Rebounding to Calm—Part II

In the last post we looked at the overlap of anxiety disorders and eating disorders and also some of the particulars of why anxious individuals experience and encode things differently from non-anxious people.

.Eddie: Flickr.com

Now we are going to take a closer look at the techniques that can help an anxious person experience and encode things in ways that will alleviate anxiety. 

Before we get to that, we are going to briefly revisit our muppet crew yet again because there is one more key muppet that needs no introduction: the muppet who represents the eating disorder…

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Dr. Bunsen Honeydew
(aka Your Eating Disorder)

As you likely know, many functional magnetic resonance imaging (fMRI) studies conducted by Walter Kaye and his colleagues suggest that there are anomalous neurotransmitter behaviors that persist in the amygdala (one of the emotional centers of the brain) for those with eating disorders.

 

And since we have already swapped out various brain structures for muppets: orbito-frontal cortex (Grover), amygdala (Beaker), prefrontal cortex (Business Guy), basal ganglia (Mr. Snuffleupagus)—we might as well complete the set and explain why the Beaker in an anxious brain has such trouble with stressful circumstances.

Beaker is already a pretty tense guy, but nothing makes it harder for Beaker to stay calm than having Dr. Bunsen Honeydew anywhere near him. Dr. Bunsen Honeydew is the personification of those unusual neurotransmitter behaviors we see in the brains of patients with eating disorders.

For those of you not too familiar with muppets, Dr. Bunsen Honeydew is an absent-minded professor who seems very in command of the situation, but essentially generates huge dangers in the lab precisely because he is so sure of himself. And it is usually Beaker who ends up in the line of fire because Beaker is Honeydew’s faithful (and terrified) lab assistant.

In the blog post The Genetic Superpowers: Another way to frame eating disorders? I spoke about both the need to identify your own thoughts and feelings as separate from the eating disorder-generated feelings, while also ensuring that the eating disorder is not made out to be a completely malevolent creature. Defining the eating disorder as really nasty can end up giving the restrictive compulsions a bit too much power.

In that sense, personifying an eating disorder as Dr. Bunsen Honeydew allows for the fact that the professor does not mean any harm, but he most certainly cannot run the lab safely or well.

Beaker is tough enough to reassure without have Honeydew careening around with open flames, bare electrical wires and puddles of water and lighter fluid all over the lab, making Beaker positively apoplectic with fear and panic.

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Getting the Boss to Step-Up

Getting the prefrontal cortex involved is easier said than done, as most of you already know from frustrating experience.

And while, as I have said already, the Boss (prefrontal cortex) is really never too keen to get involved, one thing almost always works: curiosity.

 

As I mentioned in the previous post on this topic, meta-cognition is our ability to think about our thinking or think about our feeling, as it happens. True meta-cognition triggers a powerful sense of curiosity and as soon the Boss is curious, then he’s just taken the elevator down to the lab and now everyone is standing to attention in the mess waiting for him to get things in order.

For those with anxiety, the Boss has gotten very used to taking as fact whatever strange results come out of the lab. For example if we take the hapless teacher who was anxious about asking her colleagues for advice in the previous installment of this series, her “lab results” state that she is a village idiot and the Boss in her brain is clearly not questioning that false result.

I imagine the teacher’s Boss as being some guy with his feet on the desk who simply signs off on anything and everything that hits his in-tray just to be done with it.

So the first thing we have to do is to shame him a bit by getting him to sit down with the accountant. At this rate I’m going to run out of muppets!

“You cannot cross a large chasm in two small jumps.”
                                                                        Fortune Cookie.
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Develop the Chasm Reveal
with Bert

Bert is obviously an accountant and he is great not just with numbers but also with charts and diagrams. Bert has a great little tool for helping the Boss start to develop some interest in the ridiculous lab results he’s been accepting as ‘normal’.

 

The following chart is a variation on the Idiosyncratic Model commonly used in cognitive behavioral therapy in the first or second session for those with anxiety disorders of all kinds.

Here is how a Chasm Reveal Chart works:

Take out a piece of paper, or draw it on a white board if you happen to have one handy. See Figure 1. below and what you will do is take a recent handy example of a social event or setting where something occurred to trigger significant anxiety in you (click on image to see enlargement).

Click for larger.

