Overcoming Anxiety

What makes a panic attack so scary? Well, first there comes the sudden onset of  debilitating symptoms--racing heartbeat, tightness in the chest, nausea, among others--that can be mistaken for a heart attack. Then, once you realize that you’re not dying comes the fear that this sudden anxiety will strike again.

This makes a recent New York Times article about professional golfer Charlie Beljan all the more remarkable. He had a panic attack (although he didn’t identify it as such while he was experiencing it)  before a practice round for a PGA tournament. He managed to play through his anxiety and complete the round. For some, the initial panic attack can lead to avoidance of similar situations (for example, avoiding driving after having a panic attack while driving). In this case, Beljan returned to the tournament the next day, after spending the night in the hospital getting a medical workup.And despite the residual effects of the previous day’s experience, he won the tournament.

It’s hard to imagine experiencing such anxiety and then performing so well under pressure. Golf has a well-deserved reputation as a nerve-wracking sport--one in which a player’s greatest enemy is the psychological turmoil inside. The history of professional golf is filled with episodes in which a golfer nears the end of a tournament leading by a wide margin, only to buckle under the pressure, start playing badly and lose the top spot. In this case, he attributed the anxiety not to the pressure from the tournament, but recent changes and stressors in his personal life, such as having a new baby. After the tournament, the article notes, he contacted a psychologist for treatment.

Beljan’s story shows how disruptive and frightening anxiety can be, but also shows that it is possible to overcome it. His story is truly impressive and inspirational.

Male Anorexia

“20% of Anorexics are Men” is the to-the-point title of an article in the September issue of GQ, which profiles male anorexics and highlights some of their difficulties. Some takeaways:

• The number of male anorexics is rising quickly. One contribution may be the increased focus on hard-to-attain physical attributes like the six-pack

• Risk factors include being overweight as a youth and getting teased for it; a family history of eating disorders or obesity; being gay; and having participated in a sport that emphasizes speed or weight control (distance running, wrestling, etc.).

• Anorexia has the highest mortality rate of any mental illness--between 5 and 10 percent--a result of both suicide and health complications. It lasts longer in men (8 years) than women, in part because men are likely to wait longer to get treated.

• Even with recovery, there are likely to be health complications which can affect life expectancy. The prolonged deprivation can weaken the heart muscles, the bones, and cause cognitive damage which may lead to medical issues long after treatment is completed.

The photos that accompany the article are arresting and disturbing, as are the sad stories of the suffering men profiled. Included are one man on the verge of death, so emaciated that the fat from the pads on his ear that seal his Eustachian tube is gone, leading him to hear a constant rushing of air; and a subclinical anorexic, whose weight is low but not dangerously so, but who tightly controls his exercise and food intake so as to maintain it. What is striking in all of these stories is the amount of focus and energy on food and exercise, and the isolation that accompanies it. Either because of the time and energy devoted to losing or maintaining weight or the need to hide the extent of restriction from others, the men profiled appear lonely, virtually friendless and withdrawn from others. It is truly a sad and moving article.

Why a little self-deception is good

How important is it to see yourself clearly, to be able to assess your strengths and weaknesses accurately? Maybe not as important as you might think, some researchers say.

In the July 30 Wall Street Journal, Sue Shellenbarger reports on research that looks at ways people deceive themselves to in order to feel better about themselves. Studies show, for example, that people tend to think that they are smarter, better looking, and easier to get along with than they really are.

The research brings to mind earlier studies of “depressive realism” -- the concept that depressed people are more accurate in assessing some situations, while non-depressed people displayed more “positive illusions.” We all use psychological defenses to avoid facing up to unpleasant things, and perhaps when we’re depressed, those defenses are less sturdy.

People who have studied self-deception say that a little bit of it can be good for you. Overestimating your strengths and downplaying your weaknesses may spur you to take on new challenges. In contrast, ruthlessly assessing your deficits and minimizing your strengths may hold you back.

Too much self-deception, though, can be harmful. Politicians are a good illustration of this. If you run for office, you have to be a little self-deceiving. You have to believe that you are the person most qualified person to solve the problems of thousands or millions of people. You have to shake off a lot of criticism and harsh attacks -- even if it’s all true. Yet history has proven over and over again that politicians’ self-deception can border on delusional -- most colorfully when they commit ethical misdeeds believing they have no risk of being caught. Self-deception, like most other character traits, exists on a continuum. Some is good, but too much can be destructive.

Body Image and Sororities

It was somewhat disturbing to read in the Sunday New York Times about a new kind of service business: sorority coaches. These are women who get paid to help girls at college to pledge sororities. As part of their work, the coaches advise these young women on how to dress, shape their resume, and present themselves in order to maximize their chances of being asked to join a sorority.

