Anxiety is one of the most common problems people face today, and yet, it is often complicated with other co-existing conditions, such as obsessive compulsive disorder, autism, and depression. Comorbidity can make treatment challenging, even for clinicians who specialize in anxiety.

In her new book, Tough-To-Treat Anxiety: Hidden Problems & Effective Solutions For Your Clients, licensed clinical psychologist Margaret Wehrenberg breaks down anxiety into its most common presentations, offering a host of treatment methods that work in the moment, and resist remission for years to come.

“Unremitting anxiety may be one the most frustrating situations any individual can face. Family and friends tell worriers, ‘Just don’t worry!’ as if they are somehow choosing to feel anxious. People with panic are often judged as weak or foolish for allowing what’s ‘just an irrational feeling’ to rule their behavior,” writes Wehernberg.

But the reality is that most people face anxiety, especially those with mental health problems. Anxiety is a central theme of life, a normal response to ambiguity, and a technique used to keep us watching movies and television shows.

“The problem with anxiety disorder, as opposed to ‘normal’ anxiety, is that the sense of anxiety persists even when there is no problem or ambiguity to resolve,” writes Wehrenberg.

For people with generalized anxiety disorder, worries can interrupt physical function, causing restlessness, muscle tension, fatigue and pain. It can also interrupt emotional function, causing irritability, short temper, depressed mood, and frustration. It can disturb mental function, causing poor focus, concentration, and preoccupation with anxious thoughts. Lastly, it can impact behavior, causing perfectionism, overscheduling, and controlling behaviors.

One of the first steps in treatment is to rule out the possibility that physical conditions are causing the condition, and then identify worry as worry, in other words, not serving any other purpose. While common treatment methods — such as identifying and changing self-talk, using thought stopping techniques, and changing self-defeating behaviors — can be quite helpful, anxiety can also be unremitting.

Wehrenberg identifies four different types of tough-to-treat anxiety. The logical worrier, often focuses too much on details and misses nuances in conversation. This type of worrier can also present with features of autism. For the illogical worrier, on the other hand, the root cause of the anxiety is commonly obsessive-compulsive disorder, complicated by intractable worry that is unresponsive to logic. The distractible worrier often has trouble focusing, is commonly distracted by worry, and typically struggles with attention deficit disorder. The intense worrier often also struggles with bipolar disorder, and the resulting emotional intensity frequently fuels the intense worry.

Differentiating between each of these subtypes makes all the difference in treatment. While a typical treatment approach is to correct irrational thoughts that lead to anxiety, for the logical worrier, who truly believes that anxiety is necessary and justified, a better approach may be to cultivate a sense of safety and control through interventions such as teaching influence not control, using “dial down the disaster” questions, and finding mentors for support.

Wehrenberg describes Adam, who worried constantly about losing his job and would seek reassurance from his wife on a nightly basis. Yet Adam also felt that losing his job was a very real possibility, and that his worry was justified. Wehrenberg had Adam identify mentors he could use to help mitigate his anxiety and differentiate between situations that made sense to worry about, and those that interfered with his work.

While reassurance strategies are helpful for the logical worrier, for the illogical worrier, reassurance alone does not alleviate worry.

“Non-OCD worry treatment involves techniques that analyze the worry, such as cost-benefit analysis and altering cognitive errors, such as magnifying the problem, black-and-white thinking and confusing probable with possible. But these techniques give too much significance to the obsessive thought. Once a thought is identified as obsession, the idea is to say, whenever it comes to mind, ‘There’s that obsession!’ and to immediately refocus attention on what work there is to do, or on preplanned distractions, such as listening to music, or on a relaxation technique,” writes Wehrenberg.

For the distractible worrier, the use of deadlines to reduce anxiety and adrenaline, psychoeducation, raising self-esteem, creating timed lists, keeping a calendar, transferring worry to another person and seeking special accommodations are helpful strategies. On the other hand, the intense worriers’ feelings can be caused by physical conditions such as thyroid dysfunction, adrenal dysfunction, vitamin B-12 deficiency, and hormone problems.

Here again, an important step is education.

“Most people do not like to accept a diagnosis of a chronic condition, no matter what it is. They don’t like to admit to a ‘flaw’ and want to believe they will overcome any symptom. Educating them about the condition validates that the condition is real and improves the possibility that they will receive and utilize the right treatments,” Wehrenberg writes.

Drawing on her over forty years’ experience, Wehrenberg’s book serves as an indispensable guide for those who treat anxiety. Packed full of helpful strategies, techniques, and case studies, it demystifies anxiety and its treatment, while empowering those who struggle with it.

Tough-To-Treat Anxiety: Hidden Problems & Effective Solutions For Your Clients
Margaret Wehrenberg
W.W. Norton & Company
August 2017
Softcover, 243 Pages

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