Category Archives: Anxiety

May 18, 2011 · 9:22 am

Physiology of fear


Regions of the brain affected by PTSD and stress.

Image via Wikipedia

Had a conversation regarding fear and anxiety with someone yesterday. In light of that I am resurrecting a post I wrote from 2007 (with a few edits) regarding the physiology of fear. We often view fear as only a spiritual or faith problem. But for those who want to know what is going on in their bodies when they experience fear, consider the following:

(Those interested in other posts on anxiety can search that and related terms in the search box at the upper right hand of this blog)

…

Am teaching on anxiety, panic, and OCD tonight. Definition of anxiety: Responding to ambiguous stimuli (life situations) by reading them in the worst or most dangerous possible light. The Scriptures teach us that fear and worry are not good things. Time and time again God tells his people not to be afraid. We see that God wants us to see life through a different set of eyes, much as Elisha wanted his servant to see the army of angels instead of their enemies (2 Kings 6). But given the numerous encouragements to not give in to fear, we must admit it is a common struggle for every human being. Some struggle more than others.

What is going on with those whose lives are filled with worry and fear? Are they less spiritual? More sinful? It is easy to say, “buck up” to folks who are anxious–and entirely unhelpful to most. Logical challenges to fear (e.g., really, what is the chance you will die in a plane crash today?) may help some in the moment, but usually don’t get to the root of the matter. Jesus encourages fearful people by pointing them to see life from 40,000 feet. He doesn’t deny risk and suffering but encourages folks to keep their eyes on him. And with Peter, he reaches out to grab him even when he does start looking at the waves.

But what of the physiology of anxiety? What do we know and how does the christian counselor make use of the data?

  1. Fear responses are quickly learned and seemingly etched into the amygdala. One bad experience of food poisoning from a turkey sandwich at Applebees means my stomach tenses a little when I see deli turkey, even without remembering the food poisoning. Imagine what happens if you suffer repeated assaults or worse! The earlier the person is exposed to deep fears, the more likely they suffer from hyperarousal and startle responses.
  2. Neurotransmitters are involved which means you act first and think later. There’s little conscious cognitive processes involved until after anxiety is under way. Fear inducing stimuli lead to immediate neurotransmitter changes that then divert blood from organs to muscles. Tension builds, shallower, less effective breathing begins. Carbon Dioxide levels decrease in the blood stream which in turns creates pain, numbness, and a sense of danger. And so the cycle continues. During and after, we make attributions and so enhance the connections of the feared stimuli and our flight response. The higher the perception of pain, the greater fear/flight response. Despite medical advances, most of our medications either shut down the feed-back loop (beta blockers, anti-anxiety meds like xanax) or attempt to increase the available neurotransmitter serotonin associated with positive outlook.
  3. OCD, in particular, has some probable links to early exposure to viruses such as Strep and Flu. There is a higher incidence of OCD in people born during winter months and who live in colder climates. The link is not clear.
  4. PTSD patients have higher right hemisphere brain activity (than do non-PTSD individuals) when exposed to anxiety provoking stimuli. Further, it appears that trauma patients have greater difficulty coming back to “center” after a trigger. Likely the hypothalamus and other brain structures are overactive in the stress response and do not “cool” down quickly.

That’s just a few things we think we know about the physiology of fear. Now, what do we do with fear from a spiritual standpoint?

  1. Worship. Worship/meditation on other things takes our attention away from the fear stimulus. It forms habits and relationships as we repeat what we want to believe until we actually own it and believe it on its own merits.
  2. Fight. We do challenge our thinking as soon as we can. Yes, the fight/flight chemicals are coursing through our veins but we challenge just the same so we can break some of the connections and the ways we reinforce our fears. One other way we fight may seem a bit odd. We admit there are real things that are scary and overwhelming out there. We do not try to deny the reality of suffering (past or future) but admit it over and over. It is scary to die. I was assaulted in that alley. I am in pain and more may be coming. But, God is with me and it is good to call on him and ask him tough questions about his protection of me.
  3. Stay Present. Being present in the moment is essential to avoiding living in the fear of the past or the future. Some fear is indeed in the present but most are not. When I am able to focus or describe the now, I am less likely to be imagining a future feared event. “Right now I am sitting at my desk and looking at a picture of my children and enjoying the smiles on their faces. Right now I am getting ready for bed and working on a sudoku puzzle and noticing that I am getting tired.”
  4. Work. Building habits where I do not allow myself to run from the feared situations (where appropriate!). Moving myself closer to some of the feared scenarios in a slow and consistent manner. No, this is not flooding (where you are dumped in the pit of snakes because you have a phobia of snakes…). Allow the work to take the time to reorient the deep recesses of the brain. Don’t expect or look for immediate change!

