Marybeth Viglione, Ph.D.

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Anxiety Disorders: The Role of Psychotherapy in Effective Treatment

A Publication of the American Psychological Association Practice Directorate

Everyone feels anxious and under stress from time to time. Situations such as meeting tight deadlines, important social obligations or driving in heavy traffic, often bring about anxious feelings. Such mild anxiety may help make you alert and focused on facing threatening or challenging circumstances. On the other hand, anxiety disorders cause severe distress over a period of time and disrupt the lives of individuals suffering from them. The frequency and intensity of anxiety involved in these disorders is often debilitating. But fortunately, with proper and effective treatment, people suffering from anxiety disorders can lead normal lives.

What are the major kinds of anxiety disorders? There are several major types of anxiety disorders, each with its own characteristics.

People with generalized anxiety disorder have recurring fears or worries, such as about health or finances, and they often have a persistent sense that something bad is just about to happen. The reason for the intense feelings of anxiety may be difficult to identify. But the fears and worries are very real and often keep individuals from concentrating on daily tasks.

Panic disorder involves sudden, intense and unprovoked feelings of terror and dread. People who suffer from this disorder generally develop strong fears about when and where their next panic attack will occur, and they often restrict their activities as a result.

A related disorder involves phobias, or intense fears, about certain objects or situations. Specific phobias may involve things such as encountering certain animals or flying in airplanes, whereas social phobias involve fear of social settings or public places.

Obsessive-compulsive disorder is characterized by persistent, uncontrollable and unwanted feelings or thoughts (obsessions) and routines or rituals in which individuals engage to try to prevent or rid themselves of these thoughts (compulsions). Examples of common compulsions include washing hands or cleaning house excessively for fear of germs, or checking over something repeatedly for errors.

Someone who suffers severe physical or emotional trauma such as from a natural disaster or serious accident or crime may experience post-traumatic stress disorder. Thoughts, feelings and behavior patterns become seriously affected by reminders of the event, sometimes months or even years after the traumatic experience.

Symptoms such as shortness of breath, racing heartbeat, trembling and dizziness often accompany certain anxiety disorders such as panic and generalized anxiety disorders. Although they may begin at any time, anxiety disorders often surface in adolescence or early adulthood. There is some evidence of a genetic or family predisposition to certain anxiety disorders.

Why is it important to seek treatment for these disorders? If left untreated, anxiety disorders can have severe consequences. For example, some people who suffer from recurring panic attacks avoid at all costs putting themselves in a situation that they fear may trigger an attack. Such avoidance behavior may create problems by conflicting with job requirements, family obligations or other basic activities of daily living.

Many people who suffer from an untreated anxiety disorder are prone to other psychological disorders, such as depression, and they have a greater tendency to abuse alcohol and other drugs. Their relationships with family members, friends and coworkers may become very strained. And their job performance may falter.

Are there effective treatments available for anxiety disorders? Absolutely. Most cases of anxiety disorder can be treated successfully by appropriately trained health and mental health care professionals.

According to the National Institute of Mental Health, research has demonstrated that both “behavioral therapy” and “cognitive therapy” can be highly effective in treating anxiety disorders. Behavioral therapy involves using techniques to reduce or stop the undesired behavior associated with these disorders. For example, one approach involves training patients in relaxation and deep breathing techniques to counteract the agitation and hyperventilation (rapid, shallow breathing) that accompany certain anxiety disorders.

Through cognitive therapy, patients learn to understand how their thoughts contribute to the symptoms of anxiety disorders, and how to change those thought patterns to reduce the likelihood of occurrence and the intensity of reaction. The patient’s increased cognitive awareness is often combined with behavioral techniques to help the individual gradually confront and tolerate fearful situations in a controlled, safe environment.

Proper and effective medications may have a role in treatment along with psychotherapy. In cases where medications are used, the patient’s care may be managed collaboratively by a therapist and physician. It is important for patients to realize that there are side effects to any drugs, which must be monitored closely by the prescribing physician.

