Psychologist for Anxiety in Nashville
Understanding and Treating Anxiety Disorders
Including Generalized Anxiety Disorder, Panic Disorder, Agoraphobia, Obsessive-Compulsive Disorder (OCD), and Social Anxiety Disorder
Anxiety is among the conditions for which most patients seek out a psychologist. Thus, most psychologists have a great deal of experience in how to treat the range of anxiety disorders. As a psychologist, I have been trained to diagnose anxiety and other mental disorders. Often, I will use screening instruments in my office, such as the GAD-7, to help me in making a diagnosis.
As stated in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), 2013, “Anxiety disorders include disorders that share features of excessive fear and anxiety and related behavioral disturbances. Fear is the emotional response to real or perceived imminent threats, whereas anxiety is anticipation of future threats. Obviously, these two states overlap, but they differ, with fear more often associated with surges of autonomic arousal necessary for fight or flight, thoughts of immediate danger, and escape behaviors, and anxiety more often associated with muscle tension and vigilance in preparation for future danger and cautious or avoidant behaviors.” (p. 189)
Prevalence of Anxiety
Anxiety, like depression, is one of the most common and most under-diagnosed mental disorders—suffered by as many as 30 million (9 percent of) Americans during their lifetime. One psychiatrist said to me, “Depression is often over-diagnosed while anxiety is often under-diagnosed.” If someone has depression, they have a 50-50 chance of suffering from anxiety as well.
Types of Anxiety Disorders
According to N.F. Smith, in a publication of the NIMH, “Anxiety takes a bewildering array of forms: panic disorder (recurrent panic attacks marked by overwhelming fears of imminent death or disaster; phobias (intense fear and avoidance of a specific thing or circumstance, such as animals or social situations; obsessive-compulsive disorder, or OCD (uncontrollable, repetitive behaviors or thought); posttraumatic stress disorder, or PTSD (recurrent, distressing dreams and memories in the wake of an accident or violent crime); and generalized anxiety disorder, or GAD (ongoing, unfounded worry about family, finances, health, etc.) These disorders also include physical symptoms—shortness of breath, heart palpitations, muscle aches, gastrointestinal upsets, fatigue, and insomnia.” (p. 190)
Social Anxiety Disorder
The diagnostic criteria for social anxiety disorder, as described in the DSM-5, include “Marked fear or anxiety about…social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech)….The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others)…The social situations are avoided or endured with intense fear or anxiety.” (p. 202)
Problems with self-esteem often figure prominently in individuals with social anxiety disorders. Sometimes I will say to such a patient, “You take your negative beliefs about yourself, and you put those beliefs in other people’s heads, and you imagine that they are looking at you the same way that you look at yourself.” One of my patients with prominent social anxiety symptoms avoids elevators, cafeterias, and even supermarkets. Several patients whom I have seen were abusing alcohol in their efforts to manage social anxiety. Their alcohol use declined markedly when they began taking an antidepressant (Lexapro) with strong anti-anxiety properties.
Psychotherapy with individuals with social anxiety disorder includes introducing them to meditation and relaxation techniques, and assisting them with recovering from shame and low self-esteem. Strategies for improving self-esteem include group therapy, where patients learn to let go of their “inner critic” voices and replace those with a more positive view of themselves that is reflected back by other group members. Buddhist psychotherapy, with its emphasis on lovingkindness and self-compassion, is often extremely helpful.
