Anxiety Examined: working with treatment resistant anxiety disorders in primary care

Contents
Anxiety: defined. 1
Types of source for Anxiety. 3
Triggers to Anxiety. 4
Dysfunctional and functional Anxiety. 4
Dysfunctional anxiety understood longitudinally. 5
Anxiety from a development perspective. 6
Values. 6
Anxiety symptoms. 7
Anxiety coping responses. 8
Implications for treating anxiety in primary care. 8
Implications for OCD.. 8
Implications for Social Anxiety. 9
Implications for Generalised anxiety disorder. 10
Implications for Panic Disorder. 11
Implications for Health Anxiety. 12
Implications for PTSD.. 13
Implications for Phobias. 13
Definitions: 14
Emotions. 14

Anxiety: defined

Let us start by defining our terms and propose a continuum of a threat response, which anxiety exists on. We can define different items on the continuum by a prototypical situation that would evoke certain feelings. The labels we use are going to be slightly blurry and really all we are saying is we have different levels and types of threat.

If we start from mild threat we might talk about apprehension, then we might move through fear, through anxiety to dread and angst maybe.  

What makes for a lesser threat is a function of probability vs significance of threat. So if I it is quite unlikely (probability) that I stub my toe when I walk in the kitchen (significance of threat), then I might say is a low threat, and describe my feelings as apprehensive as stubbing my toe is no big deal to me, I’m a hardy sole and its quite unlikely.

As the probability and significance both rise so we move up the threat continuum let’s say to nervousness and then to fear. One significant thing in terms of all these things I’ve mentioned on the continuum is that they are specific.

The responses we have to apprehension, nervousness and fear as there is a specific threat, is to focus on the threat, and we can avoid it, or challenge it. The main point being is when the object of our fear is not around, our fear isn’t activated. So if we are afraid of dentists, then this would only be activated in the presence of dentists, and if that happened, then I would either try to avoid dentists or work a way to make the threat easier via some level of soporific.

There comes a point where we move from a specific threat, e.g. stubbing my toe in the kitchen, to a general threat, e.g. I could die, or walking in the woods is dangerous.  Here we have an increase in threat because I don’t know where and when I will be threatened, the threat moves from an object, to a situation, which could be the woods when we’re walking through them, or the battlefield, or the garden as I’m being chased by the police. Here the response may be hyper vigilance, being continually “keyed” up, with a feeling of helplessness. You might see responses of high levels of unfocussed activity.

As you go up the threat scale from anxiety we might talk about Dread or Angst, here we can think of an increase in probability and of threat significance and add in a sense of the impossibleness of the situation.  A prototypical situation might be for a young child who sees his father trying to kill his mother, he says he will call the police to his father to save his mother, his father replies I will leave you if you do. So the feeling the child may have would be helpless and in an impossible situation, either his mother may die, or his father will leave him.  So the feeling we have here we can describe as a high level of anxiety, maybe angst, where the parents represent a crucial part of the child’s identity and he is in an impossible situation.

As you get higher up the threat continuum probability increases, threat significance increases, and also levels of impossibleness of response. In short at the top end of threat, that which is most important to you is threatened, it is highly likely it will happen but you are not sure when and there is nothing you can do about it. Indeed in the Sartre example of dread where you in the feeling of vertigo realise that you could jump, so the agent of your terror is yourself. In short with the areas of angst and dread, you are powerless and helpless in front of the apocalyptic threat to that  which is most important to you.

The below diagram illustrates the above ideas

Types of source for Anxiety

As stated above things that threaten something vital to existence will provoke anxiety. So this can be something physical e.g. death, or normative I retire and lose my identity as a prestigious worker.  There are a range of sources for anxiety that entirely depend on what the client sees as their existence, however there are some base categories that should be mentioned that relate to what I’d like to call direct sources of anxiety

1.       Physical

a.       E.g. Death or Disfigurement

2.       Cognitive

a.       E.g.: meaningless or pointless

3.       Emotional

a.       E.g.: madness or specific types of emotion

4.       Socially

a.       E.g.: Isolated or unsuccessful

5.       Behaviourally

a.       E.g.: incapacitated

6.       Values

a.       E.g.: purposeless

7.       Perceptually

a.       E.g.: Something felt as overwhelming

8.       Existentially

a.       E.g.: adopting new ways of behaviour, new values

Indirect sources of anxiety would be those things that you feel you need to protect you from direct sources of anxiety, so they are your coping response to direct sources.

