Managing Anxiety

Anxiety always results from a specific and consistent pattern of thinking. We become increasingly anxious when we anticipate some calamitous future event. Thoughts and fantasies of the future event trigger the amygdala, the part of the brain largely responsible for the "flight-fight" reaction. Adrenaline and cortisol and other preparatory substances are released into the blood; our blood pressure rises, our muscles tense, our breathing becomes more shallow and quick and our heartbeat becomes more rapid. Our bodies ready themselves for action.

Some sudden stimuli can trigger the amygdala directly without passing through the cognitive parts of the brain. Infants show a "startle response" to a loud noise, for instance. The majority of our anxiety, however, arises through conscious thought processes involving imagining a future event which we expect to be severely unpleasant. We see an object in a stranger's hand; we become anxious only when we identify the object as a "gun" and imagine the uses to which the person might put the gun. The same events taking place on a target practice range would generally produce much less anxiety, because we have assigned a different meaning to the gun and thus different outcomes. We could hardly become anxious at all if we had never seen a gun nor knew what it was. We can learn to recognize and to anticipate danger even in novel forms, which undoubtedly promotes survival.

Once we have imagined the future catastrophe our anxiety rapidly increases. The rate and degree of increase depend partially on the catastrophe we have imagined, and partially on biological and congenital factors that govern how strongly or quickly the amygdala responds. Some infants have more pronounced startle reactions than others, for instance. The same stimulus and fantasy may thus cause very different amounts of arousal in different people.

Our anxiety and arousal have now focused our brains on what may be a survival issue. One can imagine that early humans who did not focus on the future calamity and who went back to sleep or who froze like a deer in the headlights of a truck probably did not become our ancestors. Survival requires that we focus on the calamity and make a plan to deal with it. Once we have done this our anxiety drops at least somewhat and becomes manageable. Our plan lets us know what to do when and if the catastrophe happens.

However, in people who are biologically easily anxious, whose amygdala is perhaps over-responsive, the anxiety may rise to a degree that clear thinking becomes difficult or impossible. Such people may find it difficult to make a plan at all. They may find it difficult to tolerate imagining all the elements of the anticipated catastrophe because the very attempt to do so increases their anxiety beyond tolerance. Having been unable to make a plan, the brain seems to keep the calamity on a "to-do list" with a high priority, which means the catastrophe is re-imagined frequently. Each time it is re-imagined the process is cut short before the person can consider the elements in the catastrophe and develop a plan. The resultant anxiety and arousal thus can’t get resolved; the person attempts to limit the anxiety not by finding a solution or plan but by trying to avoid thinking about the problem altogether. However, lacking closure, the catastrophe is still on the "to-do list" and is brought to conscious attention again and again, resulting in chronic anxiety.

What I observe in chronically anxious people is a pattern of thinking about noxious future events that constitutes a kind of short-hand, a mental image or word that points to the catastrophe without directly invoking it. For example, when a car cut dangerously close to me on the highway at high speed, my reaction was sudden fear; I didn't imagine the potential catastrophe in any detail. The expletive that leapt to my lips in effect "stood for" the imagined disaster. As a result I decided to slow down and keep a little more distance. Even my limited plan was sufficient to reduce my anxiety somewhat.

Chronic anxiety is not a good thing. It's hard on us physically as well as mentally. It actually interferes with problem solving and may reduce our long-term survival raters. It certainly reduces our quality of life. Mark Twain said, "My life has been full of tragedies, most of which never happened". Chronic anxiety can be reduced by medication, but a more long-term solution is to recognize the importance of thinking through the elements of the catastrophe in spite of the discomfort and making a plan to deal with it. Anxiety itself is a normal function of the brain. Stopping anxiety through medication would not help us survive. There are dangerous problems and \dangerous people in our world, and we need to be wary of them. And it's best to have a plan.

Panic is another issue entirely and requires a different approach. Ask me if you want information.

What's psychotherapy for?

Psychotherapy is used in basically two situations. The most obvious of the two is to reduce symptoms, such as symptoms of depression or anxiety. The model in people's minds is the medical one: to return the patient to a previous state of health. In this model depression and anxiety are seen as abnormal processes with at least theoretically a genetic predisposition and with a biochemical base. Psychotherapy and medication are ways to re-normalize the symptomatic patient and make them well. For most such illnesses, we can predict reasonably well what kinds of treatment work, and how long they will take, on average, to produce the desired return to health. Medical insurance is designed to work well with these parameters, since expense is fairly easy to anticipate.

But many people have an underlying sense of unease and unhappiness that doesn't add up all the way to depression. Sometimes we call it dysthymia, if it comes to medical attention at all. Mostly it doesn't come to the attention of a professional person. The person may simply accept discomfort as "the way life is". Most people tend to assume that there are no better options, that life simply is more unhappy and disappointing than it is happy.

The second purpose of psychotherapy is dealing with this problem. Clearly does not appear to fit with a "medical model", as does the symptom-reduction paradigm. People in this state of mind tend not to have much fun, to have limited creativity, limited capacity to engage whole-heartedly in relationships, to have recurrent patterns of mild (or extreme) failure. They experience repetitively unsatisfying jobs or marriages. Unpleasant things seem to happen over and over again, to a greater extent than other people experience. They have "bad luck" and they expect to have "bad luck".

