Counseling in Tokyo


Normal Anxiety

Many normal persons and persons under stress may experience anxiety. Most everyone has experienced anxiety triggered by an outside stress when there is the expectation of a feared situation like driving fast in a car or when an angry dog suddenly runs at you.

Anxiety triggered by an internal fear might be that when one is going to make a presentation at work, ask out a person they like, or when one is called to see their boss without knowing what the topic is. These kinds of situations can stimulate minor defects in one’s self esteem that everyone has and that are not usually in conscious awareness. These problems are usually mild and self-limiting and not in need of any intervention such as counseling unless the stress is really great.

Personality Disorder & Anxiety

Persons with deeper or a greater number of deficits in their self identity (i.e., having core issues or mental schemas of feeling unloved, unwanted, belittled, unvalidated, incompetent, etc.), may have a more pervasive nature of anxiety related to these core issues or deficits in the “Self" or personality. This kind of anxiety may be free-floating in the sense that it is always there, and worsened by situations that stimulate these deficits (like being alone or criticized, etc.) so that they may have high anxiety at times.

The anxiety these person’s feel is related to faults in their identity or personality structure, like a software problem, but they are not illnesses of the brain per se, like a hardware problem. Person’s whose personality is affected to a significant degree may fit the criteria for a personality disorder. Intensive psychotherapy aimed at personality reorganization is the preferred treatment for these problems. Usually a mixture of various approaches including Psychodynamic Psychotherapy that uses a Core Issue-Defense paradigm, or that based on Cognitive Therapy will be helpful.

Biologic Anxiety Disorder

There are also persons who have debilitating anxiety unrelated to outside events and without evidence of personality problems. These persons often have a family history of anxiety, depression, or other mental illness. This type of anxiety would be best thought of as a biological illness of anxiety and may likely fit the criteria of an anxiety disorder.

The major types of anxiety disorder are, Generalized Anxiety Disorder, Panic Disorder, Social Anxiety Disorder, Obsessive-Compulsive Disorder, and Post-Traumatic Stress Disorder. While many clinicians, researchers, and the staff at Counseling Tokyo think of these disorders mood disorders, there is still controversy in the field of mental health whether anxiety problems should be subsumed under mood disorders or kept as a separate classification as anxiety disorders.

Persons with anxiety disorders tend to have considerable worry related to their specific illness characteristics, with many people feeling that “if I could just change my way of thinking", or “if I could just settle this issue at work", then they would not be anxious anymore. However, they tend be in an endless spiral of worry, that instead of being the cause of the problem, is really the result of having their tanks full of anxiety (a feeling state) that acts as the fuel for their worry (a cognition). The reason one can make this conclusion is that they did not have this kind of thinking style before they had anxiety and worry, and that medication treatment, if successful, usually clears up both the worry and anxiety, not only the anxiety. To see the types of evidence related to anxiety and biology, you can for example put the search words, “panic disorder and brain scans" or “obsessive compulsive disorder and brain scans" into the Pub Med web site of the U.S. National Library of Medicine to get a feel of the massive amount of work that has been done in this area.

Counseling is also necessary to rehabilitate these persons into a world that does not need worry anymore, to reduce the self-recrimination that comes with one concluding one’s thinking pattern is faulty, and to repair the relationships that have suffered because of the difficulty in relating to a person with these kinds of symptoms. In addition to the psychotherapies described above in the “Personality Disorder & Anxiety paragraphs, medication treatment is also usually necessary because of the intensity and debilitation associated with these disorders. This link also gives a more detailed description on the treatment of anxiety.

Types of Anxiety Disorder

The discussion below assumes there is no substance use involved. Persons who use cocaine, ecstasy, LSD, and other substances may induce an anxiety-like disorder in themselves, the characteristics of which may differ from the discussion below and are beyond the scope of this web site.

Generalized Anxiety Disorder (GAD)

Generalized Anxiety Disorder is characterized by excessive anxiety and worry, restlessness, irritability, muscle tension, fatigue and disturbed sleep over at least 6 months. These are exactly those types of persons who conclude that “if I could just fix this or that I would not have any worry anymore". They also often report that, “I thought something was physically wrong with me but the Dr. told me I was fine".

