Dr. Zasio: A simplistic but still accurate way of looking at this is that anxiety disorders are entirely about fear. Patients are afraid of something. In obsessive-compulsive disorder (OCD) it is contamination; in social anxiety it is fear that they are going to upset someone, or be yelled at, judged, or criticized. In post-traumatic stress disorder (PTSD), the anxiety is being triggered by events and memories. And what happens is that people tend to avoid what they are afraid of. So when I work with patients I’ll often say that the way to get over fear is to confront it. So that is where exposure and response prevention (ERP) therapy comes into play. But there’s also a role for cognitive behavioral therapy (CBT), which is very much based in working with thinking patterns.
CCPR: How do you weave CBT principles into your practice?
Dr. Zasio: A typical example is that somebody comes in as a new patient and says, “I’m here to address my anxiety and I am really motivated, but I’ve been to people before who said that they can help me and they haven’t. So I don’t believe that this will work.” Immediately, I recognize some negative thinking patterns and I look at these distortions in their thinking and begin to help them see that if they hang on to this belief then it will be hard for them to engage in treatment. I ask, “Well, where is the evidence to support this statement that you are telling yourself?” The patient can say, “Well, I’ve been to all these people.” And I can say, “Well you have been to all these people, but how many of them have done exposure therapy with you?” The patient might say, “None.” And I might respond, “Okay, so can we poke a hole in that belief system to see that maybe there is some wiggle room here and that what you are telling yourself may not be true?”
CCPR: Are kids going to be able to have that kind of abstract logical discussion with you?
Dr. Zasio: Yes, if you can talk in a language that makes sense to them at their level, then they can definitely follow it and process that. And of course we work with the parents as well, which is a key component. I have seen so many cases where parents have said, “You know I rarely talk to the therapist.” I’m thinking “Why?” Because parents are an integral part of the treatment. So we teach the parents and the patient these principles, so that if these negative thinking patterns are interfering with their ability to move forward or it comes up during the process then we can help to get over that barrier. So that’s the CBT part.
CCPR: And what about exposure therapy?
Dr. Zasio: The exposure therapy, which has come out of CBT, is very different. It is about creating a hierarchy, identifying the triggers, and then confronting those triggers so that the patient becomes desensitized to them.
CCPR: Let’s look at OCD as an example of a common anxiety disorder, especially in kids.
Dr. Zasio: OCD can hit any age. I have treated a patient as young as three-and-a-half. The way that it starts is similar regardless of age. It may be a fear of contamination, fear of getting sick, fear that they are going to do something inappropriate and harm somebody and that something bad will happen with their family.
CCPR: Do you have a particular case that you can discuss?
Dr. Zasio: Currently we have a twelve-year-old child in our intensive outpatient program. His fear is that he is going to inadvertently cause harm to others. This child plays hockey and his fear is that he might leave his skates laying around and somebody could cut themselves on the blade. He also fears that if he didn’t go around the house to make sure that all the rugs were flat that someone would walk across them and trip on them. He would also avoid going in the kitchen because he was fearful that, “What if I was using a knife to cut something and I inadvertently harmed somebody else?” So he would engage in these compulsions to ensure that his skates were in order; the rugs were in order; he would avoid the knives, which ultimately led to him being home schooled because he couldn’t bear to leave home just in case he missed a potential danger.