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Treating Anxiety Disorders: An Integrated Approach
By Dr. Brian Campbell
I thought it would be useful if gave you a brief overview of how I “think about” anxiety disorders and how I go about treating this class of disorders. I will base these comments on my experience of over 20 years in private practice doing Christian counseling and 10 years before that in secular counseling.
Prevalence: The frequency with which you will encounter individuals with anxiety disorders is very high in a private practice setting. Generalized Anxiety Disorder (GAD), Panic Attacks, Adjustment Disorder with Anxiety, and Obsessive Compulsive Disorder (OCD) are the most frequently encountered disorders. Posttraumatic Stress Disorder comes next, followed by Specific Phobias. These are followed by Acute Stress Disorder, and Social Phobia.
Medical Screening: Certain medical conditions and medications can cause symptoms of anxiety. Therefore, it is wise to make sure the client has a thorough medical check-up before, or shortly after, starting treatment.
The list of potential medical causes for anxiety is quite long: endocrine conditions (e.g., hyperthyroidism and hypothyroidism, hypoglycemia); cardiovascular conditions (e.g., congestive heart failure, pulmonary embolism, arrhythmia); respiratory conditions (e.g., pneumonia, chronic obstructive pulmonary disease); metabolic conditions (e.g., vitamin B-12 deficiency, porphyria); and neurological conditions (e.g., vestibular dysfunction, encephalitis). In addition, anxiety can be “substance-induced.” Certain medications have side effects that can cause anxiety, and starting or coming off medications (such as psychotropic medications) can cause anxiety. (Source: DSM-IV-TR).
Sometimes you will see a client before a medical exam, but it is wise to have him/her get an exam before proceeding very far in treatment.
Understanding the Nervous System: One of the most important areas of knowledge that helps me with understanding anxiety disorders is my understanding of the autonomic nervous system. There are two “sides” to this system: the sympathetic and the parasympathetic. The sympathetic nervous system is the so-called “fight or flight system. This is the system that is triggered under stress. If you haven’t done so already, it is a good idea to carefully study this system. You might also want to study the areas of the brain involved in the stress response, such as the amygdala.
The amygdala is an almond shaped mass of nuclei located deep within the temporal lobe. It forms part of the limbic system that is involved in many of our emotions, especially those involved in survival. The amygdala processes emotions such as fear, anger, and pleasure. It is also responsible for determining which memories are stored and where they are stored in the brain. To some extent, the larger the emotional response, the more likely the event is to be recorded.
The amygdala is involved in the arousal of the autonomic responses associated with fear. That is, it is responsible for “switching on” the sympathetic side of the autonomic nervous system.
Classical and Operant Conditioning: In order to treat anxiety disorders, you should also have training in, and an understanding of, classical and operant conditioning (i.e., behavior modification). Many of the anxiety disorders (such as simple phobias) can be almost completely understoodbased on a combination of classical and operant conditioning.
If you haven’t done so already, you should receive training in behavior modification if you plan to treat individual with anxiety disorders. You also need specific training in procedures that are grounded in classical and operant conditioning such as “Systematic Desensitization.”
Cognitive-Behavioral Therapy: The most efficacious treatment of anxiety disorders (based on current research) is a combination of cognitive-behavioral therapy plus medication (if needed). In my experience, medication is not always required, but knowledge of behavioral principles is essential.
In my professional opinion, it is not appropriate to treat anxiety disorders (except, perhaps, GAD and Adjustment Disorder with Anxiety), without basic knowledge of cognitive-behavioral therapy. You must understand the “flesh” and how it works (including knowledge of the principles of reinforcement and punishment).
Many Christians shy away from learning behavior modification, which is unfortunate. Some delve into cognitive therapy, but if this is used alone, it is not as effective. When you combine cognitive therapy with knowledge of behavior modification, the techniques become very powerful.
Christian Perspective: Except for GAD, or Adjustment Disorder with Anxiety, almost all of the other anxiety disorders are best treated with cognitive-behavioral techniques. This is true for Christian clients or non-Christian clients. To do otherwise would probably open you up to charges of malpractice. For example, if your treatment of an individual with panic disorder consisted almost exclusively of praying for the client and general Christian counseling, you would probably be opening yourself up to lawsuits. At least in psychology, we are mandated by ethical laws and state statutes to provide the most up-to-date treatment for clients. Since, as Christians, we need to follow man’s laws as well as God’s laws, you would need to show that you were aware of cognitive-behavioral techniques and were using them with your clients.
