THE PSYCHOLOGICAL DIMENSION
Up until the latter part of the 20th century most of the discussion about anxiety concerned psychological factors. In medical literature at least, the biological and social domains were largely ignored, let alone the spiritual ones. With the explosion of seien tifie technology and the promulgation of multi-dimensional models of disease, the panorama has changed and our horizons have expanded.
We will divide our discussion ofthe psychology of anxiety into two sections – one on Psychodynamics (the psycho-analytic view) and the other on the Cognitive Theory of anxiety (the source of cognitive-behavioral therapy).
THE PSYCHODYNAMICS OF ANXIETY
Although anxiety has existed since the beginning of time, serious reflection on this phenomenon began with the work of Sigmund Freud and the psychoanalytic movement.
Freud worked with two basic models ofthe psyche:
1 ) The topographical model, which looks at the mind as having various levels – the unconscious, preconscious and conscious.
The unconscious uses primary process thinking in which there is an absence ofthe principle of contradiction and ordinary logic. Both affirmation/negation and time (before and after) are absent. Effect may precede cause and “short” may represent “tall.” In dream interpretation, one ofthe means to the unconscious, “condensation,” is an important principle. This refers to the idea that one dream symbol may contain several meanings. As well, “displacement,” is another important concept, in which one object may contain characteristics that belong to another object or we may see our own characteristics represented in another person. In contemporary parlance we may refer to this as holistic or right-brain thinking.
The preconscious contains retrievable memories that are derived from the unconscious and may be discovered through free association.
The conscious is what we are normally aware of.
2) The structural model consists ofthe id, ego and superego.
The id is the mental structure that contains the representations ofthe drives – similar to instincts in animals. The id operates according to primary process and acts in accordance with the pleasure principal.
The ego is the seat of conscious and unconscious defense mechanisms. It functions according to logic and reason-ablencss; it is based primarily on “secondary process” thinking and negotiates the reltionship between internal and external reality.
The superego is the part ofthe mind identified with moral and ethical values.
Freud’s first theory of anxiety was known as the “toxic theory.” He proposed that anxiety was the result of repressed libidinal impulses (unconscious sexual drives). This repressed libido is converted into anxiety by reappearing either as free-floating anxiety or as an anxiety equivalent – for example a physical symptom such as a headache or chest pain. The underlying image here is one of elementary physics in which pressure is applied to a closed container incrementally. Something has to give, and the tension in this system is called anxiety.
Freud’s second theory of anxiety is the “signal theory,” which emerges from the structural model of the psyche. In this model, the ego perceives a danger signal (coming from the id) and produces anxiety to alert the organism to the threat. Repression then occurs to push the anxiety further from consciousness. Among the symptoms of signal anxiety may be apprehension about the loss of relationship, castration anxiety or superego anxiety with guilt. This theory focuses attention on the role of intra-psychic conflict among the entities of the id, ego and superego.
A 30-year-old patient of English-Canadian origin and mother of two young children comes to consult for problems related to her marriage. Although she believes her husband is kind and well intentioned, she feels more and more distant and estranged from him. As our sessions get underway, her anxiety increases until it reaches panic-like intensity. Then she starts having flashbacks and realizes that she was repeatedly sexually abused by her father at a young age. Her anxiety attacks were a signal of unconscious conflict. The abuse was buried deep in her unconscious and was now emerging into the pre conscious and consciousness. By the time she realized what was happening, she began to feel more in control.
The American psychoanalyst Glen Gabbard hypothesized a hierarchy of anxiety, which begins with the most primitive level, disintegration anxiety (the anxiety of being annihilated or losing one’s sense of identity), and goes up to superego anxiety (being in conflict with one’s own set of values).
A 50-year old woman of German descent, a long-time convert to Islam and fervent Sufi practitioner, consults for depression. After several months of treatment, she begins to realize that she doesn’t know who she is or where she is going in life after a conflict occurs at her workplace. She then dreams that she is in her mother’s house and the door to her mother’s room is locked. She makes her way in nevertheless and finds that all her clothes are in her mother’s closet and she doesn’t like any of them! We interpret the dream together and realize that her mother has “swallowed up ” her identity. This is the anxiety of disintegration. She has to reclaim her own choices and tastes in order to feel at peace, perhaps possible for the first time in her life.
