Anxiety as a Defense Against Depression: Part 8

Couples Therapy for Robert and Julia (Romeo and Juliet)

Julia and Robert have come to my office. We are discussing their desire to elope.

I’ve just asked Julia if there is any way that her parents would agree to delay her return to their home island in Portugal.
Julia: I tried to get my father to delay my trip. He went crazy on me. This is exactly what he said: “You’re going to São Miguel. And if you don’t go on your own, I’ll drag you there. You disgust me, you little bug! You worthless girl!”

I cried and cried. I said, “Father, I’m begging you on my knees, be patient and listen to me say just one thing.”

He just wouldn’t listen. He went on and on. “Forget about you, you worthless girl! You disobedient wretch! I’ll tell you what. Go to the airport on Thursday or never look me in the face again. Don’t say anything. Don’t reply. Don’t talk back to me.

“I feel like slapping you. Wife, we were cursed when we had her. She disgusts me!”

My mother and my assistant tried to help me. It was useless. The longer he yelled, the angrier he got. His last words to me were:

“If you don’t act like my daughter, you can beg, starve, and die in the streets. I swear on my soul, I will never take you back or do anything for you. Believe me. Think about it. I won’t break this promise.”

Then my father stormed out of the room.

Me: What did you do then?

Julia: I begged my mother and my assistant for help. I said, “Mother, don’t throw me out! Delay this trip for a month. Or, if you don’t delay, make my travel plans to my grave.”

Me: Did you mean that? Do you want to die instead of returning to São Miguel?

Julia: Yes, of course I mean it! How can I marry Robert if that happens? I’d rather die than live without him! If everything else fails, at least I have the power to take my own life.

Me: But what if they insist that you leave on Thursday or get thrown out of the house?

Julia: I have a plan for that.

Me: Can you share your plan with me?

Julia: Well, it’s not really my plan. I went to the parish priest after the fight with my parents. He’s from the islands and I thought he might have a solution for me.

Me: What did you say to him?

Julia: I said, if you who are so wise can’t help, please be kind enough to call my solution wise. Then, I showed him my knife. I told him, I’ll solve the problem now with this knife. Love joined my heart to Robert’s. Before I go to São Miguel and am married to another man, I’ll kill myself. You are wise and you have so much experience. Give me some advice. I want to die if what you say isn’t the solution to how I can be with Robert.

Me: What was his plan?

Julia: This is what he told me to do. He said:

“Tomorrow night make sure that you are alone. When you’re in bed, take this vial, mix its contents with liquor, and drink. Then a cold, sleep-inducing drug will run through your veins, and your pulse will stop. Your flesh will be cold, and you’ll stop breathing. The red in your lips and your cheeks will turn pale, and your eyes will shut. It will seem like you’re dead. You won’t be able to move, and your body will be stiff like a corpse. You’ll remain in this deathlike state for forty-two hours, and then you’ll wake up as if from a pleasant sleep.

“Now, when your father comes to get you out of bed on Thursday morning, you’ll seem dead. Then, as tradition demands, you’ll be dressed up in your best clothes, put in an open coffin, and carried to the church. Meanwhile, Robert will come here, and we’ll keep a watch for when you wake up. Then we’ll seal the coffin and nobody will be know that you’re not in it. That night, Robert will take you away to New York City. This plan will free you from your shameful situation as long as you don’t change your mind, or become scared like a silly woman and ruin your brave effort.”

Me: (I look at Robert) You know about this plan? What do you think?

Robert: I trust the priest. We’ve both known him forever. If this is what he thinks is best, then I’m willing to try.

Me: But suppose the medicine is too strong? Suppose Julia doesn’t wake up from the coma or suppose that she dies instead?

Robert and Julia together: It will work.

Me: But the priest is not a doctor. Suppose something goes wrong. Robert, how would you feel if something bad happened to Julia?

Robert: Well, I’d be the one to find her. So I’d just drink the same poison, and kiss Julia good-bye. That way I’d die with a kiss.

There’s no other way. Either we do what the priest suggests or she leaves the country next Thursday.

Me: (to Julia) You know about his plan to suicide if you die? Do you approve of it?

Julia: I wouldn’t say that I “approve” but I can understand it. I’m not worried, I’m not going to die so he won’t have to either.
Me: Suppose we try to come up with a different plan. If we could find one, would you agree not to take the priest’s advice?

Robert: For me, I’m in favor of our plan. We’ve already discussed it. We both think it’s our only option and that it will work. No offense, but I trust my priest more than I trust you.

