Using Anxiety to Avoid Depression: Part Two

When we left off, it was with Donovan Campbell, in Joker One, trying to establish measures to deal with the stress faced by 150 Marines trying to gain control over an Iraqi city of 350,000.

As a refresher, he was trying to act as a calm leader. As he phrases it: “Frantic-sounding lieutenants lose everyone’s confidence immediately…Calm-sounding lieutenants make everyone believe that the situation is well under control…” At the same time, he attempted to establish activities to bolster esprit de corps and rituals for the unit so that they formed a cohesive identity.

A golden rule in dealing with anxiety of unknown dangers is to turn it into a fear of a specific threat. Once that is accomplished, plans can be made to deal with the threat. Campbell spent a lot of time planning his missions and identifying specific goals and means to reach those goals. He did this despite the full knowledge that conditions could quickly change and make his plans and goals irrelevant. As Campbell writes of a detailed plan he made in early April: “Like most of my plans, this one didn’t survive very long.”

Nonetheless, a key part of his strategy was to continue identifying concrete goals and clear-cut plans.

Another helpful stress and anxiety management tactic is to simply take stock of the changing conditions and the results of earlier efforts. Do this with a neutral eye. It is decidedly unhelpful to harshly criticize oneself for plans made with the best of intentions and efforts. That leads to self-doubt which in turn brings back anxiety of unknown and uncontrollable bad outcomes. Instead, no matter what the outcome, it’s good to recall that you made the best decision possible available at the time.

For instance, Campbell, with very limited information, had to make a decision on whether or not to have a sniper shoot a man. He considered the situation for about thirty seconds and then ordered the sniper to fire. Months later, he learned that the dead man was in fact an insurgent and so the decision to have him killed was correct. However, Campbell did not revisit that earlier decision. As he puts it: “on the front lines, there are no great options, just bad ones and worse ones, so you do what you can…Then you live with the results…”

Sometimes, chronic exposure to severely stressful conditions will outmatch well made, rational plans and stress management techniques. Let’s recall the conditions these soldiers lived with. The temperature was often in the 130’s. There was insufficient water for regular showering and toileting. Sleep was often interrupted and too brief. Meals were mainly prepackaged rations. Fun activities, while highly prized, were in short supply. They were strangers to the culture. Mortars and small arms were routinely fired into their base. Their families and friends were continents away. 150 soldiers were tasked with winning an urban war fought on foot in a city of 350,000. Fellow soldiers were being killed and wounded in other units. “For many members of Joker One, death took on a very real persona…”

It should come as no surprise, then, that a weak spot in Campbell’s thoughts developed. It can be most clearly seen in his intensified beliefs in the powers of the pre-mission prayer ritual. At one point, his platoon was the only one not to have suffered a single wound. Some magical thinking crept into to his beliefs. He began to believe that due to the prayers, the lack of injuries to his platoon was a “clear sign that…God would certainly bring all of us home safely.” As explained in a Psychology Today article, “Emotional stress and events of personal significance push us strongly toward magical meaning-making.”

In a phone call to his wife, Campbell told her that the prayers were keeping his soldiers safe and that prayers would bring them back alive. His wife tried to inject some clear thinking. “She was glad that no one was hurt, she said, but she reminded me that God wasn’t a cosmic slot machine that came up sevens every time for the pious believer….All He guarantees you is your relationship with Him in the next. They were hard words of truth…And I completely ignored them.”

In retrospect, Campbell has good insight into his overemphasis on the power of his religious beliefs. “I didn’t recognize yet that my steadfast dismissal of the idea of casualties in my platoon stemmed not so much from a belief about God’s grace but from a refusal to consider the very real possibility that someday I might be responsible for the death and wounding of the men I loved so much.”

There are many reasons for avoiding the idea that he might have to order his men into situations that could lead to their and his death or injury. As he says, he loves his men. It is rational to want people you love to remain safe. Yet beyond that, Campbell has mistakenly tied his relationship to God, his idea of himself and the safety of himself and his men to events and circumstances that are clearly beyond his control. This is a formula for anxiety. To protect against the full, crippling nature of anxiety and panic, he forms unrealistic beliefs.

At the time, this symptom of anxiety, magical thinking, guarded him against both the overwhelming reality of his situation and feelings of futility and depression. “I thought that if I was just good enough, that if we just prayed hard enough,” then God would intervene and protect them and allow for victory.

The symptom of magical thinking kept a distorted form of hope alive. Hope that God would love him enough to keep him safe. Hope that he could prevent his men from being killed.

Hope that he, as a man, was just simply good enough.

