Fear of disease and dying can result in tremendous anxiety and hypervigilance to potential signs of disease.  Sensations most people would not notice or certainly not worry about can result in spiraling anxiety.  Such anxiety about health is often precipitated by a severe illness or a sudden death in the family, which makes people acutely aware of their mortality.  In a radical attempt to avoid death, or at least to put it off until later, people sometimes work very hard to notice every sensation that might indicate an illness and then try to “fix” the illness.  This anxiety impairs people’s lives, because it is difficult to find pleasure and be productive when focused on not dying. 

Ruth is an example of a person who struggled with such a fear.  She lived a quiet life. She was married at 20 years old, and two years later had a son.  Her next pregnancy ended in a miscarriage at the end of the first trimester.  Ruth’s doctor reassured her that such miscarriages were common, but Ruth’s anxiety escalated when she became pregnant again.  This pregnancy also ended in a miscarriage, as did the next two.  With every new pregnancy the anxiety increased, as Ruth learned to expect and fear the miscarriages.  After the fourth miscarriage, Ruth was diagnosed with breast cancer.  It was caught early and her surgeon was confident that the tumor was contained and no further treatment was needed after the tumor was removed.  Shortly afterward, when Ruth was 30 years old, her husband was diagnosed with a brain tumor that proved to be fatal.

With every new medical problem and particularly after her husband’s death, Ruth became increasingly aware of uncomfortable physical sensations.  She particularly noticed aches and pains in her abdomen and chest. She noticed changes in her heart rate.  She worried that these sensations were early warning signs of cancer or heart disease, so she spent hours on the internet learning about anatomy and symptoms of various diseases.  She saw her doctor at least once a month, raising new concerns, and re-raising old concerns. She had CAT scans, MRIs, EKGs, and multiple blood tests.  She felt great relief when test results determined that she was not suffering from heart disease or growing cancerous tumors. 

Ruth was quite frightened of dying and leaving her son as an orphan. He was her whole life. Ruth worked, but only to earn enough money to take care of herself and her son. She went to church, but did not socialize.  She lost contact with her friends who gave up trying to engage her.  She was afraid to go out and risk anything happening to her.

As Ruth withdrew socially, she had more time available to focus on her body. She noticed sensations in her body that she had never noticed before. When she described them to her doctor, he did not seem concerned but he also did not seem to know what to make of all of the sensations she reported. Ruth was convinced they were symptoms of something.

When she turned 40, Ruth’s doctor told her that he thought she was struggling with hypochondriasis.  He explained that hypochondriasis meant she was excessively worried about having serious illnesses that she did not have.  Ruth responded politely but remained relatively certain that she was ill and it simply was not being diagnosed. 

Despite this conviction, Ruth decided to read about hypochondriasis.  The more she learned, the more she realized that she fit the diagnosis.  She recognized that she fit into a cycle of worrying about dying, searching for signs of disease, interpreting everything she experienced as a possible symptom, reading about the symptoms, seeing doctors and seeking relief through medical tests.

Unfortunately, recognizing her pattern did not help Ruth change her behavior. She reminded herself that she was probably misinterpreting the sensations.  But she was not certain and continued to scan her body for problems and sought relief through medical tests. She could not talk herself out of the idea that the sensations would lead to death. She could not divert her attention from the frightening sensations. And, she could not break the habit of going to her doctor for the brief relief that she experienced after tests indicated she was healthy. 

As she continued to struggle, Ruth noticed a paradoxical element. On the one hand, Ruth continuously scanned her body for problems. On the other hand, she was frightened of paying attention to her body. She had difficulty focusing on her body calmly.  Ruth knew from her extensive reading that avoidance is usually at the heart of anxiety problems. Could her avoidance of her body be causing the hypochondriasis? How could this be true if it was also true that she spent too much time scanning her body for problems?

The resolution to the paradox was that Ruth did not want to experience anything in her body. After years of anxiety, Ruth did not want to feel sensations. Being numb was the ideal state for her. She did not purposely choose to scan her body for sensations, she was pulled to do so and could not pull away from those sensations.   When she did experience sensations, Ruth went to great lengths to make them go away.  This realization led to a more simple understanding of the cycle:

The solution to this problem was to learn to accept what the body does.  Ruth developed the following steps to solve this problem:

1.      She gave herself permission to feel bodily sensations while being realistic.  She said to herself, “I am going to feel things.  Accept the sensations – do not try to avoid them or make them disappear.”

