Panic Disorder and Agoraphobia Revisited

Well, surely in the past I've written about how abandonment and trauma in life, especially the death of loved ones, is a set up for Panic Disorder and Agoraphobia. 

The psychotherapy for symptom abatement in psychodynamic therapy has always been about making connections between bodily sensations and past events to resolve old trauma.  come to an understanding that simply because of that neurological set up, thinking that something awful will happen and that life is out of control, is a natural, normal process that leads to anxious conclusions about the future. But the thinking is false. 

Yes, we're programmed in that direction, but we can also deprogram. We can identify our bodily symptoms and connect them to unconscious thoughts, bring those thoughts forward and go, 

'Oh well. What's done is done. It is not predictive of anything horrible happening today or tomorrow.'

Now that's a great therapy alone. 

Since the late 80's many of us have added a Cognitive Behavioral Therapy component, mostly a pause and relaxation, breaking the cycle of misinterpreting body signals to mean catastrophe awaits. Panic Control Therapy emphasizes psychoeducation about anxiety and panic, identifies and corrects irrational thoughts, exposes (at least mentally) the patient to What If, the catastrophic expectation isn't likely and if it did happen, then what, and adds a self-relaxation to the mix. 

Add the reflective thinking (RF) of Panic Focused Psychodynamic Psychotherapy (PFPP) to address the client's assessment of the problem, and you have a dynamic duo. They both work, why not use both. That's my take-away from a relatively recent study, Processes of Therapeutic Change: Results From the Cornell-Penn Study of Psychotherapies for Panic Disorder (Barber & Milrod, et al). The authors compared CBT and the reflective function psychodynamic approach and found early signs of improvement relevant to both. 

I'd add, And take a vacation to reflect on the whole gestalt, truthfully, but I haven't seen any research on that. 

Best, 

therapydoc

Must We Stroke That Ego?

We talk about universal needs, and one of them is to feel valued, loved, and admired. The need is beat out of some of us who become self-deprecating, very humble, omniscient in social settings. For others, it is a virus.

Those of us afflicted seek admiration at work and at home. The hunger isn't labeled or talked about, it is usually unconscious. Because it is present, however, in so many of us, therapists try to interrupt blame cycles. Blame robs the blamer of the opportunity to validate, to be a therapeutic agent in relationships. We all want to be therapeutic agents, don't we?

Social encounters, all kinds, are social experiments. We walk away feeling good (it worked!) or bad.

Although the virus is nearly universal, some have it much worse than others, present as bottomless pits for positive feedback. Somebody started digging the pit in childhood, perhaps, but adult experiences create and maintain fissures, too.

Unchecked,the need for validation, love, and admiration-- what some call positive feedback, others call healthy or unhealthy narcissism-- can be really disruptive in relationships.*

Let’s take a fictional married couple to illustrate. He dresses so that people will compliment him. His hygiene is great, and because he sees himself as very male, doesn’t overwhelm with aftershave or cologne to exude class. He shakes hands, makes eye contact, and is impressive to those of us who appreciate that sort of thing. It is likely we will compliment him on something Some of us, when we're with someone who dresses well who chooses to be with us, feel good. I'm with him.

The couple is in their late twenties, make them childless for now. (Without children, socializing with friends is easy.) The two go out three to four times a week for dinner and drinks, sometimes just drinks. Our hero gets many compliments. His wife can be drop dead beautiful or not, she can be mesmerizing or not. She doesn’t care, regardless, what others think of her. She only has eyes for him.

They are in therapy because they don’t seem to connect emotionally. They take turns at verbal blunders, hurt one another with their words. Reasons turns out to be complicated, of course. Both have life experiences that teach them the art of a good offense. Experience is fertilizer for sensitivity, insensitivity. We’re working in therapy on intimacy, understanding these things.