Me: Julia, what do you think?

Julia: I agree with Robert.

Me: Julia, you mentioned your assistant. She seems to know about your situation. What does she say?

Julia: Well, she was helpful in the beginning. But then she agreed with my parents. She said, “Since things are the way they are, I think the best thing to do is leave for São Miguel.”

Me: So you don’t think that she could help us come up with an alternative to your plan?

Julia: No.

Me: There’s nothing, then, that can replace your current plan?

Julia: No.

Robert: Can’t think of anything.

Me: Well, to be honest, this plan makes me nervous. It sounds too close to a suicide pact. Or that’s what could happen, anyway, if even the smallest thing goes wrong.

Robert: (talking over me) Well, it’s our only way to be together and we’re both willing to take the risk.

Me: Oh, gee, I forgot to tell my receptionist something. I’m really sorry but I need to step out for a second. I’ll be right back.

I go to the receptionist and ask her to call 911 for me. I tell her that the couple has a suicide pact and needs to go to the hospital for evaluation.

When I go back into the room, I going to explain what I’ve just done. Both of them are very angry. They threaten to bolt from the office. I explain that the police will be here before they get to the street. I also explain my rationale for calling the police and rescue. Their pact was too dangerous. My duty is to preserve their health and well-being. Therefore, I had to call the police. I offer to continue treatment after they are safe and stabilized.

Julia breaks into uncontrollable sobs. They make all sorts of objections and threaten to sue me for violating their confidentiality.

After a few more minutes, there is a knock on my door and the rescue team comes into my office.

It will surprise no one that I am not as bright as Shakespeare. Try as I would, I could not resolve the dilemma that Shakespeare created for Romeo and Juliet with a smooth therapeutic move. Just as in the play, the resolution could only come from drastic measures.

The Chorus tells us this in the opening Prologue: “For the next two hours, we will watch the story of their doomed love and their parents’ anger, which nothing but the children’s deaths could stop.”

This was not my intended treatment outcome. However, I have no alternative. I tried several versions of this post. I used every way that I could think of to solve their dilemma without involuntary hospitalization. None of it, though, rang true to the situation or the dialogue from Romeo and Juliet.

Their circumstances are too acute and progressed. Neither of them, in my opinion, can be trusted not to act on their plan. They might even devise a more risky, impulsive course.

As Robert says, they trust the priest more than me. Our therapeutic alliance is in its nascent stage and still weak. Their thinking is concrete and action-oriented. Interpretations of their situation and plan do no good in this case. For instance, I might try to point out to Julia that her plan has at least as much to do with parental rejection as it does with love for Robert. She plans to do to herself what her father threatened. Instead of his threat that she “beg, starve, and die in the streets,” she was planning a death in her own bed. Julia would laugh at me for that interpretation. The therapy has not progressed to the point where she could use such an explanation.

Furthermore, even on a more concrete plane, they reject my offer to help problem-solve and find other options.

Neither of them can identify a trustworthy external support. That is, of course, except for their parish priest. And he designed the plan to enter a drug-induced coma.

I have found few internal resources that either of them has to self-sooth or to improve their judgement and insight. They are both overwhelmed.

Their anxiety is fueled by a fear of losing one another. Additionally, for Robert, the fear of a return to deep depression is intense. The anxiety is propelling them toward ever more dangerous and hastily conceived actions.

Even though their plan stems from anxiety and is in itself intensely anxiety provoking, it keeps their hope alive. Seeing their plan as foolhardy would leave them without hope. And that would place them on the threshold of depression. So, rather than see the reality of their situation and cope with it accordingly, they lunge into anxiety and near irrationality.

I do not want to give the impression that all cases of anxiety guarding against depression lead to such an outcome. Recall Donovan Campbell; he certainly did not meet the criteria for psychiatric hospitalization.

Hospitalization could go either way for Robert and Julia. It might make them more emotionally and cognitively available for treatment. Or, they may lose their trust in therapists and shun any further therapy. At the least, the families will find out about their plans to wed. Any immediate repercussions of that can be handled in the safety of the hospital.

If any readers can suggest a viable alternative to involuntary hospitalization, I’d be appreciative.

I want again to acknowledge that the overwhelming majority of the dialogue for Robert and Julia comes verbatim from No Fear Shakespeare’s modern translation of Romeo and Juliet.

Anxiety as a Defense Against Depression: Part 7

This is the seventh post in this series. If you are just starting in this series, then it would help you to read at least the fifth post to get the background on today’s discussion.

