Anxiety Disorders and their Common Features

Most people have experienced situational apprehension and “butterflies” in the proverbial stomach.  We get jitters and particular fears.  Clinically significant anxiety can be torturous.  Even when not the primary symptom, it can significantly increase the suffering from depression and psychosis.  Anxiety prevents people from engaging in necessary activities, like flying and driving.  It prevents some people from leaving their home.  Chronic anxiety can manifest in physical illness.  Many symptoms of anxiety overlap with physical ailments; for example, heart disease.  As it is very difficult to separate symptoms of heart disease from anxiety, I often have patients note anxiety test items they believe to be secondary to their medical condition.  Tachycardia (racing heart), diaphoresis (sweaty), clamminess, blurred vision and thoughts of dying could be a myocardial infarction or acute anxiety.  Persistent negative rumination over years may adversely effect one’s cardiopulmonary status.  Patients with chronically low blood oxygen saturation and elevated blood carbon dioxide will typically suffer with anxiety.  Anxiety secondary to medical factors will make even the calmest person feel terrible.

From these thoughts one can gather that it is best to be cautious in diagnosing anxiety.  It is safest to first rule out a medical problem, since the psychological symptom of anxiety is not, fortunately, a fatal one.  Younger woman should rule out a mitral valve prolapse, for example, before embarking on the time and expense of mental health treatment.  If you suffer from anxiety and chronically labored breathing, consider having your medical doctor check oxygen saturation.

It is often easier for a clinician to diagnosis phobias and panic than generalized anxiety.  Phobias elicit anxiety over particular stimuli; typically not anxious removed from the unpleasant stimuli.  Panic involves stark symptoms that are unique to the phenomenon.  One of the most bizarre is the scotoma, or alarming narrowing of one’s visual field-like looking backward through a telescope!  I have created a separate subcategory for panic, and invite people to leave their thoughts on panic in that category.  Many patient’s come to me complaining of panic, but not many of them actually have the disorder.  This is fortunate for them.

Most symptoms of anxiety respond to cognitive-behavioral psychotherapy and/or medications.  Often the greatest hurdle is obtaining and accurate diagnosis.  The next big hurdle is the various prescription pads filled with benzodiazepines (Valium, Librium, Xanax, etc.).  I recommend using medication in combination with cognitive-behavioral therapy, but do not support the use of medication without any behavioral therapy.  If one starts with psychotherapy as the solo treatment, the psychologist can always seek medication consultation at a later time.  If one starts off with medication, it can complicate the process of psychotherapy, and make one unsure as to which is the most beneficial.  The take home message is to take heart, help is available, and typically effective.

The Anxiety of Life

Many people have a goal of reducing or eliminating anxiety in their lives.  Through groundbreaking research in the 1950’s, the average person is aware that chronic stress may lead to unpleasant health effects.  Heart disease to hair loss is ascribed to chronic stress.  It begs the question as to how stress differs from anxiety, or does it?  Perhaps it is best to begin with a definition of terms.

Chronic anticipation of the future is considered anxiety, and if one views this future as negative and unavoidable, then it is more apt to receive the label of stress.  Anxiety is often viewed as a symptom of the mind, and stress is perceived as affecting both the mind and body in a negative fashion.  Anxiety may have positive connotations; such as anticipation of a wedding or performing in front of an audience.  The original conception of stress segregated it into the two poles entitled distress and eustress.  Distress is obvious, but eustress is a term not likely to be encountered since it was first coined.  Eustress refers to the type of anxiety experienced as relatively pleasant and stimulating.  Rushing home from work to usher a child to band practice may have multiple interpretations.  It may be experienced as an opportunity for personal time with the child.  Band practice is an enriching and stimulating activity.  The situation may also be perceived as a helpless madcap dash that always seems to end with a tardy and upset child.  Stress research strongly emphasizes the role of a person’s evaluation of their situation.  If someone feels caught and helpless in a situation, even if they have real control, they will experience the bodily effects of chronic stress.

