Chapter 1 What are Emotional Disorders?

Goals

To learn what emotional disorders are

To learn about symptoms of common diagnoses and how this

treatment aims to address these symptoms

What are Emotional Disorders?

This treatment workbook is designed to help people suffering from

emotional disorders. Disorders in this group include social anxiety
disorder, depression, panic disorder (and agoraphobia), generalized
anxiety disorder, obsessive-compulsive disorder, and other anxiety,
depressive, and related disorders such as anxiety focused on health
(hypochondriasis). In all of these emotional disorders you experi-
ence strong, intense, and/or uncomfortable emotions like anxiety,
panic, depression, or fear that are getting in the way of living your
life and compelling you to do things you may not want to do. These
emotions tend to be so uncomfortable that you might start to do
things, or avoid certain situations, just so you wont have to experi-
ence these intense feelings. The problem is, by avoiding these experi-
ences, your life may become very limited, and you may find it
difficult to go about day-to-day activities like going to work, spend-
ing time with friends, or just doing something leisurely or enjoyable.
In addition, avoiding these intense experiences may be causing you
to put off pursuing meaningful goals, to miss important events, or
to change important plans. The main problem is that these intense,
strong, and/or uncomfortable experiences have become the focus
of your existence, and are preventing you from living the life you
wantand this may be why you have picked up this book in the
first place. The program described in this workbook is new, and
integrates the most powerful psychological techniques and strategies

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 applicable to all emotional disorders, even if you have more than
one, or a disorder that doesnt quite fit the definition of one of the
major disorders previously mentioned and described later in the
chapter. This is why the program is called the Unified Protocol for
Transdiagnostic Treatment of Emotional Disorders.

To begin to see if this program is right for you, take a look at these
examples from cases we have treated at our clinic:

Sarah

Sarah is a 35-year old, single woman who works as an investment

manager at a bank. At work, Sarah was given increased
responsibilities and was even being considered for a promotion.
One of her new responsibilities involved giving a brief presentation
at a weekly staff meeting. Sarah had never liked speaking in front
of others, but had largely been able to avoid doing so over the years.
During her first presentation, she became increasingly anxious and
actually left the room before she had finished. Later, Sarah
described feeling unable to finish the talk, and noted that she had
experienced intense and scary physical sensations during the
presentation, such as increased heart rate, sweating, and dizziness.
She was concerned that she was going to pass out, and felt that she
had to get out of the room to prevent herself from fainting.
Shortly after this incident, Sarah contacted our center for help
controlling her anxiety, so that something like this would never
happen again.

Sarah had always been anxious about speaking in front of other

people. Growing up, she had rarely spoken in class and her teachers
would often comment on her report cards that she was very quiet.
This anxiety persisted through high school, although Sarah always
did well in school. She was able to get by without doing any oral
presentations using a variety of excuses or by staying home sick on
days when she was scheduled to give a presentation. In college,
Sarah found it was more difficult to get out of or avoid giving
presentations. Prior to taking a particular class, she would always
check the syllabus and drop classes that required her to give a
presentation. Despite these difficulties, Sarah was able to graduate
college and get a good job after graduation.

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 In addition to anxiety about speaking in front of others, Sarah said
she had always been anxious in social situations or in group
situations. She recalled that she had been this way since high school,
but that in recent years her social anxiety had gotten even worse.
Although she had always had a small but steady group of close friends,
Sarah noticed that her social network had been getting smaller and
smaller as her close friends got married and had children, or moved
away for work. She had a great deal of anxiety about meeting new
people, and felt that her anxiety was definitely holding her back from
making new friends. Sarah was single and had not been on a date in
a number of years. Although very interested in dating, she felt her
anxiety was preventing her from going out on dates.

Linda

Linda is a 53-year-old, married, mother of two and grandmother of

three. She had worked for several years as a school teacher, but had
stopped working two years prior in order to care for her ill father,
who had passed away six months before she came to our center. Linda
came to our center saying she felt anxious all the time and was
having difficulty sleeping. She wanted to go back to work now that
she was able, but felt like her anxiety was holding her back. She
described herself as feeling stuck. She wasnt enjoying things she used
to, like spending time with friends or going to the gym, and found
herself feeling tired and overwhelmed all of the time. She was having
frequent arguments with her husband, and felt more irritable than
usual. She told us she wanted to get rid of this dark cloud and
uneasy feeling she was carrying around with her every day.