As a refresher, this is a “case study” of Robert. He is a single male in his early twenties. Robert was recently in a Major Depressive episode and now presents with anxiety. The precipitant to the depression was Robert’s unrequited love for a woman. The anxiety came in the context of falling in love at first sight with a second woman. Robert is seeking treatment to help him plan an elopement with the second woman, Julia.
Venus, Cupid, Folly, and Time
Robert’s situation is a mess. For the past two days, Robert has acted impulsively. He was not using good judgement or insight. Julia has plans to return to São Miguel, a Portuguese island, and may marry a man there. Both Robert’s and Julia’s families intensely dislike each other. None of their parents would approve of the marriage. Further, Robert is at high risk for a relapse back into Major Depression. Ominously, Robert says that he would rather kill himself than live without Julia. However, today there is no inclination to suicide and he anxiously anticipates happy days in the near future.

We are still in Robert’s initial evaluation. I am about to present him with treatment options. In the last post, I ruled out offering him help in problem solving his elopement.

There is possibly another way to meet Robert’s request for a speedy resolution to his anxiety symptoms and improving his ability to plan the elopement. That would be a referral for a psychiatric medication evaluation.

I could suggest to Robert that he see a psychiatrist. He can ask about medication for the anxiety and the depression. An anxiolytic might provide relief from most of the anxiety symptoms within a half-hour of ingesting it. Freed of the anxiety, he could think more clearly. Robert could then probably figure out for himself how to marry Julia. The anti-depressant, on the other hand, would take 4 to 6 weeks before having an effect.

Perhaps, though, the anxiety serves more masters than we have seen so far. Symptoms can have a pig pile of underlying motivations. More formally stated, Robert’s anxiety might be overdetermined. That is, the ego is trying to satisfy a number of demands on it through the one symptom of anxiety. We have already seen that Robert’s anxiety is a defense against a return to depression and the possibility that time and events (e.g., Julia’s return to São Miguel) would prevent him from marrying the woman he loves. Let’s see if there might be other factors in his anxiety.

Robert says that he is anxious in large measure because he wants to be married as quickly as possible. He can then be with the woman he loves. He says that he wants it so badly that he cannot think straight. However, one potential subconscious purpose that the anxiety may serve is exactly the effect it is wreaking. Maybe one point of the anxiety is specifically to disrupt or prevent Robert’s elopement.

There are many reasons why Robert might subconsciously use anxiety to derail his marriage plans.

In Freud’s “The Ego and the Id,” he writes “…the ego seeks to bring the influence of the external world to bear upon the id and its tendencies, and endeavors to substitute the reality principle for the pleasure principle which reigns unrestrictedly in the id.” The reality confronting Robert stands directly opposed to marrying Julia. Robert is aware of this. His desire to elude reality accounts for some large measure of his haste to wed. Robert’s ego could use the anxiety as a means to bring reality to bear on his impulses.

Furthermore, the marriage would bring parental disapproval and rejection. The anticipation of this disapproval and rejection may cause some anxiety. He can also anticipate his own guilt feelings about breaking their rules. Expecting guilt in the future produces anxiety as well.

Freud puts it this way in “The Ego and the Id:”

“As a child grows up, the role of father is carried on by teachers and others in authority; their injunctions and prohibitions remain powerful in the ego ideal and continue, in the form of conscience, to exercise moral censorship. The tension between the demands of conscience [what Robert knows he ought to do in the eyes of his parents and society] and the actual performances of the ego [Robert’s scheme to marry Julia without his parents’ blessing or knowledge] is experienced as a sense of guilt.”

After all, his parents do seem concerned about him and love him. His father has said: “If we could only find out why he’s sad, we’d be as eager to help him as we were to learn the reason for his sadness.” (Act 1, Scene 1, Page 8 ) His mother also expressed concern for him: “Oh, where’s [Robert]? Have you seen him today? I’m glad he wasn’t here for this fight.”(Act 1, Scene 1, Page 7) We can reasonably assume that hurting his parents would cause guilt for Robert. Therefore, the anxiety would be protecting him against hurting his parents and the guilt that he would experience for bringing suffering to them.

We could hypothesize a number of other subconscious uses for the anxiety. But we’ll leave it here for the time being.

There are many instances where it is desirable to remove or reduce severe anxiety as quickly as possible. In those cases, anxiolytic medications are very useful. I think, though, that Robert is better off without the immediate introduction of medications. Removing the anxiety removes some of the emotional barriers to carrying out his impulse-ridden plans. That is, in my judgement, it is in Robert’s best interests not to elope in the next few days.

