Tag Archives: Anxiety Reduction

Using Anxiety to Avoid Depression: Part Two

When we left off, it was with Donovan Campbell, in Joker One, trying to establish measures to deal with the stress faced by 150 Marines trying to gain control over an Iraqi city of 350,000.

As a refresher, he was trying to act as a calm leader. As he phrases it: “Frantic-sounding lieutenants lose everyone’s confidence immediately…Calm-sounding lieutenants make everyone believe that the situation is well under control…” At the same time, he attempted to establish activities to bolster esprit de corps and rituals for the unit so that they formed a cohesive identity.

A golden rule in dealing with anxiety of unknown dangers is to turn it into a fear of a specific threat. Once that is accomplished, plans can be made to deal with the threat. Campbell spent a lot of time planning his missions and identifying specific goals and means to reach those goals. He did this despite the full knowledge that conditions could quickly change and make his plans and goals irrelevant. As Campbell writes of a detailed plan he made in early April: “Like most of my plans, this one didn’t survive very long.”

Nonetheless, a key part of his strategy was to continue identifying concrete goals and clear-cut plans.

Another helpful stress and anxiety management tactic is to simply take stock of the changing conditions and the results of earlier efforts. Do this with a neutral eye. It is decidedly unhelpful to harshly criticize oneself for plans made with the best of intentions and efforts. That leads to self-doubt which in turn brings back anxiety of unknown and uncontrollable bad outcomes. Instead, no matter what the outcome, it’s good to recall that you made the best decision possible available at the time.

For instance, Campbell, with very limited information, had to make a decision on whether or not to have a sniper shoot a man. He considered the situation for about thirty seconds and then ordered the sniper to fire. Months later, he learned that the dead man was in fact an insurgent and so the decision to have him killed was correct. However, Campbell did not revisit that earlier decision. As he puts it: “on the front lines, there are no great options, just bad ones and worse ones, so you do what you can…Then you live with the results…”

Sometimes, chronic exposure to severely stressful conditions will outmatch well made, rational plans and stress management techniques. Let’s recall the conditions these soldiers lived with. The temperature was often in the 130’s. There was insufficient water for regular showering and toileting. Sleep was often interrupted and too brief. Meals were mainly prepackaged rations. Fun activities, while highly prized, were in short supply. They were strangers to the culture. Mortars and small arms were routinely fired into their base. Their families and friends were continents away. 150 soldiers were tasked with winning an urban war fought on foot in a city of 350,000. Fellow soldiers were being killed and wounded in other units. “For many members of Joker One, death took on a very real persona…”

It should come as no surprise, then, that a weak spot in Campbell’s thoughts developed. It can be most clearly seen in his intensified beliefs in the powers of the pre-mission prayer ritual. At one point, his platoon was the only one not to have suffered a single wound. Some magical thinking crept into to his beliefs. He began to believe that due to the prayers, the lack of injuries to his platoon was a “clear sign that…God would certainly bring all of us home safely.” As explained in a Psychology Today article, “Emotional stress and events of personal significance push us strongly toward magical meaning-making.”

In a phone call to his wife, Campbell told her that the prayers were keeping his soldiers safe and that prayers would bring them back alive. His wife tried to inject some clear thinking. “She was glad that no one was hurt, she said, but she reminded me that God wasn’t a cosmic slot machine that came up sevens every time for the pious believer….All He guarantees you is your relationship with Him in the next. They were hard words of truth…And I completely ignored them.”

In retrospect, Campbell has good insight into his overemphasis on the power of his religious beliefs. “I didn’t recognize yet that my steadfast dismissal of the idea of casualties in my platoon stemmed not so much from a belief about God’s grace but from a refusal to consider the very real possibility that someday I might be responsible for the death and wounding of the men I loved so much.”

There are many reasons for avoiding the idea that he might have to order his men into situations that could lead to their and his death or injury. As he says, he loves his men. It is rational to want people you love to remain safe. Yet beyond that, Campbell has mistakenly tied his relationship to God, his idea of himself and the safety of himself and his men to events and circumstances that are clearly beyond his control. This is a formula for anxiety. To protect against the full, crippling nature of anxiety and panic, he forms unrealistic beliefs.

At the time, this symptom of anxiety, magical thinking, guarded him against both the overwhelming reality of his situation and feelings of futility and depression. “I thought that if I was just good enough, that if we just prayed hard enough,” then God would intervene and protect them and allow for victory.

The symptom of magical thinking kept a distorted form of hope alive. Hope that God would love him enough to keep him safe. Hope that he could prevent his men from being killed.

Hope that he, as a man, was just simply good enough.

The contrary of those thoughts are extremely painful. God does not love him. He cannot keep his men safe. Campbell is simply neither a good man nor a good soldier. If these statements proved to be true, basic trust in one’s surroundings, beliefs and one’s self crash. The result can be anhedonic depression.