Indirect sources would be anything the client uses to protect themselves from direct anxiety, so a threat to these would provoke an anxious response.

1.       A relationship with someone who care about them

2.       Attendance at church and my religious belief

3.       Having certain types of friends or jobs

4.       Being funny

5.       Obeying the rules I felt as a child

6.       Feeling angry

There can also be an extension of indirect sources of anxiety, that can provide a hierarchy, so

My base anxiety is that I need to have a close supportive relationship to feel safe in the world

I believe that being successful at work is essential to having a close supportive relationship

I believe that working over 50 hours a week is being essential to being successful at work

I believe I must have over 8 hours of sleep per night to be able to work 50 hours a week

As this hierarchy hopefully shows, we could provoke anxiety with this client, through them not getting 8 hours of sleep a night.

There is also an extension of anxiety through association.  So when mum and dad had a violent row when I was 3 and dad said to mum I’m going to kill you, and mum said to me call the police, and dad said if you do I will leave you, I felt anxiety. Now if there was a red carpet there, it could be that I could associate red with that situation, and every time I see red I might feel anxiety. Association like this, without recall of the original event, can often be seen where there isn’t conscious affective awareness of the original event.

Triggers to Anxiety

So we have anxiety as a threat to something essential to us, or that has protected something essential for us. The triggers then to anxiety can either be a direct threat

1.       Something essential to us is currently being threatened.

2.       Something I believe is important to prevent something essential to me is currently being threatened.

Alternatively the threat can be indirect:

1.        I have had something essentially to me taken before and my anxiety is that it will happen again in certain situations

2.       I imagine that it could happen in a certain situation but I have had no direct experience of its threat  or  loss

3.       I associate things with the previous experience of loss but I am not currently threatened

Dysfunctional and functional Anxiety

There are two types of anxiety which we can call functional or dysfunctional. To discriminate the two then you have to ask

1.       Is the anxiety response proportionate to the threat

2.       Is the threat realistic and probable

3.       Does managing the anxiety have an adverse impact on the client’s life

4.       Is the source of the anxiety something that can be overcome

The answer to these questions should come from the client and society at large. You can therefore get an ambiguous answer but this seems to be the nature of the beast, as there is no handbook for life, or prescribed way in which it should work.

Should the answers be that the anxiety response isn’t proportionate, there is an adverse impact on the client’s life and the source of this can be overcome, then you have dysfunctional anxiety, and one where the helping professions could get involved with.

What seems to be common in the source of dysfunctional anxiety is there is a conflict.  A child loves both his parents, and feels he depends on both of them. He comes home from school and sees them in a violent struggle, his mum says to him call the police, his dad says I will leave you if you do. So here we have an impossible situation which will provoke anxiety. How this then can come to develop dysfunctional anxiety, is if this spectre of choose your mum or your dad stays, and the dissonance, unpleasant feeling of anxiety becomes unbearable.

When the experience becomes unbearable then the child must launch their defence mechanisms.

1.       Denial

2.       Humour

3.       Frenetic activity

4.       Disassociation

5.       Substitution with symptoms

6.       Increase feeling of control

Denial, humour and frenetic activity are generally are more conscious defence mechanisms so allow the original anxiety problem to be resolved in time.  Disassociation, symptom formation and control are generally less so.

With symptom formation then the more unpalatable the anxiety is then the more displaced will be the symptom to the original anxiety, thus in the example above of the child in an impossible situation, then one set of symptoms they could develop would be feelings of anxiety every time they needed to make decisions and asking all of their friends to placate this anxiety. This would show quite a direct relation back to the original anxiety. However if the anxiety was really severe they could develop OCD symmetry behaviours where they have to keep all of their clothes in exact places otherwise they feel anxious, this then relates back to their original anxiety through the sense of things needing their place: mums in kitchens and dads in garages and this was being threatened.

