Anxiety in a man's heart weighs him down (Proverbs 12:25)
In psychology research, anxiety disturbances represent a variety of mental disorders (American Psychiatric Association, 2000). The maladies associated with anxiety include: panic disorder, agoraphobia, social phobia, obsessive-compulsive disorder, posttraumatic stress disorder, acute stress disorder, anxiety associated with medical conditions, anxiety induced by substance intake and generalized anxiety disorder.
A detailed discussion of specific disorders is beyond the scope of this presentation. As anxiety is the common feature of all anxiety disturbances, I examine the biological, cognitive, and behavioral factors associated with anxiety. I also present reflections of a few early Church Fathers who recognized anxiety as malady and, like modern behavioral scientists, sought a cure.
Features of anxiety
Those experiencing anxiety commonly describe having feelings that are very unpleasant, such as fear and apprehension, as well as perspectives that are vague and diffuse, that is to say, not concentrated in one place. Bodily features can include motor reactions such as the inability to relax, jumpiness, tightness of muscles, trembling, hyperactivity, heart palpitation, perspiration, and vertigo. These symptoms can be accompanied by apprehensive thoughts and expectations.
Etiology of Anxiety
The biological source of anxiety is the sympathetic nervous system, which includes the nerve cells and fibers that lie outside of the brain and spinal cord. The sympathetic and parasympathetic nervous systems together comprise the autonomic nervous system, and in turn, the autonomic nervous system and somatic nervous system (controlling sensation and bodily movement) form the peripheral nervous system.i
Biologists (Selye, 1982) consider anxiety to be related to the fight or flight survival system. When confronted with a life-threatening stressor, the sympathetic nervous system secretes hormones that aid in survival.ii Collectively, these hormones, called the catecholamines,iii increase cardiovascular response, respiration, perspiration, blood flow to muscles (increasing muscle strength) and mental activity. In response to a stressor, individuals can either confront the stimulus or run from it. In response to a stressful stimulus, the region of the brain called the locus coeruleusiv reacts by increasing levels of norepinephrine, resulting in an increase of cognitive function in the prefrontal cortex and motivation via the brain nucleus accumbensv region. An activation of the hypothalamic-pituitary-adrenal axisvi ensues, producing the stress response (Thase & Howland, 1995).
Anxiety without a stressor
In addition to stressor-induced anxiety, recent research has demonstrated that anxiety frequently occurs in the absence of an identifiable stressor, as well as in response to ordinary stimuli encountered in life (Barlow, 1988). Moreover, the treatment of anxiety has included the use of prescription drugs, particularly selective serotonin reuptake inhibitors (SSRI), which target serotonin rather than norepinephrine. The effectiveness of this treatment, in biological terms, suggests that brain networks or neuroanatomical pathways other than the locus coeruleus can mediate anxiety (Kent, Coplan & Gorman, 1998).
Barlow (1988) suggests that arousalvii rather than anxiety may be at the basis of non-stressor anxiety. Another research program proposes that brain systems and structures, such as the hippocampus and amygdala, might transform arousal into anxiety (Coplan & Lydiard, 1998). These brain structures regulate both verbal and memory processes with potent emotional meaning, and are part of the limbic system. The limbic system is responsible for activating the hypothalamic-pituitary-adrenocortical (HPA) axis underlying emotions.viii
The HPA pathway projects to the cerebral cortex of the brain, which is responsible for higher brain functions, including sensation, voluntary muscle movement, thought, reasoning and memory. The cortical, memory and verbal brain processes explain why the anxiety is linked to cognitive interpretations of events, whether stressful or non-stressful. The cognitive interpretations that accompany or heighten anxiety are labeled, distorted and irrational (cf. Barlow, Chorpita, & Turovsky, 1996a; Barlow, & Lehman, 1996b; Beck, 1991; Burns, 1980; Ellis, 1962; Morelli, 2006c,d,e).