Our boy could have married any girl, the female partner tells me in an individual session. It is his incessant need for attention and flattery that bothers her, makes her jealous. She gives him plenty of compliments and attention, affection, but it is never enough. When she is present and he is shouting for attention, it is one thing, watching others fawn over him. But he will repeat how women do this when she’s not around, too, and he repeats it often. She doesn’t understand why he has to throw it in her face.

The whys are interesting, the nature of the human ego, narcissism. Intellectualizing it helps, and we will do this in the therapy when he's around. In healthy relationships we don’t try to make our partners jealous, we don’t add to the stresses of everyday life. Jealousy is a negative emotion, one of fear, intimidation, being threatened. Nobody likes it.

We can do that, or we can begin to treat it quickly, with some humor. Everyone likes humor.

I suggest that the next time they are at dinner or the bar in a large group, that she somehow command everyone’s attention and ask, “Raise your hand if you think ____’s tie (points at her partner's tie) is absolutely gorgeous and makes his eyes look sexy. Don’t be shy now.”

She doesn’t like this suggestion, and I don’t either. It is just a way to get her to think. She thinks a bit, I shut up, and she comes up with several alternatives. The one we like most is that she stops random beautiful women on the street as they walk together and asks, “What do you think of his tie, seriously?”

Why do this? She brings his need for compliments to the surface, takes charge, makes sure his need is met, and everyone enjoys the experience. He will get compliments. Women will make eye contact with him. Then they will be on their merry way.

Of course the two of them could have long, deep, psychological discussions about his neediness (or her lack of empathy) in my office, and if we have several of these, I could make a lot more money. But a strategic behavioral family therapy intervention like this, talking to strangers on the street or in the elevator, works just as well.


therapydoc

*Feedback, positive or negative, isn’t calledfeed back for nothing. It is emotional food, digests well or not, yet we come back for more. Some of us wish to change the menu. That’s therapy. (Okay, the metaphors are done for today.)

The Dishwasher, Marriage, and Obsessive Compulsive Disorder

Caveat:

Before we begin, please do not consider the following post an exhaustive treatment on how to treat Obsessive Compulsive Disorder. The intervention I discuss is only one strategy, and treating OCD can be quite long-term, begs different methods. It is never a simple behavioral therapy. I'm only suggesting that without a behavioral approach, the therapy is remiss.

Nor am I making fun of people who have the disorder or dismissing them as silly. That's the farthest thing in my mind. It's a very serious, painful disorder.

The Post

Many couples argue about the right and the wrong way to stack a dishwasher. There is, apparently, a right and a wrong way, depending upon the direction of the jets. You knew about the jets, right? So couples argue about this one quite a bit, and it's not an Obsessive-Compulsive Disorder thing, not even a control thing, so much as an

Are the dishes getting clean?

thing.

So we could talk about that, for sure, but let's talk about me.

I’ve become one of those people who washes the dishes 100% before stacking them in the dishwasher. I never thought it would happen. There's no need to do this. This particular Whirlpool sounds like an airplane, but the dishes come out clean when the war is over.

So FD comes home and eats breakfast, wants to stack his plate of crusted bagel crumbs and butter in the dishwasher. He sees the clean dishes and asks me, “Are these clean? I just emptied this thing.” His tone is upset, confused.

“Yes, they’re clean. I’m using the rack to let them air dry.”

“Well, how am I supposed to know what’s clean and what isn’t?”

He has a point.

You're all thinking, I know you are, this is so obsessive-compulsive, washing before a wash. But the difference is that there is no second wash.

Another example of mythological OCD:

My mother, 84.5, lives independently but won’t cook for herself anymore. Or bake. She is a fabulous cook, a wonderful baker, and although I’ve tried to fill in, I’m too impatient for real baking; you know what I mean. She won’t cook because it’s too messy. Does she have Obsessive Compulsive Disorder?

She might, is the truth, but in this case, her behavior isn’t a function of her OCD; it’s a vestige of self-esteem. Why should she have to clean up for herself at her age? She's done enough of that, cleaning up for herself, for others. It's time to call it quits.

