PSYCHOTHERAPEUTICAL APPROACH IN

SPECIFIC DISEASES ANXIETY

Gabriela HUM URSACHI*, Ruxandra ILEA**

Contents
1. Introduction
2. Generalized Anxiety Disorder (GAD)
3. Panic Attack
4. Phobias
a. agoraphobia
b. specific phobias
c. social phobia
5. Obsessive Compulsive Disorders (OCD)
6. Post Traumatic Stress Disorder (PTSD)
7. References

* Clinical psychologist, waiting for Ph.D. in Psychosomatic, Psychotherapist and Trainer for Positive Psychotherapy
** Psychologist, MA in Cognitive Psychology, Psychotherapist and Trainer for Positive Psychotherapy

1. Introduction
If you think that you are beatenyou are!
If you think you cant do somethingyou cant!
If you want to win, but think you cantthen you wont!
Its a state of mind. What are you going to believe?

If you think you make ityou will!

If you think you can do ityou can!
If you think more rationally and turn your thoughts around,
There is nobody, anywhere that can ever pull you down. (Richards, 1996)

Anxiety is a phenomenon experienced of everybody during the daily life. Under the right
circumstances, anxiety is beneficial, heightens alertness and readies the body for action. Anxiety
or fear and the urge to flee are a protection from danger. It also appears linked with the psychic
disorders. When one has chronic state of worry and tension with a persistent fear of impending
doom, one may have an anxiety disorder. Anxiety is also defined as feeling of apprehension
accompanied by sympathetic nervous system arousal, which results in increase in sweating, heart
rate, and breathing rate (Sdorow, 1990).
Anxiety started to be studied in the last years of the 19th century by Janet and Freud (Huber,
1997). Janet describe anxiety as a fear without the object and Delay as a embarrassing feeling
of a danger, a strenuous waiting, an affective tension with the impression of a threat which
cannot be defined by the patient (Miclutia, 2000).
Since the 60s anxiety became again a studies target for developing new treatment modalities.
Nowadays Psychiatric Manuals of Diagnosis (DSM, ICD, Oxford) describe tips of anxiety for
which symptoms and treatment are different. DSM IV-R describe the following anxiety
disorders: generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and phobia disorder. ICD 10 uses another classification described
anxiety disorders as a part of neurotic disorders (ICD 10, 1998):
1. anxious-phobic disorders (F40) - (agoraphobia, social phobias, specific phobias, other forms
of anxious-phobic disorders)
2. other forms of anxiety disorders (F41) - (panic attack, generalized anxiety disorder, mix
anxiety-depressive disorder, mix anxiety disorders, specific anxiety disorders, unspecific
anxiety disorders)
3. obsessive-compulsive disorders (F42) - (obsessive predominant thoughts or ruminations,
compulsive acts, mix obsessive thoughts and acts, obsessive-compulsive disorder, unspecific
obsessive-compulsive disorder)
4. stress reactions and coping disorders (acute stress reaction, post-traumatic stress disorder,
coping disorder, severe stress reactions, unspecific severe stress reactions).
Robert Westermeyer (2001) describes a variety of useful models of anxiety which underlies the
vicious circle of anxiety:

Trigger (event,
psychological
arousal) leads
to catastrophic
interpretation,
which sets into
motion anxiety
cycle. The
anxiety cycle
fuels itself until
escape
behavior is
initiated.

Anxious
Mood

Physical
Symptoms

Escape behavior
(avoidance,
rumination,
perfectionism,
substance use,
etc) serves to
reduce anxiety,
but strengthens
likelihood of
escape behavior
reoccurring and
generalization of
activating cues.

Further Catastrophic Thinking

Fig. 1.1. Anxious Cycle

Anxiety can become a powerful self-fueling cycle. Anxiety increases physical symptoms, which
increase distorted thinking which increase anxiety and so on. These intense symptoms drive a
person to some sort of escape response. Therefore, whenever anxiety symptoms reoccur, so does
the urge to engage in escape, which has proven effective in the past. The behaviors people use to
escape anxiety often cripple their lifestyle. Some people become caged by the cycle of anxiety
and avoidance behavior (Westermeyer, 2001).
We will describe the most frequent forms of anxiety:
Generalized anxiety disorder is a constant, exaggerated worrisome thoughts and tension
about everyday routine life events and activities, lasting at least 6 months. Almost always
anticipating the worst even though there is little reason to expect it. It is accompanied by
physical symptoms, such as fatigue, trembling, muscle tension, headache, or nausea.
Phobias Three major tips of phobias are agoraphobia, social phobias and specific phobia.
People with agoraphobia have a disabling fear of open spaces or crowds. People with social
phobia have an overwhelming and disabling fear of scrutiny, embarrassment, or humiliation in
social situations, which lead to avoidance of many potentially pleasurable and meaningful
activities. Specific phobia is a disorder, which describe fear of specific objects or situations
(spiders, elevators, blood etc).
Panic disorder Repeated episodes of intense fear that strike often and without warning.
Physical symptoms include chest pain, heart palpitations, shortness of breath, dizziness,
abdominal distress, feeling of unreality, and fear of dying.
Obsessive-compulsive disorder (OCD) Repeated, unwanted thoughts or compulsive
behaviors that seems to be impossible to stop or control.
Post-traumatic stress disorder (PTSD) - Persistent symptoms that occur after experiencing a
traumatic event such as rape or other criminal assault, war, child abuse, natural disasters, or
crashes. Nightmares, flashbacks, numbing of emotions, depression, and feeling angry, irritable or
distracted and being easily startled are common (NIMH, 2001).

