CORONAVIRUS / COVID-19 UPDATE: VIRTUAL “TELEHEALTH” APPOINTMENTS ARE NOW OFFERED:
Joseph Contorer MFT and CounselingLA.com are here to offer support.
In response to the current Coronavirus Crisis, therapy sessions are being provided virtually. Various TeleHealth options include FaceTime, Skype and telephonic appointments. Effective approximately 3/17/20, several insurance companies, such as Anthem Blue Cross, have stated that they plan to cover the cost of member copayments on most plans for in-network mental health care for an initial 90-day period ending in mid-June, depending.
Thank you all and STAY SAFE!
ANXIETY DISORDERS Anxiety Disorders and Generalized Anxiety Disorder (GAD)
Anxiety can be thought of as an abnormal level or preoccupation with worry, fear and feelings of being unsafe which leads to an irregularly heightened level of concern about what might happen next.
When worrying becomes overly excessive and disruptive it may be more appropriately described as anxiety. Sometimes the anxiety becomes generalized to the point that it is meets the criteria for a disorder.
There are different types of anxiety and different types of anxiety disorders. There is generalized anxiety, which describes a chronic exaggerated sense of worry; social anxiety, which occurs mainly in response to specific social situations; anticipatory anxiety that consists of anxious thoughts in preparation of or in fear of an anticipated event or potential event.
- Excessive nervousness, worry and tension.
- Physical symptoms, such as difficulty breathing, rapid heart rate, sweating, temperature changes.
- Sluggishness or muscle weakness/shaking.
- Confusion/difficulty concentrating or focusing.
- Sleep disruption.
- Gastro-intestinal disturbance.
- Aversion to triggers, especially phobias, such as fears of flying, heights, snakes, public speaking, etc.
- Obsessive or neurotic thinking, ideas and behaviors (Obsessive Compulsive Disorder.)
- Circular reasoning/ruminating thoughts.
GENERALIZED ANXIETY DISORDER (GAD)
One of the more commonly diagnosed forms of anxiety disorders is referred to as Generalized Anxiety Disorder, or GAD. This is generally an “anticipatory anxiety” affliction. By definition this condition suggests that the person struggling with GAD will experience an excessive amount of worry and disruption pertaining to disproportionate events of triggers. The majority of time, days, events, and incidents in the life of a person suffering from GAD are spent neurotically worried about something horrible happening next.
Without proper intervention or medication, GAD sufferers are constantly plagued by their symptoms of excessive worry; they persistently focus on negative, yet mostly irrational self-imposed doom and gloom predictions of dread, fear and trauma. One of the cognitive distortions that frequently occurs with GAD is referred to as "catastrophizing" or "horribilizing." With Generalized Anxiety Disorder, the catastrophizing creates a more dramatic highly elevated perception of events and potential outcomes. The whole mental vision is one that the sufferer has now hyper-magnified in a disproportionate capacity to the actual scenario.
GAD also typically presents with physical symptoms such as muscular tension, headaches/migraines, body aches, abnormal vital signs on breathing, heart rate, and nausea. If GAD spikes to even higher levels, the end result may be what is known as a panic attack.
Possible causes of anxiety disorders might include everything from genetics and biological implications to abuse history, faulty thought processes, compromised levels of self-esteem and problems with confidence and identity development.
Anxiety may come in various forms:
- Anticipatory anxiety
- General anxiety/ (GAD)
- Obsessions/Obsessive Compulsive Disorder (OCD)
- Panic/Panic attacks/Panic Disorder
- Phobias- (specific phobias such as fear of heights, flying, snakes etc.)
- Situational anxiety
- Social anxiety/Fear of being alone,
- Abuse and trauma history and or present.
- Awareness deficiency- lacking of awareness of triggers etc; need for behavior modification.
- Cultural/ethnic considerations/symptoms resulting from environmental pressure and influences.
- Deficient level of confidence/self-worth and self-efficacy;
- Dysfunctional family systems.
