Tag Archives: psychodynamic psychotherapy

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.

Treatments for Anxiety Disorders

This post will return to anxiety treatment topics. More specifically, I would like to address the issue of treatment approaches or techniques.

As my earlier posts on this topic surely indicate, I am a strong adherent of cognitive behavioral therapy (CBT). However, in my experience, this is not always the beginning and end point of psychotherapy for anxiety.

Let’s start with the goals of treatment for anxiety disorders.

Often, treatment for anxiety and other psychiatric illnesses is called successful if the patient has fewer symptoms and is able to resume something close to a normal lifestyle. Even if some symptoms remain, there is general improvement in the person’s overall condition.

However, as Stephen M. Stahl, M.D., Ph.D. points out, “it is necessary to complete the job by aiming for complete recovery, removal of all symptoms, and return to wellness as the goal. ”

He finds this is important because a partial recovery can “increase the likelihood of relapse, poor outcome, future treatment nonresponsiveness, residual disability, and even suicide.”

Relapse into another bout of illness is a significant problem. In 2004, the Anxiety Disorders Association of America issued a report entitled “Improving the Diagnosis & Treatment of Generalized Anxiety Disorder.” The authors write that “GAD has a relatively low rate of recovery when recovery is defined as a reduction to only 1 or 2 symptoms with a subjective sense of returning to normal.” They cite another article, by Martin B. Keller, that reported that 80 percent of patients do not achieve that level of recovery.

Furthermore, a study reported in the journal Psychotherapy and Psychosomatics found that persons with panic disorder with agoraphobia treated with medications only had a relapse rate of 78.1 percent in the first year.

Another study, “Fluoxetine, Comprehensive Cognitive Behavioral Therapy, and Placebo in Generalized Social Phobia,” looked at the response rates of a variety of treatments. 50.9 percent of patients treated with Fluoxetine (Prozac) showed a positive response. 51.7 percent had a positive response to 14 weeks of group cognitive behavioral therapy. And those treated with a combination of Fluoxetine and cognitive behavioral therapy had a positive response rate of 54.2 percent. Another way to state these findings is that no matter what mix of Fluoxetine and/or CBT was utilized, more than 45 percent of the patients did not significantly improve. Also, please note that we are talking about “positive response” here and not the more difficult to achieve full remission from the illness.

Pretty discouraging numbers, especially if the goal of treatment is Stahl’s “gold standard” of complete recovery.

With these results, it seems fair to say that neither medications nor CBT nor a combination of them can claim to have solved the riddle of treating anxiety disorders.

Before going any further, let me rush to say that I am not in any way, shape or form suggesting that neither medications nor CBT are valid treatments.

I was first trained in the days before the arrival of Prozac (circa 1987), Xanax (circa 1981) was not a popular medication yet (at least in the settings where I worked and studied at that time), and Lexapro (circa 2002) was not even a gleam in the eyes of Forest Laboratories. So I have seen the before and after treatment pictures. Never would I want to return to an era when such medications were not available to the people who benefit from them.

My training started after the development of cognitive behavioral therapy (circa 1967). And I cannot imagine removing that from the treatment arsenal either.

What I am advocating is that, so far, our knowledge and understanding of the causes of and treatments of anxiety and many other emotional disorders is limited. Given that, there is no one “cure” for these illnesses. Some anxious people, for instance, seem to not respond adequately to Prozac but do just fine on Zoloft and vice versa. Similarly, in my experience, some patients do quite well with CBT alone whereas others also benefit from adding a psychodynamic approach or a family systems technique after initiating CBT. (Please note that I say adding another approach after CBT is started. From a purely practical point of view, I usually find the quickest route to symptom reduction through CBT. Whatever symptoms remain after that are targets for other treatment methods.)

In my practice, my aim is for complete symptom elimination by whatever clinically sound and effective means are at my disposal. To achieve that, I am eclectic in the use of treatment styles and pragmatic in the sense that I am interested in empirically finding the optimal results for the specific person in my office at that time.

Let me end this post on an upbeat note.

This is the story of my quickest treatment of an anxiety disorder. A woman in her mid-thirties came to my office. She complained of panic attacks that were increasing in frequency and intensity.

She was confused about why she should have panic attacks. She had a recent physical check up and was in good health. She described her life as a very happy and fulfilling one. Her marriage was solid and rewarding. Financially, she was rather well off. This woman had a number of friends and was physically active. She watched her weight and ate a healthy diet. No one in her family had a history of anxiety or other emotional problems. She did not use alcohol or smoke cigarettes. She denied any history of traumatic events. There were no recent stresses in her life to account for the panic attacks.

What had changed at about the time of the onset of the panic was that she began having a single cup of coffee several times per week.

I suggested that she stop drinking coffee and to call me in a few weeks if the panic attacks persisted. She never called.

By sheer coincidence, I ran into her about a year later. This woman had not had any coffee since our meeting and the panic attacks had gone away. She continued to have a full and happy life.

Other than telling a nice story, my point is that in this case treatment was quite pragmatic. It was limited to recommending that she avoid caffeine. She did not want a referral for medication, she did not need CBT or psychodynamic treatment. Unfortunately, this is a very rare situation. But, again the point is that the treatment selected was based upon her specific circumstances and needs with the goal of eliminating her symptoms.

In future posts, I will discuss more complicated treatments of anxiety disorders.