•embarrassment
•shame
•guilt
•a sense of personal failing
•being sure that one is flawed
•believing that you are inferior to others
•being harshly self-critical
•having low self-confidence

These are powerful, negative beliefs that some anxiety-ridden people have about themselves. They hold them to be as true as the sun rises in the East. These thoughts stem from the anxiety disorder. These anxiety-provoking thoughts are incessantly repeated, both verbally and sub-vocally, until they are soaked in apparent truth. Beliefs such as these can strongly influence a person’s behavior and interactions with others.
For instance, a person with social anxiety may repeat the phrase “I suck at meeting new people” over and over again. They practice this belief dozens of times a day. Socially anxious people may even imagine how horrible meeting someone new at school (or elsewhere) today will be. Practice, in this as in many other areas of life, makes perfect. Therefore, our socially anxious person believes that s/he “sucks at meeting new people.” S/he has visually imagined or practiced how poorly the next interaction will be.

This linking of an anxious presumption (I suck at meeting new people) with imagined interactions and outcomes leads someone to become successful at being unsuccessful in meeting new people.

Let me make an aside. When I was young, I played golf. I remember reading an article by the golfing hero of the day, Jack Nicholas. He described the technique he used to prepare for his next shot as he walked up to his ball. He visualized, from a first person point of view, making the back swing, exploding downward and striking the ball, following through and only then looking up to follow the ball on a perfect arch and direction to the exact point where he wanted the ball to land and then roll to.

At the time, I thought that was just something he came up with for the article. I tried doing it and had little success. Only later did I realize that I have a hard time visualizing such things. For me, verbal or auditory cues work much better. Years later, when I read books about NLP, I came to have a much better understanding of why Jack’s visualizations did not work for me, but talking myself through something did work.

Before getting too far afield, let me return to erroneous belief systems and self-soothing. Our socially anxious friend now has a rigid belief that they suck at meeting new people and have practiced poor outcomes in their imaginations. They have become as prepared for that bad interaction as Jack Nicholas was prepared for his birdie. In all probability, the socially anxious person will have a very upsetting encounter with the next new person.

This seems to prove the assumption that “I suck at meeting new people.” So, if anyone should ask why a person thinks she or he have difficulty meeting people, there is fresh, concrete proof. That is a fallacious line of argument.

The socially anxious person, in this case, would better be described as, due to the anxiety disorder, being successful at preparing and planning a disastrous first meeting with someone. It is not that they prepared and practiced to have a successful outcome. We do not know how the meeting would have turned out if the person had been at ease, comfortable in the setting, and had practiced a successful outcome to the meeting.

One way to try to combat negative, self-fulfilling beliefs involves my asking what seems to be a question dreaded by some of my patients.

Let me explain that a bit. Anxious and depressed persons often come to the first session well-versed and ready to discuss what is wrong with them. The descriptions of their purported flaws, shortcomings, self-criticisms flow easily.

At some point in the session, I ask them to “tell me three good things about you.”

There is usually a silence. Sometimes there are looks back at me that seem to say that I have asked a most impolite, hideous and foul question. It would seem easier to return to the lengthy list of negatives.

One of the reasons behind asking this question is to find traits that a person likes about him or herself for use in self-soothing and self-esteem. Another is to assess the constancy and quality of the person’s self-representation. The latter is relevant to this discussion but would take us into object relations theory and psychodynamic/analytic theory and is beyond the scope of this post.

With three good things about oneself in hand, many techniques become available. A simple one is to say to yourself something like the following:
“I’m a good person who is (fill in the blank with three self-positives). I am going through a difficult time (fill in the situation, e.g., meeting this new person). But I have gone through bad times before and made it through. And I’ll be able to make it through now because I’m a good person and (fill in the three self-positives). I’ll still have those good qualities even if this (meeting or whatever) goes poorly.”

In the above, I have suggested three initial strategies on building self-soothing strategies and positive self-esteem.

First, notice when you are practicing negative thoughts about yourself and preparing for self-fulfilling bad outcomes. Then attribute those thoughts and previous outcomes to the anxiety disorder. Stop those ruminations by getting up and doing a different activity, even if it is only getting up from the couch and going into the kitchen and washing dishes; if you are alone you can say “Stop those thoughts” out loud and switching your thoughts to any positive memory you might have; and similar techniques.
Second, try to picture a successful outcome to your next project, like Jack Nicholas. Alternatively, if visualization is not for you, talk yourself through the steps of the project. Imagine how one successful step will lead to the next.

Third, remind yourself of your good traits, at least as often as you rehearse the negative ones. In addition, in times of trouble, remind yourself that you will still have all your positive attributes with you through the difficult task and even afterwards.

I will return to these topics in later posts.

My apologies for the delay in between posts recently.  I will hopefully be getting back to a more regular schedule soon.

