Phobia, Anxiety, Stage Fright, Obsessive-Compulsive Disorder, Health Anxiety, Fear of Flying

World Renown


The Anxiety & Phobia Treatment Center
at White Plains Hospital

ARTICLES

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STRESS MANAGEMENT AND
"CONTEXTUAL THERAPY"

by Alan Logan, ND, FRSH, Phobia Counselor

Stress can be defined as the thoughts, feelings, behaviors and physiological changes that occur when demands placed on the individual exceed the perceived ability to cope. Why is stress management important for our anxiety patients? Contextual Therapy, as developed by Dr. Manuel Zane, itself takes place in the more global context of an individual's daily life. It is obvious that stressful periods can exacerbate anxiety disorders of all types. Higher levels of daily stress prime the sympathetic nervous system and can lead to interference with treatment outcome. Learning effective coping skills can change the perception of demands in daily life; these same skills empower the individual in the context of the anxiety-provoking situation.

Addressing more global aspects of the stress management in the patient's life has tremendous collateral benefits. Consider that those with anxiety disorders, both males and females, have an increased risk of cardiovascular disease and fatal heart attacks. Phobic anxiety is also associated with increased generation of free radicals. Clearly it is unproductive to discuss this risk with patients who are already anxious. However, stress management applications will not only increase the potential for effective treatment sessions, they will contribute to the patient's overall health and well-being.

As research continues to mount, it is becoming clear that stress contributes to the progression of many illnesses. From arthritis, to Crohn's disease, from multiple sclerosis to irritable bowel syndrome, stress management inter-ventions have been found to be an important component to remission or preventing progression. A 20-year Kaiser Permanente study showed that 60% of all medical visits are by the "worried well" with no diagnosable medical condition. Many "worried well" patients sit on the continuum between worry, health anxiety, and a diagnosable anxiety disorder.

We are well aware of the stress response and its physiology (cortisol, norepinephrine, epinephrine etc) in response to perceived threats. We are also well aware of the thoughts that go along with the physiological response. When the stress response is well regulated, the threat is extinguished and equilibrium is maintained. Maladaptive coping involves a stress response that is altered and not well regulated. The consequences are worsening of anxiety, particularly in those prone to anxiety disorders, and a worsening of physical health. We can use stress management to add to the effectiveness our well-established Contextual Therapy.

How can we incorporate stress management into Contextual Therapy? It has been estimated that the average American experiences 50 brief stress response episodes per day. Usually triggered by daily hassles, work and home stressors, these are mini versions of the stress response that is triggered in the phobic/anxious situation. The reasons for a deregulated stress response in those with anxiety disorders are multifactorial. To enhance stress coping, and "recondition" the stress response, a variety of techniques are employed. Helping anxiety patients with cognitive restructuring is at the core of Contextual Therapy. Given that life stress is about perception, the negative or irrational thoughts (inner dialogue) that occur in phobic/anxious situations are often used more globally in the patient's life. Ultimately the negative self-talk, which often takes shape as cognitive distortions, makes stress loom larger than it is. This in turn promotes stress in daily life and makes the job of the anxiety counselor even more difficult. The first target of most stress management programs is dealing with cognitive distortions.

Cognitive Distortions:

All-or-nothing thinking: Things are either good or bad, there is no middle ground.

Overgeneralization: Stress-prone individuals may view negative events as a continuous pattern of defeat.

Mental filter/discounting positives: Stress-prone individuals may filter the world with glasses that ignore the positive and let the negative events gain access to the brain. Accomplishments are discounted and are not used to enhance coping for future events.

Jumping to conclusions:

Stress-prone individuals may conclude that events will always end badly. They do so without any definite evidence. For example, the headache is a brain tumor. Turbulence is mechanical difficulties or an incompetent pilot on a plane.

a. Mind reading: Assuming that people are reacting negatively to you.

b. Fortune-telling: Predicting that things will turn out badly.

Magnification: Stress-prone indi-viduals may consider events or challenges to be much more challenging than they really are.

Emotional reasoning: You reason from how you feel: "I feel incompetent, so I must actually be incompetent."

"Should" statements: Stress-prone individuals may criticize themselves or others with definitive "shoulds," "shouldn't," "musts," "oughts," "and "have-tos."

Labeling: Everyone makes mis-takes and struggles, however, the stress-hardy individual will say "I made a mistake," stress-prone will say, "I am not a strong person" or "I am so incompetent."

Blame: stress-prone individuals may blame themselves for something they were not entirely responsible for, or, may blame others.

The 3 C's

The stress-hardy have been found to embrace 3 C's into their world view.

Change: They view change as a challenge and not something to be feared. Change is viewed as normal, and a stimulus for growth and maturity rather than a threat.

Commitment: They are engaged in life. They have something that they are committed to. We know all too well that those who are committed to recovery are those that excel in Contextual Therapy.

Control: Hardy personalities believe their effort makes a difference. They believe that they have control and are not just a victim of luck or fate. Stress-hardy individuals have no more control over most events than those who are stress-prone... they just believe they do.

DRIVING FEARS

By NELLY EDMONDSON GUPTA FOR THE JOURNAL NEWS (Original publication: February 1, 2005)

When it's snowing or raining, Sarah Bisconte, 46, a public relations specialist who lives and works in White Plains, dons "a long, royal blue goose-down coat that makes me look like a cross between an astronaut and the Michelin Man," and walks 5 miles a day to and from work — just as she does when the weather is nice.

It's not just that Bisconte likes to exercise, although she does. It's that despite living in Westchester, where most people depend on their cars to get through the day, she doesn't drive.