The diagnostic criteria for panic disorder, as described in the DSM-5, include “Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur…Palpitations, pounding heart, or accelerated heart rate; sweating; trembling or shaking; sensations of shortness of breath or smothering; feelings of choking; chest pain or discomfort; nausea or abdominal distress; feeling dizzy, unsteady, light-headed, or faint; chills or heat sensations; paresthesias (numbness or tingling sensations); derealizations (feelings of unreality) or depersonalization (being detached from oneself); fear of losing control or ‘going crazy’; fear of dying.” (p. 208)
The DSM-5 diagnostic criteria for panic disorder also include the following: “At least one of the attacks has been followed by 1 month (or more) of one or both of the following: 1) Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, ‘going crazy’); 2) A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).” (p. 208)
In my experience as a psychologist, panic attacks are often triggered by either 1) overwhelming stress, either in a work setting or in a primary relationship, or 2) the threatened loss of a source of security, which could be a job, a relationship, or financial security. Patients with panic disorder are known to avoid situations which might be difficult to get out of or away from, such as elevators, bridges, the middle of a crowd, or a center seat in an auditorium. Patients with panic disorder often get great relief from a long-acting antidepressant, such as Prozac or Zoloft, or a short-acting benzodiazepine, such as Xanax.
Psychotherapy with patients with panic disorder includes teaching meditation and relaxation techniques. The book An End to Panic describes teaching patients to simply name the physical sensations, e.g., “pounding heart” or “sweaty palms,” and to refrain from making up a story about these symptoms, e.g., “I’m going to have a panic attack.” Psychotherapy with these patients also includes helping them to take steps to lower the stress that may be triggering these attacks.
I provided psychotherapy to a 32-year-old college professor, who said to me, “Meditation isn’t soothing the anxiety. Fear. Fighting off the panic attacks. Nothing is soothing the anxiety—today, my heart was racing.” He had his first panic attack in the middle of a conference presentation, just a week after finishing his Ph.D. He struggled to get out sentences. It was one of the biggest traumas of his life. He has always been able to fall back on his academic achievement. Then, he says, “I had a panic attack in front of my peers.”
I referred this patient to the psychiatrist who was working with many of my patients at that time, Dr. Mike Reed. In his email to me after the evaluation, Dr. Reed stated, “The patient has ongoing anxiety, which he has struggled with for years. He describes a tendency to catastrophize, often imagining horrible outcomes to situations, most of which never occur. He is a worrier. His ever-present baseline anxiety can, at times, exacerbate into panic-like symptoms. I suspect he has an underlying dysthymia, but the vegetative symptoms (sleep, appetite, energy level) are kept in check by his devotion to staying fit. But, his thought processes catastrophizing/self-criticism/negativity) and marked anxiety are in need of treatment. I think he will respond well to Prozac, and I’ve asked him to begin taking 20 mg daily.” (personal email communication 9/18/2019)
The diagnostic criteria for agoraphobia, as described in the DSM-5, include “Marked fear or anxiety about two (or more) of the following five situations: 1) Using public transportation (e.g., automobiles, buses, trains, ships, planes). 2) Being in open spaces (e.g., parking lots, marketplaces, bridges). 3) Being in enclosed places (e.g., shops, theaters, cinemas). 4) Standing in line or being in a crowd. 5) Being outside of the home alone. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence).” (p. 217-218)
Agoraphobia typically develops in individuals who have had severe anxiety or panic attacks and who become desperate to avoid any situation that might trigger these conditions. For example, some patients become unable to be a passenger in a car—they can only manage their symptoms if they are the ones driving the car. Some patients begin to live severely restricted lives due to their avoidance of many situations. Psychotherapy with agoraphobic patients sometimes includes exposure therapy. For example, the patient is coached to try taking “baby steps” in exposing themselves to the feared situations or environments.
Generalized Anxiety Disorder (GAD)
According to the DSM-5, the diagnostic criteria for generalized anxiety disorder (GAD) include “Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). The individual finds it difficult to control the worry. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): 1) Restlessness or feeling keyed up or on edge. 2) Being easily fatigued. 3) Difficulty concentrating or mind going blank. 4) Irritability. 5) Muscle tension. 6) Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.” (p. 222)
Psychologists encounter many patients with generalized anxiety disorder (GAD). For example, I worked with a 28-year-old attorney who said of her anxiety, “It shuts everything down.” When her boyfriend got busy during the work week and was not in regular contact with her, her anxiety could become overwhelming. She would get nauseous and couldn’t eat. She had difficulty focusing at work. Often her sleep was impacted. She said that she had dealt with anxiety “forever.” Like others who are prone to anxiety disorders, she coped by becoming an outstanding student. She did have years of very restrictive eating, excessive exercise, and weighing herself a lot.
