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June 26, 2014

Coping with Anxiety

Reuel S. Amdur

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Sigmund Freud made a distinction between fear and anxiety. Fear is a reaction to a real present danger, while in anxiety the danger is absent. On June 19 Dr. Jakov Shlik spoke to an audience at the Royal Ottawa Hospital about living with anxiety. He is the clinical director of the hospital's Mood and Anxiety Program.

This is a report plus occasional comment on his presentation and that of his guest.  He began by addressing the magnitude of the problem.  He pointed out that one in five experience serious anxiety during a lifetime, with one in ten in any given year.  By evolution, we are programmed at birth to be afraid.  That fear serves to help us avoid danger.  Anxiety, he explained, can on the one hand be devastating, and on the other hand it can propel one to greater effort.  Worry is not bad in itself; it is how one deals with it that is important.  Looking at the negative aspect, it can be devastating for work, health, and family.  Some anxiety is normal, but when we speak here of anxiety we refer to excess.

General anxiety is very difficult to treat.  It is a complex of emotions, thoughts, sensations, and behaviors.  People try to avoid anxiety-producing situations.

Anxiety is not a “pure” condition.  There are different kinds of anxiety and anxiety is often found in combination with other conditions, especially depression.  Examples of types of anxiety are panic disorder, phobias, obsessive compulsive disorder, and trauma and stress disorders such as post-traumatic stress disorder (PTSD).  Anxiety is often found in bipolar disorder and is frequently present in schizophrenia, when paranoid thinking is present.

There is a high prevalence of anxiety.  It typically has an early onset and is long-lasting or recurrent.  The condition can be disabling and costly to the person, the family, the economy, and society.  It can lead to depression, addiction, and physical disability.  Medications to treat the problem may have limited impact, and they may produce undesirable side effects.

There are a number of barriers to dealing with anxiety.  To begin, there is the stigma that exists for all mental illness—self-stigma and public stigma.  Then there is a low level of diagnosis and an even lower level of treatment.  Availability of treatment is limited, with long waiting lists.  On top of all that, treatment has limited effectiveness.

Causation is complex, involving the brain, genetics, personality, environment, and the threat.  Anxiety, said Adam Beck, occurs when the perceived risk of a threat outweighs the perceived resources for coping. 

Shlik cited Robert Leahy’s anxiety paradigm.  The first step is detecting the danger, then turning it into a catastrophe.  To deal with the danger, the person tries to control everything and to avoid or escape the threat.  To counter the anxiety, there are things that can be done at each step.  The danger, in the first place, needs to be seen realistically, and then the consequences of the danger also need to be evaluated realistically.  Instead of total control, it is necessary to let go, and rather than avoiding or escaping, the person needs to “embrace” the anxiety.  “I live with it.  What can I do better?”  The effort is not to get rid of the anxiety but to learn to cope in spite of it.

Dr. Shlik suggested some sources of help.  There are many books and apps that are available, and as well he referred to two associations that provide information and support: the Anxiety Disorders Association of Canada and the Anxiety and Depression Association of America.  The Canadian Mental Health Association and family service agencies provide counseling. 

Shlik introduced “Lynne,” a woman who has been one of his patients.  She described her experiences with anxiety.  She can recall an event back when she was only three.  Over the years her anxiety has left her confused, uncomfortable, sad, and lonely.  At 15, she attempted suicide.  Her family and her family doctor told her not to talk to people about her problem.  This was precisely the wrong advice.  She argued that people with anxiety need to let everyone know, especially family members, including children.

When she was in her early 30’s, she still did not know what her problem was.  She took to alcohol, which increased her depression, so she stopped.  Then she gambled, and after serious losses she stopped that as well.  There were further suicide attempts.  And throughout all this time her self-image declined further and further.  When she finally began treatment, she was diagnosed with a chronic panic disorder and depression.  Her more appropriate way of coping was treatment plus work plus playing the violin—and engaging in mental health promotion.

Older psychiatric texts say that the prognosis for anxiety depends on the person’s previous success or failure in life.  Dr. Shlik was not in agreement, arguing that a life full of failure could follow an early onset of anxiety.  Anxiety typically has an early onset, as in Lynne’s case, but early onset that blossoms more extensively might explain that negative history.

Treatment modalities that may be employed include cognitive behavioral therapy and mindfulness, a practice originating in Buddhism.  Psychology Today defines mindfulness as “a state of active, open attention on the present.  When you’re mindful, you observe your thoughts and feelings from a distance, without judging them good or bad.  Instead of letting your life pass you by, mindfulness means living in the moment and awakening to experience.”

As Lynne demonstrates, it is possible to live and flourish in spite of anxiety, even if total cure is not in the cards. 

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