Judy’s annoyance with her two sisters went back further than when her father entered the long term care facility. She realized that she was angry at her siblings, not only because they didn’t do things her way, but also because she resented their intrusion into her life when she was a young child. When they were born, she lost her prime position in the household and she was given increased responsibility before she was ready. At first she was afraid to tell them that she was angry that they didn’t do their share for their father. She reluctantly took on the role of designated caregiver. Although she complained a lot, in some ways it fulfilled her needs, particularly to feel in control and therefore safe. As she started to understand these issues, she was better able to insist that her sisters share the workload.
After her twin sisters were born and her grandmother died, she noted, “I was alone.” Judy felt that she needed outside support or she would be helpless, vulnerable and isolated. In her present life, she felt that she could not rely on her son. She was angry at his behavior and had no respect for him because he had dropped out of school and was not working. She could not rely on her boyfriend because, although he was emotionally supportive, he was not always around and “didn’t always get it.” Judy had grown up trying to please people so that they wouldn’t leave her and would be there to protect her so she wouldn’t feel bad or guilty. She had been in therapy with several different counselors for a long time because she felt that she needed this constant support.
Judy felt guilty about her son’s life performance. He didn’t fit the mold that she envisioned and was not a reflection of her way of dealing with the world. He was a child of divorce and she blamed herself for his adolescent behavior. During her therapy, he started working in the same facility where she was employed. He did well and she got positive feedback from her coworkers. This helped Judy feel better about herself as a mother and allowed her to understand that perhaps he did have some potential to be emotionally supportive to her in the future.
I encouraged Judy to spend more quality time with her boyfriend, which helped her feel loved, appreciated and more supported. He had not offered on his own before, because he felt that she did not have the time and was not interested. By being more proactive, she was starting to take charge of her anxiety by saying “Stop” to the anxiety process.
Take a deep breath. Draw air in through your nose and let it out very slowly through pursed lips. Take your time and don’t rush the technique. This breathing exercise can be done one to three times in any situation. People will not even be aware that you are doing it. It will slow your pulse rate and help you calm down and relax.
The way we feel is affected by the way we breathe. When we are upset, we are often told to take a deep breath. But when we are feeling anxious or frightened, we don’t just need to take a deep breath; we need to take a breath and exhale slowly. Breathing out, not breathing in, is associated with relaxation. Deep, slow, diaphragmatic breathing is a behavioral relaxation technique that can be taught to reduce or modify symptoms of anxiety. Watch a baby breathe. You will see its stomach—not just its chest—rise and then fall as the breath is released. Breathing retraining causes arousal reduction. Just as hyperventilation is taken by the nervous system as a sign that the body is under stress, deep diaphragmatic breathing sends a signal to the nervous system that “there is no danger—you can relax.” When you are affected by a stressor, your body goes into the fight-or-flight response. One of the components of this response is an increase in your breathing rate and a move to upper-chest breathing. Diapragmatic breathing can reverse this process. This simple exercise made a great difference in Matt’s life. Let’s look at how and why:
Matt’s Story
“My anxiety is a battlefield. It has both a mental and a physical aspect. I worry and live with various fears on a daily basis. I get nervous when I am in an interview or meeting, a crowd of strangers, while driving (particularly if I am going somewhere new) or anywhere that I feel that I am trapped and can’t escape easily. I feel overwhelmed. The negative thoughts pile up and seem insurmountable. When these feelings last for a while, I start to beat myself up for not being able to get it together and I become depressed. I also start thinking that I am getting physically sick, developing a new allergy or having a stroke. I think that I am losing my mind and will need to check into the asylum. I also get obsessive and start double-checking locks and the stove to see if it is on. My chest gets tight and there is pain on either side of my upper body. My back and neck become tight. My stomach churns. I get bouts of dizziness. I feel like adrenaline shocks are shooting through my body. I sigh a lot.
Sometimes, the physical symptoms can be much worse. I feel the tightness in my neck and back as well as the pain in my chest. As the anxiety grows, I begin to feel that I am not breathing right. I can’t take a full breath. I can’t swallow. Then my heart starts beating faster and I feel tightness and throbbing in my temples. As the anxiety increases and overwhelms me, I hit panic mode. My lips, the sides of my face, hands and feet will go numb and tingle. I feel like I have hive-like blotches on my face. Once my face was so numb and hot that I thought my eyes would be forced shut while driving and that I would crash. Immediately after the stressful situation passes, the numbness starts to go away but leaves my face and lips feeling puckered. I actually feel silly at that moment looking at myself like I just sucked on a lemon.”
When I first met Matt, he was twenty-eight years old. He had had surgery for strabismus (being cross-eyed) and later a gastric bypass which brought his weight down from 430 to 230 pounds. Although his appearance was improved, it did not change his low self-esteem. He complained of feeling lonely. He had a college degree in fine arts and multi-media but in spite of being bright and creative, he only had a low-level technical job. Matt had a history of panic disorder; however, it was his generalized anxiety and low-grade chronic depression that brought him to my office for therapy. His anxiety was persistent, demoralizing and interfered with his functioning. For the most part, he had suffered in silence. The gastric surgery eight years prior had left him with multiple “stomach problems,” including gas, nausea and constipation. He reported that he had been taking an antidepressant that inhibited the reuptake of serotonin and norepinephrine for four years and at top therapeutic dose. Each time that his family physician tried to lower the dose, Matt felt that it caused “pill withdrawal,” upset his digestive system and threw his nervous system into turmoil, giving him increased anxiety, stomach pains and dizziness. He was adamant about not giving up his pills.
Matt was also convinced that many of his anxiety symptoms, particularly the numbness and the facial sensations and manifestations, had a physical cause. The presence of vague physical symptoms, often involving every system of the body, is an important feature of GAD. However, his ill-defined facial symptoms were unusual: they did not seem to be due to drug abuse, caffeine or medication. There was no family history of thyroid disease or diabetes. I was pleased when he told me that his family physician had also referred him to an endocrinologist for evaluation. A few weeks later, I received a report from the endocrinologist. He had ordered hormone studies to try to explain Matt’s symptoms but was pessimistic that the results would give him an answer. He also wanted to rule out an allergic reaction. All the studies came back within normal range.
Matt’s initial evaluation showed much “grist for the mill” for therapy. I decided to follow my gut reaction that his facial symptoms were due to anxiety. Education is a crucial part of the initial treatment