Christian Cognitive-Behavioral Therapy: I incorporate cognitive-behavioral techniques when treating most anxiety disorders, but I also incorporate my Christian beliefs. Here is an example:
Panic Disorders: Panic attacks occur because of a “false alarm” that is triggered when the brain misinterprets stimuli (internal or external) as being life threatening. The brain “panics” and sets in motion a tremendous alarm system in the body. The feeling the person gets is similar to the feeling you get when you cannot get enough air and feel like you are drowning. Your nervous system goes into “highest alert” and all systems are turned-on. Adrenaline is pumped out, the heart beats faster, breathing is altered…. It sort of feels like you are being electrocuted but don’t die. It is a horrible feeling.
The amygdala goes wild and turns on sympathetic side of the nervous system. Not only that, the amygdala also records the highly charged emotional state in the brain so that, from a survival standpoint, you don’t ever forget what happened. That is why it is so hard to treat panic attacks. Catecholaminesare released and the event is recorded throughout the brain.
Now, during the process of the panic attack, everything that occurs “around the event,” such as where the person was located, the furniture, the way the person was breathing, etc. is also recorded and “associated” with the panic attack. Through the process of classical conditioning, all these other stimuli become “tied into” the panic attack and can become triggers for future panic attacks.
Think of this example: What if you were taken down a long corridor to an electric chair, strapped to a chair, and then someone threw the switch. Fortunately, you didn’t die; but you did go through an experience of excruciating pain. Now, what do you think would happen the next time you started to walk down the same corridor? Obviously, even the sight of the corridor could produce extreme anxiety. In the same way, events that occur “around” the panic attack are “associated” with the attack.
You do not have to evoke Christian principles to deal with this conditioned response—just as you would not need to treat a bruise that you received (when someone kicked you) from a spiritual framework. You may pray about healing, but the best thing to do would be to put ice on the bruised area. What I am trying to say here is that panic attacks are mainly “physical/flesh” events. They do not occur because of a lack of faith. They occur because of a misfiring of the brain and the nervous system.
My treatment for panic attacks normally begins with educating the person that what has happened is more or less a “physical/flesh” problem and not a spiritual problem. I teach the client about the nervous system and share the DSM symptom list with them. Once they see that their symptoms are listed there, they are immediately less afraid. This occurs because most people who experience panic attacks fear that they are dying or losing their mind. Assurance that this is a “known disorder” that is highly treatable, if very important.
Along these same lines, I teach clients that “no one ever died from a panic attack.” “It may feel like you are dying, but this never occurs.” (Of course, I make sure that clients with panic attacks have been thoroughly evaluated medically to rule out heart disease, etc.). In fact, most of the clients, by the time they get to me, have already visited the hospital emergency room many times and have been thoroughly checked out by medical doctors. Very often, they have been referred to me because the doctors have found nothing wrong them physically.
During my initial evaluation of the client, I find out when the panic attacks started, where they tend to occur, how frequently they occur, and how long they tend to last. I obtain this information, because my goal is to reduce the frequency of their panic attacks and I want to establish “baseline” information. In addition, I want to get an idea of the severity of the panic attacks and get an idea of what might be triggering them.
By definition, the client experiencing panic attacks is almost always completely unaware of the nature of the stimulus that triggers the panic. However, research has shown that there is probably always a trigger; it is just not very obvious to the client. For example, panic attacks may be triggered when the heart “skips a beat.” The brain then misinterprets this event as evidence that the person is dying, and he/she is “off to the races.”
My main objective with individuals with panic attacks is to reduce the overall level of autonomic arousal. Most people who develop panic attacks are sensitive people whose nervous systems are vulnerable to arousal. My first line of attack is to help the individual reduce his/her arousal level by teaching him/her slow deep breathing techniques. It is at this point that I introduce Christian perspectives.
When teaching individuals slow deep breathing, I use a technique called “cue-controlled relaxation.” In this technique, the individual is taught to respond to a cue (a vibrating beeper) and take a slow deep breath, in through the nose, and out through the mouth. The device I have the client purchase is called a “Motivaider.” This device allows me to set the Motivaider to vibrate (silently) at fixed intervals throughout the day. The individual wears the motivaider on his/her side (like the old pagers). When the vibration “goes off” the individual is instructed to take his/her slow deep breath.
Next—at the same time the person is taking his/her breath, I have the client say something (silently) such as “relax.” If the person is a Christian, I have him/her choose a scripture or saying that will help him/her find comfort from God. When I wore this device myself (for three years!), I used the expression: “Let go (while inhaling); let God (while exhaling). This was meaningful and powerful for me as I was training myself to turn everything over to God (including, even my life, or the perceived threat on it). (By the way, when I wore the Motivaider, I was not suffering from panic attacks—just acute anxiety).