2.      She acknowledged her anxious thoughts about the sensations (such as thoughts about cancer) and then let these thoughts go.  She reminded herself that, “They are just thoughts.  The thoughts distract me from the sensations.  Focus on the sensations and let the thoughts go.”

3.      She reminded herself not to be surprised when the anxious thoughts recurred, especially thoughts that try to explain the sensations.  So, she would repeatedly let go of the anxious thoughts.

4.      She stopped researching and investigating diseases.

5.      She took the approach of: “Let’s just see what happens.”  She did this in a non-anxious way, in an accepting/watchful/curious way.

6.      She reminded herself: “I am feeling sensations – not symptoms.”

Ruth practiced these steps daily.   She spent fifteen minutes every day paying attention to her body – either an uncomfortable sensation or her entire body. While doing this she went through the six steps and learned to feel comfortable with her body.  After a couple of weeks, she felt dramatically better.  Ruth then stopped practicing the steps because she still preferred not to notice her body.  Unfortunately, the anxiety quickly returned and she needed to practice again.  In the end, she learned that she needed to be willing to experience her body every day.

Sometimes we need to change our relationships in order to change our behavior.  Charlie was a good example of this principle.

Charlie appeared to be a very cute five year old boy.  He was well dressed and often polite. He also had magnificent temper tantrums.  The tantrums occurred primarily at home, but were spreading out of the home into grocery stores, the doctor’s office, and once even in school. Almost all of the tantrums occurred when someone said “no” to Charlie.  His parents hoped he would grow out of it. But, the school insisted Charlie receives help after he kicked his teacher and tried to bite the principal. 

Charlie lived with both parents and three older brothers, who were 8, 11 and 12 years old.  His parents – Jeanne and Robert – lived with the usual stresses of making a living, dealing with day-to-day struggles and raising four boys.  Robert was an electrician and Jeanne was a teacher.  Even though Charlie was their fourth child, they had never seen tantrums like his.  He would scream, yell, run around the house, hit people as he ran past them, and throw whatever he came near. He had broken two lamps and almost broke the television.

Jeanne and Robert tried the usual things that parents try. They talked to him about his temper. They punished him by taking toys away. They gave him time outs. They tried rewarding him with stars and stickers for being nice. They spanked him. Nothing helped. And, as Charlie grew, his tantrums became more intense.  Robert and Jeanne felt entirely helpless in the face of Charlie’s rage. They learned to cope by avoiding saying “no.” They avoided taking him places he did not want to go. The family stopped going out to restaurants, because Charlie embarrassed everyone.  Increasingly, Charlie was given everything he wanted.  Over time, he was given more and more control over family decisions and he was only five years old.

Charlie, unfortunately, refused to talk about the tantrums.  He was not interested in receiving any help and denied any dissatisfaction with life.  He related that everything was “fine,” but complained that his parents wasted his time by making him see a therapist.

Charlie was asked what he would do if, miraculously, all of the problems stopped. Although Charlie denied there were any problems, he was willing to consider this question. After several minutes of thoughts, he said he would be happy.  He was asked who would notice he was happy.  He said his parents would notice and maybe his teacher, because he would play catch with his dad and bake cookies with his mother (or at least help eat the cookie dough).  Beyond that, Charlie refused to say any more and stopped participating in the discussion.

Jeanne and Robert were torn by Charlie’s responses. On the one hand, they were quite annoyed when he refused to continue participating. On the other hand, they were shocked and excited that the miracle he imagined was doing things with them. He never played with them, and until that moment, neither parent imagined he had any interest in playing with them.

Charlie, Jeanne and Robert went home and tried to make the miracle happen.  Almost like clockwork, Charlie’s behavior improved every day that he played with, baked with or read with his parents. Almost every day these things did not happen, Charlie exploded. 

Only later, when Jeanne and Robert thought about what happened, it made sense to them. When Charlie was born they were relieved that the other boys could help supervise and entertain him, as they already felt stretched.  Charlie, on the other hand, felt tormented by his brothers.  He resented them telling him what to do and constantly complained to his parents. He tried to make his brothers leave him alone by yelling, screaming, and destroying their toys.  Jeanne and Robert attributed the complaints and fights to normal sibling disputes, but had not realized how isolated Charlie felt.  And, the more Charlie complained and misbehaved, the more his parents reacted with punishments that made Charlie feel cut-off from them. And the more cut-off he felt, the more he misbehaved. 

Children need discipline to mature into well socialized, respectful, and responsible adults. Even after Charlie’s behavior improved, he continued to need this from his parents.  What was missing in Charlie’s case was the emotional connection with his parents that enabled him to learn from the discipline.