The prevalence of these kinds of anxiety disorders is high on the general population.

Any anxiety disorder

Panic disorder
Obsessive-compulsive disorder
Post-traumatic stress disorder
Any phobia
Generalized anxiety disorder

PERCENT

POPULATION ESTIMATE
(MILLIONS)

13.3
1.7
2.3
3.6
8.0
2.8

19.1
2.4
3.3
5.2
11.5
4.0

Table 1.1. Anxiety Disorder One Year Prevalence (based on 7/01/1998 U.S. Census resident
population estimate of 143.3 million, age 18-54)
As it is shown in table 1.1. phobias are the most common type of anxiety, circa 8 % of general
population in U.S. suffered from different forms of phobia. It is followed by PTSD (3.6%) and
GAD (2.8%). OCD has a prevalence of 2.3 % and panic disorder of 1.7% on the general
population.
The most popular explanations of anxiety disorders are the psycho-dynamic theory and learning
theory. Psycho-dynamic theory suggests that anxiety results from unconscious conflicts, that is,
a tension between certain wishes and desires, and counteracting guilt associated with these
desires. Learning theory links fearful situations in childhood to anxiety-provoking situations
later. This has been used to explain agoraphobia, in which the fear of being abandoned in the
past may lead to fear of public places.

2. Generalized Anxiety Disorder (GAD)

2.1. ICD 10 diagnosis
Generalized Anxiety Disorder (GAD) is a characterized by extreme worry about more than one
thing. The people suffering from Generalized Anxiety Disorder (GAD) are fixated on the
feelings of worry and dread. For them, the normal anxiety has become a serious problem that
needs treatment. GAD affects all aspects of the patients life: the activity, their decision, their
health, their jobs, the thoughts and their family life. When these people are in a stressful situation
their anxiety erupts into symptoms.
As in the other anxiety disorders the symptoms are very variable and include permanent
irritability, trembling, muscle tension, perspiration, dizziness and racing heartbeat. The fear that
the patient or somebody else from the family will have an accident or will become ill is very
frequent. This disorder is common for women and often correlate with a chronic stress.
To diagnose the Generalized Anxiety Disorder (GAD) the following primary anxiety symptoms
have to be manifest at least few weeks:
1. Apprehensive feeling: fear for future misfortune events like somebody from the family will
be hit by a car, the fear not to follow down, concentration difficulties.
2. Physical tension: permanent worry, headache, trembling, difficulties to relax.
3. Hyper vegetative activity: dizziness, perspiration, racing heart beat, digestive discomfort, dry
mouth (ICD 10, 1998).

2.2. Psychological treatment

An efficient psychological treatment of Generalized Anxiety Disorder (GAD) is Behavior
Therapy and Cognitive Behavior Therapy.
There are specific cognitive strategies used in psychological treatment of Generalized Anxiety
Disorder (GAD).
Cognitive Restructuring: transform the catastrophic and tragic interpretation of the events that
generate anxious feelings into more reasonable ones. The catastrophic thoughts are called
automatic cognition (Boulware, 1999).
Desensitization: the patient is exposed to situations that provoke fears in order to built his or her
strength.
Relaxation Methods as meditation, breathing techniques, progressive muscle relaxation and
visualization help patient to reduce and to control stress.
Helping patients to find a better balance in their lives between self-enrichment, work, family and
relation with the others is very important.
Hypnotherapy: is an appropriate treatment modality for those who are suggestible. Often
hypnotherapy is combined with other relaxation techniques.

2.3. Specific techniques

Cognitive Behavioral Therapy includes specific techniques to reduce the Generalized Anxiety.
Progressive Muscle Relaxation: the patient tenses each major muscle group for 10 seconds,
thinks relax and releases muscle tension while exhaling slowly. After a pause of 20 seconds
the exercise is repeated. It is recommended on waking up and before going to sleep.
Abdominal breathing: The patient is breathing slowly for 10 minutes through the nose. He or
she expands the stomach without moving the chest. Slowly exhales and thinks calm. The
exercise is practiced several times a day.
Autogenous training: the patient scans his/ her body from head to toes. Uses abdominal
breathing and focuses on each area of tension. While the patient exhales he or she visualizes the
area becoming warm and heavy.
Biofeedback: the patient learns to increase the skin temperature of the hands (for example)
through a process of vasodilatation. The autogenous exercise is used to raise the hand
temperature or to lower the heart rate.
Aerobic exercise: before the evening meal swimming, walking, stair climber is recommended.
Maintain the daily routine: it is very important to wake up, eat 3 meals and go to sleep at the
same time every day (Boulware, 1999; ADAA, 2000).

3. Panic Attack
3.1. ICD 10 diagnosis
Panic disorder is a chronic, relapsing problem that can have devastating effects on the persons
work, family and social interactions. Because its symptoms may mimic a variety of medical
conditions, panic disorder frequently goes undiagnosed. The characteristics of the panic disorder
are the panic attacks (sever anxiety) which do not appear in specific situation. These panic
attacks are totally unexpected. As in others anxiety disorders the symptoms are different from
person to person. There are also common symptoms as: palpitations, chest pain, swoon
sensation, dizziness, depersonalization, fear of losing control or going crazy, fear of dying. The
panic attack persists for a few minutes. Often a panic attack is followed by a strong fear that
another attack will happen.
The panic disorder is different from the panic attack, which appeared in specific phobic
situations.
5

To have a clear diagnostic of a panic disorder few severe panic attacks have to appear in a month
and the following criteria to be accomplished:
1. The panic attacks appear in situation where there is no objective danger.
2. The panic attacks are not related with familiar or anticipating situations.
3. There are free intervals between the panic attacks, when there are no anxiety symptoms,
(even if the anticipatory anxiety usually exists) (ICD 10, 1998).

