Treating Anxiety is a central concern in psychiatry as it is a common symptom shared by most patients.
Anxiety is expressed in both the mind and body when facing a dangerous or unfamiliar situation. This happens whether that danger is tangibly real, such as when facing an enemy approaching with a weapon; a mistaken perception, such as mistaking a rope for a snake in a dark shed; or a projection into the present of past traumatic situations, such as when you encounter a triggering perception like the smell of alcohol and sweat as had been present on an perpetrator during an abuse situation.
Ordinary vigilance in the form of alertness and focus of attention, is not anxiety. Anxiety is an anticipatory sense of uneasiness, distress, or dread. Ordinary vigilance has a protective function. It allows you to scan for danger but without the anticipatory fearful qualities. Anxiety can be more likened to hyper-vigilance in DID, where the constant scanning is based on the assumption, the anticipation, that a dreadful circumstance is about to appear.
Consider a performer on stage who modulates their anxiety about the quality of the performance with their confidence based on training and experience. This allows a performer to maintain an appropriate measure of focus of attention and alertness. Unfortunately, when it rises to an ongoing level of hyper-anxiety, of hyper-vigilance as to each step, it becomes “stage fright” – a disabling experience for a performer.
It needs to be clearly understood that anxiety in those with DID is similarly disabling. Those with DID who have not healed from their early traumas, have good reason to be anxious. That is because it is, like the performer, also based on training and experience. In those with DID, that training and experience is repeated abuse from early childhood. Those with DID were trained to understand that they would continue to be attacked, and that their safety was dependent on dissociative based responses. Because DID doesn’t result from a single isolated event, they develop confidence that they will be attacked because of that repeated and ongoing experience of trauma. It should not be a surprise that their everyday experience is a disabling stage fright playing out in real time every day.
The core components of anxiety include feelings of distress, helplessness and fear. While these sound like only symptoms of the mind, there are always accompanying physical responses. Anxiety activates the autonomic nervous system (mainly the sympathetic nervous system) in preparation for a flight, fight, or freeze reaction. All three options are connected to the intensely stimulated sympathetic nervous system going into survival mode. Ongoing anxiety, such as results in DID from repeated trauma, can create a vicious cycle – a self-perpetuating feedback loop. Understanding this is important in the management of anxiety disorders, in those with DID and others.
Merely taking a pill to calm down the hyper-stimulated sympathetic nervous system is, at best, an incomplete treatment for anxiety. In the short term, it may enable one to bypass some of the mental and physical distress of anxiety, but especially for those with DID, alone it will not address the root causes. The dis-empowerment, experienced as fear-laden helplessness, and the establishment of a vicious self-perpetuating loop must also be addressed. Unless these are addressed, healing will remain incomplete.
Without fully addressing the root causes, stress now and in the future will always bring back this experience of helplessness, leaving the individual gravely predisposed to a recurrence of the anxiety or, in the case of DID, dissociation. One’s first thought is likely to be, “If only I had those pills the doctor gave me last time.” This is just another self-perpetuating feedback loop of reliance on chemical intervention. This loop of reliance will take precedence regardless of the accuracy of any current experience – including those in which anxiety is well-warranted – as well as precedence over the difficult therapeutic work of processing one’s trauma history.
Therapists and patients should understand the potentially life-saving value of a healthy internal warning system. Learn how you to keep anxiety in balance. It is useful as a warning system so long as one is able to control the uneasiness so that it doesn’t overpower one’s basic vigilance. I suggest it is important to treat anxiety as an adjunct, neither an enemy nor a replacement, of your friend vigilance.
The best results in treatment is when self-empowerment is incorporated into the healing regime. When the patient makes the efforts to participate and accomplish healing, that healing process is ever more firmly established. The present and future protection a patient acquires over the dysfunctional symptom by him/herself, with the support of the therapist, is far superior to protection which is chemically dependent or overly dependent on the therapist. Therefore, working with anxiety with the tools of self-empowerment is an important part of the healing journey.
Guidance on addressing anxiety
[1] Assess the current situation to see if the anxiety is related to a present warning signal or an echo of distress in the past. If the anxiety is related to a distressing current situation, pay attention to it so as to resolve the present issue. If it is related to some distant past distress, ground yourself in the present so that you can identify that the past is really in the past, a memory rather than a crisis in the present.
Focus on the direct experience of the present, like returning the attention to the breath to the diaphragmatic movement of breathing. As I have discussed in my blog and Engaging Multiple Personalities series, confirming the specific details of any original early trauma is not critical. However, being aware that there is some antecedent primary trauma/distress impacting the present is critical.
Reclaim control of the body and empower yourself in the present. When anxiety causes a disconnection between the mind and the body, try using self-initiated physical methods, such as working with the breath, to reconnect the mind and the body. With any type of working on the breath, we are re-directed to pay attention to our body and our internal state. Anxiety is all about worrying about the future. The essence of breath work is to bring your attention to the NOW.
[2] Understand the risk of feedback loops, and work to interrupt them. This is the way to undermine one’s habituation to those loops which further supports staying grounded in the present. Your heart rate is pounding because adrenaline is pumping into your bloodstream. There is a reason for the heart to go fast – it is preparation for a fight or flight. If you start doing sit-ups or push-ups, you give yourself a physical basis for the heart to beat faster. You are in fact causing the heart to go faster, rather than passively experiencing the heart rate going out of control. Feeling a rapid heart beat when you are physically at rest can be a frightening experience. Anything you do either to match physical activity to your heart rate, or anything you can do to directly bring the heart rate down can very quickly calm your both your body and mind.
In a previous blog post, I mentioned that eliciting the diving reflex can similarly be very useful. Just apply a cold towel or cold water on the forehead. This alone can bring your heart rate down. It is better to access this kind of physiological response than to use a pharmaceutical agent, unless the physiologic response remains overwhelming.
This article from the New York Times is about breathing exercises that may be helpful. I hope readers will find this useful.
Please do remember that any physical process that begins to interfere with the trauma dynamic needs to be practiced, beginning very gently. Proceed slowly as it is like building up your muscles. In other words, you don’t begin to start lifting weights by using a 100 pound barbell. You begin with just a bar, and then add a small amount of weight as you gain strength. View grounding exercises in that same way.
Practice the exercises every day rather than trying them only in the middle of an anxiety attack. That way, when you do call upon them to deal with an anxiety attack, those “muscles” are already primed for actions.
Best wishes
