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.

•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.

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

This is the second entry in the discussion on anxiety and panic.

Before we can get to more practical issues, I need to define one more term. And that is: stress.

There are hosts of definitions for stress. The way in which I will use stress here is most nearly defined by The Free Dictionary. Their definition reads in part, “A mentally or emotionally disruptive or upsetting condition occurring in response to…external influences and capable of affecting physical health, usually characterized by increased heart rate, a rise in blood pressure, muscular tension…”

Note again, like fear, stress occurs in response to events or conditions in the world outside ourselves.

Importantly, the stressor, the outside event or condition, can be either good or bad thing. This was first discovered by Hans Selye. Getting married, an event that is usually very much desired, is a stressor. A meeting with your boss about more job duties for lower pay, a very unwanted situation, is also a stressor.

The experience of stress is less intense than anxiety, fear or panic. There is a world of difference between the situations where someone says “Man, this is stressing me out” and “Oh my God, I’m gonna die. Run!”

But the effects of having a panic or anxiety attack lowers your ability to handle the next stress that comes your way. The same is true if you go through a major stress or a number of lesser stresses. In this way, something that yesterday you might have handled easily might cause an anxiety attack today if you encountered a number of problems in the last 24 hours.

A degree of stress can be helpful. For instance, your wedding is coming up in a month and you still have not selected the wedding cake. The stress associated with that can arouse to you focus on the task and give you the energy to see it through to completion. If a sense of stress was missing, the wedding cake might never get bought.

But stress is a bit more complicated. For one, it is rare that there is only one stressor in a person’s life. While comparing wedding cakes, you might also be trying to impress your soon-to-be in-laws, and trying to stay within a budget and managing to meet all the normal daily demands on your time. The effects of these different stressors are cumulative. That is, the effects of the stress remain with us, adding one upon the other, until we do something to purge them.

And we have to take into account that one person’s stress threshold may be very different from the next person’s. Moreover, one person’s stress threshold can improve or decline over time.

Making matters more complicated, no stressor exists in a vacuum. There is also the person and his or her background to take into account. Buying a wedding cake may be a quite different experience for someone who is pregnant and has morning sickness versus one who is not.

Further, the person and the stressor occur within a social and cultural context that may decrease or increase the stress load. The wedding cake bought by a pregnant teen might be a very different stressor in settings tolerant of teen pregnancy versus a culture of intolerance for sex before marriage.

Hopefully, my point is getting clearer. Calculating the degree of stress someone is under is not a matter of simple math. One wedding cake = One unit of stress. That is just not the case. So, it makes little sense to think that another person “should just get over it. It was no big deal.”

This leads us to George L. Engel. He proposed a biopsychosocial model. As the name implies, it suggests that we have to include the biological or physical aspects of a person; the psychological context or meaning the stress or symptoms have for that person; and the social context in which the person lives.

For our purposes, the take home points of the biopsychosocial model are that stress is the particular effect, mentally and physically, an external event has on a unique individual at a particular point in time within a given social setting.

Remember also that stress levels can build up over time. As stresses increase on a person, it can lead to a worsening situation that might include anxiety, panic, physical illness or other problems.

Treatment strategies have to take all of this into account. That cannot happen with a cookie-cutter or one treatment fits all approach. The type of treatment provided, the style of the therapeutic relationship and other aspects of therapy have to take into account the biopsychosocial status of the person seeking treatment.

Next time, we will consider some of the varieties of treatment available for anxiety and panic related disorders.

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.