Anxiety and stigma

I am mentally ill.

I say it that openly, and that bluntly, for a reason: mental illness still has a significant and entirely undeserved stigma in our society, a stigma shared by virtually no other group of illnesses.  I've never heard of someone ashamed to say they have bronchitis, high blood pressure, arthritis, heart disease, or cancer.  While no one would question the gravity of any of those or the impact on the patients and their families, none of those carry the same sense of shame -- the underlying feeling that somehow, it requires an apology, that it's the sufferer's fault for "not trying hard enough."

"Suck it up and deal."  "Just focus on the good things."  "Let go of the negatives."  All, perhaps, well meant, and all entirely useless.  Whatever the underlying cause of the anxiety and depression I've battled my entire life -- whether they're from a neurochemical imbalance, a genetic predisposition (there is good evidence that depression, at least, runs in both sides of my family), trauma from the emotional abuse I endured as a child, or all three -- what I experience is just as real as any symptoms coming from a purely physical illness.

I've gone to hell and back trying to find a medication that helps; none of the standard meds made much of a difference, and several gave me horrible side effects.  Right now the depression is reasonably well in check from the combination of the compassion and support of my family and friends and a set of coping mechanisms (exercise being top of the list).  The anxiety is tougher because it can come on without any warning, and is often triggered by activities that "should be positive" -- getting together with friends, engaging in creative pursuits, even leaving the house.

Edvard Munch, Anxiety (1894) [Image is in the Public Domain]

The reason this comes up is a pair of studies I ran into last week that resonated so strongly with my experience that I found myself saying, "Why didn't the researchers just ask me?  I coulda told them that."  The first, that appeared in the International Journal of Psychophysiology, investigated fear responses -- specifically, how quickly startle reactions ceased once a person realized something surprising wasn't actually a threat.  What they did was show test subjects photographs of two women, then suddenly substituted one with a photograph of a woman showing fear and accompanied it by the sound of a woman screaming at 95 decibels, delivered through headphones.  (I'm so sound-sensitive that just reading about this made me anxious.)  What was fascinating is that (of course) all the test subjects startled, but the ones without anxiety disorders very quickly learned that it wasn't a threat -- on repeated exposures to the same stimulus, they stopped reacting.  The people with anxiety disorders didn't.  Every time the photo changed and the scream came, they reacted, even when they knew it was coming.

This is all too familiar to me.  I once lamented to a therapist, "Exposure therapy doesn't work on me."  I have dreadful social anxiety; I take a long time to open up to people, and when I'm in a large group I tend to shut down completely.  I've been at parties where all night long, I've said exactly two sentences: "Hi, how are you this evening?" and "Good night, thanks for inviting me."  It doesn't seem to matter how many social gatherings I go to where nothing bad happens; I still get overwrought the next time, and spend the lead-up to the event hoping like hell there'll be a dog there to socialize with.

The second study, that appeared in the journal Behavioural and Cognitive Psychotherapy, looked at the ways that people with social anxiety cope, and found that those same "safety behaviors" -- such as rehearsing ahead of time what they'll say, avoiding eye contact, shying away physically if they feel like they're in the way, and not talking unless spoken to -- cause others to perceive them as less likable, more standoffish, aloof, and superior, and less authentic.

Which, of course, is the most vicious of vicious cycles.  I know I do all of those things, not to mention finding an excuse to leave early.  I also have a tendency to get tongue-tied when people do speak to me directly, which probably is why in short order they decide that they'd be better off finding someone else to chat with.

Both studies had me saying, "Yeah, exactly."  Even so, I'm glad these sorts of papers are appearing in well-respected journals.  All of it is a step not only toward finding out what underlies mental illness, but toward reducing the stigma.  Sufferers from disorders like depression and social anxiety aren't simply weird, and we're certainly not doing it for attention (something I was accused of pretty much continuously when I was a kid).  We're just struggling, in the same way that someone with a physical illness might struggle.

I have some hope that the stigma is diminishing.  I've been heartened by the support Senator John Fetterman of Pennsylvania has received following his revelation that he was entering the hospital for treatment for clinical depression.  We still have a long way to go -- there are still people who look at Fetterman's actions as evidence of weakness or instability -- but far more are responding with empathy, with an understanding that we sufferers from mental illness are every bit as deserving of compassionate care as someone dealing with any other kind of illness.

