THE MIND’S RESPONSE TO ANXIETY
When more messages are arriving than the brain can properly handle, we have anxiety. Our mental apparatus becomes keyed up in an effort to cope with the situation. There is an increase of available mental energy, and this mobilized energy of the mind provides the force which produces all the various psychological symptoms of anxiety.
In its mobilized state, the mind becomes very alert, too alert, so that all the time it- seems to be searching for the cause of its own disquiet. There develops a pathological over-alertness, and as a result the mind reacts to very minor stimuli which would not normally produce any response at all. Thus a noise which would normally go unheeded causes the anxious person to start. Then he feels irritated and upset in the knowledge that he has overreacted to a matter of little consequence, and his inner tension is further increased.
This over-alertness shows itself in many ways. The individual is on the lookout all the time. He is fidgety and cannot let himself go off guard. He cannot rest because his mind keeps him alert even when there is no need for it. It becomes hard to sit and watch television without getting up from the chair to relieve the tension within him. To relax and sit still becomes a near impossibility because all the time he is plagued with this distressing over-alertness of the mind.
We see, then, that this over-alertness is a natural result of anxiety. Sometimes, however, another type of reaction takes place so that the anxious individual is in no way over-alert, but on the contrary appears to be dulled and apathetic. This reaction may occur when the individual is confronted with overwhelming disaster on either a national or a personal scale. He is struck dumb. He is in a daze, unable to think or to move. Even when some purposeful action on his part would minimize the disaster, he still does nothing. This is a common reaction in times of war, particularly in the civilian population. It is seen in personal calamity as when an individual suddenly sees his home burned or his family killed in a road accident. This reaction is so
completely different from the primary response to anxiety by over-alertness that it requires some explanation. It comes about by the overactivity of the self-regulatory mechanisms of the body. There is a surge of anxiety with its accompanying over-alertness, but if this were too great the body would be overwhelmed and unable to respond effectively. To prevent this, the
self-regulatory mechanisms come into play and inhibit the anxiety reaction. It is thus the overreaction of the inhibiting mechanism that causes the individual to be dulled, apathetic, and unable to take effective action.
The same reaction may occur in less dramatic form. The student when confronted with an important examination usually reacts to his, anxiety by being so keyed up from over-alertness that the mind is flooded with too many thoughts that are often not well related to the problem on hand. In such circumstances it is not uncommon for the opposite reaction to occur. His mind goes blank, and try as he will, relevant thoughts to the problem simply will not come. We can now understand this paradoxical reaction to anxiety as due to the overactivity of the inhibiting mechanism. In a mild chronic form, over-inhibited anxiety may make the individual tired, listless, dull, apathetic, and unable to get going in his ordinary daily tasks. Because of his lack of initiative in doing things, such a patient often complains of depression. Furthermore he may say that he feels guilty because of his inability to work; but this reaction of inhibited anxiety is distinguished from true depression in that there is no real moral self-accusation as when the conscience is offended.
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ST JOHN’S WORT AT WORK: FIRED BY A CHEMIST’S ASSISTANT
'This letter is to cancel my appointment,' wrote Malcolm, who worked as an assistant at a chemist's. 'I suppose I could come in and "show myself to the priest" ... but I had only mild to moderate depressions, not leprosy ... I have never been a danger to myself or others, only a danger to my chequebook. And in the interests of protecting my current account, I would like to cancel further appointments.
'I am relatively happy with my current "prescription" of St John's Wort. It is working as well as, or better than, any of the anti-depressants I have tried so far. So I'll keep with it for now, and see how well it does as the days get longer. If I feel the need to try more prescriptions, I will feel free to call.'
Well, I have always encouraged my patients to express themselves freely to me - and apparently Malcolm took me at my word. But his letter captured my attention more for its substance than its style. Malcolm's depression had been very difficult to treat. It was not that his symptoms were so severe. He was correct in describing them as 'mild to moderate' and he had never felt suicidal, but it was long-standing and seemed to sap his life of all joy. His energy level was very low and he withdrew from others in order to conserve his meagre energy reserves for his job. His only pleasure came from buying things, such as compact discs. 'Music seemed to fill my emptiness,' he said. Two women he had dated over the previous 10 years had remarked that his main problem was that he wasn't happy, though he was barely aware of this unhappiness himself.
