Anxiety
Dr. Christian Jonathan Haverkampf, M.D.
Anxiety disorder can be very debilitating. Between 15% and 20% of the population may at any point in time be affected by anxiety. From a communication perspective there is much that can be done to help a person suffering from anxiety with the help of psychotherapy. At the same time, medication can be an important and fast acting support while psychotherapy is taking full effect. This article gives an overview of both, while focusing on communication-focused therapy in the treatment of anxiety.
Keywords: anxiety, generalized anxiety disorder, panic attacks, social anxiety, psychotherapy
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Contents
Psychotherapy and Medication. 4
Psychodynamic Psychotherapy and CBT. 12
Communication-Focused Therapy® (CFT) 12
Awareness of the Inner Workings of Anxiety. 23
Values, Needs and Aspirations. 25
Meaningful Messages as the Instrument of Change. 27
Selective Serotonin Reuptake Inhibitors (SSRIs) 27
Second Generation Antipsychotics (SGAa) 29
Non-benzodiazepine anxiolytics. 30
Introduction
Anxiety is a normal human emotion which can confer and advantage on the individual experiencing it. Repeated intense anxiety, however, can interfere with life, and a good size of the population suffers from anxiety disorder, and in many instances repeated panic attacks.
Psychotherapy is often the preferred approach to treat anxiety in the long run. At the same time, medication can be very helpful in the beginning to lower the anxiety to a tolerable level and to maintain this state until the effects of psychotherapy bring about a lasting effect. In some cases, medication may also be necessary for the long run.
There are various kinds of psychotherapy which have shown to treat various anxiety conditions, such as generalized anxiety disorder, panic attacks, social anxiety, and more. CBT, psychodynamic psychotherapy, interpersonal psychotherapy and others have made valid contributions. The author has developed communication-focused therapy (CFT) which focuses on processes which underlie most of these approaches, and which has been described by the author for several mental health conditions, including anxiety and depression. (G)(H)
Psychotherapy and Medication
Medication can be an important support to lower the level of anxiety significantly, while the psychotherapy is beginning to work. (Haverkampf, 2017a, 2018a) Except for short acting anxiolytics, there are no specific long-term ones. However, serotonergic antidepressants, such as the selective serotonin reuptake inhibitors (SSRIs) and the serotonin and norepinephrine reuptake inhibitors (SNRIs), are usually considered first choice in the treatment of anxiety disorders and panic attacks. Other types of medication, which work primarily on GABA receptors, such as the antiepileptics gabapentin and pregabalin, or on the dopamine neurotransmission system, such as second-generation antipsychotics, are also used to increase the effect of the antidepressant. The effectiveness of SSRIs in the treatment of anxiety and panic attacks is usually good to very good, while the mentioned augmentation strategies often decrease anxiety levels in patients who respond only partially to the SSRIs. The SNRIs are also effective in most cases of anxiety but can increase the anxiety in the beginning more than the SSRIs.
In the case of anxiety, medication should always be combined with psychotherapy and optimally also with a therapeutic approach which involves the body or some form of meditation, such as mindfulness, or both. Since anxiety is experienced through the body, approaches involving the body can help to stop the vicious cycle in which anxiety causes bodily sensations, which in turn again cause anxiety.
Symptoms
Anxiety is an emotion characterized by an unpleasant state of inner turmoil, often accompanied by nervous behavior, such as pacing back and forth, somatic complaints, and rumination. (A) If the anxiety becomes sudden and more intense, it can lead to panic attacks, episodic anxiety attacks of high intensity with the fear of impending doom.
Fear is, unlike anxiety, a response to a real or perceived threat (B) or the expectation of a future threat. (C) Anxiety contains an element of uncertainty, which is often less directed at the outside world, but more at the inside. There may, for example, be a sense of losing control over an important bodily function or over one’s emotions. In a sense it is a perceived need for control over a part of oneself that is not under conscious control.
Physical Symptoms
Anxiety is often accompanied by muscular tension (C), restlessness, fatigue and problems in concentration. The physiological symptoms of anxiety may include: (E)(F)
- Neurological, as headache, paresthesia, vertigo, or presyncope.
- Digestive, as abdominal pain, nausea, diarrhea, indigestion, dry mouth, or bolus.
- Respiratory, as shortness of breath or sighing breathing.
- Cardiac, as palpitations, tachycardia, or chest pain.
- Muscular, as fatigue, tremors, or tetany.
- Cutaneous, as perspiration, or itchy skin.
- Uro-genital, as frequent urination, urinary urgency, dyspareunia, or impotence.
Avoidance
People facing anxiety may withdraw from situations which have provoked anxiety in the past. [4] This may be certain situations or groups of people. In the extreme, anxiety can lead to total withdrawal into one’s room and avoidance of life itself.
The problem with avoidance is that it can further increase the levels of anxiety. Meaningful communication helps to regulate one’s inner life, and withdrawal can lead to even more anxiety, a worsening of the mood and decreases in motivation and initiative. Frequently, people suffering from anxiety get into a vicious cycle, which maintains the anxiety and can also come with the mentioned symptoms of depression.
Co-Morbidity
Anxiety has been linked with physical symptoms such as Irritable Bowel Syndrome (IBS) and can heighten other mental health illnesses such as OCD and panic disorder. As the anxiety level increases, the activation of the autonomic nervous system increases, and various brain regions can be activated or deactivated. Over time, this can lead to various psychiatric and physical symptoms, which could be managed if the anxiety is treated.
Causes
Anxiety may have biological, psychological or social/external reasons. Often, there is a combination of all these factors. One may have a biological predisposition for anxiety, which is heritable to an extent, have been exposed to anxious family members and/or have experienced traumatizing events, that compromised one’s sense of certainty and predictability in the world. Anxiety can then be triggered by events, often on an interpersonal level, which cause strong, and usually conflicting emotions. The anxiety may not begin right away, and panic attacks can often be delayed by days or even months.