Getting some Klonopin or Xanax or another anxiolytic today would be roughly the same as helping him problem solve the marriage today. For the same reasons I ruled out helping him problem solve the elopement, and the reasons mentioned here, I would not want him to get the medicines now.

Some bad situations have unseen benefits. In Rhode Island, the state where I practice, it takes about six to eight weeks for a new patient to get in to see a psychiatrist. Usually that is thoroughly undesirable. But not this time. Such a lengthy wait means that I can refer Robert to a psychiatrist today. However, he won’t get an appointment any time soon. That, in this case, is a good thing. It will buy some time to work through the complexities of his crisis.

Now I can tell Robert his diagnosis: Panic Disorder without Agoraphobia. I provide him with some information about this illness. In addition, I give him the names and phone numbers of several psychiatrists.

I then have to tell him to expect about a two-month delay before he can get an appointment.

Obviously, Robert does not like this recommendation. He sees time as an enemy. Two months is far too long to delay his elopement. For one thing, Julia will be out of the country by then. There will be no wedding if that happens. Depression lurks there.

Honestly, I agree with Robert. Two months is too long to wait for a remedy to his problems. He is in a lot of emotional pain and turmoil. I also agree that the situation is complex. It needs to be broken down into its component elements and sorted out. Moreover, there is another person involved, Julia. And in her, I find an option that might satisfy everyone.

I suggest to Robert that we schedule another appointment, as soon as can be arranged. If I get a cancellation, the appointment can be as soon as tomorrow.

I also propose that he bring Julia to the next appointment. We can get her point of view. After all, it is her elopement/wedding, too. At the least, a couples session would give the two of them a chance to look rationally at their situation and to get to know one another better.

In the short-term, my goal is going to try to find an alternative to an abrupt elopement. Perhaps Julia can defer her trip to Portugal. Or maybe between the two of them, they can identify the parent or another authority figure who is most likely to be sympathetic to their situation. We could then try to enlist that person as an ally to the couple. Potentially, that third person could come in at the third session. At this point, I am not sure what assistance Julia can be. But starting couples counseling is the best option I can think of at this point.

In the long-term, I want to provide Robert with treatment to address his vulnerability to both depression and anxiety. Providing successful short-term couples counseling around the elopement may be the best way to engage him in therapy.

In the next post, I plan to take a brief look at another possible explanation of Robert’s anxiety: adult anaclitic depression.

Anxiety as a Defense Against Depression: Part 6

If you are just picking up on this series, you might do well to start by reading at least the last post. Today’s post will refer extensively to the last one.

To review where we are in this “case study,” Robert has come to my office about 36 hours after meeting a woman. He and she have fallen in love at first sight. Robert was in a Major Depression until meeting her. His condition is now one of anxiety verging on panic.

The couple’s situation is fraught with dangers. Julia is soon to return to a Portuguese island and possibly marry a man there. Both Robert’s and Julia’s families are at odds with each other. Each of the families would forbid the marriage. Last, and certainly not least, Robert could fall back into a severe depression if the new relationship fails.

Just as Romeo sought out Friar Lawrence to help him solve his dilemma with Juliet, Robert has come to my office to get help with his situation.

This is a tricky case to bring to a successful conclusion. Robert wants a quick and practical solution. He insists on planning his elopement and later announcing the fait accompli to their families. He is not seeking on-going therapy. Robert believes that all he needs to do is marry his love, tell the families and the rest will more or less sort itself out. He is an impetuous young man. Robert will not tolerate me dilly-dallying with clinical nuances.

In Shakespeare’s play, “Romeo and Juliet”, Friar Lawrence provides the service that Romeo requests: help getting married. To be fully fair to the Friar, he does say to Romeo “Go wisely and slowly. Those who rush stumble and fall.” [Act 2, Scene 3, Page 4] But, despite any misgivings, the Friar marries the couple.

This course of action has a terrible outcome. Romeo, as we know, suicides when he believes that his new bride is dead.

“Come, bitter poison, come, unsavory guide! You desperate pilot, let’s crash this sea-weary ship into the rocks! Here’s to my love!
ROMEO drinks the poison.
Oh, that pharmacist was honest! His drugs work quickly. So I die with a kiss.” [Act 5, Scene 3, Page 5]

From a clinical point of view, this tragic end came from overlooking both the underlying psychological conditions and the real external stressors. Marrying Juliet may temporarily alleviate Romeo’s anxiety. The marriage gives him the false belief that the external dangers are vanquished. Moreover, eloping does not address Romeo’s vulnerability to severe depression.