There does not appear to be much difference between eustress and optimistic nervous anticipation.  Perhaps anxiety commonly denotes short-term nervous anticipation and eustress tends to favor a longer experience of the pleasant anxiety.  Unpleasant anxiety is experienced as stressful if the person becomes convinced that they are unable to help themselves or others in a meaningful way.  A perceived lack of power to effect the unpleasant situation is the most direct route to physical decline.  When rodents are punished in an arbitrary fashion, shocked on a random basis, they will uniformly give up and sit shaking in a corner.  A reduced appetite, weight loss and a diminished lifespan result if this torture is continued.  Sexual activity in the rodent disappears, and subsequent socialization is minimal and not helpful to their survival.  The key cognitive factor initiating distress appears to be helplessness-a profound lack of control.

Unfortunately, there is no research to support that a greater level of real control results in a less anxious person.  If a person believes they have control over their environment,  then they typically report less symptoms of anxiety than most people.  Many of my patients over the years report chronic anxiety over the welfare of children and other close others.  Most of these people do not classify themselves as anxious, nor do they meet the criteria of an anxiety disorder.  Many of my patients worry about their jobs on a chronic basis, their health and the fidelity of their partners.  Few of these patients meet the criteria of an anxiety disorder, nor are they experiencing stress-related illnesses.  On the other hand, many people believe they are in control of their life, but they cannot consciously admit certain fears that conflict with their confident self-image.  For example, a wealthy business owner came to be evaluated for his emotions and cognition, secondary to several stress-related symptoms.  He was happy at work, which he controlled, but felt foolish and incompetent at home, which he did not control.  This person did not meet the criteria for depressive or anxiety disorders, rather the chronic stress he experienced at home made him avoidant of his family.  He doctor shopped to explain the hair loss, stomach troubles and irritable sadness he experienced in the presence of his family.

Perhaps the only way to avoid anxiety is to avoid living.  Less anxiety is also equatable with less joy, less expectation and a diminished sense of being fully alive.  The avoidance of stressful anxiety appears to balance on a person’s perception of control.  The strange truth is that an easy-going homeless pauper may experience less stressful anxiety than the King of Araby!  Maximizing the anxiety that enlivens and minimizing the stress that kills is a key challenge to constructing an ideal life.

Happy-What Does That Really Mean?

The primary meaning of happiness, according to the dictionary, is to be favored by luck or fortune.  The third most common usage of the word suggests well-being and contentment.  It is likely that  Tom Jefferson and Ben Franklin meant the latter rather than the former.  The Bill of Rights proclaims that it is a god-given mandate to be happy. It appears that happiness is a good thing.  Unfortunately, happiness is often regarded as a state of being, rather than a label one places on their emotions.

If happiness is considered as a mood state, it should also be considered time-limited.  Emotions ebb and flow throughout days and weeks, and happiness is a qualitative label to describe the flow.  Mood is conceptualized as the average of emotions across time.  One may feel anger and happiness in extremes throughout a difficult day, but the overall rating of one’s mood may not change significantly.  Affects are the facial expressions indicating emotions to others on an immediate basis, and summing these over time reveals mood.  For example, a surly mechanic may inspire an angry affect, but the injured party’s mood will return to baseline after the incident.  Affect is typically fleeting, and mood is considered the emotional baseline.

Aristotle believed that happiness is the only human activity pursued for its own sake.  People pursue health, wealth, and power in order to be happy; as a means to an end, and not an end unto itself.  Happiness could be considered as a goal of behavior.  Jefferson was an ardent admirer of Aristotle, and likely influenced his thinking on the subject.  Happiness for Aristotle was not just a label for an emotion, but described the behavior of one who acts in accord with their virtuous nature.  When the purpose(s) inherent in our nature are fulfilled, we may be labeled “happy.”

A realistic definition of happiness incorporates the behavioral features of Aristotle, combined with modern knowledge of the brain.  While mood is considered the baseline, this does not mean the base is stationary.  When we accomplish a goal that is considered important, the affect is one of happiness.  Goals may be a manifestation of purposes inherent in our nature, but this is not necessary the case.  It is a modern certainty that environment plays a huge part in developing our “natures,” and the process continues throughout our lives.  How people define “virtuous” and their “nature” changes throughout the lifespan.  Consider that we are born as a book, and others may write in it as they please.  We may edit and filter, but graffiti will influence the copy.  Our genes define the size, shape and quality of the binding, yet the content is a joint venture.  To construct a modern theory of happiness is to realize that goals are products of genes shaped by experience- filtered through the prism of immediate need.

