Anxiety: A Physician’s Perspective

Andrea Kulberg, PhD, CEDS, is a licensed psychologist with more than 25 years of experience in treating anxiety and eating disorders, and is also a certified eating disorder specialist. She has been trained through the International OCD Foundation in the use of exposure with response prevention (ERP), the number one treatment for anxiety. Dr. Kulberg is also the clinical director at Anxiety Experts in Santa Barbara, Calif.

BSTQ: What is generalized anxiety disorder (GAD) and how is it diagnosed?

Dr. Kulberg: Anxiety disorders are mostly named for situations in which people experience anxiety (such as social phobia — a sense of entrapment and fear of negative evaluation in social situations). However, GAD is characterized by excessive worry about average things that may keep them up at night or may intrude upon their minds during normal daily activities.

BSTQ: What are common symptoms of anxiety in adults?

Dr. Kulberg: Everyone experiences anxiety that results in paranoid thoughts and body sensations such as nausea, heart racing, sweating, shallow breathing, etc. Anxiety disorders are diagnosed only when the anxiety interferes with people’s ability to live the lives they want because it results in avoidance behaviors, reassurance-seeking or rituals. 

BSTQ: Can GAD be cured or only managed?

Dr. Kulberg: The goal of effective anxiety treatment never involves ridding people of anxiety, but rather getting better at understanding the feared thoughts and body sensations to help them get over it more quickly.

BSTQ: When is medication recommended and/or helpful?

Dr. Kulberg: If my clients are not responding well to non-medicinal treatment, I will refer them to a psychiatrist for medication management. Depending upon the severity of symptoms, I may even refer them for a medication consultation at the outset of treatment to avoid a higher level of care. Unfortunately, instead of trying psychiatric medications, many individuals with anxiety turn to taking something habit-forming when they are distressed (e.g., THC in cannabis, benzodiazepines or alcohol), all of which perpetuate the lie that the anxiety can harm them. Of course, when the substance leaves their systems, the individuals are left with a spike of anxiety that is often worse than before, and they usually end up using the substance more frequently and in greater amounts.

BSTQ: Tell us about your two primary treatment protocols at Anxiety Experts.

Dr. Kulberg: We employ ERP and acceptance and commitment therapy (ACT). ERP, a type of cognitive behavioral therapy, is considered the number one treatment for all anxiety-spectrum disorders. While everyone experiences anxiety, some people drive anxiety up by repeatedly engaging in the three safety behaviors — avoidance, reassurance-seeking and compulsions (or rituals) — that are so named because they create an illusion of safety or certainty regarding feared outcomes. The focus of ERP is to interrupt the safety behaviors and help clients learn to accept the uncertainty and discomfort that people with lower levels of anxiety are better able to manage. First, we slowly expose people to the things that make them anxious in hierarchical fashion such as thinking thoughts on purpose that they have been trying to avoid or going into anxiety-inducing situations. Then, we focus on response prevention by having the clients invite anxiety while refraining from engaging in the usual safety behaviors. Over time, it becomes easier to resist safety behaviors, and baseline anxiety is gradually reduced.

ACT teaches people to make their own happiness in life (rather than waiting for it to come along accidentally) by going after things they value. ACT focuses on accepting thoughts and emotions while committing to living by values anyway (ergo, the ACT acronym). This means that people can still do something meaningful while experiencing distressing thoughts and emotions. With ACT, we learn to pursue a rich, full, meaningful life while tolerating the pain that inevitably comes with it.

BSTQ: Are there any promising studies on anxiety that shed light on this increasingly common diagnosis?

Dr. Kulberg: The top researcher on these matters is Jonathan Abramowitz at the University of North Carolina at Chapel Hill. His book Exposure Therapy for Anxiety discusses the important research showing the efficacy of exposure-based therapies. The recently released movie “Anxious Nation” also explains the problem very well in our society. Sadly, children and parents often self-diagnose on the Internet and pathologize normal human struggles and distress as anxiety disorders. I fear that children are leaving school in record numbers due to accommodation of normal childhood anxiety because we are so afraid of requiring children to face average stressors and discomfort. This “prevalence inflation hypothesis” is discussed in a recent article titled “Are Mental Health Awareness Efforts Contributing to the Rise in Reported Mental Health Problems?”¹ It’s definitely worth a read.