The contrary of those thoughts are extremely painful. God does not love him. He cannot keep his men safe. Campbell is simply neither a good man nor a good soldier. If these statements proved to be true, basic trust in one’s surroundings, beliefs and one’s self crash. The result can be anhedonic depression.

So, with the apparent choice being between the alluring hope and belief that one is good and deserving enough for God’s love and protection, on the one hand, and despair, desolation and damning self-blame, on the other hand, which would you choose? However, because this alternative is based on magical premises, it is a false dilemma.

Anxiety and its varied symptoms can, temporarily, protect against depression. That is why, in some cases, the successful treatment of anxiety leads to a depressive state. We have taken away the shield against depression and not treated the underlying problem. And, if we just treat the depressive symptoms and not the underlying defense against the reality of one’s situation and the accompanying distortions in thought, then anxiety can rekindle.

This is an insidious problem. The anxiety or depression in these cases is a defense against the full truth of one’s situation. The person may not consciously be aware of the root of the problem. So, even taking a careful history and assessment of a patient may not reveal the psychosocial stresses that are being guarded against. For example, if I ask an anxious woman how her marriage is, she may adamantly present a picture of a warm relationship and loving husband. Ruling out real stressors, I might view the condition as a biologically-based anxiety or depression. I start to treat the symptoms and try to extinguish them.

Only later do I discover that the anxiety covers a depression which in turn covers an abusive husband.

But let’s go back to the book and see what happens to Campbell and his Marines.

Anxiety, even with Campbell’s stress management skills and magical thoughts, still managed to poke through intermittently. And anxiety struck him particularly hard on the morning of one very tragic day. He writes: “I woke up to a horrible feeling of dread. I can’t really properly put that heavy sense of impending doom into words…I had been scared before other missions, of course, but never before had I felt such a deep certainty that something bad would happen to my men if they left the Outpost that day.”

The Ox, which is the nickname for Campbell’s commanding officer, was to be in charge of a mission that day. The Ox had proven to have flawed judgement on a number of previous occasions and this was a particularly difficult mission. On most missions, Campbell was in direct control of his men. That was not the case on this day. The Ox would lead them and one more element of control was taken from Campbell. The balance tipped and he was acutely anxious.

Part of the mission involved having the Ox inspect repairs that were made to a local school. This would subject the men to a relatively long period of remaining in one place with little or no cover from the enemy. Campbell objected to the plan on the grounds of it being unsafe for his men. He was overruled.

As Campbell feared, his men became sitting ducks and came under fire by insurgents’ guns and rocket propelled grenades. In the first round of the battle, “the rocket had missed us. Instead it had impacted squarely in the middle of the crowd of small children. Dead and wounded little ones were draped limply all over the sidewalk…”

Campbell then had to make a quick decision. He could leave the area and get his men to relative safety. Or he could stay and tend to the wounded children until ambulances arrived. But this latter alternative came with the certainty that the Marines would continue to be at risk from enemy attack.

“I wish,” Campbell writes, “I could say that I stepped back and cooly and dispassionately evaluated the situation, but if I said that, I would be lying. The fact of the matter is…we were United States Marines and a bunch of dying children needed our help. It was just that simple.”

Tragically, there was an unduly long delay in getting ambulances to evacuate the children. In the meantime, there were more attacks by the insurgents. During the firefights, one of the Marines was horribly, severely wounded. The soldier died a few days later at a hospital in Germany.

The immediate emotional consequence for Campbell was depression.

“I found that my hope, built so painstakingly over the past eight months, had been ruthlessly extinguished in one terrible moment…I fell into a deep depression. For a week, I didn’t want to eat, and I didn’t want to leave my bed, even though I found no respite in sleep. Instead of sleeping, I spent my time endlessly replaying the scene…wondering where I had gone wrong…”

The defense against anxiety through planning and strategy and a prayer ritual had failed. Anxiety led to some magical thoughts. Those thoughts took Campbell beyond mourning and into a hopeless state of depression.

Our initial question of how anxiety protects against depression and how resurrecting hope might lead back to anxiety is now mainly answered. And with that we will leave Campbell and the rest of the Marines of Joker One except for some brief references in future posts.

I wish them well.

Healthcare Reform Frustrations

In a plain-spoken way, Sarri Gilman on expresses many of my sentiments on the pace of healthcare. You can read her opinion piece here.

The Huffington Post reprints a depressing AP article today. The AP reports that the Senate Finance Committee has a plan to “exclude a requirement many congressional Democrats seek for large businesses to offer coverage to their workers. Nor would there be a provision for a government insurance option..” You can read the entire article here.

Now, Senator Max Baucus is the chairman of this committee. Could his efforts to drop these two key provisions have anything to do with special interest groups donating money to him?