Biological Causes
Anxiety disorders are partly genetic but may also be triggered, due to drug use, including alcohol and caffeine, as well as withdrawal from certain drugs. They often occur with other mental disorders, particularly major depressive disorder, bipolar disorder, certain personality disorders, and eating disorders.
There are other psychiatric and medical problems that may mimic the symptoms of an anxiety disorder, such as hyperthyroidism. It s important that other medical issues are treated before psychiatric medication is initiated, unless treatment either takes a long time or is not possible.
Neuroanatomy
Neural circuitry involving the amygdala (which regulates emotions like anxiety and fear, stimulating the HPA Axis and sympathetic nervous system) and hippocampus (which is implicated in emotional memory along with the amygdala) is thought to underlie anxiety. People who have anxiety tend to show high activity in response to emotional stimuli in the amygdala. Some writers believe that excessive anxiety can lead to an overpotentiation of the limbic system (which includes the amygdala and nucleus accumbens), giving increased future anxiety, but this does not appear to have been proven.
Research upon adolescents who as infants had been highly apprehensive, vigilant, and fearful finds that their nucleus accumbens is more sensitive than that in other people when deciding to make an action that determined whether they received a reward. This suggests a link between circuits responsible for fear and also reward in anxious people. As researchers note, “a sense of ‘responsibility’, or self agency, in a context of uncertainty (probabilistic outcomes) drives the neural system underlying appetitive motivation (i.e., nucleus accumbens) more strongly in temperamentally inhibited than noninhibited adolescents”.
Genetic
Genetics and family history (e.g., parental anxiety) may predispose an individual for an increased risk of an anxiety disorder, but generally external stimuli will trigger its onset or exacerbation. Genetic differences account for about 43% of variance in panic disorder and 28% in generalized anxiety disorder. Although single genes are neither necessary nor sufficient for anxiety by themselves, several gene polymorphisms have been found to correlate with anxiety: PLXNA2, SERT, CRH, COMT and BDNF. Several of these genes influence neurotransmitters (such as serotonin and norepinephrine) and hormones (such as cortisol) which are implicated in anxiety. The epigenetic signature of at least one of these genes BDNF has also been associated with anxiety and specific patterns of neural activity.
Medical conditions
Many medical conditions can cause anxiety. This includes conditions that affect the ability to breathe, like COPD and asthma, and the difficulty in breathing that often occurs near death. Conditions that cause abdominal pain or chest pain can cause anxiety and may in some cases be a somatization of anxiety; the same is true for some sexual dysfunctions. Conditions that affect the face or the skin can cause social anxiety especially among adolescents, and developmental disabilities often lead to social anxiety for children as well. Life-threatening conditions like cancer also cause anxiety.
Furthermore, certain organic diseases may present with anxiety or symptoms that mimic anxiety. These disorders include certain endocrine diseases (hypo- and hyperthyroidism, hyperprolactinemia), metabolic disorders (diabetes), deficiency states (low levels of vitamin D, B2, B12, folic acid), gastrointestinal diseases (celiac disease, non-celiac gluten sensitivity, inflammatory bowel disease), heart diseases, blood diseases (anemia), cerebral vascular accidents (transient ischemic attack, stroke), and brain degenerative diseases (Parkinson’s disease, dementia, multiple sclerosis, Huntington’s disease), among others.
Substance-induced
Several drugs can cause or worsen anxiety, whether in intoxication, withdrawal, or from chronic use. These include alcohol, tobacco, cannabis, sedatives (including prescription benzodiazepines), opioids (including prescription pain killers and illicit drugs like heroin), stimulants (such as caffeine, cocaine and amphetamines), hallucinogens, and inhalants. While many often report self-medicating anxiety with these substances, improvements in anxiety from drugs are usually short-lived (with worsening of anxiety in the long-term, sometimes with acute anxiety as soon as the drug effects wear off) and tend to be exaggerated. Acute exposure to toxic levels of benzene may cause euphoria, anxiety, and irritability lasting up to 2 weeks after the exposure.
Psychological Causes
Poor coping skills (e.g., rigidity/inflexible problem solving, denial, avoidance, impulsivity, extreme self-expectation, affective instability, and inability to focus on problems) are associated with anxiety. Anxiety is also linked and perpetuated by the person’s own pessimistic outcome expectancy and how they cope with feedback negativity.
Evolutionary psychology
An evolutionary psychology explanation is that increased anxiety serves the purpose of increased vigilance regarding potential threats in the environment as well as increased tendency to take proactive actions regarding such possible threats. This may cause false positive reactions but an individual suffering from anxiety may also avoid real threats. This may explain why anxious people are less likely to die due to accidents.
When people are confronted with unpleasant and potentially harmful stimuli such as foul odors or tastes, PET-scans show increased blood flow in the amygdala. In these studies, the participants also reported moderate anxiety. This might indicate that anxiety is a protective mechanism designed to prevent the organism from engaging in potentially harmful behaviors.
Cognitive Distortions
Cognitive distortions such as overgeneralizing, catastrophizing, mind reading, emotional reasoning, binocular trick, and mental filter can result in anxiety. For example, an overgeneralized belief that something bad “always” happens may lead someone to have excessive fears of even minimally risky situations and to avoid benign social situations due to anticipatory anxiety of embarrassment. Such unhealthy thoughts can be targets for successful treatment with cognitive therapy.
Psychodynamic Processes
Psychodynamic theory posits that anxiety is often the result of opposing unconscious wishes or fears that manifest via maladaptive defense mechanisms (such as suppression, repression, anticipation, regression, somatization, passive aggression, dissociation) that develop to adapt to problems with early objects (e.g., caregivers) and empathic failures in childhood. For example, persistent parental discouragement of anger may result in repression/suppression of angry feelings which manifests as gastrointestinal distress (somatization) when provoked by another while the anger remains unconscious and outside the individual’s awareness. Such conflicts can be targets for successful treatment with psychodynamic therapy.