- Environment: Stress and pressure of dealing with day to day living (work/school/social media/competition, domestic or global disasters or fear of them.)
- Faulty thinking/habitual conditions.
- Fear and irrational fear.
- Genetics/heredity; chemical and genetic factors influence the presence or severity of anxiety symptoms and disorders (similar to depression and mood disorders.)
- Poverty/other unsafe. environmental living conditions.
- Political climate: reactions and involvement with histrionic sensationalism.
Anticipatory- wondering, worrying and obsessing in general or specifically about what might happen next; very common with all anxiety disorders.
General- “Generalized Anxiety Disorder” (GAD) is more about a general chronic level of worry and emotional discontent about most everything.
Obsessions/obsessional- typically part of the Obsessive-Compulsive Disorder- they are the mental and cognitive ruminating thoughts and circular reasoning that become intensified at an exponential rate while they build up to sometimes becoming panic attacks. Other times, as part of classic OCD, obsessions are then ritualized with compulsions- which are actual actions and behaviors that are taken to mitigate the obsessions in an insidious cycle; hence the reference "OCD" (such as: hand washing, counting numbers, and performing various other behavioral rituals involving routines, numbers, repetitive actions that are self-imposed in some cyclical, self-driven fashion.)
Panic Attacks- Severe intense extreme spike in worry and anxiety that comes with physical symptoms such as heart palpitations, sweating, nausea, light- headedness. Panic attacks are sometimes referred to as a “fear of fear.” Sometimes so intense, clients report feeling like they are dying and can end up in hospital emergency rooms with false symptoms of cardiac arrest or heart attack that must be medically safely ruled-out.
Phobias- Fears that develop specifically related to things like being alone, the dark, heights, public speaking, snakes, spiders, flying, small spaces, known as “Claustrophobia," or large spaces- like being out of the home, known as “Agoraphobia.”
Situational- A specific, fairly identifiable situation, incident or event(s,) like preparing for a test, a party, a speech, a trip, a surgery/medical issue, an extremely stressful or an unpleasant time period at work or school for example.
Social- Anxiety that develops related to social situations, being around others in various capacities. This anxiety may occur in social settings, special events, gatherings and school or place of employment.
Panic Disorder and Panic Attacks
One of the most severe forms of anxiety is referred to as a Panic Attack. For many people who suffer from more extensive or frequent panic attacks, they may be diagnosed specifically with Panic Disorder. A panic attack is an intense escalation of anxiety and fear to the point that there is also notable physical symptoms, such as rapid heart beat, nausea, difficulty breathing or cold clammy sweating. Some people experiencing panic attacks will mimic symptoms of a heart attack or other extreme physical events. It has been reported that some patients seeking emergency room treatment for heart attack symptoms are actually having a panic attack, which must be carefully confirmed and still treated somehow.
Panic Disorder is an insidious condition because it is the cause and result of what is essentially an intense fear of being in fear. Panic Attacks are so noxious, unpleasant and debilitating, that part of the cause/effect vicious cycle is that it is common to develop a strong pathological aversion to experiencing the symptoms or the panic attack again in the future. The fear of another attack continues to fuel the disorder itself.
In other severe cases, panic disorder is associated with a fear of leaving home known as Agoraphobia, because there is also a related aversion to leaving a safe space, primarily the home environment. Agoraphobics can become so debilitated that they are unable and vehemently unwilling to leave their home. The terror and fear of having a panic attack causes some to rigidly refuse to leave their home sometimes for extended periods of time, even years or longer.
As with most anxiety disorders, there may be physical/organic and emotional/psychological causes for the symptoms. Sometimes this disorder warrants the prescription by either a Psychiatrist or other attending physician of medication, such as Selective Serotonin reuptake inhibitor (SSRI) drugs like the Prozac family or more acute sedative/ "anti-anxiety" drugs in the Benzodiazepine family. Other times, patients will seek therapy or a combination of medication and talk therapy to manage and treat this disabling condition.