Work through the diagram answering the questions of the two “ears” of anxiety (the smaller circles on either side of the large red anxiety circle): the right ear is all the catastrophizing (disaster sensing or your all-powerful doom-monitoring) you went through in your mind, and the left ear is all the safety behaviors that you may have applied long before the event and also during the anxious experience in question that you believe helped to alleviate the situation in some way (or you hoped would do so).

Once you have fully mapped out the two “ears” of the anxiety circle, then you head back to the top of Figure 1 to begin the process of revealing the chasm between what you think you know and what you really know. But before we get there we have to identify how you know what you know…

Self and Other Not One and the Same

The delineation between self and other is not as obvious as we think it might be and it is one of the most important elements for revealing the chasm so that you can begin to moderate your social anxiety successfully.

Vilayanur Ramachandran’s work in analyzing the mirror neuron network in the human brain is interesting stuff indeed.

In the areas of our brains associated with movement, we have neurons that fire when we perform an action of some sort (such as picking up glass off the table). Intriguingly, these neurons also fire in our brain when another person performs the same action and we watch it happen. Now I should clarify that for humans, this is observed indirectly through fMRIs etc. and so while we have evidence of dedicated mirror neurons in macaque monkeys, no such direct evidence really exists for humans.

Ramachandran suggests that this neuronal capability enables us to imitate or mimic what we see another doing and that this ability has allowed for the “great leap forward” in human evolution. 1,2 Furthermore, many other researchers have performed studies that indicate the same areas of the brain that are active when we ourselves experience certain emotions: disgust, happiness, pain and so on, are equally active when we witness another experiencing the same emotions. 3

In other words, mirroring does not appear to be limited to motor functions for humans—not just “monkey see, monkey do”

There are disagreements in the scientific community as to whether specific neurons function in these ways in the human brain. There are also philosophical disagreements as to whether this ability to imitate and mimic is predicated on dedicated neurons or not, and whether, dedicated neurons or not, this ability is evolutionarily responsible for human development.

I am going to do my usual squint and look far into the distance and predict that “mirror neurons” are actually another module—the mirror module. Similar to our language and morality modules, we perhaps are not graced with dedicated neurons that mirror the actions and thoughts of others so that we might develop theory of mind*, but rather we come into the world with brains built to develop those skills with adequate environmental inputs.

(*theory of mind is our ability to identify that what we know and what someone else knows (or thinks or feels) can be different.)

I’ve likely already mentioned Noam Chomsky’s work in identifying that our ability to develop language is innate (not learned) but in the sense that it is a basic module ready to accept the environmental inputs (the language spoken around you as a baby) and only up to a certain age is the module able to do so.

Sadly, Mark Hauser, one of the key scientists involved in the investigations of our morality being inherent to our brain’s function (with suitable environmental inputs and critical ages in childhood), was found guilty of scientific misconduct in 2010 by his employer (Harvard University). The lack of transparency associated with the internal investigation at Harvard on his misconduct makes it difficult to ascertain what of his published works are really in question (the university cites three papers). In any case, the study of morality continues with other researchers and hopefully more solid data will result in future. That’s a bit of a long detour on the topic at hand, namely our mirror module (as I’ve decided to call it).

Brains think while moving. Our motor networks are inextricably linked to memory, and creative thought processes. It also appears as though our ability to empathize is linked to both our auditory and motor mirror systems. Valerie Gazzola and her colleagues found that those who self-reported higher levels of empathy (using a questionnaire) appeared to have more activation in both the auditory and motor mirror systems than those with lower self-reported levels of empathy. 4

Essentially, our mirror module is likely an innate system that enables us to develop empathy and theory of mind with relevant environmental inputs at key points in our development in childhood. And, as with other functions such as language and morality, all human beings naturally fall out on a bell curve of capability. Almost all of us are highly skilled at empathy and theory-of-mind with a few who are exceptionally skilled and a few who are exceptionally deficient in these areas.

Puppets and Marbles

The ability to identify our thoughts and feelings as not being automatically known and shared by another person (theory of mind) develops for most of us around the age of four.

Here is the common way in which this theory of mind is tested on young children:

Two puppets come on stage and there is a red box and a blue box in front of them. The first puppet drops a marble into the red box and they both leave the stage.

Next, the first puppet comes back on stage alone and takes the marble out of the red box and drops it in the blue box. He then leaves the stage.