To be happy is to accomplish a goal.  The goal must be consistent with what we consider to be justified and necessary.  It must be meaningful to the person.  A state of happiness necessarily ebbs until a new goal is accomplished.  Happiness is less a mood state than an emotional reaction to the attainment of a goal.  It medicates a sense of stagnation by obtaining an assurance of progress.  Happiness cannot be pursued for its own sake.  We pursue happiness through our goals.  The Bill of Rights was correct in writing the “pursuit of happiness,” since it is never the object of lasting attainment.  If your goal was to read this post, I hope you’re happy.

Panic Disorder

Panic is not a disorder unto itself, and neither is a panic attack.  The modern conceptualization is that panic is a form of anxiety that may or may not include agoraphobia.  This last term is taken from the Greek, and literary means “fear of the marketplace”.  It is a fear of being unable to escape in a crowded situation, fear of bridges, and fear of travel in any kind of conveyance.   Much of the fear is anticipation of having a panic attack in these sort of situations.  The fear is heightened if the person believes the situation is such that no one will come to their assistance.  The agoraphobia is rarely initiated by a specific trauma, as is a post-traumatic stress disorder.  It is also not secondary to a fear of being socially embarrassed, as is a social phobia.  All these anxiety disorders impel one to flee the situation, but for different reasons.  Situations that involve travel or crowds  are feared and consequently avoided.  Many agoraphobics do not experience panic, but most suffer with the disorder.

Many agoraphobics develop anticipatory anxiety of being in public places, then avoid these situations for fear of having an attack.  Phobic avoidance develops over time, which reinforces the avoidant behavior.  The combined disorder of agoraphobia with panic tends to be more functionally debilitating than either disorder in isolation.  Anticipation of a fearful situation reaches the point of panic, and the panic is so startling that a person would do anything to avoid another panic attack.

Many patients complain of panic, but rarely do they meet the criteria.  Most people experience acute unpleasant anxiety and label that as panic.  Several symptoms overlap with generalized anxiety, but a few are better indicators of true panic than the rest.  The onset of panic and anxiety may be sudden, but panic tends to peak within ten minutes and then subside.  Generalized anxiety has less intensity at the onset, and tends to take a long time to resolve-if ever.  There are intense fears of dying or going insane while enduring a panic attack.  It almost seems like a medical problem when the heart beats so strongly.  A miasma of nausea, dizziness, palpitations, chest pains and shortness of breath overwhelm one to the point they fear dying.  Sweat pours forth in buckets.  Generalized anxiety often is accompanied by sweat, but typically not as intense or circumscribed.

The good news is that most people who believe they are experiencing panic are actually experiencing acute anxiety.  The onset of panic is so strong and unforgettable, that it creates a cycle of fear and avoidance.  Generalized anxiety does not have specific fears that could be avoided.  Many people have agoraphobic symptoms, but fortunately, few will fall prey to the disorder.  It is commonplace for people to fear bridges, especially if they can see through a metal roadbed.  It is also normal to have fear of being trapped while waiting in line, or have a fear of being immobilized in a crowded elevator.  It is rare these mild anxieties develop into a Panic Disorder with Agoraphobia.

Treatment of all phobias is cognitive-behavioral in nature.  The main thrust of the therapy is to gradually expose the patient to the feared object.  The hope is to decouple the feared situation from the biological and psychological reaction. A psychologist will have the person imagine driving over a bridge, and discuss their emotional and cognitive apprehensions.  As the therapy progresses, the psychologist will attempt increased contact with the feared situation until the person masters their reaction.  Another method is to directly expose the patient to the feared situation in an aggressive fashion, which often alleviates the anticipatory anxiety of the next exposure.  There is a greater risk of being overwhelmed or even traumatized by this second sort of treatment, such that it should only be attempted with professional assistance.  Medication is not advised for long-term control of panic, but temporary usage can assist the therapy by lowering the overall level of anticipatory anxiety.

