Tag Archives: Anxiety

One treatment protocol for many DSM diagnoses?

Could we devise one mental health treatment for many counseling problems? Given that so many problems have similar symptoms (anxiety, mood dysregulation, vigilance, intrusive and unwanted thoughts, etc.) and appear to involve common neurobiological processes (limbic systems), might we be able to find a single treatment for multiple expressions of problems?

David Barlow and others say yes.

The Renfrew Center (an eating disorder clinic) publishes Perspectives: A Professional Journal of the Renfrew Center Foundation, a free journal. In their Winter 2011 issue they have a brief article by David Barlow and Christina Boisseau about a new “transdiagnostic unified treatment protocol” (UP) that can be applied to all anxiety and depressive (and eating) disorders. Let me summarize a few points from the article:

  • 70 to 80% of clients with eating disorders also have anxiety disorders, 50% meet criteria for depression
  • A number of anxiety and depressive disorders have emotional dysregulation as a central theme
  • Etiology of these diagnoses may be best accounted for by “triple vulnerability theory”: biological vulnerability to negative mood…early negative childhood experiences due to attachment issues or unpredictable environment leading to an elevated sympathetic nervous system…and psychological learning from an event focusing on a particular issue (anxiety, panic, observation of parent’s panic, etc.)
  • The Unified Protocol (UP) focuses on “the way that individuals with emotional disorders experience and respond to their emotions” (p. 3). UP consists of 5 core modules
    • emotional awareness training (focus on “nonjudgmental present-focused awareness”)
    • cognitive reappraisal (“identifying and subsequently challenging core cognitive themes”)
    • emotion driven behaviors (EDB) and emotional avoidance (identifying maladaptive EDBs, learn new responses and avoid avoiding emotions)
    • awareness and tolerance of physical sensations (self-explanatory…as they relate to emotions)
    • emotion exposure (“…goal is to help patients experience emotions fully and reduce the avoidance that has served to maintain their disorders(s)”)
  • These modules are flexible and shaped to the individual needs of the client

Obviously, there is much work to be done to validate this protocol but it makes sense. You can see the CBT foundation but also a greater focus on emotion rather than cognition.

Those interested in the full text and references can find it here!


Filed under Anxiety, counseling, counseling science, cultural apologetics, Doctrine/Theology, Psychology

The unpardonable sin

Ed Welch has a good post at www.ccef.org on the “unpardonable sin” passage found in Matthew 12. This is a worrisome passage for many–especially those with scrupulosity (aka Obsessive Compulsive Disorder). He hits the nail on the head that the flip answer, “if you are worried about this, you haven’t committed it” is both likely true but also insufficient for the true worriers among us. So, his post goes in great detail about the passage, its context and good conclusions to draw from it. Well worth your read!

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Filed under Anxiety, biblical counseling, Biblical Reflection, christian counseling, Ed Welch

Fear and trust hand in hand?

This week I’ll be speaking to a group of counselors about complex PTSD. One of the hallmarks of C-PTSD is the combination of chronic relational fear AND chronic shame/guilt over having said fear. It manifests itself as, “I’m afraid of you but I know it’s my fault for being afraid.” (NOTE: the reverse is not necessarily true: that those who have chronic fears, trust problems, and self-condemnation have PTSD or C-PTSD.) My focus at that training will be on this question: How do you lead someone (in therapy) in the repetitive work of “Do not give in to fear”?

On Sunday, Tim Lane of CCEF preached a sermon about fear and disappointment. In that sermon he mentioned our propensity to “flail ourselves”–assuming that we must be doing something wrong–if we experience fear. Instead of focusing on the experience, we ought to examine our responses to fear. Do we shut down? Do we believe that we are alone and isolated? Do we turn inward and act only in self-interest?

He gave us this quote from CS Lewis (Screwtape Letters): “The act of cowardice is all that matters, the emotion of fear is, in itself, no sin.”

Here’s my question: Is it possible to be afraid and to trust nonetheless without much reduction in the level of fear? Don’t we assume that if we act in a trusting way that our fears should abate? Especially in light of trusting God? Is it possible to trust God fully and yet fear? What might such fear and trust together look like? If we could do both at the same time, would it reduce inappropriate self-condemnation?