So, with the apparent choice being between the alluring hope and belief that one is good and deserving enough for God’s love and protection, on the one hand, and despair, desolation and damning self-blame, on the other hand, which would you choose? However, because this alternative is based on magical premises, it is a false dilemma.

Anxiety and its varied symptoms can, temporarily, protect against depression. That is why, in some cases, the successful treatment of anxiety leads to a depressive state. We have taken away the shield against depression and not treated the underlying problem. And, if we just treat the depressive symptoms and not the underlying defense against the reality of one’s situation and the accompanying distortions in thought, then anxiety can rekindle.

This is an insidious problem. The anxiety or depression in these cases is a defense against the full truth of one’s situation. The person may not consciously be aware of the root of the problem. So, even taking a careful history and assessment of a patient may not reveal the psychosocial stresses that are being guarded against. For example, if I ask an anxious woman how her marriage is, she may adamantly present a picture of a warm relationship and loving husband. Ruling out real stressors, I might view the condition as a biologically-based anxiety or depression. I start to treat the symptoms and try to extinguish them.

Only later do I discover that the anxiety covers a depression which in turn covers an abusive husband.

But let’s go back to the book and see what happens to Campbell and his Marines.

Anxiety, even with Campbell’s stress management skills and magical thoughts, still managed to poke through intermittently. And anxiety struck him particularly hard on the morning of one very tragic day. He writes: “I woke up to a horrible feeling of dread. I can’t really properly put that heavy sense of impending doom into words…I had been scared before other missions, of course, but never before had I felt such a deep certainty that something bad would happen to my men if they left the Outpost that day.”

The Ox, which is the nickname for Campbell’s commanding officer, was to be in charge of a mission that day. The Ox had proven to have flawed judgement on a number of previous occasions and this was a particularly difficult mission. On most missions, Campbell was in direct control of his men. That was not the case on this day. The Ox would lead them and one more element of control was taken from Campbell. The balance tipped and he was acutely anxious.

Part of the mission involved having the Ox inspect repairs that were made to a local school. This would subject the men to a relatively long period of remaining in one place with little or no cover from the enemy. Campbell objected to the plan on the grounds of it being unsafe for his men. He was overruled.

As Campbell feared, his men became sitting ducks and came under fire by insurgents’ guns and rocket propelled grenades. In the first round of the battle, “the rocket had missed us. Instead it had impacted squarely in the middle of the crowd of small children. Dead and wounded little ones were draped limply all over the sidewalk…”

Campbell then had to make a quick decision. He could leave the area and get his men to relative safety. Or he could stay and tend to the wounded children until ambulances arrived. But this latter alternative came with the certainty that the Marines would continue to be at risk from enemy attack.

“I wish,” Campbell writes, “I could say that I stepped back and cooly and dispassionately evaluated the situation, but if I said that, I would be lying. The fact of the matter is…we were United States Marines and a bunch of dying children needed our help. It was just that simple.”

Tragically, there was an unduly long delay in getting ambulances to evacuate the children. In the meantime, there were more attacks by the insurgents. During the firefights, one of the Marines was horribly, severely wounded. The soldier died a few days later at a hospital in Germany.

The immediate emotional consequence for Campbell was depression.

“I found that my hope, built so painstakingly over the past eight months, had been ruthlessly extinguished in one terrible moment…I fell into a deep depression. For a week, I didn’t want to eat, and I didn’t want to leave my bed, even though I found no respite in sleep. Instead of sleeping, I spent my time endlessly replaying the scene…wondering where I had gone wrong…”

The defense against anxiety through planning and strategy and a prayer ritual had failed. Anxiety led to some magical thoughts. Those thoughts took Campbell beyond mourning and into a hopeless state of depression.

Our initial question of how anxiety protects against depression and how resurrecting hope might lead back to anxiety is now mainly answered. And with that we will leave Campbell and the rest of the Marines of Joker One except for some brief references in future posts.

I wish them well.

Tips on Anxiety Management

The Atlantic this week has an article entitled Surviving Uncertainty: A Few Tips by Lane Wallace.

As part of her credentials on this matter, she notes that:

“I’ve flown small aircraft on five continents. I’ve been stranded alone on a glacier in shorts and tennis shoes. I’ve found myself in the middle of rapidly destabilizing situations in African countries.”

She finds it helpful to

  • Focus on the present.
  • Keep perspective. Ask yourself, “what’s the worst thing that happens here?”
  • Separate what you can’t control from what you can, and then focus on taking action on those items you can control.
  • Learn to prioritize what’s essential, and loadshed everything else.

Take a few minutes to read her informative article by clicking here.