And while understanding that won't cure us, it certainly goes a long way to making us feel like we're not so alone.

(IMPORTANT NOTE: if you, or someone you know, are considering self-harm, please call the Suicide Hotline number now.  The number is 988, and there are people there who can help you and provide the emotional support you need.)

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The merry-go-round of self-blame

Depression is, at its heart, a completely irrational condition.

One of the (many) therapists I've seen during my life told me that the way to deal with depression and/or anxiety was to do a reality check.  Is this feeling I'm having right now consistent with what I know reality to be?  It sounds good, but in practice, it's extraordinarily difficult to do.  Depression and anxiety make it harder for you to be certain what reality is.  The problem is that the depressed and/or anxious response feels just as real as reality does.  You can analyze those feelings in as dispassionate a way as you want, but when the things you're trying to discern seem to be equally plausible, you're in trouble.

One good example is my continual fear of talking too much or calling attention to myself in social situations, especially when I've had a drink or two.  If I'm stone-cold sober there's usually no question, because I hardly ever say anything, much less too much or the wrong thing.  But the inhibition-releasing tendency of alcohol consumption blurs the ability to self-perceive accurately, and afterward, I'm always convinced that I said more than I should have or something I shouldn't have, and nearly every time I have to appeal to my wife to do my reality checking for me.

This is why my reaction to a piece of research that appeared last week in the Journal of Psychiatric Research made me say, "Well, duh."  Not, understand, that I am at all critical of research to support what are honestly anecdotal claims; more that what they found is essentially how I live.  A team at King's College London, led by clinical psychologist in mood disorders Roland Zahn, studied the reactions of a group of test subjects -- some of whom had a history of suffering from depression, and others who did not -- to various hypothetical social interactions, and had them identify what would be their most likely responses if it were a real situation.

[Image licensed under the Creative Commons Sander van der Wel from Netherlands, Depressed (4649749639), CC BY-SA 2.0]

What the team found was that people who have depression tend to blame unpleasant social interactions on themselves, even if the circumstances make it unlikely that they were at fault.  "Self-blaming feelings such as guilt, self-disgust and self-directed anger are key symptoms of depression and Freud is widely credited for pointing to the importance of excessive self-blame in depression," Zahn said, in an interview in PsyPost.  "Social psychologists have done research into these so-called ‘action tendencies’, i.e. implicit feelings of acting in a certain way, such as hiding or creating a distance from oneself, which are entailed in complex feelings.  This is why my PhD student Suqian Duan set out to investigate this question.  In this study, we investigated blame-related action tendencies for the first time systematically in people with depressive disorders."

The response Zahn describes is strikingly similar to my experience of clamming up completely in social situations.  "Many people with a history of major depression, despite having recovered from symptoms, showed an action tendency profile that was different from people who had never experienced major depression and are thus at a lower risk of depression overall," he said.  "They were more likely to feel like hiding, creating a distance from themselves and attacking themselves when faced with a hypothetical scenario of acting badly towards their friend whilst being less likely to apologize.  Interestingly, we showed that the label of the emotion did not map one-to-one on specific action tendencies as was often assumed but rarely tested.  Feeling like attacking oneself was specifically associated with self-disgust/contempt, a feeling which we had previously found to be the most common form of self-blaming feeling in depression."

Zahn points out (correctly) that one of the difficulties is there is such a thing as reasonable guilt.  Purging oneself of all guilt feelings shouldn't be the goal; sometimes we feel guilty for a very good reason, and those feelings can prompt us to make amends for mistakes we've made.  "There is... a controversy around how to measure and define healthy forms of guilt, which help us to apologize and try to repair the damage we might have done from unhealthy forms of self-blame, where we take responsibility for things that are out of our control and feel paralyzed by our guilt or sense of failure, so that we hide away from the situation," Zahn explains.

The trouble is, with depression and anxiety, the ability to discern between justified and unjustified guilt or self-blame gets blurred, and depression and toxic narcissism lead to opposite and equally damaging false conclusions; the former, that every negative interaction is our fault, the latter that none of them are.

