333: Ask David. Questions about the Causes and Treatments for Anxiety

Ask David: Featuring Matt May, MD

What causes anxiety?

Is recovery permanent?

What if the cognitive distortions aren’t helpful?

Do hormones cause anxiety and depression?

What’s the role of vitamins and nutrition?

How do Exposure and Response Prevention work?

And many more answers to your questions!

In today’s podcast, three shrinks discuss many intriguing questions about anxiety from individuals who attended one of Dr. Burns’ free workshops on anxiety sponsored by PESI more than a year ago. Several of the questions were answered on the podcast, and a great many more are answered in the show notes below.

But first, Rhonda opened the podcast by reading an endorsement from a listener named Rob, with a link. Here it is!

Hi Dr. Burns:

I’m a long-time listener/reader, first-time caller. I stumbled upon this endorsement for Feeling Good today, and I thought it was worth sharing with you. I can’t think of a better endorsement for a book. I hope you enjoy it!

“I’ve replaced my copy close to ten times, as I keep lending it to friends who never give it back.”

Have a great day!


Thanks, Rob! And now, for the many excellent questions submitted by listeners like you! Many were answered in depth on the podcast, but you’ll see that all questions have written answers as well.

When you talk about someone recovering, is that free of panic attacks and anxiety forever, or a great decrease in symptoms but you will always be an anxious person to a certain extent? Especially for someone who has fundamentally been anxious since they were young so not episodic but continuous.

David’s Answer. Some people are anxiety-prone, and that is likely due to a genetic cause. I am like that, for example. Once you are 100% free of any form of anxiety, like my public speaking anxiety, you need to continue with exposure, or the old anxiety will try to come creeping back in. So, I do public speaking all the time!

What if your client/patient understands the Cognitive Distortions but doesn’t believe them to be true?

David’s Answer. It is hard for me to comprehend what you mean. But I will say this. Anxiety and depression and other negative feelings result 100% from distorted negative thoughts. And the exact moment when you stop believing the thought that’s triggering your anxiety or depression, you will almost instantly feel relief.

And here’s the precise answer to your question. When someone says, “I understand the distortions but it doesn’t help,” they still believe their negative thoughts.

Resistance, too, is an issue. Nearly 100% of therapeutic failure results from jumping in and trying to help the patient without first comprehending the many reasons why the patient will fight against the therapist’s efforts to “help.”

Has research been done on the possible relationship in hormone levels in women and anxiety or depression? Especially during pregnancy, post pregnancy, and those going through menopause? Also, can negative thoughts also depend on the person’s nutrition? Could it be that vitamins that are lacking?

David’s Answer.  First, I am not aware of any convincing evidence linking hormone levels with depression, anxiety, irritability, or any other negative feelings. However, we can say with certainty that whatever the cause, which is unknown, distorted thoughts will always be present and will be the trigger for the negative feelings.

In or near the first chapter of my most recent book, Feeling Great, I describe case of post pregnancy depression, and you can take a look and see the mother’s negative thoughts clearly. And you will also see that the moment she crushed those thoughts, her depression disappeared!

People want to “biologize” emotional problems, and I started out as a “biological psychiatrist” and researcher, but found the biological explanations to be erroneous and unhelpful.

Could you please give a brief overview about Exposure with Response Prevention for OCD treatment.  Thank you!

David’s Answer. Sure, these are tools that can be helpful, along with many other kinds of tools, in the treatment of anxiety, including OCD. They are not, for the most part, treatments. I use four models in the treatment of every anxious patient: the Motivational, Cognitive, Exposure, and Hidden Emotion Models.

Exposure is facing your fears and enduring the anxiety until the anxiety subsides and disappears. Response Prevention is refusing to give in to the superstitious rituals OCD users when anxious, like counting, arranging things in a certain way, and so forth.


The answers to the questions below were written by Dr. Burns but not discussed on the Podcast.

Questions can I ask to overcome the Cognitive Distortion “jumping to conclusions”? That is the toughest for me.

David’s Answer. I would need a specific example. Jumping to Conclusions includes a vast array of topics and negative thoughts. Fortune Telling and Mind Reading are the most common forms of Jumping to Conclusions. Feelings of hopelessness always result from Fortune Telling. All forms of anxiety always result from Fortune Telling as well. Social Anxiety typically includes Mind-Reading, and Mind-Reading is almost universal in relationship conflicts.

In addition, I never treat a distortion, an emotion, a diagnosis, or a problem. I treat human beings systematically, using the T E A M algorithm.

Matt’s Answer. There are many methods in TEAM that can be applied in the form of a question. These methods and how they are carried out, depends on the circumstances and the specific thoughts a person is having. Below are some examples of negative thoughts (NT’s) and the types of questions that might help overcome them.