In one sense, it would be easy to help Robert problem solve an elopement. Let’s play this option out for a moment.

After all, I am human. It would be hard to resist this good looking, articulate young man’s impassioned pleas for help now, today. Then there is his seductive, raw belief in true love. On another front, if I practiced in an HMO or a capitated system, there would be pressure to get this case done with the least expenditure of resources. Long gone are the days when the first four sessions were considered to be the initial evaluation. Active treatment started only with the fifth session after an exhaustive collection of psychosocial history and mental status evaluation. That was then.

Quite possibly, Robert’s treatment could be completed in the first session. I open my laptop computer and google “marriage requirements RI.” Google then helpfully provides me with the link to’s summary of the Rhode Island marriage laws. The requirements, as it turns out, are pretty simple.

My next step is to print the page and give a copy to Robert. Together, we plan how he and Julia can meet each of the steps necessary to get married. I encourage Robert to take written notes on the back of the page. Ten minutes later, we are done. Robert feels a great sense of relief to have a concrete plan. He thanks me profusely and leaves without scheduling another appointment. I have a sense of satisfaction in providing almost immediate relief for his symptoms and giving him the treatment that he requested.

The technique of improving a patient’s problem solving abilities is certainly a valid clinical tool. According to Wikipedia, this method has been studied for over 100 years. Mills, Reiss, and Dombeck have written about improving a person’s “self-efficacy.” This is the “belief in your own effectiveness as a person, both generally in terms of managing your life, and specifically with regard to competently dealing with individual tasks.” Positive self-efficacy helps to “decrease people’s potential for experiencing negative stress feelings by increasing their sense of being in control of the situations they encounter.” Thus, the choice of improving Robert’s problem solving skills for the task of getting married to Julia appears, at first glance, to be a good tactic.

However, I would do well to recall Romeo’s fate in my treatment recommendations for Robert.

As Mills, Reiss, and Dombeck also point out, “The perception of being in control (rather than the reality of being in or out of control) is an important buffer of negative stress.” In Robert’s case, helping him to problem solve how to elope only improves his perception of being in control. It does virtually nothing to address the real world stressors and his risk for depression.

Moreover, the odds are that the passion will fade for Robert and Julia. Acevedo and Aron studied various types of love and the outcomes in their article “Does a Long-Term Relationship Kill Romantic Love?” They found that:

“Results from the factor analysis and correlations with satisfaction support the notion that in long-term relationships, romantic love and obsession are quite distinct: Romantic love (without obsession) is positively associated with relationship satisfaction, but the obsessive aspect is negatively associated with it.” (p.61)

At the time when Robert enters the office, he is quite obsessed with Julia and his quest to marry her. He barely mentions her personal qualities. In fact, Robert and Julia know very little about each other. They have little information or shared experiences upon which they can ground their romance.

As Friar Lawrence observes about Romeo’s love for Juliet:
“Young men’s love then lies
Not truly in their hearts, but in their eyes.” [Act 2, Scene 3, Page 3]

Acevedo and Aron’s work indicates that even without the tragic outcome in the play, Romeo and Robert’s loves are likely to be short-lived.

Problem solving the elopement, then, is likely to yield only a temporary relief of anxiety and leave the much bigger problems lurking in the background.

The following is my own impression and is not a valid legal opinion. If a clinician did choose this route, I do not see that the families would have any firm basis for legal recourse against the clinician. The practice of improving problem solving and self-efficacy is well established. In addition, there are many, many intervening variables between the time of the interview and the outcomes of either suicide or falling out of love. Those variables would make it difficult to pin the blame on negligent treatment. In the lawsuit of Palsgraf vs. Long Island Rail Road, an employee helped a man get on a moving train. This resulted in a domino effect ending with the injury of a woman. The court ruled however “If the harm was not willful, he must show that the act as to him had possibilities of danger so many and apparent as to entitle him to be protected against the doing of it though the harm was unintended.” The families, I think, would be hard pressed to show that the clinician either intended harm or could reasonably see the “possibilities of danger so many and apparent.”

In summary, helping Robert problem solve his elopement would be what Robert wants. A “successful” one-session treatment would please any cost-conscious administrator. Problem solving is also a well-documented clinical strategy. There seems to be little legal risk to the tactic.

However, for all the reasons mentioned above, it would be in Robert’s best long-term interests not to give him what he thinks he wants. The trick is going to be in convincing Robert to tolerate the anxiety and hold off on his impulsive plan.