3.2. Psychological treatment

Panic disorder is highly treatable. In fact, appropriate treatment can reduce or completely prevent
panic attacks in 70 to 90 percent of patients.
Cognitive Behavioral Therapy is often used in effective treatment of the panic disorder. By
using the Cognitive Behavioral Therapy the patients learn to anticipate the situation and the
bodily sensations that are associated with their panic attacks. In this way the patients are helped
to control their attacks.
Cognitive Restructuring is a process of re-thinking the automatic cognition and developing
more reasonable interpretation of threat and failure, safety and success. People who experience
anxiety and panic tend to overestimate the potential for tragic outcomes. This catastrophic
thinking generates the tendency to avoid the feared situations. The patient learns to distinguish
what actually occurs from his or her unreasonable interpretation of what occurs. The goal of
cognitive restructuring is to transform self-defeating, catastrophic perceptions into proactive
cognitive style (ADAA, 2000; CWCP, 2001).
Desensitization (Systematic Desensitization and Flooding) is a process of building strength by
facing the fear.
Supportive therapy is also used in panic disorder treatment.
The therapy for panic attacks usually includes the following components:
Explain anxiety and how to identify symptoms
Learn to monitor panic attacks and keep a record of anxiety inducing situation
Relaxation and breathing techniques are used
Developing skills to help block automatic reaction to fearful situations
Learn to recognize thoughts and beliefs that trigger anxiety and change their interpretation
from catastrophic to realistic
Expose the patient to situations that cause anxiety
Practice in everyday life what is being learned in therapy
Cognitive Behavioral Therapy is a short-term treatment, typically lasting 12 to 15 sessions.
Patients with panic disorders that go through Cognitive Behavioral Therapy are reported to have
a relatively low relapse rate of panic attacks.

3.3. Specific techniques

Panic attacks generally occur when the body is extremely stressed and can no longer manage the
stress. At the first sign of panic the key is to relax. There are a few simple things that help a lot
in preventing and controlling panic attacks.
Deep Breathing: One hand is put on the chest and the other on the stomach. The patient takes a
deep breath in and makes the hand on the stomach move and the hand on the chest remains still.
The patient takes a deep breath in, holds it for a count to three. Then breathe out through the
mouth and count to five before taking the next deep breath.
The patient has to practice this breathing daily for at least ten minutes so that it becomes an
automatic response.
This simple technique prevents from hyperventilation during an attack.
6

Muscular Relaxation: Starting with the toes, tighten the muscles for thirty seconds to one
minute until they start to ache. Then completely relax the muscle group letting it go limp like
spaghetti and repeat the process until the patient learns how to relax the muscle. This exercise is
repeated with all the muscle groups finger, hands, arms, shoulders, neck, legs. The patient has
to do this relaxation daily. When panic attack hits, the patient will mentally check to see which
muscles are tensed up and then relax them.
Music: The music has unexpected influence on our body. Relaxing music (and soft piano music)
often helps patients to prevent panic attacks.
Physical exercise: walking and physical exercise are important in fighting with panic attack but
also for the body and mental health.

Sixteen ways to reduce panic symptoms

Use abdominal breathing

See, touch and feel the objects around you
Tell yourself that feelings are not harmful
Tell yourself that feelings will pass
Visualize a peaceful scene
Let your mind go blank
Passively accept your symptoms
Meditate
Sing
Read a book
Talk to a friend
Pet your dog or your cat
Take a walk
Take a warm bath
Splash cold water on your face
Clean the house or wash the car (ADAA, 2000; Farnsworth, 2001)

4. Phobias
The word phobia comes from the Greek word fobos, which means fear and refers to the
experience of excessive or inappropriate fear. The person realizes that the fear is irrational but
cannot control it. Phobias are among the most common psychological disorders, afflicting about
6% of Americans (Boyd, Rae, Thompson, Burns, 1990). There are some classes of phobias:
agoraphobia, simple phobias (or specific phobias) and social phobia.

4.a. Agoraphobia
4.a.1. ICD 10 diagnosis
Agoraphobia is the fear of being in places or situations from which escape might be difficult or
embarrassing or in which help might be unavailable if an unexpected or situational predisposed
panic attack or panic-like symptoms occur. Agoraphobic fears typically involve characteristic
clusters of situations that include being outside the home alone, being in a crowd or standing in a
line, being on a bridge, and traveling in a bus, train or automobile (Cahill, 1995). This is the most

incapacitating phobia because more patients have to stay in the house because of it. Most of the
patients are female and initial symptoms start at the adulthood.
All following criteria have to appear for a certain diagnosis of agoraphobia (ICD 10):
1. The psychological or vegetative symptoms must be primarily manifestations of anxiety not
secondary to delusion or obsessive thoughts.
2. Anxiety has to be limited of (or to appeared in) two of the following situations:
- crowds
- public places
- travel (by car, by bus)
- walk
3. Avoiding the phobic situation has to be a principal characteristic.
There are two types of agoraphobia: with panic attack and without panic attack.

