Dr Robert London

Treating Situational Anxiety

Clinical Psychiatry News - Volume 36, Issue 8, Page 27 (August 2008)

Former Texas Sen. Phil Gramm's recent comment that we are in the midst of a “mental recession” did not go over well on the campaign trail. However, we psychiatrists know that today in America, we do find ourselves in a state of national anxiety.

We are in the midst of a financial crisis that appears to have affected many walks of life. Job loss, fear of job loss, and excessively high food and gasoline prices are stressing the American psyche. People are falling behind on car, health, mortgage payments—leading to worry, stress, and anxiety. For many, just the thought of being cash poor is anxiety provoking.

The reality of being in this vulnerable position is causing a national trauma affecting millions. It might even include the beginnings of posttraumatic stress disorder or, perhaps, the subthreshold variety (“Latest Evidence on PTSD May Bring Changes in DSM-V,” CLINICAL PSYCHIATRY NEWS, November 2007, p. 1).

For many, not being able to buy food or pay the rent or the mortgage is causing tremendous anxiety and can lead to the usual terrors of rapid heart beats, shortness of breath, excessive sweating, tingling/numbness, choking, insomnia, nightmares, even chest pain and dizziness with the potential of fainting or collapsing. Tremendous anxiety also can lead to frustration and anger—which can manifest in physical and verbal abuse, and abuse of alcohol and other substances. Such severe responses can be expected, considering the magnitude of the stressors affecting patients.

When we add in the population with anxiety disorders and those who are more vulnerable to stressors because of heredity or what they have learned, it becomes clear that a major psychosocial problem needs to be addressed—not unlike the epidemic of childhood obesity or diabetes.

Obviously, medication management with benzodiazepines or selective serotonin reuptake inhibitors has been helpful in treating many anxiety disorders. However fast these medications may work, though, medication combined with psychotherapy appears to be more helpful in moderating the anxiety or controlling it completely. For many, some form of counseling or psychotherapy alone is what's necessary. However, parity for mental health care has never been a reality.
Identifying Treatments
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The technique I use for treating generalized anxiety disorders involves the learning, philosophizing, and action (LPA) technique I developed many years ago. With this, I explore with patients how they could have learned to be anxious in so many different situations and why their anxiety is having a negative effect on their work, social life, or both.

I have found that patients very early on are able to recall being taught to worry or fear within the environment in which they grew up. The learning part of the LPA technique quickly emerges, and a matrix of recall heightens what was learned. Of course, the challenge now developing is a treatment strategy aimed at easing the anxiety or controlling it.

A second type of person trying to deal with a generalized anxiety disorder might remember a family dynamic in which fear and danger of things permeated the environment. For those patients, it's important to offer insight that helps them learn how this view of the world developed, in addition to including a philosophical review of how these fears and worries might have occurred. Philosophizing about possibilities usually brings to the forefront a series of real memories that place the patient at the same level of learning as person number one, who learned it straight away.

The memories I explore most often relate to issues of abandonment; dependence; heredity; lack of attention when stressed; and ongoing issues centering on danger, fear, or growing up surrounded with anxiety—and the notion that that anxiety is normal. Most patients are then able to philosophize further at an even greater extent about these issues, giving them a concrete reason to be anxious.

The action approach revolves around the development of mental challenges that allow the patient to overcome the anxious state. John is told over and over again to be careful when going to school or to the movies with friends because danger lurks, so a model of worry and fear gets laid down. However, when Jim goes to school or to the movies with friends, the message is that going to school and the movies is fun. Obviously, John and Jim will grow up with different mental sets of the world around them. For the anxiety disorder patient, we need to help reprocess thoughts that lead to anxiety.

Anxiety is a learned response acquired in previous anxiety-producing situations. As we substitute how school or the movies most often are good and positive experiences, the patients motivated for change, as the dialectic continues, are able to redo the wiring through these cognitive challenges.

In addition, I like to add a rapid de-escalation of anxiety technique in the form of reciprocal inhibition, in which relaxation techniques are used as quick methods to control anxiety. The idea is to try visualizing a pleasant, relaxing experience, usually with the eyes closed. With practice, the relaxation techniques can be used to stop the surge of anxiety quickly. When a person is able to enter a relaxed state, that relaxed state is incompatible with anxiety and the patient quickly gets empowered with a mastery effect.

But with money less available and managed care offering less, we psychiatrists should think about anxiety reduction methods that help people calm down and think clearer as they move toward solutions in this serious economic downturn.

Now I'd like to discuss strategies for treating people who are anxiety ridden because of the current severe economic downturn.
The Role of Exercise
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As part of my examination of these issues, I spoke with a friend, Heather Nicole Combs. Ms. Combs, who is an attorney and advertising executive, was a tennis star in the South Atlantic Conference while in college. She said that, during periods of stress and anxiety in high school, college, and law school, an hour of tennis—although tiring—gave her tremendous, long-lasting relief from anxiety states.

Although that does not mean we should all become athletes, this example does suggest that alternatives to psychotherapy exist that can reduce anxious states for those who are facing the loss of a home, health insurance, or automobile and are unable to think clearly as a result of severe situational anxiety.

The refocusing of thoughts through various diversions, as Ms. Combs discussed, is an example of how anxiety reduction can be self-managed. Research has shown that the use of meditation and yoga appears to offer a similar decrease in anxiety. Hypnosis and self-hypnosis probably do the same thing. After all, many of these techniques appear to be different ceremonies or expressions of the same human ability we have to shift gears mentally.

While discussing these issues, Taisiya Tumarinson, a medical student with whom I'm working, mentioned the brain-imaging work of Richard J. Davidson, Ph.D., of the University of Wisconsin, Madison. She pointed out that Dr. Davidson has shown that, with regular meditation, prefrontal activity shifts from the right to the left hemisphere—reorienting the brain from fight or flight (anxiety) to a place of acceptance and contentment.

What does all this mean?

If we can slow or change frontal lobe or even limbic system activity without long-term or even shorter-term behavioral/cognitive strategies for anxiety treatment in these overwhelmed people, why not try doing so? By slowing or changing the activity in specific cerebral/limbic areas, we allow patients to feel better, think in a clearer manner, and become better informed about moving toward a set of solutions.

For patients with situational anxiety, solid psychiatric advice in anxiety reduction that helps them figure out how to negotiate with lenders or scale down unaffordable vacations—might be the most valuable kind of contribution we can make after we've directed them toward anxiety reduction techniques that are broader than medication and psychotherapy. Just as physicians with expertise in infectious diseases or emergency department medicine provide guidance to the community during periods of crisis, so can we. I'm sure that many schools and community centers would open their doors and let us share our knowledge and guidance.

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