The second puppet then comes back on stage alone. The researcher then asks the children who have watched this play which box the puppet will go to, to find the marble.

Two year olds all invariably will say the puppet will go to the blue box. Four year olds will say the puppet will go to the red box. Importantly, four year olds with autism spectrum disorder will say the puppet will go to the blue box.

To translate the findings: by the age of four, children (without autism spectrum disorder) are able to recognize that the second puppet did not see the first puppet swap the marble from the red box to the blue box and so, of course, the second puppet will return to the box in which she knows the marble was originally placed.

If you think about it, it is a very complex ability to have developed as young as age four—not only are the children aware that the first and second puppets have different knowledge but also that their knowledge of having watched the play unfold is also different from what the first and second puppets know!

Social anxiety and other forms of anxiety disorders are common for those on the autism spectrum disorder. It is understandable that those with a delayed or impaired development in theory of mind will develop social anxiety as we depend heavily on our ability to understand our thoughts and feelings as distinct from another’s, in social situations. Given that most with autism spectrum disorder who interact in social situations (i.e. high-functioning) are not intellectually impaired, they can identify that they are missing something in social circumstances but are completely at a loss as to identify what it might be.

This twinning of disorders is likely why there have been many attempts to suggest through research studies that eating disorders and autism spectrum disorder have common underpinnings. Nonetheless those studies have been disappointingly inconclusive.

However, I believe that we are accidentally looking at the outcomes of the two long tails at opposite ends of the bell curve of theory of mind capabilities in human populations.

Just as those with autism spectrum disorder can struggle to identify what someone else knows and feels as being not the same as their knowledge and feelings, there are others who struggle to disentangle what they know and feel from what they can identify as someone else knowing and feeling.

And this finally brings us back to those with social anxiety who are actually projecting what they feel and know onto others. The chasm is actually between you and “the other”.

Back to Re-Assess the Right Ear of Disaster

Now you are going to pull out a new sheet of paper and place it alongside the answers you provided for the Right Ear in Figure 1.

While there are historical situations that you probably dredged up as soon as you sensed things were going wrong, we’ll first focus on Items 3 and 4 of the Right Ear responses you have provided:

List the specific reactions you identified in the other person (or people) on the new sheet of paper: facial reactions, comments, body language, non-verbal expressions, looking away, sighing…everything you noticed at the time in their behaviors.

You now have to identify 12 possible reasons for their reactions.

Initially you will list the things that you usually come up with:

  1. They hate me.
  2. They find me boring and irritating.
  3. They are distracted by how odd I look.
  4.  They think my interests are weird. At this point it should start to get more difficult to come up with reasons for their behaviors because you are used to the reasons revolving around you. But now imagine the reasons are self-generated. In other words, their reactions had nothing to do with you.
  5. They are tired, hungry, had a horrible day at work…
  6. They had a huge fight with their partner on the way here.
  7. They are completely distracted because they had some really bad news earlier in the day.
  8. They are shy and socially awkward and so they struggle to send out the right signals of being interested and involved.
  9. They are coming down with a cold or flu and feel unwell.
  10. They are introverted and are starting to feel exhausted by all the interactions.
  11. They think you don’t like them.
  12. They are anxious that talking to you may alienate the person they came to the event with

At the end of the list, you write out in full the following sentence:

“What I know and feel is not what others know and feel. I cannot know for certain what another person is thinking and feeling and I cannot fill in the blanks with my own negative self-talk.”

Critically, our mirror network may allow us to empathize and interpret other people’s facial expressions, comments and actions, but it does not allow us to mind-read.

Feel free to enter way more than just 12 items as this gives you practice in reinforcing that you cannot read minds.

Then take Item 4 of "the right ear" above and perform the same type of exercise.

List all the physical signs you experienced and underneath each symptom you write down:

  1. They noticed my reactions and decided I am (stupid, inept, lame, loser—the usual self-hatred adjectives you might use)
  2. They noticed my reactions and decided that they were (stupid, inept, dull, lame, loser…)
  3. They noticed my reactions and decided I was just anxious and they tried to put me at ease.
  4. They noticed my reactions and decided that something else was going on and they did not take it personally.
  5. They didn’t notice a thing. 

Just as with Item 3, there is no way you can absolutely be sure the other person thinks and feels what you think and feel.

The mirror network does not allow your brain’s neural network to seamlessly hook-up to the neural network of another individual. All it allows us to do is identify that another individual may be experiencing a different reality from us.