4.a.2. Psychological treatment

1. The most efficient techniques used to treat agoraphobia without panic attack are cognitive
and behavioral techniques. Following the initial evaluation, a treatment plan is developed
according to the individual problem and needs of the client. There are some steps which have
to be followed in the psychological treatment of agoraphobia:
a. Creating a hierarchy: the therapist and the patient create a hierarchy of the
situations in which the feared events occur more and more intensely. The patient has
to score these situations in a scale from 1 to 10, depending on the self-symptoms.
b. Learn relaxation techniques: the client is instructed in relaxation techniques in
order to reduce his/her physical symptoms that accompany his/her anxiety. The most
used relaxation techniques are Schultz technique, Jacobson technique, Windy Driden
technique. On the basis of relaxation the proper treatment of agoraphobia can start.
c. Systematic desensitization: the patient uses the relaxation technique to progress
further and further along the hierarchy with the therapist (from the less feared
situation to the most feared situation), until he or she can handle to most anxietycausing event in the series. The progression could be imagined (in-vitro
desensitization), (e.g., imagine you are in the store, or on the bridge), virtual (e.g.
have an animated virtual store on the computer the patient has to visit), or even real
(in-vivo desensitization), (e.g., the therapist helps patient to cope with a feared
situation in the store or on the bridge).
This is the most used method of treatment for agoraphobia. There are some other methods such
as:
2. Exposure therapy: uses the same method as systematic desensitization except the relaxation
techniques. The patient is exposed to the feared situation in-vivo, without learning relaxation
techniques.
3. Flooding: instead of going through a hierarchy that works from less traumatic to most
traumatic anxiety provoking events, the patient is exposed to the most traumatic anxietycausing event at once. With this technique the patient confronts the feared situation directly.
4. Cognitive Therapy: clients learn to identify and alter erroneous beliefs related to their fears.
Improved thinking patterns result in increase self-confidence and a greater sense of control.
During the psychological treatment the patient has to keep in mind the 5 Rs:
1. React
2. Retreat
3. Relax
4. Recover
5. Repeat

Psychological literature describes also other types of therapy used for agoraphobia treatment as it
is represented in the graphic 1.2. but the cognitive-behavioral therapy has the greatest
effectiveness (Bandelow, 2001).
Means satisfaction with psychological treatment in patients
with agoraphobia
Autogenic Training

1.0

Progressive
Relaxation

1.2

Biofeedback

1.3

Psychodymamic
Therapy

1.5

Cognitive Behavioral
Therapy
0.0
Level of satisfaction

2.6
1.0

2.0

3.0

4.0

5.0

Graphic 1.2. Satisfaction level in patient with agoraphobia and panic attack, regarding different
types of psychotherapy (scale between 1 to 5) (Bandelow, 2001).
As graphic 1.2. shows, Cognitive-Behavioral Therapy (CBT) is the most preferable
psychotherapy, because its approach and the short time spend during the therapy. A very good
result has the combination between a form of relaxation (autogenous training, progressive
relaxation, or biofeedback) and CBT because the effects are complementary and healing is quick.
Psycho - Dynamic Therapy gains the second place in the hierarchy.

4.a.3. Specific techniques (case presentation)

The following description is a case of a 23 years patient, student in the second year at the
Engineering Faculty, who came to the doctor because of his trembling, sweating, insomnia,
palpitations and breathing problems. He was sent to the psychological department with the
diagnosis of agoraphobia with panic attack.
His first panic attack started at school during a long and boring course, after some nights spent
with friends in the bars. He was exhausted, bored and very attentive to his body symptoms
because he started to feel palpitations.
His childhood was a good one, the only child in the family, with a very good relation with his
parents but with al primarily capabilities overdeveloped (love, trust, patience, time etc.). When
he started his High School in the other town in the country he was for the first time alone,
without his mother who makes everything for him (washing, cooking, shopping). He took
advantage of this situation and started to spend nights with friends, not to sleep, not to eat
regularly, to drink a lot of coffee to keep him awake at school. In this context, his first symptoms
were probably caused by the high level of coffeine and the tiredness. After the first symptoms he
started to avoid large classrooms, or, if he had to go to courses, he tried to find a place near the
window or near the door, in order to open the window or to escape from the classroom if the
symptoms appeared. Day by day his feelings started to appear in buses, restaurants, stores, in
places were there are a lot of people or in large places.
We started to make a hierarchy of the situations when he felt these symptoms and to score the
level of anxiety in these situations:
1. in the bus 3 points
2. in the stores 5 points
3. in the restaurant 6 points
9

4. at school, during the courses 10 points.

After that he was teach to use autogenous training, Schultz method, during 6 weeks. At same
time a psychiatrist recommended him a treatment with anxiolytic. After the first 6 weeks we
started to work on desensitization.
I.
Firstly the patient was asked to relax using the already known exercises.
II.
After that he was asked to imagine the least feared situation, traveling by bus. During the
imagery exercise he was asked all the time about the level of anxiety (on a scale from 1to
10 points). When the anxiety symptoms grew up over 5 points, the patient was asked to
breathe deeply and to imagine a machine with a button, which can be switched. If it is
switched to the right, the intensity of the symptoms increases. If it is switch to the left
side, the intensity of the symptoms decreases. Using this method, the patient was
instructed to control the feared situation in-vitro.
III.
When the symptoms disappeared he was asked to travel by bus and to use the same
technique till the symptoms disappeared in-vivo.
IV.
After this symptom was cured, we started to desensitize the others symptoms in the order
the patient indicated (the store, the restaurant, the classroom).
After 12 weeks he was cured. Now he is capable to handle all situations where there are a lot of
people or any large spaces.