Dysfunctional anxiety understood longitudinally

To think about how previous anxiety based conflicts may still have effect after the conflict has been resolved, so for instance the child we talked about in the impossible situation, has now grown up and has a family of their own, the father went to jail, but our client adjusted successfully to this, then the two transmission mechanisms to keep anxiety symptoms going can be:

1.       Association

2.       Repeated patterns

3.       Beliefs

So with association, then the client might start to associate taking decisions as anxiety provoking, and each time there is a decision to take it produces certain feelings which they then manage.

The other way would be repeating patterns so they look to have relationships with people who can put them into impossible situations, so maybe people who like conflictual situations who offer both love and hatred to their partners.

With beliefs then the child may start to believe I am incapable of taking difficult decisions or I am incapable of looking after myself without a powerful person around. These beliefs can be acted upon and used as a filter to understand the world, both of which provide some evidence to the truth of them for their holder.  When these beliefs are threatened then this can re-evoke some of the original felt anxiety, as they have used these beliefs to keep themselves safe, so they think.

Anxiety from a development perspective

Anxiety is seen in babies where they show a fear response, without any obvious trigger, its precursor being the startle response. As they grow then they start to develop specific fear responses, e.g. when the stranger comes in the room, when mother leaves etc.

As a child develops through punishment and reward being used by the parents to indicate what is and what isn’t acceptable. This in turn helps to develop the character. What is and isn’t acceptable, will include acceptable ways of expressing emotion, and important characteristics, for instance being clever, working hard and achieving and a set of rules and beliefs to support these values.

Behaviours\emotions and desire which are outside then of the personality as thus constructed become things that are unloved by the parents, and indeed objects of punishment.  Thus who I am, the worth and love-ability that I have is co-extensive with the surface area that my parents have helped construct. I then feel anxiety if I break these rules as this calls forth the dissolution of what I am, and casts me into the unlovable pit of despair.

Of course there are more influences than just the parents, there will be peers, school, media, but in principle each social group that the child encounters will put another part on what is loveable and what not. The parents seem to have one of the biggest parts to play in this, in the early years.

Values

As parents use punishment and reward to develop the child, then as reward is used then the child is held in esteem, receives strokes and loves and feels valued. They have some power over the parent as the parent will do things to ensure that they do the things worthy of reward. So doing homework for instance, ensure that a parent will talk to you about it, or maybe watch you as you do it.

In time, with enough repetition, then these punishment and reward approaches become internalised. I guess the economics of this is that I can avoid more punishments from my parents if I do it myself first, I can get more rewards, if I reward myself first, which will encourage me into the area where I can get reward from  my parents.

Values therefore get constructed in the first instance as the things I do, to get love and avoid rejection from my parents. I also get valued by my parents as being good, as having interest and being worthy of attention, when I do the valued thing.

My parents in the early days are my whole world, so the world is saying in the initial values, I am worthy of love, interest and affection if I do the valuable things.

As a child’s world develops so they get exposed to more parts of the world. Their peers and teachers at school being one. Again similar attitudes happen, there are values from certain groups of what is and what isn’t desired, and worthy of love, and respect and power. Power becomes more obvious in the school scenario as those who exhibit certain desired values, e.g. popular, have power over others who will be subservient to those who exhibit the values that they would like. Again a similar effect happens where in time the values get internalised, so whilst created to get love,  validation, strokes, respect and power in  a social group, this then gets replicated internally, so the person’s value, and therefore the parts of personality start to get created.

As time goes on new values get created, which can either be through similar mechanisms with personal interactions, or through two other mechanisms. One through extrapolation and projection. So a person on the basis of their existing value set, and what they see as others value sets then creates a value for themselves in so far as they think they will get love, respect and power, from people they want. Then either through enough repetition on their part or if they get the external engagement from others that they want then they can internalise it.

Therefore what you get is people having values that give pleasure when acted upon and pain when not. 