How can a qualified therapist help someone suffering from an anxiety disorder? Licensed psychologists are highly qualified to diagnose and treat anxiety disorders. Individuals suffering from these disorders should seek a provider who is competent in cognitive and behavioral therapies. Experienced mental health professionals have the added benefit of having helped other patients recover from anxiety disorders.

Family psychotherapy and group psychotherapy (typically involving individuals who are not related to one another) offer helpful approaches to treatment for some patients with anxiety disorders. In addition, mental health clinics or other specialized treatment programs dealing with specific disorders such as panic or phobias may also be available nearby.

How long does psychological treatment take? It is very important to understand that treatments for anxiety disorders do not work instantly. The patient should be comfortable from the outset with the general treatment being proposed and with the therapist with whom he or she is working. The patient’s cooperation is crucial, and there must be a strong sense that the patient and therapist are collaborating as a team to remedy the anxiety disorder.

No one plan works well for all patients. Treatment needs to be tailored to the needs of the patient and to the type of disorder, or disorders, from which the individual suffers. A therapist and patient should work together to assess whether a treatment plan seems to be on track. Adjustments to the plan sometimes are necessary, since patients respond differently to treatment.

Many patients will begin to improve noticeably within eight to ten sessions, especially those who carefully follow the outlined treatment plan.

There is no question that the various kinds of anxiety disorders can severely impair a person’s functioning in work, family and social environments. But the prospects for long-term recovery for most individuals who seek appropriate professional help are very good. Those who suffer from anxiety disorders can work with a qualified and experienced therapist such as a licensed psychologist to help them regain control of their feelings and thoughts -- and their lives.

October 1998

This document may be reproduced in its entirety without modification

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How Psychotherapy Helps People

Recover From Depression

A Publication of the American Psychological Association Help Center

According to the National Institute of Mental Health, an estimated 18.8 million adult Americans suffer from depression during any one-year period. Many do not even recognize that they have a condition that can be treated very effectively. This question-and-answer fact sheet discusses depression with a focus on how psychotherapy can help a depressed person recover.

How does depression differ from occasional sadness? Everyone feels sad or "blue" on occasion. Most people grieve over upsetting life experiences such as a major illness, loss of a job, a death in the family, or a divorce. These feelings of grief tend to become less intense on their own as time goes on.

Depression occurs when feelings of extreme sadness or despair last for at least two weeks or longer and when they interfere with activities of daily living such as working or even eating and sleeping. Depressed individuals tend to feel helpless and hopeless and to blame themselves for having these feelings. Some may have thoughts of death or suicide.

People who are depressed may become overwhelmed and exhausted and stop participating in certain everyday activities altogether. They may withdraw from family and friends.

What causes depression? Changes in the body's chemistry influence mood and thought processes, and biological factors contribute to some cases of depression. In addition, chronic and serious illnesses such as heart disease or cancer may be accompanied by depression. For many individuals, however, depression signals first and foremost that certain mental and emotional aspects of life are out of balance.

Significant transitions and major life stressors such as the death of a loved one or the loss of a job can help bring about depression. Other more subtle factors that lead to a loss of identity or self-esteem may also contribute. The causes of depression are not always immediately apparent, so the disorder requires careful evaluation and diagnosis by a trained mental health care professional.

Sometimes the circumstances involved in depression are ones over which an individual has little or no control. At other times, however, depression occurs when people are unable to see that they actually have choices and can bring about change in their lives.

Can depression be treated successfully? Absolutely. Depression is highly treatable when an individual receives competent care. Psychologists are among the licensed and highly trained mental health providers with years of experience studying depression and helping patients recover from it.

There is still some stigma, or reluctance, associated with seeking help for emotional and mental problems, including depression. Unfortunately, feelings of depression often are viewed as a sign of weakness rather than as a signal that something is out of balance. The fact is that people with depression can not simply "snap out of it" and feel better spontaneously.