Normal-What Do You Mean By That?

It is often overlooked.  How do clinicians diagnose mental illness without knowing what it is to be normal?  This is not a trivial question.  Defining normalcy is a central issue in the training of psychologists.  Researchers focus on symptoms that reliably differentiates normal from abnormal functioning.  It is the path of least resistance to dwell on symptoms, since through the use of informants, the researcher may obtain some degree of objectivity.  What is overlooked, for the sake of objectivity, is what normality actually feels like to those who experience this state.  Unfortunately, the feeling of being in a normal state of mind is hopelessly subjective.

People who are labeled as mentally ill often comment that they just want to be “normal like everyone else.”  Like looking over the fence into the neighbor’s yard, people imagine the thoughts and emotions of others.  Implicit assumptions are made with a minimum of data.  It is often assumed that a labile (roller-coaster) mood is a sure sign of mental illness.  Patients often assert that they are more tense and anxious than normal people.  Everyone knows that seeing bugs that aren’t there definitely means one is crazy.  This could be termed a trinity of assumptions regarding normal people; that they are less moody, less tense, and never experience hallucinations.

There is some truth to the trinity, but more often than not, it serves as an ideal that is always out of reach.  Most people seriously under appreciate the degree to which normal people suffer with low moods, anxiety and transient hallucinations.  A large distinction is that for normal people, these symptoms ebb and flow, whereas for the mentally ill, these states of mind merely continue to flow.  Stated another way, normal people suffer low moods and anxiety states.  It surprises many people to learn that most normals experience transient hallucinations.  Large well-controlled studies of average people reveal how often they experience bizarre sensory phenomenon.  Almost on a weekly basis, the average person is prone to experience a bug crawling on their skin or up a wall, only to have it disappear when they look again.  If the bug disappears when they again look, psychologists call this normal, if they multiply when the person takes another peek, then we label these unfortunates as psychotic.

Do not be deceived as to what normal people experience.  Normalcy is not an ideal state of being, often imagined as being in a good mood and free of tension.  If this were the average state of the individual, most would never be motivated to leave their homes.  Tension drives behavior.  Tension is interwoven with life and abandons us at our death.  It is a river that needs to be channeled, not dammed into a confined space.  Similarly, bad moods are inescapable, yet they also may be a vector for change.  Research into the sensory experiences of normal people should convince us that we are all a little crazy.  Psychotherapy is typically more effective and rapid when the patient entertains realistic goals.  The ideal of the normal person is often a fantasy, and it may drive people towards emotional goals that are impossible to obtain.

Psychotherapy Basics

Many people ask, sheepishly, how psychotherapy really works.  The term “therapy” is mentioned constantly in the media as a short form of the word “psychotherapy.”  It’s natural that people are curious about something that is seemingly ubiquitous, yet apparently defies easy explanation.  There is nothing magical or new about psychotherapy.  Like most medications, however, there are aspects of its intrinsic functioning that remain a mystery.  The nebulous and fleeting words strewn about a psychotherapy session appear, mysteriously, to be less important than the conditions demanded by the therapeutic frame.  The “frame” of psychotherapy refers to all aspects of the session divorced from the actual words used within the session: for example, cost, time, place, office policies, etcetera.

Whatever the psycho-therapeutic school of thought, there are set features that are standard across most styles and techniques.  The most important element of effective psychotherapy is the promise of confidentiality.  Without a solid confidential therapeutic base, psychotherapy is nothing more than a Socratic conversation for hire.  One’s life may be blessed by many intimate trusted contacts, yet one cannot divulge literally everything to any one friend.  There are always social consequences, and consciously or unconsciously, all of us must monitor and filter the content of our conversations.  I do not believe that this encompassing social information management is strictly selfish.  As often as not, the filtering of information is used to protect the feelings of others.  Having intimate  friends is certainly important to one’s mental health, yet even the closest of relationships may be of little use when one’s situation is altered by psychological suffering.  For instance, most of my patients are very conscious of becoming a “burden” to others through ventilating their distress.  Unless the intimate attachment is based upon this sort of negative ventilation, the voicing of complaints may alter the basis of the friendship.  Existing social support may be lost.  For this reason alone, close friends are often of little help when psychological distress becomes significant.

