Areas of Expertise

Anxiety disorders are clinical syndromes, which are characterized by irrational fears, avoidance, and consequent interference in functioning. Irrational fears are fears that occur in non-threatening situations. Obviously, fears of unsafe situations (e.g. walking a tightrope) are adaptive and therefore not a characteristic of anxiety disorders. Avoidance is a common sequelae of both rational and irrational fear. Avoidance resulting from irrational fears can be maladaptive when it impinges upon an individual’s functioning. For example, developing a fear of driving can have a significant impact on a person’s functioning. So, if you experience fear in the face of normal, relatively safe situations and, as a result, you avoid that situations (or situations like) it and this avoidance interferes with your ability to function, it is likely that you have an anxiety disorder. The Diagnostic and Statistical Manual for Mental Disorders, 5th edition (DSM-5; American Psychiatric Association, 2013) has organized anxiety syndromes into diagnosable disorders. These include panic disorder, agoraphobia, social anxiety disorder (formerly social phobia), specific phobia, and generalized anxiety disorder (GAD). Obsessive compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) were formerly categorized as anxiety disorders, but now have their own categories in the DSM-5.

Clinical research studies have shown that cognitive-behavioral therapy is the most effective approach for treating anxiety and anxiety disorders, in many cases more effective than medication. Some studies have shown success rates to be as high as 80-90%. Cognitive-behavioral therapy (CBT) is a problem-oriented, time-limited form of therapy where techniques for changing, thoughts, behavior and physiological responses are learned. Specific techniques include education about anxiety, relaxation training, breathing re-training, cognitive restructuring, exposure (typically graduated), and systematic desensitization.

MORE ABOUT OUR THERAPY FOR ANXIETY DISORDERS

Up until recently, OCD has been categorized as an anxiety disorder. However, in the most recent version of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5; APA, 2013), OCD now has it’s own category and is grouped with “related disorders,” for example, hoarding and body dysmorphic disorder (BDD). Persons with OCD experience persistent intrusions which are often very distressing as they may go against important values and beliefs. These intrusions are recognized as being “all in the head” but at the same time seem impossible to get rid of. Persons with OCD will attempt to cope with them through engaging in rituals (either behavioral or mental) or through avoidance of situations that trigger the thoughts. Cognitive-behavioral therapy (CBT), specifically exposure and response prevention (ERP) often in combination with cognitive therapy has been shown to be the most effective form of treatment for OCD. A newer approach, Inference-based CBT (I-CBT) offers another option for OCD treatment.

Extensive research has shown cognitive-behavioral therapy (CBT) to be an effective treatment for depressive disorders. Interventions center on changing maladaptive thought patterns that are believed to give rise to depressive symptoms. The primary underlying principle is that thoughts determine feelings. Ergo, individuals who experience depressive thoughts develop depressive feelings and symptoms. Thought patterns are believed to be learned, and therefore, can be unlearned. Individuals who are seen for CBT learn skills to “unlearn” depressive thoughts and re-learn more rationale less depressive thought patterns. In addition, it is also very important to engage in behaviors (e.g. increasing pleasurable activities, exercising) that can reduce depressive symptoms.

BFRBs include trichotillomania (compulsive hair pulling), skin picking and nail biting. These problems can be very difficult to overcome and can cause people who suffer from them a great deal of distress and functional impairment. The state-of-the-art treatment for BFRBs is based on the ComB model and includes a thorough assessment of the individual, tailoring treatment to his or her particular needs, and relapse prevention. In addition, maintaining motivation to work on a BFRB can be particularly challenging and is often a focus of treatment.

At CBT Specialists, our providers take a neurodiversity-affirming stance in therapy with autistic clients, viewing autism as a way of being different rather than through historic deficit models. Therapy focuses on supporting autistic individuals in better managing co-occurring mental health diagnoses such as anxiety, depression, and OCD, improving interpersonal effectiveness skills such as assertiveness and communication skills, and working through the impacts of this diagnosis in domains of their life.

Posttraumatic stress disorder (PTSD) may occur as a result of experiencing one or more traumatic incidents. The traumas must involve experiencing or witnessing an event that involves actual or threatened death or a threat to the physical integrity of self or others. It should also involve a fear response. Traumas can occur as a single incident (such as a rape) or can be ongoing (such as combat or child abuse). Common PTSD symptoms include nightmares, flashbacks (a recurrence of a memory, feeling or perception from the past), intrusive thoughts about the incident, avoidance of situations reminiscent of the incident, avoidance of thoughts and feelings about the incident, isolativeness, anhedonia (lack of pleasure in usual activities), feeling numb, a sense of foreshortened future, irritability, poor sleep, poor concentration, poor memory, guilt, hypervigilence (excessive scanning of the environment for threat), and an exaggerated startle response. To be diagnosed with PTSD, there must be a significant adverse impact on functioning, typically involving interpersonal relationships. Two CBT interventions have demonstrated effectiveness, specifically cognitive-processing therapy (CPT) and prolonged exposure.