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Filed under Anxiety, biblical counseling, christian counseling, christian psychology, counseling science, counseling skills, Mindfulness

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February 22, 2011 · 11:47 am

One treatment protocol for many DSM diagnoses?


Could we devise one mental health treatment for many counseling problems? Given that so many problems have similar symptoms (anxiety, mood dysregulation, vigilance, intrusive and unwanted thoughts, etc.) and appear to involve common neurobiological processes (limbic systems), might we be able to find a single treatment for multiple expressions of problems?

David Barlow and others say yes.

The Renfrew Center (an eating disorder clinic) publishes Perspectives: A Professional Journal of the Renfrew Center Foundation, a free journal. In their Winter 2011 issue they have a brief article by David Barlow and Christina Boisseau about a new “transdiagnostic unified treatment protocol” (UP) that can be applied to all anxiety and depressive (and eating) disorders. Let me summarize a few points from the article:

  • 70 to 80% of clients with eating disorders also have anxiety disorders, 50% meet criteria for depression
  • A number of anxiety and depressive disorders have emotional dysregulation as a central theme
  • Etiology of these diagnoses may be best accounted for by “triple vulnerability theory”: biological vulnerability to negative mood…early negative childhood experiences due to attachment issues or unpredictable environment leading to an elevated sympathetic nervous system…and psychological learning from an event focusing on a particular issue (anxiety, panic, observation of parent’s panic, etc.)
  • The Unified Protocol (UP) focuses on “the way that individuals with emotional disorders experience and respond to their emotions” (p. 3). UP consists of 5 core modules
    • emotional awareness training (focus on “nonjudgmental present-focused awareness”)
    • cognitive reappraisal (“identifying and subsequently challenging core cognitive themes”)
    • emotion driven behaviors (EDB) and emotional avoidance (identifying maladaptive EDBs, learn new responses and avoid avoiding emotions)
    • awareness and tolerance of physical sensations (self-explanatory…as they relate to emotions)
    • emotion exposure (“…goal is to help patients experience emotions fully and reduce the avoidance that has served to maintain their disorders(s)”)
  • These modules are flexible and shaped to the individual needs of the client

Obviously, there is much work to be done to validate this protocol but it makes sense. You can see the CBT foundation but also a greater focus on emotion rather than cognition.

Those interested in the full text and references can find it here!

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Filed under Anxiety, counseling, counseling science, cultural apologetics, Doctrine/Theology, Psychology

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January 3, 2011 · 5:25 am

Edna Foa and prolonged exposure therapy


Happy New Year everyone!

Check out the Philly Inquirer today (Sunday) for a lengthy piece on Dr. Edna Foa and her creation of prolonged exposure therapy for PTSD victims. It gives nice background info on her and how she came to transition from work with children to adults with anxiety disorders. This is the treatment that is used at UPenn in their treatment of war vets. While this treatment won’t work for everyone, many with OCD and PTSD could be vastly helped with this treatment.

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Filed under Anxiety, Post-Traumatic Stress Disorder, ptsd

December 21, 2010 · 4:02 pm

Christian anxieties?


In light of the holiday stresses and anxieties, I bring you a couple of thoughts regarding “Christian” anxiety.

Everyone faces anxiety at times in their life (unless you lost your amygdala) But some anxieties are unique to evangelical Christians:

1. What if I am out of God’s will? What if I make the wrong choice?

2. What if I committed the sin of blaspheming the Holy Spirit?

3. What if I am missing out on the blessing of God? What does it mean if I don’t feel thankful?

4. What if God wants me to stay in this awful situation? What if my situation is God’s punishment for previous sins?

5. What if I’m not sure I believe? Am saved? Have faith?

6. Is God holding out on me because I have weak faith?

I’m sure there are more you could list (feel free to add to this!) that are unique to Christians.