Confidentiality is the boiler plate of psychotherapy.  Psychotherapy research of the last 50 years is convergent in revealing that the particular therapeutic technique employed is less important than confidentiality in achieving a favorable patient outcome.  Part of these findings may be explained by the decreased social risk obtained by ventilating to a professional.  Another aspect of these findings may be explained by the very nature of psychotherapy technique.  Each school of psychotherapy tends to focus on particular features of the human experience, yet similarities do exist.  Broadly, psychotherapy is dedicated to resolving problems that negatively affect one’s life.  The relative importance of thoughts versus behaviors differs, yet nearly all seek to identify “maladaptive” thoughts or behaviors that lower a person’s psychosocial functioning.  Many schools, such as Rogerian, eschew the whole notion of maladaptive, yet even the most positive and uplifting psychotherapy is seeking to alter one’s thoughts and/or behaviors.  It is unlikely that anyone would pursue psychotherapy as a treatment if they perceived their thoughts and behaviors to be wonderful.  Many schools of psychotherapy are better at appearing more positive and uplifting than others, but the mission is essentially the same.  For example, a new form of psychotherapy is termed “coaching.”  This form of psychotherapy/counseling even eschews the whole notion that it is a psychotherapy!  As in Rogerian therapy, there is a strong accent on the therapist being positive and proactive.  The word “coaching” is synonymous with “instructing.”  It appears that some people would forgo the benefits of an intimate attachment to a therapist, in order to avoid being perceived as a “psych case.”

Schools of psychotherapy are targeted towards individuals, couples or families.  While the number and relation of the individuals is different in various schools of thought, the mission to discover less than desirable thoughts and behaviors is the same.  Many therapists and schools of thought voice a focus on “communication.”  I am at a loss to know what else could be a focus of psychotherapy.  All psychotherapy assumes communication as essential to the experience, since no therapeutic school pretends to work with comatose or catatonic individuals.  Nonverbal behavior communicates a great deal to the therapist and others involved in the session.  Verbal and nonverbal communication is the very stuff with which we work, such that the notion of “communication” being a special focus is a bit absurd.  The greatest difference between psycho-therapeutic schools of thought are that each tend to emphasize particular features (subsets) of the therapeutic experience; thoughts versus behaviors and individuals versus groups.

If I may draw on the medication analogy again, the use of different forms of psychotherapy is similar to considering side effects in proscribing a particular medication.  If we know that two medications will work equally well to cure a condition, which should be employed?  The medication with side effects better tolerated by a particular individual would be the obvious choice.  For example, the new class of antidepressants called SSRI’s are very good, yet most cause serious reversible symptoms of sexual impairment.  If the patient is very sexually active, it might be better to use an older, though less effective, antidepressant without the unwanted sexual impairment.  Similarly, group psychotherapy is the most obvious choice to reduce social anxiety, yet initially it may be the worst form of treatment.  Exposed to the stimuli they fear the most, a group of people, the patient may experience recurrent trauma as a consequence of this treatment.  For this person, it is better to lessen the initial anxiety with individual psychotherapy, and then save the finishing touches for group psychotherapy.

The basics of psychotherapy are centered about confidentiality, a solid frame, and the identification of unwanted thoughts and/or behaviors.  The choice of which psychological technique to employ is similar to choosing amongst equally effective medications.  The choice of interventions should be based upon the comfort level of the particular patient, in light of their unique situation and lifestyle.

Psychotherapy 201

Perhaps you have read my last post “Psychotherapy 101” or “Psychotherapy Basics.”  The post “Psychotherapy 101″ is an introduction  into fundamental aspects of psychotherapy.  It also attempts to dispel common myths regarding psychotherapy.  I am satisfied with the post’s information, but a bit unhappy with its tone.  Perhaps in my rush to dispel the “fruit and nut” aspects of psychotherapy, I did not give an accurate description of its softer side.

Even though most people seek psychotherapy to solve particular problems, there are those whose mission is to grow as a person.  It is easy to categorize these people under the “problem” label, since a desire to grow as a person assumes a certain degree of dissatisfaction with one’s life.  Perceived in another way, one may regard these seekers of growth to be satisfied with their lives, yet eager to exceed the boundaries of their current existence.  It is less improving a bad thing than making a good thing even better.