What changed that enabled Charlie to become happier and to interact more nicely? First, he recognized his wish to connect with his parents.  Second, his parents’ ideas about Charlie were challenged. They had seen him as angry, stubborn, and controlling. They did not think he was interested in being connected and having fun with them.  And, they were quite frightened for his future. They imagined that by the time Charlie was a teen-ager he would be arrested.  More and more, they saw Charlie as a five year old monster.  Every time he misbehaved they became more frightened, so they tried harder to correct his behavior. Unfortunately, the more intensely they corrected him, the more disconnected and angry Charlie felt. This cycle is illustrated in this diagram:

When Charlie simply said he wanted to play ball and bake cookies, his parents saw their little five year old boy as a little five year old boy. When Charlie and his parents started to enjoy their time together, they all felt connected. And, then he could behave.

People often try to control life – even the parts of life that cannot be controlled.  We believe that the more we take control over our lives and our environment, the less we risk.  We learn to control our temper, to control our emotions, to control our urges. Similarly, we think that the more we control our children, the more likely they are to succeed. The more we control our spouses, the more content we will be in our marriage.  The more we control our employees, the more productively they will perform.  The more we as a nation actively involve ourselves in controlling our senators and congressmen, the more accountable they will be.  The more we as a nation take a stand to control other countries, the better the world will be. 

Control can certainly be beneficial.  Without control, people give into their urges and harm others.  Without control, children never learn to cope with the demands of society.  And, we can learn to control our behavior -- our facial expressions, fists, sexual urges, and violent urges.  We can make decisions before we act.  We can evaluate the costs and benefits of various options, and then choose how to respond.

However, there are many things we cannot control.  Consider children: we can provide rewards and punishments for behavior, but we cannot be present twenty-four hours a day to control their behavior.  Our spouses control themselves – they are adults and determinate their behavior.  Controlling employees can be effective for certain operations, but employees are individuals and will bring their individuality into whatever jobs they perform.  Our control over senators and congressmen must be shared with all of our fellow citizens.  And, of course, we have extremely little control over foreign countries. 

We also have little control over our immediate internal emotional responses. The immediate emotional response is automatic. We automatically feel sadness when we experience a loss, fear in dangerous settings, anger when we are wronged.  Such emotional reactions normally rise and fall in a reasonable period of time. 

However, when people are frightened of such feelings, the feelings tend to escalate.  For example, when someone experiences intense anxiety and is further frightened by the racing heart and shortness of breath that accompany anxiety, then the anxiety will escalate.  As fear of anxiety continues to escalate, a panic attack is the inevitable result.

People often try to avoid such intense negative experiences by controlling their emotions. Unfortunately, it is impossible to avoid emotions as they are internal and automatic.  Attempts to avoid or control emotions lead people to such extremes as never leaving their homes, and even inside their homes they experience anxiety.

Panic attacks result from such fear of anxiety.  Panics involve the experience of intense anxiety for no apparent reason.  It can include sweating, increased heart rate, shaking, shortness of breath, stomach pain, dizziness, muscle tension, and fears that one is having a heart attack or going crazy. It is extremely uncomfortable. Panic attacks feel more difficult to cope with than a fear of heights or snakes because the panics seem to come out of nowhere. With a fear of heights, one can stay away from heights but how can anyone avoid something inside the body? 

Shirley provides a good example of a person with panic attacks.  She was an intelligent and attractive 40 year old woman who was riddled with panic attacks. She had a history of excellent jobs, but was unemployed and uncertain as to what work she wanted to do. Her previous employment included working as a teacher and as an accounant.  As her husband was a successful sales executive, Shirley was able to remain at home with the children but felt quite vulnerable without her own source of income.

Shirley experienced her first panic attack as a side effect of a medication.  During her panic, Shirley thought she was becoming psychotic.  She was unable to think clearly, her stomach hurt, her heart raced, and she found herself shaking.  She was so frightened by this event that she later became frightened by any sensation suggesting she might have another panic attack.  She was wary of any thoughts or physical sensations that indicated she was becoming anxious.  She read every book that she could find on anxiety. And, she determined that she needed to stop every anxious thought as it arose, before it led her to become incapacitated and psychotic.

Of course, it was impossible to stop every anxious sensation and every anxious thought. Everyone has such sensations and thoughts, and they cannot be eliminated. Rather than eliminating them, Shirley became vigilant to watch for such sensations and thoughts, and became quite anxious when she experienced them. She was particularly frightened that an upset stomach might be an omen of impending anxiety.  She eventually became anxious in reaction to any sensation in her stomach, including hunger, nausea, feeling full, and butterflies.

