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Sep 07

Treating Anxiety – An Update by Kelsey

Treating Anxiety - The Role of Exposure TherapyTreating anxiety is an important part of working with people with depression or bipolar. This update focuses on changes that have taken place in the field in the last five years that might be relevant to many people dealing with depression and anxiety.

Imagine that you are taking a nice, peaceful walk in the woods. It is a lovely, warm, clear day. You are strolling along, listening to the sound of the wind blowing through the leaves, noticing hundreds of shades of green and brown in the foliage and along the path, feeling the warmth of the sun on your skin where it peeks through the trees. Suddenly, you hear some rustling in the brush just behind you. Your mind creates images of a bear or a bobcat peering out at you, waiting…and your heart starts to race. Memories surface of an article that described the increased prevalence of bobcats in the area. Wait, did the article specifically mention this trail?! You might start to perspire and your breathing becomes more rapid as you quickly pick up your pace. Further down the path, you find the courage to turn around and as you glance back, you see a rabbit hopping across the trail.

Anxiety. We all have it. We all need it. Our fight or flight response serves us well in many situations AND it has a tendency to run amok in other situations that our mind perceives as dangerous despite it not actually being dangerous. When this happens, our anxiety can begin to also run our lives! In an attempt to avoid feeling anxious, we might start to begin to craft our lives so as to avoid anxiety provoking situations. For those of you who have had this experience, you can attest to the fact that we frequently need to avoid more and more situations and over time it can feel as though our world gets smaller and smaller. A heartbreaking consequence of avoiding discomfort is that we also often move further away from aspects of our lives that we value.

Alternatively, treatment for anxiety actually involves repeatedly encountering the anxiety provoking situation to prompt new learning experiences. So, you have to be willing to feel anxious to treat your anxiety! For example, if someone has been avoiding elevators due to a fear of getting stuck, it would be important to have them ride many different elevators repeatedly to test his/her hypothesis regarding her/his feared outcome. Historically, treatment providers have focused on the concept of habituation as an essential component of a successful exposure. Habituation is the process that occurs when you acclimate to a sensation over time. For example, you walk into a room and notice a strong smell, at first it seems overwhelming and you have a hard time focusing on anything else, but gradually you habituate to the smell and within a short while you literally can’t smell it any more.

Similarly, if, instead of trying to escape from a situation that causes you anxiety, you chose to stay in that situation, your subjective rating of fear would go down over time.

Recently, Michelle Craske, PhD and colleagues found that habituation is not necessary for successful treatment. In other words, even if you continue to feel anxiety, just staying in contact with the feared situation will still reduce your fear.

This fits with our experience working with many people with posttraumatic stress disorder (PTSD). The traditional notion was that for prolonged exposure therapy to work in people with PTSD you had to stay in the feared situation until your level of distress came down significantly. However, some of the people we worked with seemed to not habituate very quickly.

A young man who had a traumatic experience in a hospital spent an hour in the feared situation (the ER) and yet his subjective rating of distress did not come down. Did that mean that his exposure therapy was not successful? No. He did seem to respond to treatment even though he did not experience much habituation.

Dr, Craske suggests that inhibitory learning is a more important reason exposure-based therapy is effective (Craske, Kircanski, et al., 2008; Craske, Treanor, Conway, Zbozinek, and Vervliet, 2014).

Inhibitory learning is the process by which people (and animals) learn that a fear association is not valid. Imagine that you have received a shock every time you were shown a picture of a golden retriever. Pretty soon you would start to anticipate a shock whenever you saw the picture.

Inhibitory learning occurs when you are exposed to the golden retriever and nothing happens.

Many of us try to escape from the feared stimulus (the golden retriever picture) and this means that we avoid learning that nothing is going to happen.

Dr. Craske has shown that it is not necessary for one’s anxiety to go down during an exposure to a feared situation; our brains can learn that a feared situation is not actually a threat by staying in the situation and not having the feared outcome occur, even if anxiety does not decrease in that moment.

We continue to add to our understanding of how to treat anxiety most effectively to help folks live full, values-based lives.

This is a very brief and basic review of a couple components common to anxiety disorders treatment. For those of you who may struggle with anxiety and have questions about treatment, I encourage you to talk with your treatment providers for more information. Providers, please review the cited articles for additional, rich information.

Kelsey E. Schraufnagel, PsyD
Psychological Assistant, PSB94020139

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  1. Anxiety and Bipolar - MoodSurfing ™

    […] Treating Anxiety – An Update by Kelsey […]

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