Step 1: Label your anxiety as a false alarm
Fear and fight-flight-freeze response are basically good. They were designed to keep you alive. We run into problems when the fight-flight-freeze response misfires. Think of it as being similar to a car alarm: you want the alarm to sound when someone tries to break into your car, but you don’t want the alarm to go off when a strong wind blows or a bird lands on the car’s roof. When your car alarm goes off too easily, it is too sensitive. Yes, it will let you know when someone is trying to steal your car, but it will also go off at the wrong times. So even though in reality there is only a strong wind, the alarm reacts as if someone is breaking into your car.
People who have excessive fears have an internal alarm system–the fight-flight-freeze response that is too sensitive. The object of your fear–whether it is flying, public speaking, dirt, the dark, or something else–is like the strong wind, and your internal alarm system reacts as if it were really threatening. When your car alarm acts this way, it needs to be fixed or recalibrate. Similarly, when your internal alarm–your fight-flight-freeze response–is overly sensitive, you have to retrain it. The first step is noticing it and labeling it as a false alarm.
Step 2: Catch your anxious thoughts
Father of Cognitive Behavioral Therapy (CBT), psychiatrist Aaron T. Beck, pointed out that people become anxious not merely because of the feared object or situation, but also because of the particular thoughts or beliefs they have about the object or situation. For example, instead of saying, “This airplane flight scares me,” it would be more accurate, according to Beck’s theory, to say, “I feel scared because I am telling myself that this airplane is going to crash.” It is my thought process, not the airplane itself that scares me.
When are beliefs are completely rational and proportional to real danger, the system works just fine. Unfortunately, the cognitive system can sometimes misfire in which case our threat-related thoughts or beliefs tell us than an object or situation is more dangerous than it actually is. When thought processes go wrong, they tend to do so in predictable ways, and fearful people make the same mental errors (which Beck termed cognitive distortions) over and over again.
Step 3: Recognize your tendency to probability overestimate a bad outcome
One common cognitive distortion is probability overestimation: believing a bad outcome or event to be more likely to occur than it actually is. For example, if you had asked me, in the middle of a turbulent flight, what the probability of a plane crashing is, I might have said that there was a 25 percent chance of a crash. Of course, now that I’m off the plane and can think about it a bit more rationally, I realize how illogical my thoughts were: if there was a 25 percent chance of a plane crashing, that would mean one out of every four planes crashes. There would be planes falling out of the sky all over the place! In reality, the odds of being in a plane crash are about 1 in 11 million. So my belief about the likelihood of a plane crash was extremely exaggerated. In fact, if my thought process had been based on actual probabilities, I should have been much more afraid of the drive to the airport than the flight, because the odds of dying in a car crash are a thousand times greater than those of dying in a plane crash. Come to think of it, because the leading causes of death (by a huge margin) are heart disease, stroke, and cancer, maybe I should be most afraid of the burger and fries I had at the airport while waiting for my plane!
Take-home message: When anxious, ask yourself (and write down):
(1) Catch it: what upsetting thought or image am I having right now?
(2) Check it using helpful questions: am I engaging in the cognitive distortion of probability overestimation? what is the evidence that I am magnifying the likelihood of a bad outcome? what good things might happen?
(3) Change your thought: Record the actual probability of your feared scenario, 0-100%? And summarize what you learned.
Trial-Based Cognitive Therapy (TBCT) is a three-level, three-phase, case formulation approach developed by Dr. Irismar Reis De Oliveira at the Federal University of Bahia, Brazil in 2011. TBCT’s foundation is in Cognitive Therapy.
Like CBT, TBCT is an active approach to treatment that helps clients to recognize situationally based thoughts and unhelpful beliefs that exacerbate emotional distress. One of the main goals of both approaches is to help clients modify the so-called core beliefs (CBs) which are those global, rigid, and over-generalized perceptions about themselves, and accepted as absolutely true to the point that they do not question them. However, TBCT has a unique approach to conceptualization and techniques that make it a distinct intervention in modifying clients’ CBs.
- One of the main techniques used in TBCT is the Trial-Based Thought Record (TBTR or Trial I), a structured strategy that is presented as an analogy with Law, in which the therapist engages the client in a simulation of the judicial process. Inspiration for this technique came from the surreal novel by Franz Kafka, The Trial; in the book, the character Joseph K., for reasons never revealed, is arrested and ultimately convicted without even knowing the crime of which he was accused. The TBCT therapist uses a creative and stimulating process to make clients aware of their core beliefs about themselves (self-accusations) and, differently from Joseph K’s process, engages them in a constructive trial to develop more positive and functional beliefs.
Emotional Support Animal Prescription Letter
Are you anxious? depressed?
Have panic attacks? Fear flying?
You may be eligible for an Emotional Support Animal Prescription Letter to allow your dog or cat access to “no pet” residences and airplanes.
To schedule an assessment, contact NYC Cognitive Therapy at 347-470-8870 or email email@example.com.
What is an Emotional Support Animal?
- An emotional support animal is not a pet. It is a companion dog or cat that provides therapeutic benefit to an individual with a mental or psychiatric disability.
- Any size or breed of dog or cat can be an emotional support animal. They do not have to be professionally trained to perform any task, but must be trained to behave appropriately in a public setting.
