Category Archives: anxiety

Hippocrates on Social Anxiety Disorder

Hippocrates of Kos (c. 460 BCE – c. 370 BCE)

Hippocrates of Kos (c. 460 BCE – c. 370 BCE)

I’m catching on that many Anxiety Disorder NOS diagnoses may be Social Phobia. To quote the Father of Medicine:

“(this man) … through bashfulness, suspicion, and timorousness, will not be seen abroad; loves darkness as life and cannot endure the light or to sit in lightsome places; his hat still in his eyes, he will neither see, nor be seen by his good will. He dare not come in company for fear he should be misused, disgraced, overshoot himself in gesture or speeches, or be sick; he thinks every man observes him.”

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Grief: Stages, Waves and Tasks

Clare Bidwell Smith has written a worthy essay on grief and anxiety, one that challenges Elizabeth Kübler-Ross‘s ‘bargaining’ stage:

Many of my clients immediately begin to assess their current state in terms of where they are with denial, anger, bargaining, depression, and acceptance. But while the stages were meant to be helpful, this is often where people begin to get confused. I don’t think I’m following the stages correctly, they’ll admit in a worried tone.

I don’t understand the bargaining part. I’ve been depressed for too long. I skipped the anger stage—is that okay? I don’t know where my anxiety fits in. These are the kinds of things I hear over and over again. In fact, I’ve heard them so often that I’ve now come to believe that when the five stages are applied to grief, bargaining should be replaced with anxiety.

Contemplating © 2013 by Anders Engelbøl

Not every mourner gets a soothing vista to grieve by.

Smith deserves kudos for drawing attention to anxiety’s role in grief. The loss of a loved one is a hole in our safety net. It reminds us of our own mortality. How does one not feel anxious about that? Her suggestion we make anxiety a stage of grief, on the other hand, propagates long-standing problems with the model.

For all of its cultural dominance, Kübler-Ross’s magnum opus has taken heavy fire. Bonnano, Wortman, et al (1)  found grief might take five different paths, including one of resilient recovery.  Maciejewski, Zhang et al (2) found symptoms of grief such as yearning, anger and depression rose and fell along overlapping curves, while acceptance rose along a steady upward slope.  Kübler-Ross herself freely admitted not everyone will experience each stage, the stages may not come in order, and that stages might recur once they’ve faded.  So, why describe grief in such terms?

A figure from Maciejewski and Zhang's research. While each psychological response peaks about a month apart, they all begin within three weeks of the loss and remain present throughout the process.

A figure from Maciejewski and Zhang’s research. While the first four ‘stages’ peak about a month apart, all begin within three weeks of the loss and continue nearly to the end. (see complete figure at the link)

James William Worden’s ‘task’ model drops the view of grief as a commuter ride on the Dysphoria Local.  Worden, professor at Biola University’s Rosemead School of Psychology, frames mourning as a set of chores:

  1. Accept the reality of the loss. Completely.
  2. Work through all of the emotions tied to the loss. All of them.
  3. Make all the adjustments needed to function without that person – inside and out.
  4. Find a way to maintain a link to the loved one, while you move on with your life.

Each task can be worked on a bit at a time. They don’t need to be completed in order. Anxiety, yearning, anger, depression? Each fits each task. No one needs to wonder why they still feel angry after being depressed for so long.  Worden’s model empowers our clients, because it makes grief a mission to complete, not a storm to be weathered.

The flaw in Smith’s plan to substitute ‘anxiety’ for ‘bargaining’ is the same that undermines Kübler-Ross’ model.  Symptoms like anger and anxiety rise and fall, but they don’t come in stages. They pervade the process. Let’s reassure our clients the loss of a loved one can be terrifying. Let’s not shoehorn that anxiety into an misfired concept like ‘stage’.

Citations:

1: Resilience to loss and chronic grief: A prospective study from preloss to 18-months postloss. Bonanno, George A.; Wortman, Camille B.; Lehman, Darrin R.; Tweed, Roger G.; Haring, Michelle; Sonnega, John; Carr, Deborah; Nesse, Randolph M. Journal of Personality and Social Psychology, Vol 83(5), Nov 2002, 1150-1164. doi: 10.1037/0022-3514.83.5.1150

2: Maciejewski PK, Zhang B, Block SD, Prigerson HG. An Empirical Examination of the Stage Theory of Grief. JAMA. 2007;297(7):716-723. doi:10.1001/jama.297.7.716.