Social Factors
Social risk factors for anxiety include a history of trauma (e.g., physical, sexual or emotional abuse or assault), early life experiences and parenting factors (e.g., rejection, lack of warmth, high hostility, harsh discipline, high maternal negative affect, anxious childrearing, modelling of dysfunctional and drug-abusing behavior, discouragement of emotions, poor socialization, poor attachment, and child abuse and neglect), cultural factors (e.g., stoic families/cultures, persecuted minorities including the disabled), and socioeconomics (e.g., uneducated, unemployed, impoverished (although developed countries have higher rates of anxiety disorders than developing countries)).
Social Anxiety
Social anxiety varies in degree and severity. For some people, it is characterized by experiencing discomfort or awkwardness during physical social contact (e.g. embracing, shaking hands, etc.), while in other cases it can lead to a fear of interacting with unfamiliar people altogether. Those suffering from this condition may restrict their lifestyles to accommodate the anxiety, minimizing social interaction whenever possible. Social anxiety also forms a core aspect of certain personality disorders, including avoidant personality disorder.
Humans generally require social acceptance and thus sometimes dread the disapproval of others. Apprehension of being judged by others may cause anxiety in social environments. This is often the result of ‘projection’ by projecting one’s own criticisms and doubts into other people, and then dreading that one is being criticized or judged by one’s own criticisms or judgments. Since we do not know what other people think, we make assumptions of what they might think. In social anxiety, one makes assumptions that others are very critical and unforgiving, which is often how one feels towards oneself if one suffers from (social) anxiety, especially in combination with some form of depression.
Treatment
There are various therapeutic approaches to treat anxiety, among them cognitive behavioral therapy (CBT), psychodynamic psychotherapy and communication-focused therapy (CFT) which was developed by the author.
Psychodynamic Psychotherapy and CBT
Both of these therapies have shown effectiveness in the treatment of anxiety and panic attacks. Both have theories about why they help. The former sees learning processes and certain thought patterns as central, the latter the processing of content at various levels of consciousness and certain processes between therapist and patient. However, they both place little emphasis the communication processes between therapist and patient and inside each that often in clinical processes are what brings about substantial change in the right direction. (Haverkampf, 2017b) Communication-Focused Therapy (CFT) in this respect may be seen as a standalone therapeutic approach or combined with one of the other two approaches.
Communication-Focused Therapy® (CFT)
Ineffective or maladaptive communication patterns and styles can often be observed in individuals suffering from anxiety. They tend to have a greater difficulty communicating their emotions and their needs, wants and aspirations. Identifying and analyzing these patterns is part of CFT, a therapeutic approach which has been developed by the author. This also includes better communication patients have with themselves to better identify own needs and values. The objective should be to have more meaningful communication with oneself and others, which is anxiety reducing and makes it easier to perceive and identify meaning in the world and oneself.
Communication-Focused Therapy (CFT) focuses more specifically on the communication process between patient and therapist to help the patient better communicate internally and with others externally. Improvements in these communication patterns make it easier for the patient to fulfil own needs, values and aspirations and be more effective in the world. Working with communication patterns has been described by the author elsewhere. (Haverkampf, 2010b, 2017e, 2017c, 2018c)
The central piece is that the sending and receiving of meaningful messages is at the heart of any change process. CBT, psychodynamic psychotherapy and IPT help because they define a format in which communication processes take place that can bring about change. However, thy do not work directly with the communication processes. CFT attempts to do so.
Communication is Life
We engage constantly in communication. The cells in our bodies do so with each other using electrical current, molecules, vibrations or even electromagnetic waves. People communicate with each other also through a multitude of channels, which may on several technologies and intermediaries. It does not have to be an email. Spoken communication requires multiple signal translations from electrical and chemical transmission in the nervous system to mechanical transmission as the muscles and the air stream determine the motions of the vocal chords and then as sound waves travelling through the air, followed by various translations on the receiving end. At each end, in the sender and in the receiver, there is also a processing of information which relies on the highly complex networks of the nervous system. Communication, in short, happens everywhere all the time. It is an integral part of life. Certain communication patterns can, however, also contribute to experiencing anxiety and panic attacks.
Communication supports autoregulatory processes by making information available which leads to better adaptation to given situations but also helps to create a better future for the individual by making greater insight into the world available. At the same, communication also takes place on the inside. Unresolved emotional memories and conflicts maintain trigger and maintain anxiety and panic attacks and lead to anxiety about the own emotional states in the sense of being anxious about becoming anxious. Better connectedness on the inside and better insight about the own emotional states and what triggers and maintains them can thus reduce anxiety and panic attacks. However, it is important that this information can lead to changes, hence be meaningful, which usually requires significant openness and flexibility on the inside, as well as in one’s communication with others. This can be developed in CFT.
As already discussed, communication also helps bring more certainty in the world. The more confidence one has in oneself to communicate effectively, the safer one feels in life and the more certain it seems. Being able to deal with a certain amount of uncertainty s important to come up with novel answers and solutions to problems or to be creative in any meaningful way.
Communication Confidence
Anxiety often occurs when the confidence to communicate one’s needs, wishes or feelings is compromised. Humans learn early on that their well-being and survival depends on communicating their needs to others, originally their parents, later their work colleagues, friends, and romantic partners. Communication makes us feel safer in the world, because it is the main tool with which we fulfil our needs, values and aspiration. (Haverkampf, 2010a) Thus, the more confidence one has in one’s communication abilities, internally and externally, the less uncertain the world seems and the safer one feels. This can also reduce anxiety in general, but probably requires a somewhat lengthy learning process.
