The People's Therapist

This week a patient complained he wasn’t sleeping well.  He said he was feeling like a hypochondriac – obsessively worrying about his health.  He’s young, and perfectly well, but suddenly every little ache and pain was bubonic plague.

Cognitive-Behavioral Therapy (CBT) is usually effective for anxiety, so we did a little CBT exercise together, in which you:

1. identify the cognition;

2. reality-test the cognition; and

3. formulate a soothing counter-message.

This sounds simple enough, and it makes good sense.  Anxiety is caused by cognition – predictive thoughts.  You predict that something terrible is going to happen, and that triggers a freak out:  your pulse races, you start to sweat, you can’t sleep – all the standard symptoms of anxiety.

So…first step:  identify the cognition.  The prediction that was causing his anxiety was the thought that his sore throat was caused by herpes.

Second step:  reality-test that thought.  He’d already checked with his doctor and online.  This was not herpes.  Herpes in the throat is a rare condition and would produce different, and far more severe symptoms.

So far so good.

Step three:  formulate a soothing counter-thought.  I asked my patient to tell himself what we both knew – this is just a sore throat, it isn’t herpes.  Relax!

That’s where we ran into trouble.

My patient insisted it wouldn’t work.  He couldn’t help it, he said.  He just kept worrying about his health.

I said he could help it – we can all control our thoughts, if we set out to.  He just didn’t want to.  Some part of him was enjoying scaring himself.

Huh?

Scaring yourself, oddly enough, can be soothing.  By telling yourself you are expecting the very worst, you assure yourself you are prepared for it.  That is intended to calm you down.

Consider what truly scares you.  It isn’t just scary monsters.  It’s scary monsters jumping out of nowhere and saying “boo!”  What scares you most isn’t what you’re expecting – it’s what you aren’t expecting.

So you try to expect everything.

That’s why you have nightmares.  Your unconscious mind brings you the very worst, in an attempt to calm you down by assuring you that you’re ready for it.

Fear is an ancient emotion, located in the amygdala, a primitive part of the brain, near the center.  Fear evolved early, as part of the fight or flight instinct.  Little animals needed fear to tell them to run from danger, just as they needed anger to tell them to fight for their life when a predator had them cornered.

When you are under extraordinary stress, like a mouse being hunted by a cat, you become hyper-alert, in an attempt to assure yourself you aren’t going to be taken by surprise.

But you can’t stay hyper-alert forever.  Soldiers who are in combat for long stretches can develop PTSD – post-traumatic stress disorder – a condition in which the brain is harmfully affected by trying to stay hyper-alert for too long a stretch.

My patient grew up in a world where nasty surprises happened all the time.  His father died when he was young.  His mother, an immigrant, raised him alone, amid poverty and discrimination.  As a boy, he was picked on constantly and never felt safe in his neighborhood or at school.  Now, as an adult, he was attempting to stay hyperalert so he wouldn’t be taken by surprise again.

I urged my patient to switch from dwelling solely on fear to giving his other most primitive emotion a try – anger.  Instead of constantly staying afraid, he could stand up to what scared him and fight back.  His new attitude could be – there’s nothing out there I can’t handle.

Like in Aliens, when Sigourney Weaver grabs the really big flame-thrower and says to the monster “You want to take me on?  Bring it, bitch!”  Every horror movie ends like that.  Someone – a long survivor, maybe – has finally had enough of being picked off one by one by the ax-murderer, and decides to fight back, even against the odds.

My patient liked that approach.  He’d survived plenty already in his life.  He could handle whatever came his way.

Heck, even if it were herpes (which is wasn’t) – he’d deal with it.  Whatever happened, he’d be okay.

Better to fight back than to live your life afraid.