@ 2013 Jonathan Miller All Rights Reserved

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One More Reason to Quit Smoking

Chill out, pal. Relax. Just don’t smoke a cigarette. Tobacco may make your anxiety worse instead of better.

1933 Lucky Strikes ad. "To anxiety ... I bring relief."

Tobacco ads once implied smoking improved your health by reducing anxiety. Ha-ha! Good one, guys.

Máirtín S. McDermott, Theresa M. Marteau, et al, tracked 491 smokers as they tried to quit.  After six months, 76% of the participants had relapsed, and only ten of those with a psychiatric diagnosis (mostly anxiety and depression) were still tobacco-free. Those who quit reported their anxiety score went down by an average of seven points, while those who relapsed scored three points higher than before.  Which group saw their anxiety drop the most after they quit, or soar the highest when they relapsed? Those who said they smoked, “to cope,” as well as for pleasure.

All the usual caveats apply. 491 smokers is not the world’s largest sample. Pharmaceutical companies didn’t pay for the study, but they’ve paid McDermott to work on smoking-cessation before.  A different  study recently found exactly the opposite effect; these researchers believe low doses  of nicotine (not standard doses or high doses) may clog  a subclass of the brain’s nicotine receptors so they can’t relay anxiety signals. On the other hand, those researchers studied mice rather than people, and most first-time smokers report nausea rather than serenity.

Too many people smoke, and too many rationalize tobacco use by saying, “I need it for my nerves.” We can boost our client’s motivation to quit by explaining tobacco  actually seems to increase anxiety – through our fears for our health, if no other way.

“Sure, cigarettes help you relax,” I’ve said. “They take away the anxiety you get from craving a cigarette.”

Citations:

Change in anxiety following successful and unsuccessful attempts at smoking cessation: cohort study
McDermott MS, Marteau TM, Hollands GJ, Hankins M, Aveyard P British Journal of Psychiatry, 2013; 202: 62-67

Anderson SM, Brunzell DH (2012) Low Dose Nicotine and Antagonism of β2 Subunit Containing Nicotinic Acetylcholine Receptors Have Similar Effects on Affective Behavior in Mice. PLoS ONE 7(11): e48665. doi:10.1371/journal.pone.0048665

@ 2013 Jonathan Miller All Rights Reserved

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Bad for your heart, bad for your mood

It’s a therapist’s job to help people find their own answers. When it comes to healthy living,  we spend a lot of time telling them what they should do. By the time you’ve explained how one’s mood and stress level benefit from exercise, regular hours, spiritual practice and skipping drugs and alcohol,  your index finger can be exhausted from the waggling.

Luscious, hot, salty yummy-nummies, just dripping with despair

This paradox will only grow worse, with the University of Montreal Hospital Research Center’s new study on diet and mice’s behavior.  Stephanie Fulton, Ph.D and her team found that after twelve weeks of high-fat, high sugar meals, their subjects froze under stress. They were less likely to explore new environments, and more likely to scurry for safety. Compared to a control group of mice fed the pelletized equivalent of grilled quinoa and kale, they gave up faster in tests of  ‘behavioral despair’.  In short,  they looked anxious and depressed.

Behavior can have lots of explanations, of course. It’s  been assumed that anxiety and unhealthy eating correlate, because we seek solace in ‘comfort food’ when we feel stressed.  Sadly, Fulton’s study suggests the reverse. Brain scans indicated the mice on high-fat diets had elevated levels of corticosterone, a hormone conclusively linked to anxiety and CREB, a molecule implicated in the fear response. Saturated fat appears to be the enemy here – the mice who were fed “good fats” like olive oil didn’t show as much anxiety.

