If the economy isn’t enough to give you agita (see my earlier post), then all the press about swine flu might do the trick.

Let’s recall the basics of anxiety: something bad, we’re not sure just what but it’s bad, may happen in the future and there’s nothing we can do about it. I discussed this in the third post in this series, last October. More formally stated, Wikipedia has it that “Anxiety is a generalized mood state that occurs without an identifiable triggering stimulus. As such, it is distinguished from fear, which occurs in the presence of an external threat.”

If you’ve been following along, those two sentences give a key to one of the ways to deal with anxiety. That is, turn anxiety into fear. We should get as specific as we can about the nature of the threat and then do what we can to prepare for it. After that, get on with your daily life, stop ruminating about the potential threat, enjoy the Spring.

In that vein, here are links to the most recent and reliable information I could find about swine flu.

• Centers For Disease Control and Prevention

By the way, doesn’t the very name of that agency help your anxiety? The name promises control and ways to prevent disease.

• United States National Library of Medicine
• Medline Plus

In addition to the tips on what to do in those articles, here are some recommendations for general emergency preparedness.

• Ready America

Now, turn off the TV and do a bit of light exercise. Then make plans to go out and have some fun. And remember to get seven to eight hours of sleep per night and eat a sensible diet. Avoid caffeine, nicotine, alcohol and other drugs.

Long term stress suppresses the immune system. So by following these steps, you can reduce your stress levels and maintain a healthy immune system just in case you need it later.

As my earlier posts on this topic surely indicate, I am a strong adherent of cognitive behavioral therapy (CBT). However, in my experience, this is not always the beginning and end point of psychotherapy for anxiety.

Let’s start with the goals of treatment for anxiety disorders.

Often, treatment for anxiety and other psychiatric illnesses is called successful if the patient has fewer symptoms and is able to resume something close to a normal lifestyle. Even if some symptoms remain, there is general improvement in the person’s overall condition.

However, as Stephen M. Stahl, M.D., Ph.D. points out, “it is necessary to complete the job by aiming for complete recovery, removal of all symptoms, and return to wellness as the goal. ”

He finds this is important because a partial recovery can “increase the likelihood of relapse, poor outcome, future treatment nonresponsiveness, residual disability, and even suicide.”

Relapse into another bout of illness is a significant problem. In 2004, the Anxiety Disorders Association of America issued a report entitled “Improving the Diagnosis & Treatment of Generalized Anxiety Disorder.” The authors write that “GAD has a relatively low rate of recovery when recovery is defined as a reduction to only 1 or 2 symptoms with a subjective sense of returning to normal.” They cite another article, by Martin B. Keller, that reported that 80 percent of patients do not achieve that level of recovery.

Furthermore, a study reported in the journal Psychotherapy and Psychosomatics found that persons with panic disorder with agoraphobia treated with medications only had a relapse rate of 78.1 percent in the first year.

Another study, “Fluoxetine, Comprehensive Cognitive Behavioral Therapy, and Placebo in Generalized Social Phobia,” looked at the response rates of a variety of treatments. 50.9 percent of patients treated with Fluoxetine (Prozac) showed a positive response. 51.7 percent had a positive response to 14 weeks of group cognitive behavioral therapy. And those treated with a combination of Fluoxetine and cognitive behavioral therapy had a positive response rate of 54.2 percent. Another way to state these findings is that no matter what mix of Fluoxetine and/or CBT was utilized, more than 45 percent of the patients did not significantly improve. Also, please note that we are talking about “positive response” here and not the more difficult to achieve full remission from the illness.

Pretty discouraging numbers, especially if the goal of treatment is Stahl’s “gold standard” of complete recovery.

With these results, it seems fair to say that neither medications nor CBT nor a combination of them can claim to have solved the riddle of treating anxiety disorders.

Before going any further, let me rush to say that I am not in any way, shape or form suggesting that neither medications nor CBT are valid treatments.

I was first trained in the days before the arrival of Prozac (circa 1987), Xanax (circa 1981) was not a popular medication yet (at least in the settings where I worked and studied at that time), and Lexapro (circa 2002) was not even a gleam in the eyes of Forest Laboratories. So I have seen the before and after treatment pictures. Never would I want to return to an era when such medications were not available to the people who benefit from them.

My training started after the development of cognitive behavioral therapy (circa 1967). And I cannot imagine removing that from the treatment arsenal either.