Cognitive Factors in Anxiety
According to the cognitive model, anxiety is related to a series of appraisals that the anxious individual makes of the events in the world they encounter (Lazarus, 1966, 1993a,b). The general theme of these appraisals is the perception of threat. Threat is described by Beck (1971): “ the main problem in the anxiety disorders is not the generation of anxiety but in the overactive cognitive patterns (schemas) relevant to danger that are continually structuring external and/or internal experience as a sign of danger.”
Appraisal is conceptualized by Lazarus as the individual’s interpretation of events they confront as challenging, harmful or threatening and his assessment of whether he has the coping skills to respond efficaciously to these events.
Types of appraisal
Primary appraisal is an interpretation about whether an event in life involves harm, regardless of whether the harm or loss has already occurred or is a potential or threat in the future. Primary appraisal can be further classified into three types: an irrelevant appraisal, which is of little significance; a benign-favorable appraisal, which has pleasing or beneficial consequences; and a stressful appraisal. Stressful appraisals are further delineated into three sub-types, damaging-loss, threat and challenge-stimulating. Challenge-stimulating appraisals do not have the same unfavorable implications as a damaging-loss or threat appraisal. Rather, challenge-stimulating appraisals can be perceived as enhancing-profitable or exciting. For example, if you missed an important meeting because you wrote down the wrong time on your calendar, the harm has already been done. A threat appraisal would assess the potential damaging consequences of having missed the meeting. A challenge-stimulating appraisal, on the other hand, would focus on the objective to turn around the potential dire consequences and find an enhancing outcome. Taking responsibility for the mistake and the willingness to pursue and re-schedule the meeting can demonstrate honesty and leadership.
Secondary appraisal is an evaluation of resources and determination of their efficacy in coping with stressful events. Coping involves metacognitive processes such as regulating problem solving strategies and putting the strategies to use. Of course, coping also presupposes that an individual has learned the skills to employ the problem solving strategies and has the ability to employ them. In the example of the missed meeting, you may first pose a question to yourself: “Do I know any way of making a favorable outcome? How would I look at this from the point of the other person scheduled to be at the meeting?” You might answer these questions as follows: “I appreciate honesty and initiative, and the other person might value these qualities too. The best defense being proactive; I will call immediately and take responsibility for the scheduling error and communicate the desire to pursue the agenda.” Coping also involves developing emotional control, which is discussed below.
In the cognitive model, following appraisal subsequent information processing is organized by constellations or assemblies of neural structural components called cognitive schemas (Beck & Emery, 1985). These neural constellations are often referred to by cognitive researchers and clinicians by their original name, cognitive sets, with the proviso that the concept of cognitive sets be extended to include the biological “relatively enduring” neurological structural element. Once activated, cognitive sets determine the construction of an individual’s associations, interpretations, memories and perceptions of the activating events, which in turn allow for classification, evaluation, explanation, labeling and assigning meaning to situations and objects. These sets can either be in verbal-semantic modality or visual-imagery modality.
Cognitive sets can be quite specific, such as labeling objects: automobile, cup, or glass. Sets also can include principles and or rules to discriminate between objects: compact car, midsize car, and SUV. Cognitive sets can also encompass abstractions such as freedom, liberty, and love. Complex sets can further identify an object or event that may be dangerous. For example a snake with a rattle would be perceived as dangerous versus a common black snake as non-threatening. A particular political party or ideology could be perceived as a danger to freedom.
When an activating event construed as a threat occurs, specific cognitive schemas relevant to the particular “characteristics and context” of the event are triggered. Beck and Emery (1985) point out the characteristics and context are a series of adjustments to fit the appropriate schema to the particular threat. The adjustments in turn provide the range of affective, that is to say emotional responses and behavioral patterns related to the threatening stimulus. The cognitive constellations allow for a rapid appraisal of objects and events previously appraised, in effect by-passing any re-analysis of previously encountered events, objects and situations. This rapid appraisal, also called automatic thoughts, has two consequences: first, a beneficial consequence of facilitating a rapid response to a real threat, and second, a deleterious consequence of perceiving non-threatening stimuli as dangerous, thus producing cognitive-emotional ‘false alarms.’ Continuous activation of a danger set in response to objects or events that are genuinely non-threatening is considered an expression of psychopathology.
