Some of the many interesting points from the interview of Dr. Anne Germain are:

• “…there is growing evidence that sleep problems are actually the cause of many psychological and physical illnesses, rather than a side effect of them.”
• “‘Whether we’re dealing with depression, anxiety or post-traumatic stress disorder, when we target sleep problems, we can have a significant improvement in people’s daytime functioning,’ she said.”
• There are ” two effective therapies available to reduce or eliminate nightmares….
  One is an older high blood pressure medication called prazosin.
  [The other is] imagery rehearsal therapy, it provides ways for people to rewrite their nightmares into less threatening dreams, and it is effective in more than 90 percent of people who have tried it…”
• And, of course, “the vast majority of people need between 6 1/2 and 8 hours of sleep a night to function well.”

First, Charles M. Blow, in the New York Times, writes about two 11 year old boys who recently suicided.  It is thought that being bullied at school played a major role in their separate decisions to end their lives.  A very moving and thought provoking article.  You can read it hear: “Two Little Boys”

Second, a short post in the Research of Culture blog discusses the results of a study on the effects of the California High School Exit Exam.  One of the findings is that minority and female students do worse on the exam-even when compared to other students with the same skills and previous levels of success in schools.  A possible explanation:
“Stereotype threat is the phenomenon whereby the fear that if one performs poorly on a high-stakes test it will confirm a negative societal stereotype about one’s group (leading) to increased test anxiety among negatively stereotyped student groups…”

It’s an interesting article and you can read it here: “The anxiety of test taking.”

That may be true, but someone experiencing intense anxiety or a panic attack feels under great pressure to do something, anything to relieve the anxiety and improve their situation.

Nevertheless, actions born from anxiety often have poor or unintended outcomes.

Those negative outcomes reinforce one’s feeling of being out of control, or of being inept, flawed. There is no sense of having a certain mastery or competence in the situation. In turn, those thoughts and emotions fuel further anxiety. There is now "objective" proof that the situation is overwhelming and threatening. The anxiety and panic is now grounded in hard evidence. This is the same situation I wrote about in "Anxiety, Self-Esteem and Self-Soothing."

Some recent studies shed a bit more light on this self-fulfilling prophecy.

The Rockefeller University posted "Stress disrupts human thinking, but the brain can bounce back" on January 27, 2009. In sum, they found that:

• "A new neuroimaging study on stressed-out students suggests that male humans…don’t do their most agile thinking under stress."
• "[stressed persons] had a harder time shifting their attention from one task to another than other healthy young men who were not under the gun."
• In research on rats, the workers found further biological basis for poor performance under stress:
  "repeated stress on rats shriveled nerve cells of the medial prefrontal cortex, and that a shrunken prefrontal cortex is linked to slower performance on attention-shifting tasks."
• However, there is good news as well. Within a month after the stress ends, the brain bounces back to its normal state and attention and performance returns to a person’s baseline level.

These findings are generally verified in another recent study: "Driving Under the Influence (of Stress): Regional Effects of 9/11 Attacks on Driving." "The authors found that there was an increase in the rate of traffic fatalities in the three months following the 9/11 attacks, but only in the Northeast, the region closest to the terrorist attack…" Further, there was "a 100 percentage point increase in the rate of drug- and alcohol-related fatal traffic accidents in the Northeast."

The authors theorize that "being close to the location of a traumatic event, such as the 9/11 attacks, may increase psychological stress, which may, in turn, impair one’s driving ability and thus lead to an increase in fatal traffic accidents."

Being under stress, whether from an upcoming test or a nearby terrorist attack, impairs a person’s ability to think, plan, perform. The consequences of choosing a course of action under stress and anxiety (for example, is it a good idea to drink alcohol if I know that I will have to drive later), can be severe. Doing poorly on a test or getting into a car crash can provide the illusory conclusions that I am not smart or I am a really bad person. With those beliefs, one is even more likely to become unduly anxious and underperform in the future.

But again notice the silver lining in the second study-traffic fatalities declined again three months after the stress of the 9/11 attack.

However, the effects of long-term stress or life-threatening events may not be so quickly reversed.

A study from the University of Wisconsin, published in the January 26, 2009 Proceedings of the National Academy of Sciences, looked at the immune systems of children who had lived in orphanages in Romania, Russia or China and were later adopted by American families. They found that, even after ten years of life in "stable, affluent, loving environments…their immune systems are compromised as well. In fact, they look just like the [more recently] physically abused kids."

"’Even though these children’s environments have changed, physiologically they’re still responding to stress. That can affect their learning and their behavior, and having a compromised immune system is going to affect these children’s health,’ says senior author Seth Pollak, a professor of psychology and pediatrics at UW-Madison."