Personal growth through psychotherapy is not problem oriented or solution focused.  There is no mountain of empirical literature to guide the psychologist’s movements.  It is a free style exploration of one’s existence.  Psychodynamic therapists have an interesting perspective on this form of exploration.  They maintain psychotherapy is the construction of a story that both the patient and therapist agree upon.  It is a simple sounding phrase, yet its meaning tends to enlarge as it is turned over in the mind.

The path of the growth oriented patient is less clear than the problem-oriented one.  The explicit goals and techniques of traditional psychotherapies render the measurement of progress and success rather easy.  The only goal of growth psychotherapy is to exceed one’s current psychological limitations.  Neither the psychologist or patient knows how or when the process will end.  The psychologist may perceive the patient as complete, but only the patient has the privilege of considering themselves complete.  In traditional psychotherapy, the psychologist is largely the owner of this privilege.  For example, once the patient stops smoking or their mood is brighter, the psychologist will pronounce success.  Psychotherapy is considered complete with the resolution of the problem-oriented goal.  In growth therapies, only the patient will truly know when they have reached their goal.

Many growth-oriented therapies eschew goals as an unnecessary stifling of personal exploration.  Perhaps this is based upon the assumption that the goals of an incomplete person will be incomplete as well.  It may be true that one has to reach a certain level of psychological sophistication to formulate reasonable goals.  While this concept rings true for many high functioning people, it is not very applicable to those with more fundamental problems.  Working with victims of head injury, the formulation of any goal may be a great victory for the patient.  Lacking awareness into their deficits, the psychologist must maintain the privilege of  controlling the nature and extent of the treatment.  Growth-oriented psychotherapy assumes good cognitive functioning.

Growth-oriented psychotherapy is likely most beneficial to those whose work and home-life are generally satisfactory.  Personal growth work is easily derailed by current emergencies and old traumas.  Personal growth as a goal is certainly noble and worthwhile.  The time and expense are considerable, and the commitment is extraordinary.  The shared experience of building an autobiography is very powerful.  One cannot help but be altered by the experience.  The person emerging from this process has yet to be revealed.  It is hoped that greater awareness will bring greater clarity, and the clarity will strength our purpose.

Anxious about Anxiety

Anxiety is a common experience that is difficult to define.  The diagnosis of an anxiety disorder may come as a surprise, because the symptoms are often attributed to a different source.  Symptoms of anxiety overlap with many physical disorders, such that the etiology of the symptoms is apt to be confusing.  Anxiety overwhelms conscious thought, decreasing the brain’s  overall processing power.  The more the symptoms are willed to subside, the more the symptoms appear to increase.  Symptoms of anxiety may be ignored with willful effort, but never willed to go away.  Anxiety is often an unwelcome guest that cannot be forced to leave.

What underlies the most common form of anxiety is fear.  People are loath to admit a fear of nearly anything, which often allows the anxiety to tighten its grip.  People want to imitate the cool control of the action hero.  They want others to regard them as cool and in control.  Their judgments about themselves and others reflect this cultural value, instilled by TV and the movies.  One will never see the action hero cringing in the face of their enemy-paralyzed with fright.  The reality is that fear is a primal emotion that shatters the illusion of control.  It not only infects humans, but may be witnessed on the faces of all mammals.  It is the emotion experienced before fighting or fleeing.  It erases the past and future in an instant to focus on the present predicament.  It is as necessary to survival as food and water.

Fear and aggression are flavors of avoidance and approach.  We withdraw from objects we fear and towards those we want to destroy.  Constant flight leads to starvation and constant aggression leads to a violent death.  The choice of how and when to fight or flee is the key to remaining on top of the food chain.  A person who is constantly aggressive would be labelled as foolish, not brave.  A person who consistently flees from conflict would be labelled as a coward, not judicious.  A wise person listens and learns from their fears.  It is the voice of self-preservation.  It’s the voice of the survival instinct.  Anxiety is a necessary part of life.