Persons with depression who do not seek help suffer needlessly. Unexpressed feelings and concerns accompanied by a sense of isolation can worsen a depression. The importance of obtaining quality professional health care can not be overemphasized.

How does psychotherapy help people recover from depression? There are several approaches to psychotherapy - including cognitive-behavioral, interpersonal, psycho-dynamic and other kinds of "talk therapy" - that help depressed individuals recover. Psychotherapy offers people the opportunity to identify the factors that contribute to their depression and to deal effectively with the psychological, behavioral, interpersonal and situational causes.

Skilled therapists such as licensed psychologists can work with depressed individuals to
* Pinpoint the life problems that contribute to their depression, and help them understand which aspects of those problems they may be able to solve or improve. A trained therapist can help depressed patients identify options for the future and set realistic goals that enable these individuals to enhance their mental and emotional well-being. Therapists also help individuals identify how they have successfully dealt with similar feelings, if they have been depressed in the past.

* Identify negative or distorted thinking patterns that contribute to feelings of hopelessness and helplessness that accompany depression. For example, depressed individuals may tend to overgeneralize, that is, to think of circumstances in terms of "always" or "never." They may also take events personally. A trained and competent therapist can help nurture a more positive outlook on life.

* Explore other learned thoughts and behaviors that create problems and contribute to depression. For example, therapists can help depressed individuals understand and improve patterns of interacting with other people that contribute to their depression.

* Help people regain a sense of control and pleasure in life. Psychotherapy helps people see choices as well as gradually incorporate enjoyable, fulfilling activities back into their lives.
Having one episode of depression greatly increases the risk of having another episode. There is some evidence that ongoing psychotherapy may lessen the chance of future episodes or reduce their intensity. Through therapy, people can learn skills to avoid unnecessary suffering from later bouts of depression.

In what other ways do therapists help depressed individuals and their loved ones?

The support and involvement of family and friends can play a crucial role in helping someone who is depressed. Individuals in the "support system" can help by encouraging a depressed loved one to stick with treatment and to practice the coping techniques and problem-solving skills he or she is learning through psychotherapy.

Living with a depressed person can be very difficult and stressful for family members and friends. The pain of watching a loved one suffer from depression can bring about feelings of helplessness and loss. Family or marital therapy may be beneficial in bringing together all the individuals affected by depression and helping them learn effective ways to cope together. This type of psychotherapy can also provide a good opportunity for individuals who have never experienced depression themselves to learn more about it and to identify constructive ways of supporting a loved one who is suffering from depression.

Are medications useful for treating depression? Medications can be very helpful for reducing the symptoms of depression in some people, particularly for cases of moderate to severe depression. Some health care providers treating depression may favor using a combination of psychotherapy and medications. Given the side effects, any use of medication requires close monitoring by the physician who prescribes the drugs.

Some depressed individuals may prefer psychotherapy to the use of medications, especially if their depression is not severe. By conducting a thorough assessment, a licensed and trained mental health professional can help make recommendations about an effective course of treatment for an individual's depression.

Depression can seriously impair a person's ability to function in everyday situations. But the prospects for recovery for depressed individuals who seek appropriate professional care are very good. By working with qualified and experienced therapists, those suffering from depression can help regain control of their lives.

The American Psychological Association Practice Directorate gratefully acknowledges the assistance of Daniel J. Abrahamson, Ph.D., Lynne M. Hornyak, Ph.D., and Lynn P. Rehm, Ph.D., in developing this fact sheet on depression.

Documents from apahelpcenter.org may be reprinted in their entirety with credit given to the American Psychological Association. Any exceptions to this, including requests to excerpt or paraphrase documents from apahelpcenter.org, must be presented in writing to helping@apa.org and will be considered on a case-by-case basis. Permission for exceptions will be given on a one-time-only basis and must be sought for each additional use of the document.

Controlling Anger -- Before It Controls You

A Publication of the American Psychological Association Help Center

We all know what anger is, and we've all felt it, whether as fleeting annoyance or as full-fledged rage.

