anxiety as concrete is to imagined, actual is to forecast, or today is to tomorrow. From a cognitive standpoint, fear pertains to a real, tangible, identifiable, and often immediate source of danger. For example, if a lion is standing in front of me, I will be afraid (not anxious!). If I am about to jump out of a plane, standing by the open door at 3,000 feet, I will be afraid (not anxious!). On the other hand, anxiety applies to situations where I perceive a potential for danger. I have not yet seen the lion, but I think that the lion may be lurking close by. Or coming for me at any time. Or just feeling hungry. I worry about something that has not happened yet and may never happen, But then, it could conceivably happen.
In psychotherapy, we may address both fears and anxiety using Cognitive Behavior Therapy. Problematic fears often come up in the context of phobias (e.g., fear of flying or driving across bridges). Clinically-relevant anxiety tends to manifest itself in the form of excessive worrying, tension, restlessness, over-sensitivity and hypervigilance. Both feelings trigger our "fight or flight" response mechanism, which I will describe in more details in my next blog post. The treatment of choice most often involves Exposure Therapy, an evidence-based intervention in which the client learns how to gradually expose themselves to stimuli that they fear, with a lot of support and guidance from the therapist.
In the meantime, here is Will Smith talking about his "fears," which actually pertain to both anxiety and fear. Enjoy!
Dr. Daniele Levy is a licensed psychologist offering CBT via Teletherapy from Menlo Park, CA. Her background uniquely combines leading edge training in behavioral sciences with deep expertise coaching and mentoring working professionals in dynamic organizations.