Pathological anxiety is to maintain a state of anxious/fearful apprehension, even though the threat is far removed.  Anxiety is no longer adaptive in this situation, and may cause behavioral paralysis.  It is rare for people to pull back at this point; to realize the generalized nature of their fear.  Medication may reduce tension sufficiently to increase psychotherapy gains, but it is not recommended as the sole intervention.  The patient will quickly depend on medication to allow daily functioning, but rarely understand the fear sufficiently to master the anxiety.  Psychotherapy without medication is often successful for those with mild anxiety.  Moderate to severe anxiety sufferers may be too anxious to make an appointment, or too tense to ingest the therapist’s words.  As with the treatment of depression, a combination of psychotherapy and medication appears to be most successful.

The first task to rule out anxiety is consulting with a physician regarding the physical symptoms.  Radiating numbness and tingling in the arms may be an early sign of a heart attack.  Constant GI distress may be diverticulitis.  As mentioned, anxiety has many physical manifestations that may lead the patient and clinician astray.  Once the physical causes are believed to be benign, the second task is to make an appointment with the psychologist.  This may be the most anxiety provoking task of all.  Take heart.  The determination to seek professional guidance is the first therapeutic intervention.

Losing It

Losing it.  All of us lose “it” at some point.  The “it” appears to be the control exerted by the prefrontal cortex of the brain.  The prefrontal cortex serves many functions, and one of the most important is the inhibition of impulses.  The most common impulses to inhibit are sexual and aggressive urges; though they are not mutually exclusive.  The research of Amy Arnsten at Yale has shown that acute stress releases chemicals that reduces the influence of the prefrontal cortex over these impulses.  Not only is prefrontal control weakened, but more primitive areas of the brain emerge to pick up the slack.

In response to the stress confronting the brain, the less evolved brainstem releases two primary neurotransmitters called dopamine and norepinephrine.  Dr. Arnsten discovered that these neurotransmitters actually diminish the communication between the prefrontal area and other regions of the brain.  Once the regulatory network is down, the base of the brain sends a chemical message to the adrenal glands adjacent to the kidneys, and the adrenal releases a hormone that influences the brain in turn.  Norepinephrine and the adrenal hormone cortisol promotes emotional areas of the brain to be fearful and prepare for possible danger.

Chronic unrelenting stress may actually reduce connections between nerve cells in the inhibitory prefrontal area.  Conversely, nerve connections in the more primitive emotional areas of the brain may expand.  There is some evidence to suggest that shrinkage of neural connections in the prefrontal cortex may play a role in depression, addiction and anxiety disorders.  The neurotransmitter dopamine has been long implicated in addiction, due to its strong influence on habit forming areas of the brain.  It appears that a relatively brief exposure to stress has little lasting affect on brain structure.  The longer stress is experienced, the greater the chance the more primitive emotional brain areas will dominate one’s behavior.

This feedback loop of the brain may play a role in post-traumatic stress disorder.  The habit forming areas of the brain allow us to quickly acquire skills and behaviors that ensure success in novel environments; for example, a war zone.  The prefrontal cortex allows us to formulate plans and inhibit fearful impulses that would reduce effective functioning.  Once the threat is removed, the dangers already experienced may overwhelm the prefrontal cortex’s ability to inhibit the emotional excitement.  Over time, the dopamine, cortisol and norepinephrine may weaken the prefrontal control to the point that the fearful impulses are rarely blocked.  The unfortunate person may re-experience highly emotional scenes in an uncontrolled and repetitive fashion.  This person would experience substantial stress in a peaceful environment, since the brain continues to assault them with feelings and images that inspire fear and avoidance.

It is still a mystery why some people manage chronic stress well, and others-not so much.  It is conjectured that some lucky people have an enhanced ability to digest the dopamine and epinephrine excreted during stress. They would possess an innate biological resistance to stress.  On the other hand, psychological research has revealed that people with a long record of mastering challenging situations are better able to tolerate stress.  People who are often defeated and overwhelmed by events are more liable to suffer with chronic stress and depression.  A person’s perception of control is a key element in the subjective experience of stress.  To what degree the subjective sense of control is a product of training or brain chemistry is anyone’s guess.  As with most psychological phenomenon, it is likely that both elements play an important role.  Effective behavioral training increases a sense of personal control; decreasing the excretion of stress chemicals.  Inheriting favorable brain chemistry may reduce the biological strength of the stress response.  Nature and nurture.  Can’t get away from it.

