The road to recovery is paved with details! We need to identify and observe the details of your anxious moment to know what to challenge, what to expose you to, and how to do the opposite.
Anxiety disorders are created, maintained, and intensified by avoidance, and overcome with approach and exposure.
Let’s start with understanding the difference between an anxiety state and an anxiety disorder.
Anxiety disorders are maintained by different avoidances
An anxiety state is a normal, natural, healthy and adaptive reaction to a threat or perceived threat. In the presence of a perceived threat, we get anxious sensations — the fight or flight response — as well as catastrophic thinking.
Your fight or flight response might include an increase in heart rate, sweating, blood rushing out from your stomach to your arms and legs, an increase in blood pressure, pupil dilation, and muscle tension. In the presence of muscle tension, people often take deeper breaths. As you breathe out, you experience a change in CO2. This is not dangerous to you, but can make you feel dizzy and tingly.
In addition to the fight-or-flight response, people often experience catastrophic thinking or worry thoughts. The various anxiety disorders are marked by the difference in the content of the fear. For instance, in the presence of their fight-or-flight response, some people will fear their sensations and then avoid in response to sensations. We call that panic disorder. Some people fear the feeling of judgment, rejection, or embarrassment and avoid in response to situations that could trigger those experiences. That’s social anxiety.
Generalized anxiety disorder (GAD) and OCD can be seen as existing on a spectrum of thoughts, from ego-syntonic to ego-dystonic. These are just fancy words for what seems reasonable versus unreasonable to the person having the thoughts.
A GAD (ego-syntonic) worry thought might be what if I lose my job? The avoidance behavior in response might be:
- Checking and rechecking my work email
- Checking and rechecking the reports I’m writing
- Getting reassurance from my boss or my co-workers
Comparatively, an OCD (ego-dystonic) thought would be something like what if the door isn’t locked? Even when a person just watched their own hand lock the door, this thought would still give them a feeling of uncertainty. In the presence of the feeling of uncertainty, the avoidance behavior in response might be:
- Checking and rechecking the door
- Taking a picture of the door
- Getting reassurance from a friend that the door is locked
All of these responses are examples of avoidance behaviors. Avoidance behaviors function to temporarily reduce discomfort, but just create more and more uncertainty over time. When you do something in response to a feeling of uncertainty, it makes the feeling of uncertainty more likely to occur in the future. If that becomes a frequently used behavioral pattern, we call this an anxiety disorder. In order to get through anxiety disorders, we have to do the opposite. It’s very important to identity the specific avoidance behavior we are engaging in and specifically choose to do the opposite of that avoidance. This is the basis of exposure exercises.
Another name for avoidance is experiential avoidance. Avoidance isn’t just situational avoidance (e.g., leaving a party where you feel uncomfortable or self-conscious). Other forms of experiential avoidance include:
- Cognitive avoidance
- Somatic avoidance
- Emotional avoidance
- Emotion-driven behaviors
We call it experiential avoidance because there are all kinds of ways that we can avoid our experiences.
Cognitive avoidance can include:
- Mental compulsions
- Thought control
- Thought suppression
We discuss cognitive avoidance frequently in the process of overcoming anxiety because people experience many forms of cognitive avoidance for many different reasons. Sometimes you distract yourself because you are afraid of your thoughts. Sometimes you do mental compulsions because you are afraid of what it means if you don’t pay attention to your thoughts. Both of these can happen in the same person at the same time. Once you’ve learned about using exposure thoughts to avoid avoiding, it can sometimes be difficult to tell if the way you are responding to your worry thoughts is cognitive avoidance or a useful exposure exercise. When you can’t tell, look at the function of the thought. Ask yourself if the thought functions to reduce anxiety or allows you to move toward the anxiety? Another way to choose to avoid avoiding in any given is to ask yourself what am I afraid of thinking? Then, make the choice to think exactly that.
Somatic avoidance occurs when you avoid sensations.
Emotional avoidance occurs when you avoid emotions.
Emotion-driven behavior is marked by its urgency. Emotion-driven behavior can be compulsive and it can also be impulsive. You can have both.
Compulsive behavior feels like I don’t want to do this, but I have to.
Impulsive behavior feels like I want to do this despite the risks.
Examples of compulsive behavior include getting reassurance, checking, and washing.
Examples of impulsive behavior include substance abuse, risky sexual behavior, and emotion-driven shopping.
In both cases, you are avoiding the reality that a feeling is a feeling and a thought is a thought. When we see feelings as feelings and thoughts as thoughts, we have the freedom to act based on our values.
Get the details of the moment of suffering
So, with that in mind again, we’re trying to notice all these different avoidances and do the opposite. In their book, What Every Therapist Needs to Know about Anxiety Disorders, Marty Seif and Sally Winston explain how fear of flying can really be a catch-all for all kinds of different problems. They use this example to demonstrate how important it is to get into the specific details of a fear in order to make effective decisions about how to avoid avoiding.
Contamination OCD is another example. There are a number of different fears someone with contamination OCD can experience and a number of avoidances that could maintain their suffering. Some examples include:
- Avoidance of the feeling of disgust
- Avoidance of the feeling of uncertainty
- Situational avoidance (e.g., avoiding places that are contaminated)
- Worry about situations where they could become contaminated
- Mental compulsions about situations where they could be contaminated
Those are just a few examples of the many different avoidances that could maintain contamination OCD. All of this is to say that lots of people avoid in a number of different ways at the same time. In order to effectively avoid avoiding, it is critical that you understand the various forms your avoidance takes.
Although, the concept of exposure and response prevention might seem relatively easy and simple: go towards the thing that you fear and don’t do anything to avoid, the reality is that the details are the difference between continuing to suffer and recovery. Your anxiety and OCD are as smart as you are. Oftentimes there are many different details going on at the same time. The details can be really nuanced. Let’s talk more so we can observe those behaviors and you can recover.