Because she was so fearful of anxiety, normal experiences of anxiety often escalated into panics.  Her heart rate increased and she would sweat, shake, and feel short of breath. She worried she was becoming psychotic.

Panic is a difficult problem, because people who panic are afraid of even low levels of anxiety.  They do not believe that arousal of anxiety is useful.  To get past this, Shirley needed to learn how anxiety can be useful.  It is normal and even useful for people to become anxious when faced with a challenging task. The anxiety motivates us to focus our energy and attention on the task. Before a competition we become anxious, which energizes our body, engages us with the competition.  Before a test, we become anxious, which motivates us to prepare and study.  Without some anxiety people would not perform well.  Decades ago, psychologists concluded from experiments that people do not perform at their best unless they experience some anxiety. On the other hand, excessive anxiety interferes with performance. 
                                                      
Thus, when Shirley became frightened of anxiety, she was actually frightened of a normal human state and preferred not to experience any of that normal state. However, it is impossible to eliminate anxiety.

Her cycle involved noticing a stomachache, worrying that the stomachache meant she was about to panic, fearing that she might panic, becoming hyper-vigilant to other symptoms of anxiety, and becoming increasingly anxious until she panicked.

It was hard for Shirley to imagine how to overcome the fear of anxiety.  When asked what she would have to do to get over a fear of heights, Shirley immediately knew that she would have to go to high places. When asked what she must do to get over her fear of panic, Shirley was unable to answer the question. The correct answer is to face the fear – to be willing to panic.  Shirley could not conceive of panicking on purpose, because she feared the panic would never stop.   

Shirley acknowledged that she could not stop the panics by fighting them. And, she understood the cycle. So, while she did not agree to panic on purpose, Shirley agreed to allow panic attacks to continue, rather than try to stop them.  Initially, Shirley responded to panic attacks with her usual fearful response. However, with practice she learned to simply watch the course of each panic attack rather than try to stop it. Her panics gradually became shorter in duration. As they became shorter, she became less frightened of them so they occurred less frequently.  Some panics may continue for the rest of Shirley’s life; but they do not last long and she has confidence that they will not harm her.

The change Shirley made was that she stopped trying to control the panics, and instead allowed herself to panic.  Shirley learned that if she watched her body closely for signs of anxiety and feared the anxiety, she would drive herself to panic.  Trying to control or stop panic attacks increased her sense of panic.  It required courage for her to stop trying to control the panics and instead to welcome them and simply watch them. She was rewarded with much shorter, less frightening, and less frequent attacks.   

Overcoming a fear of heights provides a good example of how people can interrupt the vicious cycle of feelings, thoughts, physiological changes, behaviors, and relationships. Consider John Rogers, a 70 year old, successful and retired physician. He happened to fear heights and as a result, he also feared bridges. Other than the fear of heights, John was quite successful. He graduated from medical school and started a successful family practice. He was married for 45 years.  And he had two grown children who were also successful.

Throughout most of his life, the fear of heights caused John little trouble, because he had been able to avoid much time near heights and tolerated his suffering as he occasionally crossed over bridges.  However, once he retired, John wanted to travel. The more he traveled, the more he feared going over bridges. He hated the anxiety he experienced – the stomach twisting, the painful tension in his neck, the sweating, the racing heart. He feared that if he continued going over bridges, he would have a heart attack. And, he hated the words that raced through his head as he crossed a bridge – “I’m going to drive off the side.  I’m going to drive over the side.  I’m going to drive over the side….”  He was afraid that he would listen to these words, turn the wheel, and drive through the rail. The rational part of John knew he would not have a heart attack. And, he knew he would not drive off the bridge.  But as he approached bridges, the anxious thoughts over-powered his reason.  He was nearly convinced that the problem could not be fixed.

When John was at a place he considered too high, he became anxious and expected to fall. His body became uncomfortably aroused, his heart sped up, he shook, his neck became taught and his stomach hurt. As he descended from the height, John experienced tremendous relief. The relief unfortunately taught him that leaving heights alleviates distress, so it is best to avoid heights.  When he had to drive over bridges, he asked his wife to drive while he closed his eyes.

Inherent in this cycle is an underlying idea that experiencing distress is not acceptable. We believe that we should feel good. If we do not feel good, we believe something must be wrong.