So we don’t have to treat Mom. But when should we treat compulsions? (Obsessions are the thoughts, compulsions the behavior). And when should we leave symptomatic behavior alone?

We might suggest that if a younger person refuses to cook for herself because a splat of omelet on the range causes her too much distress, then that might be something to treat, depending upon a host of other variables.

And how would we do that, treat it?

It’s not necessary to talk about toilet training as a child, although a therapist could make decent money off this approach. And it’s fun to talk about early childhood, for we do establish much of our irrational tendencies as children just coping with life stress. Life, if you're a kid, has inherent stressors, mainly having to do with weird rules and the behaviors of large people.

But far more elegant than talking about childhood is a behavioral approach. You start (I do) with something that’s upsetting to the patient, like a spill. A therapist like me might pour grape juice into a pitcher and leave it close to the edge of my desk for an entire visit to see how long it takes for the patient to say,

“Could you please move it? It’s going to fall.”

Ridiculous, right? It’s not going to fall. It is a full pitcher. It isn't going anywhere. I move it an inch away from the edge.

“Good enough?”

Of course not.

“Does this make sense?” I ask.

Well yes, it does. We could have an earthquake. Anything could happen. We talk about the concept of stressing the mental set, making the brain grapple with the thought that it could fall, all kind of bad things can happen. But it won't. I won't let it. The thought is irrational and dysfunctional.

Dysfunctional because while under the influence of an obsessive thought, or a compulsive behavior, whatever else is going on in our lives, whatever else is important, is taking a second to something as small as a pitcher of grape juice. And we make other people miserable, waiting for us.

Sure, caution is a good thing, and most of us avoid precarious situations like spills, but when the caution is obligatory, rigid, symbolic for everything, somehow, then we have to tickle many sources, not only a difficult childhood. Pick a trigger, any cause for anxiety, then another, and play with it, talk about it, test it.

Try syrup, working with a spill phobe. No one with this set of compulsions (the cleaning set) is comfortable with spilled syrup.

Hold a spoonful of syrup over the floor, make like you’re going to spill it, but don’t. Get very close to spilling it, but definitely don't. This requires some coordination, but repeat the near accident over and over, each time measuring the length of time the patient is holding his or her breath. (Not literally, just look for any change in expression).

A little anxiety is what we’re shooting for, not too much, and a gradual magnification of the stimulus. This teaches the patient to manage his or her anxiety some other way, and hopefully you're familiar with relaxation techniques and have passed them on, or cognitive strategies, like the rational thinking we discussed above.

The technique of gradually increasing the stress of a feared stimulus is called desensitization. Gradual is key. No need to give anyone a heart attack with spilled grape juice of syrup. Not until you're sure that spilling won't cause a heart attack.

The therapy really can take years. There's always another trigger to desensitize the patient who has this disorder. Medication is helpful, and surely a couple's therapy is always in order, psycho-education for the spouse, and coaching, even shadowing.

So what about me and FD? With the dishwasher. We could dedicate one side of the dishwasher to clean dishes, another to dirty. But I feel this contaminates the clean ones that are minding their own business, just resting across from the dirty ones.

Maybe someone can think of a better idea. I’m not sure I want to quit washing the dishes 100%. It feels good, hot soapy water on skin (I never thought of it this way until a friend mentioned it to me). And it seems like something that should become a permanent bit of the home’s personality, saving counter space, like we're heading in a new direction.

And FD could actually look at a dish to see if the dish is clean. Would that be so bad?

therapydoc

Nobody Said It Was Easy

Not to overdo it with the music videos, but sometimes video gives a whole new meaning to a song. It's like doing therapy. As soon as you get the rest of the story in therapy, a person's life makes more sense. You get it when you get the whole truth, the history.

ColdPlay has a song that I like, The Scientist.

