Forms & Worksheets
Psychoeducation About Anxiety, Fear, and the Role of Exposure
This chapter provides psychoeducation about the nature, causes, and exposure treatment of anxiety and related disorders in a patient-friendly format. The handout that follows can provide guidance in the first sessions as you socialize patients to treatment. We often describe to patients how common it is to have difficulties thinking clearly during episodes of high anxiety. Overlearning relevant material (including home review of therapy concepts) increases the chances it will be available even during such times. The goal is to make patients informed collaborators on the treatment of anxiety. Psychoeducation represents a first step. Additional materials for psychoeducation as well as the text that follows in “handout” format are available on the companion website (http://www.oup.com/personalizedexposure).
2. The alarm system: worry, anxiety and panic
Fear is designed to protect us and keep us safe. It motivates us. If it were not for anxiety and fear we would not show up to meetings on time or jump out of the way of an approaching car. Fear, when it happens in response to exposure to a real threat (i.e., true alarm), is very important for survival. However, if fear and anxiety are cued by things that do not actually pose significant physical threat/danger (e.g., insects/animals, people, emotions, bodily sensations, images, thoughts, traumatic memories; i.e., false alarms) these symptoms and associated avoidance can get in way of living. Thus, in exposure therapy we work to knock out false alarms that get in the way of achieving happiness.
3. Definitions: stress, worry, anxiety, and fear/panic
What is the difference between stress, worry, anxiety, fear/panic? Stress is best defined as the psychobiological reaction to demands. A demand is anything that takes mental space (good or bad). Examples include your job, family, friends, activities, a wedding, a death, or hobbies. The more demands and the larger they are, the more mental space they occupy (see Figure 1). Thus, either a lot of small demands or one single huge demand can cause significant stress. The total magnitude of all demands determines the amount of stress experienced.
When the body detects too many demands/stress, the natural biological drive/urge/reaction is to isolate and withdraw. This natural reaction can precipitate depression. To feel depressed at times is also normal. The problem is when people do not eventually re-enter the world and their activities in which case the depressed mood can continue because of a lack of positive reinforcement. It should be noted that this is one way in which prolonged depressed mood emerges, but there are many more pathways to depression. People frequently ask if stress is harmful. The answer may surprise you. Acute or temporary stress actually improves your immune system. For chronic stress, however, it depends on how you think about or perceive stress. Many very busy people are stressed but do not suffer the negative consequences of chronic stress while others do. Some research shows that if you believe your stress is dangerous and extremely aversive, then you are at greater risk for health problems. However, if you feel that your stress is a natural reaction to help you get through all the things you have going, then people do not suffer the same health problems.
Fear is different from stress and can be described as an alarm system. Fear is not unique to humans and most living things have some form of it. The alarm system is designed to keep us safe from danger much like a fire alarm (see Figure 2).
People could have designed actual fire alarms that include a nice green glow with a quiet pleasant soft voice that tells us, “Greetings all, a fire has been detected, please pursue safety at your leisure”.
In this case many of us would ignore such a warning and keep working, assuming it was a false alarm. For this reason fire alarms are wisely designed so that we are not capable of ignoring them - they drive even the most unflinching of us to leave the building. Your alarm system is designed the same way. It is designed to be annoying and uncomfortable so that it motivates us to fight or flee danger, and importantly, like the fire alarm it is also completely harmless in itself. Your alarm system is designed to be motivating but is itself completely safe.
In more advanced animals including humans, fear is can be conceptualized as being on a continuum including worry, anxiety, and panic. All humans worry, have anxiety, and panic or fear from time to time. The proximity of the threat determines where one is on the continuum (see Figure 3).
Worry is a response to perceived threats that are off in the distance (e.g., going camping in 6 months and you hear there are venomous snakes in the woods). Worry is a verbal activity, which implies thinking in sentences such as, “Ok, so I have that camping trip in 6 months and I am afraid a snake will bite me and I will die”. This activity is associated with feelings of tension, being on edge and “nervous,” but it does not activate your fight/flight system to the point where you see major increases in adrenalin and heart rate etc. This worry part of the alarm system motivates you to prepare for things in the future but without activating the cascade of physiological responses seen later along the fear continuum. Also, given the threat is way off in the distance, behavioral inhibition or freezing is uncommon.