In normal cognitive processing cognitive constellations are factually related to the object or events being processed. In this case the cognitive constellation is activated by the situation one encounters, or in other words, the constellation coincides with the reality of the situation. A woman going to church, for example, might be expected to have a cognitive set activated that includes adoration, love, trust and worship of God. However, a cognitive set that is not relevant to the situation might be pre-activated, becoming hypervalentix and thus likely to be used in interpreting or cognitively processing the objects or events encountered. A semantic or imagery associative neural network can be pre-activated. In the case of anxiety the neural network associated with threat or danger would be activated, and the woman could interpret her church attendance as a sign of weakness, thinking that others view her as weak, this threatening her view of herself as strong and self reliant. Alternatively, she may associate church with death and sense an impending doom. In the case of depression, a depressogenic mode or pre-activated associations would be readily available, and a cognitive set for going to church might include such impressions as: “What is the use of going to church?—God won’t listen to me anyhow—Things will still be the same—Whatever I do there won’t make a difference.” A significant intrusion mode (anger) might include associations of wanting to strike back at God or an authority figure for a perceived injustice. Some unjust tribulation may have occurred in the woman’s life, and church might be interpreted as a way of striking back at God for having allowed the injustice.
Cognitive appraisals, cognitive constellations and their modes are also subject to the following eight distortions related to anxiety:
- Selective Abstraction: Focusing on one event while excluding others. In one of my recent cases, Jack (all names are changed), an employed young man, selectively focused on an accident he witnessed: a truck filled with molten tar overturning on a car while making a turn at an intersection. Jack’s focusing on this event triggered anxiety and fear of travel.
- Arbitrary Inference: Drawing a conclusion unwarranted by the facts in an ambiguous situation. For example, Jill was stuck in an elevator for about five minutes. She concluded that she would get stuck again if she entered an elevator. This fear seriously impacted her ability to do her work, which required elevator usage.
- Personalization: Interpreting a general event in exclusively personal terms. Jill became anxious after a business meeting (attended by about 25 managers) when her supervisor mentioned that one manager was about to be laid off. Linda immediately personalized the statement by assuming the supervisor directed the comment at her, even though no evidence supported that conclusion.
- Polarization: Perceiving or interpreting events in all or nothing terms. Jill became anxious after receiving an “average” in her annual employment evaluation as a teacher. She polarized events into two categories: good teacher versus bad teacher. Her Average rating fell into the bad-teacher category. She failed to see that all events can be graded on a continuum between two poles. On such a scale, an average evaluation is actually as the term implies: average. Furthermore, she had tenure and was one of the senior educators in her district and the only teacher in her school district in a state-mandated specialty that could not be eliminated.
- Generalization: The tendency to see things in always or never categories. Jill was anxious she would loose her job and never get a good evaluation to be employed again. Her anxiety led to a self-defeating pattern of behavior that distracted her from her work, thereby negatively impacting her performance.
- Demanding Expectations: Beliefs that there are laws or rules that must always be obeyed. This distortion is sometimes referred to as the “tyranny of the shoulds.” Jack came into treatment because he was anxious about his ability to be an effective father. His son consistently talked back to him and would not follow his instructions. Jack irrationally believed that there is a universal law that children should always do what their parents ask. If his child didn't obey, he had the right to get upset and see himself as a poor parent. Jack failed to apply the Christian principle that God asks and never coerces obedience. A program of rewards for appropriate behavior and punishment for inappropriate behavior administered without anxiety or depression would be the constructive response to apply here (Morelli, 2006a,b).
