Dr Robert London

Anxiety Disorders: A Proposal

Clinical Psychiatry News - Volume 37, Issue 3, Page 37 (March 2009)

While reviewing various iterations of the DSM and thinking about my experiences in treating many types of anxiety disorders, something occurred to me.

Clinicians who treat these disorders—some of whom still refer to them as “neuroses”—are treating patients who suffer from emotional pain, anxiety, heart palpitations, shortness of breath, flashbacks, dizziness, and a myriad of physical complaints connected to autonomic irregularities. These problems often are based on internal conflicts or learned responses.

Today, patients with these symptoms are diagnosed with illnesses such as posttraumatic stress disorder (PTSD), subthreshold PTSD, panic disorder, and generalized anxiety disorder (GAD). As we know, these diagnoses fall under the broad category of anxiety disorders.

Last month, I offered some thoughts about how those who are working on the DSM-V might approach the manual philosophically (CLINICAL PSYCHIATRY NEWS, February 2009, p. 13). This month, I have another proposal: Why not conceive of anxiety disorders as a spectrum set of disorders rather than as single entities?

Some years ago, I saw a patient who typifies what many of us see in clinical practice. The man, a successful attorney and litigator, had aspects of GAD, PTSD, and panic disorder. He had sought psychotherapy twice previously to address a PTSD problem relating to locking himself accidently in a closet as a child and being stuck in there for almost a half-hour before he was found. As an adult, the patient had flashbacks. He was a consummate worrier but knew that his worries were out of proportion to actual events.

He described bouts of feeling lightheaded, an impending sense of doom, chest tightness, and rapid heart beat that would come over him for no reason he could explain.

The first psychiatrist's treatment consisted of an antidepressant and psychotherapy. The medication made the patient feel sick. The talk therapy centered on feelings of rage growing up that transformed into anxieties. It was even suggested that the patient had become a litigator because this career allowed him to vent his anger in an acceptable manner. This psychiatrist lasted about 8 months.

The patient's second therapeutic experience was with a psychologist. The patient reported the same patterns developed as those he had with the psychiatrist—unresolved feelings of abandonment, rage, anxieties, and panic.

Again, the therapy centered on his feelings. What finally discredited this approach for the patient was an incident in which the patient related to the psychologist that he had nailed a court case, had a great payday, and was actually feeling happy. But the psychologist suggested that the patient was getting revenge by proxy for his underlying anger and rage by beating his opponents in court.

The patient ended the therapy that day.

Enter his internist, who was prescribing Valium for him at the time. Although the patient did not like the slowing effect the medication had on him, it offered some relief from his symptoms. And unlike the antidepressant, it did not make him sick. After giving the patient a clean bill of health, the internist referred him to me.

I met the patient, heard his story, and reviewed his recollection of his past psychotherapy. I explained my plan for relief of his symptoms. My plan, I told him, would be to use a combination of relaxation, and cognitive, and behavior therapies, including my own learning, philosophizing, and action (LPA) technique. I also told him that when I used the cognitive techniques, I might take a time shuttle back to earlier periods in his life. All was agreed upon, and we began.

His combination of disorders could be treated using my favorite technique—the split screen. First, he became skilled at getting to this imaginary movie screen. Next, he would learn to project worries, fears, and anxieties on the left side of the screen, seeing the scenes but not experiencing them. Then he would shift to the right side of the screen, which remained blank, and visualize any pleasant experiences he wished. By doing this, he linked the left side of the screen—where he had projected his anxieties, fears, and worries—with the pleasant scenes on the right, subsequently desensitizing/extinguishing the anxieties in real life.

The practice effect is critical; the patient is instructed to practice this 10 times a day for 2–3 minutes.

PTSD, subthreshold PTSD, and generalized anxiety disorders can be successfully treated this way. Panic disorder can be treated with relaxation techniques alone.

By challenging thoughts cognitively, the patient was able to develop different perspectives about the genesis of his anxieties. This patient's work and family relationships improved as he improved. He spent about a year in treatment with me, but the visits numbered no more than 25.

Had this been a Woody Allen movie, the attorney would have been identified as “neurotic.” In many cases, the word still works, and it remains a globally understood concept. Perhaps the term should be resurrected, because the overlap of symptoms inherent in this category of disorders is tremendous. I hope that those preparing the DSM-V consider bringing this spectrum set of disorders in line with every day clinical realities.

PII: S0270-6644(09)70092-X