Anxiety occurs when the perceived threat is right around the corner. Using our camping example, you are now at the campsite and hear a rustling in the bushes. Given your concern, you will notice physical symptoms caused by nervous system activation like racing heart, sweaty palms, rapid breathing, shaking, nausea, and/or an urge to urinate. Anxiety prepares us to fight or flee at a moment's notice when the threat actually emerges. High anxiety can last for days.
Panic occurs when the perceived threat is here and now. You're at the campground and a snake darts from the bushes toward your ankle. Panic can only last a short time; it comes on quickly and also dissipates in a short time. It motivates you to fight or flee immediately. The take home message is that your alarm system is designed to protect you. It is designed to feel uncomfortable to motivate you to flee or fight in response to danger.
4. True vs. false alarms
It is important to make a distinction between a true alarm and a false alarm. A true alarm is useful because it occurs and when you perceive a threat that is real, whereas a false alarm is not useful because it occurs and when you perceive a threat by mistake. For example, a sympathetic nervous system response is helpful and appropriate when you suddenly see a car headed toward you as you cross the street - i.e., it helps you get out of the way and avert harm. Having the same reaction when you notice an increase in heart rate, when you attend a party, when you experience an intrusive thought, or when you're reminded of a traumatic experience is not helpful - i.e., it just leaves you with excess “energy” as you will not use it to fight or flee from a threat because there is none. One job for your clinician is to help you redefine your fears into true alarms and false alarms, and to help you develop a new approach for reacting to false alarms.
Our alarm system is set to err on the side of caution - sensitive to not miss danger/disease (more false positives than false negatives). That's why roughly 40% of people report having a panic attack at some point in their lives. You can see that it is appropriate to fight or flee when there is an actual danger. However, if there is no actual threat, then fighting or fleeing is not adaptive. The appropriate behavioral response to a false alarm is to do nothing and continue your current planned activity. Exposure therapy is about helping you become better at that, and by doing so, get rid of false alarms altogether.
5. Anxiety vs. anxiety disorder
As discussed above, worry, anxiety, and fear are designed to protect us and keep us safe. So, when do they become disorders? First, they must be false alarms - worry, anxiety, and/or fear in response to relatively safe stimuli (fear of flying, fear of public speaking etc.). Second, for the fear to be considered a disorder, it must interfere with the life and activities of the person a lot. Examples include: not being able to leave the house for fear of having a panic attack, refusing to live on a ground floor or house due to a fear of spiders, missing meetings and deadlines and getting fired due to time consuming obsessions and compulsions, getting a divorce over constant reassurance seeking due to a fear of cheating. The stimuli that are the focus of the fear helps determine the specific anxiety and related disorders.
6. Understanding your anxiety
In Figure 4, we describe the impact of the body's alarm system (the sympathetic nervous system) on various bodily functions, the designed purpose for helping us, and finally the symptoms one may notice as a result. None of these effects are harmful, but they are designed to be annoying and motivating like the fire alarm to get us to act (even if we do not need to, as in the case of a false alarm).
The take home message from these tables is that your alarm system is designed to:
(1) protect you from danger
(2) create discomfort to motivate you to act
Everyone has their own profile of symptoms that define their anxiety response. Some people sweat more, some people tremble more, and some people feel dizzy. Some people have a brief burst of anxiety when they confront something they fear, other people have their symptoms wax and wane over a longer period. As part of treatment, you and your clinician will get to know your particular profile of symptoms and will help you react differently to these symptoms to meet your goals. One aspect of this profile includes how quickly your body turns off the alarm reaction. The body seeks balance (homeostasis) and there is an opposite system (the parasympathetic nervous system) that kicks in and reverses all the effects of the arousal/fight/flight (sympathetic nervous) system. The sympathetic nervous system cannot stay activated. Nor should it; an alarm system is only valuable if it turns on and off. A system that stays on has no value. After periods of arousal, the parasympathetic nervous system kicks in and calms things down, often leaving you tired after a strong anxiety/panic episode.
