Today I respond to a request for advice. A reader writes, “Jack, I have many patients with high levels of anxiety. 2020 has been especially hard on them because of covid and politics. Some of them have been in treatment for years or decades and complain they have never felt relaxed or free of anxiety. One said, “I have forever anxiety.” Many of these patients have tried CBT to various degrees but either dropped out or didn’t benefit from it. Many have been on multiple meds too. I could use your advice. Thanks.”
Patients with severe and / or ‘forever’ anxiety are common – unfortunately. We have effective treatments, both meds and psychotherapies, but many people do not respond. Below are ideas to consider.
Set Out Treatment Parameters
Patients with chronic anxiety are often desperate to feel better right now. Some may have started treatment with multiple clinicians and been disappointed each time. Some have a magical belief that this time the outcome will be different, but the process will be the same. This time can indeed be different – better – but the process will have to be different too. A successful outcome will require much more in-depth assessment than is likely to have occurred previously. I like to set the expectations of assessment and treatment right from the start with the patient. Here is a sample script:
“Dear new anxious patient, I’m glad you’re here. You have had anxiety for a long time, and everything you tried hasn’t resolved your anxiety. This is what I can promise you: My team and I will conduct a thorough evaluation. In fact, it will be so thorough you may find it painful and frustrating. Your years of seeking treatment and failing to get good results indicate that throwing whatever treatments at the problem hasn’t worked. The goal, therefore, is to better understand the problem. I am asking you today to make a commitment to fully engage with a thorough assessment, even if you feel frustrated or disappointed by the delay in getting to the treatment. This is a commitment you make to yourself, to find out, better than you have before, what’s going on. Then we can move to treatments.”
Conduct Expanded Assessment
Having spent a large part of my career as a clinician in a tertiary care clinic, I have learned never to assume anything, especially that a thorough evaluation has been, in fact, conducted. These are areas of focus in a thorough evaluation.
Possible Missed Diagnoses and Misdiagnoses: there are many mimics of anxiety disorders and overlapping disorders. Here are just some:
- Major Depressive Disorder: MDD or another depressive disorder can be missed under two circumstances: when the patient’s mood is more anxious than sad, and when the patient is alexithymic, that is, does not have a distinct sense of their mood or, perhaps, an inability to describe it. In MDD, the first criterion is “depressed mood.” Depressed mood is not equivalent to sad mood. In some people, their mood can be more prominently one of fear, anxiety, dread, or doom. The last two relate to a sense of impending disaster, of things uncontrollably falling apart.
- Obsessive-compulsive disorder: ruminations are common in depression and anxiety, and their features overlap with obsessions. Both ruminations and obsessions are recurrent, compelling, time-consuming, and distracting from other things going on in the moment. The sufferers of both may report that their ruminations or obsessions are possibly exaggerated or illogical, but that they can’t stop thinking or visualizing them. So, assess carefully for the nature of these recurrent thoughts and images and for possible compulsions that try to neutralize the anxiety triggered by the obsessive thoughts or images. This is true even in children. Someone in my clinic once had a case of school refusal that turned out to be OCD. The child had obsessions of his parents being murdered while he would be away at school.
- Psychosis: it seems ridiculous that a psychotic disorder could be mistaken for anxiety. But a less-than-thorough evaluation can indeed lead to this misdiagnosis. I have had dozens of patients with schizophrenia who, at one time or another, talk about being anxious. Oftentimes they are reporting a state of anxiety, often related to their paranoia, but sometimes anxiety is their term for their psychotic symptoms more generally. “I’m on olanzapine for my anxiety,” is not an uncommon statement to hear.
- Anxiety secondary or a medical condition or substance: Again, never assume that even the most basic assessment has been conducted even over a history of treatment spanning decades. Conduct a physical exam or send the patient for one. Get all relevant labs. I have seen “anxious” patients end up having diabetes, Addison’s disease, Cushing’s syndrome, Huntington’s disease, hypothyroidism, dementia, etc.
Review of Past Treatments: Another area that requires a painfully thorough review is that of past treatments. This can be so time-consuming that tasking the patient with filling out very detailed forms is an alternative or at least a start. The patient’s statement of “failed treatments” often does not stand up to scrutiny.
- Medication Review: which med, what was the top dose, how long was the top dose maintained, was the med prescribed as monotherapy or with other meds, what were the other meds if any, how was the med tolerated at its top dose, to what degree was the medication effective, what was the level of daily adherence to the med?
- Psychotherapy Review: which therapies, how many sessions of each were attended, what was the focus, were there homework assignments, were the homework assignments done, was there something that sounds like cognitive restructuring being done or exposure therapy or breathing exercises, or progressive muscle relaxation or guided imagery?
- Anxiety Review: describe physical symptoms of anxiety, describe mood and affective nature of symptoms, is there anticipatory anxiety, what are the anticipated situations that trigger anticipatory anxiety, have panic attacks occurred, what coping strategies are used to deal with the anxiety, what is the exact nature of the anxious thoughts, what seems to trigger them, what are the times the anxiety is not present, what do these times have in common, what does it feel like to not have the anxiety, what is the first memory of anxiety having occurred, was it in childhood, what were the circumstances, how did parents respond?
- Life Outside Anxiety Review: what is the level of functioning, what work / leisure activities / tasks does the patient engage in and which ones are no longer engaged in, what would the patient like to do or accomplish in life if anxiety were to resolve, what would life be like without the anxiety, what is the number one thing that would need to change for the patient to begin accomplishing what’s important to them despite any remaining anxiety?