I listened to it over and over again, which I do, like a four-year old, if I like a melody. After the tenth time on this one, I thought I had it figured out.

A couple has a fight, The Big Fight, and in The Big Fight they break up. ColdPlay bemoans the break-up in the ballad.

Nobody said it was easy

It's such a shame for us to part

Nobody said it was easy

No one ever said it would be this hard

Oh take me back to the start.

He wants to try again, go back to the start. Take Two.

It's what we do in therapy, really. We go back to the start, take a look at what went wrong, try something different. Generally the try something different is called an intervention, a part of a treatment plan. We determine which intervention by putting our heads together. It helps to have a therapist armed with dozens of these things different.

Trying something different, being somebody different is much harder than it sounds. Change is packed with difficulty. And it feels like a risk, usually. We like things the same.

But I got it wrong, the meaning of the song. It's not about The Big Fight, the one that you never forget, hard as you try.

The Scientist by Cold Play

Come up to meet ya, tell you I'm sorry
You don't know how lovely you are
I had to find you, tell you I need ya
And tell you I set you apart
Tell me your secrets, and nurse me your questions
Oh let's go back to the start
Running in circles, coming in tails
Heads on a science apart

Nobody said it was easy
It's such a shame for us to part
Nobody said it was easy
No one ever said it would be this hard
Oh take me back to the start

I was just guessing at numbers and figures
Pulling the puzzles apart.
Questions of science, science and progress
Don't speak as loud as my heart.
Tell me you love me, and come back and haunt me,
Oh, when I rush to the start
Running in circles, chasing tails
coming back as we are.

Nobody said it was easy
It's such a shame for us to part
Nobody said it was easy.
No one ever said it would be so hard
I'm going back to the start.



Surely about regret.

And whether or not it was his fault is immaterial. He wants to roll back time.

When something bad happens, something unexpected, something out of the ordinary, life threatening perhaps, there are emotional stages of grief. We think that for most of us, these are unavoidable, quintessentially human emotions.

We want to turn back the clock, do something different.

Forget ColdPlay for a moment.

Say you've been told you have cancer and have only so long to live (not the norm, that kind of news, but it happens). You'll grieve your future loss of life. Even if you've been told that your prognosis is good, that you'll be fine, that it is not life-threatening, your mind will play tricks on you. You'll still worry. You'll regret not having lived your life to the maximum, you'll think you've done something wrong, that you're being punished for the disease.

Forty years ago Elizabeth Kubler Ross (1969) let us in on the ways we grieve, even when we haven't lost anything yet. Anticipating loss can make us sick, just as having lost someone or something (money, for example) can make us sick.

I read her wonderful little book, On Death and Dying, in high school, and felt as if I had been let in on some big secret. Someone recommended it to me when I was dealing with my brother's death. It is probably still required or recommended reading for most graduate students in mental health fields, for mental health is all about holding it together. And loss wrecks our equilibrium. Maybe by now undergrads read it, too, high school students even.

Kubler-Ross defines the five stages of grief work, but there are more. We can thank my son-in-law for reminding me about guilt and self-blame. Kubler-Ross would have filed those under depression:

denial (this can't be happening, it isn't true);

anger (this is SO wrong, I don't deserve this);

bargaining (I'll give more charity, I'll be a better person, just change the decree!);

depression (no point in even trying to be happy here, life is meaningless now);

and acceptance (It is what it is, keep cool and play it out, stay in the moment, don't catastrophize, don't make it what it isn't just because you can, just because you have an imagination).

Acceptance tends to be the baseline for emotional management, but it's a goal, not a given. That's why Kubler-Ross puts it last. I would call it a mediating variable. Without it, no matter the intervention, the resolution of the problem isn't likely to happen. We'll still feel we're in the grieving process.

Acceptance underlies one of the lesser known cognitive-behavioral treatment modalities, Acceptance and Commitment Therapy (ACT) . Here acceptance is the springboard, the starting point, the place from which the real work in treatment begins.

