Tag Archives: Cognitive Behavioral Therapy

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 About.com’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.

Depression Resources from NIMH

While I’m on the topic of depression, The National Institute of Mental Health has a number of valuable resources on depression and its treatment.

The newest one, I believe, is a video. It is aimed at a general audience so that they can “learn about signs, symptoms and research on depression.” The video can be viewed at the NIMH website, click here.

The NIMH also has a fact sheet: Depression: A Treatable Illness.

They also have a pamphlet for men:Real Men Real Depression. Judging by how quickly this pamphlet vanishes from the reading material in the waiting room, you may find it very helpful.

Not to leave women out, the NIMH’s Women and Depression: Discovering Hope is a more extensive booklet than the others mentioned here.

For more information about depression and other mental health topics from authoritative sources, please visit the Links and Search Engines page on my website.

Treatments for Adolescent Depression

A new study takes a look at the effectiveness of various treatments for teenage depression. Unfortunately, I cannot give you a link to the article as it is on a subscription service. But here’s the citation for the article:
Treatment of adolescent depression: what we have come to know
Benedetto Vitiello, M.D
Depression and Anxiety
Volume 26, Issue 5, 2009.
Pages: 393-395

Three months after starting treatment, fluoxetine (Prozac) brought about a higher response rate than cognitive behavioral therapy (CBT). A response rate is a reduction in some but not all of the symptoms. Whereas the elimination of all symptoms of the depression is called a remission. 61% of the patients studied showed improvement from fluoxetine alone versus 43% of the patients who had CBT by itself. So fluoxetine is clearly better at bringing more adolescents into the response range than CBT or placebo. And fluoxetine is more cost-effective (cheaper than) psychotherapy at the three month point.

But a combination of fluoxetine and CBT was most effective at achieving remission of symptoms at three months (37%). Furthermore, “the combination (of medication and psychotherapy) was also superior to (medication alone or CBT alone) at improving functioning, overall health, and quality of life at the 3-month assessment.”

“(A)t the 9-month assessment, fluoxetine, CBT, and their combination did not differ in response rate (81, 81, and 86%, respectively) or remission rate (55, 64, and 60%, respectively). Thus, it appears that the value of antidepressant medication consists in speeding up the process of improvement and recovery, whereas psychotherapy gradually catches up and, given enough time, it does not seem to make too much difference which treatment modality was used.”

There was “a greater incidence of suicidal events (a category including suicide attempts and suicidal ideation) was found in the fluoxetine condition (14.7%) than on CBT (6.3%).” But there appears to be “a protective role of CBT when used in conjunction with medication” because “the suicidality rate in the combination group” dropped down significantly to 8.4%. And this level of suicidality was not statistically higher than when patients were treated with CBT alone.

In conclusion, the study found that “Although fluoxetine was clearly the most cost-effective treatment modality during the first 3 months…, combined treatment was more cost effective than fluoxetine when the entire 9-month outcomes were taken into account, primarily due to the higher number of suicidality-related hospitalizations in the fluoxetine group.”

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.

Anxiety, Self-Esteem and Self-Soothing

If you have been following these posts, perhaps you will recall one entitled “The Experience of Anxiety and Panic.” In that essay, I briefly noted some of the thoughts people with anxiety disorders sometimes have about themselves. The self-attributions or labels that they attach to themselves relevant to today’s discussion include:

•embarrassment
•shame
•guilt
•a sense of personal failing
•being sure that one is flawed
•believing that you are inferior to others
•being harshly self-critical
•having low self-confidence

These are powerful, negative beliefs that some anxiety-ridden people have about themselves. They hold them to be as true as the sun rises in the East. These thoughts stem from the anxiety disorder. These anxiety-provoking thoughts are incessantly repeated, both verbally and sub-vocally, until they are soaked in apparent truth. Beliefs such as these can strongly influence a person’s behavior and interactions with others.
For instance, a person with social anxiety may repeat the phrase “I suck at meeting new people” over and over again. They practice this belief dozens of times a day. Socially anxious people may even imagine how horrible meeting someone new at school (or elsewhere) today will be. Practice, in this as in many other areas of life, makes perfect. Therefore, our socially anxious person believes that s/he “sucks at meeting new people.” S/he has visually imagined or practiced how poorly the next interaction will be.