Linda said she often felt overwhelmed by worries and concerns.

She frequently worried about her two grown children, even though
they both were happily married, doing well financially, and had
started families of their own. She worried about their happiness,
their health, whether they would have enough money to survive,
if her grandchildren were developing okay, and if she was doing
enough for them. She often found herself imagining something
terrible happening to them, like their house burning down, or
having a fatal car accident. Linda also worried about her
husbands job, even though he had been at the same job for
22 years. She worried about what would happen if they decided to

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 replace him with someone younger, if the company decided to lay
him off, or if the company folded. She described always feeling like
the rug might be pulled out from underneath her and her family,
and that something terrible might happen at any moment. Linda
described feeling tense and restless much of the time. She found it
very difficult to fall asleep, often lying awake with her thoughts
racing. She would also frequently wake during the night and begin
worrying about things she needed to do the next day. She also
described feeling a wave of panic wash over her at certain points
in the day, particularly when she felt overwhelmed. Her heart
would begin to race, her palms would get sweaty, and she would
find it difficult to breathe. She stated this happened mostly when
she worried about many different things at the same time, when
she thought about something really terrible happening, or when her
thoughts felt out of control.
Linda very much wanted to return to work, but was finding it
difficult to go about finding a new job. As soon as she would begin
to look through job postings, she would start to worry about not
being good enough, not finding the right job, being too old, or her
new coworkers not liking her. Once these thoughts started, she
would find herself looking for other things she needed to be
doing, like cleaning the house, which would take her away from
her job search. She would later feel bad about herself for not
looking for a job, and would end up feeling blue and depressed.
She stated she often felt helpless and worthless, and sometimes
felt so heavy she couldnt motivate herself to do anything at all.
Linda stated she had had similar struggles and worries that
something bad was going to happen for as long as she could
remember, and was tired of feeling this way.

Kevin

Kevin is a 51-year-old married male, who lives with his wife of

20 years and their two children, aged 12 and 16. He works as a
lawyer, which he has been doing for the past 25 years. Kevin came
to our center experiencing intense panic attacks that consisted of
heart palpitations, shortness of breath, dizziness, a lump in his
throat, nausea, and sweating. He had his first panic attack while he
was on the highway driving to work one day. Kevin immediately

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 pulled off to the side of the road and got out of his car. Kevin had
never experienced anything like this before and he was terrified that
he would lose control as a result of these attacks. He called his wife
to pick him up to take him to work, and had his car towed, telling
his wife it had broken down. He had been experiencing increased
stress at work and had been having some marital problems. The
night before, he and his wife had talked about separating for the
first time. Following this first attack, Kevin began having
additional panic attacks that occurred in a variety of situations.
Most felt like they were coming from out of the blue, but he felt
that he was especially likely to have them in situations where he was
unable to escape or where he felt trapped. Kevin was almost
constantly worried about having another panic attack and felt tense
and anxious for most of the day due to this concern. Since this first
attack, Kevin no longer drove on the highway. Instead, he took
surface roads to work, which added another 3045 minutes to his
commute. In addition to avoiding the highway, Kevin noticed that
he began to avoid traffic or driving on busy roads. In fact, he had
begun leaving for work an hour earlier than before and leaving an
hour later, in order to avoid rush-hour traffic. He also began
avoiding other situations and places, such as airplanes, elevators,
stores, shopping malls, theaters, and crowds, where he feared being
trapped and embarrassed if he had a panic attack. Wherever he
went, Kevin carried his cell phone (so he could call for help if
anything happened to him) and his medication bottle with him.
Although the medication bottle was empty, he said looking at it
made him feel more comfortable and better able to cope. Kevin had
tried a number of different things to get rid of his panic,
including relaxation, hypnosis, and even medication that his doctor
had prescribed. However, none of these things had helped.