What I am advocating is that, so far, our knowledge and understanding of the causes of and treatments of anxiety and many other emotional disorders is limited. Given that, there is no one “cure” for these illnesses. Some anxious people, for instance, seem to not respond adequately to Prozac but do just fine on Zoloft and vice versa. Similarly, in my experience, some patients do quite well with CBT alone whereas others also benefit from adding a psychodynamic approach or a family systems technique after initiating CBT. (Please note that I say adding another approach after CBT is started. From a purely practical point of view, I usually find the quickest route to symptom reduction through CBT. Whatever symptoms remain after that are targets for other treatment methods.)

In my practice, my aim is for complete symptom elimination by whatever clinically sound and effective means are at my disposal. To achieve that, I am eclectic in the use of treatment styles and pragmatic in the sense that I am interested in empirically finding the optimal results for the specific person in my office at that time.

Let me end this post on an upbeat note.

This is the story of my quickest treatment of an anxiety disorder. A woman in her mid-thirties came to my office. She complained of panic attacks that were increasing in frequency and intensity.

She was confused about why she should have panic attacks. She had a recent physical check up and was in good health. She described her life as a very happy and fulfilling one. Her marriage was solid and rewarding. Financially, she was rather well off. This woman had a number of friends and was physically active. She watched her weight and ate a healthy diet. No one in her family had a history of anxiety or other emotional problems. She did not use alcohol or smoke cigarettes. She denied any history of traumatic events. There were no recent stresses in her life to account for the panic attacks.

What had changed at about the time of the onset of the panic was that she began having a single cup of coffee several times per week.

I suggested that she stop drinking coffee and to call me in a few weeks if the panic attacks persisted. She never called.

By sheer coincidence, I ran into her about a year later. This woman had not had any coffee since our meeting and the panic attacks had gone away. She continued to have a full and happy life.

Other than telling a nice story, my point is that in this case treatment was quite pragmatic. It was limited to recommending that she avoid caffeine. She did not want a referral for medication, she did not need CBT or psychodynamic treatment. Unfortunately, this is a very rare situation. But, again the point is that the treatment selected was based upon her specific circumstances and needs with the goal of eliminating her symptoms.

In future posts, I will discuss more complicated treatments of anxiety disorders.

I spent a while trying to describe how it feels to have a problem with anxiety and panic.  The results were dissatisfying; perhaps because I was presenting a secondhand account.

This is the list of emotions and thoughts that I have often observed in people with anxiety disorders:

•feeling fearful, angry, frozen in place
•experiencing physical weakness
•embarrassment
•shame
•guilt
•feeling emotionally vulnerable, weak
•a sense of personal failing
•being sure that one is flawed
•believing that you are inferior to others
•feeling out of control
•assuming that others are looking at/talking about you in a negative way
•being scared
•one should, ought to be able to do better and to “be normal”
•being harshly self-critical
•having low self-confidence
•I’m gonna die
•I’m going crazy
•second guessing oneself
•feeling sick, nauseous
•the worst thing ever just happened or is about to happen
•being alone, uniquely stricken
•nobody understands, I’m all alone in this

What I wanted to present was the meaning that people take from their anxiety problems.  Somebody with another medical problem, say the flu, would not so readily interpret it to hold importance for their view of themselves.  But persons with anxiety, depression or other emotional/mental illness are quick to take their symptoms as unquestioned truths about themselves.

Then it occurred to me that there must be some first person accounts on the web.

A little searching revealed that YouTube has a number of videos submitted by persons with anxiety disorders.  These people do a much better job of describing their experience than I can from a secondhand vantage point.

Please spend some time watching the video posts.  It’s well worth your time.  Perhaps one of the most remarkable things is how open these people are about their experiences.  Yet, as many of them say themselves, they have trouble just being around other people.  Somehow the Internet affords them a sense of comfort in talking about themselves that they don’t experience with many of their family and friends.

These are just a few of the videos available on this topic at YouTube.  I think you will find these posts to be poignant and illuminating.

httpv://www.youtube.com/watch?v=cl8t6Xo2Syw

httpv://www.youtube.com/watch?v=QfbdwIDcs-Q

httpv://www.youtube.com/watch?v=1tDEpkZ9Aps

httpv://www.youtube.com/watch?v=bHKhMP0wuHU

httpv://www.youtube.com/watch?v=EFrz8lsz4dQ

httpv://www.youtube.com/watch?v=t5-Pxtv1nSQ

httpv://www.youtube.com/watch?v=RhaHYumW0pQ

In future posts, I will talk more about the psychological meaning and impact of chronic anxiety and panic.

This is my first effort at a blog. So, it may take a while to get it right. I appreciate your patience and any comments or suggestions you may have are welcome. My hope is to get one installment on to the blog per week.