The fact is that there is “something physically wrong" with these people in that there is some abnormality in the brain functions that control anxiety, it is just that there is no simple medical test yet on the complexities of the brain to prove this and there is no “obvious" physical problem-unless you consider debilitating anxiety physical which is probably the case. However, twin studies show a high incidence of concordance of this disorder. Also, stress can push people over the edge into this kind of anxiety, but usually the stress is such that most persons would bounce-back to normality quickly, indicating that persons with GAD have some kind of vulnerability to anxiety. Counseling can help these persons to stop fixating on and amplifying their problems; and medication can help alleviate the underlying anxiety.

Panic Disorder

Persons with Panic Disorderare more shocked by the intensity and sudden nature of their anxiety than those with GAD. They have repetitive panic attacks with anxiety that is intense, sudden, usually out of the blue and may awaken the person at night. They have palpitations, sweating, rapid respirations, choking, dizziness, shaking, feeling like the world will come to an end, and tingling in their extremities (secondary to metabolic changes from all the hyperventilation). These persons begin to worry about when and where the next panic will occur (anticipatory anxiety), and also start to avoid going to places where they may not be able to get help (phobic avoidance or agoraphobia).

Persons with panic attacks are often first seen in the emergency room, given a sedative and told “there is nothing wrong with you". Lately, medical doctors are more aware of panic attacks, but many still do not refer the patient to a psychiatrist. Again, the “there is nothing wrong with you" is not true, the person has Panic Disorder, and as noted above, there is some evidence from brain scans and other test that this is probably due to a dysregulation of some anxiety areas I the brain; there is just no standard medical problem (on rare occasion these persons have hyperthyroidism or other endocrine problems, and it is best to be seen by an M.D. psychiatrist who can diagnose these disorders). Again, if you put “panic disorder and brain scans" into the Pub Med web site of the U.S. National Library of Medicine or other search sites you can see the types of biologic findings in panic disorder.

First degree relatives are 8 more times to also have Panic Disorder than the general population, and medication is extremely effective to turn off the panic. Sometimes panic attacks only occur in the context of depression, and in this case we like to consider that the panic is an associated symptom of depression rather than give a person 2 mental illness diagnoses as the panic will go away with the depression.

Psychotherapy is extremely important in education, decreasing irrational fears, decreasing self-recrimination of one’s personality flaws which are usually not really there, and in breaking the cycle of anticipatory anxiety and phobic avoidance. Cognitive restructuring, gradually increasing doses of exposure to fears, and support of one’s innate strengths, can be of immense help to these persons who are usually very grateful to the therapist for their help.

Social Anxiety Disorder (SAD)

Social Anxiety Disorder is a very common problem, and including the very mild forms may affect near 10% of the population. SAD is mainly defined as fear of social situations in which embarrassment may occur. It may be generalized to many social situations or circumscribed to one or two specific situations. The most common form is intense anxiety in public speaking. The person may get red and flustered and shaking in voice and hands. Other situations can include fear of meeting new people, fear of going to public toilets, and fear of drinking, eating, or writing in public. Situations are avoided and there can be much subjective distress and significant impairment in one’s functioning. There is a tendency for Social Phobia to run in families.

The psychological mechanism is that the person has some sense of low self-esteem and they project this onto the people they are speaking to and meeting with which amplifies their anxiety.

Education, exposure training, psychotherapy and medication may all be beneficial in this disorder which usually responds well to treatment.

Obsessive-Compulsive Disorder (OCD)

There are 2 forms of Obsessive-Compulsive Disorder. One is where the person mainly has obsessions, the other is where the person has obsessions and compulsions to act on the obsessions. These must be time consuming or cause significant distress and/or impairment, and the person is aware of their excessive nature.