Other forms of anxiety in this hierarchy in ascending order of sophistication are:
1 ) Persecutory anxiety (fear of the hostility of the other)
2) Separation anxiety (fear of the loss of the other)
3) Fear of the loss of love (fear of disapproval or rejection)
A mature woman has begun a relationship late in life with a very affable younger male who happens to have an attention deficit disorder. She enters my office one day very upset. Her partner had promised to trim a hedge at their home but completely forgot to do so. The hedge is not the problem but rather the conclusion she had arrived at that he must not care about her since he keeps forgetting his promises. For this type of situation, psychologists do groups for the partners of those sufferingfrom attention deficit disorders. My client had to understand the difference between the act and the intention. The behavior was the symptom of a disorder rather then a deliberate act of malice. Once she let go, briefly at first, of her conviction of being unloved , the couple ‘s relationship became viable once again.
4) Castration anxiety (losing one’s power or one’s capacity)
It should not be difficult for the reader to relate to any or all of these forms of anxiety. At this point, the reader may find it useful to think of situations in which he or she has experienced or witnessed others experiencing these various forms of anxiety. In fact, anxiety is ubiquitous in our lives. We can see it at a very young age in schools and daycares when children are separated from their parents. We can see it when we undertake a new job or project and are afraid that we will not succeed. And we can see it when we fail to live up to our own moral standards. In the section on social factors, we will look at how contemporary society generates an overabundance of anxiety-provoking situations.
OTHER PSYCHOANALYTIC THEORIES
Melanie Klein, one of the foremost disciples of Freud, developed a substantially different view of anxiety and of psychodynamics in general. In her theory, aggression and hostility play a greater role than sexual instincts in child development and in the development of symptoms. Klein worked with an object relations model that put emphasis on the infant-mother relationship and specifically on the breast as a symbol.
As this infant-mother relationship contains inevitable frustrations and disharmonies, the “death instinct” comes into play, according to Klein’s theory, as the child reacts with overwhelming feelings of hate and destruction. The child then projects these hateful feelings onto the mother who then becomes the feared persecutory object. The helpless and undersized child is now in enemy territory next to the “bad breast” of the mother. One can just imagine the anxiety thus generated.
According to the Kleinian theory, after this “paranoidschizoid” phase, the child develops “depressive anxiety” and moves into the “depressive phase” of development. Here, the child begins to experience loss (the weaning process) as well as guilt and remorse because of his previous hostility and destructiveness. The child then compensates by offering gifts and attempting to charm his parents.
Harry Stack Sullivan introduced a more interpersonal and social model to his analysis. For him, anxiety arose primarily from anticipated disapproval from significant people in early life, most notably the mother. Anxiety arises from the emergence of unacceptable thoughts and feelings that elicit the expectation of punishment or of the loss of love and approval. Human beings will do almost anything to achieve a state of security that comes from the approval of others, according to Sullivan’s theory.
Freída Fromm-Reichman, one of Sullivan’s main students, added that a small but optimum level of anxiety is essential to promote human innate tendencies toward growth.
Karen Horney, another important theorist in the field of anxiety, emphasized the intensity and ubiquity of anxiety. She believed that drug addiction, “workaholism” and sexual promiscuity are attempts to control this intense anxiety. One of her important contributions was realizing the need to grapple with one’s hostile influences while maintaining one’s connection to others. This is one of the basic strategies often used in helping patients to deal with the outside world. For example, those who constantly need to “say it like it is,” end up in all kinds of social and occupational difficulties. Simply cutting off relationships in these situations does not constitute an adequate response, as this type of situation is unavoidable in most occupational and interpersonal contexts. As the saying goes “discretion is the better part of valor.” At times it is best to remain silent, especially when one is angry, if one hopes to maintain one’s social or professional circle. Otherwise anger may ruin it all.