4.b. Specific phobias

4.b.1. ICD 10 diagnosis
It is an intense, irrational fear of a specific object or situation. People with simple phobias may
avoid the object or the situation they fear pe o perioada din ce in ce mai lunga. Specific phobias
usually start during childhood or early adulthood, and when left untreated can last very long.
There is some common simple phobias show in the table 1.2.
Phobia
Source of phobia
High places
Acrophobia
Cats
Ailurophobia
Pain
Algophobia
Water
Aquaphobia
Spiders
Arachnophobia
Lightning storms
Astraphobia
Enclosed places
Claustrophobia
Dogs
Cynophobia
Blood
Hematophobia
Fear of water
Hydrophobia
Being alone
Monophobia
Dirt
Mysophobia
Darkness
Nyctophobia
Crowds
Ocholophobia
Death
Thanatophobia
Number thirteen
Triskaidecaphobia
Strangers
Xenophobia
Animals
Zoophobia
Table 1.2. Common simple phobias (Sdorow, 1990)

10

For diagnosis the patient has to have all the following symptoms (ICD 10, 1998):
a. psychological and vegetative symptoms have to be primarily manifestations of anxiety, not
secondary symptoms of delusions or obsessive thoughts.
b. anxiety has to be limited to the particular situations or objects.
c. phobic situations or objects are avoided as long as possible.

4.b.2. Psychological treatment

There are two principles to treat simple phobias.
1. Systematic desensitization consist in a progressive exposure to the phobic stimulus: first in
vitro (using relaxation and imagery) and second in vivo (into the real life). Wolpe, who
described for the first time this method, asks for a behavior analysis, a list of stimuli, which
determine fear, and a hierarchy of these stimuli. In vitro desensitization starts with the least
fearful stimulus and progress to the most fearful stimulus, till the patients reactions to these
stimuli disappear. When in vitro desensitization is finished, the therapist leads the patient into
the real situations, which are fearful.
A new and modern method of desensitization uses virtual reality (VR) computer simulation to
help persons with specific phobias to reduce their fears. The most researches were made on fear
of heights.
2. Second principle is the principle of exposure and reaction deterrence. This principle is
based on the observation that anxiety decreases step by step if the person is confronted with
it without live anxious situation or fight with anxiety. The therapists role is to deter the
patients escape reaction and to encourage him/her.
Exposure and reaction deterrence is a paradoxical technique, which involves the following
principle: patient has to face with the situation he/she fears, but in the same time therapist has
to impede the patient from finishing his feared activity (Dafinoiu, 2001).
3. Biofeedback is a technique by which certain automatic functions (such as heart rate or blood
pressure) are brought under the voluntary control, usually by means of device that provides
the patient with continuous feedback regarding the particular function. EEG biofeedback is
an effective treatment for phobias. The basic idea is to enhance certain naturally occurring
brain wave rhythms by providing EEG feedback to the subject. Some data suggest that alpha,
theta and alpha-theta enhancements are effective in treatment of anxiety disorders (Somer,
1995).

4.b.3. Specific techniques (case presentation)

One of my patients was a young girl, 24 years old, a student at the Medicine School, who cannot
use the elevator because of her fear of it. When she came to me she was working in a big hospital
during the summer holiday and the department where she was working was placed at the ninth
floor and the Emergency Room, where she had to go when she was on duty, was on the
basement. She was all day on the run, from the ninth floor to the basement and back, and she was
exhausted.
Her fear of elevator started when she was 7 years old and when a power failure occurred while
she was in the elevator. For 10 minutes she was paralyzed, could not breathe well and a feeling
of dying appeared. After this episode she never used the elevator again.
The first step in the therapy was to decompose the behavior using the elevator into little steps:
going near the elevator, pushing the button, opening the doors, first step inside, pushing the
button to indicate the floor you want to go to, closing the doors, feeling of being elevated,
stopping the cabin, opening the doors and going outside. These steps were used during the
desensitization.
11

I.

The first step in therapy was to talk with an electrician about the elevators and the
modalities of getting out of it when it stops.
II.
After that we started to work on relaxation training, a short method which can be used
anywhere (in the bus, in the classroom).
III.
After three weeks of training we started to work on the specific fear fear of elevator.
Firstly she was asked to relax and to imagine she is in the basement of hospital where she
worked. She was looking at the elevator and the people who used it. At the same time the
patient was asked to focus on the feeling she had and to describe it. For a short period of
time she felt palpitations but after breathing deeply and relaxing more she was capable to
look at the elevator.
IV.
Next step was to go closer to the elevator (in her imagination) and to push the button of
the elevator. Nothing else. Just to push the button and to wait for the elevator. When the
elevator appeared the patient was asked to look inside the elevator, to measure the cabin
and after that to go away. When the symptoms appeared she was asked to control them
both by breathing exercises and by thoughts control (I am just looking, Everything is
OK, It cannot hurt me).
V.
During the next session we started to imagine the first step in the elevator, just for staying
there for 2 minutes and going out afterwards. Her feelings were control by the same
techniques.
VI.
When the patient was capable to stay in the elevator without symptoms for more than 5
minutes she was asked to imagine that she was pushing the button of the first floor and
that she was waiting for the door to close and for the elevator to start. Because the
distance was short she handled this situation very well, even if, when the elevator stopped
she described that she went out very, very quickly. Next steps were to imagine that she
goes up higher and higher.
VII. When the feelings of panic disappeared we started to work on in-vivo desensitization,
following the same steps. Even though I was all the time with her, supproting and
encouraging her only after 20 sessions she was capable of using the elevator from the
hospital where she worked, and started to practice with other different elevators (at home,
in stores, in banks).
The most important step during the therapy was the first one, to decompose the behavior to the
little steps.