Dopamine depletion in T-minus 100… 99… 98…

In interviews, Fulton theorized there’s also a neurological link between scrumptiously unhealthy food and depression. She surmises  that because high-fat, high-sugar eats are so ineffably delicious, they trigger releases of dopamine. That’s a neurotransmitter associated with pleasure, particularly with reward-driven learning. Life being unfair, the rush of dopamine leads to a corresponding crash, which causes symptoms of depression. Over time, per Fulton, this can reshape the brain’s reward circuits. Instead of easing life’s suffering, steady consumption of greasy, sugary treats may create an addictive pattern of short-term highs and long-term gloom.

… told you so.

David C.W. Lau MD PhD, editor of Canadian Journal of Diabetes emphasized this study only shows association, not causation.  The researchers freely admit it is hard to square their findings with other studies where mice on similar diets became more docile. Given that, two points come to mind:

1. The clash between offering health advice and helping people find their own answers? It’s an irony, but not a conflict. We’d be remiss if we didn’t tell people there are quick steps to improve one’s mood. “You have worse problems than lack of exercise,” I’ll say. “But exercise would help.”

2. Occasional indulgences are not a high-sugar, high-fat diet. Vegetarians’ organic, easy-going good humor is enviable, but not every client will be pried away wholly from sugar and fats. Good food is one of life’s great pleasures, and life has to be worth living. As  clients often ponder when they’re offered MAOIs: if you give up chocolate, cheese and wine entirely in trade for an effective antidepressant, has your life actually improved?

Citation: Diet-induced obesity promotes depressive-like behaviour that is associated with neural adaptations in brain reward circuitry. Sharma S, Fulton S. Int J Obes (Lond). 2012 Apr 17. doi: 10.1038/ijo.2012.48. PMID: 22508336 [PubMed – as supplied by publisher]

@ 2012 Jonathan Miller All Rights Reserved

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Can Trauma Make Us Stronger?

Stephen Joseph, PhD, professor of psychology at University of Nottingham, UK. (Photo credit: Maria Tanner at Lace Market Photography)

Great – another f***ing growth opportunity,” reads the classic bumper sticker. “Classic” here means, “old”, especially given that ‘personal growth’ seems as outdated as Esalen, hot tubs and encounter sessions. In his new book, “What Doesn’t Kill Us”, Stephen Joseph, PhD pries the concept free from associations with self-indulgence by linking it to Grandpa’s good, old-fashioned ‘character building’ – finding strength through suffering.

In 1990, Joseph conducted three-year follow-up interviews with survivors of the Herald of Free Enterprise sinking. Those who lived through the tragedy reported all of the pain, guilt and sleeplessness researchers expected. Yet, surprisingly, 43% also made comments like, “I live everyday to the fullest now,” and “I am more determined to succeed in life now.” Joseph, professor of psychology at the University of Nottingham, UK, used these findings to develop his Changes in Outlook Questionaire (CiOQ), and found it repeatedly confirmed such signs of personal growth in hundreds of trauma survivors.   Like Viktor Frankl, Joseph “… saw two sides of suffering, noting that while there might be nothing inherently good in misfortune, it might be possible to extract something good out of misfortune.” He argues against Freud’s view that therapy’s role is to get clients back to common unhappiness. Rather, the therapist’s job should be to help people lift themselves above their pre-trauma level of functioning – to grow.

"... 'terror'... 'torment'... 'tragedy' .... here it is, 'trauma'."

Every trauma survivor seeks information. They’re filled with questions such as, “ What happened? Why can’t I put it behind me? Why did this have to happen at all?” Joseph presents PTSD as an information-processing problem. To be traumatized is to be blasted with unbearable knowledge at an intolerable volume.  So much, so fast, creates an overload that destroys neurons in the hippocampus and hampers one’s ability to process the memory. These ‘uncategorizable’ recollections drift about the mind in the form of flashbacks and nightmares, like so many piles of paperwork on a desk. To file such memories away properly, the survivor’s understanding of the world must grow. A new file folder with a new category, (one that makes sense of the memory), must be labeled.  Unanswerable “Why me?” questions aren’t resistance or self-pity – they are the start of the search for meaning. 