Obviously you can't rush it, you're going to have to feel all of those bad feelings first, you have to, it's the way we're made. If you don't, you will eventually. They come back to bite you. But the idea in either case is to shoot for accepting things as they are.

Impossible. It really feels that way. Impossible.

So in therapy we try to make it possible. You work through the stages, the emotions, try all kinds of interventions, and at some point, miraculously, over time, if you don't rush it, you're there. Or you accept that you can never accept. That's accepting, too.

We'll talk more about ACT another day. It can wait.

But let's go back to the start, to ColdPlay. The fellow in the video, the one who regrets his part in the accident, is going to be stuck feeling bad for quite awhile. By making a video, turning grief into something creative, he has worked a fabulous intervention, something therapists forget to recommend sometimes. Stimulating another part of the brain like that, creating something new, if only for a little while, relieves some of the pain.

Unless. . .

he took Ecstasy the night before the accident, or maybe had some other drug in his system at the time. In that case, in therapy he might be encouraged to work a program* of some sort, commit to changing something about himself. We would stress behavioral change in this case, shoot beyond acceptance. Some kind of program.

I'd say, one that puts his science where his heart is.

therapydoc

*Working a behavioral program is not exclusive to the Anonymous programs for individuals with substance abuse problems. The 12 steps are really just a form of treatment protocol. You can see how they "work if you work them" at The Second Road).

Relatively

I knew I should have posted about prom week. Now I'm in trouble.

I said, only a couple of days ago,

Relativism is the one (intervention) we can’t ram at you for fear you’ll think us not empathetic. Yet we hope. . .

In other words, Give it a shot.

And you voiced objections, of course. You said, basically, that when you're depressed, the relativism doesn't click. It works when you're feeling okay, but when you're depressed you don't care about the suffering of other people. Letters From Exile said it best, Misery is relative. My misery is my misery, and it feels pretty darn miserable to me, no matter how it compares to yours or anyone else's.

Of course.

And it breaks you. As I've said before, depression, misery's first cousin, is the enemy.

So me telling you that many Holocaust survivors think relativistically probably won't help you if you can't get out of bed. And anyway. Who's to say that they're happy?

It's not something I personally would ever say in therapy, You should think relativistically. There are others in worse situations than you. But it surely comes up.

It comes up from you.

You say to me, from your position on the couch,

Not only don't I care about people running for their lives in the Congo. But I feel guilty for not caring .

So many times have I heard this. Not about the Congo, but feeling guilty for not caring about things. Mainly other people.

So. Not only do I agree with your objections, but I'll see you (your objections) and raise you. . . (Why, oh why, do poker metaphors pop out of my mouth at the most inappropriate times!?)

I'll raise you by saying, Relativism is evil. Counter-productive. Salt in the wound. It makes things worse.

And yet. (Nicole Krauss, author of The History of Love, is fond of saying this, And yet. Ms. Krauss writes much like her spouse, Jonathan Safron Foer. You can just hear their pillow talk if you read their books).

And yet, if you're not suffering from depression, if you only have a low-grade fever and are a little on the down side, thinking relativistically does sometimes help. It's a cognitive behavioral strategy, and although there are surely more powerful strategies, comparing one's lot to others in worse straits isn't the worst intervention out there. When you've got nothing to do. And you're watching the news. It kind of depends upon, I suppose, where you're at. Where you're holding.

Relatively speaking.

copyright 2008 therapydoc

Therapy = Cognitive Behavioral Therapy

First there was B.F. Skinner, the behavioral conditioning guru. A few years later, the rat in the maze concept didn't sit so well with the intelligentsia and Albert Ellis's rational emotive therapy got the nod.

On Ellis' heels, Aaron T. Beck engineered a fusion of the two that he called cognitive behavioral therapy or CBT, the Lexus of all individual therapies. We now feel that ALL talk therapies are really forms of CBT because talking is a behavior and listening is cognition.

