Reflections From A Chair

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.

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 MentalHelp.net’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 MentalHelp.net: “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.

[This is the third installment in my series on anxiety as a defense against depression.]

QuixoticBlues has a number of videos on YouTube. One of them is titled: “Yeah I’m a bit crazy.” The following is a transcript of some of his opening thoughts (expletives omitted).

“I’m sure that everyone who watches these things [his YouTube videos], thinks I’m a nut case. What I’m worried about is that they might be right.

“God, I hate wondering if I’m crazy, you know.

“…In my free time, most people would want to go hang out with their friends. They would not endorse spending hours alone by themselves in their room. And yet that is exactly what I do.

“There it is, though. I’m worried that, you know, I’m crazy.”

Those are really common thoughts for people with anxiety disorders.

In a typical evaluation of someone with anxiety, they might start out by saying:

“I don’t know why, but every time I think about going out dancing or even to church…any place that’s crowded, I get really anxious.”

I then ask what they worry about happening if they go out.

“I’m not sure. I like dancing and I like going to church. But I’m worried that I’ll do something that will make people look at me weird. That I’ll do something stupid. People will look at me funny or they’ll think I’m a jerk.”

So, I ask, has anything like that happened to you recently?

“No, not really. When I go places, I’m quiet and stay by myself. I don’t want to stand out. I don’t want people to see how nervous I am. I don’t want people to judge me or make fun of me. I think it could happen if people see how I really am. Or maybe I’d say something dumb and they’d think I wasn’t smart. I dunno. It’s bad enough that I see how messed up I am; I don’t want other people to know.”

The list of potential bad outcomes is usually pretty long. And so are the number of flaws that the anxious person thinks might be discovered. It’s very painful for people to think like this. It would be even more painful, they believe, if they really were made fun of, rejected by or judged poorly by other “normal” people.

But notice in these statements that the bad things remain only potentially true. They haven’t happened yet. There is a big “IF” in front of all the negative judgements and embarrassments.

This “IF” does at least two things. One, it preserves a slim hope that a person is not as messed up as s/he thinks. Two, it forms a tightly reasoned and logical argument. This bit of logic provides the rationale for giving into some of anxiety’s other symptoms such as isolation, avoidance, self-doubt, worry and others.

Bear with me for a moment while I get a bit technical about the reasoning involved here.

Cut down to the essentials, these concerns form a valid logical argument called a chain or hypothetical syllogism.

If I go out, then people will judge me as flawed and no good.

If other people, too, judge me as flawed and no good, then my worst suspicions about myself will be confirmed.

Therefore, if I go out, then my worst suspicions about myself will be confirmed.

We can look at this in its symbolic logic form.

Let “P” equal “I go out.” Let “Q” equal “people will judge me as flawed and no good.” And “R” will equal “my worst suspicions about myself will be confirmed.” The symbol means “If…then…” And the symbol means “Therefore.” The tilda ~ means “not” or the negative of the statement.

P Q

Q R

P R

So, once I go out, people will confirm my worst fears about myself.

Now let’s see the opposite or negative of those statements.

If I dont’ go out, then people won’t judge me as flawed and no good. ~P ~Q

If people don’t judge me as flawed and no good, then my worst fears about myself won’t be confirmed. ~Q ~R

Therefore, if I don’t go out, then my worst fears about myself aren’t confirmed. ~P ~R

Okay, the technical aspects of this bit of logic is over. (By the way, this same logic holds true for most anxiety-ridden thoughts. You can fill in the lines with contamination, orderliness, phobias, etc.)

We can now see the logic behind choosing anxiety. Doing so fends off the final proof of one’s worst fears and the depths of depression. There is no “if” in these depressions. It is seen as a proven truth that I’m no good. There is, then, a logical argument backing up the desire to isolate. Staying home, or putting on a false front if I do go out, lets me have some lingering doubt about my worst fears about myself. Hope remains alive.

But if I go out, I am damned. In my anxious reasoning, it’s a foregone, logical conclusion that my worst thoughts about myself will be validated. There’s no doubt or hope left.

Once it seems like someone looks at me oddly, then it’s proof that I suck, my life sucks and everybody knows it. There is no escape from these facts. This is depression.

Sometimes people believe that it will never get any better. I suck and always will. That road leads, at times, to suicidal thoughts. Why continue in the pain of depression if there will never be any relief?

An example of depression crashing in after anxiety is found in Donovan Campbell’s Joker One. This book was discussed in the first two posts in this series. Towards the end, he writes that “I wished fervently that I had died in Bolding’s stead [a soldier under his command]….I finally realized that, no matter how hard I prayed, God didn’t owe me anything, not even life….Finally, I considered myself already dead, with each day a precious gift that I didn’t deserve.”

Campbell was not frankly suicidal. But there is a darkly depressive quality in the belief that he should have died, that he was already dead and did not deserve another day of life.

Okay, on the level of how some people rationalize and experience anxiety and the transition to depression, I think the point is made by now. There are any number of other levels at which we could discuss this topic. Those other realms range from the biological to object relations theory. But those discussions will have to wait for different series of posts.

The next question is, what’s to do when people use anxiety as a guard against depression? How is that situation best treated in therapy?

Clearly, we don’t want to take away someone’s defensive anxiety if that will plunge them into a depression.  Nor would we want to eliminate the anxiety at the cost of an otherwise preventable divorce or similar problem.  Yet, we do want to treat the anxiety and bring about a higher quality of life.

I’ll try to shed some light on those issues in the next few posts in this series.

