In Part I of this two-part series, we looked at what anxiety is and how to tell if you or someone close to you is suffering from an anxiety disorder.
Now let’s explore the causes of anxiety disorders and the treatments for them. We’ll also delve into the best self-help strategies anxiety sufferers can practice themselves and how their friends and families can help.
Types of people who are prone to anxiety disorders
The causes of anxiety disorders are not completely understood, but most people I’ve worked with seem to have one or more of the following: a more sensitive temperament, to have suffered events that felt traumatic to them early in life, and to have endured a period of stressful situations. The combination of these factors brought them to a tipping point that created an anxiety disorder. Specific risk factors for anxiety disorders include:
- Childhood trauma, such as abuse, neglect, or witnessing a traumatic event.
- Stress build-up due to a single, very stressful event or a sequence of smaller stressful situations.
- Having close relatives with an anxiety disorder.
- Chronic physical illness.
- Substance abuse.
- Borderline Personality Disorder and Histrionic Personality Disorder.
The most common misconceptions about anxiety
Common misconceptions about anxiety disorders include:
- Anxiety is not a “real” illness and people who have anxiety just need to get over it.
- Anxiety is part of who a person is and can’t change.
- Anxiety disorders can’t be cured, you just have to live with them.
- An anxiety disorder is a brain disorder.
- There are quick-fix remedies for anxiety disorders.
None of these is true. Anxiety is a real illness, it is caused by multiple factors, and although there are no “quick fixes,” it can be cured by a combination of therapy, self-help strategies, supports, and life-affirming activities.
When to consider medication
When I work with people who have anxiety, I suggest medication only after we have tried other methods.
Most people can resolve an anxiety disorder by developing a “package” that includes developing a different attitude toward their lives, doing specific practices and activities that relax and stabilize, removing unnecessary stresses, and understanding the underlying issues that caused their anxiety disorder.
When the anxiety is so great that a client can’t make the needed changes, medication can often be a helpful supplement to therapy and self-care. Occasionally, medication is necessary in an ongoing way, but I haven’t found that often to be so.
The one exception is Obsessive-Compulsive Disorder (OCD). People who have OCD often respond very well to the Prozac family of antidepressants, usually administered in larger doses than given for depression.
Medications that help with anxiety come in two varieties: antidepressants and anxiolytics.
Some antidepressants help with both depression and anxiety, particularly the antidepressants in the Prozac family, known as selective serotonin reuptake inhibitors (SSRIs). Sometimes people remain on antidepressants for a long time, but often they can stop after they have learned other ways to handle anxiety and depression.
Anxiolytics work on the specific parts of the brain that are associated with anxiety. These include medications such as Xanax, Ativan, Klonopin, and Valium. They are fast-acting, but they don’t address underlying causes. Although they are sometimes prescribed as long-term treatments, in my experience they are best used on a short-term, as-needed basis. They tend to lose effectiveness when they are taken regularly, and they are physically addicting. For many people, stopping an anxiolytic they have become physically dependent on is harder than quitting smoking.
The right approach to tackle anxiety
The most important thing people with an anxiety disorder can do is to learn as much as they can about their problem and how to treat it. People who take charge of their illnesses, whether physical or psychological, always do better than people who are more passive.
The next most important thing to do is to find a therapist who understands anxiety disorders, has had success working with them, and who seems to “get” you. All therapists are not created equal.
Interview your prospective therapist on the phone about how he or she might help with your anxiety, and ask how many clients he or she has successfully treated. If someone is helping you, keep seeing that person. If, after a few sessions, you don’t feel significantly helped, discuss it with the therapist. If, after the discussion, you continue not to feel helped, this therapist is probably not right for you. Ask for a referral, and also consult therapist directories such as Goodtherapy.org and the Find-a-Therapist service sponsored by Psychology Today.
A good self-help book on anxiety disorders is an extremely useful supplement to therapy. The best I’ve found, and one I often recommend to clients, is The Anxiety & Phobias Workbook by Edmund Bourne. It’s a virtual encyclopedia of knowledge, self-tests, and strategies for dealing with anxiety.
Along with therapy, some of the most effective activities I’ve found helpful for reducing anxiety and becoming more resilient include:
- Learning to treat yourself with the same compassion you would show to others you love.
- Developing a healthy lifestyle, including proper nutrition, exercise, and good sleep habits.
- Building nurturing relationships with friends, families, and other social supports.
- Regularly practicing centering, self-soothing techniques such as meditation, yoga, and walks in nature.
- Developing a creative activity that you can look forward to doing even when you feel anxious.
- Noticing what helps – and doing more of it!
What not to do when having anxiety
The list of things NOT to do is pretty short:
- Don’t use alcohol and drugs, since they can make anxiety worse.
- Quit smoking, as nicotine can also worsen anxiety.
- Cut down on your consumption of foods and beverages that contain caffeine, such as coffee, tea, cola, energy drinks, and chocolate. Caffeine can increase anxiety symptoms.
- Don’t overcommit to activities that increase your anxiety. Pushing too hard doesn’t speed up recovery.