I had treated Malcolm's symptoms with a comprehensive list of anti-depressant medications, trying each one diligently for the right amount of time, calibrating dosages, using novel and unusual combinations and integrating the medications with all sorts of health-enhancing recommendations. While these interventions were quite helpful, we were always brought up short by side-effects, especially problems with his sinuses, dryness of the mouth and feelings of spaciness. Of all medications we had used, Lustral seemed best but he still felt unhappy and 'out of touch' emotionally. He decided to stop Lustral after finding out about St John's Wort on the World Wide Web and concluded that he felt he had enough information on which to base an intelligent decision.
Malcolm followed his earlier communication to me with a second letter, to reassure me that T was in no way displeased with your "psychiatric care" (I guess the term is) 'and to report on' "my current herbal concoction".' He was now on Hypericum 900 mg per day, which appeared both to reduce his anxiety and to energize him. He was 'more positive and upbeat, more apt to say things instead of sitting around and being quiet'. He was amazed to find himself more outgoing and confident, even among strangers. He felt a qualitative difference between the effects of Lustral and those of St John's Wort. While the Lustral had helped his mood, it had not allowed him to communicate that improved mood to others and to engage with them as freely as was now possible.
Over the next six months, while taking St John's Wort, Malcolm made certain changes in his life. He made sure to get enough sleep, which helped his energy level, and kept his time awake constant, even at weekends, which he believed had a marked stabilizing effect on his mood. He left the chemist's, where he had felt isolated, and took up a job in a home for mentally disabled adults, where he had more daily contact with people. He involved himself in religious activities, which added a spiritual dimension to his life. Finally, he plucked up the courage to approach a young woman whom he had met at church and whom he is now dating.
My experience with Malcolm was my first direct encounter with the new herbal anti-depressant, and to say that I was amazed would be an understatement. After treating him with so many potent anti-depressants both individually and in combination and observing his responses to them, I discounted a placebo explanation for his improvement. In his case, I was convinced that the herb had exerted a specific anti-depressant effect. His story reminded me once again, however, how important it is to add healthy activities to any anti-depressant intervention - though again I realized how little these activities help unless the disturbance in brain chemistry has been turned round. I now wonder whether the tendency for St John's Wort to make Malcolm more outgoing might have been related to its effects on the neurotransmitter dopamine, which is important in modulating social behaviour in animals, while the mood-enhancing effects that he experienced on both Lustral and St John's Wort might have been related to the effects of both of these substances on serotonin.
The lessons I learned from Malcolm encouraged me to try St John's Wort in my own practice. The first patient I treated was Adele, whose story I describe below.
*2/75/2*
ANXIETY IN THE MIND: NERVOUS TENSION
There is a difference between true apprehension and the more common nervous tension. They may occur either separately or in combination. Nervous tension is a less complicated sensation and lacks the feeling of impending disaster. We feel tense in the mind, the brain, or the whole self. Relaxation seems impossible. We feel wound-up like a spring and cannot let go. There is an absence of normal mental ease, and in its place there is the feeling of being overwrought.
This nervous tension of anxiety is often accompanied by physical muscle tension. When we are anxious, our muscles are tensed, ready for the call to action which in fact never comes. The tensed muscles may become sore and tender. If this is generalized we are said to suffer from nervous rheumatism, but more often the stiffness is confined to certain muscle groups, particularly those around the neck and shoulders.
Minor degrees of nervous tension show themselves in the way we function in our everyday life. There is a lack of ease about our reactions. Even in such a simple thing as walking, the natural ease of movement is lost, our arms do not swing in the accustomed fashion and our gait has the appearance of being strained and awkward. Sometimes these symptoms of anxiety very closely resemble those of organic illness.