None of Joseph’s ideas fit on a bumper sticker, and all are ripe for misinterpretation. One can sense his desire for a rubber stamp reading, “OF COURSE”.  Of course trauma survivors suffer, he says. Of course no one would choose trauma for the benefits of post-traumatic growth. Of coursePositive Psychology” doesn’t mean clients censor their pain with smiley-face stickers. He makes it clear that growth is not a guaranteed result of trauma, and lack of growth is not evidence of poor character. First, Ryan and Deci’s basic needs (such as acceptance and belonging) must be met. A client must choose to engage in the growth process before that process can begin. When a person is traumatized enough to meet criteria for post-traumatic stress disorder, growth won’t happen until those symptoms ease in treatment. A more specific, less marketable title might have been, “What Doesn’t Kill Us or Give Us PTSD.”

The last issue is particularly relevant, given Salon.com’s try at shoehorning the author’s ideas into an “over-diagnosis” narrative.  Joseph straddles the diagnosis debate. He observes that a PTSD diagnosis validates a client’s story. It’s undoubtedly a good thing  survivors have been moved from the file marked, “Malingering coward,” into the one labeled, “Someone with an understandable, treatable illness who is deserving of our compassion.” He’s troubled, though, that the same redefinition moves trauma from the, “I will survive this and grow stronger,” category  to the, “This is something the doctor needs to fix,” file.  In his view, our current understanding can file trauma survival under stiff-lipped perseverance or a treatable illness, but not the process of becoming someone new.

Friedrich Wilhelm Nietzsche (1844-1900). Personal-growth pioneer - not actually to blame for WWII.

Perhaps this critique of the medical model explains why the book is weakest when it addresses treatments for post-traumatic symptoms. It’s clear Joseph’s focus is to break up our thinking about trauma. He encourages therapists to speak in the disease model’s terms long enough to engage the client in the process of growth, but rushes past descriptions of how specific symptoms can be eased so growth can begin. With all of the book’s valuable advice for clients on coping with stress and finding professional help, one wishes the author spent more time on why, how, and how well different treatments work.

In “What Doesn’t Kill Us”, the author wire-walks his way between the fact-free fluff of self-help and the rigid, symptom-focused empiricism of insurance panels, to show how Nietzche‘s maxim can apply to leading a fulfilling life, not just survival in a vicious world. What doesn’t kill us provides the opportunity to nurture changes in our thoughts, behaviors and understanding of how life works. We can grow enough from adversity that the answer to, “Why did this have to happen?” becomes, “So I could be a stronger, more compassionate, more fully-alive person.”

(The New York Times has an excellent article about post-traumatic growth among members of the U.S. military here.)

@ 2012 Jonathan Miller All Rights Reserved

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What (exactly) is Anxiety?

If you were to see this, technically, you would feel anxiety.

There’s a terrific post here from Joseph LeDoux, professor of neural science and psychology at New York University, that defines anxiety, from the amygdala on up. LeDoux specifies anxiety as a flavor of fear. When you expect that you might face a threat, you feel anxiety. When you actually face that threat, you feel  fear.

The explanation is more necessary than it might seem. Twice in recent months, I’ve had male clients stare blank-faced and ask, “What exactly is anxiety?”  The first time, I had to stammer out an explanation of apprehension, physiological arousal and the fight-or-flight reaction, while hiding my surprise that  someone would need to ask. The second time, examples worked well: “Anxiety is what you feel when you walk in a room and everyone goes quiet.” “Anxiety is what you feel when the police car behind starts its’ siren.” For this client, “Anxiety is what you feel when your girlfriend says, ‘We need to talk’,” made the concept crystal-clear.

If you were to see this, technically, you would feel fear.

These conversations made me wonder why the question isn’t more common, and why only men have asked. In session, guys often seem more comfortable talking about ‘edginess’ or ‘agitation’ than with the A-word.  LeDoux’s explanation of anxiety hints at one possible reason why:

“… human anxiety is greatly amplified by our ability to imagine the future, and our place in it, even a future that is physically impossible.  With imagination we can ruminate over that yet to be experienced, possibly impossible scenario. We use this creative capacity to great advantage when we envision how to make our lives better, but we can just as easily put it to work in less productive ways — worrying excessively about the outcome of things.”

For some men, especially those with long memories of junior high school,  the best definition  might be, “Anxiety is what you feel when you think your buddies can see you’re nervous.”

 

@ 2012 Jonathan Miller All Rights Reserved

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