Obsessive Compulsive Disorder (OCD)
The term “OCD” has been utilized and generally discussed more frequently and perhaps more informally in recent years, likely because of television, movies and social media. However Obsessive Compulsive Disorder is a serious condition. The symptoms of OCD typically include both obsessions (born out of various cognitive thoughts,) and compulsions, which are usually repetitive or ritualistic behaviors. The driving force behind OCD is predominantly organic and physiological, but there are also influential behavioral and situational/lifestyle aspects. The more effective treatment outcomes for OCD sufferers seem to typically include a combination of both talk therapy and medication, depending on each case and the extent of the symptoms and severity.
Exposure Response Prevention (ERP) is a useful therapy technique that ultimately helps reduce or eliminate OCD rituals and cyclical obsessive ruminating thinking. ERP works by gradually inviting the patient to face some of the specific experiences that would typically trigger the OCD response.
For example, a classic trigger for some OCD sufferers involves hygiene/sanitation-related issues. In this case, a patient would first be exposed to a normally noxious OCD trigger. Then they would be encouraged to withstand a minimal or “normal” amount of anxiety as part of their predictable response (of either avoidance and or ritualistic behaviors such as hand washing, cleaning, counting etc.)
After being carefully monitored by a mental health professional, the hope is that this process will inevitably reduce the OCD and anxiety symptomatic responses and also allow them to obtain an increase in confidence and sense of empowerment. The improvement occurs as a result of acknowledging that there is a sense of satisfaction and safety achieved from overcoming this previously debilitating situation.
ERP is also sometimes referred to as "Systematic Desensitization" or "Flooding."
Post Traumatic Stress Disorder (PTSD)
PTSD is another complex anxiety disorder. Awareness of this term has become more common in association with specific events, such as veterans who return from volatile war experiences and those who have been traumatized, in such ways like being victims violence, assault, rape or other severe violations. PTSD is a serious condition, but like panic disorder, psychotherapy is the preferred modality to address this disorder. Those who suffer from this disorder or these symptoms often feel a sense of shame, dis-empowerment, severe fear and hyper vigilance of a re-occurrence for many years after the event(s) were encountered.
TREATMENT FOR ANXIETY:
Anxiety is a likely a symptom of other underlying issues. Each client will have a unique situation, however the general theme is often due to a case of either low self-worth or a deficient level of confidence. Why don’t you feel (emotionally) safe? Why all the nervousness, the worry, the neuroses, the obsessing, the rumination, the drama and efforts to avoid the presumed triggers??
In addition to medications that are utilized a good portion of the time, particularly in more severe anxiety disorders, examining faulty thinking and generalized belief systems can be extremely beneficial for anxiety management. Also as mentioned related to OCD, the technique called “Exposure-Response-Prevention” has been helpful in behaviorally modifying the symptoms and severity of OCD, phobias and even panic or Generalized Anxiety Disorder (GAD) symptoms.
Enhancing Confidence and A Sense Of Empowerment
With the use of Cognitive Behavioral Therapy, and similar affirmative therapy techniques, the end goal is that faulty thinking can be adjusted enough to reduce the symptoms. Ultimately, anxiety disorders can be greatly strengthened by achieving an elevated sense of systemic confidence. When confidence levels are up, it is generally invariably related to the levels of anxiety, including the incidence of panic attacks.
So, a question you may ask is: What needs to happen to increase my level and sense of confidence overall?
ANXIETY TREATMENT: TOOL BOX
The following list summarizes some of the therapy tools and techniques that may be prescribed, modeled, or utilized to assist with managing and treating anxiety or depression.
- Affirmation work- constructing thoughts in a firm conclusive present tense manner.
- Assertiveness training (vs. aggression, avoidance or being passive-aggressive.)
- Boundary setting.
- Coping Mechanisms- trigger identification and choosing healthier more constructive responses.
- Educating/Becoming informed about what, why and how the various conditions occur.
