Reflections From A Chair

[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.

[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.

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.

Time Magazine has an online article titled “Study: ‘Depression Gene’ Doesn’t Predict the Blues.”

The article reviews a recent meta-analysis published in JAMA.

Time’s writers report that “The meta-analysis of 14 prior studies concludes that the so-called depression gene — a variant of a serotonin-transporter gene called 5-HTTLPR — may not be associated with an elevated risk for depression, as many researchers had believed.”

However, the meta-analysis did find that there was a significant correlation between the number of a person’s stressful life events and depression.

The researchers found that “This meta-analysis yielded no evidence that the serotonin transporter genotype alone or in interaction with stressful life events is associated with an elevated risk of depression in men alone, women alone, or in both sexes combined.”

As the Time article concludes:
“So what does this mean for anyone who is struggling with depression? The science of linking specific genes to the disorder is still in its infancy, so no one should worry that their genes alone doom them to a life of sorrow. And while no single treatment works for every patient, there are many — including simple physical exercise or strengthening social relationships — that can help to lift the blues.”

Stephen Ilardi, associate professor of clinical psychology at the University of Kansas has a new research program on depression, he calls it TLC. The Daily Kansan reports about in its article Professor develops six-step program to cure depression.
Professor Ilardi says that his research recommends six points.
They are:

• exercise,
• omega 3 fatty acids,
• sunlight exposure,
• anti-rumination strategies,
• social support
• and sleep hygiene.

It is his contention that modern, urban lifestyles deprive us of these six simple factors. One of the results is a higher rate of depression.
You can read more about the research here.

From WebMD comes the article Depression Raises Risk for Type 2 Diabetes .

It reports on a study done by Julie Wagner, PhD, of the University of Connecticut Health Center.

Dr. Wagner’s research finds that:

“Depressed participants who were not being treated had significantly greater insulin resistance than study participants who were not depressed. But treatment for depression appeared to improve insulin sensitivity, with depressed participants on antidepressant therapy having similar insulin sensitivity to non-depressed participants.”

She concludes that:

“the more depressed someone is, the more cortisol they produce, which leads to more belly fat and more diabetes…(and) Depression may also influence type 2 diabetes risk by disrupting the immune system or levels of serotonin, which helps modulate metabolic function as well as mood…”

Treating depression is important in its own right; but it also helps lower the risk of type 2 diabetes.