This linking of an anxious presumption (I suck at meeting new people) with imagined interactions and outcomes leads someone to become successful at being unsuccessful in meeting new people.

Let me make an aside. When I was young, I played golf. I remember reading an article by the golfing hero of the day, Jack Nicholas. He described the technique he used to prepare for his next shot as he walked up to his ball. He visualized, from a first person point of view, making the back swing, exploding downward and striking the ball, following through and only then looking up to follow the ball on a perfect arch and direction to the exact point where he wanted the ball to land and then roll to.

At the time, I thought that was just something he came up with for the article. I tried doing it and had little success. Only later did I realize that I have a hard time visualizing such things. For me, verbal or auditory cues work much better. Years later, when I read books about NLP, I came to have a much better understanding of why Jack’s visualizations did not work for me, but talking myself through something did work.

Before getting too far afield, let me return to erroneous belief systems and self-soothing. Our socially anxious friend now has a rigid belief that they suck at meeting new people and have practiced poor outcomes in their imaginations. They have become as prepared for that bad interaction as Jack Nicholas was prepared for his birdie. In all probability, the socially anxious person will have a very upsetting encounter with the next new person.

This seems to prove the assumption that “I suck at meeting new people.” So, if anyone should ask why a person thinks she or he have difficulty meeting people, there is fresh, concrete proof. That is a fallacious line of argument.

The socially anxious person, in this case, would better be described as, due to the anxiety disorder, being successful at preparing and planning a disastrous first meeting with someone. It is not that they prepared and practiced to have a successful outcome. We do not know how the meeting would have turned out if the person had been at ease, comfortable in the setting, and had practiced a successful outcome to the meeting.

One way to try to combat negative, self-fulfilling beliefs involves my asking what seems to be a question dreaded by some of my patients.

Let me explain that a bit. Anxious and depressed persons often come to the first session well-versed and ready to discuss what is wrong with them. The descriptions of their purported flaws, shortcomings, self-criticisms flow easily.

At some point in the session, I ask them to “tell me three good things about you.”

There is usually a silence. Sometimes there are looks back at me that seem to say that I have asked a most impolite, hideous and foul question. It would seem easier to return to the lengthy list of negatives.

One of the reasons behind asking this question is to find traits that a person likes about him or herself for use in self-soothing and self-esteem. Another is to assess the constancy and quality of the person’s self-representation. The latter is relevant to this discussion but would take us into object relations theory and psychodynamic/analytic theory and is beyond the scope of this post.

With three good things about oneself in hand, many techniques become available. A simple one is to say to yourself something like the following:
“I’m a good person who is (fill in the blank with three self-positives). I am going through a difficult time (fill in the situation, e.g., meeting this new person). But I have gone through bad times before and made it through. And I’ll be able to make it through now because I’m a good person and (fill in the three self-positives). I’ll still have those good qualities even if this (meeting or whatever) goes poorly.”

In the above, I have suggested three initial strategies on building self-soothing strategies and positive self-esteem.

First, notice when you are practicing negative thoughts about yourself and preparing for self-fulfilling bad outcomes. Then attribute those thoughts and previous outcomes to the anxiety disorder. Stop those ruminations by getting up and doing a different activity, even if it is only getting up from the couch and going into the kitchen and washing dishes; if you are alone you can say “Stop those thoughts” out loud and switching your thoughts to any positive memory you might have; and similar techniques.
Second, try to picture a successful outcome to your next project, like Jack Nicholas. Alternatively, if visualization is not for you, talk yourself through the steps of the project. Imagine how one successful step will lead to the next.

Third, remind yourself of your good traits, at least as often as you rehearse the negative ones. In addition, in times of trouble, remind yourself that you will still have all your positive attributes with you through the difficult task and even afterwards.

I will return to these topics in later posts.