The sense of connectedness is important to human beings in general, but this need increases particularly in situations that are stressful, pose conflicts or exert some other psychological pressures that make one more aware of the limitations as an individual. Particularly when emotions cannot be communicated, whether sadness or even happiness, one feels any loneliness or disconnectedness more intensely. (Haverkampf, 2010c) This is because the perceived ability to communicate is much more important than an objective physical loneliness. One can, for example, feel very lonely in a large group of people, or feel very connected when sitting by oneself in a tent in a forest. This is because communication can be internal and external, and the confidence in one’s ability to communicate in any area, or lack thereof, largely determines one’s feelings of loneliness.
So, what is communication confidence? Confidence is the feeling or belief that one can have faith in or rely on someone or something. Thus, communication confidence is the feeling that one can rely on one’s communication skills, which is the result of various factors. The better one feels in general, the higher the level of confidence will be. This may also explain why depression and anxiety frequently go together. If I feel more negative in general, I will also be less confident that I can use my communication skills, external and internal, to get what I need, or even to just keep me alive.
The more confidence an individual has in being alert to and send meaningful, relevant, or even vital information which is related to one’s needs, values and aspirations, the lower the anxiety usually is. This can be achieved by feeling better in general, but most importantly by having good communication experiences, which depends on one’s ability to be aware of and influence flows of information, whether in an interpersonal setting or even within oneself. This ability in turn depends on the set of adaptive and effective communication patterns one has at one’s deposal and the skills to select and use them. Therapy is an important setting to work on them.
Uncertainty
In life, one has to live with uncertainty. Uncertainty just means that there is no manual in the beginning and there are still unknowns which leave room for excitement and exploration. Life is a learning experience. An individual suffering from anxiety may have areas in life where she thrives on excitement, and other areas where images of worst case scenarios cause her to freeze when she just considers a change in action or any action at all. Uncertainty to someone suffering from anxiety seems to be bearable in some areas and avoided in others. Often, the areas where it is not tolerated feel meaningful only to the person suffering from anxiety.
Anxiety requires a certain amount of uncertainty. It often occurs in situations when there is uncertainty about external events or situations, often interpersonal ones, or uncertainty about one’s own feelings, mental or physical states. Without uncertainty about oneself or the world around there is no room for anxiety. However, this it is impossible to achieve a state of complete certainty, which would also make any change or progress impossible. The environment does not even have to change to make changes in the individual necessary. For example, if one develops greater insight in something in the environment or in oneself, changes in one’s thoughts, perspectives, behaviors and interactions may become necessary. Change helps people not only to survive but also to make the best out of their place int the world. The more open an individual is to change and the easier it is for one to implement the change the less reason there is for anxiety. Accepting that there is a level of uncertainty in life makes it easier to develop the tools to deal with it. This raises self-confidence, the sense of efficacy in the world, self-awareness and lowers anxiety.
Information reduces uncertainty, and communication is the mechanism which provides information. Meaningful information has the potential to bring about adaptive and beneficial changes in an individual, even if it only leads to a change in perspective. The information can be about the environment or about oneself, come from the outside or the inside. Communication-focused therapy (CFT) has at its objective to improve the internal and external communication to lead to a reduction in mental health symptoms, greater satisfaction and contentment, as well as greater success in the world to get one’s needs, values and aspirations met. Especially in cases of anxiety and panic attacks, an ability to deal with and integrate uncertainty into one’ s life is very effective in reducing the symptoms.
‘Out of Sync’
Individuals often are more likely to encounter anxiety when there is an underlying feeling that something or things in their life are ‘out of sync’. This can occur in many situations in professional or private realms. A patient with anxiety may not be aware of the signal directly but of the anxiety which is triggered by it. Anxiety then makes it even more difficult to connect with oneself or others to gain insight into what is causing the anxiety. Communication on the inside and on the outside suffers in states of anxiety which makes it more difficult to resolve the issues that have led to the higher anxiety states.
A life is ‘out of sync’ if it does not correlate anymore with one’s values, basic interests, aspirations, true needs, wants and desires. Through one’s behaviors and thoughts one finds out more about oneself, but one does not have to know these parameters consciously in order to have a sense for what is meaningful in one’s life, which, however, requires being connected emotionally to one oneself in a meaningful way. Individuals who are suffering from burnout, for example, often experience this disconnect.
Anxiety is always caused by some form of perceived disconnect, a perceived need for some relevant information which is not met, either by oneself or by other people. If one is, for example, on a date and has a significant need for a certain form of feedback, such as affirmations, but this information is not provided, the anxiety increases. Or if one is experiencing a disconnect with an area of one’s own mental inner world, anxiety is often the result, if there is a perceived need for this information. In other words, there is no anxiety without a perceived need for some meaningful information, whether intrapersonally or interpersonally.
Communication Deficits
Areas which people often feel anxious about are where there has been an issue with their interpersonal interactions in the past. Early traumata, like a disappearing or abusive parent, stay unresolved. For example, if a parent feels fearful and angry with himself and this is picked up by a child, the latter may decode these messages correctly in that the parent is angry, but since the parent may not be conscious about it, the child does not pick up on the second important half of the message, that the parent has a problem with himself and his issue is unrelated to the child. Of course, one can learn to pick up on the self-blame and frustration of the parent, and therapists should become experts at reading between the lines in this fashion, but it requires experience, reflection and insight into transference and counter-transference phenomena, for example, to use the psychoanalytic terms.
Avoidance
Anxiety can lead to avoidance, which in turn can attach even more anxiety to the situations or behaviors which are being avoided. In social situations, not interacting with others deprives the person of continuously updating and honing the skills and confidence of interacting with others. Avoidance can thus lead to an increase rather than a decrease in anxiety in the long-run.
Since helpful communication, an open exchange of meaningful messages internally and externally, reduces anxiety, an avoidance of sources of meaningful information increases anxiety. Unfortunately, avoidance may not be self-correcting and lead into a vicious cycle in which ever greater anxiety leads to ever greater avoidance to the point where a patient can become house or even bed bound, and a normal work or private life are no longer possible.