Anger is a completely normal, and usually healthy, human emotion. But when it gets out of control and turns destructive, it can lead to problems: problems at work, in your personal relationships, and in the overall quality of your life. And it can make you feel as though you're at the mercy of an unpredictable and powerful emotion.

What is Anger?

Anger is an emotional state that varies in intensity from mild irritation to intense fury and rage. Like other emotions, it is accompanied by physiological and biological changes; when you get angry, your heart rate and blood pressure go up, and so does the level of your energy hormones, adrenalin and noradrenalin.

Anger can be caused by external or internal events. You could be angry at a specific person (such as a coworker or supervisor) or event (a traffic jam, a canceled flight), or your anger could be caused by worrying or brooding about your personal problems. Memories of traumatic or enraging events can also trigger angry feelings.

Expressing Anger

The instinctive, natural way to express anger is to respond aggressively. Anger is a natural, adaptive response to threats; it inspires powerful, often aggressive, feelings and behaviors that allow us to fight and defend ourselves when we are attacked. A certain amount of anger, therefore, is necessary to our survival.

On the other hand, we can't physically lash out at every person or object that irritates or annoys us. Laws, social norms, and common sense place limits on how far we should let our anger take us.

People use a variety of both conscious and unconscious processes to deal with their angry feelings. The three main approaches are expressing, suppressing, and calming.

Expressing your angry feelings in an assertive -- not aggressive -- manner is the healthiest way to express anger. To do this, you have to learn how to make clear what your needs are, and how to get them met, without hurting others. Being assertive doesn't mean being pushy or demanding; it means being respectful of yourself and others.

Another approach is to suppress anger and then convert or redirect it. This happens when you hold in your anger, stop thinking about it, and focus on something positive to do instead. The aim is to inhibit or suppress your anger and convert it into more constructive behavior. The danger in this type of response is that if your anger isn't allowed outward expression, it can turn inward--on yourself. Anger turned inward may cause hypertension, high blood pressure, or depression.

Unexpressed anger can create other problems. It can lead to pathological expressions of anger such as passive-aggressive behavior (getting back at people indirectly, without telling them why, rather than confronting them head-on), or a perpetually cynical and hostile attitude. People who are constantly putting others down, criticizing everything, and making cynical comments haven't learned how to express their anger constructively. Not surprisingly, they aren't likely to have many successful relationships.

Finally, you can calm yourself down inside. This means not just controlling your outward behavior, but also controlling your internal responses, taking steps to lower your heart rate, calm yourself down, and let the feelings subside.

Anger Management

The goal of anger management is to reduce both your emotional feelings and the physiological arousal that anger causes. You can't get rid of or avoid the things or people that enrage you, nor can you change them; but you can learn to control your reactions.

Are You Too Angry?

There are psychological tests that measure the intensity of angry feelings, how prone to anger you are, and how well you handle it. But chances are good that if you do have a problem with anger, you already know it. If you find yourself acting in ways that seem out of control and frightening, you might need help finding better ways to deal with this emotion.

Why Are Some People More Angry Than Others?

Some people are really more 'hotheaded' than others; they get angry more easily and more intensely than the average person. There are also those who don't show their anger in loud spectacular ways but are chronically irritable and grumpy. Easily angered people don't always curse and throw things; sometimes they withdraw socially, sulk, or get physically ill.

People who are easily angered generally have what some psychologists call a low tolerance for frustration, meaning simply that they feel that they should not have to be subjected to frustration, inconvenience, or annoyance. They can't take things in stride, and they're particularly infuriated if the situation seems somehow unjust: for example, when they are corrected for a minor mistake.

What makes these people this way? A number of things. One cause may be genetic or physiological; there is evidence that some children are born irritable, touchy, and easily angered, and that these signs are present from a very early age. Another may be how we're taught to deal with anger. Anger is often regarded as negative; many of us are taught that it's all right to express anxiety, depression, or other emotions, but not to express anger. As a result, we don't learn how to handle it or channel it constructively.