Filed under Abuse, Anxiety, biblical counseling, Biblical Reflection, christian psychology, Christianity, counseling, Post-Traumatic Stress Disorder

How fear works

[For those looking for a serious discussion of anxiety on this site, you can check out this post or use the search engine on the top right for more posts. This post isn’t one of them.]

You know you have fears that make no sense–that you rarely share with another. They show up in your dreams (like being at work without your pants) and they cross your mind from time to time. Where do they start? I’m not sure but this story is one of mine. On a recent flight across the the Atlantic some woman had temporary psychosis and tried to call the president from the bathroom of the plane to tell him she had been hijacked. Apparently, she drank too much after taking a sleep aid.

See, I was told I should consider taking a sleep aid on my trip to Africa in June. I can’t sleep on planes. But I worried that I would end up doing something like this woman did or like the man who recently took off his clothes in order to be comfortable.

How does fear work? Your mind imagines the possible and turns it into the probable. No matter that thousands of people take sleep aids every day and do not do crazy stuff. Since it is possible, I assume it is likely for me. That is how fear works–the possible becomes probable.

By the way, do you think the doctor who helped this poor woman should have been compensated for his work for 4 hours?


Filed under Anxiety

Disorders of Extreme Stress Not Otherwise Specified (DESNOS)

I recently scanned a book, Healing Trauma(published by Norton in 2003), and ran across a new name (for me) for the problem of complex PTSD–Disorders of Extreme Stress NOS or DESNOS.  Because many christian counselors are only marginally aware of the research on complex PTSD I’ve decided to give a brief summary here.

The following symptom presentation may be found in those with prolonged and severe personal abuse (and often starting at an early age): 

  1. alterations in the regulation of affective impulses, including difficulty with modulation of anger and being self-destructive,
  2. alterations in attention and consciousness, leading to amnesias and dissociative and depersonalization episodes,
  3. alterations in self perception, such as a chronic sense of guilt and responsibility, and chronically feeling ashamed,
  4. alterations in relationships with others, such as not being able to trust and not being able to feel intimate with people,
  5. somatizating the problem: feeling symptoms on a somatic level when medical explanations can’t be found, and
  6. alterations in systems of meaning (loss of meaning or distorted beliefs)

Some folks include a 7th characteristic: (alterations of perceptions of perpetrator(s).

Check out the this paper(44 pages long) written on the assessment and treatment of DESNOS.  Though written for psychiatrists, I found the language easy to understand. The authors do a nice job of helping counselors differentiate between Borderline Personality Disorder and DESNOS. While they recognize significant overlap between the two constellation of symptoms, DESNOS folks tend to experience less relational push/pull (less manipulative behavior) and more push behaviors coupled with more intense sadness and grief.

Counseling work falls (per this paper) into 3 categories: stabilization, trauma processing, and re-integration into their world.


Filed under Abuse, Anxiety, counseling, counseling science, counseling skills, Post-Traumatic Stress Disorder, Psychology

Be Anxious for Nothing???

Posted slides on my “Articles, Slides…” page (#13 on the list) from the talk I gave last night at Macedonia Baptist Church. Talk entitled: Be Anxious for Nothing??? Dealing with Anxiety in a Frightening World.

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Filed under Anxiety, biblical counseling, Biblical Reflection, christian counseling, christian psychology, counseling

Physiology Phriday: Abuse alters genes?

Check out the following link for some very interesting research on how abuse alters the NR3C1 gene in the hippocampus which functions to limit our stress responses. It appears that when the gene is altered, it inhibits natural control of stress responses thereby leaving the abuse victim on high levels of alert.

This may give new meaning to “the sins of the fathers passed on to the third generation” comment in Scripture.


Filed under Abuse, counseling science, Psychology

Physiology Phriday: Anticipation and Anxiety

Anticipation and its relationship to anxiety.

This week we have been thinking about how we evaluate our world. Evaluations or judgements come from a variety of locations. Our expectations and desires prep us to look for certain kinds of “data.” Our histories and past perceptions prep us as well. Finally, what is actually happening is part of the data we use to evaluate ourselves and our world. Notice that we aren’t as logical and objective as we’d like to think. Instead, we ANTICIPATE life and then respond to data that fits into that anticipation.

The primary feature of chronic anxiety is that anticipation of negative, dangerous outcomes. The anxious person views ambiguous data (e.g., a boss who is grumpy, a funny feeling in the chest, etc.) and reads that data in the worst possible light (I’m going to get fired, I’m having a heart attack).