When working with someone struggling with these kinds of intrusive spiritual fears (aren’t all fears intrusive?), I have noted that they often

  • struggle with frequent guilt
  • are comforted by voices around them telling them that they are okay…but the comfort doesn’t last very long as cognitive efforts to convince them they are wrong fail
  • work very hard to do Christian service–sometimes to the point of compulsion

If you or someone you love struggles with these fears consider the following recommendations

1. Listen for the deepest concern. What if’s are almost always present in anxiety. What if I’m not saved? What if God isn’t going to give me my desires? Instead of responding to the surface fear, listen between the lines for deeper concerns (without debating them). For example, fears about not being sure about faith may really be a deep sensation of guilt and or failure to be perfect.

2. Validate AND encourage re-evaluation of the meaning of the fears. Always begin with validation—communicating that (a) it is clear the counselee has a real problem that needs attention, (b) such concerns are painful, BUT—and this is important—, (c) it might be possible that they have mis-identified their spiritual problem. Fear tends to deceive the mind and misdirect attention away from more important matters (e.g., a worry about germs focuses attention on cleanliness but away from underlying fears of being out of control).

3. Counter fear with STOP and MEDITATE techniques. Most people have their self-soothing techniques. Unfortunately, some of these can add to the anxiety. For example, repetitive “Lord save me” prayers will only lead to more belief that you may not be saved. Look for these repeated responses to fear and try to stop them–even if they seem rather religious in nature. Instead, look to meditate on some other part of the bible or of the character of God–something completely out of the orbit of the fear.

4. Develop alternate goals. Most anxious people would like not to be so. Who can blame them? But eliminating anxious spiritual thoughts may not be a good goal. And, the efforts to do so may only increase the spiritual angst. Yes, medication and preceding efforts may reduce anxiety, often the fears remain active in the background. An alternate goal might include (a) resisting the old dialog that engages the fear as important, (b) choosing to use the stimulus of the fear to focus on a specific person in need (a shut-in who needs a call, praying for someone else, etc.). These alternate tasks will reduce the anxious person’s thoughts about self…and thus reduce their anxiety.

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July 26, 2010 · 10:53 am

Ecstasy (MDMA) as treatment for PTSD?


Back from vacation and reading up on my piles of emails. This one came via my Medscape.com subscription to psychiatric news–Ecstasy-assisted Psychotherapy May Help Patients with Treatment-Resistant PTSD. You can read about it here on WebMD.

Interesting…a date rape drug being used to treat PTSD. There is some irony here I think in that many a date-raped woman was taken advantage of when slipped this drug.

How is it purported to work? By reducing or blocking symptoms (intrusive, emotionally laden feelings when thinking about traumatic events) and thereby allowing therapy to do its work. The therapy was done in an intensive manner rather than spaced out as most people do therapy. One wonders if prolonged exposure therapy was used as the therapy. If not, would PE therapy do as well or better than traditional PTSD therapy and MDMA?

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Filed under Abuse, Anxiety, counseling, counseling science, Post-Traumatic Stress Disorder, Psychiatric Medications, Psychology

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July 10, 2010 · 11:09 am

Gardening illustration that works for persistent problems in life


5 years ago a friend of mine asked if I wanted some purple cone flowers for my flower garden around my house.

Having admired them in other gardens, I said yes and promptly planted them in a spot next to some other flowers. Turns out they were Brown Eyed Susans, a relative of the intended flower. And, further, they spread terribly. I enjoyed them the first summer but began ripping them out the next year as they spread through the iris and choked out some other plantings.

Now, some five years later, I am still pulling these plants. They grow and spread quickly. I never let them flower but pull them as soon as I can make sure I get them and not another plan that might be right in the same spot. When I pull them I know that some little root fiber remains and so I’ll be back pulling again in a week or so.

The truth is I will never be free from these plantings. I do have some choices:

  • ignore them and let them take over the garden (BTW, they would be fine in an isolated spot surrounded by grass so they couldn’t take over another planted area)
  • be irritated that I can’t get rid of them and thus fail to see the beauty around them
  • stay vigilant but enjoy the garden
  • try shock and awe by killing everything in that spot.

I find this is much like our persistent life problems. Whether by naive choice or by something beyond our control, we develop persistent struggles with things like anxiety, depression, addictions, relational challenges, etc. While God sometimes provide miraculous removal of these struggles, we rarely find complete freedom from these kinds of struggles. We may not be in crisis mode forever, but total relaxation and assumption of no return of the problem is rare also.