4.c. Social phobias

4.c.1. ICD 10 diagnosis
Social phobia is a persistent fear of one or more social or performance situations in which the
person is exposed to unfamiliar people or possible scrutiny by others. The person fears that he or
she may act in a way that will be humiliating or embarrassing. This fear leads to the avoidance of
the social situation. It is common both for females and males. Social phobia could be limited to
some situations such as eating, speaking in public or meeting with the opponent sex. Decrease of
self-esteem and fear of being criticized are two of the symptoms that could be associated with
social phobia. Other symptoms such as redden, head tremor, dizziness is common and the patient
is convinced that some of these symptoms are the primarily problem.
All following criteria has to be diagnosed (Cahil, 1995; ICD 10, 1998):
a. psychological, behavioral or vegetative symptoms have to be primarily manifestations of
anxiety, not secondarily of other symptoms such as delusions or obsessive thoughts.
b. anxiety has to be constraint to (or to be predominant to) particular social situations.
c. social situations are avoided as much as possible.

12

4.c.2. Psychological treatment

1. The most used technique in social phobia is cognitive restructuring. The cognitive work
focuses on distorted expectations of negative social outcomes and hypercritical evaluations in
social situations. Patients are taught to identify their negative thoughts (e.g. It would be
awful to make a mistake and say the wrong thing, I am a loser), to find ways to concretely
test and disconfirm them, with the goal of replacing these thoughts with more accurate selfstatements.
2. Another technique is exposure. The basic principle of graded exposure to increasingly
challenging situations, with sufficient duration to allow desensitization to occur, is the same
as in all exposure-based treatment. The keys to treatment are development of appropriate
graded exposure exercises to the patients personally relevant social cues and compliance
with exposure exercises of adequate frequency and duration.
3. Relaxation and imaginary techniques are also helpful in social phobia. The patient is
taught to relax his/her body and to imagine some events where he/she had to face social
meetings. Some other imagining techniques could be effective for treating this disorder such
as healing the inner child. Many of our anxieties and fears come from our inner child rather
than our adult self. Sometimes it is difficult to realize that the emotional upsets we feel are
actually feeling left over from childhood fears, traumas or experiences. When unhealed, they
remain with us into adulthood, causing emotional distress over issues that competent grown
up people feel they should be able to handle. Fear of unlovable, fear of rejection, which are
common for people with social phobia, often originate in early dysfunctional and unhappy
experiences with our parents and siblings (Lark, 1999).
4. Exercises of diaphragmatic breathing are other techniques used to cope with social anxiety.
It is a special breathing involving slow, deep breaths, which reduce anxiety. This is necessary
because people who are anxious in social situations often hyperventilate, taking rapid
shallow breaths that can trigger rapid heartbeat, lightheadedness, and other symptoms. It is a
simple exercise, which could be experienced in social environments. It is important to inhale
through the nose, never through the mouth. The exhaling should be through the nose or
through pursed lips as if trying to blow through a drain (Rowe, 2000).
5. Group treatment is particularly useful as it provides a ready context for developing and
practicing exposure treatment. Observing and correcting a fellow patients obviously
distorted self-assessment of performance is a powerful way to convince a patient that his or
her self-assessment may also be distorted (Anxiety Disorders Program, 2001).

4.c.3. Specific techniques (case presentation)

It is about a young girl, 21 years old (R.), student in the first year at the Philology Faculty. She
came to me because her feeling of embarrassment when she was in meetings or when she had to
make a presentation.
We started to talk about her childhood and I discovered a powerful fear of failure started when
she was a little girl. She has a sister (F) who was all the time the bad girl because she was a
revolutionary child. She was not polite, she didnt like to study, she was not clean and she
didnt like to be organized. Everybody (parents, grandparents, relatives) treated the sisters
differently. More than that, the parents often tried to reinforce Rs behavior by buying her a lot
of things and not buying any for the sister F.
When R. started her high school in the other town, far away from her city, she started to think
about what would happen when her parents were only with her sister? What would happen if she,
R., didnt have good results at school? Of course, her parents would love more her sister and R.
would become the revolutionary girl who will get nothing. These thoughts were on the
background of my patients problem. Because of her wish to be perfect and have only good
13

results she started to be anxious during social events: meetings, presentations, exams,
colloquium, etc.
Due to the fact that her problem had roots in her childhood, we started to work with the inner
child. Sitting in a comfortable position, breathing slowly and deeply, she was asked to get in
touch with her inner child. The inner child (a she) was located in her abdomen, where she felt
discomfort and fear. We asked her how old she was and the answer was three years old. It was
the time when the second child appeared in the family. The inner child was also asked what
feelings she had, and the answer was fear and sadness. The patient was asked to visualize the
inner child and to pay attention to her size, her clothes, her smell and her particular things. After
that I asked the patient to see her upsetting feelings flow out of her body and into a container on
the floor. Watch the sadness and fear wash out every part of her body until they are all gone and
the container is full. Then seal the container and slowly watch it fade and dissolve until it
disappears completely, carrying all the negative feeling with it. After that the patient was asked
to begin to fill her inner child with peaceful, healing, golden light, to watch her become peaceful
and mellow as the light was filling every cell in her body. To give her a toy or a doll or even
cuddle the inner child in her arms (adapted from Lark technique, 1999).
After this relaxation exercise my patient verbalized for the first time the background of her
problem. From that moment on our work focused on the negative thoughts and on their
modification. We discussed about the conflict between her primary and secondary capabilities
(achievements, performance and love, trust). She was capable to see the conflict between these
capabilities and to change her mind regarding the source of motivation and trust. After 10 weeks
she was capable to take her oral exam in front of her professor and her colleagues. She practiced
the relaxation and imaginary exercises once a week. She talked with her parents and her sister
about their relationship and some things have changed between them since. She is now not at all
dependent of reinforcements from her parents and she doesnt consider she has to do all the
things perfectly. She is on her own now and she has very good results at school.