This then becomes a source of direct anxiety when either sufficient numbers of valued traits of a person are threatened to such a point that the person would see themselves as without value, or one major value is threatened. Of course these values may be outmoded, in that the internal valuer maybe out of step with the external world. So at school, you may get praise for academic success, then you may continue looking for academic success later but not get the praise from the people that you want. 

Again it can be that you’re values change but because they are quire internalised then you may act on them as fact rather than choice, and when you hold them up and look at them, find out that they no longer suit you.

Of course in terms of the development of the identity then parents, society and peers all have their roles to play.  As the identity changes over the years, then what is seen as vital may change, thus the attack surface for anxiety may change.

So to summarise then, values are an internalisation of a cognitive attitude (beliefs and rules), plus behavioural patterns, that have been constructed socially and provide someone with the means to be given plaudits, esteem, love and worth. 

The benefits of values originally came from the parents through their love and care, their lack through punishment of some description, or the threat of withdrawal of love.  After internalisation then the self continues to provide both punishment and rewards for values. This is done through a variety of human systems.

Firstly their cognitive system would register how they have performed, be it well or badly. This would then trigger pleasure or pain circuitry would operate, releasing dopamine, or adrenaline. This in turn would provoke the emotional system, which I define in the footnote below.

Anxiety symptoms

Physiologically as the sympathetic nervous system is firing, anxiety symptoms are the same as anger or fear, as adrenaline is pumped through our system.

What makes it different is the feeling of helplessness, this can then either manifest through a freeze response or by frenetic activity

Anxiety coping responses

Given that there is a strong feeling of helplessness then the response from the sympathetic nervous system will be to freeze. The response to this can be an attempt to gain more power and control which generally happens through activity. 

As anxiety is an indeterminate threat for things to become more specific is a help. This can mean that if the anxiety is too great to bear then what can take its place is a more specific fear, so if a child is frightened that either his dad or mum will leave, but he doesn’t know which or how to stop it, he could start to displace this anxiety onto a specific fear e.g. of ghosts.

Implications for treating anxiety in primary care

The clinical recommendation by NICE for treating anxiety is generally either CBT or pharmacotherapy or a combination of the both of them.

For the choice of these two, pharmacotherapy can only remove the symptoms, and it is only through thinking and acting differently that the source of anxiety will be dealt with so I will look at the implications of the above thinking for CBT.

Whilst it is difficult to talk of CBT as a unified thing as it has a range of theories and practitioners under its banner, I’d like to look at CBT in terms of its two targets. These are either what maintains the problem or what are the vulnerabilities a person has to the problem.

Implications for OCD

So if we take a fictional client, i.e. one that has been aggregated out of several clients I have worked with, who suffers with OCD symptoms, in that they have unpleasant thoughts about harming themselves or others? When they have these thoughts they take this as evidence that they could do it, then start to avoid provoking situations, and try to suppress the thought.

Now CBT faced with this client, might use the downward arrow technique to find out what would be so awful if the client did hurt themselves or someone else, which let us say is the rule of

I must be responsible or I will do something terrible

We could use the downward arrow technique some more and end up with

If I do something terrible then no-one will love me

So now we can understand the anxiety as

1.       I have a thought about harming someone

2.       This means I want to

a.       This breaks my rule about being responsible which causes me anxiety

3.       This means I could do something terrible

a.       If I did no-one will love me which causes me anxiety

So if CBT takes a maintenance approach, they can start challenging the idea that having a thought means I want to, they could do this by exposing the client to all the means to do something terrible, holding a large axe over the head of their therapist, to disprove they had the desire.

They could also dig a bit deeper, and look for early experience to understand the rule and belief that are causing difficulties here. Maybe they find that as a child that they were put in an impossible situation, where they had to look after their sibling whilst parents went to work and their parents repeatedly said how terrible they would be if they didn’t do this, and how they would be both put into a home if they didn’t do this well.

If CBT gets this piece of the puzzle then this can provide more sense to the rules and beliefs they operate with and they might see how they learnt these beliefs for one reason, that is now no longer, and how they could replace them.

However despite all the meaning put into their beliefs, despite the challenging of beliefs by cognitive therapy, despite the challenging of beliefs by exposure and response prevention the client can still maintain their behaviours.