While people who live like this are not "mentally ill", therapists who treat such problems and who want insurance reimbursement must have a diagnosis. We may call the patterns "personality disorders", but that's misleading. A personality "disorder" is way of life and pattern of values that is dysfunctional to the degree that the person is actively inconvenienced or harmed. The same pattern of choices and values that does not interfere with one's life is called a personality "trait". Personality traits are what recognizably distinguish us from one another. For instance, we like surgeons who are meticulous and precise. We like teachers who are funny and "show-offy".

The definition for the difference between personality "traits" and "disorders" is the degree of dysfunctionality, but that's a very relative and personal thing. Who isn't (at least sometimes) dysfuntional? and what does that mean, anyway? Dysfunctional by whose standards? Some of the definitions the psychiatric textbooks offer refer to their negative impact on others; other definitions refer to unhappiness of the individual or even to the individual's unwillingness to live up to the standards of society. If the surgeon described in the preceding paragraph spent hours obsessively counting sponges until the patient bled out we would consider his meticulous and precise traits as dysfunctional, or at least, the patient would.

Personality traits are simply our preferred styles of operating in this world. Different families and family circumstances produce different personality styles in their children, although there is considerable evidence for innate temperamental differences among neonate children. These styles are simply preferential patterns of behavior, and they are not problematic unless they are so rigid or so limited that they interfere with normal functions. At what point they become "disorders" is not at all clear. For instance, with "borderline personality disorder" there are many criteria which can exist in varying degrees and combinations, so there may be (using "official" criteria) as many as 84 different ways one can be "borderline".

For a psychotherapist working to reduce symptoms (the first type of psychotherapy described) an accurate diagnosis is very important. A variety of techniques exist to quantify the type and severity of the many symptoms associated with the many disorders. Criteria exist to separate "normal" symptomatology from "clinical" disorders. However, in working with unhappy people, people with limiting or even dysfunctional personality traits, diagnosis is not very important. In fact, to lump people in this category with "mental disorder" or "mental illness" is inappropriate in the extreme.

Psychotherapy with people who are mildly but persistently unhappy or who are dysfunctional in some very circumscribed ways is a very different operation requiring very different skills than those skills required when engaging in symptom reduction. Clients in this category may be highly successful in many ways; they typically have problems only in very specific areas. A brilliant academician might have difficulties with intimacy; an entrepreneur running several companies might find themselves chronically bored; an entertainer, loved by many, might find it impossible to respond lovingly to any one person. The newspapers are full of examples.

These people do not fit within the medical model. There is no "normal" state to return them to. There may be few or no symptoms to reduce. There may be no predictable time-frame for psychotherapy. There may be no clear "cure" or point at which therapy should terminate. (Freud addressed this issue in an article published in 1937, entitled "Analysis Terminable and Interminable). Insurance companies hate this kind of"treatment" because it's hard to label, hard to predict, has uncertain outcomes when outcomes are measurable at all. When can one say they are "done"?

I do not believe that medical insurance companies should be liable for payment for treatment of this kind of disorder. Most people who suffer chronic dissatisfaction and unhappiness don't ask for help. Much of the time they don't even realize that it is their choices and values that are causing the problem, and they may assign blame to others or society, not because they are somehow "irresponsible", but because they don't see the connection between their choices and their lives. Do they "need" therapy? No. They can live their lives out without ever changing the things that contribute to their unhappiness. Could they benefit from psychotherapy? Unquestionably, if they're willing to make the changes they will need to make. Usually they don't ask for psychotherapy until their difficulties become intolerable and unavoidable. In a later note I will post some thoughts on how this kind of therapy works (or doesn't work).

Psychological contagion

When you spend a significant amount of time with another person (or persons), you begin to adjust your behavioral choices to that person. You tend to do things that please the other(s) if you like them; if you don't you tend to do things that may not please them.

As you enact your choices, you reinforce some values you hold and weaken others. Over time your values shift in the direction you have been choosing. You become more the person who has adjusted to the other. In some instances, especially if you have a strong bond with the other person(s), your values become more like theirs. Moreover, as I said in the most recent post, the other person tends to "pull" certain kinds of behavior from you, just as you "pull" certain kinds of behavior from them.

An extreme (and somewhat bizarre) example is the psychiatric diagnosis of "folie a deux". In this situation, the significant other of someone who is delusional begins to develop the same delusions as their partner, even though they do not have the physiological structure for delusional disorders. They may literally become psychotic as their partner, though for this member of the partnership the psychosis will abate if the two are kept separate for a while.

In long-term relationships this becomes fairly obvious. As the members adjust to each other, their values become correlated (though not identical). In an unhealthy or dysfunctional relationship, Victims in relationship with a Persecutor or Rescuer become more firmly ensconced in their Victim position. So also do Persecutors and Rescuers. When the relationship is firmly dysfunctional, it is very difficult for either member to change out of their unhealthy role while remaining in the relationship. To do so would require a real commitment to change by all members of the relationship.

I continue to be surprised by how malleable and flexible our personalities are, at least over time. We may think we know who we are, but we don't necessarily know who we may become.