Brian

Brian is a 34-year-old male who lives with his wife and 4-year-old
child. Starting about three months ago, after beginning a new job,
Brian noticed he was becoming increasingly concerned about the
possibility of getting sick from touching items such as doorknobs and
money, and when interacting with others in public. Recently, he
experienced an increase in these symptoms. In response to these fears,

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 he has been washing his hands frequently throughout the day and
avoids touching things he believes may be dirty. For instance, he
opens doors with his shirtsleeve or with a tissue, and on one
occasion, even wore a pair of latex gloves when using public
transportation. Currently, he washes his hands about 30 times
per day, under hot water, and uses nearly one bottle of liquid soap
every couple of days. He generally avoids public places where germs
may congregate, including movie theatres, restaurants, and the
mall. He tries to reduce direct contact with others as much as
possible, and refuses to shake hands with business colleagues. In
addition, he is overly cautious around his son, out of fear that he
came into contact with someone who was sick at preschool. Usually,
he asks both his wife and son to change their clothes immediately
when they get home each day, and has even asked his wife to take
an extra shower, all in an attempt to reduce his exposure to germs
and potential illness. His showers typically last about 45 minutes.
He usually showers about twice per day, but has showered up to
four times in a single day. Taken together, his washing behaviors
require at least two hours per day and have been causing significant
tension between him and his wife. He is also struggling at his job
because he is so focused on staying clean (as opposed to completing
daily activities) that he is falling behind in his work. On one
occasion, Brian got stuck washing his hands in the bathroom at
work for over 20 minutes straight. As a result, he was very late for
an important meeting. Brian is concerned about these symptoms
but has been unable to stop obsessing about the possibility that he
may be contaminated. He noted that the more he washes, and tries
to get clean, the worse his fears become. Brian remembers having
similar concerns when he was in high school, but feels that these
symptoms have now gotten out of control.

In each of these cases, strong, intense, and/or uncomfortable emo-

tional experiences are getting in the way of these individuals ability
to live the life they want, and driving them to do things they dont
want to do. You may recognize your own experience in these cases,
or you may find you have a very different experience than the ones
presented here. The important question to ask yourself is: Am
I having similarly intense or uncomfortable experiences that are
getting in the way of my life?

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Is this Treatment Right for My Symptoms?

You may notice that in each of the cases presented each person is
experiencing slightly different symptoms. Sarah is experiencing
intense anxiety about speaking in public and social situations, which
is getting in the way of earning a possible promotion at work and
limiting her social life. Linda is overwhelmed by worries and con-
cerns about something terrible happening to her and her family, and
often feels down and worthless, all of which is getting in the way of
her finding a job and doing things she enjoys. Kevin is experiencing
out of the blue panic attacks and constant worry about having
more attacks, which is causing him to avoid highway driving and
spend a considerable amount of extra time commuting to work.
Brian is so afraid of germs and getting sick that he spends almost
two hours each day showering and washing his hands. Even though
each individual experience is different, they all have one thing in
commonintense, strong, and/or unwanted emotions are getting
in the way of living their lives.

To help you think about how your own symptoms might relate to
the experiences described here, ask yourself the following questions
and record your responses in the space provided.

What symptoms do I feel I need help with?

________________________________________________________
________________________________________________________
_________________________________________________________

What emotions seem to go hand and hand with these

symptoms? Fear? Anxiety? Depression?

________________________________________________________
________________________________________________________
_________________________________________________________

How are these experiences getting in the way of my life?

________________________________________________________
________________________________________________________
_________________________________________________________

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What Types of Disorders is this Program Intended for?

The treatment program described in this book is designed to help

people like Sarah, Linda, Kevin and Brian, and people like you,
regardless of the specific emotional problem they might have. Each
of the experiences just described would meet a diagnosis for separate
anxiety or mood disorders; however, each has at its core intense emo-
tional experiences that are beginning to take over the persons life.
We designed this program to address these common experiences
and, as such, to be able to help with a range of disorders including
panic disorder, generalized anxiety disorder (GAD), social phobia,
obsessive-compulsive disorder (OCD), depression, or any other dis-
order in which strong, intense emotional experiences are the main
symptoms a person experiences.
To help you figure out where you fit in to this treatment program,
lets look a little closer at these diagnoses. To diagnose a person with
an anxiety, mood, or any other disorder, mental health professionals
rely on the Diagnostic and Statistical Manual of Mental Disorders
or DSM, published by the American Psychiatric Association.
(DSM-IV; APA, 19941). In this manual, certain symptoms experi-
enced by individuals go together to make up a specific disorder.
Here are some examples of what these disorders might look like:

Panic Disorder

In panic disorder, people experience intense panic attacks, or a wave

of fear that washes over them, which causes uncomfortable sensa-
tions including some combination of the following: a racing, pound-
ing heart; shortness of breath or smothering sensations; hot or cold
flashes; a feeling of choking; sweaty palms; nausea or stomach dis-
tress; dizziness, lightheadedness, or faintness; feelings of unreality or
being detached from oneself; a fear of dying; a fear of going crazy;
or a fear of doing something uncontrolled. These panic attacks seem
to come from nowhere, and last around ten minutes or less at their
peak. People who experience panic attacks often describe a sense
of feeling trapped and needing to escape, even though they are not

1
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed., text revision). Washington, DC.

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 in any real danger or cant figure out why. When a person starts to
experience panic attacks, they become very worried about having
another panic attack, and may begin to change their lifestyle or to
avoid certain situations as a result.

Obsessive-Compulsive Disorder

People with obsessive-compulsive disorder experience frequent and

recurring unwanted, irrational thoughts, images, or impulses that
dont make sense to them. For example, someone might find himself
having horrific or aggressive images pop into his mind that he finds
very disturbing, or someone may be plagued by doubt about whether
she turned something off, or filled out a form correctly, even though
she has already checked several times. These intrusive thoughts cause
the person a great deal of anxiety and distress, and the person tries to
suppress them or neutralize them in some way in order to get rid of
them. The person may also feel driven to repeat some behavior, or
repeat some phrase or word over and over, in order to feel less uncom-
fortable. For example, someone with intrusive thoughts about getting
germs from everything he touches may find himself driven to wash his
hands repeatedly. Or, someone who keeps having unwanted or non-
sensical blasphemous thoughts may find herself saying a prayer over
and over in her head. Or, someone who feels intense anxiety when
things are out of place may feel driven to put things back in order.

Many people have fleeting thoughts that dont make sense to them
and that seem to come out of nowhere, or may have idiosyncratic
behaviors or habits like keeping things in a certain order or doing
things a certain way. For someone to be diagnosed with obsessive-
compulsive disorder, however, these intrusive thoughts and/or com-
pulsive behaviors must take up a great deal of time in the persons
day, happening for at least an hour or more, and must be very inter-
fering and/or distressing for the person.

Generalized Anxiety Disorder

People with generalized anxiety disorder experience excessive worry

and concern over a number of different areas of their life. They may
worry about minor matters, such as getting errands done or getting
places on time; issues related to work or school, such as finishing a

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 project or meeting expectations; their family and friends health and
well-being; their own health and well-being; their finances; how they
are getting along with others; or even community or world issues.
Someone with generalized anxiety disorder doesnt just worry about
one of these things; they worry about several of these different things.
Most importantly, they find it very, very difficult to turn off these
worries, even when they are trying to do other things. These worries
come with physical sensations as well. They may feel restless, wound
up, irritable, and/or distracted. They may experience muscle ten-
sion, and have trouble sleeping. Just as with obsessive-compulsive
disorder, it is not uncommon for people to worry about things in
their life, and quite often worrying about something can act as a
powerful motivator to get something done, making worry quite
helpful. To receive a diagnosis of generalized anxiety disorder, a
person must be worrying about a number of these different things
more days than not, for at least six months, find these worries diffi-
cult to control, and experience at least three of the symptoms that go
along with worry (e.g. restlessness, muscle tension, difficulty sleep-
ing). In addition, these worries must be getting in the way of the
persons life and/or be very distressing to them.

Social Anxiety Disorder

People with social anxiety disorder or social phobia experience intense

fear of social or performance situations in which they are around
unfamiliar people, are being evaluated or possibly scrutinized by
others, or may do something that will embarrass or humiliate them,
such as going to a party, or giving a presentation at work. When they
are in one of these situations they experience intense, overwhelming
anxiety, and may even have a panic attack. The person knows the fear
is likely unreasonable, or at least excessive, but cant control it. As a
result, the person either starts to avoid social and/or performance
situations, or finds himself enduring them with a great deal of
distress. As with other disorders, it is not uncommon for people to
get nervous or anxious when meeting new people or speaking or
performing in front of a group of people. However, to receive a diag-
nosis of social anxiety disorder or social phobia, this fear has to be so
intense and the avoidance so great that it interferes in the persons
social life, work, and/or ability to go about her daily routine.