- Exposure/Response Prevention (ERP) Systematic de-sensitization and flooding.
- Goal work.
- Mindfulness about what defense mechanisms are being applied how or why to consider extinguish less healthy options.
- Thought Record.
Treatment WITH Medications
Prescribed by MD, Psychiatrist / Psychopharmacologist
Since the advent of Selective serotonin reuptake inhibitor (SSRI) medication, such as the first one: Prozac, (Fluoxetine) became widely utilized for depression and anxiety disorders after it was approved in 1987, these drugs seem to be one of the more preferred psychopharmacological options to treat depression and anxiety.
SSRI medication works by chemically blocking a mechanism that limits serotonin levels. Serotonin has been found to be directly linked to alteration of mood, anxiety and or obsessional thinking. There are several other psychotropic medications and classes of medications used to treat mood disorders and other mental health conditions as prescribed by your doctor or psychiatrist.
There other SSRI derivatives of Fluoxetine that have been released since Prozac became widely used for treatment of depression, anxiety and several other disorders and conditions. Patients respond differently to SSRI drugs, so sometimes their physician will prescribe one and later switch to another SSRI variation, depending on effectiveness and side-effect issues.
Some clients will be prescribed and or also elect to take anti-depressants, mood stabilizers, anti-anxiety or other similar related psychotropic medications. The need for medication therapy is generally determined by a medical doctor as part of the treatment plan. Often times the physician is a psychiatrist who specializes in mental health disorders and conditions, and sometimes also involves input or referral from the psychotherapist. Ultimately, the final decision to enter a course of treatment of psychotropic medications is up to the client.
Treatment options vary depending on the diagnosis. The prescription may include drugs like Prozac and other similar SSRI derivatives; Wellbutrin (Bupropion); a mood stabilizing drug such as Lamictal (Lamotrigine) or Lithium also used for BiPolar Disorder. Your physician may prescribe other classes of medication or a combination of psychotropic drug therapy may be utilized.
Some research suggests that medications have been found to greatly influence a positive outcome particularly when they are combined with psychotherapy (talk therapy.) Not every patient who takes anti-depressants is in therapy or has even necessarily had therapy in the past. Similarly, not every patient who is in therapy is concurrently also prescribed psychotropic medications. However, approximately 30-50% of therapy clients are either currently on antidepressants or have been on them in the past.
One conclusion suggests that being on medications can help with managing emotions in a constructive manner that allows the patient to “do the work” they are trying to do via psychotherapy. Medications can help reduce the intensity of symptoms like depression, anxiety and mania, for example; thus the client may experience an increased ability to manage their depression/anxiety by using therapeutic techniques they experience in psychotherapy.
Some patients have been on psychotropic medications like anti-depressants for many years and will need to remain on them likely for the remainder of their lives. Other patients are temporarily prescribed medications for a more acute case, incident or specific time period. This may include a single episode of depression or anxiety that is typically connected to a designated event or present stressor, crisis trauma or death/loss etc.
In the more temporary type of scenario the patient may opt to discontinue the psychotropic medications in the semi-near future, perhaps in as little as 6 months, but usually they are on it about 1 year. Most psychiatrists maintain the following philosophy about psychotropic meds like anti-depressants: If a patient has been prescribed psychotropic medications, like anti-depressants, and they have engaged in trial termination of usage (titrating off,) but shortly thereafter, they determined that they were unable to stop taking meds because symptoms re-occurred or they felt too uncomfortable/unstable, this patient will likely opt to or need to be on medications permanently. This is especially relevant if they have unsuccessfully tried to stop on several occasions. In these cases the implication is that there are perhaps more biological/organic based chemical conditions at play on top of or instead of a situational type of depression/anxiety. Also relative with longer-term/permanent psychotropic medication necessity, there is usually a family history of clinical and chemical depression, mood disorders or anxiety disorders, often times with a close family member currently under psychiatric care and prescribed medications as well.