So from here we could go to schema therapy and look at the core beliefs that the client has about themselves, around love-ability and responsibility, and again old ones can be challenged, and new ones attempted to be created.

However despite all of this the client can still maintain their behaviour.

What seems to be the vital link to relate the original traumatic event, the impossible situation with the parents and to its symptom formation. This relation seems to require a re-experiencing, whilst you can talk about it and make a link, if there are no related images, or emotions active then the relation is an abstract one only rather than a fully experienced relation.

To prepare the groundwork for treatment then what you would need to do is:

1.       Talk with the client about the original event

2.       See how a vital part of their personality was threatened and how this caused anxiety

3.       Ask them how they dealt with the anxiety

4.       Ask them when them symptom formation started happening

This would hopefully create the cognitive relations between the original event and the symptom.

Then you could re-experience the trauma

1.       Take client back to the original trauma and get them to create a first person image of it

2.       When affect is aroused then ask them how they can alter the image and rescript

3.       Repeat exposure to rescripted image until affect is reduced

Now if there is any residual symptom then adopt the standard CT and ERP approaches.

Implications for Social Anxiety

The standard CBT treatment for Social Anxiety will involve understanding what maintains the social anxiety and it will treat that in the first instance. This could mean understanding what safety behaviours are used (rehearsing what to say, avoiding eye contact etc.) and then noticing how they increase the fear of social difficulty and decrease the likelihood of social success.

Given the argument above that values are socially constructed and used, then with Social anxiety one of the base anxieties could be that without being able to socially engage then values would seek to operate and life would be valueless or pointless. This could illuminate one tract of enquiry with the client.

Many people who present with social anxiety, seem to have their anxiety modulated by the status of the social group they are presented with, so with people the client thinks are of an appreciably lower status then them their anxiety reduces, and contrariwise a higher status group produces more anxiety.  So the base anxiety then for the client is that their existence becomes pointless as they can’t socially engage with the type of people who hold their values.

The other potential line of enquiry that this paper points to is the impossible position.  The contradiction that could be faced here is some strong feelings of hostility felt to the creators of their values. So let us imagine that the client’s parents were the main creators of the client’s values. The client through having these rules imposed on them felt feelings of hostility to their parents, however they depended on them as well. They now have an impossible position where they can’t show their hostility to their parents through fear of their parents abandoning them. As they grow up they develop an association between hostility and holders of their parent’s values. Thus when they encounter certain social groups this original anxiety situation is felt.

Again what this paper points to is discriminating between fear and anxiety and that sometimes a fear can be used as a way to reduce the anxiety. So in the case of social anxiety, what we need to get to is where the clients fear is of something that is vital to their personality.

When you downward arrow a client and this ends with their worst fear is that others would see them as boring, then you need to find out how this relates to an essential aspect of their existence, it could be that if they are seen as boring then they wouldn’t be able to have values in their world as above, alternatively this could be a fear that they are using to reduce the anxiety they feel from their impossible situation. In this instance when you can’t find something that is absolutely vital to their existence that is threatened, then a longitudinal analysis can help this process by first of all establishing when the first instances of social anxiety were felt. When the earliest instance can be elucidated, then we can ask the questions about what the group provides for the client and also what it demands of our client and then with these two lines of enquiry we can start to understand the impossible situation. Maybe there were feelings of hostility felt toward the demanding group but they couldn’t be expressed as the client depended on this group. This can then help our client make a new understanding of their situation, outside the contradiction of their current one.

Implications for Generalised anxiety disorder

In GAD there can be a variety of factors at stake. Firstly there can be worrying used as a cognitive avoidance, secondly there can be worrying as a considered useful strategy in an area that standard reactive skills are not valued and finally there can be worrying as a response to an intolerance of uncertainty.

On the basis of the above understanding I would argue that in the face of anxiety, then a need to exercise control is palliative in a neurotic sense. Anxiety has the feeling of helplessness, so the client to deal with the symptoms of anxiety, rather than its cause.

With GAD you standardly find the worries will be in certain areas, e.g. health, finances, social esteem. On the basis of this the three possible roots of GAD, i.e.