If the problem is bad habits in thought patterns, it would make sense that the treatment ought to be to challenge these logical fallacies with the truth. And while cognitive counseling does indeed work (clear data that one can challenge and reject anxious, ruminative thinking) most find that counseling stops anxiety from growing but doesn’t often stop it from starting in the first place. This struggle to fight anxiety leaves many Christians feeling quite guilty for not trusting God more. 

But what about the amygdala? There is significant research that anxious people have very activated flight/fight activity in the amygdala. In fact, brain scans of this area show greater activity in anxious people than non-anxious people even when they are responding to neutral events. Thus, the anxious person’s brain is in a chronic state of hypervigilance even when nothing is going on. Hypervigilance maintains higher levels of norepinephrine the body, which in turn keeps the adrenal system in high alert. Medications (of the SSRI and NSRI type) have the capacity to positively impact serotonin and Norepinephrine and thereby allow individuals to decrease the negative hormonal activity in the brain.

Which comes first?

So, does biological hyperactivity in the amygdala result from either bad experiences or bad thinking? Or does a predisposition towards overactivity of this part of the brain encourage negative and anxious thinking, forming a vicious cycle? 

Seems to me good treatment needn’t answer this question. Good treatment would include (a) medications that might make it easier to slow down the anxiety processes (biology and behavior), (b) recognition that vigilance can be directed via counseling work away from the feared object and to a better understanding of the brain, and finally (c) that one changes the goal from cessation from fear to a more godly and humble response to Jesus in their fear.

What I mean by (b) is that the anxious person see themselves as like unto a person with colorblindness or dyslexia. In each case, the brain functions in a way to send the wrong messages. The dyslexic person learns to recognize the problem and designs a means to compensate in order to truly see the right order of letters/words. The anxious person accepts that their brain sends certain messages but that their job is to stay remember that while something real is happening it is not necessarily the way their brain is putting the “facts” together. Thus, the work is not to remove the fear but to practice a better response to it.

Ironically, when the person reinterprets the stimulus differently, they do see a marked reduction in fear triggers.

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Filed under christian counseling, christian psychology, Cognitive biases, counseling science, Psychiatric Medications

Identifying Fears: Welch session 1

Ed Welch suggests that we live with so much fear that we may ignore how omnipresent fear actually is throughout our life. Books, media and friends don’t invoke our fear but express the fears we already have. Fear is universal, whether it is the fear of the bogeyman in the closet or the fear of rejection when we get older. Fear is universal.

The most prominent command in Scripture? Do not worry. We should expect that the Bible would have something to say about worry.

Is this command not to fear a holy version of, “Stop it!” No, Welch says it is a pastoral encouragement and comfort and God reserves his most precious and penetrating word to our universal struggle. When you see Jesus repeatedly saying, Do not be afraid (Luke 12) don’t hear it as a nagging or threatening command but a soft and parental reminder of the truth. God is pleased to repeat himself. He, like us, takes deep joy in being trusted.

Is fear sinful? Welch says, “maybe” but that we should rather focus the question on to whom will we turn when we are afraid. We are going to be afraid. That is a fact. But, focus rather on the relationship with God. God has constructed a world based on trust and relationship.

Fear is a relational matter. Many of the treatments ignore this fact and focus solely on the cognitive side. What if we think more relationally about the healthy response to anxiety? Of course, this means the focus is on our relationship with the Sovereign God.

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Filed under Anxiety, biblical counseling

Running Scared Opening

The conference is underway. Already had the opportunity to meet up with several friends. The best part of most conferences are these times of reconnection. Also got to meet a reader of this blog, Jason Kovacs and his wife Shawnda, for the first time and share transracial adoption stories.

Tim Lane opened the conference by meditating on Acts 18 where Paul is facing attack from local Jewish officials. Tim connected this situation with a verse in 1 Cor 2:1 where Paul says he came in fear and anxiety and the Lord’s answer in Acts 18 that He will be with him in spite of the real attack that is all around him. Why? Because God has many people there and has a mission.

Do most of us think that God has a mission for us and is with us and will guide us?  

Take away quote: “Fear and anxieties are predictions of the future.” Ed Welch


Filed under Anxiety