by Margaret Wehrenberg
W. W. Norton, 2015
Review by Roy Sugarman, PhD on May 19th 2015
If the essence of psychology is measure to manage, in respect of any conditions, then that is where Wehrenberg begins, describing various forms of anxiety, including panic attacks vs panic disorder for instance, as well as social anxiety and other divisions we use to diagnose and treat patients. In reading this, you will then see this is a self-help book meant for the lay public who are rather uninformed about these things. In doing this, experts have to be able to communicate effectively so as to both inform and educate within the limits of these nosological categories that give even experts problems in application. The chapter headings guide you in knowing what is to come, from the evidence base of available treatments, including rather unusually, CATS, namely caffeine, alcohol, tobacco and sugar/sweeteners. Whilst I am sure she is correct, most of my patients couldn't manage that! The other issue is whether or not avoidance, a key component of how anxiety disorders play out in daily life, is wise. Wehrenberg comments that what you put into your body, and how stimulating or pressurized your environment is, affect how anxiety plays out, using vignettes to illustrate that. What is interesting is how far psychology has moved from treatment of some ghost in the machine entity, to the idea of a physical condition and the need to live a healthy lifestyle as the author illustrates here. She moves beyond CATS in her first bit of advice, into the whole concept of correct fuelling of the machine, ghost or no ghost! In this way, eating, sleeping, limiting technology and so on are given prominence.
The most common approach for all of us in the therapy business is to advise on breathing, given the known connections between the lower third of the vagus nerve, the heart and lungs, and the effect of regulating in and out breaths on the autonomic nervous system. The first advice given here is to learn to avoid the scalenes and intercostal muscle-managed chest breathing, and learn to use the diaphragm. Without saying so directly, she advises the act of breathing in for short periods, and breathing out more and more slowly, so that the short inbreath and long outbreath conforms to Heart Rate Variability Training, which allows parasympathetic dominance of the rest-digest modes leading to calmness. I am not sure using breathing to AVOID panic is the wisest choice, as this may enforce avoidance overall, as many of my CBT colleagues teach. However, she does cleverly advise training HRV breathing when no panic or anxiety are present, thus conditioning the system to spend more time in a calm state. I think a brief discussion of the various forms of breathing in more depth would help, but now we are past food and air, the two big pillars, the only logical next step would be mindfulness, and she does just that.
Anxiety is the fear of the future or consequence, and often involves over-awareness of the bodily sensations and the discomfort of the anxious system, so clearly in one both focusses on being in the moment, while shifting awareness of things then the rumination is avoided. This is true for pain as well as anxiety issues. This technique, which I have come to know and call "Go Narrow…Go Wide", involves alternating your conscious awareness on the body and outside world in turn, for short periods, allowing the focus of your brain to move from the inner or mesial temporal areas, to the outside, with corresponding shift from inner to outer aspects of the body and world outside, creating flexibility of focus, rather than fear and fixation on one or other area of concern, whether panic or social anxiety or generalized worrying. Progressive relaxation is an older method compared to western acceptances of mindfulness, and this is dealt with next, both in progressive and cued terms, as well as using imagery, exercise and so on.
The essence of worrying about the future is certainly a tendency to catastrophize, and so this is common both here and in pain syndromes, which also include ruminating and catastrophizing. Challenging the end result of wayward emotions, namely by confronting one's feelings and attributions, common to all kinds of cognitive approaches, is dealt with here. This leads to the somewhat paradoxical approach to planning on panic, and the steps to do this rather than avoid.
Stopping and swapping is another way to deal with the "what if's?" of catastrophizing. Here, one challenges and replaces these thoughts with other equal, but different "what if" outcomes.
Containing worry is another issue, alluded to often above. Here, step by step rules are given to work through the worry in order to reduce it to realistic proportions and a solution-driven approach, e.g. identify the problem, set goals, brainstorm solutions, select an option and so on. In the thinking and doing something chapter that follows, the author does get to grips with the avoidance aspect with an interesting vignette, as with all chapters, this one dealing with social anxiety. Dealing with negative self-talk and replacing it with more positive views is dealt with comprehensively here, something I think she could have placed earlier in the book as this is often such a major part of our work in treating anxiety. Obsessions with activity and perfectionism are also major targets of therapy, and she deals with them here under the Too Much Activity label, again enhancing the offering of practical interventions for the lay patient.
The planning and practice chapter brings this all together, followed by her final word, but this is not the end of the book. She then adds an addendum of more specific themes in which anxiety becomes troublesome, namely flying, waiting during delays, visiting family where there are issues, death in the family, the end of relationships, saying No, meeting new people, interviews, taking tests, and finally vacations.
Most people just starting out on the anxiety treatment clinical pathway will need just such a clear and simple book, with little explanation of why our how these interventions work, but that is academic. This is after all her list of what she finds works with clients, and they do indeed form part of most of our practices in dealing with anxiety to the level of anxiety disorders in the community.
The stories or vignettes she offers are clear and precise, and easily a source of identification, in the 'people like me' genre, so that the sufferer feels they are not unique or indeed alone in feeling and experiencing anxiety to the point of dysfunction. Our non-conscious predilections or biases that trigger the emotions we experience as anxious are impossible to foresee, but here are the things we can do to avoid the escalation that leads to dysfunction. Small victories as pointed out here in the book, do add up, so that the seemingly overwhelming is not so provoking of helplessness.
© 2015 Roy Sugarman
Roy Sugarman PhD, Director Applied Neuroscience, Team EXOS USA