In the next post, we will investigate other treatment options for Robert.

Anxiety as a Defense Against Depression: Part 5

This is a case study of anxiety being used as a defense against a return to a depressive state.

Robert left an urgent message on my voicemail. He said that he was anxious and panicky. He wanted an appointment as soon as possible. I returned the call and arranged an intake appointment for him the next day.

When we met, this is the story that he related to me. The remarks made in brackets […] are some of my clinical impressions of his situation.

Robert is a first generation Portuguese American. He is single and in his early twenties. Robert’s speech came in rapid bursts. He complained that his thoughts were racing almost faster than he could speak them. He felt that any number of bad things could happen to him in the near future.

His problems began a number of months ago. He had met a woman, Rosaline. He said she was “rich in beauty” and he had fallen in love with her. Unfortunately for Robert, this woman believed that she had a calling to the Catholic convent. She was kind to Robert and admitted that she had strong feelings for him. However, Robert could not persuade her to give up her calling. Seeing that Robert could not settle for a simple friendship with her, she told him it was best that they not see each other.

Robert began to isolate himself. He called out of work frequently. During the day, he would remain in his room and close the curtains. He ate little. Sleep only came in fits and starts. He cried often. This went on for a number of weeks. He got no pleasure out of his hobbies, music or day-to-day life. Robert despaired of ever getting Rosaline to love him and he believed that no other woman could replace her. Robert ruminated relentlessly about Rosaline. He was convinced that he would remain depressed forever.

[Clearly, at that time, Robert met the criteria for Major Depressive Disorder.]

His friends worried about him and tried to get him to go out with them. Robert refused their invitations for quite a while. However, a friend learned that the woman Robert loved was going to attend a party later that week. The friend convinced Robert to go with him to the party if only to be able to see the woman from across the room. As an alternative, the friend also suggested to Robert: “Make yourself lovesick by looking at some new girl, and your old lovesickness will be cured.” Reluctantly, Robert agreed.

A funny thing happened at the party. Robert did see Rosaline but she did not return his gaze. He was shattered. In looking away, he saw another woman and he says that he instantly fell in love.

He remembered thinking that “her beauty is too good for this world; she’s too beautiful to die.” In the fit of this new love he thought “did my heart ever love anyone before this moment? No!”

[Here we can see overvaluation, idealization of the new woman and devaluation of and perhaps reaction formation against Rosaline. Robert is probably also using displacement to redirect his assessment of and affections for Rosaline onto Julia. Anxious not to return to his depression, he is employing some primitive defenses.]

He went over to her and held her hand. Surprised, she turned to look at him. Robert gave her one of his best lines.

“If you’re offended by the touch of my hand, my two lips are right here, ready to make things better with a kiss.”

He quickly kissed her before she could respond. She teased him back by saying: “You kiss like you’ve studied how from books.”

Yet, the young woman was taken by him. They flirted and talked for the next hour or so. Each told the other that they had fallen in love at first sight.

Then, the more they talked, the more they revealed the details of their lives. An unfortunate fact came out. Their families were both from the same island in Portugal. There was a lot of bad blood between the families. Moreover, this new girl, Julia, planned to go back to the island in a few short weeks. There, her family hoped, she would settle down and marry a man who was a family friend. If she returned to the island, they both knew that there was little hope of a long-term love between them.

Neither quite knew what to do. Robert became acutely anxious.

[Anxiety comes in as a defense against the loss of his new love as well as against the return to his depressive state.]

As the party broke up, both of them promised to call each other the next day.

In the parking lot, Robert couldn’t stand the tension. His mind filled with fears of losing his new love. He bitterly remembered how depressed he was only hours ago. He got in his car and followed Julia to the house where she lived with her parents. When she went into her home, Robert got out of the car and went into the backyard. He waited there till he saw a light turn on.

He gently rapped his knuckles on the ground floor window and Julia looked out.

She scolded him and said that her parents would kill him if they saw him in their backyard.

Robert replied, “one angry look from you would be worse than twenty of your relatives with knives. I’ll hide in the dark. And if you don’t love me, let them find me here. I’d rather they killed me than have to live without your love.”

Julia whispered to him:

“You can’t see my face because it’s dark out. Otherwise, you’d see me blushing about the things you’ve heard me say tonight. Do you love me? Robert, if you really love me, say it to me. Or if you think it’s too easy and quick to win my heart, I’ll frown and play hard-to-get, as long as that will make you try to win me, but otherwise I wouldn’t act that way for anything. In truth, I like you too much, so you may think I’m loose. But trust me, I’ll prove myself more faithful than girls who act coy and play hard-to-get. I should have been more standoffish. So excuse me, and do not assume that because you made me love you so easily my love isn’t serious.”