- Catastrophizing: The perception that something is worse than it actually is. Jill erroneously reacted to her average job evaluation as if it represented a grave and catastrophic event and thus reacted with even more anxiety.
- Emotional Reasoning: The judgment that one's feelings are facts. Jill had a feeling that her new supervisor did not like her. When asked how she knew this, she responded that her "feelings were always right.” She was afraid her next evaluation would be “needs improvement.” She failed to discern the fact that although real, feelings cannot prove whether something is true or false. I tell my patients that no matter how strongly some people "felt" the world was flat when Christopher Columbus set sail, Columbus proved the world was round. Feelings are not facts.
Disputing and restructuring distorted cognitions
In previous presentations on cognitive intervention of dysfunctional emotions, I have emphasized that effective clinical intervention first involves helping the patient to recognize and label the cognitive distortions and themes, followed by helping the patient to restructure the distortions. Three questions are helpful in challenging the patient's thinking so that restructuring can occur:
- Where is the evidence?
- Is there any other way of looking at the situation?
- Is the situation as bad as it seems?
In treating anxiety additional questions have been shown to be useful (Beck and Emery, 1985):
- Where is the logic? In an example given by Beck and Emery 1985, a patient was anxious about his health condition and concluded that his physician was holding back important information. Examination the logic of the conclusion found it was unlikely his doctor was lying to him.
- Is a causal relationship being oversimplified? A priest thought that a mistake in a homily meant that the congregation would loose trust in him. He observed other priests making mistakes in their homilies without loosing the credibility of their parishioners.
- Are habits being confused with facts? The cognitive distortion of arbitrary inference can be developed into a mind-reading habit. One woman who was anxious when she came into church had developed the habit of thinking what others are thinking about her, and concluded that parishioners were judging her appearance and personal life. Her habitual internal message went something like this: “She does not know how to dress and she is not a true ‘Christian.’” This woman had to learn to apply a reality test to overcome her mind-reading habit.
- Are interpretations of a situation far enough removed from reality to be accurate? As a guideline, stay only with behavioral pinpointing (Morelli, 2006a), focusing on what was said and or done and when and where the behavior occurred. Avoid any interpretation. For example, Mary ignored me when I said hello [behavioral fact]. She must think I am a bad person [interpretation].
- Is the version of the facts being confused with the facts as they are? The rule is that facts are facts. Interpretations or opinions vary, and can trigger dysfunctional emotions such as anxiety.
- Is the thinking in all or nothing terms? Anxious individuals often conclude that others will categorize them in one of two diametrically opposite groups. A parishioner thought others would think of him either as a total saint or a depraved sinner. Rather than impose the two-pole opposites, this man can learn to view himself somewhere in the middle. We all sin, but can repent, yearn and trust God for Him to indwell in us.
- Are extreme or exaggerated words or phrases being used? Making exaggerated statements is related to the cognitive distortions of generalization, demanding expectations and catastrophizing. Words that signify these distortions such as always, can’t, must, ought, need, and should can be replaced by a more accurate, realistic descriptions: “I am feeling anxious.”
- Are examples being taken out of context? A patient who is afraid of sliding off the freeway in a car may fail to consider that sliding accidents are most likely to happen at high speeds or in slick or icy road conditions.
- Are cognitive defense mechanisms being used? Sometimes anxiety is avoided by rationalizing, denying or projecting. A person may deny they are afraid to speak out by claiming others do not want to hear their viewpoint. Alternatively, a fearful person may claim that others would be uncomfortable if he were to communicate how he really feels.
- Is the source of information reliable? Patients who are afraid of a particular outcome, such as bankruptcy, might be hyper-sensitive and inclined to believe the financial information that fits their fear without evaluating the validity or reliability of the information.
- Is the focus on certainties rather than probabilities? Some anxious patients want a 100% certainty they will not experience fear before they engage in a task previously fearful. In clinical and pastoral settings I have told those struggling with anxiety that no one who appears brave in the face of danger (for example, a soldiers exiting a foxhole, a fireman entering a blazing building) is without fear. One has to learn to carry fear around like a suit case. Paradoxically, the more it is carried, the lighter it gets. Some fear will probably always be with each of us, but it need not be disabling.