Obsessions are recurrent and persistent thoughts, impulses, or images. These tend to be related to contamination, e.g., that one has touched some contaminated object, repeated doubts (e.g., that one may have harmed someone else in an accident, that the electric lines are emitting dangerous waves, needing things in a strict order, or impulses that one might harm or kill someone, etc.). Persons with excessive hording of old newspapers or garbage in their homes often have OCD and are unable to relinquish the doubt that there might be an important item in the garbage they might someday need.

Compulsions are repetitive acts often in response to the obsessions in order to suppress or neutralize them, (e.g., hand washing, counting, checking, praying, etc. ) and there may be rituals (e.g., making a round of the house windows and locks 5 times before one can leave the house). These compulsions are often very difficult for a partner or spouse to live with often causing conflict.

You can see that obsessions and compulsions are extreme and pathological versions of thoughts and behaviors that most normal persons have to some slight degree and that may cause severe problems in social and occupational functioning. Many of these persons first have symptoms before adulthood, there is a greater incidence of OCD in ones relatives than in the general population, and a greater concordance in monozygotic vs. dizygotic twins suggesting some genetic predisposition. As noted above, you can do a search of “obsessive compulsive disorder and brain scans" in the Pub Med web site of the U.S. National Library of Medicine or other sites to get a picture of the biologic findings in OCD.

Education, exposure training to the fears, behavioral modification for the compulsions, psychotherapy, and medication may all be beneficial for OCD. A percentage of persons with OCD may be partially or fully resistant to various combinations of therapy and require intensive and complicated therapy regimens.

Post-Traumatic Stress Disorder (PTSD)

While it is normal to feel disturbed or shocked by a serious traumatic event, persons who develop PTSD seem to be vulnerable to develop a constellation of symptoms that causes significant distress or impairment in functioning. These events may include but are not limited to events of war, natural disasters, violent crime, etc. Traumas may also be psychological in nature, not just physical. The classic PTSD situation is that of “shell shock", where some (not all) persons who were in the front lines of war return with this syndrome.

The major symptoms these persons experience are related to 1. Reexperiencing the traumatic event, 2. Avoidance of stimuli that may be associated with the trauma; often accompanied by a general “numbing", and 3. Increased level arousal.

Reexperiencing symptoms mainly include recurrent thoughts or dreams about the event or feeling like the event will recur or is recurring; avoidance symptoms include efforts to avoid thoughts, activities, places, or people who may be associated with the event; “numbing" may include apathy or detachment from others, and increased arousal typically include exaggerated startle to loud noises, irritability, difficulty sleeping, and aggravated reactions to situations that may be reminiscent of the event.

Persons with PTSD often also develop depression, and a history of depression in first-degree relatives has been related to increased vulnerability to PTSD. If you search “post traumatic stress disorder and genetics", or “post traumatic stress disorder and serotonin", or “post traumatic stress disorder and brain scans" in the Pub Med web site of the U.S. National Library of Medicine you can get a picture of the kinds of biologic studies and findings seen in PTSD.

Along with medication, counseling is extremely important to try to re-work the conclusions of these persons that the trauma will reoccur, to convince them that they were not the cause of the trauma, and to bring them back to a world where they can feel sure the trauma is finished and in the past.

As a side note, many psychiatrists and researchers question whether OCD and PTSD should really be classified as Anxiety Disorders, or whether they may be best thought of as independent conditions. While OCD an PTSD do entail considerable anxiety symptomatology, there is clearly more going on besides just anxiey, and Counseling Tokyo opines that they will probably be reclassified once there is adequate genetic and neurophysiologic data to sway the nosologic system makers.

Summary of the links on this page:

AnxietyPersonality DisorderPsychodynamic PsychotherapyCore Issue-DefenseCognitive TherapyGeneralized Anxiety DisorderPanic DisorderSocial Anxiety Disorder
Obsessive-Compulsive DisorderPost-Traumatic Stress Disordermood disordersmedication treatmentPub Medanxiety medication treatmenttreatment of anxiety

Counseling Tokyo provides counseling, support, and advice, for both the international community in English, as well as the local Japanese community in Japanese.