Recent Anxiety Research and News

  • Washington University’s newspaper reports on a study of social phobia among college students. One of its findings is that unstructured discussion of past upsetting events raises the distress level for some people. On the other hand, when the interview was structured, the “subjects’ moods did not worsen.”
  • The NIH is promoting meditation, yoga, tai chi and Pilates as means to improving physical and mental health. There is also discussion of the interconnection between physical and mental well-being. You can read the Washington Post’s article here.
  • Empowerher.com reports on a study of the long-term relationship between childhood separation anxiety disorder and adult panic disorder. “Genetic determinants appear to be the major, underlying cause…” However, “childhood parental loss is a truly environmental risk factor uninfluenced by genetic factors, it can further affect susceptibility to panic disorder and perhaps alter an individual’s respiratory physiology for a long time.” Read more about this interesting article here.
  • The Capital Times” writes about the effect of the current economy on persons’ mental health. Some of the conclusions are “As people lose jobs or watch their retirement savings dry up, some local psychiatrists say they are seeing an increasing number of new patients with depression or anxiety, and that the symptoms of some current patients have worsened.Beyond that, these doctors say, many who need treatment aren’t receiving it because they cannot pay, having lost their jobs or their insurance.”
  • A study on “unexplained chest pain” finds that there are “several common factors among those affected, including stress at work, anxiety, depression and a sedentary lifestyle.”
    Which reinforces the benefits of stress reduction and an active lifestyle, as mentioned above in the reference to the NIH’s recent efforts.

You Don’t Have To Be A Brain Surgeon: But It Even Helps Them

This is the fifth post in the series on anxiety.

This post covers the relationship between the 3rd and 4th 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.


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

Anxiety Reduction: The Basics

This is the third installment on anxiety.

My apologies for the delay in between posts. My previous web host ran into all sorts of difficulties and I had to move the blog and the web site to a new host.

Before going further, let me again say that this site does not substitute in any fashion for treatment or diagnosis by a professional. And this is a good time to mention that whenever someone first experiences anxiety or any other psychiatric illness, a thorough physical examination by your PCP is in order. Many physical illnesses lead to changes in mood, functioning, mental status, etc. Once those illnesses are ruled out, then seeking professional treatment is indicated.

We can now start talking about various anxiety reduction and stress management techniques now that the definitions are in hand.

As a refresher, according to Wikipedia, “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.”

One of the first steps in assessing anxiety is to determine if there is any actual external threat. If so, the job of anxiety reduction is made easy. For example, if a person complains of anxiety in the late afternoon, we look to see what may be happening in the late afternoon or evenings that might lead to anxious feelings. If we find that the husband often comes home from work in a foul mood and yells a lot, then this may lead to anxious anticipation of his arrival at home.

The question might arise about why someone would be anxious rather than fearful in these situations. The answer, for better or worse, is lengthy. I will try to devote time to this topic in a later post. For now, let’s simply say that anxiety sometimes seems more bearable than the idea that your life partner is intolerable.

Where there is an external threat, two lines of approach are helpful.

First, anxiety reduction techniques come into play. I’ll get to those in a moment.

Second, if the threat is the husband (or any other external stressor), then more effective ways need to be developed to better deal with the threat. The specific strategies will vary according to the nature of the threat. If it’s the husband, perhaps helping the wife with expressing how his yelling affects her would help. Or perhaps some assertiveness and limit setting is called for. Yet again, it may be that marital therapy would be most beneficial. The list of possibilities goes on. However, the point is to improve the person’s skills for dealing with the situation that threatens them.

Back to anxiety reduction techniques. There are five cornerstones. 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 direct you to 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 becomehealthynow.com as well as the glycemicindex.com. 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. But it does not include competitive sports and similar events where there are goals and expectations (read those as stress inducing).

There is a way to cheat on this if you absolutely cannot fit 20 minutes of light outdoor exercise into your day. But it should not be used as a substitute on a regular basis. Again, for the sake of brevity in this post, I’ll direct you to two other sites. The first one is from About.com. The second one comes from RealAge.com. These instructions aren’t quite the same as the ones I use, but they are close enough so that it doesn’t really matter.

4.Fun. This simple word is often the most difficult for people to be able to do. Whatever it is that you consider fun, schedule it in to your week. Fun is an antidote to the build up of stress and anxiety.

5.Get out of the house and socialize, do things with friends and family. Yes, even if you don’t feel like 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 breathing. For a host of physiological reasons, that I will get to in a later post in this topic, 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. Until I get to the physiological basis of anxiety, you’ll have to trust me on this.

Here are two youtube videos that demonstrate the process. Once you learn how to do it, you can use it everywhere and no one can tell that you are doing. It does not at all need to be as formal as in these videos. They are lying down and being thorough to make a good instruction aide. You can breathe with your diaphragm while walking up the stairs or sitting in a chair at dinner.

  • Center For Hindu Studies
  • Yoga Breathing and Warmups
  • I think that’s enough for this post. Next, I’ll try to get to the physical processes involved in stress and anxiety.