As an adult long past this stage of life, I feel sympathy for young women who have to, or feel they have to, put so much effort into packaging themselves in a particular way to find a circle of friends at school. But what I found most disappointing in the article was its offhand discussion about weight and the necessity of losing weight before sorority rush. The author writes, “Many aspiring sisters spend their summer working out and dieting,” and cites a study that among girls in a normal weight range, the thinner ones are more likely to end up in a sorority. “It’s just you are being judged on how you look,” says one college student quoted in the story.

That the author and the participating girls just accept this without question or comment strikes me as sad. It also shows how ingrained in our culture it is that girls should strive to attain the a thin ideal. Given the pressure for conformity in sororities that this article describes (in many areas, not just weight), it is not at all surprising how prevalent body image concerns are among college women.

College Students and Prozac

What does it mean that there has been an explosion in the number of college students taking psychiatric medication? Does it mean that more students with mental illness are attending college? That people are more willing than in the past to seek treatment for anxiety and depression? That mental illness has been redefined? Or is it something else?

Katherine Sharpe -- a writer who discloses that she took antidepressants while attending college in the late 1990s -- makes a thoughtful attempt to answer these questions in the latest issue of the Chronicle of Higher Education. Facing increased stress, competition and pressure on campus, students feel the need to present themselves to others as being without flaws or weaknesses, writes Sharpe. Citing the research of Joseph Davis, a sociology professor at the University of Virginia, Sharpe says that students use medication to protect themselves from experiencing the emotions that they deem unacceptable -- emotions such as “discouragement and loneliness, nervousness and insecurity, jealousy and emotional vulnerability, shame and humiliation, shame and self-blame.” The desire to avoid such emotions diminishes, for these students, the appeal of traditional therapy, any form of which will require some exploration of the unpleasantness they feel. Medication, by contrast, can seem quicker and less painful.

What is going on, Sharpe writes, is a kind of “medicalization” of negative emotions -- a perception that if you experience these emotions, they must be connected to some kind of disorder. What can be lost is the opportunity to explore and reflect on normal negative emotions that may in fact have some significance and meaning. Overall, the emergence of effective psychiatric medications has enabled many students and non-students to thrive and few would argue with that. However, it is unfortunate if these medications also contribute to college students’ sense that they must achieve emotional perfection, and their mistaken belief that those around them have already achieved it. Much research shows that medication and psychotherapy can be more effective when used in tandem than either approach is when used by itself; it would be a shame if college students were to lose the added benefit of therapy because they want to avoid feelings of vulnerability.

Technology and Eating Disorders

Technology has changed our lives in ways that we don’t often think about. Remember when the only way to look something up was in a book? Or the only way to access the Internet was on a desktop computer? Now we have uninterrupted access to information that’s always easy to seek out -- even when it may not be good for us.

Information access, for example, is not always such a good thing when it comes to eating disorders. In a recent article at Thefix.com, a website covering addiction and recovery, a colleague, Diana Freed, discusses how technology can be detrimental to people with eating disorders. She describes working with a 24 year-old woman who constantly checks her iPhone -- a phone loaded with apps that count calories, record her weight, and track her body mass index and body fat. Though the patient severely restricts her own food intake, she has also downloaded onto her iPhone recipe apps that she can look at and think about. In other words, at the same time she is seeking treatment to help her alter her preoccupation with weight and food, technology makes it easier for her to constantly retrieve images and information fueling the very impulses she is seeking to change.

Freed’s article raises an array of technology-related issues that I need to consider in my work. It’s important to know how much time a patient is spending on the Internet or engaging in social media, and what he or she believes to be getting from those experiences. Does using a certain app make you feel worse about yourself? Or are there apps you can use in the service of recovery? These are just two of the questions about technology that I and other psychologists must now explore.

How to Change a Habit

Habits die hard. In The Power of Habit:Why We Do What We Do and How We Can Change It, Charles Duhigg tries to make it easier, by exploring how habits develop, how entrenched they can become, and how they can be changed.

From my perspective as a psychologist, the most interesting part of the book focuses on what Duhigg calls the habit loop. A habit loop consists of a cue, a routine, and a reward. Follow the loop a few times, and the habit becomes automatic and, well, a habit. Start smoking when you have your morning coffee, and pretty soon the coffee will cue you to crave the cigarette. The cigarette becomes the routine, and the nicotine, relaxation and distraction of the cigarette and coffee become the reward.

The key to changing the habit, says Duhigg, is identifying the cue, substituting another routine, and providing the same reward. One example he uses is how Alcoholics Anonymous can help people break the cycle of alcohol abuse. AA members are encouraged to explore the triggers, or cues, to which they have responded in the past by drinking. The hope is that, when faced with these cues again, they will instead develop the routine of going to a meeting or talking with a sponsor and enjoy the reward of companionship and support, rather than the reward they felt in the past from taking a drink.

Of course, real life is not as straightforward as the habit loops Duhigg describes. Motivations and rewards can be complicated. For example, the first part of the loop, identifying the cue, is not always immediately clear. When you walk into your apartment and immediately go to the refrigerator, what is the cue? Is it boredom, hunger, or a desire to escape from responsibilities? Next, you have to change the behavior -- perhaps going into another room first or finding a different escape. The last part to identify is the reward. Is it relaxation? Numbness? Without having a real understanding of what the payoff is for you, it will be difficult to find another behavior that can provide as reliable a reward.