The Washington Post reported recently that “Health-related companies and their employees gave Baucus’s political committees nearly $1.5 million in 2007 and 2008…” In late May, Baucus held a dinner to discuss “health-care legislation under consideration by his Senate Finance Committee.” In attendance were 20 healthcare industry representatives. To attend this dinner, a donation of “$10,000 or more to the Democratic Senatorial Campaign Committee” was required.

Moreover, the healthcare industry “gave nearly $170 million to federal lawmakers in 2007 and 2008…”

The Post’s article can be found here and you can judge for yourself how unbiased the Senator is in crafting this legislation.

Why People Might Use Anxiety to Avoid Depression

[A quick administrative note. I recently entered into an agreement with to provide blog posts for them. Some of the entries made here will also appear in their blog. This is the first such post.]

Back in March of this year, I was listening to NPR while driving around town doing errands. Terry Gross was interviewing Donovan Campbell, the author of Joker One. His book is about a platoon of Marines stationed in Ramadi, Iraq. Campbell was talking to Gross about a soldier under his command that was killed in Iraq. Campbell began crying while talking about the death. I found it remarkable that a battle-hardened Marine officer who served three tours in the Middle East and had written a book on the topic could still allow himself the candor and authenticity to cry on national radio about a man who died several years earlier.

I bought the book. I was not disappointed.

Joker One

Around the same time, I was puzzling over a clinical question that was happening frequently enough to catch my attention. In some cases, when treatment of anxiety symptoms was successful, depressive symptoms emerged. The reverse of that seemed also true: alleviation of depression sometimes led to resurging anxiety symptoms. I spent a lot of time thinking about the psychological and social conditions that might be at work in these instances.

Patients sadly asked me why it should be that now that the anxiety attacks were gone, instead of being happy they had become depressed. I had some stock answers to the problem. However, they no longer satisfied me. More importantly, I don’t think my answers were helpful to them.

This process occurred both in individual and marital therapies. Anxiety symptoms apparently were defenses against becoming depressed. And if someone was previously anxious and then became depressed, the depression-in part-served as a defense against a return of anxiety.

Further, the symptoms themselves guarded against fully coming to terms with the reality of the person’s or couple’s situation.

That all sounds complicated and I will attempt to unpack it as we go along.

Hope, I believe, also plays a pivotal role. Hope, that is, in both its manifestations: an alluring, sweetly promised desire and as an unfulfilled, tormenting, scoffing longing. But we’ll get to that later.

In subsequent posts I will also provide clinical examples of anxiety as a defense against depression (and vice versa) for individuals and in marriages. I will also try to work out some of the dynamics involved.

But to get started, let’s return to Donovan Campbell’s Joker One. It was while reading this work that I began to formulate an answer to the clinical questions that were dogging me.

Some caveats before I begin. This is not a review of the book itself. Nor is this intended as an analysis of the book’s author or the other Marines. Nor am I making any comment on America’s current wars or politics.

Rather, I simply want to look at some of the psychological effects of exposure to urban warfare.

I deeply respect and admire Mr. Campbell and the other Marines in this book. Nothing that I write below is intended as a slight or criticism of those men. I strongly recommend that you read Joker One. It is a work of art and love birthed in one of earth’s many hells.

Okay, now to the book.


The setting is Ramadi, Iraq in 2004. In Campbell’s words, the city “contained roughly 350,000 people…one of the highest population densities on earth…its alien nature struck me almost like a physical blow. No amount of training at abandoned U.S. bases could have prepared us…” Add to this that none of the 150 Marines spoke the local language. The city was home to unknown numbers of well-armed insurgents who did not wear identifying uniforms. Mortars were fired routinely into the Marine’s base. Their job was to “walk the city on foot” where “trash and human waste littered every street” and for the 150 Marines to secure and stabilize the city of 350,000.

If that is not a recipe for anxiety or panic, then I have never heard one. Obviously, a platoon’s commander cannot afford to have anxiety spread through the troops. Therefore, they would need good anxiety reduction strategies. I have written elsewhere on this topic and won’t repeat my views here; a number of them would not apply to his battlefield conditions anyway. So, let’s see how Campbell devises a real-time strategy for anxiety reduction and stress management in the midst of a hostile chaos and in the fog of war.

For one, he acts in the fashion of a true leader. Here’s how he writes about it:
“I had a responsibility to my men to provide for all their needs…Marines will only listen to those who have suffered alongside them, and if you want any credibility as a leader, you not only have to bear the same burdens as they, but you also have to try, to your utmost ability and every single day, to transfer those burdens from their shoulders onto yours.”