Contrary to this widely held belief, humans are not designed to always feel good. As we go through our days, we experience myriad negative sensations including our stomach signaling hunger, our skin letting us know when we are hot or cold, and everything from our eyelids to our feet letting us know when we are tired. Anxiety also involves uncomfortable sensations – at times extremely uncomfortable. Anxiety serves a useful purpose. It prepares us to be more alert, more ready to react to problems that arise.  For example, being at a great height can produce anxiety so that we are alert to where we should and should not walk.

The cycle described above can be illustrated as follows:

When people are asked what they think someone else should do to get over a fear of heights, ninety percent of people respond, “They should stand someplace really high and stay there until they are not afraid.” Most people intuit that if we face our fears, the fears will pass. To make the exposure to a fear useful, it must be repeated frequently until the brain accepts the idea that the situation is safe, falling off a height (or driving off a bridge) is quite improbable, and the anxious sensations are temporary. Thus for John to overcome his fear, he would need to go to heights until he became willing to experience the uncomfortable sensations of anxiety and until he recognized that he was safe at high places.

Most people can accept this idea, but not everyone has the courage to act on it. John accepted the idea in theory, and had the courage to gradually encounter increasing heights. He started by imagining himself driving over high bridges. Simply closing his eyes and creating an image of driving over a bridge was sufficient to arouse John’s anxiety.  John initially fought the sensations of anxiety. He tried to make the sensations stop, but they continued to escalate as he imagined the drive.

Over time he learned to allow the anxiety to rise and run its course.  In particular, he learned to accept the very real experiences of his heart rate increasing, his stomach hurting, his neck becoming tight, and his body shaking. He simultaneously learned not to focus on the anxious thoughts about driving off of bridges.  As he accepted the anxious physical sensations, he found that the anxiety did not rise so high and it passed more quickly.

John imagined himself driving over high bridges until he was no longer bothered by the anxiety in these imaginary trips. He then stood on bridges, and approached the edges to look over.  And finally he actually drove over low bridges, medium sized bridges, and eventually high bridges. He learned not to fight the anxiety he experienced during these encounters; and when he stopped fearing the anxiety it stopped escalating.  The anxious sensations continued to occur, but they did not escalate because John did not fear them.  He stopped challenging his fear of heights when it stopped interfering with his travels.

This blog will share stories of people making changes in their lives – sometimes seemingly simple changes, sometimes remarkable and complex changes.  The stories are based on people I have worked with but various changes are introduced to protect their identity and confidentiality.  I hope the stories provide examples of the variety of ways people change their habits, their behaviors, their moods, and their relationships. 

What guides the changes in these stories is the idea that our feeling, thoughts, behaviors, physiological responses and relationship are inextricably connected with one another.  In a very real sense they are intertwined with one another.  The intertwining is evident at a neurological level, where scientists find that pathways that are frequently activated are better insulated and the insulation results in the pathways becoming stronger and more automatic. 

For example, if sadness frequently leads one to isolate, then the pathway in the brain between the emotion of sadness and the behavior of isolating is likely to become better insulated and thus more automatic.  In turn, isolation is likely to lead to loneliness and hence more sadness.  As a result, there is a continuous feedback with sadness causing more isolation and isolation causing more sadness, often leading to depression.

Of course, the reality is more complicated.  In addition to sadness and isolation, depression also entails negative thoughts, such as viewing oneself as ineffective and losing hope for the future.  There are also physiological changes, such as lack of energy, loss of appetite, and difficulty sleeping.  And there are changes in relationships, as family and close friends might become worn out by a depressed person’s mood and pull away from that person, even unintentionally.  The negative mood, behaviors, negative thoughts, physical changes, and changes in relationships all become intertwined and tend to magnify one another. 

As a result of the intertwining of these experiences, a cycle develops in which the mood, behaviors, thoughts, physiological changes and relationship changes exacerbate one another.  The cycle feels impossible to change when one is in the middle of it.

However, one can break the cycle by changing any of its elements.  If a person can change his mood, or his thoughts, or his physiology, or his relationships, then the cycle is interrupted. Not only is the cycle interrupted, in addition new cycles are created.  This change can require a good deal of effort and practice, but the effort and practice have a big payoff – at a neurological level new pathways become better insulated, stronger and more automatic; while the depressive pathways gradually lose their insulation and become weaker. 

This approach to understanding and overcoming depression is also applicable to anxiety, anger, embarrassment, family problems, and life transitions. I hope the stories that will follow help to clarify how people break out of such difficult cycles.