But there are forms and there are forms. Is a dodo bird a dodo bird a dodo bird?

The relationship therapy I push here on the blog is heavily laced with old fashioned CBT. Using a relationship therapy to reinforce cognitive behavioral therapy is like having a freaking Rolls Royce.

I like driving the Rolls, but totally will accept CBT, the Lexus, if that's all they've got at Avis Rent-A-Car.

The National Institute of Mental Health knocked off the big study on affective disorders and determined that the best way to treat depression is to use a combination of psychotropic medication and cognitive-behavioral therapy (CBT).

Of course.

So you should learn it. You'll get better. You'll stop spleening me, Why aren't I better?

It's an interactive therapy that requires the patient to think and behave differently. One would think they're all like that, all therapies require you to think and behave differently, but this one has a nice structure to it, so anyone can learn it. No huge amount of psychobabble, no tricks. I use it to manage emotions. Yeah, mine, too.

So it can't hurt you to know the basics of CBT to help control your anxiety, anger or depression.
Everyone needs help with at least one of those. Tell me you don't.

The emphasis in CBT is on rationality.

Rationality is not nearly as sexy as emotionality so people resist it like crazy. But at some point you have to grow up.

The path to staying rational is countering irrational beliefs that make us emotional, especially those nasty core beliefs. Irrational core beliefs are deep. They're what makes us deep, all of us. People discover them in therapy, or if they're lucky, when their significant others and friends wriggles them out in intimate conversation.

Sometimes it's perfectly obvious to us, that a negative core belief is disabling, dis-empowering us. They're the windows that slow down our computers, the ones we forgot to close years ago. There may be only one or two programs running back there, using the ram we need for other things, but they're a real pain to shut down. They slow up the whole works.

Sample core beliefs: I'm a loser, I'll never amount to anything, I'm a charlatan, a fake, I'm not a good person.

Such beliefs (thinking) trigger automatic negative feelings. The feelings (always bad) don't let up. They feel unmanageable.

So there you are, feeling down and looking for something to do to feel better, searching for some coping strategy, some behavior to make you feel better. The chosen behavior, unfortunately, driven by uncomfortable arousal (anger or anxiety) or grinding depression, and negative thoughts, tends to be dysfunctional.

Sample dysfunctional behaviors: drinking, over-eating, sending a letter that shouldn't have been sent, having a tantrum, missing work, beating the spouse or kicking the dog, buying a boat.

The dysfunctional behavior fuels a feedback loop. STAY WITH ME HERE. IT'S NOT THAT HARD.

I'm a loser (thought). I feel bad because I'm a loser (feeling). I'll eat a pint of ice cream (behavior). I'm such a loser (thought for having eaten it), I feel bad I'm such a loser (feeling). . .repeated over and over, reinforcing the core belief.

The therapy is as simple as A-B-C.

A stands for affective, or feeling.
B stands for behavior,
C stands for cognition, or thinking

Intervene ANYWHERE, but intervene.

Docs like me have you go home and analyze the events of the day using the A-B-C s. I make you write stuff down, go over it, argue with your thoughts, think twice about your default behaviors. The doc's your worst nightmare, the new program in that computer.

But the doc disappears over time and you take charge of your life pretty soon. You do the therapy yourself. You won't just do it in your head, by the way, you'll have to put the ice cream back into the freezer and find something else to do. But you will challenge your beliefs, become your own advocate, the best lawyer in the hood. Your own best friend.

That said, it helps to have someone else, a friend or a family member help you. Or get a therapy doc. I'll give you some more examples in future posts, I hope. I'll leave out the ice cream, go for the nail biting, pen smashing. Maybe.

The therapy is always about thinking, feeling, and behaving, and how these processes constantly reinforce one another.

Doesn't matter where you begin. Begin anywhere. It'll be work. Sorry about that.

Any questions?

Copyright 2007, therapydoc