So, we too have some choices:

  • be angry and bitter that the problem continues to have some place in our life
  • blame others for our problems
  • ruminate on why only we seem to have these problems
  • try shock and awe and so destroy lots of other things
  • accept the need to stay vigilant, going after the roots and shoots as soon as we notice them.

Does this illustration work for you?

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Filed under addiction, Anxiety, christian counseling, christian psychology, Christianity, counseling, Depression

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February 2, 2010 · 2:27 pm

The unpardonable sin


Ed Welch has a good post at www.ccef.org on the “unpardonable sin” passage found in Matthew 12. This is a worrisome passage for many–especially those with scrupulosity (aka Obsessive Compulsive Disorder). He hits the nail on the head that the flip answer, “if you are worried about this, you haven’t committed it” is both likely true but also insufficient for the true worriers among us. So, his post goes in great detail about the passage, its context and good conclusions to draw from it. Well worth your read!

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January 12, 2010 · 5:06 am

Perpetuating vulnerable feelings?


Feel unsure of your mate’s love for you? Should you tell them that you are not feeling safe or secure in the relationship? When you tell them (accuse them of not caring?) and they profess their love for you, what will tell you that you can believe their promises? What will tell you to doubt their words?

Two Yale University psychologists (E. Lemay, Jr and M. Clark) explore this problem in 2008 in their “Walking on Eggshells: How Expressing Relationship Insecurities Perpetuates Them” (Journal of Personality & Social Psychology, v95, 420-441).

Their study is fairly long (5 studies in fact). But here are some key points.

When people feel insecure about a partner’s regard and acceptance, they often judge their own prior behavior as having communicated insecurity and emotional vulnerability to the partner. Consequently, they come to believe that they are viewed as especially insecure and vulnerable. Then, due to shared beliefs that people walk on eggshells around insecure, vulnerable others, such reflected appraisals of vulnerability elicit doubts about the authenticity of the partner’s expressions of regard and acceptance. Once authenticity is doubted, positive expressions are discounted, negative expressions are augmented, and hidden negative regard is inferred even when partners are accepting and actually hold positive regard. (p. 436)

What they are saying is that our own anxiety fuels are belief that they know we are vulnerable and are tiptoeing around us and that we doubt they love us and then we read their actions through a lens that denies the evidence of love and declares their love to be inauthentic. Which of course, we then share with them. Repeat this action and sooner or later they don’t want to be declared a liar anymore and distance from us thereby proving our deepest fears of abandonment.

In short, anticipated rejection leads to presumption that it has happened and that any activity countering that presumption is rejected and re-read through the lens of rejection. Because that is what we believe happens to weak people–they are abandoned.

So, should we keep our fears to ourself? No say the researchers. Then what should be done? The researchers say only a little on this (since it is not the focus of their research here). But, challenging cognitive distortions are at the top their list? What distortions in particular? Believing that others see you as weak as you feel; challenging the interpretations of another’s motivation. Also in their suggestions is practicing reading the commitment of the mate to the relationship by re-appraising and collecting the evidence of authentic responses from that mate.

The next time you feel the need to express your fears that your mate doesn’t really love you check to see whether your insecurity isn’t already telling you the answer you fear and rejecting evidence to the contrary. Dig a little and you may be able to find evidence that shows they love you. Then, be specific and tell them one concrete thing you would like to see changed, something that bothers you. Do it in love so as to not trigger their fears that you do not love them. Be wary of listening too much to your fears!

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January 6, 2010 · 11:33 am

Some thoughts on “This Emotional Life”


Caught part II of a 3 part, 6 hour, series on PBS last night. This Emotional Life, moderated by Dr. Dan Gilbert. I recommend you check out, at minimum their website but if you get a chance, tonight your local pbs station may air the 3rd part. The website includes lots of info about the various topics, individuals interviewed, and the whole first episode (which I have yet to watch). The series focuses on love and family relationships and attachment (#1), negative emotions such as anger, fear, and depression (#2), and happiness (#3).