It's hard to see, in the absence of someone like my wife to do an external reality check, what you could do to get off the self-blame merry-go-round.  When the heart of the problem is an inaccurate but compelling view of oneself and the situation, trying to do any kind of internal reality check is likely to meet with limited success.  That's certainly been my experience.  I can even go into a social situation with the mantra, "I know I don't talk too much, everything is going to be fine, I should loosen up and just chat with people," but afterwards the inclination to self-blame anyhow is awfully powerful.

No wonder we feel like hiding a lot of the time.

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Reunion recap

Robert Burns famously said:

O, would some power the giftie gi'e us
To see ourselves as others see us.
It would frae many a blunder free us,
An' foolish notion.

I got a lesson in that general principle this past weekend, when I went to my 40th high school reunion.  Which was a little surreal from another aspect, which is that I can't really believe that much time has passed.  I don't feel like I'm a week or so shy of 58 years old, but I had confirmed for me several times at the party that yes, actually we are that old.

Maybe the reason I don't feel old is because my personality, and especially my sense of humor, kind of plateaued some time around tenth grade.  I mean, I still laugh at fart jokes.  I suppose that's why I ended up teaching adolescents, I'm right on their emotional level.

But there was another eye-opening thing about the reunion, which was how many people remembered me with apparent fondness.  I didn't think I was disliked in school so much as I felt invisible, kind of a nonentity.  Because of my shyness and anxiety my social life was zilch, and I figured most of my classmates had their attention focused on the popular kids -- the confident ones, the star athletes, the party animals, the class clowns.

Me, I read a lot, ran a lot, listened to music, and tried to figure out how to do the bare minimum homework it took to get by in classes I didn't like.  Other than that, I pretty much just tried to keep my head down and fly under the radar.  I did have a bit of a reputation for being a smartass (something that got me in trouble more than once), but overall, I felt like someone no one much would have a reason to notice.

I was bowled over by the warmth with which I was greeted on Saturday night.  I received dozens of hugs and handshakes, and was told over and over how well people remembered me.  I thought that some of it might be Facebook -- since I post links to my novels and to Skeptophilia there, I knew that the dozen or so of my former classmates who are Facebook friends would know a bit about me.

But it's more than that, because I received the same kind of welcome from people who aren't connected to me on social media, and most of whom I literally have not seen since we graduated in June of 1978.  I left that evening feeling a mixture of elation and sadness -- elation because I was evidently much better liked than I ever dreamed, and sadness because I hadn't realized it at the time, and had spent the intervening years thinking of myself as having been the amiable, bookish nobody, the kid who everyone looked past, who never got into the yearbook, whom no one really knew.

What this all points up is how completely inaccurate our own self-assessments are.  I wish I'd known sooner.  I might have been less afraid, less worried about what others thought, less concerned that everyone else seemed more popular than me.  I might have had the courage to join clubs, go to dances, ask out the cute girl I had a life-threatening crush on.  To put it succinctly, I might have had a hell of a lot more fun.

Me having fun, of all things

But as my grandma always said, if wishes were horses, then beggars would ride.  You can't change the past; all you can do is recognize it for what it is, realize you were doing the best you could with what you knew then.  Forgive yourself for what you didn't know, what you misunderstood, for your missteps and fumbles and awkward moments.  We've all had them, and they apparently matter far, far less than we usually think at the time.

So the party was great, and being that this is southern Louisiana, there was enough food to feed the French army, a well-stocked bar, and music and dancing and socializing until the wee hours.  I arrived home Monday night, exhausted and still feeling a little disembodied.  And the oddest thing of all is that I -- as neurotic and anxious as I am -- fell asleep with the thought, "Hey, they said there'll be a 45th reunion in five years.  I'm already looking forward to it."

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This week's Skeptophilia book recommendation is something everyone should read.  Jonathan Haidt is an ethicist who has been studying the connections between morality and politics for twenty-five years, and whose contribution to our understanding of our own motives is second to none.  In The Righteous Mind: Why Good People are Divided by Politics, he looks at what motivates liberals and conservatives -- and how good, moral people can look at the same issues and come to opposite conclusions.

His extraordinarily deft touch for asking us to reconsider our own ethical foundations, without either being overtly partisan or accepting truly immoral stances and behaviors, is a needed breath of fresh air in these fractious times.  He is somehow able to walk that line of evaluating our own behavior clearly and dispassionately, and holding a mirror up to some of our most deep-seated drives.