One therapeutic technique is to have people participate more actively in life. One problem is, however, that a patient suffering from anxiety must also have a sense of why he or she is engaging in a particular activity. Behaviorally or cognitive-behaviorally informed approaches point out the necessity of a change, however, without really making that change stick through internal changes. One important internal change that can reduce avoidance significantly is by a greater connect with oneself that allows greater awareness for and insight into the basic parameters including needs, values and aspirations. They can help make engaging in activities and interactions more meaningful and relevant to the individual.
Panic Attacks
Panic attacks are intense phases of anxiety and can often occur ‘out’ of the blue. Still, in any case, exploring and looking into the panic attack can often unearth reasons for the panic attack. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something bad is going to happen. The maximum degree of symptoms occurs within minutes. Typically, they last for about 30 minutes, but the duration can vary from seconds to hours. There may be a fear of losing control or chest pain. Panic attacks themselves are not dangerous physically.
Panic attacks are an episodically increased awareness of various emotions, that may form around content that often appears to be conflictual. For example, on a date a person may simultaneously feel both fear, which calls for greater distance, and attraction, which aims at greater closeness. Often, the conflicting emotions are then not felt individually, but the anxiety to which the conflict gives rise. The strength of the emotions is still felt, but under a blanket of feeling anxious.
Panic attacks often contain the sense of an existential threat, because of the uncertainty about oneself that is underlying the anxiety. The large fear of losing control that is a cardinal feature of panic attacks reflects this internal uncertainty. However, uncertainty can be resolved through better information, such as by searching and being open to better information and developing more helpful ways of processing it internally. For example, a patient with social anxiety may get more input and feedback from outside by searching out situations that expose him or her more to other people in dating environments, while becoming more aware and reflecting on internal thoughts, emotions and other information that appears internally in dating situations. On the other hand, when working with a patient who experiences more generalized situation independent anxiety, a place to start may actually be the internal communication dynamics and events, although even in seemingly independent anxiety triggers can still often be found. At the same time, other techniques, such as exercise, meditation and various other relaxation techniques and approaches that involve the body to a greater extent should not be overlooked.
Autoregulation
Communication is an autoregulatory mechanism. It ensures that living organisms, including people, can adapt to their environment and live a life according to their interests, desires, values, and aspirations. This does not only require communicating with a salesperson, writing an exam paper or watching a movie, but also finding out more about oneself, psychologically and physically. Whether measuring one’s strength at the gym or engaging in self-talk, this self-exploration requires flows of relevant and meaningful information. Communication allows us to have a sense of self and a grasp of who we are and what we need and want in the world, but it has to be learned in a similar fashion to our communication with other people.
Anxiety is, as we have seen, a state in which something is ‘out of sync’. Some meaningful information
- disagrees with other information or
- there is a perceived lack of information,
while we have also seen that conflicting information is usually a result of a lack of meaningful information. Conflicts are usually resolved through greater insight into an issue, whether change is then desired or not.
However, a feeling of anxiety may make it even harder to resolve these problems. A patient suffering from social anxiety, for example, may no longer leave the house, which does not help to resolve the information deficit problems. It can actually increase them. So, what is the autoregulatory purpose of anxiety? It provides the signals that something is out of sync in the life of the patient, but it does not necessarily provide the tools to change cognitions or behaviors. These tools need to be learned, such as more awareness of and better skills in adapting or creating new internal and external communication patterns.
Future Directed
Communication bridges the present and the future, as well as the past and the present. It helps store information or transmit it to people somewhere else we have never met. The principle behind it is that information will be transmitted on as long as the sender feels the message is relevant to another and/or oneself. Information endures as long as it is relevant to the people who communicate it. In an emergency information can get through because it is relevant, and the sender can expect help as long as he or she believes that the own emergency situation is relevant to others. The ability to communicate by various means, spoken, gestures, email, smoke and so forth, can thus make people feel safe, if they trust in their own skills and that their message will be relevant and meaningful to another. Patients with anxiety often have lower confidence or faith in either or both.
Experiencing anxiety means mentally living in the future. Without concern about what could happen in a year or a second, there would be no anxiety. Important is to realize that the uncertainty in the future one feels anxious about is some information and, more precisely, some meaningful message. For example, a patient who is afraid of flying is usually afraid that he or she will feel anxious on the plain, that is be exposed to a meaningful message on the inside in the form of an unpleasant emotional signal, and cannot leave the plain, or that their may be perceptions or sensations of ‘something not being right’. The fear that the plane actually crashes is frequently less than that one could experience a panic attack on the plane without the possibility of leaving the plane or getting some urgently needed help.
Better connectivity with oneself and others can help to focus more on the present. Mindfulness and other techniques can be helpful in this regard. What they all focus on is exposing the patient to current information flows associated with sensations and perceptions that are presently being made relative to the outside world or the inside of the own body. Focusing on a tree in all its complexity or an inside feeling in its emotional texture at the same time directs the focus away from the past and the future towards the present and looks at things, internal and external, at more depth and with greater focus. It is often the new information provided when one looks at something at greater focus and with better resolution that can stimulate the curiosity and provide the motivation to be more here in the now. Meaningful information is after all a powerful motivator and highly attractive. To a patient with anxiety there seems to be too little needed meaningful information in the world. The truth, however, is that there is much more potentially meaningful information than one could process in a lifetime. Therapy should help the patient pick the communication situations and approaches that exposes him or her to information that is both meaningful and relevant specifically to the own person.