A woman in her early fifties had been thoroughly investigated by a competent physician, and had had psychiatric treatment with drugs and discussion of various domestic problems. She complained to me that she was tired and lethargic. She was dizzy when she stood up and would become breathless when walking up a slight hill. She said that she was wobbly on her legs so that she had difficulty in standing to do the cooking.
I thought that an organic cause for her symptoms may have been overlooked, and I referred her back for further investigation, but nothing could be found. So I started her with relaxing mental exercises, and she has made a dramatic improvement, which shows that her symptoms were in fact due to anxiety. I later discovered that her unsteadiness on standing was due to the increased nervous tension in the muscles of her legs.
Nervous tension may be seen in our manner of speech. There is a tendency to talk abruptly and too quickly. The flow of words is interrupted and the observer is aware of a loss of natural ease of communication. In simple things such as writing, our tension makes us hold the pen too tightly. Our hand starts to shake, our writing becomes jerky, and the letters lose their normal rounded outline.
There is another aspect of nervous tension which further disturbs us. We do not like other people to know that we suffer in this way. It is considered socially desirable to be relaxed and at ease. To be tense and uncomfortable is to be socially inept, and as a result we do all we can to disguise our inner tension from those around us. We try to behave in a relaxed manner, and when we are seated we assume a posture of ease in the hope that others will not guess what is going on in our mind. In this attempt to keep from the others the truth as to how we feel, we concentrate on what we are saying and on the tone of voice as we say it. We try to present a facade to them so that they will not guess our true state of mind. To keep up this facade requires more and more effort. We have to concentrate on it so much that we can only give half our attention to the matter in hand. We become aware that we are not functioning to our full ability; we become more apprehensive, and our anxiety is still further increased.
*7/57/2*
ST JOHN’S WORT AT WORK: MATTHEW’S STORY
What would you do if you came home one day to find that your wife had left you, had taken your two children with her and had cleared all the furniture out of the house? This is the state of affairs that confronted Matthew one day when he returned home from his job as a security officer. There had been some difficulties in the marriage, but nothing that made Matthew suspect that it was almost over. 'She was so nice to me the night before she left,' he mused wistfully 'it was as though she was giving me a going-away present.' In fact, his wife had met another man and moved away to live with him, taking the two children with her.
For Matthew the loss was devastating. He had always been a sensitive person. Even as a young boy he had always been 'thin-skinned', feeling more stung than most by ordinary taunts from other boys in the playground. Later, when it came time to date girls, he was always painfully aware when he did not have a girlfriend while others did. 'I was always crushed by rejections,' he recalls 'and would often be disinclined to try things because of fear of failure.' He wondered whether his extreme sensitivity was somehow related to his pale sun-sensitive skin which went along with his ginger hair.
Being abandoned by his wife was one of the biggest blows of Matthew's life. He felt like a failure as a husband and a father and went into a profound depression that was to last six years. During this time he felt like a bad person - if that were not the case, he reasoned, why would his wife have left him for another man? He couldn't sleep at night as his mind 'would race to places I wouldn't want it to go - back to the memories of being abandoned and betrayed by my wife'. During the day, on the other hand, a cloud of exhaustion would overwhelm him when he was at work and should have been attending to the security of the business for which he worked. He recalls how his eyelids 'weighed 1000 pounds each' and he could barely stay awake. He craved junk foods - sweets, donuts, chocolate ice-cream and cakes. His blood sugar became elevated and he needed medications to lower it.
Things became so bad that he felt as though he no longer had any reason to live. Life seemed to lose its meaning and he would ask himself, 'What is this all for?' He went to the doctor for help, mindful that he had proven to be hypersensitive to almost all medications he had been given in the past. The doctor recommended Lustral, but Matthew suffered a serious allergic reaction after only a single dose. His eyes swelled shut, his heart 'raced 100 miles per hour' and he had nightmares and hallucinations.