Robert jumped at this chance and swore that he’d love her forever.

They then returned to the difficulties that their new romance faced. Eventually Robert suggested that they elope as soon as possible and get married by a justice of the peace. He figured that, after a while, both families could come to accept their marriage. Then they could have another, more formal marriage in a church.

[The idea of getting married within hours of first meeting Julia is Robert’s impulse to stave off both anxiety and depression. Unfortunately, it ignores all sorts of reality-based considerations.]

Julia agreed. Sometime later, they said good night and promised to see each other the next day.

All of this had occurred two days earlier. Since then, Robert had suffered several panic attacks. He had called me to get treatment for those symptoms. His anxiety and difficulties thinking clearly were getting in the way of preparing for his elopement.

At this point, I need to acknowledge my sources for this story. It is the tale of “Romeo and Juliet” by William Shakespeare. I have modified only minor elements of the plot. The dialogue is taken almost verbatim from the No Fear Shakespeare’s modern translation of “Romeo and Juliet.”

This is a story tested by time. According to Wikipedia, it was first translated into English from its Italian original in 1562. Before that, Wikipedia tells us that the story has origins “stretching back to antiquity.” For that reason, it shows that anxiety as a defense against depression has old roots.

The outcomes of its use, however, were no better for Romeo than they are now. Recall Donovan Campbell’s plunge into depression when anxiety finally failed to protect him against the reality of his situation.

My plan for the next post is to discuss treatment options for Robert/Romeo’s condition.

Stressed like a rat

Stuck in a rut? There is new research that explains how, under high stress loads, the brain prefers habits and routines over new learning. The New York Times published an article about this study titled “Brain Is a Co-Conspirator in a Vicious Stress Loop” on August 17.

In the rats studied, “regions of the brain associated with executive decision-making and goal-directed behaviors had shriveled, while, conversely, brain sectors linked to habit formation had bloomed.”

These neurological changes can evidently be reversed: “with only four weeks’ vacation in a supportive setting…the formerly stressed rats looked just like the controls…”

So if you’re under a lot of stress and keep repeating the same behaviors, getting the same frustrating results, then take a lesson from these rats. The answer may lie in putting the problem aside for a while. Take a break and give the brain time to regenerate “atrophied synaptic connections in the decisive regions of the prefrontal cortex…” Then you can approach the problem from a fresh and hopefully more effective perspective.

Using Anxiety to Avoid Depression: Part 4

A reader’s comment on the third post in this series has led me to rework the post that I had planned for today. In essence, I was asked if I thought that all persons with anxiety were using that as a defense or screen against depression. The short answer to that is: No, not at all.

In fact, I am not at all certain how often anxiety is a screen over depression. I do not know of any statistical studies of this phenomenon. My thoughts on this matter come from on my own clinical observations.

I have a confession to make. Sometimes it takes repeated exposure and then being slapped in the face with it before I recognize the importance of an issue.

What happened was that a cluster of these cases occurred over the span of a few months. I did not have a good explanation of it for the patients or myself. This process of anxiety followed by depression was not new to me. Right now, off the top of my head, I can think of at least a dozen times that I have seen anxiety lead to depression. Its previous occurrences, though, were sporadic. At those times, I shelved the process as an unimportant anomaly. Not until the cases came in a group did I start to look for common threads and a decent explanation.

To repeat myself, I do not think that anxiety necessarily covers over depression nor that anxiety must lead to depression. That has not been my clinical experience at all.

My sense is that anxiety guards against depression in a limited number of cases. It seems to happen mostly to people with long-standing anxiety problems. These persons are in difficult life situations. In addition, they have difficulty separating anxiety-generated worries from objective concerns and thoughts. Further, it also appears that due to either other factors or the anxiety itself, there is a damaged self-esteem.

However, it also can happen abruptly. Imagine, for instance, a person who unexpectedly finds some evidence that his/her spouse is having an affair. This could lead to anxiety and doubt. On a level not quite conscious, the person could choose to remain anxious and doubtful rather than openly talk to the spouse about their suspicions. If the spouse confessed to the affair, it would be too depressing and painful for that particular person to bear. The anxiety is seen as the lesser of two painful situations. Recall that in anxiety some hope remains. In depression, hope is no longer present.