Trust
Trust in oneself is built through communication with oneself and others and an expectation that one can get one’s needs, wants and aspirations satisfied through these interactions. Trust is thus a two-way street as it depends on the own competency to send messages about one’s needs, wants and aspirations into the world in a way that is most likely to get a result and for the world to respond in the way expected. From a communication viewpoint many parts to have to fall in place, from the own identification of what one truly needs and values to other people’s own sense of their needs, values and aspirations. What makes the match possible is internal and external communication. Practicing communication, internally and externally, can therefore build trust.
Building trust in oneself is an important component in the treatment of anxiety. A first step usually is that the patient can identify own needs and wishes, which is an important step in reconnecting with oneself. Feeling this reconnection is ultimately what builds more trust. If one is more connected with something, it becomes more predictable and closer to oneself. Thus, being better connected with oneself and others, in a more meaningful and open way, reduces anxiety and builds trust. However, the level of trust one experiences still depends on other factors that have much to do with the perceptions, sensations, cognitions and emotional information stored in memory. The experience of the present necessarily takes important cues from past thoughts and emotions, otherwise there would be no opportunities for growth and learning. Still, greater flows of meaningful information usually lead to increases in trust, and greater openness to information and with information, or more transparency, lower anxiety.
Reversing the Disconnect
The disconnect with oneself and others can be reversed quite easily. The fears that are connected with it are often the hardest obstacles to overcome. Various CFT techniques are described elsewhere. (Haverkampf, 2010b, 2017c, 2017d, 2018b) Through greater awareness for the communication patterns and information flows one uses with oneself and others, the fears to experiment with them is usually reduced and meaningful change can happen. This can be achieved in a therapeutic setting through working with the external communication, which is also the only one visible to a therapist. Reflecting on the external communication is then transposed to the inside, where the same skills can be used with the internal communication. It is important to realize, however, that these observation processes have to come from the patient to be successful. This is why manualized therapies are unhelpful in this regard, because the patient has to find a style of communicating about communicating, or reflecting, which is his or her own. Thus, in a therapeutic setting the therapist should not merely supply the own style of thinking about communication, but support the patient in finding back, or forward, to his or her own style.
Looking Back
Memories of past experiences and the emotions associated with these past experiences can have an impact on how one feels in the present and the strategies one uses to act and interact in everyday life. Better internal communication allows to gain an understanding for any emotions that still have not found closure and other issues that have not been resolved yet. However, fears may prevent this, such as the fear to get lost in the past without resolving anything in a constructive way.
When patients learn to better connect with themselves emotionally, cognitively and in all other communicative ways, the fear usually of confronting unresolved issues usually decreases. The reason is that a better connection with oneself also makes the own resources more accessible, and hence visible, while making the sense of self feel more present and more clearly defined. These processes may not happen in complete synchrony, which can require a greater emphasis on support in therapy, whenever the pain is clearer than the positive resources. However, usually the process of connecting with oneself in itself makes the patient feel stronger an in more in charge of his or her owner inner life.
Meaning
Individuals suffering from anxiety and panic attacks often see less meaning in the things they do. In therapy an important part is to rediscover meaning, and find it in the things that are relevant to the patient. Relevant is anything that is close to his or her values, basic interests, aspirations, wants, wishes and desires. Meaning has the potential to bring about change, and meaningful information is what the individual should learn to select for more. Anxiety often leads to a withdrawal from meaningful information in the form of social withdrawal or greater rigidity in one’s daily activities by increasingly shutting out sources of valuable information. In a therapeutic setting this should be reversed by encouraging the patient to ask questions again, by having an inquisitive mind in the world which always looks out for meaningful information. The goal is not to shut off the constructive facilities of the mind. Many forms of meditation, for example, thus not have as the objective to turn off the mind but to actually find more meaning in the world in the form of information which brings about a beneficial change. A greater openness to meaningful information can so also decrease anxiety and the feelings that can lead to a panic state in a panic attack.
Awareness of the Inner Workings of Anxiety
An important step in therapy thus to make the person aware of how anxiety affects one’s thinking. Individuals from anxiety often focus differently from other individuals. There is often a focus on worst outcomes and strong fears which are caused by it. Underlying this are often strong emotions or conflicts which need to be defended against. The danger and uncertainty are quite frequently inside oneself, rather than on the outside. An individual with a fear of flying may be more afraid of not containing oneself and not being able to leave the plain than anything else. Anxiety is the fear of crashing oneself and the feelings of a dreaded uncertainty about oneself and one’s emotional states.
This insight into the inner workings of anxiety is useful because it helps to formulate new strategies in interacting with oneself and with others. A feeling of anxiety has usually the same basic mechanisms in most people, the uncertainty about one’s inner world and affective states, the helplessness, the emotions where one has little insight, and which maintain the anxious state, as well as the at least partial disconnect which reduces the insight into the thoughts, sensations, perceptions and feelings which underlie the anxiety. But there are also the individual aspects of what triggers and maintains the anxiety, the own patterns and styles of communicating with oneself and others, which can be scrutinized and experimented with in therapy. Particularly the experimentation can be a helpful tool to create greater awareness for the communication pattern an individual engages in. In the practical context of therapy, questions about irreconcilable thought content or feelings, for example, can be helpful to get the patient to experiment with new perspectives and communication patterns. (Haverkampf, 2010b, 2013, 2017e, 2018d)
Understanding the internal and external communication patterns and styles also provides and understanding for the workings of the anxiety. The reason is that it is not particular content which necessarily leads to anxiety, but how this information is retrieved, viewed and processed. In a neural or any information network all these processes are different version of communicating information from one point to another. Manipulating information also requires communication. If different bundles of information are sent to one point they can be combined, and so on. On a larger scale, there are mechanisms which can malfunction and impede the proper workings of communication, information selection, and so on. In therapy, the focus should be on creating awareness for those points where helpful information cannot happen or can only happen partially. Important for this to work is a good therapist-patient relationship, which id itself the product of awareness for, reflection about and experimentation with communication patterns and flows.