Do not presume that the brain in the skull across from you is entirely focused on you, because 9 times out of 10 it is not. And that means the facial expression, or the silence, or the sigh you just witnessed could be something entirely private and internal to that other brain and not in reaction to anything you have just said or done at all.

Dear Little Me

Given that you likely brought up many historical situations in your mind, we will now revisit those (Item 1 of Figure 1).  It is similar to the exercise you just went through with Items 3 and 4 but there is an additional step because in most cases both you and the other person were children or adolescents, and that added a layer of confusion that you now need to use your adult brain to clarify.

Usually historical situations that come to mind involve much more extreme interactions that hurt your feelings and may even be the source of the development of social anxiety for you.

We tend to simply relive the hurt and experience by catapulting ourselves back in time, rather than assessing it with our more developed and mature brain today.

Let’s take a common example for many: that you recall somewhere in your childhood having one kid say something nasty to you and then a bunch of kids joined in:

“You’re so stupid.”, “You’re ugly.”, “No one will ever like you.”

You were mortified. And whether you pretended to laugh it off, or you ended up in tears, you recall the event with razor sharp detail to this day.

Now identify 12 possible reasons why the kid who initially uttered that nasty comment(s) did so due to his or her own internal state at the time.

  1. She was jealous of you.
  2. Her parents were going through a divorce at the time.
  3. She was being bullied at home.
  4. Her parents were constantly criticizing her and telling her she was a failure.
  5. She was angry with her friend and took it out on you.
  6. She felt you made her look stupid in class and wanted to get back at you.
  7. She was hungry and irritable.
  8. Someone in her family was very sick and she felt neglected.
  9. Her favorite pet had just died.
  10. She thought she was being funny and you didn’t seem to mind.
  11. She was too young and immature to know that what she said was rude and unkind.
  12. She felt really bad afterwards but had no idea how to tell you that.

Now consider whether the list you come up with is more or less likely to be true than the fact that you have assumed all these years that the comments were valid from the get go.

The next part of this exercise is to write down what you would tell your young self as though you are your own big sister or brother to yourself. You can compose it as if it were a letter to “Dear Little Me”. Include what you know now about how cruel and irrational kids can be and how bullying is more about the bully’s issues than anything to do with who you really are or who you will become in future. Show yourself some compassion as if you were talking to a little sister or brother who had experienced the situation.

In these ways you can upgrade your childhood memory. You are no longer that child. You have skills, maturity and understanding that you have developed since that time. You are not that vulnerable anymore. The next time you start to re-live the experience, you remind yourself that it was your X-year old self that experienced that and you are no longer that person or that age.

The same holds true if the initial onset of your social anxiety did not involve cruelty at the hands of another.

Sometimes the circumstance that triggers social anxiety is experiencing a level of embarrassment that overwhelmed you at the time (again, when you were young).

Perhaps you had a stage fright at a recital or presentation in class; or you threw up at somebody’s birthday party; or you forgot your lines in a school play; or you ended up in a witch costume for Halloween when everyone else went as fairy princesses.

If that is the case then you pull out a sheet of paper and write out examples (as many as you can think of) since that time when you have been under stress and saw your way through it. Examples may include:

  1. I moved out from my parents’ home and away to college.
  2. My pet died and I grieved but was okay.
  3. A family member got very sick and I still managed to carry on and go to school/work.
  4. I failed a test/course and persevered to pass the course/year.
  5. I had a fall/accident doing (whatever activity) and still went back to do the activity when I was healed.
  6. Other friends/family come to me when they want to talk or need support and I am there for them.

You have to come up with at least 3 examples of tough things you have faced and managed to get through. You will still likely undervalue them, but these examples show that you are indeed resilient and that the embarrassment that once overwhelmed you is far less likely to overwhelm you as the person you are today, because you have learned how to persevere and overcome.

Hopefully the above exercises will help you to upgrade the cascade of wrong assumptions that generate the disaster-thinking during social situations.