[If you purchase the book from Amazon using the image/link below, part of the proceeds goes to supporting Skeptophilia!]

Fear itself

Past experiences in my life have instilled into me a deep dislike of being the center of attention.  Talking about what you love, what you're interested in, is arrogance and conceit -- I learned that lesson early.  Also, protect what you care about, or it'll be ridiculed, demeaned, or taken away.  The result was that even in safe situations, I have always been afraid to open up, and even people I've known for years really hardly know me at all.

The fact that I no longer have to spend my life in a protective crouch has not eradicated that fear.  It's a significant part of why I'm as shy and socially awkward as I am, and why I'm the guy at parties (if I get invited in the first place) who's standing there with a glass of scotch, looking around frantically for a dog to socialize with.  I've tried for years to be okay with graciously accepting compliments when they come, and to open up to others about my interests, but to say it doesn't come naturally to me is a wild understatement.

This all comes up because of some research released last month from scientists at the RIKEN Center for Brain Science in Saitama, Japan.  A team consisting of Ray Luo, Akira Uematsu, Adam Weitemier, Luca Aquili, Jenny Koivumaa, Thomas J.McHugh, and Joshua P. Johansen published a paper in Nature: Communications called "A Dopaminergic Switch for Fear to Safety Transitions," wherein we find out that a single neurotransmitter (dopamine) acting in a single part of the brain (the ventral tegmental area) is apparently responsible for unlearning fear responses.

The authors write:

Exposure therapy, a form of extinction learning, is an important psychological treatment for anxiety disorders such as post-traumatic stress disorder (PTSD).  Extinction of classically conditioned fear responses is a model of exposure therapy.  In the laboratory, animals learn that a sensory stimulus predicts the occurrence of an aversive outcome through fear conditioning.  During extinction, the omission of an expected aversive event signals a transition from fear responding to safety.  To switch from fear responding to extinction learning, a brain system that recognizes when an expected aversive event does not occur is required.  While molecular changes occurring in the ventromedial prefrontal cortex (vmPFC) and amygdala are known to be important for storing and consolidating extinction memories, the brain mechanisms for detecting when an expected aversive event did not occur and fear responses are no longer appropriate are less well understood... 

[Our] findings show that activation of VTA-dopamine neurons during the expected shock omission time period is necessary for normal extinction learning and the upregulation of extinction-related plasticity markers in the vmPFC and amygdala.  Notably, inhibition of VTA-dopamine neurons during the shock period of fear conditioning facilitates learning, suggesting that activity in VTA-dopamine neurons is not simply important for learning in response to any salient event.  These results also reveal that distinct populations of VTA-dopamine neurons... are important for the formation of stable, long-term extinction memories.

Team leader Joshua Johansen was unequivocal about the potential for this research in treating long-term anxiety and PTSD.  "Pharmacologically targeting the dopamine system will likely be an effective therapy for psychiatric conditions such as anxiety disorders when combined with clinically proven behavioral treatments such as exposure therapy," he said in a press release from RIKEN.  "In order to provide effective, mechanism-based treatments for these conditions, future pre-clinical work will need to use molecular strategies that can separately target these distinct dopamine cell populations."

Illustration from Charles Darwin's Expression of the Emotions in Man and Animals (1872), captioned, "Terror, from a photograph by Dr. Duchenne."  [Image is in the Public Domain]

I have suffered from serious anxiety most of my life, and I have a dear friend who has PTSD, and believe me -- this is welcome news.  My one attempt to use an anxiolytic medication was a failure (it killed my appetite, which someone with as fast a metabolism as I have definitely doesn't need), and "exposure therapy" has, all in all, been a failure.  The idea that there could be a way to approach these debilitating conditions by targeting a specific molecule in a specific part of the brain is pretty earthshattering.

I know it's a long way between identifying the brain pathway involved in a disorder and finding a way to alter what it's doing, but this is a significant first step.  The idea that I might one day be able to go to social gatherings without feeling a sense of dread, and to talk to people rather than just dogs, is kind of amazing.  Until that happens, I'm probably still going to have to deal with my anxiety, but it's nice to know someone is working on the problem.

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This week's book recommendation is especially for people who are fond of historical whodunnits; The Ghost Map by Steven Johnson.  It chronicles the attempts by Dr. John Snow to find the cause of, and stop, the horrifying cholera epidemic in London in 1854.