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Major Depressive Disorder

People with major depressive disorder, or what we commonly refer

to as depression, find themselves more days than not feeling very
down, blue, or depressed. They may find themselves losing interest
in things that used to interest them, like playing sports, reading
books, or going out to dinner with friends. They may feel like theyve
lost their appetite, or they may find themselves overeating. They
might have trouble sleeping, or feel like they cant get enough sleep
or cant get out of bed. They may feel tired all the time, unmotivated
to do much of anything. They may have difficulty concentrating, or
find their minds going blank. They may feel restless and agitated, or
they may feel very sluggish and slowed down. They may have a sense
of worthlessness or feel guilty. Some people even have thoughts
about hurting or even killing themselves. As with all of the disorders
we have discussed, it is not uncommon for people to have days when
they feel down or unmotivated, or even restless and agitated. To
receive a diagnosis of major depression, the person needs to have
been feeling this way more days than not, for at least two weeks or
more. Along with feeling sad, blue or depressed, and/or feeling like
he has lost interest in things, the person also must be experiencing at
least three or four of these other symptoms at the same time:

loss of appetite or overeating

sleeping too little or too much

feeling unmotivated or tired all the time

feeling restless or agitated, or sluggish and slowed down

finding it hard to concentrate

feeling worthless or guilty

having thoughts of hurting or killing oneself

An important note: If you are feeling so down and depressed

that you have thoughts of hurting or killing yourself, we urge
you to please go to your nearest emergency room right away, or
at the very least telephone a suicide support hotline. There, you
can find someone to help you through this period before you
do something you regret that cannot be changed.

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 These are just some of the diagnoses people can receive through an
assessment by a health professional using the DSM, and some of the
more common ones. Even though we have listed these separately
here, it is important to note that at our clinic it is not uncommon
for people to be experiencing many of these symptoms at the same
time. In fact, it is probably more common at our clinic for people to
receive two, or even three or four diagnoses at the same time, or to
have symptoms that dont quite meet the definitions for one disorder
or another. This is another important reason why we developed the
treatment program here: we want to help you to address all of the
symptoms you are experiencing, regardless of the disorder, instead
of looking at them one at a time.

How Can You Treat Several Disorders at the Same Time?

This treatment was developed following several decades of research

into how anxiety and mood disorders develop, what makes someone
experience symptoms of anxiety and mood disorders, and what causes
the symptoms to stay around and get worse. Our research draws from
the science of psychopathology, the science of emotion, neuroscience
or the science of the brain, and the science of human behavior. Through
this research we have learned that the disorders just discussed actually
have much more in common than their separate diagnostic labels might
lead you to think. At their core, all of these disorders arise out of a ten-
dency to experience emotions more frequently, more intensely, and
as more distressing than someone without these disorders. Because of
this, people tend to do certain things and behave in certain ways in
order to try and manage or control these experiences, but these strate-
gies tend to backfire. Therefore, this treatment program focuses on
allowing you to understand your emotional experiences better, identify
what you may be doing that actually causes your symptoms to worsen,
and what you can do to start feeling better and live the life you want.

Summary

This treatment program is designed to help individuals suffering

from a variety of anxiety and depressive disorders, which all fall into

12
the category of emotional disorders. Emotional disorders are charac-
terized by a tendency to experience strong, intense, and/or uncom-
fortable emotions that seem to take over the persons life. These
aversive experiences may cause people to change their behavior or
avoid situations, in ways that begin to interfere in their lives in
important ways. In this chapter, we presented four different case
examples demonstrating how emotions might interfere in a persons
life. We also reviewed the symptoms and criteria for meeting a diag-
nosis of a range of disorders, including generalized anxiety disorder,
obsessive-compulsive disorder, panic disorder, social anxiety disor-
der or social phobia, and depression. Research has shown that indi-
viduals with these disorders tend to experience emotions more
frequently, more intensely, and as more distressing than individuals
without these disorders. Further, even though individual diagnoses
exist, more often than not individuals suffer from more than one
disorder at the same time. Therefore, this treatment program is
designed to directly address the aversive emotional experiences at the
core of all these disorders.

In the next chapter, we will provide an overview of the treatment

program, giving you an idea of what this program entails, and allow-
ing you the opportunity to decide if this treatment is right for you.

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