Allow me to start with the treatment of a “pure” anxiety disorder. This will show the types of anxiety cases that are not engaged in a defense against depression or some life event. Let us assume that the person obtained a thorough psychological evaluation. There is no suggestion of an underlying depression. The person expresses confusion about why they are anxious since there are no major stresses in her/his life. There is no history of trauma or substance abuse. Recent medical examinations found the person to be in good physical health. Anxiety or panic is the only clinically significant finding.

In such a case, I would proceed straight to cognitive-behavioral treatment. Any thoughts of anxiety shielding a depression are aside unless new clinical evidence called for their return.

In these instances, the following is the treatment that I have found most often to be helpful.

Before going further, let me emphasize that this does not substitute in any fashion for treatment or diagnosis by a professional.

There are five cornerstones in my approach. Each is critical in the reduction of anxiety, although some are harder to achieve than others.

1. Good sleep habits. To keep this post brief, allow me to suggest a page from the University of Maryland Medical Center. That will help explain the basics of good sleep hygiene.

2. Good diet. Caffeine, sugar, missed meals, highly processed foods are all gasoline to the fires of anxiety. While not exactly a food group, at least for most folks, alcohol and other intoxicants as well as nicotine can also ignite anxiety. For more details on good eating habits, you can go to’s article “A Healthy Diet.” It’s hard to overemphasize how much of a role diet plays.

3. Light exercise. This means nothing more than a 20-minute walk around the block. Any kind of physical activity that involves your whole body will do the trick. However, it does not include competitive sports and similar events where there are goals and high expectations.

There is a way to cheat on this if you absolutely cannot fit 20 minutes of light exercise into your day. But I have found that it is not as effective as exercise on a regular basis. For the sake of brevity in this post, I’ll direct you to another post on “Progressive Muscle Relaxation for Stress Reduction” by Mills, Reiss and Dombeck. There you will find detailed instruction and explanation of this stress relief practice.

4. Fun. This simple activity is often the most difficult for people to be able to do. Whatever you consider fun, schedule it into your week. Fun is an antidote to the buildup of stress and anxiety.

5. Get out of the house and socialize, do things with your friends and family. Yes, even if you don’t feel like it or think that you won’t enjoy yourself or worry that you’ll spoil everything because of your anxieties.

If those are the cornerstones, then the ground upon which they rest is air. Or, to be more specific, it’s a type of breathing. For a host of physiological reasons, breathing is an essential element in both the kindling process of anxiety as well as in reducing anxiety.

Breathing by using your diaphragm is the simplest and most effective anxiety reduction technique that I know (excluding medications). The main problem with this method is that it is so easy, most people don’t think it can be effective.

There is another post by Mills, Reiss and Dombeck, entitled “Methods of Stress Reduction” that explains how to breathe in this fashion. You’ll find the instructions near the bottom of the page.

If you prefer a visual instruction, a YouTube video demonstrates the process. The video is from the Center for Hindu Studies and is called “Diaphragmatic Breathing.”

Once you learn how to do it, you can breathe this way everywhere you go and no one can tell. It does not need to be as formal as in the video. With practice, you can breathe with your diaphragm while walking up the stairs or sitting in a chair at dinner. It works best as a preventative measure and is only minimally effective if you wait until a panic attack to use it. So breathe with your belly regularly and often for best results.

Once these are accomplished, the cognitive aspect of the treatment comes into play. Here I listen for distortions, generalizations and other effects anxiety upon the thought process. We can then look at those assumptions and objectively assess them.

The following is a typical anxiety-ridden statement. “Whenever I try something new, I make a mess of it.” This can be challenged gently. I might ask if there really have been no successes ever in the person’s life. There has to be one in there somewhere and I build on it. That patient’s sentence is also loaded with anticipatory anxiety. One believes that “a mess” will be the result. To get past the dreadful anticipation, a mess is made sooner rather than later. It then helps to discuss ways to recognize when you’re setting yourself up for failure through anticipatory anxiety and how to substitute in thoughts that are more constructive. These and other strategies improve the thought processes and minimize anxiety.

In a thumbnail, that summarizes my initial treatment plan for dyed-in-the-wool anxiety disorders. I also offer to refer the person to a psychiatrist to see if medications can also be of assistance. Most of the cases that I treat fall into this category. The anxiety disorder stands by itself. Here, anxiety does not cover or shield a depressive disorder or a painful life circumstance that is being avoided.

I hope that this post has clarified that my focus in this series is on a limited sub-set of anxiety disorders. In the next post, I plan to look at the treatment of persons who do have anxiety standing guard against depression and painful life events.