I referred this patient to the psychiatrist who was seeing many of my patients at the time, Dr. Mike Reed. He wrote to me after evaluating this patient and stated: “She has suffered severe anxiety most of her life. She does have intermittent problems with sleep. Early morning awakening accompanied by fear and worry has now become common. She has long been a “worrier.” She is often anxious. Frequently she fears that something bad will happen. I think her condition can best be described as a generalized anxiety disorder. I think she will respond well to Prozac and have initiated her on 20 mg each day. Also, I have given her a prescription for Lunesta to use if her insomnia persists.” (personal email communication 6/5/2019)
Excessive worry is a hallmark of generalized anxiety disorder (GAD). As N.F. Smith has written in a publication of the National Institute of Mental Health (NIMH), “Sometimes anxiety is more of a reflection of a temperament. Some people are, in common parlance, worriers. The anxiety they experience is an interaction between their temperament and the major or minor events in their lives.” (p. 190) In treating patients with excessive worry, I sometimes will quote my Nashville colleague Terry Huff, LCSW, who once said to me, “A definition of worry is trying to control the future by thinking about it.”
Anxiety Mixed with Depression
Smith writes about the situation when “anxiety is a secondary symptom to depression, which is ‘extremely common.’ The implication, scientists believe, is that both anxiety and depression reflect (among other things) imbalances in norepinephrine, serotonin, and dopamine, the neurochemicals that regulate mood, thought, and movement. The patient with coexisting anxiety and depression may be whipsawed mercilessly by the symptoms.” (p. 190)
In this article, Smith quotes extensively from an interview with psychiatrist James Potash, M.D., of the Johns Hopkins School of Medicine: “People come to see me when their anxiety is interfering with their ability to work or to conduct normal relationships with family and friends. The most dramatic example of serious anxiety is when people become suicidal. Typically, it’s mixed depression and anxiety that leads a person to such intense despair.”
Dr. Potash continues, “If someone comes in with lots of depressive symptoms and also lots of anxiety, one key thing is, has she always been anxious, or did the anxiety begin at the same time as the depression? If the two clearly coincided, I would expect that by treating the depression, I’d also treat the anxiety. But if she’s always anxious, and if her anxiety is severe, she may need psychotherapy just for that.” (pp. 190-191)
The Role of Perfectionism in Anxiety Disorders
Many patients with excessive anxiety also have a profound degree of perfectionism. This was especially illustrated to me in treating a 36-year-old patient. She was a perfectionistic, high-achieving physician who said that she “had never made less than 100 on a test.” She had struggled with anxiety for as long as she could remember. She constantly imagined worst-case scenarios involving her children and family. She was afraid to travel and feared taking her children out due to “fears they will be abducted.” I referred her to psychiatrist Dr. Mike Reed for an evaluation.
Dr. Reed emailed me his clinical impressions. He wrote, “Despite the respect showered upon her at her place of work, inside, she ‘feels like an imposter—a fraud.’ Her primary problem is that she worries needlessly. Most often, the nature of the worry has morbid undertones. ‘What if my husband dies? What if the kids get skin cancer because they didn’t wear enough sunscreen?’ She realizes her worry is excessive, unrealistic, and unnecessary, so she tries to ‘only let it hurt her.’ She is a kind, thoughtful, and extremely intelligent woman. She does not suffer from depression. She has had chronic insomnia her entire life. Although she does not fit neatly into a DSM-5 category, she is a ‘worrier.’ I think she will respond well to Prozac, which she is willing to try.” (personal email communication 7/25/2019)
Obsessive-Compulsive Disorder (OCD)
The diagnostic criteria for obsessive-compulsive disorder (OCD), as outlined in the DSM-5, include the “presence of obsessions, compulsions, or both. Obsessions are defined by 1) recurrent and persistent thoughts, urges, or images that are experienced, at some point during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. And 2) The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).”