Imagine, if you will, how easy then it would be for those children to form negative opinions about themselves and their abilities. They are ill more frequently than the children around them, have more difficulty making correct judgements. Their behaviors are not as well controlled as their peers’. They have more difficulty learning and in school. All this despite the apparent advantage of now living in "stable, affluent, loving environments." Who else to blame but themselves?

Let’s look at the sheerly biological side of this matter. In 2006, the Department of Neuroscience, Mount Sinai School of Medicine studied rats exposed to 21 days of restraint stress. [Readers interested in the effects of restraint stress on animals, in simpler language, are recommended to read Restraint and Handling of Wild and Domestic Animals By Murray E. Fowler] Mount Sinai’s study found significant impairment of the medial prefrontal cortex. "[N]early one-third of all axospinous synapses on apical dendrites of pyramidal neurons in medial PFC are lost following repeated stress…Dendritic atrophy and spine loss may be important cellular features of stress-related psychiatric disorders where the PFC is functionally impaired."

That’s a dense packet of jargon. Let’s break down those last two sentences a bit.

Click here for a look at the medial prefrontal cortex.

Now, why is the medial pre-frontal cortex important?

Here’s what Wikipedia says about that area of the brain:

"The most typical psychological term for functions carried out by the pre-frontal cortex area is executive function. Executive function relates to abilities to differentiate among conflicting thoughts, determine good and bad, better and best, same and different, future consequences of current activities, working toward a defined goal, prediction of outcomes, expectation based on actions, and social ‘control’ (the ability to suppress urges that, if not suppressed, could lead to socially-unacceptable outcomes)."

So the pre-frontal cortex assists in judgement, planning, decision-making (e.g., should I drink if I am going to have to drive home).

The dendrites bring information into the cells of the medial pre-frontal cortex. A loss of "nearly one-third" of these information carriers would have significant and negative impact on the ability to make judgements, plans, etc.

This same area of the brain has been implicated in Post-Traumatic Stress Disorder. In "Amygdala, Medial Prefrontal Cortex, and Hippocampal Function in PTSD", the authors find that the "medial prefrontal cortex appears to be volumetrically smaller and is hyporesponsive during [PTSD] symptomatic states and the performance of emotional cognitive tasks in PTSD. Medial prefrontal cortex responsivity is inversely associated with PTSD symptom severity."

So, in both PTSD and situations of significant, chronic stress, there is long-term impairment of the medial prefrontal cortex. In turn, the afflicted person’s executive functioning (judgement, planning, decision-making, etc.) is worsened for lengthy periods of time.

It appears that shorter periods of lower grade stresses (e.g., an upcoming important test) produce briefer periods of poor executive functioning and less extensive impairment of the medial prefrontal cortex.

These studies can be used to make another point. We have seen that a stressed person has impaired executive functioning that stems at least in part from damage to the medial prefrontal cortex. Consequently, a stressed person will be cognitively, emotionally and behaviorally functioning at a lower level than their best capabilities. Therefore, these persons should be especially cautious before making and carrying out plans (even one as simple as whether or not to drive to a keg party). Equally important, their choices and behaviors have to be viewed in the context of being stressed and having a damaged prefrontal cortex.

With this knowledge in hand, a stressed, anxious or panic-stricken person can revise their opinions of themselves in a more objective fashion.

We would not judge how good a runner one was if the judgement was based on a 100 yard dash done when the person had the flu. All that can tell us is how they perform when significantly ill and impaired.

Forming your self-image and self-esteem on the evidence of beliefs, judgements and actions while stressed or suffering its after-effects is equally absurd.

Unfortunately, many people with anxiety, panic and other psychiatric disorders do exactly that. The net result is to generate further stress because of the internal self-criticisms and anxiety about their ability to function in the world. That, in turn, yields more impairment of the prefrontal cortex and consequently worsening executive functioning. A person’s self-image and self-esteem will then be in a graveyard spiral.

I will return to these studies and their implications in a later post about anxiety and self-image. For now I will leave you to ponder Socrates’ claim that "No one knowingly errs." Especially as it might apply to persons who are anxious, panicky, stressed and make invalid assumptions, poor judgements and mistakes in their actions.

The video is short but makes a dramatic point about the effects of the fight/flight response in everyday human life.  It’s well worth the five minute viewing.  Here’s the link:

http://killerstress.stanford.edu/about-robert-sapolsky

(For some reason I had difficulty watching the video in my web browser.  I downloaded the video with realplayer and it worked fine.)

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