Heinz Kohut, founder of the school of Self-Psychology, tended to see human beings in kinder and more benevolent terms. He hypothesized that the real cause of anxiety was a lack of empathy (“mirroring” was the term he used) on the part of the parents (known as self-objects in this theory). From these “empathie failures,” the child would experience a primary anxiety, which he called “disintegration anxiety,” instead of the more healthy responses of liveliness, joy and pride. According to Kohut’s theory, the way to correct this is to provide the patient with more mature self-objects in the form of a therapist, who would provide the structure and “soothing” the child had missed in his childhood. Through this process, the patient would eventually understand his past and forgive the errors of his parents, realizing that we are all heirs to an imperfect history.
Kohut made an important contribution to our view of child development, but unfortunately for his followers, his contributions occurred just as psychoanalysis was beginning to lose its predominance in psychiatry in favor of biological psychology and cognitive therapy. His kinder and gentler ways have been replaced by medications and rational analysis.
COGNITIVETHEORIES OF ANXIETY
Cognitive therapy, as developed by Dr. Aaron Beck, was originally intended to treat depression. With time, however, the model was extended to include many other pathologies including anxiety. Two major reasons, I believe, account for the success of cognitive therapy. First, it was a more practical approach than psychoanalysis, dealing in its approach with observable realities. Instead of treating abstract entities like “castration anxiety” and “Oedipal complexes,” it dealt with observable behaviors – panic attacks, obsessions and depressive states. This led to, among other things, better research studies, since the results and the processes were easier to measure. The second factor in its success was that the cognitive therapists were diligent, systematic and skilled researchers, not the case with psychoanalysts, who often treated their “science” more like a religion in which you either believed or didn’t.
Many of the recent studies – in which cognitive methods are compared with other short-term therapies, such as interpersonal therapy or even short-term analytic therapy, in a head-to-head manner – do not convincingly demonstrate the superiority of cognitive therapy except, perhaps, in compulsions and specific phobias where it is easy to design a behavioral protocol.
Most clinical psychiatrists I have spoken to do not feel that cognitive therapy Uves up to its promise of superiority as heralded in research studies. Nevertheless, it is a useful tool in our therapeutic armamentarium. Perhaps its greatest contribution has been to force the field of psychotherapy back into the realm of reality and require all schools to test out their theories in well-designed research protocols rather than relying simply on their theories and beliefs.
According to cognitive theory, the core feature of generalized anxiety – worry – is seen as maladaptive information processing that leads to the perception of threat. This is in contradistinction to cognitive theories of depression where the cognitive distortion is about loss and inadequacy. Cognitive models of anxiety may be subdivided into models of generalized anxiety disorder and panic attacks.
GENERALIZED ANXIETY DISORDER
The beUefs or dysfunctional assumptions involved in generalized anxiety may be highly varied, but tend to revolve around the following themes:
1 ) Interpersonal confrontation and conflict
“I get upset every time she calls.”
“How am I going to tell him this?”
“He makes me furious every time I speak to him.”
2) Competency and Capacity (actually the lack of these two)
“If I make any mistake, I have failed.”
“If something is imperfect, the entire product is no good at all.”
“I cannot cope with this. I am not up to it.”
3) Acceptance (the lack thereof)
“I am nothing if I am not loved.”
“I always have to please others.”
“If someone criticizes me, I am worthless.”
4) Excessive Responsibility for Otíiers
“I am responsible for people’s enjoyment when they visit with me.”
“I am totally responsible for the way my children turn out.”
“I worry about my children having a bad day in school.”
5) Social Catastrophe (may be in GAD or Panic Attacks)
“I am going to make a fool of myself.”
“What if I sound stupid making that presentation?”
“If I faint at the restaurant, I wiU be totally humiliated.”
6) Worrying about Minor Matters and Ruminating
The person here worries about things that don’t bother other people, such as being late for an appointment, catching a virus (the avian flu is a popular one these days), or getting lost.