Interacting with Oneself
One of the most relevant exchanges one can have is with oneself. But it cannot be separated entirely from one’s interactions with one’s environment. They both are two sides of one coin. The same rules apply to internal communication as for external communication and vice versa. It is not only necessary to develop awareness for the information coming from inside oneself but also to form patterns that are helpful in the internal communication. As we have seen, anxiety is largely due to a disconnect from oneself and the outside world, as various memories and pieces of information can no longer be seen in the context of other information for the relevance and meaning they truly have, and the lack of cognitive and emotional insight attaches uncertainty not only to them but to one’s inner world as a whole.
A therapist can help a patient reconnect with himself or herself in several ways. Using the external communication as a reflection of the internal communication, and vice versa, is a starting point. Patterns where the patient filters information in a certain way or a fear of certain messages may be obvious in patients from anxiety. Apparently high arousal levels without verbal messages that can explain the heightened arousal levels or the attempt to wrap an emotional signal in superficial rationalization of the information may be others. However, awareness of certain patterns is not necessarily a prerequisite of change. Using certain patterns to think about the patient’s communicated thoughts and experiences can alter how the patient experiences this information, if the therapist’s way is helpful to the patient. The patient integrates the meaningful information gained in a therapeutic setting with the other information contained in the various aspects of memory as well as in the neural network as a whole, which then influences the individual’s communication patterns with himself or herself and others. The most effective messages to bring about a change in these communication patterns are those which are about communication itself and which are meaningful in the sense that they can be understood and lead to change. This requires that the therapist makes sure that the information from and about the interaction is understood by the patient. At the same time, both will try to keep the information relevant and helpful. The patient learns in the process to identify what is relevant to him or her, which then has an impact on internal and external ways of communicating.
Interacting with Others
Better interactions with others, which reduces anxiety, follows from better interactions with oneself. The reason is that since one cannot know the thoughts or feelings of another person fully, one will always project an element of oneself into the other person. We assume that another person will behave either as they did in the past or in a way that seems to us reasonable, if we judge the other person as reasonable. Thus, to a degree one interacts with oneself when one interacts with another person, while being corrected by the other person about one’s assumptions as the exchange progresses. It is thus important to have a good sense of oneself to know what is a projection and what is not.
Interacting with oneself is also practicing communication, which helps in communicating with others. It is not a substitute for communicating with others but helps in experimenting with different communication patterns. Also, since there are significant similarities among people on a more basic level, one’s own reaction to a thought or feeling can be a good first indication of what another person might feel. This is how art, literature and films can excite multitudes because they touch what is shared by most people.
Experiencing the World
To break through the vicious cycle of anxiety, in which emotions like fear and anxiety cause safety thoughts and behaviors, which in turn reinforce feelings of fear, loneliness, sadness, and so forth, it is helpful to focus on identifying what is meaningful and having more of it in life. Communication helps in identifying and finding meaning, either communication with oneself or with others. The exchange of messages is like a learning process in which meaning can be identified, found and accumulated. Through meaningful interactions one accumulates more meaning, more connectedness with oneself and the world and reduces the need for thoughts and behaviors which are triggered by fears, guilt, self-blame and other negative emotions. This also helps against depression and anxiety.
Perceiving more meaning also makes interacting with others and oneself more meaningful. This has a positive effect on one’s interaction patterns, how and in which way one relates to one’s environment and exchanges messages with it.
Values, Needs and Aspirations
Often, individuals suffering from anxiety or burnout have become uncertain about what is really important to them and the fit between these values and interests and their current life situation. Whether in the professional or romantic realms, following one’s needs, values and aspirations has the best chance of maintaining happiness, satisfaction and contentment in the long run. If I value helping people, it is important that I do that to make me feel better in the long-run. Important is to identify those basic parameters which do not change much over time. Often people might be too focused on the short-run at the expense of a greater quality of life in the long-run and potentially higher anxiety levels. Open and rich communication with oneself and the environment can ensure that one gets the correct information about oneself and the world in this respect to make better decisions. Fears of connecting with oneself and the world may interfere with this openness, and it is important to find insight into them in the therapeutic process. Making the fears visible through greater awareness of the own communication patterns, internally and externally, leads to their resolution. This is in turn can then allow the autoregulatory mechanisms of internal and communication to lower the anxiety.
Since values and basic needs remain relatively stable over time, knowing about them can give a patient a greater sense of safety about oneself. Having knowledge of them also helps in interacting with others, partly because one feels more secure about oneself and partly because having a clearer idea about one’s needs also helps one to have a clear of others’ needs.
Self-Exploration
The process by which one identifies one’s own needs, values and aspirations is self-exploration. It means engaging in communication with oneself, being open and receptive to the information one is receiving from one’s body and mind, while also being perceptive to one’s emotions. The emotions can play an important role in gauging what is ‘good’ and what is not, because they are the end product of a large amount of information which has been integrated into them over time. So, if one truly feels contentment and satisfaction when engaged in an activity, it may be needed or of special value. Self-exploration is thus not a process of getting lost in one’s thought but an active appraisal of the various aspects and activities in life. In a therapeutic setting it helps to ask the patient about how he or she felt in various situations and activities in life. Rather than focusing on the anxiety, greater focus should be placed on the areas in life which are meaningful and valuable to the patient. When focusing on the anxiety, the main focus is on exploring potential emotional conflicts, which can also include the patient having to do something which goes against the patient’s needs, interests, values or aspirations.
Self-exploration has internal and external components, an assessment of internal basic parameters, needs, values and aspirations, as well as an assessment of activities, situations and interactions a patient may engage in. Improvements in internal and external communication can therefore lead to a shift towards following the own needs, values and aspirations, which reduces the level of anxiety.
Meaningful Messages as the Instrument of Change
Communication is the vehicle of change. The instruments are meaningful messages which are generated and received by the people who take part in these interactions. In a therapeutic setting, keeping the mutual flow of information relevant and meaningful brings change in both people who take part in this process.