“Compulsions are defined by 1) Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. And 2) The behaviors or mental acts are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.”
The DSM-5 OCD criteria also include “The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.” (p. 237)
In discussing the functional consequences of OCD, the DSM-5 states, “OCD is associated with reduced quality of life as well as high levels of social and occupational impairment. Impairment occurs across many different domains of life and is associated with symptom severity. Impairment can be caused by the time spent obsessing and doing compulsions. Avoidance of situations that can trigger obsessions or compulsions can also severely restrict functioning.” (p. 240)
One patient with whom I have worked for a number of years met the diagnostic criteria for both OCD and Major Depression. In evaluating her, I utilized the Brief Symptom Inventory (BSI), in which she checked “extremely” for such items as “nervousness or shakiness inside, pains in heart or chest, thoughts of ending your life, suddenly scared for no reason, feeling fearful, feeling inferior to others, nausea or upset stomach, having to check and double-check what you do, difficulty making decisions, numbness or tingling in parts of your body, feeling hopeless about the future, trouble concentrating, feeling tense or keyed up, thoughts of death or dying, spells of terror or panic, the idea that something is wrong with your mind.”
This patient was being seen for medication management by psychiatrist Dr. Jack Koch. He wrote a letter about this patient which included, “She described a life-long struggle with both major depressive disorder and obsessive-compulsive disorder evident prior to elementary school. Prior to my evaluation, she had seen an outpatient therapist specializing in obsessive-compulsive disorder and was later referred to the Rogers Memorial OCD program.”
Dr. Koch’s letter also stated, “As I am sure you are well aware, both obsessive-compulsive disorder and major depressive disorder episodes may be triggered by and/or exacerbated by external stressors.” He added, regarding her stressful work environment, “The high-stress nature of (her workplace) would certainly be expected to increase the risk of significant exacerbations of her mental health condition; her day-to-day experiences in her work became inextricably entangled with her obsessive-compulsive disorder and her major depressive disorder. Her desire for perfectionism and the urge to compulsively check/recheck undermined her knowledge and skills, potentially creating dangerous liabilities (in the workplace)” (letter dated 1/28/2019)
In treating patients with OCD, I often share with them information from The Anxiety and Phobia Workbook, Appendix 5, which states, “It has been my repeated impression that obsessive-compulsive individuals are very wound up and tense. They appear to be almost continually in a state of high stress—hurried or ‘speeded up’ to the point that they can’t relax and slow down. Accompanying this state of high tension is a tendency to be very out of touch with their bodies and their feelings. Sufferers from this disorder are frequently very intelligent and tend to spend a lot of time ruminating in their heads, at the expense of being centered and relaxed in their bodies and able to experience their feelings…Unfortunately, there are relatively few ways to avoid something that causes you anxiety when it’s strictly in your own head.”
The author states, “I believe that a more lasting solution to this problem may be found in dealing with the tension that I mentioned before; that is, trying to undo the condition of being ‘speeded up’ and out of touch with your body and feelings. It requires lifestyle changes and a fundamental change of attitude. If you’re willing to incorporate some of the changes suggested below on an ongoing basis, you may be surprised to find that your problem with obsessions tends to diminish.”
The most helpful practice that is suggested is as follows: “Engage in activities that help you to be more in touch with your physical body. A regular exercise program…will be helpful. Other physical disciplines such as yoga, martial arts, dancing, or working in the garden, practiced on a regular basis, can be helpful too. Some of you may choose to experience body therapies…or other forms of massage. All of these activities will help you to feel more ‘grounded’ in your body. And this, in turn, will reduce your tendency to become (preoccupied with)…your inner thoughts and impulses.”
