Dr Robert London

Managing Anxiety in Stressful Times

Clinical Psychiatry News - June 2009 (Vol. 37, Issue 6, Page 16)

A few weeks ago, at the height of the H1N1 flu scare, I thought about a gentleman I once treated.

This patient became anxious over any mention of an impending flu season or epidemic as the winter approached. He also collected any information he could on the flu—where it hits, and how bad it is—and he made sure to follow any precautions he could to make sure that he did not get sick. After hearing of a flu death or serious complication, this patient's mind would race, and his autonomic responses of headache and gastrointestinal/urinary tract symptoms would dominate a good part of his day.

His symptoms of autonomic hyperactivity, anxiety, and a cognitive vigilance were consistent with generalized anxiety disorder, or GAD.

Survey data on the prevalence of GAD suggest that 5% of the population suffers from this disorder, and at any give time, if the information from anxiety disorder clinics is evaluated, 25% of patients in these programs suffer from GAD (“Synopsis of Psychiatry,” Benjamin Sadock and Virginia A. Sadock, [Philadelphia: Lippincott, Williams & Wilkins, 2002]).

I prefer to view anxiety disorders as a spectrum set of disorders with subthreshold and subclinical forms, and therefore, far more people than are officially documented actually suffer from a form of GAD, and should be diagnosed and offered treatment.

The large number of people with confirmed GAD and subthreshold and subclinical variants of GAD are profoundly affected mentally and physically by their disorder.

In addition, they are affected by official- and media-generated messages about events such as the recent swine flu “pandemic.”

Their frightening daily remarks resembled a group cognitive therapy session gone wrong, where common-sense thinking was challenged with anxiety-stimulating doom and gloom perspectives. These messages offered little reassurance and hope, but rather laid the groundwork for increased anxiety and stress in the entire population.

When an extremely serious issue such as swine flu threatens the general public, and the media is used daily, around the clock to broadcast information, the result can be an unintended spread of negative cognitive challenges.

This kind of barrage can worsen negative, fearful, and anxiety-producing thoughts on a global level, and this is contrary to positive thinking.

When expert after expert makes an ominous comparison of the current H1N1 to a disastrous epidemic of almost 100 years ago—when our medical knowledge was far less advanced than it is today—not only those with GAD and subthreshold/subclinical GAD, but a large portion of the general population is affected.

Use of the term pandemic—which refers to the global spread of the illness rather than its intensity—without a specific definition produces serious anxiety in the general population.

As I listened to the experts, the only consistent voice of clear clinical insights, reassurance, and balance was that of Dr. Thomas R. Frieden, the New York City health commissioner, now President Obama's appointed director of the Centers for Disease Control and Prevention. In television interviews, Dr. Frieden—an infectious disease specialist—provided perspective that was measured and thoughtful.

This is the kind of approach we should use with our patients. Cognitive therapy, which is aimed at using thinking to challenge and alter thoughts and behaviors, can provide some relief.

Therapeutically alternative perspectives are offered in a structured manner, sometimes using a hierarchy of ideas and concepts to offer a person a different or modified way to change thoughts and behaviors. A person who is fearful of crossing a bridge or going through a tunnel can be offered various ways to rethink and therefore restructure his behavior surrounding this type of phobia.

So, too, can personality styles be modified or changed using cognitive processes. One of the methods I use in cognitive therapy or cognitive challenges is the concept of possibilities and probabilities.

My approach has been to have a person begin to think that the world might end the next day as possibility (usually getting a good laugh at the unreality of that possibility vs. the probability of the world ending).

In working with the gentleman mentioned earlier, we established a series of challenges using possibilities vs. probabilities regarding many of his GAD-related worries, which included concerns about catching the flu.

We took the least of his worries, fears, and anxiety, and created cognitive challenges that avoided his all-or-nothing thinking to more a moderate type of thinking as the concept of possibilities and probabilities were taught. His thought patterns were changed over a period of time, giving him more options and greater latitude in his thinking.

When it comes to public health, care should be taken to avoid psychological epidemics in our population created when spreading anxiety-provoking news about the dangers and spread of a physical illness that can affect millions.

Providing information properly and lowering the “epidemics of anxiety” to prevent unnecessary suffering in people with full-blown or subclinical GAD should be at the forefront of public health policy.

Let me know your thoughts about this topic and how we might treat anxiety individually—and nationally—and I will try to pass them along to my readers.

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