(NT): ‘Something really bad is going to happen’

 (Be Specific Technique): ‘Like what? What’s going to happen?’

 NT: ‘I’ll fail my biology test’

 What-If Technique: ‘What if I failed my biology test, why would I be worried about that? (write down any new thoughts) What if those things happened, too, what then? (write down any new thoughts) What’s the absolute worst thing that could happen? (write this down).

 Measurement: How certain am I, that these things will happen? On a scale from 0 – 100%, how likely are each of these predictions, in the form of negative thoughts, to occur?

 Socratic Outcome Resistance: What do each of these negative thoughts say about my values that I can feel proud of? (write these down) What is appropriate about how I’m feeling and thinking? (write these down) What are the advantages of having these thoughts? (write these down). What would I be afraid of, if I didn’t have this thought? (write these down)

 Pivot Question: Given the many positive values related to worrying, the advantages of doing so, the disadvantages of a carefree existence and the many reasons why my worry is appropriate, why would I change this?

 Forgetful Clone (Double-Standard Amnestic Technique for Outcome Resistance): What would you say, to a dear friend, in an identical situation, when they asked these questions: ‘I’m really worried about failing my biology test, would you be willing to help me? (if ‘yes’, then continue) … Don’t I need to keep worrying? Won’t that protect me from failing? Don’t I need to worry, so that I’m highly motivated to succeed? Don’t I need to worry, so I avoid making mistakes? Don’t I need to worry, to maximize my rate of learning new material? Won’t I get lured into a false sense of security, if I stop worrying? Won’t I jinx it, if I get too confident? What would you recommend to me? How much do you think I should worry? I am prepared to do so … would it be helpful for me to go into a sustained panic, at this time?’

 Cost-Benefit Analysis: Is worrying about failure worth the price? How would you weigh the advantages of worrying about failure against the disadvantages? What are the pro’s and con’s? How would you divide 100 points, to reflect the power of these two arguments?

 Examine the Evidence, Motivational: What evidence is there that worrying improves academic performance, concentration and learning? What evidence is there that worrying worsens academic performance, concentration and learning?

Magic Dial Question: ‘‘Should I remain maximally worried, at all times, forever? (If not, keep going) ’What amount of worry is best, for me, in this moment?’, ‘How about future moments? How frequently do I need to worry and for how long?’

 Process Resistance for Activity Scheduling, Worry Breaks/Cognitive Flooding, Self-Monitoring/Response Prevention: ‘Would it be alright to ignore my worry most of the time and only focus on it during scheduled times? Let’s say I could learn how to be extremely calm and focused most of the day, without worry … would I be willing to worry as intensely as possible, for ten minutes, three times per day, to achieve this? When my worry comes up at other times, would I be willing to observe and record that event, then return to the task on my schedule?

 Socratic Questioning: Am I absolutely certain that this thought is true, that I will fail? How do I know that I will fail? What specific questions will be on the Biology test that I will get wrong? What number grade will I get? A 60? 58? 39?’, ‘Would I bet money on my getting precisely that grade? Why not?’.

 Examine the Evidence (cognitive): ‘What evidence is there that I will fail? What evidence is there that I will pass?

 Reattribution: Let’s say that I fail. Would that be entirely my fault? Are there any other factors, outside my control, that might have contributed to this outcome? My genetics, for example? Or the nature of the world, into which I was born? Did I choose my genetics? Did I choose the world into which I was born, when I was born, my parents, teachers, etc.? Could any of these factors have played any role in the outcomes in my life?

 Other examples of Inquiry-based methods, using different NT’s:

 Negative Thought: ‘People will be angry and judge me, if I fail’

 Interpersonal Downward Arrow: ‘What kind of people are they, if they judge me and look down on me, when I fail? How would I feel towards those types of people? Is it possible I feel angry? How do I express that feeling? What ‘rule’ am I following, in my relationships?’

 Outcome Resistance: What’s good about me, for feeling anxious, rather than angry? What are the advantages of keeping my feelings inside? What would I be afraid of, if I expressed my feelings?

 Process Resistance, 5-Secrets: Would I be willing to spend the time to learn the skills required to express my feelings, including anger, to people, in a way that made them feel good?

 Negative Thought: ‘I’ll get sick and die’

 Be Specific: ‘When? What time of day will that occur? What illness is going to kill me?’

 Negative Thought: ‘I’ll lose my mind, crack up and go crazy’

 Examine the Evidence: Has that ever happened to me? When was the last time?

When you are working with clients, how do you handle it when they can challenge their thoughts very convincingly using a variety of techniques, state that they can see the logic in their restructured thought BUT they are still experiencing heightened anxiety and state that this hasn’t helped them?

David’s Answer. They still have a strong belief in their negative thoughts. It is 100% untrue that they have “challenged them very convincingly.”