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.

[A quick administrative note. I recently entered into an agreement with MentalHelp.net to provide blog posts for them. Some of the entries made here will also appear in their blog. This is the first such post.]

Back in March of this year, I was listening to NPR while driving around town doing errands. Terry Gross was interviewing Donovan Campbell, the author of Joker One. His book is about a platoon of Marines stationed in Ramadi, Iraq. Campbell was talking to Gross about a soldier under his command that was killed in Iraq. Campbell began crying while talking about the death. I found it remarkable that a battle-hardened Marine officer who served three tours in the Middle East and had written a book on the topic could still allow himself the candor and authenticity to cry on national radio about a man who died several years earlier.

I bought the book. I was not disappointed.

Around the same time, I was puzzling over a clinical question that was happening frequently enough to catch my attention. In some cases, when treatment of anxiety symptoms was successful, depressive symptoms emerged. The reverse of that seemed also true: alleviation of depression sometimes led to resurging anxiety symptoms. I spent a lot of time thinking about the psychological and social conditions that might be at work in these instances.

Patients sadly asked me why it should be that now that the anxiety attacks were gone, instead of being happy they had become depressed. I had some stock answers to the problem. However, they no longer satisfied me. More importantly, I don’t think my answers were helpful to them.

This process occurred both in individual and marital therapies. Anxiety symptoms apparently were defenses against becoming depressed. And if someone was previously anxious and then became depressed, the depression-in part-served as a defense against a return of anxiety.

Further, the symptoms themselves guarded against fully coming to terms with the reality of the person’s or couple’s situation.

That all sounds complicated and I will attempt to unpack it as we go along.

Hope, I believe, also plays a pivotal role. Hope, that is, in both its manifestations: an alluring, sweetly promised desire and as an unfulfilled, tormenting, scoffing longing. But we’ll get to that later.

In subsequent posts I will also provide clinical examples of anxiety as a defense against depression (and vice versa) for individuals and in marriages. I will also try to work out some of the dynamics involved.

But to get started, let’s return to Donovan Campbell’s Joker One. It was while reading this work that I began to formulate an answer to the clinical questions that were dogging me.

Some caveats before I begin. This is not a review of the book itself. Nor is this intended as an analysis of the book’s author or the other Marines. Nor am I making any comment on America’s current wars or politics.

Rather, I simply want to look at some of the psychological effects of exposure to urban warfare.

I deeply respect and admire Mr. Campbell and the other Marines in this book. Nothing that I write below is intended as a slight or criticism of those men. I strongly recommend that you read Joker One. It is a work of art and love birthed in one of earth’s many hells.

Okay, now to the book.

The setting is Ramadi, Iraq in 2004. In Campbell’s words, the city “contained roughly 350,000 people…one of the highest population densities on earth…its alien nature struck me almost like a physical blow. No amount of training at abandoned U.S. bases could have prepared us…” Add to this that none of the 150 Marines spoke the local language. The city was home to unknown numbers of well-armed insurgents who did not wear identifying uniforms. Mortars were fired routinely into the Marine’s base. Their job was to “walk the city on foot” where “trash and human waste littered every street” and for the 150 Marines to secure and stabilize the city of 350,000.

If that is not a recipe for anxiety or panic, then I have never heard one. Obviously, a platoon’s commander cannot afford to have anxiety spread through the troops. Therefore, they would need good anxiety reduction strategies. I have written elsewhere on this topic and won’t repeat my views here; a number of them would not apply to his battlefield conditions anyway. So, let’s see how Campbell devises a real-time strategy for anxiety reduction and stress management in the midst of a hostile chaos and in the fog of war.

For one, he acts in the fashion of a true leader. Here’s how he writes about it:
“I had a responsibility to my men to provide for all their needs…Marines will only listen to those who have suffered alongside them, and if you want any credibility as a leader, you not only have to bear the same burdens as they, but you also have to try, to your utmost ability and every single day, to transfer those burdens from their shoulders onto yours.”

He also instituted “a pre-battle ritual…that we only performed every time we left the base’s confines…” The aim of this was to have “each of my Marines…think of himself first as a member of Joker One and only thereafter as an individual with needs and desires different from that of the team as a whole…a focus on the group and an overriding concern with the service and welfare of others.” The ritual was a recitation of the Twenty-third Psalm.

So far, so good. Against an unknown, unseen force whose members were prepared to suicide if it would cause Marines to die, Campbell presents himself as a strong, competent and compassionate leader of a group of soldiers with an intense, common identity. Yet, within the recitation of the psalm was a paradox that ultimately threw Campbell into despair. But I am getting ahead of the story here.

There’s much more to Campbell’s campaign against anxiety and the dread of the unknown.

But this is a good place to take a break. I will continue analyzing his strategy in the next post. In the meantime, may I again suggest that you pass the time by reading Joker One.

The Examiner has an article addressing the treatment of dogs that are fearful of the noises accompanying fireworks. It’s called, appropriately enough,: Does your dog dread July 4th?

The top tips are:

• “melatonin…the most likely non-pharmaceutical product to help” [though she does not mention dosages].
• “contact their vet and consider anti-anxiety medications to provide their dog with relief”
• “essential oils…used in any combination by direct contact to the pads of the feet or used in a diffuser…chamomile, lavender, geranium, marjoram, bergamot, frankincense, neroli, and sandalwood, vervain and valerian”

There are a number of other suggestions as well. I found this article too late to try this year. So, I can’t provide any reviews. Any comments, suggestions by the readers are welcome, as always.