“What is wrong with me?”
“Why do I feel resdess all the time?”
“I think too much. Why am I always so nervous?”
Here again the reader may try to see which of these kinds of dysfunctional thoughts bother him most. The cognitive approach would then involve trying to replace the pathological thinking with realistic thinking. This may be done with a therapist, on paper or simply through “self-talk.” For exam-pie the thought “If someone criticizes me, I am useless,” could be replaced by “If someone criticizes me, they may be right, in which case I can try to correct myself or their idea may be unfounded and just be their opinion.” This is easier said than done, of course, as our thought patterns tend to be repetitive and deeply ingrained.
Outside the biological domain, most psychologists and psychiatrists work with a tripartite model of human experience. In this circular model, emotions, ideas (cognitions) and behavior are interconnected. The psychoanalytic school and many of its offshoots, such as Gestalt Therapy emphasize the emotions, which generate thoughts and behavior. The behavioral school focuses primarily on behavior, arguing that it is the only observable entity. The cognitive school works mostly with the cognitions and claims to be able to change the ensemble through altering the thought processes. Thus, once we identify the anxiogenic thoughts, like those mentioned above, and replace them with reasonable ones, the problem is resolved. The debate as to whether this is true still rages on.
Much of this discussion may seem academic and theoretical but there are serious practical implications to these ideas. I was reminded of this recently when I went to the local handy store on my daily walk. A young man loading up the refrigerator at the store, knowing I was a psychiatrist, collared me and presented me with his difficulty doing multiple-choice exams. He would obsess about each of the possible choices on the exam and then feel totally blocked. It was clearly affecting his performance and possibly undermining his possibilities of completing his degree. I politely referred him to a cognitive therapist but couldn’t help wondering about which negative cognitions were hindering his task completion. They could have been any ofthe following:
“I’m not smart enough to understand the course material. ”
“IfI don’t get a good grade on this course, my friends will think I’m stupid.”
“If I don’t pass this course I’ll be stuck at a menial job for the rest of my life.”
“My teacher is trying to trick me and make me fail so he can feel smart himself.”
“I’m just not made to be a student, “etc. , etc.
The possibilities are infinite but any of them could be enough cause underachievement and the effort to neutralize them is vital.
In Panic Disorder, the catastrophic interpretations involve perceiving sensations as indicative of impending physical or mental disaster. For example, perceiving a slight feeling of faintness, the person is convinced he is in danger of imminent collapse, or on experiencing palpitations, he beUeves that this is evidence of an impending heart attack.
In the mental domain, perceiving unusual or racing thoughts is seen as evidence of an impending loss of mental control and, consequently, insanity. The thoughts may sound like this: “I am losing my mind”; “I am going to end up in die mental hospital”; “What if I lose control and end up hurting someone?”
The cognitive therapist works with a client to help him identify these pathogenic thoughts and then to detoxify them. This is done in a number of ways, including finding rational thoughts to displace the dysfunctional, catastrophic ones and practicing relaxation techniques to counteract the anxiety response. Education is used as well to explain the neurophysiology of anxiety and its natural neuro-chemical limits. At times, it is necessary to design a hierarchy of anxiety-provoking situations so the client may gradually, step-by-step, expose himself to more and more threatening situations. This is known as “Systematic Desensitization” and is used to help people learn to adapt to feared situations (phobias) in graded doses.
If we break these techniques down to their essentials, we realize that we are coming very close to common sense, i.e., to what discerning people and wise counselors have long been advocating. If you are afraid of something and your fear is irrational, expose yourself to the feared situation over and over again until you have mastered it. Che Guevara, a hero of the 1960s generation, was known to have said, “Courage is not the absence of fear but rather the abiUty to act in the presence of fear.” He was thinking like a cognitive therapist.
The other side of the equation is that if you misperceive a situation through irrational thinking, you may attempt to render your thinking more objective. Then you may compare your realistic analysis with your fearful thoughts and discriminate between the reality and the illusion. Spiritual advisors have been suggesting just such an approach since time immemorial.