My objective in using the Motivaider (to address the “flesh”), is to condition a relaxation response in the individual so that his/her overall level of anxiety is significantly reduced. I use a “1-10” scale when asking clients their overall level of anxiety, where “1” is no anxiety at all, and “10” is extreme anxiety. Most people with panic attacks are walking around at an 8-10 level of anxiety. Because of this, it is relatively easy for stimuli to trigger additional attacks. However, if the individual can reduce the overall level of autonomic arousal, it is less likely for panic attacks to occur.
At this point in therapy, I usually turn my attention to spiritual issues and use scriptures to help reduce the overall level of arousal. For example, I use a tape I created called “Overcoming Anxiety” and have the client listen to God’s Word on a regular basis. It is almost impossible to listen to the scriptures on the tape and stay at the same level of anxiety. Of course, we also pray to God to bring peace by the power of the Holy Spirit.
By the way, the Motivaider is an excellent tool because of the frequency with which the individual practices the biblical “restructuring” element (e.g. “Let go; Let God) and the slow deep breathing. If you set the device to “go off” every 7 minutes throughout the day, the individual will practice slow deep breathing and cognitive restructuring nearly a hundred times per day. This makes it a very powerful technique. Also, because the individual wears the Motivaider in a variety of different settings during the day, this aids in “generalizing” the relaxation response. “Generalization” is a behavior modification principle.
GAD and Adjustment Disorder with Anxiety: With these disorders, it is easier to proceed with traditional Christian counseling. However, even here, I still address the “flesh” (through relaxation techniques); thinking (through cognitive-restructuring techniques); and spirit (through prayer and scriptural intervention).
Diet and Exercise: When treating all anxiety disorders, I also encourage the individual to exercise and control his/her diet. As the Romans said: “healthy body—healthy mind.”
Relaxation Techniques: There are various types of relaxation techniques that can be useful to help “turn off” the individual’s autonomic arousal (the so-called “fight-or-fight” response. These techniques include: progressive muscle relaxation; meditation; mental imagery; biofeedback; and clinical hypnosis. In addition, there are commercial audios that teach slow deep breathing techniques. Many tools are available as APPs on smartphones, including a flower that opens and closes at a specified rate to encourage clients to practice slow deep breathing as a means of reducing anxiety.
Christian Relaxation Tape: I have produced an audio tape that features scriptures for anxiety put to music. I have included this in the course spreadsheet (Cell G8). The audio is called: “Overcoming Anxiety,” and is available for download at a minimal price on my website. The file downloads as an MP-3 file, which can then be put on a smartphone or an MP-3 player. Many of my clients listen to this on a regular basis.
Scriptures Dealing with Anxiety: I have collected a number of scriptures that can be used to help treat anxiety in Christian clients. These scriptures are available on my internet site, so you might want to refer clients to this website: Counseling4Christians.com
Chapter on Anxiety: My chapter on Anxiety from my book, “Godly Counsel,” is available at the bottom of the page on the following link: Anxiety/Worry/Fear.
General Information on Anxiety Disorders: General information on anxiety disorders can be found on my internet site at the following link: Anxiety Disorders. I have included information on Adult anxiety disorders and Childhood anxiety.
Videos on Anxiety: There are some introductory videos on anxiety (featuring OCD), that will be helpful to view to see someone who is suffering with OCD and to hear about treatments. There are a series of six short videos. They were developed by the Anxiety and Depression Association of America.
Medications for Anxiety: General information on psychotropic medications is included on Counseling4Christians.com. There is also specific information on medications for anxiety disorders in children, and in adults.
Books on Anxiety: Books can be very helpful for anxiety clients. A big part of the treatment for many forms of anxiety is to convince individuals that they are not “going crazy” or “losing their minds.” Reading about anxiety in a book helps them understand that anxiety is a common disorder, and that they are “not alone.”
I have compiled and annotated numerous books that I recommend for treating anxiety. Many of these books are Christian based. They can be found in the Christian library that I have developed. Just look for books under the heading of “Anxiety/Worry/Fear.
Apps for Anxiety: Recently, my clients have alerted me to a number of Apps that are helpful in the treatment of anxiety disorders. For example, there is a “flower App” that helps people learn to breathe slowly and deeply. The user sets the amount of time it will take for the flower to “open up,” and the amount of time for the flower to “close up.” The user then “breathes in” slowly as the flower opens up on the smartphone, and “breathes out” as the flower slowly closes up.
I am excited about the possibilities of this new technology. I can’t wait to see what is coming. I’m sure we will someday be able to monitor the frequency and intensity of panic attacks through sensors that attach to smartphones. Also, we will be able to monitor an individual’s level of stress, and prompt him/her through the smartphone to “slow down and take a deep breath.” In other words, we will be able to do biofeedback through the smart phone.
Dr. Campbell