Bert and the Boss Sum Things Up

At this point, you should have a better understanding of Bert’s Chasm-Reveal:

  1. You have an overactive mirror neuron system where your ability to empathize has been misinterpreted by you as an ability to read minds. You cannot read minds. 
  2. You do not know why someone reacts the way they do for absolute certainty unless they actually come out and clearly say so. There is a pile of misinterpretations that may occur between you and another person and that happens to everyone all the time. Remind yourself often that the chance their reaction is about you is far less likely than you think.
  3. You drag forward many circumstances from your past where you relive the emotional trauma of the event without applying the benefit of your current more mature, more resilient and more capable adult skills to re-evaluate your understanding of the historical data. We are all more resilient, flexible and skilled as 20 year olds than we were as 8 or 11 year olds, so what happened back then really cannot happen now.
“You cannot cross a large chasm in two small jumps.”
                                                                        Fortune Cookie.

In considering this fortune cookie saying again, you are now ready to take your big leap from the fallacies of mind-reading and historical childhood traumas over to the other side where you can at least begin to entertain the possibility that a negative reaction from someone else in a social situation is not your doing, and that traumas from childhood do not limit how flexibly and capably you can react to stressors today. It takes practice but with practice you find the anxiety lessens.

The Left Ear: Safety Behaviors

As mentioned in Part I, safety behaviors are often presumed to be the things that save the day, but in fact they often reinforce the anxiety and inadvertently worsen it too.

The Left Ear of anxiety has to be as carefully assessed as the Right Ear because it keeps you locked in social anxiety as much as the Right Ear does.

Safety behaviors are difficult to remove from the equation because their removal seems counter-intuitive to alleviating anxiety:

“But if I don’t wear that jacket, or if I eat at the event, or if don’t bring my ‘safe’ friend, then the things I fear will absolutely happen.”

Here is a comprehensive framework developed Jonathan Abramowitz and his colleagues that clearly identifies the reinforcement of anxiety that safety behaviors can elicit.

Because they temporarily reduce anxiety, safety behaviors develop into habitual anxiety management strategies.

Misattribution of safety

Attributing the nonoccurrence of feared outcomes to the power of the one’s safety behaviors, rather than the possibility that the situation was not dangerous.

Distraction from disconfirmatory information

The attention required to engage in safety behaviors prevents the individual from attending to information that might disconfirm threat appraisals.

Prevents the development of adaptive coping strategies

Reliance on safety behaviors prevents opportunities to develop and practice positive coping strategies.

Directly worsens feared stimuli

Some safety behaviors magnify the intensity of fear cues or increase the probability that feared outcomes will occur.

Increases awareness of feared stimuli

Some safety behaviors increase selective attention to the fear cues, which elicits greater awareness of them.

Inference of danger

Safety behaviors may transmit information about the threatening nature of feared stimuli; individuals may infer the presence of danger from their own behavior. 5

Stepladder to Safety-Behavior Eradication

From the responses you gave to the Left Ear of Anxiety in Figure 1, pull out a new sheet of paper (or do it up in MS Word or Excel) and draw a line down the middle. Mark “SB” for the left-hand column and “Rating” for the right hand column.

Now extract all the safety behaviors you engaged in before, during and after the incident you used for the Figure 1 exercise. Write each one down as separate line items in the left-hand column.

On a scale of 1 to 100 for anxiety level (where 1 is you are asleep and 100 you are calling the emergency services because you are sure you are about to die) rate each of the safety behaviors (SBs) if you had to attend a social event and not use that safety behavior to do so.

It would look something like this:

SB                                                                                                                                         Rating

Attended with my partner                                                                                                    90

Wore dark jacket (to avoid sweat showing)                                                                                                                                  75

Re-styled hair from the morning                                                                                          40

Made sure cell-phone was fully charged (in case of emergency)                                     35

Applied thick make-up (to minimize how obvious it is when I blush)                             65

Made sure to have snack (to avoid embarrassment of stomach
gurgling and making noises)                                                                                                 90

The above example is obviously not a complete list but it provides some idea of how to start off your own Stepladder. The person who wrote the above list finds the idea of having to attend a social function without her partner and not having a snack right before the event as extremely anxiety provoking, whereas she finds the concept of not being able to re-style her hair or check that the cell phone is fully-charged as less threatening.

Now you re-arrange the list (hence the value of doing this on the computer) using your rating system of lowest to highest ratings if you had to forego applying the safety behavior in question.

Then you systematically begin to remove these behaviors as you, at the same time, increase the number of social functions in which you would be sure to ‘need’ them. You work from least threatening to most threatening on the list.