The therapeutic setting is a microcosm in which the internal world can be played out and the external world be experimented on. An important quality in the therapist is not to take anything that happens in this setting as personal. What happens in the therapeutic setting should be seen as relevant to that specific setting only, which can give the patient a greater sense of safety to bring the internal world out into the setting. By then experimenting and daring new patterns in the setting, the patient develops insight and builds confidence in the communication process with oneself and others. It is the task of the therapist to support the dynamics of this process through observations, reflection, feedback, and by maintaining healthy boundaries between the therapeutic setting and the outside world. At the same time, the patient will carry more of the insight and skills gained into the therapeutic process into the outside world if it appears helpful and relevant.
Medication
Selective Serotonin Reuptake Inhibitors (SSRIs)
The long-term solution should be a combination of psychotherapy/counselling and, if indicated, an antidepressant from the group of serotonin reuptake inhibitors (SSRIs). Neurobiologically, all SSRIs can be effective in reducing anxiety and allowing even house bound patients to partake in daily life again, but a few of them are usually prescribed in practice. While they can take up to three weeks, and sometimes even more, to show their full effect, they are generally described as non-addictive and especially in the case of the newer ones, such as escitalopram, patients report few, and in many cases no side-effects. If there are mild side-effects, they often tend to go away after a couple of days. In the case of anxiety, starting with a very low dose (a quarter tablet) for two days and then increasing the dose slowly mostly eliminates subjective side-effects. In practice, if there are side effects in the beginning in the form of tension and an increase in anxiety, this often actually means that they will work. The side effects probably come from the increased serotonin levels at the synapses meeting a hypersensitivity to serotonin. A reconfiguration in the receptor density takes time but will lead to a fading away of the symptoms and the heightened anxiety levels.
The mainstream opinion is that they can be taken over many years and are quite safe. One should pick the SSRI with the best side effect profile for the specific patients. Escitalopram, for example, is linked less with weight gain and nervousness. Sertraline can be more activating, citalopram and paroxetine more sedating. Paroxetine can be increased in dose to 60mg if OCD is also an issue. Higher doses of fluoxetine and sertraline can also be helpful if an eating disorder is a comorbid problem. However, at least in theory, in different doses all the SSRIs can have similar effects.
SSRIs can be combined with a variety of other drugs. However, they should not be combined with MAO inhibitors (antidepressants), certain neuroleptics and other medication, which can increase the serotonin level and in combination lead to the rare but potentially life-threatening serotonin syndrome. They can increase the effect of alcohol, so additional care should be taken in this regard.
Being for at least six months to a year on SSRIs often seems to have the effect, that once the medication is discontinued anxieties are less likely to return for some time. The reason does not seem to be entirely biological but also an effect of learning. As the memory of feeling anxious becomes a distant memory, one is less likely to feel anxious.
Before an SSRI is given certain conditions should be excluded in a conversation with the patient. Among them are a certain type of heart arrhythmia (abnormalities in the QT interval). If the patient is treated for a medical condition, it helps contacting the GP or specialist and asking if there are any indications the patient might suffer from a condition that may be a reason for caution.
But overall, the SSRIs, with escitalopram as a personal favorite, have shown to be an enormous help in treating anxiety and allowing patients to lead normal lives. In combination with psychotherapy / counselling the long-term prognosis for anxiety disorders in most cases has become very good.
Antiepileptics
Among the antiepileptics, pregabalin is increasingly used in the treatment of anxiety, most frequently as an add-on to an SSRI. It is mostly well-tolerated, although it may have to be used at a relatively high dose. Aside from treatment for anxiety disorders, some other off-label uses of pregabalin include restless leg syndrome, prevention of migraines, and alcohol withdrawal.
When pregabalin is taken at high doses over a long period of time, addiction may occur, but if taken at usual doses the risk of addiction is low. Pregabalin is a gabapentinoid and acts by inhibiting certain calcium channels.
Second Generation Antipsychotics (SGAa)
SGAs are often used to augment an SSRI, but they can also be used in the treatment of anxiety disorders by themselves. They usually work faster and can be quite powerful in their effect, while potential side effects can be more severe than in the SSRIs, although from clinical experience they are quite rare. An increase in appetite and metabolic side effects is, however, more common in olanzapine, and possibly to a lesser degree in quetiapine. There is little consensus on the use of SGAs in anxiety disorders. Many psychiatrists would probably say that in their clinical experience, they are helpful, while some studies did not find a difference between SGAs and placebo. They may thus be a worthwhile option in the individual case, but the risks and benefits need to be weighed off.
Benzodiazepines
Most anxiolytics belong to the group of benzodiazepines, and although they can be very effective in reducing anxiety for up to a couple of hours, they have three main disadvantages.
The first disadvantage is that they are potentially addictive if taken regularly, the second that they do not work instantaneously, and their effect only lasts for a short time, and the third that they can lead to drowsiness and a lowered reaction time, which means that a patient on this medication should not be driving a car or operating heavy machinery while taking them. If someone suffers from sudden anxiety bouts of anxiety or even panic attacks, it can be over by the time the medication starts working. However, many patients are helped quite effectively by merely having an anxiolytic in their pocket. This works because often the anxiety about feeling anxious and having all the physical symptoms associated with it is the main factor in maintaining the anxiety.
Non-benzodiazepine anxiolytics
There are alternatives to the benzodiazepines. However, drugs like buspiron (Buspar®), can take weeks to unfold their anxiolytic effect and many patients do not find them as effective as the benzodiazepines. Often a better option is to start with a benzodiazepine and an SSRI and to wait until the benzodiazepine is no longer needed. For most SSRIs, this interval is in the region of two to three weeks. However, it can be much faster or in some cases even take months.
Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He also has advanced degrees in management and law. The author can be reached by email at jo****************@***il.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.
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