Dwell with Patient in Their Experience
Patients with chronic anxiety might feel very alone and misunderstood. They may believe or have an inkling that their previous clinicians never really understood what was going on. And, very often, they do not have much insight into their anxiety either. Especially deficient is understanding the ebbs and flows of their anxiety. Many times, the chronically anxious person says, “I’m anxious all the time.” This is unlikely to be true: there are circumstances, either present or anticipated ones, that are associated with anxiety and other circumstances associated with a lack of anxiety.
Also, many times anxious patients do not realize how oddly comforting their worry ruminations are. When they catch themselves not worrying, they are flooded with anxiety about having forgotten to worry. They often respond with feelings of guilt or anger at themselves for not worrying.
Worry ruminations are a strategy, a misbegotten one, to cope with their fears. After all, anxiety is an internal state that the experiencer sees as a realistic reflection of real dangers in the world. Not keeping dangers in mind is like not keeping in mind that a pack of wolves are circling around you as you picnic in the wilds of Alaska. The anxious person feels and believes that continuous worry is maintaining situational awareness of real-world threats.
I once treated a highly anxious woman who was overcome with worry every time her husband and children were outside the house. Once we dwelled in her experiences, she realized she was visualizing seeing her children getting run over by a car when crossing the street on the way to school, and of her husband being killed by falling debris or ice from a skyscraper when walking to his office in downtown Chicago. She further realized that she felt guilty when she wasn’t having these thoughts and visualizations. She said, “I”d feel like a bad mother if I didn’t worry about my children.” I said, “So, to be a good mother every day, you must visualize your children being horribly killed?” She paused, stunned, and said, “I didn’t realize how crazy that sounds. That can’t be right, but I don’t know what else to do.” She and I engaged in the planning technique I describe below, and she started psychodynamic psychotherapy because she felt her fears related to experiences from her childhood. On another note, this case shows how close or overlapping ruminations and obsessions are.
Decrease Rumination and Increase Planning
One interesting phenomenon I’ve noticed is that often the people who are most strongly ruminating are least likely to plan and prepare. Rumination is thinking about aspects of the world the person cannot control, while planning and preparing is thinking about how to anticipate threats and taking concrete steps to minimize them. Thus, the focus is on thinking and doing what is in a person’s control.
So, the anxious person may benefit from problem-solving skills. For example, the mother ruminating about her children crossing the street can ensure she trains them to maintain proper situational awareness when crossing streets. Additionally, some intersections are much more dangerous than others because they are confusing to drivers and pedestrians. Children can be taught particular routes to and from school.
An entire additional aspect related to rumination is the “addiction” many anxious people have to watching news shows or internet content related to their particular fears. And today’s media is designed to be addictive by aligning with and furthering or radicalizing a person’s existing views, whether they are covid-related, political, or whatever. One very important area to assess is the anxious person’s viewing habits. If you want to learn more about how media is driving people crazy, look up Tristan Harris or Social Dilemma.
Put Sources of Anxiety into Words
As occurred with my patient who was visualizing her kids getting splattered by passing cars, coming to fully understand one’s fears puts them into a more rational perspective. The anxious thoughts and feelings suggest a monster always lurking about and threatening malevolence. When the person can put their fears into words, that shines a light on them, and the irrational can be separated from the rational aspects of the fears.
What can really help is journaling, in which a patient writes their thoughts privately and with as much openness and detail as they can muster. I think about this as a form of domesticating these wild fears. The threats that anxious people worry about may be exaggerated but often are real. At the end of any kind of therapy and recalibration, the fact remains that bad things happen, that we are likely to get sick and injured, and that we will die. And it is that ultimate end, of death, that may be a foundation of many anxieties. Finding creative and adaptive ways of coping, including through writing and art, can be a focus of therapy.
Live, Live, Live Despite the Anxiety
The sad thing about anxiety, which often focuses on threats of injury or death, is that anxiety interferes with living. A person who is ruminating is not living in the present. What is more compelling: having a nice conversation with a friend or imagining your children being run over. The conversation with a friend has no chance. The anxious person fears death and maybe more so because they are barely alive to the present moment. Much of their lives are spent elsewhere, on compelling but dystopic thoughts. They are not present to enjoy reading, cooking, jogging in the woods, working, and conversing.
As I wrote in the Assessment section above, one important area to assess is what the patient wants to do or accomplish in their life. The miracle question is: “If a miracle happened and you woke up tomorrow without the anxiety, what would you do with your life?” This single question, part of solution-focused therapy, can be life-altering. It opens the patient to realizing that they can start living now. There is no need to wait until the anxiety is all gone because maybe it will never be all gone. We are not going to eliminate disease, injury, and death. So, in a way, we all must live with anxiety and threat. It’s just a matter of how we choose to live in these unavoidable circumstances.
Psychotherapies Other Than CBT for Anxiety
I will go into the psychotherapies at a different time. But know that CBT is not the only option for a person with chronic anxiety. ACT, DBT, IPT, problem-solving therapy, solution-focused therapy, schema therapy, and psychodynamic therapy are all possibilities. We have one hell of an armamentarium, and we should be grateful for that.
Thanks and take care.
“Anxiety is love’s greatest killer. It makes others feel as you might when a drowning man holds on to you. You want to save him, but you know he will strangle you with his panic.” ― Anais Nin
“Worrying is carrying tomorrow’s load with today’s strength- carrying two days at once. It is moving into tomorrow ahead of time. Worrying doesn’t empty tomorrow of its sorrow, it empties today of its strength.” ― Corrie Ten Boom
“To venture causes anxiety, but not to venture is to lose one’s self…. And to venture in the highest is precisely to be conscious of one’s self.” ― Søren Kierkegaard
“Out of your vulnerabilities will come your strength.” ― Sigmund Freud