Women experience unique emotional needs as mental health problems present differently in men and women. For instance, hormonal changes related to the menstrual cycle, fertility complications, postpartum, and the menopause transition can interact with other factors to affect symptoms of anxiety and depression. Therefore, it is critical that treatment is tailored to address the unique interplay of hormones and experience in women. Specialized treatment for mental health needs of women often focus on infertility, postpartum anxiety and depression, trauma, adjusting to the demands of work/life balance, and transitioning to the changes associated with perimenopause and menopause.

Tics are defined as “a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization,” which are involuntary but can be suppressed. Typically, urges precede tics such that performing the tic reduces the urge. A diagnosis of Tourette’s Disorder is given if there are multiple motor and/or one or more vocal tics that wax and wane over time, persist for at least one year, cause distress and functional impairment, have an onset before age 18, and are not attributable to consumption of a substance or to another medical condition. Comprehensive Behavioral Intervention for Tics (CBIT) is a state-of-the-art empirically supported intervention, shown to help reduce the frequency of tics in children and adults. Its components include 1) changing daily activities to promote the reduction of tics, 2) becoming more aware of tic onset, and 3) learning to reliably perform a competing unobtrusive behavior instead of the tic.

Treatment for individuals with problem drinking or cannabis misuse secondary to a mental health diagnosis is usually short-term and relies on both cognitive-behavioral techniques as well as strategies to enhance motivation to change. We follow a model that focuses on learning skills for either eliminating or reducing the behavior. Components include education, identification of triggers, recognition of both positive and negative consequences, development of an action plan, drink/drug refusal skills, urge control techniques, and relapse prevention. Additional components may be added as needed. As part of the treatment, patients choose either moderation or abstinence as their goal.

Although anger is a normal human emotion, problems managing anger are all too common. Cognitive and behavioral techniques can be used to help clients gain control of their anger by learning to recognize high risk situations for angry responses and planning accordingly. Examples of interventions include pausing to question whether there was any disrespect intended and whether the situation was really that important to warrant an angry response. In the heat of the moment, implementing these kinds of interventions can be difficult, but with the recognition that anger control is an important personal goal and continued practice, better anger management can become a reality.

Difficulty being assertive often underlies both depression and anger management problems. Assertiveness is a style of behavior whereby both the individual’s rights and the rights of others are considered. Assertiveness is contrasted with three other behavioral styles: passive, aggressive, and passive-aggressive. The passive person will forego their own rights in deference to others. He or she will avoid making decisions for fear of offending someone else. Ironically, although the goal of this style of behavior is to please others, this can often backfire as others in their sphere become frustrated with their inability to make a decision and put off by their lack of backbone. The aggressive style is the opposite of the passive style in that this individual disregards the rights of others whenever they conflict with his or her own. In the short run, this can be an effective means for the aggressive individual to have his or her needs met. However, in the long run, friends and family become resentful that they always have to give in to them to avoid a tirade or other form of intimidation. The passive-aggressive person might appear passive on the surface, but they attempt to get their needs met indirectly. Typical passive-aggressive behavior can include procrastination, the “silent” treatment, door-slamming, no-showing, and arriving late. Assertiveness training involves learning to recognize one’s style of behavior, and learning to formulate and implement assertive responses.

It is ironic that with all the advances in technology designed to save time, people are busier than ever. Stress continues to be a significant problem for many people, along with stress-related disorders such as chronic headache, irritable bowel syndrome, and hypertension. Cognitive therapy, relaxation training, assertiveness training, and time organizational skills can help individuals learn to cope better with the stress in their lives and these strategies have also been shown to be effective for the aforementioned stress-related disorders.

The term “life problems” refers to a number of difficulties that many of us experience all too often. These include (but are not limited to) romantic relationships (or lack thereof); infertility and IVF; unplanned pregnancies; unemployment or other occupational issues; separation and divorce; difficult children; difficult parents (elderly or otherwise); difficult neighbors; responding to teasing (adolescents); issues with friendships, legal problems, and financial problems. Although encountering life problems is inevitable, in some cases the challenge of overcoming some difficulty or making a tough choice may seem daunting. Over time, you may feel “stuck.” Cognitive and behavioral techniques are well suited to helping people make tough decisions and cope with difficult situations.