Research has also found that family background plays a role. Typically, people who are easily angered come from families that are disruptive, chaotic, and not skilled at emotional communication.

Is It Good to 'Let It All Hang Out'?

Psychologists now say that this is a dangerous myth. Some people use this theory as a license to hurt others. Research has found that 'letting it rip' with anger actually escalates anger and aggression and does nothing to help you (or the person you're angry with) resolve the situation.

It's best to find out what it is that triggers your anger, and then develop strategies to keep those triggers from toppling you over the edge.

Do You Need Counseling?

If you feel that your anger is really out of control, if it is having an impact on your relationships and on important parts of your life, you might consider counseling to learn how to handle it better. A psychologist or other licensed mental health professional can work with you in developing a range of techniques for changing your thinking and your behaviors.

When you talk to a prospective therapist, tell her or him that you have problems with anger that you want to work on, and ask about his or her approach to anger management. Make sure this isn't only a course of action designed to help you 'get in touch with your feelings and express them' That may be precisely your problem.

With counseling, psychologists say, a highly angry person can move closer to a middle range of anger in about 8 to 10 weeks, depending on the circumstances and the counseling techniques used.

Thanks to Charles Spielberger, Ph.D., of the University of South Florida in Tampa; and to Jerry Deffenbacher, Ph.D., of Colorado State University in Ft. Collins, Colorado, a psychologist who specializes in anger management.

Stress Tip Sheet

A Publication of the American Psychological Association Help Center

In today’s fast-paced and ever-connected world, stress has become a fact of life. Stress can cause people to feel overwhelmed or pushed to the limit. The American Psychological Association’s 2007 “Stress in America” poll found that one-third of people in the U.S. report experiencing extreme levels of stress. In addition, nearly one-in-five report that they are experiencing high levels of stress 15 or more days per month. While low to moderate levels of stress can be good for you when managed in healthy ways, extreme stress takes both an emotional and physical toll on the individual.

With the consequences of poorly managed stress ranging from fatigue to heart disease and obesity, it is important to know how to recognize high stress levels and take action to handle it in healthy ways. Being able to control stress is a learned behavior, and stress can be effectively managed by taking small steps toward changing unhealthy behaviors.

APA offers the following tips on how to manage your stress:

Understand how you experience stress. Everyone experiences stress differently. How do you know when you are stressed? How are your thoughts or behaviors different from times when you do not feel stressed?

Identify your sources of stress. What events or situations trigger stressful feelings? Are they related to your children, family, health, financial decisions, work, relationships or something else?

Learn your own stress signals. People experience stress in different ways. You may have a hard time concentrating or making decisions, feel angry, irritable or out of control, or experience headaches, muscle tension or a lack of energy. Gauge your stress signals.

Recognize how you deal with stress. Determine if you are using unhealthy behaviors (such as smoking, drinking alcohol and over/under eating) to cope. Is this a routine behavior, or is it specific to certain events or situations? Do you make unhealthy choices as a result of feeling rushed and overwhelmed?

Find healthy ways to manage stress. Consider healthy, stress-reducing activities such as meditation, exercising or talking things out with friends or family. Keep in mind that unhealthy behaviors develop over time and can be difficult to change. Don't take on too much at once. Focus on changing only one behavior at a time.

Take care of yourself. Eat right, get enough sleep, drink plenty of water and engage in regular physical activity. Ensure you have a healthy mind and body through activities like yoga, taking a short walk, going to the gym or playing sports that will enhance both your physical and mental health. Take regular vacations or other breaks from work. No matter how hectic life gets, make time for yourself — even if it's just simple things like reading a good book or listening to your favorite music.

Reach out for support. Accepting help from supportive friends and family can improve your ability to manage stress. If you continue to feel overwhelmed by stress, you may want to talk to a psychologist, who can help you better manage stress and change unhealthy behaviors.

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