The author also suggests that OCD patients overcome isolation. He writes, “Social isolation tends to aggravate obsessions and compulsions, whereas connecting with, and feeling close to, other people will tend to reduce the problem because it brings you more into the present—more in contact with your whole self and your feelings. If you’re dealing with obsessive-compulsive disorder and find that you spend a lot of time alone, work on increasing your support system and make time to be with people. If you are already with someone a lot of the time, then work on upgrading your level of intimacy and communication with that person. You’ll find, as a rule, that you tend to let go of obsessions when you’re having a good time being with someone.”
So many patients, especially those with anxiety or OCD, have very busy minds and are tormented with ruminations. For example, an OCD patient may hear the car go over a bump, and s/he will drive back around to where the bump occurred to see if they have run over a pedestrian. I encourage my OCD patients to utilize their bodies to engage in yoga, massage, meditation, and exercise in order to get out of their heads and into their bodies so that their obsessions and ruminations are not so prominent.
Obsessive-Compulsive Disorder versus Obsessive-Compulsive Personality Disorder
It can be helpful to distinguish between these two disorders. This was illustrated to me while treating a 56-year-old man in my practice. I suspected that he had been dealing with dysthymia (low-grade depression) for many years, along with chronically low self-esteem. He has exhaustive collections of films and CDs. He said to me, “My compulsive CD listening makes me less social.” He completed an exhaustive compilation of every song from the 60’s and 70’s. He also has perfect handwriting. I referred him for an evaluation with psychiatrist Dr. Mike Reed.
Dr. Reed sent me an email with his clinical impressions of this patient. These included, “His wife says he has been depressed a very long time. He has a true obsession with collecting music and film. Equally as notable, he does the same with logging about these collections. Although he is ritualistic about doing so, he does not have any other rituals that are meaningless in nature. He is not worried about germs, does not count meaningless things, nor seems to have a preoccupation with insignificant sets of numbers or the like. I think he clearly has obsessive-compulsive personality disorder, but I would not diagnose him as having OCD itself. I think he is suffering from dysthymia (low-grade depression). As a result of such, he seems to have intermittently suffered from self-defeating behavior. I think he will benefit from a trial of Cymbalta.” (personal email communication 5/18/2019)
Summary and Conclusions
Patients with anxiety disorders, including OCD, often benefit from a combination of psychotherapy and medication. I quoted earlier from a NIMH publication written by N.F. Smith. He quotes geriatrician Dr. Robert Zorowitz, who states, “Psychotherapy is helpful for every patient who has serious anxiety and/or depression because these disorders affect the way people think about themselves and interact with people around them. “ Dr. Zorowitz mentions one patient “whose insomnia was relieved by the antidepressant Paxil. Another patient uses three-times-a-week yoga and two drugs—the antidepressant Elavil and the anxiotytic Ativan—to prevent panic attacks. Another patient conquered her escalator phobia through behavior therapy, desensitizing herself through repeated exposure.” This article ends with the statement, “The pity is that so many people just choose to live with high anxiety. ‘Cut yourself some slack and get help.’”
An article in The Nashville Scene (8/16/ 2018) was entitled “On Mental Illness” by Libby Callaway. She writes, “I am a depressed person. I suffer from acute anxiety. I am a recovering alcoholic and anorectic. I have been in therapy for 29 of my 48 years. I don’t know what it’s like to live without constant anxiety—it’s just how I’m wired…One of the lone upsides to dealing with mental illness for such a long time is that I have learned what to do when the fog sets in. I make an appointment with my shrink. I speak to my psycho-pharmacologist about tweaking my meds. Most importantly, I talk about it…I believe that in order to fight the prejudice (against mental illness) and save afflicted people from living what feels like a solitary existence, those of us who have been through the wringer need to talk about it openly and frequently.”
Callaway adds, “I have to be vigilant. I have to take my meds. I have to exercise. I have to engage with friends. I have to tell other people what’s going on and be honest with them when they ask me if I’m okay. I have to be honest with myself.” (p. 31)