- But don’t always give in to anxiety, either. Gently challenging anxiety is helpful.
The best things friends and family can do to help
These are some of the things friends and family can do to help people who have anxiety disorders.
Learn about anxiety disorders
Knowledge is power. The most helpful thing friends and family can do is to help the person with anxiety feel seen, heard, and understood. You can’t help someone if you don’t understand what they are going through.
Ask how to help
Everyone is different, and everyone needs different kinds of support. People with anxiety can tell you what helps and what doesn’t.
Remind anxiety sufferers not to be too hard on themselves, and reassure them that the disorder is not their fault. Praise accomplishments and progress. Let them know you care.
Be a companion
People with anxiety are often reluctant to start new things. Offer to go to a yoga class, take a walk or bike ride, or do some other kind of relaxing physical activity together.
No matter how compassionate and how smart you are, someone with an anxiety disorder probably also needs professional help. Offer to help them find a therapist. See if they would like a ride to a therapy session.
Get help yourself
Being supportive of someone with an anxiety disorder can sometimes be taxing, so make sure you have someone to talk to, too.
The worst things friends and family can do
These are some of the things people with anxiety disorders have described as unhelpful:
Acting like nothing is wrong or minimizing the problem
Minimizing the problem, in an attempt to make someone feel better, often has the reverse effect.
Telling them that if they stop dwelling on their issues they’ll go away
Part of the problem is that they can’t simply stop dwelling on their issues. Don’t ask them to do what seems impossible.
Telling them to “get their act together.”
If people with anxiety could just “get their act together,” they would have done so already.
Blaming their problems on bad life decisions
Anxiety is not the result of bad life decisions.
Giving unsolicited advice
Like almost everyone else, people with anxiety welcome advice when it’s asked for, but not when it’s unsolicited.
Pressuring them to go out and do things
People with anxiety have to go at their own pace. Encouragement is fine. Pressure is counterproductive.
It’s difficult to remain patient when someone seems to keep suffering in ways that you, the non-anxious person, would find easy to change. If you feel frustrated, imagine how you’d respond to someone with a physical problem and you’ll probably regain your patience.
Although pushing is rarely helpful, enabling anxiety by never challenging the “rules” the anxious person has set up is not helpful either. Finding the right balance between encouraging and accepting current limitations is an ongoing experiment, both for the anxious person and for the people who are trying to help.
Treatments I’ve found most effective
The generally recommended treatment for anxiety disorders is Cognitive Behavioral Therapy (CBT). Cognitive Behavior Therapy is a structured form of therapy that focuses mainly on identifying and correcting mistaken beliefs and on teaching skills to modify dysfunctional thinking and behavior.
In my experience, CBT is a useful framework around which to structure therapy for anxiety disorders, but it is not usually sufficient. I adapt the treatment to the individual, and to where the individual is in his or her recovery. Although treatments are different for different people and vary throughout the course of recovery, the basic components include:
- Forming a trusting client/therapist relationship.
- Helping the person build additional supports that help him or her to thrive.
- Identifying contributing factors in the person’s history, environment, and their ways of processing perceptions, thoughts, and feelings
- Identifying contributing factors that can be changed, and developing strategies for changing them.
- Identifying contributing factors that cannot be changed, and developing strategies for accepting them.
- Teaching skills necessary for functioning in a more satisfying way.
- Teaching methods for monitoring and maintaining progress.
To give you an idea of how varied treatment for anxiety disorders can be, here are a few snapshots of clients who have successfully dealt with their disorders.
With a client who had social anxiety, we focused mainly on helping her remove stressors, including a too-demanding job and a dysfunctional romantic relationship. Then we worked on developing the ability to enjoy small talk and other social lubricants and on understanding how some of her patterns in social situations were shaped by her family of origin but didn’t apply to her current life.
With a client who had a phobia about germs as well as OCD symptoms, what helped most was asking the client to research the germ situations he was afraid of and really test them. I also asked him to vary his counting and checking routines to help him see that they were not always necessary. For example, instead of always locking a door three times, he would sometimes do it seven times, sometimes two, and so on. Eventually, he stopped counting entirely.
A client whose untreated OCD made it impossible to leave a room without a complex set of time-consuming rituals was unable to make progress with therapy until she started on a relatively large dose of Prozac, after which the OCD symptoms quickly subsided. When she tried getting off the Prozac, the rituals returned. Staying on Prozac was the best solution for her.
I helped a client who had Generalized Anxiety Disorder and I found that her anxiety was not really related to the things she worried about. Instead, it was an ever-present free-floating anxiety that “landed” on various circumstances in her life. Using a technique from Gestalt therapy, she learned to befriend her anxious part and to pay direct, compassionate attention to it rather than trying to suppress or correct it.
Where to go from here?
Over the years, I’ve worked with many people who have fully recovered from anxiety disorders and now live much richer, fuller, and far less worried lives. Where there’s a will there’s a way. With the right kind of professional help, the right supports, and, most importantly, the right person at the helm – you! – I’m confident you’ll find your way, too.
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