Forget Me Not

Memories are typically useful and pleasant.  It is fortunate that relatively few are unpleasant and aversive.  Both pleasant and unpleasant memories are sustained by the same brain system, though the strength of the memories may be unequal.  It is advantageous for a person to encode emotionally charged information over neutral memories.  Events that provoke an emotional reaction tend to leave a stronger trace than those that do not leave an emotional impression.  Remembering where food poisoning was contracted is likely more important than the lyrics to a song.  The first memory avoids illness or death while the second avoids boredom.  Obviously, survival of the organism is more dependent on the first memory than the second.  The trouble begins when the emotionally charged memory trace is over-activated.  It transforms the memory from helpful and adaptive to unpleasant and aversive.  Moreover, the overactive memory may decrease adaption and jeopardize survival.  The memory of contracting food poisoning may make the person afraid of all food sources.  The once useful memory may become a liability.

Posttraumatic Stress Disorder evolves by this mechanism.  Being harmed or confronted with death is highly emotionally charged, and will certainly make a lasting impression.  This is a necessary adaption in order to avoid harm in the future.  Avoidance of specific situations that risk harm to the organism is necessary for survival.  Avoidance of all situations that are even remotely related to the original is called over-generalization.  The more the fear is generalized to related stimuli, the greater the overall impairment in the person’s functioning.  A man holding an umbrella may generate as much fear as that of a man holding a gun.  The over-generalization becomes increasingly entrenched.  Repeated alarming experiences that are close to the initial trauma are reinforced.  It is not only the gun that that generates anxiety and fear, but any object that remotely resembles a gun.  Each time the person has frightful reactions to related stimuli, the maladaptive memories become stronger and stronger.  Like any road, furrows widen and deepen with use.  The longer the maladaptive memory persists, the wider and deeper it becomes.

The act of filling in the maladaptive furrows with neutral recollection is termed extinction.  It is a very difficult process for the patient, in that it entails approaching the feared stimuli.  Moreover, it is very common for the extinguished traumatic memory to reappear months later.  This can be very disconcerting, as the patient and doctor believe the trauma is extinguished, only to reappear at a later date.  It is only natural for the patient to become increasingly hopeless that their suffering will be alleviated.  They feel powerless in the face of their traumatic memory.  Recently, there has been progress towards increasing the effectiveness of extinction training; both behavioral and medicinal.

It appears that the extinction of traumatic memories may be accelerated by drugs that block the physical aspects of an emotional response.  The beta blocker propranolol blocks a neurotransmitter that induces excitation in the brain.  It may help the brain to reconsolidate traumatic memories in a less fearful way.  Unfortunately, the research has been inconclusive as to its efficacy during extinction training.  Some studies indicate that it is useful in this regard, others do not.  A new behavioral approach has received greater experimental support, and does not have the typical disadvantages of medication.  Researchers (principally Elizabeth Phelps at NYU) have included an extra reminder trail ten minutes prior to the usual extinction trial.  For example, an extinction trial for the person with food poisoning may consist of pairing pictures of the food with its odor.  As the trials proceed, the odor is gradually removed until the patient no longer displays a reaction to the feared object-say a hot dog.  It appears that merely showing the picture without the odor, ten minutes prior to the extinction trial, significantly increases the effectiveness of the procedure.  It is believed that the reminder trial opens the brain to change during the extinction trial.  The effectiveness of the extinction is enhanced if the brain is already considering the feared stimuli.  There may be a window during recollection where memories are vulnerable to alteration.

It is hoped that this new technique will significantly enhance behavioral treatment of Posttraumatic Stress Disorder.  The reminder session during extinction may shed light on how humans consolidate their memories.  This process has been studied intensively for decades, and yet remains murky.  If this new technique receives additional experimental support, it may not only help those suffering with traumatic memories, but reveal a fundamental property of how we form memories.  It’s two revelations for the price of one.  A bargain at any price.