- Emotional support animals are protected under the Fair Housing Amendments Act (FHAA) and the Air Carrier Access Act (ACAA),
- The FHAA prevents landlord and homeowner associations from restricting your emotional support animal from living with you–even when there is a no pet policy in place. These associations are also not allowed to assess special pet fees on you because of your companion animal.
- The ACAA protects individuals by allowing an emotional support animal to fly with them in the cabin of an airplane, without having to pay any additional fees.
- While emotional support animals are often used as part of a medical treatment plan, they are not considered service animals under the Americans with Disabilities Act.
This is a post from 2015 on how we can be more rational in responding to our fears of terrorism.
Key points were clarified and fascinating information was shared at an incredibly insightful presentation I attended with Noah Clyman, LCSW-R and colleagues from NYC Cognitive Therapy earlier this month, Imagined Ugliness: Understanding and Treating body Dysmorphic Disorder, given by Sabine Wilhelm, Ph. D.
Body dysmorphic disorder (BDD), can be briefly defined as having a preoccupation with one or more perceived defects or flaws in physical appearance that is not observable or appear slight to others (Diagnostic and Statistical Manual of Mental Disorders, DSM-5). BDD usually begins during adolescence, but can occur earlier in childhood and presents almost evenly among genders.
Common physical appearance obsessions:
- Body or facial hair
- Thinning hair on head
- Scars or markings on skin
- Coloring of skin complexion
- Facial Asymmetry
- Shape or size of facial features, various body parts, or muscles
Maladaptive behaviors include: mirror checking, excessive grooming, skin picking or mental acts of comparing appearance to that of others. Many patients also exhibit avoidance behavior. They may avoid places that are very appearance focused (e.g. weddings), brightly lit places and mirrors. This can lead to problems with friends, family or work (calling out, arriving late due to rituals, etc). Preoccupations cause significant distress or impairment in social, occupational or other important areas of functioning. The preoccupations are not attributable to other medical conditions or better accounted for by concerns with body fat or weight in an eating disorder. Muscle dysmorphia–a psychological disorder marked by a negative body image and an obsessive desire to have a muscular physique—is a subtype of BDD.
There are many causes of BDD:
- environmental factors (teasing, childhood neglect/abuse, socio cultural pressures)
- psychological factors and personality traits (perfectionist, rejection sensitivity)
- interpretation biases and information processing abnormalities (detail oriented, self-focused, misperception of neutral facial expressions or situation as threatening)
- biological theories (involvement of frontal-striata/amygdala brain circuitry, family history).
Associated problems include depression and/or anxiety. Alarmingly, the suicide rate for BDD patients is approximately 45 times higher than the general population.
Effective vs. Ineffective treatments
A few treatments are considered by BDD patients. Non-psychiatric treatments are often sought out, such as dermatologist or plastic surgeons. These are usually ineffective and often the patient consequently feels worse after. They can be disappointed when the desired social result is not achieved (e.g., belief that surgery will lead to having friendships, feeling confident, and so on). A significant amount (27%) of BDD patients obtain cosmetic surgery or dental procedures. Medications that are best studied are antidepressants (SRI’s: fluvoxamine and clomipramine). However, all the SRI’s appear to be effective. Typically patients who suffer from BDD require dosages at the higher end of the therapeutic range for SRI’s. Cognitive behavioral therapy, time-limited psychotherapy that modifies maladaptive thoughts, beliefs and behaviors has been proven effective.
Tips to help a friend or loved one overcome barriers to treatment:
- Don’t argue with loved one over the existence of the perceived flaw (or agree).
- Focus on the excessive preoccupation and how it may be impairing their daily lives. In regards to discussions about surgery or dermatological treatments, start a cost/benefits conversation of strategies (consider CBT and/or medication).
- If friend or loved one wants to drop out of CBT to get cosmetic treatment, have them consider postponing the surgery. The surgery can always be an option later, see if they are willing to try a certain number of sessions first.
- Embarrassment about being seen in the waiting room – think of a plan to manage anxiety (arrange appointment time with practitioner so there is no waiting time with other patients).
Tips to enhance motivation for loved one or friend:
- Look forward by asking loved one a question such as: What do you want life to look like in 5 years (what would it look like with or without CBT)? Also think of extreme scenarios (what is the best/worst case) and encourage change talk.
- Start at the end by asking questions like: What do you want people to say about you when you aren’t here? When you look back on your life? What memories do you want to have?
Results of a recent study (24 treatment completers): BDD Severity of sample decreased and results were sustained post treatment. The mean BDD YBOCS score (questionnaire used to measure BDD severity) was 32.5 pre treatment, 15 post treatment (week 24) and 13.5 at the 6 month follow up.
About the author:
Kaley Montgomery is a second year MSW student at New York University Silver School of Social Work. Making a career change after seven years in the fashion industry, she revisited her long standing passion to help people improve functioning in their lives and relationships. Having worked in corporate offices with a variety of companies in New York City, she understands the stress and pressure that can accompany juggling the many demands of city life. She takes a joint approach while working with clients and is an avid believer of CBT, mindfulness and meditation. To book an appointment with Kaley, visit www.nyccognitivetherapy.com.