Although Bisconte got her license at 19, she drove only once and then, feeling too frightened to continue, stopped. "I turned a corner — I took the turn too wide — and saw the face of the woman in an oncoming car," recalls Bisconte. "I could tell she thought I was going to hit her. After that, I said, 'I don't want to drive; you'll never get me to drive. Forget it.' "

A not-uncommon fear

Bisconte is far from alone. There are no firm statistics on the number of people with driving fears, but social worker Judy Chessa, coordinator of the Anxiety and Phobia Treatment Center at White Plains Hospital Center, says they are quite common, especially among women. Of the more than 3,000 people that have been treated for phobias at WPHC over the years, Chessa says, driving fears rank in the top three.

According to Dr. Fredric Neuman, director of the Anxiety and Phobia Treatment Center, a fear of driving is actually a form of agoraphobia, the literal definition of which is a fear of "open spaces." However, agoraphobics are not necessarily afraid of open spaces; rather, they are afraid of having panicky feelings, wherever these feelings may occur. "People are really afraid that they are going to go out of control," says Neuman. "They fear that they'll start screaming, vomit, soil themselves, or lose control of the wheel. They think if a feeling gets very strong, it will translate into action."

Many non-drivers have relatives with similar fears, and some have had a traumatic experience behind the wheel. Some non-drivers once relied on a now-deceased spouse for mobility, and there are those who can drive in their own neighborhoods but not on highways. Regardless of the variation, says Chessa, most suburbanites with driving fears wish they could climb courageously behind the wheel. "Even though they make excuses and manipulate their lives around it, many of them come to a point where they say, 'I don't want to live like this any more.' "

After cancer, driven to drive

That is what happened to Heidi Ravis, 42, a wife, mother of two and part-time career counselor in Dobbs Ferry. Although Ravis' mother never drove, Ravis got her license at 22. Shortly thereafter, a minor fender-bender halted her driving career. "I was proud of myself for getting my license but then I thought, 'Maybe I'm not ready for this,' says Ravis. "Over time, my anxiety about driving took on a life of its own."

Although Ravis had promised herself she would get back to driving "eventually," after she and her husband moved to Westchester from Manhattan in 1998, for years it simply didn't happen.

Then, in 2002, Ravis was diagnosed with breast cancer. After completing treatment in 2003, her desire to overcome her fear grew stronger. "I felt, 'If I can deal with cancer, I think I can drive a car,' " she says. Ravis also wanted to be a good role model for her children, Michael, 11, and Dorrie, 8.

"I knew it was weird for them to have to say to their friends, 'My mom doesn't drive,' and I didn't want them to think of me as being scared of doing something that's a basic life activity."

Ravis, who'd kept her license current throughout her non-driving years, took lessons from a local driving school and talked frankly to her driving instructor about her fears. "I told him I had been scared for a long time," she says. "He was unfazed by it; he just wanted me to drive."

To that end, Ravis' teacher drove with her: First around her neighborhood and then in heavy traffic and on highways. Although the driving school's car had dual brakes, Ravis' teacher rarely used them. "He noticed that when I had to make split-second decisions, I managed fine," says Ravis.

A turning point came when Ravis' husband went out of town for a weekend leaving her to manage on her own. "In the past, he would take the car, and the kids and I would have to scrounge for rides or walk. This time, I said, 'Rent a car for yourself and leave me our car.' "

Getting in the driver's seat

What Ravis did with her driving teacher is what experts say all fearful drivers must do: talk about their fears and force themselves into increasingly challenging situations behind the wheel. At the Anxiety and Phobia Treatment Center, Neuman and Chessa use group therapy and trained phobia aides to help people do just that. "To overcome any fear, you have to confront it a little at a time," says Neuman. "We start by having people drive with an aide, first in the driveway, then around the block, then one exit on the highway, and so on. There is no magic wand; it requires a lot of hard work and practice."

Unlearning a fear of driving can be painful. When they begin to tackle the problem, people may experience heart palpitations, blurry vision and rubbery legs, and they often imagine horrible scenarios, such as crashing the car, says Chessa. The key to success, she explains, is to realize, as Ravis did, that one can be afraid — very afraid — and still function. "Despite how you are feeling, there is always something you can do. You can slow down, put on your flashers, or even pull over or get off at the next exit."

Interestingly, in an age where medication is often used to help people cope, it is used only sparingly in those with a fear of driving. Although Neuman sometimes prescribes antidepressants or anti-anxiety drugs to people with underlying depression or panic disorder, if a person has what he calls a "simple" driving phobia, he steers clear of medication.

However, Neuman is a strong advocate of other tools, including cell phones (after a driver has pulled over, of course) and the trip-planning Web site Mapquest, which he says have become extremely important tools in the fight against fear.

"The ability to be in touch with another human being is what a lot of phobic people need," he says, "and Mapquest helps people who feel they have no sense of direction."

At the wheel — or not

These days, Ravis can often be found behind the wheel, ferrying her children to local destinations, including Hebrew school and play dates with friends. "I'm still a work in progress," she says. "But I'm a lot more confident and my kids are really proud of me."

As for Sarah Bisconte, she's still relying on her own fuel to get from place to place — and happy about it.

"The upkeep of a car is a big economic responsibility; car insurance is astronomical and gas is getting more and more expensive," she notes. "I never take a cab home from work — even if it's pouring. I have a big umbrella."

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The Anxiety & Phobia Treatment Center
at White Plains Hospital

Davis Ave. at East Post Rd.
White Plains, NY 10601
Phone: (914) 681-1038
Email: jchessa@wphospital.org
Online: www.phobia-anxiety.org

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