Shortly after this experience, his mother saw a television programme in which the benefits of St John's Wort were discussed. She suggested that he might try it. Recognizing his sensitivity to medications, Matthew began by taking 300 mg of St John's Wort per day. He felt some relief from the very first day and the improvement continued over the subsequent two months, by which time his depression had lifted completely. His sleep improved and even though he was sleeping fewer hours than he had been, he 'seemed to get more out of it' and felt more rested and alert during the day. His energy level 'was boosted back to its normal level'.
Matthew has returned to his old passion, music, and has begun to play his guitar again. He finds himself walking around the house, singing and dancing. For a long time he'd forgotten that music even existed. Now he is overjoyed to have rediscovered it and will literally burst out into song. He has returned to church again, visiting different denominations to discuss religious ideas with different people. Along with his improved mental condition, Matthew's physical health is also better. Remarkably, given his sensitivity to medicines of all types, Matthew has experienced no side-effects whatsoever on St John's Wort.
Even though his depression is over, Matthew recognizes that he is now faced with having to rebuild his life. 'I am just beginning to see the light at the end of the tunnel,' he observes, 'but I'm not there yet.' He plans to go to the gym and enrol in classes so that he can get a better job. He is even contemplating beginning to date again 'without the old defeated attitude'. He has begun to chat with an old sweetheart from his school days and is thinking of buying some new clothes and taking her out dancing.
He sums up his experiences with St John's Wort as follows:
'After six years of solid depression, of feeling crippled and at the edge of a cliff, ready to jump ... all my ailments have subsided.
I no longer feel any need for a medical professional. My faith has been restored. It's a miracle.'
No doctors involved. No side-effects. Complete remission of a chronic and disabling depression. Small wonder, therefore, that Matthew regards St John's Wort as a miracle herb that has given him back his life.
*6/75/2*
ANXIETY IN THE MIND: APPREHENSION
We experience anxiety in pure form as apprehension. This is a particular form of nervous tension. There is the feeling of fear, but it is an objectless fear, and at the same time as we experience it we are aware that there is nothing that should make us afraid. When we feel real fear, we can always attach our emotion to some outside object, and say that we are afraid of this or that. But because of the objectless quality of anxiety, apprehension is extremely disturbing. We simply do not know of what we are afraid. We feel that something is going to happen, but we do not know what. Something bad is about to befall us, but we cannot imagine what it might be. If the anxiety is severe, this irrational element may evoke feelings of approaching insanity, and the disquiet of our mind is still further increased.
A patient of mine, a forty-six-year-old school teacher, showed:
Signs of this kind of severe apprehension. In spite of quite a massive physique, he had always been rather tense and jittery. Twelve months previously he had suffered a severe allergic reaction to one of the antibiotic drugs, and since then he had been in a terrible state.
He described his anxiety condition in these terms: "Get vague heart attacks." "All kind of fears." "Heart thumps and bangs." "Keep sweating." "Get very het-up." "Attacks come on with physical effort such as moving the TV set." "It started with pain in legs and arms." "I walk down the street and become stricken with fear and have to return." "Keep waiting for something to happen." "Don't want my wife to leave me even for a short time." "In bed the sheet touched my throat and I thought I was strangling."
In reading this, please remember that these excerpts from my case histories nearly all concern patients who have been referred to me by other doctors because of the severity of their nervous symptoms. This is intended to help patients like this, but it is also intended to help the great host of others who suffer only in mild degree, and who in ordinary circumstances would never seek the help of a psychiatrist or even the local doctor. Consequently, these notes about various patients whom I have seen will serve to illustrate the point I am trying to make. But although they may refer to conditions which you yourself have, in all probability in your case it is in much milder form.
In less severe form, apprehension may show itself as a vague uneasiness. The feeling is difficult to describe. We lose our natural calm and repose. We are uneasy. We try to pass it off, and say to ourselves that we are all right; but we know that we are not quite right, and the strange feeling of disquiet remains, and persistently disturbs us at our work, at home, and even in our sleep.