50 Quick and Easy Ways to Calm Your Anxiety

Season’s Greeting!!

The New York Times reports on a study funded by the National Institute of Mental Health.  They found that a combination of psychotherapy and psychiatric medication led to 80 percent of the children either improving very much or recovering altogether.  This compared to a 60% recovery rate for psychotherapy alone and 55% for medication alone and less than 25% getting only a placebo (sugar pill).

Here’s the link to the whole article, it’s worth a read:

http://www.nytimes.com/2008/10/31/health/research/31anxiety.html?em

I can’t count the number of times people have told me that they did “nothing” since the last session.  As we saw in earlier posts, staying at home, isolated with one’s worries and problems only increases stress loads and the likelihood of an anxiety or panic attack.

To prompt people to get out and do something, anything, I have made a fairly extensive list of activities, places to go and events in Rhode Island.  It can be found at this link:

http://ripsychotherapy.com/things%20to%20do.html

I couldn’t make it a post or a page in this blog as the size of the listings just did not fit into the blog’s layout.  Sorry if that causes any inconveniences.

I welcome any suggestions, comments, additions to this list that you might have.  I’ll try to keep the list current.  But also let me know if you come across any dead links in the page. You can email me at madamowicz@ripsychotherapy.com.

For readers who are not in Rhode Island, you can use this list to generate suggestions on what you can do in your area and then do a google or yahoo search to find venues close to you.

Happy Halloween!

This post covers the relationship between the 3^rd and 4^th posts. That is, the relationship between some of the stress reduction techniques and the biology of the stress model.

Once more, I need to repeat that this is a tremendous simplification of a highly complex process. In addition, microbiology and neurophysiology are not my strongest points. I welcome all corrections to any of those processes in these posts. References are available at the end of the post for anyone wanting further details. As always, none of the information in this post is intended to replace diagnosis and treatment by a licensed professional. This is for informational/educational purposes only.

During normal times, the body is in a general state of alertness and homeostasis. Even then, "muscle is never completely relaxed-it is in a state of continuous but variable contraction." ( The Nature of the World and of Man, p. 487)

When we need to move or perform some task, we don’t use the whole muscle with all its force for each movement. This is a good thing. Otherwise, you’d smash your teeth and spill the tea into your lap each time you raised the cup to your lips.

Muscles, like the biceps for instance, are separated into smaller groupings or layers by the fascia. The fascia, according to David A. Winter , are sheaths that "enclose the muscles, separating them into layers and groups and ultimately connecting them to the tendons at either end." (p. 166)

A single muscle, then, can have a number of different layers or groupings (motor units).

These layers or units are called into action through a sequence known as "The Size Principle." Winter writes that according to this principle, "the smallest unit is recruited first and the largest unit last. In this manner…movements can be achieved in finely graded steps." (p. 167) The first muscle groups or motor units involved will be the last ones released back to a relaxed state. This allows you to raise a cup gently to your lips and sip, without spilling the tea or splitting your lips.

After getting a drink and returning the cup to the saucer, the task is done. A cortisol message informs the hypothalamus. The hypothalamus then sends out corticotropin-releasing hormone (CRH) to the muscles involved in the task. (This is an oversimplification because there are a number of sub-routines or minor tasks included in the larger goal of taking a sip and placing the cup down. It is the general point that we are interested in.) The muscles in the arm begin to relax, with the largest motor units turned off first and the smallest ones last.

So much for normal daily life.

Now, recall that when we detect a threat, the fight/flight/freeze response starts. The brain initiates a complex series of biological processes that prepares us for the danger.

One way that the body is prepared is an increased tone or readiness of the skeletal muscles. However, in anxiety, there is no clearly identified external threat. Without a specific threat, it is not possible to plan a reaction.

The muscles are tensed, but there is no action to take. A wrong move might get us killed. Yet we have to be prepared to make any move. So long as we believe a threat might be present, the muscles will remain at the ready. CRH is not sent to the muscles to tell them to stand down.

All dressed up in our shiniest battle gear, and no place to go.

To counter this situation, you can give your muscles a direction. Get up and go into the next room. Better yet, go out for a vigorous walk around the block, play catch with one of your children, go for a walk on the beach with a friend, etc. If for some reason you cannot get out, you can do progressive muscle relaxation right where you are sitting.

The point is to give the muscles a useful, conscious goal and to carry it out to completion. Once that is accomplished, the brain, in turn, will send out CRH so that the muscles can go back to their resting point.

It is tempting to sit in the same spot and mull over the worries and anxieties. There has to be a solution to all this worry, stress and anxiety. If only I think harder, longer, I will come up with an answer. That is the wrong response.