London of the mid-nineteenth century was an awful place.  It was filled with crashing poverty, and the lack of any kind of sanitation made it reeking, filthy, and disease-ridden.  Then, in the summer of 1854, people in the Broad Street area started coming down with the horrible intestinal disease cholera (if you don't know what cholera does to you, think of a bout of stomach flu bad enough to dehydrate you to death in 24 hours).  And one man thought he knew what was causing it -- and how to put an end to it.

How he did this is nothing short of fascinating, and the way he worked through to a solution a triumph of logic and rationality.  It's a brilliant read for anyone interested in history, medicine, or epidemiology -- or who just want to learn a little bit more about how people lived back in the day.

[If you purchase the book from Amazon using the image/link below, part of the proceeds goes to supporting Skeptophilia!]

Anxiety shrinkage

I think one of the reasons I'm so interested in neuroscience is because there is still so much to be explored.  In my Intro Neuroscience class, I frequently have to answer questions students ask with the frustrating statement "That's unknown at this time."  Even such simple things as how memories are stored and recalled are poorly understood, although we are making significant progress in finding out how they work.

My friend and mentor Rita Calvo, Professor Emeritus of Human Genetics at Cornell University, once told me that we are currently at the point in understanding the brain that we were in understanding genetics in 1915.  We have some knowledge of what's happening, a lot of descriptive information, and little in the way of comprehension of the underlying mechanisms.  I still recall her telling me that if she were a college student in biology now, she'd go into neuroscience.

"The 20th century was the century of the gene," she said.  "The 21st will be the century of the brain."

So any time there's an advance, I'm pretty keen on finding out about it.  Which is why the article my wife sent me yesterday was such an eye-opener.  Entitled "Neuroplasticity in Response to Cognitive Behavior Therapy for Social Anxiety Disorder," this study (published this week in Translational Psychiatry) has found that social anxiety might be due to a hyperactive part of the brain called the amygdala, which has been known to be involved in fear, anxiety, and the fight-or-flight response.  More interesting still, they found that cognitive behavioral therapy can literally cause this hyperactive bit to shrink.

K. N. T. Månsson of Linköping University in Sweden, who led the group that did the study, writes:

[W]e demonstrate interrelated structural plasticity and altered neural responsivity, within the amygdala, after CBT for social anxiety.  Both GM volume and neural responsivity in the bilateral amygdala diminished after effective treatment.  Left amygdala GM volume was positively associated with symptom severity before treatment, and amygdala volume decreased significantly with CBT, correlating positively with symptom improvement in both hemispheres...  [O]ur results reinforce the notion that structural neuroplasticity in the amygdala is an important target for psychosocial treatments of anxiety, as previously suggested for pharmacological treatments of post-traumatic stress disorder.

Did you get that?  Cognitive behavioral therapy -- essentially, a kind of talk therapy -- actually had an equivalent result to anti-anxiety medication, and caused the part of the brain that was hyperactive to become physically smaller.

Are you amazed as I was at this result?  Because I read this with my mouth hanging agape.  The idea that cognitive behavioral therapy actually has a measurable result in the form of an anatomical change is absolutely mind-blowing.

Pun (lame though it is) intended.

I have another reason to find this result fascinating.  I have suffered for years from serious social anxiety, starting when I was in my mid-twenties and becoming progressively worse for the following thirty years.  Those of you who read Skeptophilia but don't know me personally might have a hard time picturing someone who is as verbose as I am being a social-phobe, but you'll have to take my word for it; in most social situations, I get myself a glass of wine and then hope like hell that the hosts have a dog I can interact with.  I have gone entire evenings at friends' houses, listening politely, laughing at the right times, and not saying a word.

Michelangelo Buonarroti, The Last Judgment (1541) [image courtesy of the Wikimedia Commons]

I've also been in cognitive behavioral therapy for about a year to try and deal with some of this, with guardedly positive results.  I'm not expecting such a deep-seated and pervasive problem to go away quickly; Rome, as they say, wasn't built in a day.  But the idea that by participating in CBT I am not only working toward alleviating my anxiety, but am causing long-lasting anatomical alterations in my brain -- that is amazing.

Because I have to say that living with an anxiety disorder is not particularly enjoyable.  Anything I can do to shrink that overactive left amygdala is fine by me.