Because the Boss and Bert have sat down to carefully work through the Chasm-Reveal, you are much more protected from an anxiety cascade even as you begin to remove all the safety behaviors because your Boss is now thoroughly engaged in questioning false lab results (from the emotional center of your brain).

But we can give your Boss just a couple more tools to keep you moving forward as you practice your anxiety reducing behaviors.

Investigate Thoroughly the Worst-Case

With anxiety, we are pretty sure we have thoroughly figured out the worst-case scenario because that’s what we fear the most. But in reality, the anxiety itself often short-circuits our ability to get right to the end of the scenario such that we realize we can still survive.

Let’s take that teacher one more time who is sure her colleagues view her as the village idiot. Here is how a therapist might guide her through the process of a worst-case scenario investigation:

Teacher: “I know my colleagues think I am a complete idiot.”

Therapist: “Let’s say that your assessment is true just for the moment and your colleagues do think you are an idiot, what is does that mean for you?”

Teacher: “Well, it means that they won’t want to talk to me or involve me in projects or ask for my input or advice because I’m too stupid to offer up anything useful.”

Therapist: “And if you are not involved in projects and no one talks to you, what does this mean for you?”

Teacher: “Well then the administration will think that I am not doing my part and then I will get a bad assessment from the principal.”

Therapist: “What would a bad assessment mean for you?”

Teacher: “Well, I’d probably lose my job.”

Therapist: “If you lost your job, what would you do next?”

Teacher: “Well, we’d be okay because of my husband’s income, but it would certainly impact our finances.”

Therapist: “So, you could lose your job and although you and your husband would have to watch your money, you would likely be okay financially without your teaching income. What would happen then?”

Teacher: “Um, well, I guess I’d probably start looking for another post?”

At this point, the therapist may summarize the conversation to indicate that even the worst-case scenario (she loses her job because her colleagues really do think she is an idiot) is survivable.

Up until this worst-case discussion, the teacher simply would stall at the point at which her colleagues interpreted her anxiety as her being a complete idiot and she would hunker down on that thought.

Let’s even imagine that losing her job is absolutely catastrophic and the conversation goes like this:

Teacher: “Well, I’d probably lose my job.”

Therapist: “If you lost your job, what would you do next?”

Teacher: “Well, I couldn’t afford my rent, or food and I’d be thrown out on the street.”

Therapist: “Then what?”

Teacher: “Well, what do you mean, then what?”

Therapist: “Well, you are now on the street with no shelter and no food, what would you do next?”

Teacher: “I’d kill myself.”

Therapist: “And that would mean the end of all your problems, right?”

Teacher: “Right!”

Therapist: “So, at that point you are not going to care anymore about anything because you are dead. If this worst-case scenario comes to pass, then you have an exit strategy that will solve all your problems if needed.”

Teacher: “But I’d be dead! How is that a solution?”

Therapist: “Well, are there other solutions that don’t involve killing yourself?”

From there, the teacher then begins to apply some resilience and flexibility to her problem solving efforts and discovers that she might be able to get some help from a friend for a few months while she looks for another job etc., etc.

The value of walking through right to end of the worst-case scenario is that the end point is exactly the point at which your Boss starts to engage in real problem-solving and you discover that you really aren’t quite as terrified of the situation as you originally thought you might be.

There are many, many more tools out there for overcoming social anxiety and this post is really just scratching the surface.

Rebounding to calm is all about knowing you have enough spring in your resilience to bounce back. Both knowing and applying that resilience is achieved through practice.

“How long one can live blighted by defensive strategies built up as a child, not quite recognising greater strengths of adulthood?”  Alain de Botton (tweet)

1. Ramachandran, Vilayanur S. "Mirror neurons and imitation learning as the driving force behind “the great leap forward” in human evolution." (2000): 29.

2. Rizzolatti, Giacomo, and Laila Craighero. "Mirror neuron: a neurological approach to empathy." In Neurobiology of human values, pp. 107-123. Springer Berlin Heidelberg, 2005.

3  Gazzola, Valeria, Lisa Aziz-Zadeh, and Christian Keysers. "Empathy and the somatotopic auditory mirror system in humans." Current biology 16, no. 18 (2006): 1824-1829.

4. ibid.

5. J.S. Abramowitz, BJ Deacon, SPH Whiteside, Exposure Therapy for Anxiety, Guilford Press, NY, 2011, p. 43