In the previous post, we looked at ways to handle anxiety in the moment -- how to talk yourself off the ledge when you are feeling worried, nervous, or panicky. In this post, we’ll discuss identifying the source of your anxiety -- whether it’s part of another disorder or a specific type of anxiety disorder -- and begin to discuss Exposure and Response Prevention (ERP), one effective treatment for many of the anxiety disorders.
Anxiety can be a disorder of its own, or a symptom of another disorder. A longer-term approach to treating anxiety must first focus on determining:
Anxiety as a Symptom of Another Disorder
The The Diagnostic and Statistical Manual, 5th edition (DSM-5) describes several primary disorders where anxiety is a possible symptom that a person may experience.
Just briefly, I will describe a few:
When a person has Bipolar Disorder, increased anxiety (along with irritability) can be a temporary stage in the mood cycles they experience.
Borderline Personality Disorder
A person who has Borderline Personality Disorder often experiences a considerable amount of anxiety. They may experience strong fears of being abandoned in important relationships. They may also feel considerable anxiety after an episode of emotional dysregulation, where they fear they damaged an important relationship or another aspect of their life.
When a person has a Dissociative Disorder or experiences dissociative symptoms, they may feel anxious simply because they have lost time, or feel cut off from some part of themself or reality. If they are trying to hide their disorder from others, they may also feel anxiety about being discovered.
Post-Traumatic Stress Disorder
When a person has Post-Traumatic Stress Disorder*, they can feel considerable anxiety any time they are reminded of the original trauma, or if they fear they are in a similar situation and are likely to be retraumatized.
*Post-Traumatic Stress Disorder is actually a type of anxiety disorder, but I differentiate it here because PTSD treatment can sometimes be very different from treatments for other anxiety disorders.
It’s important to have a proper and thorough evaluation and accurate diagnosis so that if the anxiety is simply a symptom of another disorder, then the primary disorder is addressed.
The short-term coping skills for anxiety outlined in the first part of this series can still be helpful. You can use those skills to help manage the anxiety you feel as you are working to make progress with your primary disorder. Addressing the primary disorder is important for long-term healing and benefit.
It is common for a person to have more than one diagnosis at a time: Bipolar Disorder and Social Anxiety, Autism Spectrum Disorder and Social Anxiety, Post-Traumatic Stress Disorder and a Dissociative Disorder. Mental health professionals call two or more coexisting diagnoses “comorbid” or “comorbid conditions”.
When this is the case, your therapist will help you determine what is causing you the most distress in the present. This will guide you and your therapist to decide what needs to be addressed first and how to go about addressing it.
When Anxiety is the Primary Disorder
The DSM-5 recognizes five types of anxiety disorders:
Generalized Anxiety Disorder
Obsessive Compulsive Disorder
Social Phobia Disorder, aka Social Anxiety Disorder
And Post Traumatic Stress Disorder
This page gives a good brief description of each anxiety disorder.
What is Exposure and Response Prevention (ERP)?
This technique is pretty much what it sounds like: you and your therapist identify the triggers to your anxiety, and you then expose yourself in small, manageable little bits to the things that trigger your anxiety, while at the same time, using the techniques to retrain your brain to have a different response.
Exposure and Response Prevention (ERP) is considered the gold standard treatment for Anxiety Disorders, with a couple of caveats:
Medications are often prescribed for Anxiety and Panic Disorders. Benzodiazepines (Valium, Xanax, Klonopin and Atavan) can be highly addictive and if prescribed, should be used with caution and for short term assistance.
Beta-blockers are also intended for short term use in conjunction with therapy due to longer term negative health effects.
Antidepressants are frequently helpful with anxiety and are often prescribed for longer term use. The best results with antidepressants are to use them in conjunction with therapy.
Exposure and Response Prevention is not appropriate for some people with PTSD. You can’t ethically “expose” an assault survivor to assault, or a combat-exposed person to combat. Additionally, many people with PTSD need to build up their inner strengths and resources before they can address their trauma without decompensating.
There are methods for “exposing” a traumatized person through imagination work such as in EMDR (Eye Movement Desensitization and Reprocessing,) and with Clinical Hypnosis, and there are other more somatic therapies using body movement, meditation and yoga that have been very effective in treating PTSD and I feel all of these are kinder and gentler for healing PTSD than using ERP.
Minus the above caveats, if anxiety is your primary disorder, ERP is the best method for a longer term approach to kicking anxiety’s ass and kicking it out of your life. "Stopping the Noise in Your Head," by Dr. Reid Wilson is a very readable book that explains how to use ERP techniques. I have found it useful myself and recommend it to my clients with anxiety disorders other than PTSD.
In my next and final post in this series, I will describe several of Dr. Wilson’s techniques in more detail and how to apply them.