Now, there are a number of irritations I have about the program but the good outweighs the bad. What don’t I like?  I don’t like the way they say, “Science says…” and then do not discriminate between data and interpretation of said data. I don’t like the repetitive evolutionary comments. For example, “the newer part of your brain can’t communicate with the older part” assumes that because we have a cerebral cortex and animals don’t have as well-developed cortexes, that part of our brain is “newer.” Further, the view of humanity in episode 2 seems to be that of the human physical robot. There is no space for the spiritual. One quote from the episode, “Mental illness is nothing less than a physical illness that has psychological consequences.” It is as if emotions are only chemical.

But these small problems can be easily forgiven. Here’s what I like from episode 2:

  • The honest admissions of struggles of celebrities (e.g., Katie Couric’s admission she has intrusive thoughts of jumping off high balconies, Chevy Chase’s admission of depression, etc.)
  • The gripping stories of struggler’s with anger, anxiety, and depression (especially two vet’s struggle with PTSD) and the significant impact of the struggles on the other family members
  • You really get a window into their interactions with their therapists. Lots of good video that is rare to see!
  • The scientific discoveries relating to the brain and the experiences of these negative emotions. For example:
    • Stress hormones seem to strengthen memory formation. Thus traumatic experiences likely etch bad memories much deeper than other memories.
    • Re-appraisal (neutral re-evaluation) of events where you experience negative emotions supports more control of these emotions whereas rumination causes us to be more reactive
    • Prolonged exposure therapy (telling, retelling and retelling again) for PTSD patients seems to have significant positive benefits (though it defies logic–most people want to get away from their bad memories)
    • Depressed individuals tend to have reduced hippocampus volume. Antidepressants and ECT seem not merely to change brain chemistry but actually increase cell growth. Depression actually seems to change the brain and antidepressant use stops hippocampus shrinkage

A couple of other interesting tidbits:

  • Emotion regulation: not trying to turn off emotion but tools to change the course of emotion
  • “Don’t believe everything you think.” But, we tend to nonetheless
  • Struggling with overwhelming anxiety? Accept that you have these feelings (crying, tension, fear), accept that they are physiological experiences, avoid labeling them as awful. You will have scary thoughts and you can live with them
  • “What is the worst thing that could happen right now?” I might cry. “And what if you do?” That would be bad. By accepting these emotions you can distance from the meaning you are applying to them.
  • There are biological indicators in those who are highly reactive to stress. These folks can’t help their reaction but they can recognize their tendencies and respond differently to them.
  • Untreated mental illness is harder to treat if left untreated for long periods of time.
  • Richard Lewis on the benefits of therapy and getting to talk about things he never talked about with anyone: “Maybe for the time I left her (his therapist) office til I got in my car I was floating on air”. Hmm, is that worth the 150 dollars he probably paid?

Finally, I leave you with this. Perceptions of progress, or lack thereof, have a huge impact on your perceptions of happiness. One young girl thought her ECT would help sooner than it did. When it did not, she crashed even worse. Even more than our physiology of emotions, our perceptions of our well-being and our progress often dictate our beliefs about ourselves and our futures.

If you saw it, what did you think?

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Filed under anger, Anxiety, counseling, Psychiatric Medications, Psychology

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October 26, 2009 · 9:13 am

PTSD and surgery mortality rates


Today I begin “Counseling & Physiology”, a crash course (6 weeks!) for my students to explore the mind/body connections and how counselors pay attention to the body even if not their primary focus.

Last week I saw this news item on my Medscape.com feed: “Veterans with PTSD twice as likely to die after surgery”

Here are some of the highlights from a research study done at the San Francisco VA and UC San Francisco:

  1. 10 year retrospective study of 1792 vets (ending in 2008). 7.8% had established dx of PTSD. On average vets with PTSD were 7 years younger than those without the diagnosis (you would think then, younger = higher survival rates). Surgeries studied were elective surgeries.
  2. 25% increase in mortality 1 year post surgery for vets with PTSD, even if surgery happens years after getting out of the service
  3. Mortality rates for these vets were higher than those with Diabetes
  4. PTSD is an independent risk factor for mortality
  5. DX of PTSD was associated with increased cardiac issues (may point to why the mortality rates are higher

Sobering research if you ask me. Let us not become lazy in our thinking. Emotional problems such as severe depression and anxiety (which PTSD tends to bring both together) have a substantial impact on the entire person, affecting every part of the person from cells to spirit. Neither let us believe that if the cells are involved in such a disorder that there is nothing that counselors can do. Clients can learn to manage and even defeat some of the symptoms of PTSD by taking control of their thought life.

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