Nevertheless, the model of the habit loop does provide an interesting way to look at behavior and can be helpful in devising ways to cue yourself in a positive direction. If you want to exercise, for example, you can put your gym clothes out the night before. At the very least you can use the concept of the habit loop to recognize habits you may not even be aware you have.

Yoga and Mood

There are many paths to managing moods, and one is through the body. Exercise has been shown in many studies to help with depression and anxiety. In his new book The Science of Yoga, William J. Broad takes a close look at one form of exercise, and finds it can have a dramatic effect on people’s mood.

Advanced yoga practitioners, says Broad, have a superior ability to control their autonomic nervous system, which controls bodily functions such as respiration rate, heart rate, digestion, and sexual arousal. Yoga has a particularly strong effect on the parasympathetic system, which enables us to slow down our body’s fight-or-flight response. In other words, certain poses, such as inversions, induce the heart into beating more slowly, which contributes to relaxation. Other research has shown that yoga can increase levels of the neurotransmitter GABA, which aids in relaxation and reducing anxiety.

Broad writes:

The portrait of yoga that emerges from decades of mood and metabolic studies is of a discipline that succeeds brilliantly at smoothing the ups and downs of emotional life. It uses relaxation, breathing, and postures to bring about an environment of inner bending and stretching. The actions echo, in a way, how yoga pushes the limbs into challenging new configurations. They promote inner flexibility.

Psychotherapy is one way to address anxiety or depression. But it is limited to time spent in the therapist’s office. Yoga is one of many helpful activities that people can pursue on their own and that increase one’s ability to manage emotions and control stress.

Mindful Eating

On the same day that The New York Times published a front-page story about the latest trends in multi-tasking (think multiple computer screens), the newspaper also ran an article about the benefits of something that is almost exactly the opposite of multi-tasking: mindful eating.

Based in Buddhism, mindful eating is the practice of attending closely to how the senses are engaged when one has a meal. When one mindfully eats, one is focusing on nothing but the food. There’s no reading the newspaper, no watching TV -- not even any conversation at the table.

Mindfulness offers a take on food different from the more common view of “good” and “bad” foods. Instead of avoiding a certain food because it’s “bad” to eat too much of it, you slow down the experience of eating the food. You savor it, think about it -- try to really taste it. Mindful eating is a surprisingly challenging thing to do, since we have so many distractions at mealtimes and we’re so used to using food itself to distract ourselves from what we’re feeling, both emotionally and physically. Mindful eating is widely used in treating people with eating disorders because so much of that disordered behavior is about consuming food, not tasting it.

Mindful eating is a difficult practice to master; even the experts quoted can’t do it all the time. But even thinking about the concept and trying it can help us. Compare the difference between really looking, smelling and tasting a piece of chocolate and then just popping it into your mouth without paying attention. It can be a completely different and more pleasurable experience when you taste the chocolatey taste and feel the melting texture of the chocolate. You may find that you feel satisfied with less, and enjoy what you have eaten more.

Athletes and Disordered Eating

Knowing when we have taken a healthy behavior too far can be hard to judge. In the March issue of Runner’s World, Caleb Daniloff writes about how his attention to nutrition, while training for his first marathon, drifted into bad eating habits. Believing that losing weight would help him train better and run faster, he ended up restricting his eating, drastically cutting calories, becoming preoccupied with his weight and body, and avoiding foods that he formerly ate with abandon. He caught himself before developing a full-fledged eating disorder, but the article describes several elite athletes who didn’t.

Disordered eating — that is, eating behavior that doesn’t meet the medical definition of an eating disorder, but can be injurious nonetheless — is widespread. Three-fourths of American women between 25 and 45 display some disordered eating, according to a study cited in Daniloff’s article.

How do you know whether your eating is disordered? The most common sign, according to Leslie Bonci, a nutritionist quoted in the story, is this: “Food choices become about what not to eat.”

The article includes some common food rules people adopt that can signal disordered eating. The magazine’s list of danger signs is directed at athletes, but it’s useful for everyone. Here’s a paraphrase:

1. Eating energy bars as meals rather than eating real foods.
2. Avoiding fat, or carbs, or a particular basic food group.
3. Rigidly scheduling mealtimes rather than eating according to feeling hungry.
4. Logging calories precisely.
5. Avoiding eating with others if it doesn’t fit with your food rules.
6. Skipping fuel on long runs.

When you’ve taken all the pleasure out of food for yourself — when food rules take precedence over friends and family, when it’s all about what you’re taking away from yourself, rather than what you’re giving to yourself — you’ve crossed over from moderation to disordered behavior. Athletes and non-athletes alike would benefit from shifting their focus from food as an obstacle to weight loss to food as a means of fueling and replenishing one’s body.