1.       Cognitive avoidance

2.       Useful Strategy

3.       Intolerance of uncertainty

What all three areas point to is that in a certain domain of the client’s life, they feel anxiety and a fear of the ability to respond to it. Now with our argument we would need to know is their anxiety a symptom or the cause.  Generally the texts argue that with GAD the problem is worrying and not the content. So following on in this manner you would have to argue that the worrying is a symptom for anxiety in the domain, presumably where the client has their anxiety.

To decide between the two, and on the principle of least intervention first and Ockham’s razor. You should treat the worrying as the base anxiety, i.e. its self-standing in terms of managing anxiety, feel anxiety, worry to reduce it, then any time a feeling of anxiety comes then worry to reduce it. Of course in our terms we would be more likely to call it fear as it has an object. For instance a client thinks What if I’m late for work, which then starts a worry chain, involving them getting fired.  The base anxiety situation is that I have to work to support my life I can’t cope if something goes wrong at work. So here we have an impossible situation and the response to this is to worry, to increase a sense of control, in front of the felt helplessness.

The question then remains, how did the client learn that they couldn’t cope in such situations, and they needed to worry? This would then take us back to some original event(s), where the client finally came to learn I can’t cope but I need to.

If however the direct approach doesn’t yield dividends or the cognitive avoidance strategy is what the client is using, then worry would be a symptom formation for their base concern, and the coming to terms with\overcoming of the base anxiety would be the direction to take.

What this would mean would be seeing the GAD as a symptom formation to give the illusion of control over where they feel helpless, or in an impossible situation.

So the idea would be to find this impossible or helpless situation which could be

1.       From the original onset of GAD time

2.       Within the current situation, for instance, it would be dreadful if I didn’t have sufficient money to send my children to private school but I really resent having to work that hard to do it, which would provide the impossible situation for the anxiety to come from, and then the GAD can mask this.

When this early\current experience can be unearthed, then treatment can take place through working out how the impossible situation can be worked through or faced. This can be done through exploring fully both sides, which can help towards a synthesised solution.

Implications for Panic Disorder

In panic disorder then there is a fear of panic attacks, the standard fears of this are that the client may die, go mad, fainting,   or be socially shunned.  Generally panic disorder goes with agoraphobia and can be lessened with the accompaniment of a supportive person, usually an adult who doesn’t suffer with panic disorder.

Thus in some ways, even though panic disorder is a fear of panic attacks, actually there is more to it than that.

1.       There can be a fear

a.       of death

b.      of social embarrassment

c.       of going mad

d.      of fainting

e.      of the feelings of anxiety as it means I can’t cope

In light of this paper, what you might find useful if you are stuck and a standard exposure and psychoeducation isn’t working then is look to the fear of panic attacks associating with a previous event that generated a lot of anxiety.  Likewise as has been mentioned above, look to see if this specific fear is masking any anxiety that is related to an initial trauma. The base fear, i.e. of death, going mad etc. may well be a pointer to the initial trauma.

To understand more about their fear within panic attacks masking a base anxiety. Take the fear in panic attacks, e.g. of going mad, and look in the rest of their lives if this fear affects them in any way. If you can elucidate more about the specific fear then as above find out when the onset was and if there was trauma at that time, that is related to their specific fear.

Taking the idea as a specific fear as a symptom formation for underlying anxiety then the type of fear that is used is related back to the underlying anxiety. So if there is a fear of going mad then has this ever been a problem in their lives apart from panic attacks, when was the first time they remember being afraid of going mad, was there conflict in this, where they were asked to look after their sister by their mum and they found it really difficult to do, and they were afraid their mum was going mad, so they had to help her.

Again the fear of panic attacks, might also be the fear of the abandonment of the coping resources that have been used for previous bouts of anxiety. So the person that they need to be with to reduce their feelings of anxiety, may well relate to a time where the client felt unsafe and they felt the anxiety reduce when a powerful person was present. The idea then would to understand how it has had this neurotic symptom formation, so then there would be the idea of trying to construct the historical conflict that resulted in the production of these symptoms.