Here’s an example. Let’s say you have an intense fear of glass elevators. You will say, “I can see that they are unsafe, but I am still terrified of going in one.”

The moment you get on the elevator your belief that you are in danger will suddenly skyrocket to 100%. In other words, you still believe your negative thoughts.

Of course, it is nearly always easy to overcome phobias, including an elevator phobia. As stated above, I use four models in treating every anxious patient. Simplistic formulas are just that—Simplistic! Treating humans is not like changing the oil in your car!

Matt’s Answer: I am hard pressed to add anything of value to David’s awesome response, above. I might just reiterate that the Cognitive model, challenging the logic behind negative, anxiety-producing thoughts, is the least powerful of the approaches we have to anxiety. It is necessary, but almost always insufficient. Exposure, motivational methods and Hidden emotion are the real heavy-hitters. Until trying these, it is likely that the negative thoughts can be disproven ‘intellectually’ but not at the emotional level.

How do you work with clients who state they are anxious all the time, experience strong somatic symptoms (body sensations) and cannot identify specific thoughts. They don’t catastrophize these somatic symptoms but really, really dislike them and want them gone!

David’s Answer. I just ask them to make up some negative thoughts. That works well. For example, they may have the belief that the anxiety must be avoided because it may never disappear, or may believe that they are on the verge of going crazy, and so forth.

Matt’s Answer, Anxiety can cause people’s brains to shut down, experiencing the ‘deer in the headlights’ phenomenon. Try to identify just one upsetting thought, then use the ‘what-if’ technique to expand on that. You’ll be off and running!

How do you do techniques with a person who has active suicidal thoughts?

David’s Answer. I don’t “do techniques.” I find out if they’re actively suicidal and in danger. If I know for certain that the person is safe, I treat them like human beings, with T E A M. I’m not a formula person. Each person will be different, and will respond to different methods. My books and podcasts are chock full of examples of actively suicidal people who responded.

Matt’s Answer. I let them know that I don’t have the skill to help them unless I know they’re safe. If I’m worried for their safety, I’ll be afraid to use aggressive methods that may be required for them to recover. I’d need them to convince me of their safety before agreeing to work with them. If they can do so, I offer TEAM. If not, I ask if they’re willing to escalate the level of their care, e.g. to meet with me while hospitalized in a safe setting. I don’t work with patients who are at risk of harming themselves because I don’t believe in my ability to be helpful to them.

Is it really okay to keep continuing the experimental technique when the patient does not want to continue? And, what if the therapist is not confident and something goes wrong in this situation?

David’s Answer. I would need a specific example, but you are right that 75% or so of therapists are afraid of exposure and will not use it, fearing that something will “go wrong!”

Matt’s Answer. It’s important to identify the resistance before initiating the method of exposure and to talk it through. Why would they not want to continue? What are they afraid of, if they get really anxious, during exposure? Write this down.

Then, surrender, acknowledging that these are some excellent reasons to avoid exposure, in which case we can’t help them with their anxiety. Perhaps there’s something else they want help with? If they can convince you, and themselves, that exposure is precisely what they want to do, and they’re willing to keep doing it, even if it makes them very anxious, it’s appropriate to push a bit, in the moment of their doing exposure, to bolster them and help them through the rough patch. That said, I always give my patients a way out, if they don’t want to continue. That’s their choice, I just want them to be aware of the consequences, including a worsening of their anxiety.

When doing experimental method, or the exposure method for example with who has sweating issue, how do you handle the hyper-vigilance he would have with people around, especially if someone actually laughed at him?

David’s Answer. I would use the Feared Fantasy Technique, and Self-Disclosure. I would likely go with the patient into the real world to do these things, and have done so on hundreds of occasions.

How would you work with someone who suffers from  Selective/Situational Mutism?

David’s Answer. I have not run into that in my clinical practice. But 100% of the time, I would want to know what the patient’s agenda is. I would also want to know if there are powerful motivational factors that need to be addressed, looking at the whole person rather than the symptom.

How different are Team CBT treatments for teens as compared to adults?

David’s Answer. My experience is limited, but I would say no difference, really. I have loved working with teens, even though my main focus was on adults.

When working with little kids, I think you need to incorporate play and games, although the basic concepts are the same. For example, you can do Externalization of Voices with puppets, the “Bad, Mean Self” and the “Positive, Loving Self,” or some such.

We have featured shrinks who work with kids on many times on our podcasts.

Thanks for joining us today!

Matt, Rhonda, and David

Rhonda and I are convinced that Dr. May is one of the greatest therapists on the planet earth. If you have a question or would like to contact Dr. May, please check out his website at:

Dr. Rhonda Barovsky is a Level 5 Certified TEAM-CBT therapist and trainer and specializes in the treatment of trauma, anxiety, depression, and relationship problems. You can reach her at

You can reach Dr. Burns at

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