5. Obsessive Compulsive Disorders (OCD)

5.1. ICD 10 diagnosis
Obsessive thoughts and compulsive behaviors represent recurring efforts to control
overwhelming anxiety, guilt, or unacceptable impulses that persistently enter the consciousness.
The word obsession refers to a recurrent idea, thought, impulse or image that is intrusive and
inappropriate and causes marked anxiety and distress.
The most common obsession is described by repeated thoughts about contamination (i.e.,
becoming contaminated by germs or by shaking hands); repeated doubts (wondering whether
one has performed some act, such as having left a door unlocked or a coffee pot brewing on the
stove); a need to have things in a particular order; aggressive or horrific impulses (which the
person might never act on); or sexual imagination that is extremly frightening.
A compulsion is a ritualistic, repetitive, and involuntary defensive behavior (hand washing,
checking) or mental act (praying, counting, or repeating words silently). Performing a
compulsive behavior reduces the patients anxiety and reinforces the probability that the
behavior will recur. Compulsions are often associated with obsessions.
Patients with OCD are prone to abuse psychoactive substances, such as alcohol and anxiolytics,
in an attempt to relieve their anxiety. In addition, major depression and other anxiety disorders
often coexist with obsessive-compulsive states. The disorder is common in male and female, and
usually there are some anancast characteristics in the background personality.
Mild forms of the disorder are relatively common in the population at large. Generally an OCD
is chronic, often with remission and flare-ups.

14

For a certain diagnosis obsessive symptoms and/or compulsive behaviors have to be present
almost every day for 2 weeks, to be source of suffering and to interfere with the daily life
activities. Obsessive symptoms have to have the following characteristics:
a. the patient has to recognize the symptoms as personal
b. there has to be present at least one thought or action the patient fights against.
c. the thought or the achievement of an action has not to be seen as pleasant (the simple
reduction the tension or anxiety is not a pleasure)
d. the thoughts, the images or the impulses have to be repetitive and unpleasant (ICD 10).

5.2. Psychological treatment

1. Psychological and psychiatric literature state that the most effective treatment plan for OCD
is a combination of behavioral therapy and drug therapy. About 70-75 % of people who
use either type of therapy without the other shows moderate improvement. When behavioral
or therapy and drug therapy are used together, about 90 % of the people show improvement.
The medication gives the person a quick boost by reducing the obsessions and compulsion.
This change often gives the person extra motivation and time to succeed with therapy.
2. Behavioral therapy that has worked for many people with OCD is called exposure and
response prevention. In this approach, the patient deliberately confronts a feared object or
idea. The therapist then encourages the patient to refrain from ritualizing to obtain relief. A
compulsive hand washer, for example, may be asked to touch an object believed to be
contaminated, and may than be urged to avoid washing for several hours, until the anxiety
has decreased.
3. Hypnosis is another technique useful for treating OCD. It can be the first step in stopping the
compulsive behavior. Hypnosis can directly decrease anxiety by inducing a state of
relaxation. The therapist can use the hypnotic state to help the patient focus more clearly on
issues that might be causing the OCD. Often the use of fictional stories, used as metaphors,
can give the patient a new way of looking at his or her problems. Story telling is more
permissive than direct suggestions (Watkins, 2000).

5.3. Specific techniques (case presentation)

It is about a young lady, 23 years old, who took the position of nurse at the Pediatric Clinic in
my town. It was her first year of experience since she had finished Nursing School.
After 3 months of work she started to wash her hands very often and after 5 months she could
not work anymore because of the plagues on the hands. She was sent to me with the diagnosis of
obsessive-compulsive disorder. At the same time she visited a psychiatrist and she took some
medication.
She described two events which started with symptoms similar to hers: a case of a little boy who
came to the hospital with burning plagues when she was on duty. She and her colleague had to
offer the first aid for this case. After two days her colleagues called the hospital and announced
that she was sick, she took some dermal disease from the little boy she cared. After these event
my patient couldnt work anymore without often washing her hands. She was in a danger of not
being able to have her plagues treated because of her attitude and because she couldnt stand any
dressing on her hands.
The first meeting was a very interesting one because my office is also in the hospital and my
client started the meeting by washing her hands after touching the door. After that she was
staying with her hands in the air not to touch anything in the chamber. We negotiated to put her
hands on her pockets where they are safe and after the session she could wash her hands.
Because a session lasts about 50 minutes she was calm during it and after that she could wash
her hands. She didnt take her hands out of her pockets even for a minute during the meeting.
15

First session was designed to make a description of the problem and to have a personal history of
the patient. Also we established the objective of our work together.
We worked two sessions on the DAI, which showed a very strong point on cleanliness,
orderliness, punctuality and other secondary capabilities. We discovered that her idea about
health and illness was very limited and that in her childhood her mother used to pay a lot of
attention to secondary capabilities and the terms of health and illness. She thinks that the illness
is a punishment from God and when somebody is ill that is because he/she has sinned. We
discussed a lot about her sins and about what is right and what is wrong in front of God. She
came to the idea that it is more important to admit your sins instead of washing them or
hiding them in your pockets. The hands were the symbols of purity for her, and because she
didnt consider herself as a pure person she started to use this behavior so that nobody should see
who she really was.
At the same time we worked on the behavioral elements to lengthen the period between the 2
washes, and to have a list of the things which could be contaminating.
Using the 2 approaches, the Positive approach and the Behavioral one, after 3 months the patient
was free of her behavior and capable to return to her working place.
Now, after 2 years, she is OK. She likes to go to church and pray, she likes her job and her work
very much.