You will only generate an increasing level of threat perception and the body will continue to get tense. Remember that the brain calls on increasingly large groups of muscle as the demands of the task get greater (the size principle). As the muscle groups involved become larger and more widespread, the more uncomfortable the body becomes, the more difficult it is to breathe, and so on.

The brain is receiving feedback that the body is under stress and this increases the sense of anxiety/panic. Some people start taking their pulse at this point and get further freaked out because their heart rate is well above normal and they feel short of breath.

All this seems to confirm that one should be anxious. Even if there is no external threat, the brain has in fact found something frightening. It has identified that something is wrong with the body itself. Again, though, I have no idea why my pulse should be 102 and I feel dizzy. That alone makes me anxious. This is now a completely self-fulfilling circle of thought.

Breathing with the diaphragm is so easy that babies do it. However, that simplicity is often an objection to breathing in that fashion. After I tell people about it during a session, I often hear doubt in their voice. "How’s that going to help with dealing with my boss?" It seems too simple to be of any help with real problems, panic and anxiety.

Remember that as the perceived stress/threat grows, more and larger muscle groups are called into service. As my pectoral, trapezius, intercostal, deltoid, and other chest/back/shoulder muscles tighten, they press in against very important items: my ribcage and the lungs. As pressure builds against the ribcage and lungs, it becomes more difficult to take a deep breath.

By the same principle, as the stress/threat level increases, so does the tension in the muscles of my neck. Underneath and around the neck muscles are my throat, spinal cord, major arteries and veins. Pressure on the throat makes it more difficult to breathe. Constricting the arteries causes problems getting blood to the brain.

Understandably, having difficulty breathing is very upsetting to people. It increases the anxiety level. People often start to hyperventilate to compensate for the pressures on the ribcage and throat.

The way out of this is to use the stomach muscles to push out the abdomen and allow the diaphragm to drop, expanding the lungs fully. Pulling the abdominal muscles in pushes the diaphragm up and pushes air out of the lungs. The muscles of the rib cage and shoulders are not used. problems associated with hyperventilating are avoided.

While I was researching this post, I came across a very interesting article that uses a number of the above principles. The article, A quiet hand for microneurosurgery , is by and for neurosurgeons performing microneurosurgery. You don’t want your neurosurgeon to have a shaking hand. The authors found that the following variables are associated with worsened tremors:

Long-term factors include health and age. Intermediate factors are skill, alcohol, nicotine, and caffeine. Short-term factors, which occur during surgery, include limb support, direction of movement, physical fatigue,and anxiety. (p. 542) (I have italicized the elements shared between their article and our discussion.)

The neurosurgeons note that with increasing involvement of more muscle groups, the tremor worsens:

We also became familiar with the size principle of motor unit recruitment; that is, the smallest motor units are recruited first….one should recruit the least number of motor units to perform a task because each contracting muscle fiber adds to the tremor. (p. 542)

For anxiety, the increasing involvement of more and larger muscle groups adds to the anxiety and physical problems associated with anxiety.

These authors found that fatigue was nearly impossible to eliminate in neurosurgeons given their demanding schedule and hours. So they devised a work-around solution. Use only the most energy and movement required for the task-the "quiet hand technique."

Furthermore, avoid alcohol, caffeine and nicotine. Reduce or eliminate anxious thoughts. Focus on the present task. Exercise: " An exercise specific to the quiet hand technique involves taping the four fingers together or placing them together on a tabletop and stretching the thumb in all directions." (p. 543) Finally, they stress the role of breathing. Proper breathing control plays a role in microsuturing:

3) Flex the thumb so that its tip holds the needle holder to the first finger.

4) Inhale with thumb flexion.

5) Position the needle.

6) Extend the thumb .

7) Exhale with thumb extension to ensure smooth rotation. (p. 542)

As you see, many of the principles for stress/anxiety reduction are the same in both our lives and in the practice of neurosurgery. If the principles help physicians working inside a patient’s brain, it would seem like reasonable that the same principles would help with stressful situations in other areas of life.

This post has covered why diaphragmatic breathing, progressive muscle relaxation, light exercise and other factors work to reduce stress and anxiety. Another post will handle good sleep and diet in more depth. A separate post will deal with ways to turn down the dial on anxious thoughts so that the thinking/emotional aspect of anxiety is covered.

The following are references for people who would like more detail on the topics in this post; again they are listed in no particular order.

emedicinehealth.com

Wikipedia-action potential

mcgraw-hill.com Animation: Myofilament Contraction

Mechanism of Tension Generation in Muscle An Analysis of the Forward and Reverse Rate Constants — Davis and Epstein

GetBodySmart.com-action potentials

Wikipedia-muscle contraction

A quiet hand for microneurosurgery: twiddle your thumb

GetBodySmart.com-Skeletal Muscle Fiber Contraction Physiology