A fifty-year-old woman, whom I had known for most of my life as a robust extrovert, consulted me professionally. She said that she had felt depressed and frightened. She could not get going with her former zest. Her most disturbing symptom was a difficulty in breathing which was associated with a feeling of panic, so that she would catch her breath and could not properly relax.
She very quickly lost her symptoms with the relaxing exercises.
*6/57/2*
ST JOHN’S WORT IN THE BREAKFAST VITAMINS: A SINGLE-BLIND STUDY
Louise, a professional woman who has been in treatment with me for several years, has in the course of this time become knowledgeable about the administration and regulation of antidepressant medications and, as a consequence, is much sought after for her opinions in this regard even though she has no formal medical training. Accordingly she was consulted by her friend Sylvia, in connection with Sylvia's husband's difficulties. Sylvia believed that Sam, her husband, was suffering from depression because he seemed 'down in the dumps, sits in front of the television till late at night and self-medicates with junk food - anything he can eat without cooking it; anything that comes in a box, such as our baby's rusks'. In addition, he was having a hard time getting to sleep at night, was staying up till the early hours of the morning and was isolating himself. Sylvia was worried because Sam had previously been a very optimistic person, believing the world essentially to be a good place, full of opportunities, before a series of business reversals had set off these changes in him. She knew that several members on both sides of his family had suffered from depression. When he barricaded himself in the bedroom one night, a highly unusual thing for him to do, Sylvia had reached her limit. It was time to consult Louise. The idea of suggesting that Sam go to a psychiatrist was completely impractical. 'He doesn't think there is anything wrong with him,' Sylvia explained to me. He would never have gone and wouldn't have considered taking Prozac or any anti-depressant. How might she handle such a refractory patient, she asked Louise in one of their regular phone calls. Louise suggested that Sam try St John's Wort.
The idea was immediately appealing to Sylvia, but certain logistical problems presented themselves. First, she was unable to get her hands on St John's Wort in the small town where they lived, and second she knew Sam to be highly suggestible and she wanted to be sure that he was really better and that she was not dealing with some half-baked placebo effect instead. Louise told her that the first problem could be easily solved, as she herself would send Sylvia the right type of St John's Wort. As to the placebo effect, Louise enquired about Sam's daily activities, and on discovering that he was in the habit of taking vitamins every morning with breakfast, suggested that Sylvia simply inform Sam that the St John's Wort tablets were additional vitamins and add them to the mix. Sylvia approved of the plan. She knew that Sam was generally distracted by work-related matters at breakfast time and, not being by nature a suspicious person, would readily take whatever tablets Sylvia gave him. 'He's lucky I like him,' she observed, adding 'I'm a suspicious person; you could never get away with giving me extra pills.' Nevertheless, she could not push her luck too far and ask him to take vitamins in the evening, which would have constituted a major change in his daily activities and would have elicited suspicion even in a highly trusting husband. In addition, as she noted, T have no control over his lunch.' So even though St John's Wort is supposed to be administered three times a day, Sylvia decided he would have to take all three tablets at breakfast. She knew that the herbal remedy was best taken with food and reckoned that 'if he gets sick, it will be immediate and I will know what caused it.' She was pleased to see that he tolerated the new pills just fine.
After about five to six weeks, Sylvia noticed a remarkable improvement in Sam's mood and demeanour, which she characterized as 'happy but not manic'. He became 'more balanced, grounded, present and alive, better than he has been in years'. He stopped watching as much television, picked up his old musical interests again and spent more time with the baby. In addition, he became 'like a sex machine, morning and night, he was ever-ready' Every time Sylvia walked into the room 'there was a look in his eye'. She had not seen anything like it in him since they were first married 10 years before.
In fact, Sam was feeling so good that he told Sylvia that he no longer needed the new vitamins. At that point she felt constrained to explain to him why he was feeling so good and why he had better not stop the new vitamins. He took the news like a good sport, and acknowledged that he felt a new lease of positive energy in him. Now he says that he feels so good that he will happily take St John's Wort for the rest of his life, if that's what it takes to stay happy.
*5/75/2*