Implications for Health Anxiety

As with any of the other primary care anxiety disorders you need to find the sense of it for the client. What is it that is the base fear that their health anxiety represents? Some possibilities are death, the inability to look after children, the inability to do anything and be dependent, the importance of responsibility for your health and from being contamination free.

Again the treatment recommendation would be to use E-RP and cognitive restructuring to see if the maintenance of this disorder can be changed by this.  The rationale for how this would be effective using this papers thoughts would be to show to the client that they no longer need to use this symptom to deal with their original anxiety as it has been dealt with.

The development of their symptom would be to substitute it for their original anxiety. The symptom formation would lessen the anxiety, then over time they continue with their symptoms, and indeed their symptoms have their own rationale, i.e. of anxiety management, indeed you could argue a classical conditioning piece of how the current symptoms can provoke anxiety. Thus the original traumatic situation which the symptom was created in the initial instance has now been dealt with, and it is now only the classical conditioning relating the symptom to anxiety, that keeps the symptom going. When you use E-RP and cognitive restructuring the symptom can then fall away.  Where E-RP and cognitive restructuring wouldn’t work is where the base anxiety has not been resolved and is still an active concern to the client.

You may also notice with the Health anxiety symptoms an attempt to get control of the uncertain, it has a similarity with, indeed used to be classified as, OCD.  This would be shown in how repetitive, how compulsive the checking, reassurance seeking are.

To understand health anxiety, then you need to firstly understand the context and trigger when you get an instance of difficulty with it. So when the symptoms are first activated, what was the context for this, what was going on in the client’s life immediately before the symptom arose, and what was the context within the client’s day. You may also want to find out what the functional effect of the symptom is for the client.  The combination of these three will give you an indication as to the meaning and the function of the symptom.  This in turn will allow you to establish the original trauma that underlies this symptom and to see establish if it is still an active conflict for the client or whether a pure maintenance approach can be used.

Implications for PTSD

With PTSD we have a trauma that continues to affect a person. It seems that people who struggle with PTSD are the ones whose trauma confirms dysfunctional underlying beliefs that the person has about themselves. 

In light of this papers thoughts, PTSD you have an active source of anxiety. There was a threat to something essential to a person’s existence and they felt overwhelmed. As the PTSD memory gets re-experienced by the client, they feel the anxiety again. Again a useful line of enquiry if the standard re-living and re-scripting doesn’t work, is to look at any impossibleness of the trauma. This could cache out in something like the threat posed by the trauma, and the belief that is held that I can’t cope in the world (but need to). Thus there is on one part of the contradiction a felt need that I can’t cope, and on the other an active threat to self.  Here the way through this is to have the client bring to consciousness this conflict and to understand longitudinally how the belief was created, see how the trauma was exceptional and not something anyone could have done anything about, to overcome this conflict.  The idea being here that it is the conflict, enabled by the trauma re-activating dysfunctional beliefs that keeps the trauma from being fully processed and stored in autobiographical memory.

Again the argument runs, either the trauma is kept alive through classical conditioning in which case the reliving and re-scripting approach will work, or there is active anxiety underneath it, which points to a neurotic conflict between the trauma event and previously held beliefs. In the case of the latter, then conflict needs to be surfaced, and then both sides need to be re-structured.

Implications for Phobias

Phobias would be the prototypical example of symptom formation for underlying trauma as the client when they talk about their phobic object e.g. the spider, away from the spider, they don’t talk about any inherent threat from the spider, although when they are in its presence then they become highly anxious.

Here as with the disorders mentioned above then you need to understand the nature of the phobia and when it started, to understand what the underlying anxiety is, that it is a symptom for. Of course there might only be a tenuous if any relation to it.

As mentioned above you should treat a phobia with exposure and if this isn’t successful then look to surface the original anxiety that it is a symptom for.

Definitions:

Emotions

I would like to define an emotion as the nexus of a variety of human system, i.e. cognitive, behavioural, affective and physiological. So when an internalised value is achieved then the rewards system that a child has learnt would come into play, they might feel joy, feel happy, i.e. that they are held in esteem, feel loveable, feel pleasure.