He also instituted “a pre-battle ritual…that we only performed every time we left the base’s confines…” The aim of this was to have “each of my Marines…think of himself first as a member of Joker One and only thereafter as an individual with needs and desires different from that of the team as a whole…a focus on the group and an overriding concern with the service and welfare of others.” The ritual was a recitation of the Twenty-third Psalm.

Praying Before Mission

So far, so good. Against an unknown, unseen force whose members were prepared to suicide if it would cause Marines to die, Campbell presents himself as a strong, competent and compassionate leader of a group of soldiers with an intense, common identity. Yet, within the recitation of the psalm was a paradox that ultimately threw Campbell into despair. But I am getting ahead of the story here.

There’s much more to Campbell’s campaign against anxiety and the dread of the unknown.

But this is a good place to take a break. I will continue analyzing his strategy in the next post. In the meantime, may I again suggest that you pass the time by reading Joker One.

Dogs and Fireworks Anxiety

The Examiner has an article addressing the treatment of dogs that are fearful of the noises accompanying fireworks. It’s called, appropriately enough,: Does your dog dread July 4th?
The top tips are:

  • “melatonin…the most likely non-pharmaceutical product to help” [though she does not mention dosages].
  • “contact their vet and consider anti-anxiety medications to provide their dog with relief”
  • “essential oils…used in any combination by direct contact to the pads of the feet or used in a diffuser…chamomile, lavender, geranium, marjoram, bergamot, frankincense, neroli, and sandalwood, vervain and valerian”

There are a number of other suggestions as well. I found this article too late to try this year. So, I can’t provide any reviews. Any comments, suggestions by the readers are welcome, as always.

The Genetics of Schizophrenia, Bipolar Disorder (and Schizoaffective Disorder)

The Independent reports on a new study of the genetics involved in schizophrenia and bipolar disorder.

The article, Unlocked: the secrets of schizophrenia, covers three studies published in the journal Nature.

Here are some of the results:

  • “Scientists have discovered a remarkable similarity between the genetic faults behind both schizophrenia and manic depression”
  • “thousands of tiny genetic mutations – known as single nucleotide polymorphisms (SNPs) – are operating in raising the risk of developing the illness.”
  • “Each mutation on its own increased the risk of developing schizophrenia by about 0.2 per cent but collectively they were found to account for at least a third of the total risk of developing schizophrenia.”
  • “Some of the genetic variations associated with schizophrenia appear to occur within a region of the genome known to be involved in controlling the immune system. This might help to explain why babies born in winter and spring when influenza is rife, or to women who have had flu during pregnancy, are at slightly increased risk of developing schizophrenia in later life, the scientists said.”
  • “Some of the genetic variations associated with schizophrenia appear to occur within a region of the genome known to be involved in controlling the immune system. This might help to explain why babies born in winter and spring when influenza is rife, or to women who have had flu during pregnancy, are at slightly increased risk of developing schizophrenia in later life, the scientists said.”

It’s actually that first point that has me rethinking some of my beliefs. Specifically, I am reviewing my disdain for the diagnostic category of Schizoaffective Disorder. Till today, I generally considered that disorder to be an overly broad, sloppy diagnosis best used by people who can’t make up their mind about what is the real diagnosis.

eMedicine’s discussion of the disorder notes that “Making the diagnosis of schizoaffective disorder can be difficult because it encompasses 2 other diagnostic entities, namely schizophrenia and mood disorders. An accurate diagnosis is made when the patient meets criteria for major depressive disorder or mania while also meeting the criteria for schizophrenia.”

However, as the Mayo Clinic’s website phrases it: “Not all experts agree that schizoaffective disorder should be treated as a distinct disorder. Some regard the condition simply as schizophrenia with some mood symptoms…”

Or as Hales and Yudofsky put it in Essentials of Clinical Psychiatry,

  • “Investigators have found the interrater reliability of the DSM-IV schizoaffective disorder diagnositic category to be low.” [In other words, trained clinicians do not often make this diagnosis for the same patient.]
  • “The validity of the schizoaffective disorder construct, as well as its division into depressive and bipolar subtypes, has also been questioned.”

Being less generous than those authors, I have long believed that schizoaffective disorder was used by clinicians when they did not take enough time (or interest) to fully evaluate the patient. To cover all possible bases, schizoaffective disorder could be used.

humble pie
However, in light of this recent research, maybe I should be eating some humble pie for breakfast.

If there are “thousands of tiny genetic mutations” common to and underlying both schizophrenia and bipolar disorder, then it could be expected that the expression or result of those mutations could be varied and diverse among individuals. A third “fuzzy” category of schizoaffective disorder may well cover the middle ground between the two more “pure” categories.