6. Post Traumatic Stress Disorder (PTSD)

6.1. ICD 10 diagnosis
PTSD is a disorder that occurs after a person has experienced a traumatic event, such as a natural
disaster, participating in a combat, or being the victim of a physical assault or rape. Stressors that
might trigger PTSD must be outside the range of typical human experience. Typical problems
such as grieving the loss of the loved ones or marital conflicts are not considered severe enough
to lead to PTSD.
Typical symptoms include persistent re-experiencing of the event through intrusive thoughts,
flashbacks, dreams or nightmares, when the patient is acting or feeling as if the events were
reoccurring. Also it can appear an intense distress and psychological reactivity when exposed to
cues that symbolize or resemble the event. Patients with PTSD avoid stimuli associated with the
event and numbing of general responsiveness by:
- avoiding thoughts, feelings, conversations, activities, places, or people
associated with the trauma,
- an inability to recall important aspects of trauma
- a loss of interest in participating in activities,
- a feeling of detachment to others,
- a restricted range of emotions, often unable to have loving relationships,
- little hope for their future.
Also other symptoms appear such as increased arousal: sleep difficulties, irritability, angry
outbursts, difficulty in concentration, and exaggerated startle response. These disturbances
continue at least for a month and cause significant distress or impairment in social, occupational,
or other important areas of functioning.
Not all people who experience traumatic events develop PTSD, so it must be the case that some
people have a physical or emotional vulnerability that allows PTSD to develop.

6.2. Psychological treatment

Treatment most often consists of individual and/or family therapy, group meetings with other
PTSD sufferers, and sometimes medication.

16

1. Psychotherapy can help people who have PTSD regain a sense of control over their lives.
Many people who have this disorder need to confront what has happened to them and, by
repeating this confrontation, learn to accept the trauma as part of their past. Another focus of
psychotherapy is to help people who have PTSD resolve any conflicts that may have
occurred as a result of difference between their personal values and how behavior and
experience during traumatic event violated them.
2. They also may need cognitive-behavioral therapy to change painful and intrusive patterns
of behavior and thought and to learn relaxation techniques.
3. Diaphragmatic breathing is also a good technique to reduce anxiety, which follows PTSD.
4. Support from family and friends can help speed recovery and healing.

7. References
ADAA (Anxiety Disorders Association of America ) (2000) The Anxiety Panic internet
resource, Roccckville, MD
Bandelow, B.; Sievert, K.; Hajak, G.; Adler, L.; Ruether, E. (2001) Available effective
treatments for panic attack with agoraphobia and satisfaction with treatment, Psychiatry
Journal
Boyd, J.H.; Rae, D.S.; Thompson, J.W.; Burns, B.J. (1990) Phobia: Prevalence and risk
factors, Social Psychiatry and Psychiatric Epidemiology, 25, p. 314-323
Boulware, C. (1999) Do I have anxiety needing treatment?, Internet Information
Cahill, M., & al. (1995) Psychiatric Disorders, Professional Care Guide, Springhous
Corporation, Pennsylvania
CWCP (Columbia Weill Cornell Psychiatry) (2001) Anxiety, Panic Disorder and Agoraphobia,
NY
Dafinoiu, I. (2001) Elements of Integrative Psychotherapy, Polirom Ed., Bucharest
Farnsworth, T. (2001) Anxiety relaxation techniques for panic attacks, Page Wise
Huber, W. (1997) Psychotherapies: the therapy fits for each patient, Technique & Science Ed.,
Bucharest
Lark, S.M. (1999) The Menopause Self Help Book, Relaxation Techniques For Relief Of Anxiety
And Stress, Teorra Ed., Bucharest
Miclutia, Ioana (2000) The anxiety, Medical Ed. Iuliu Hatieganu, Cluj-Napoca
Richards, T.A. (1996) The Anxiety Bookstore, The Anxiety Network International Home Page
Rowe, J.E. (2000) Breathing Techniques Significant Help for Those Anxious Moments,
Anxiety Self Help
Sdorow, L.M., (1990) Psychology (2nd edition), Brown & Benchmark Ed, NY
Somer, E. (1995) Biofeedback-aided hypnotherapy for intractable phobic anxiety, American
Journal of Clinical Hypnotherapy, 37, 54-64
Watkins, C. (2000) Medical Hypnosis Uses, Techniques, and Contraindications of Therapy,
Northern County Psychiatric Associates, Internet Information
Westermeyer, R. (2001) Anxiety and Stress, Internet Information
*** (2001) Facts about Anxiety Disorders, National Institute for Mental Health.
*** (1998) ICD 10, Mental and behavioral disorders classification, clinically symptoms and
diagnosis, ALL Ed. Bucharest
*** (1998) U.S. Census resident population estimate, National Institute of Mental Health
*** (2001) Synopsis of treatment for anxiety disorders, Anxiety Disorders Program Department
of Psychiatry, University of Michigan.

17