I will start by providing some educational material about some of the common problems that bring people into my office. Given the nature of blogs, I can neither answer questions about specific cases nor provide an exhaustive coverage of the topic. It is, after all, a blog and not a book. None of the information presented in this blog is a replacement or substitute for psychotherapy, diagnosis, or treatment by any professional. (Please refer to the privacy policies of my website for a fuller discussion of this matter.)

What’s In a Word?

Anxiety in one form or another is perhaps the most common problem for people in my practice.

One of the best starting points for the treatment of anxiety comes from the definition of anxiety. For such a common emotion, the Wikipedia definition is technical and stuffy. However, it still helps to make a clear distinction between anxiety and fear. They write: “Anxiety occurs unconnected to a specific identifiable external stimulus; as such it is distinguished from fear, which occurs in the presence of an identifiable threat.”

Now, let’s look at the history of those two words, anxiety and fear.

The Online Etymology Dictionary traces the original meanings of anxious and anxiety to “uneasy, troubled in mind” and “choke, cause distress,” “tightness, narrowness.”

Their history of the meaning of fear includes “danger, peril…harm…risk…”

All right, we have the definitions and their history. Now let’s see how they apply in practice.

Anxiety is a state of vigilance, being on alert, worrying that there is a looming problem. There is no clearly identified threat. We are troubled or worried about something hard to define or to put our hands on. For example, “I’m anxious because I heard a noise in the dark.” However, a noise in the night does not clearly identify any harm or risk.

Fear, as we found out above, is an emotion we have when confronted with a real, external danger. For example, “I am afraid of the growling, drooling dog that is coming toward me.” The danger and peril are clear-the rabid dog wants to bite me.

In day-to-day life, both anxiety and fear play important and necessary roles. Anxiety alerts us to the possibility of danger. Fear informs us about a clear and present threat.

When we are anxious, a host of biological processes kicks into gear. (In a later blog entry, I will deal more with the biological side of anxiety.) At the same time, our thoughts turn towards identifying potential threats. This is as it should be. Our internal warning systems engage when there is a vague but still potentially real risk to our welfare.

In anxiety, it is difficult if not impossible to plan a course of action. That holds true because we are still uncertain about what the real threat is. Without knowing the source and nature of the threat, we cannot make reliable plans for our protection and defense.

Actions based on anxiety are often regrettable. Perhaps you can recall reading about one of those instances where a parent hears a noise in the middle of the night. He or she grabs the bedside pistol and anxiously goes down to investigate. Hearing the noise again, the levels of anxiety rise and they pull the trigger. Thinking that they have defended the home against an intruder, they are shocked to learn they have shot one of the children.

In these cases, anxiety warns the parent of the possibility of danger. However, before fully determining if there really is any threat, they act blindly. It is important to see that anxiety itself can be the foe. It is crucial to hold back until verifying if there is anything to fear.

These tragic scenarios show us the real value in fear. Fear occurs when we can identify the threat. When we are fearful, we have a lot of energy and our thoughts focus solely on the threat. Now we can make plan to deal with the threat. When in fear, the who, what, when and where are known. The rabid dog is right now ten feet in front of me. Our job is to use fear to figure out how to deal with the dangerous situation.

Using the intruder in the night scenario, the anxious parent goes down the hallway and yells down the stairs “Who’s there; is that you Johnny?” The parent then turns on the light. If he or she sees little Johnny getting a glass of water, the anxiety vanishes with a sense of relief.

However, if it is a thief, anxiety turns to fear. The parent can now make and evaluate plans. Is it best to yell and order the thief out of the house? Is it better to use a cell phone to call the police? How would it work out to run back into the bedroom and lock the door? Is there no other option but to shoot?

Closely related to anxiety and fear is panic. Panic, according to the NIMH, is “characterized by a fear of certain disaster or a fear of losing control.” Someone panics when they judge that there is no escape from an overwhelming external threat. Alternatively, panic comes when someone no longer has a feeling of control over oneself. Panic abandons the attempt to reason or plan one’s way out of danger. The instinct to run or to freeze in place takes over. Like the old joke: When all else fails, Panic!

Panic has a valid role in survival. It is logical to run from an oncoming disaster. “Run, the house is on fire.” It can be just as logical to become immobile and play ‘possum. “Shh! Don’t move and he won’t see us hiding here.”

Anxiety, fear and panic in the right context are healthy and adaptive responses. They become reasons to enter into psychotherapy when they occur without apparent reason or in situations where they don’t belong.