Whether you leave the frightening situation (avoidance/fleeing) or not, the parasympathetic nervous system will always return the system to rest/digest. Indeed, a principle of exposure therapy, staying in the frightening situation without doing anything allows your parasympathetic nervous system to kick in and reduce your physiological response and fear eventually. Obviously people ask us, “how long does this take?” The answer is that “it depends.” Think of the alarm again like a fire alarm with a battery. Some people have an alarm with a AAA battery while others have an alarm with a larger battery. However, we do know that for everyone the fear will subside. The rate in which it subsides depends on how you approach your fear cues, and one job of your clinician is to coach you in the skill of “doing nothing” to manage the situation, and “relaxing with the sensations” that occur when you get anxious. That is, by not fighting an alarm reaction, that alarm reaction subsides more quickly. This is because anxiety conditions rely on feed forward cycles. An alarm reaction is cued by a concerning situation, attention is honed to the most fearful aspects of this situation, the accompanying anxiety makes the situation feel more dangerous, and the false alarm is further cued. To short-circuit this cycle, your clinician will guide you in evaluating the actual safety of the situation and learn how not to react to symptoms with increased concern. When this happens, the alarm turns off quickly. But to achieve this, you will need some direct experiences with your feared situations. We call this experience exposure practice, and for this practice your clinician will show you ways to “lean into the fear” and practice doing nothing so that you have the chance to evaluate the situation and your competence in it more objectively.
7. More on exposure therapy
The central feature of exposure therapy is that it is an opportunity to learn from experience when you approach that experience in a mindful, systematic, and controlled way. One particular aspect of exposure therapy is discovering the difference between what one thinks (expects) will happen and what actually happens. To do this well, one has to be able to see around the many things one tells himself about a situation, and what is actually occurring in that situation. This is what we mean by the term mindful - an awareness of all the elements of an experience and the difference between what we say to our self about an experience and all the other elements of that experience. To help this process along, your clinician may ask you to specifically review your expectations about your exposure experience and then have you decide whether those things happened or not. One important feature of this process is making sure you do not decide the reality of the situation based on how you feel. Feelings are temporary, and while your therapy is dedicated to reducing anxiety, fear, and panic, during early exposure practice you will be asked to see how comfortable you can become with your false alarm while deciding if there is actual threat in the situation. To do this well, exposure needs to have a number of characteristics:
(1) The exposure is systematic, which means there is a specific program aimed at helping patients reestablish a sense of safety around feared cues - including careful planning as collaboration between the clinician and patient. For example, a fear of flying patient and clinician may design a list of fear cues (a picture of an airplane, being at an airport, the smell of jet fuel, a video of a flight, virtual reality exposure to a flight, taking a very short actual flight with the clinician, taking a short flight without the clinician, taking a long flight) and decide together which one to start with and on what session.
(2) The exposure is deliberate, which means that it is planned and initiated by the patient. Alternatively, brief exposures in the real world - such as being randomly called on to answer a question in a meeting for a patient with social anxiety - although not harmful, is not ideal to result in lasting safety learning. By planning specific exposure exercises, with a specific focus, and a specific time the patient learns they control the exposure exercise rather than the exposure exercise controlling them.
(3) The exposure is prolonged, which means that you stay with it until a predetermined time has passed. Often patients may leave an exposure exercise when their fear starts to get high rather than staying in the situation and seeing that even when their fear rises - nothing catastrophic happens.
(4) The exposure is repeated, which is one of the most critical conditions. Facing a feared situation once is courageous but not sufficient to result in lasting change. Also, repetitions should occur close in time to work properly. For example, giving a talk once every six months is not likely to ever eliminate a fear of social rejection.
The role of your clinician is to help coach you before, during, and after exposure therapy to attend to how your exposure experiences are different from your expectations. That is, we know that individuals in exposure therapy have tried to overcome their fears on their own and were not successful. But, like almost everything, exposure therapy is different depending on how you approach it, what you pay attention to, how long you persist with it, and how you think about it later. safety learning is active learning, and your clinician will take you through a series of learning exercises to develop a stronger and stronger sense of safety around feared cues, providing stronger and stronger tests that your anxiety-ridden expectations for how you will do in these situations are not accurate.
You have come to treatment to rid yourself of anxiety, fear, and avoidance, and your clinician is dedicated to this goal. The process of achieving this goal involves developing a new relationship with anxiety and fear, with learning to approach these emotions as potential false alarms. Exposure therapy involves approaching your fears in a new way, learning to get more comfortable with your experience of anxiety as you develop a sense of safety in the situations with the events that have caused you distress in the past. You will be testing out your expectations, looking past your assumptions, and developing a stronger sense of resilience and confidence with both your anxiety and the situations that evoke it. This investment in safety
13 learning (and the temporary anxiety that comes with re-entry into avoided situations) offers you the payoff of dramatically less anxiety over time and a return to full engagement in your life and your valued activities.