- Is a low probability being confused with a high probability? One can come to embrace the idea that just because something could happen does not mean it will happen.
- Is the focus on irrelevant factors? A patient heard about several people who died in an accident and felt that he would also be in an accident and die. Such an anxious person has to be helped to perceive the independence of certain events. This of often called the “gamblers fallacy.” For example, when tossing coins, each coin toss is an independent event. If someone tosses ten heads in row, the eleventh toss is still a 50-50 chance of being a head or a tail. This is true with all life events. This explains why casinos make money and most gamblers loose.
Behavioral Factors in Anxiety
In the behavioral model, anxiety can be influenced and attenuated by the same factors that influence learning. In the Classical Conditioning paradigm developed by Ivan Pavlov (1927), associations that evoke anxiety are formed between two types of stimuli (events): Conditioned Stimuli (CS) and Unconditioned Stimuli (UCS). These stimuli are paired once to several times and occur to the individual himself or can even be observed to occur to someone else. A CS-UCS pairing viewed as occurring to someone else (a model), as discovered by Bandura (1986), is labeled or called vicarious or observational learning. In either case the previous neutral stimulus, the CS comes to elicit the anxiety response previously evoked by the UCS. Responses to the UCS are called Unconditioned Responses (UCR), while responses to the CS are Conditioned Responses (CR). A simple example: a dog (CS) bites (UCS) a child, evoking a pain response (UCR). Later, the sight of a dog (CS) elicits an anxiety (pain) response (CR). The child becomes afraid of dogs.
The Operant Conditioning paradigm, first uncovered by B. F. Skinner in the 1930s (Skinner, 1968), often interacts with responses that may have first been classically conditioned, although some fear and anxiety responses may spontaneously occur and then be shaped by the laws of learning. A summary of the Operant Conditioning paradigm follows: Behavior is shaped (made stronger or weaker) by its consequences. Consequences that make behavior stronger or more likely to occur again:
- Positive reinforcement: After behavior occurs it is followed by a pleasant event.
- Negative reinforcement: After behavior occurs an unpleasant event is taken away.
Consequences that make behavior weaker or less likely to occur again:
- Positive punishment: After behavior occurs it is followed by an unpleasant event.
- Negative punishment: After behavior occurs a pleasant event is taken away.
A child who emits fearful behavior in response to a dog (as in the example above) may be positively reinforced for their fear behavior. A parent or guardian may shower the child with consequences found very pleasant such as hugging, kissing, or giving the child a much desired toy. Fear or anxiety behavior is thereby strengthened. Here is an example of negative reinforcement using the same example: after the child emits the fearful response, the child is rewarded by a particularly odious task being removed; he does not have to mow the lawn or help in garden chores for the coming week. Once again, the anxiety response is strengthened. Behavioral management techniques as applied in parenting situations are reviewed more thoroughly in a recent article (Morelli, 2009).x
Behavior therapy is based on the principles of learning that have been successfully employed in treating a variety of behavioral and emotional problems, including the anxiety disorders (Martin & Pear, 2006).
- Contingency management: Programs consist of pinpointing behavior, that is what is said and done and when and where the behavior occurred, and determining if the behavior is appropriate or inappropriate. Appropriate behavior is increased by application of the reinforcement procedures outlined above. Inappropriate behavior is decreased by the use of the punishment procedures outlined above.
- Social skills training: Teaches patients to perform behaviors that facilitate interaction and communication with others. Socially appropriate rules and standards of pro-social relational behavior are targeted, communicated, and modified by verbal and nonverbal interaction. Learning such skills increases access to naturally occurring reinforcers that take place in life, and decrease life punishments and can be applied to social interaction, parenting and other relevant life skills.
- Modeling: The patient learns a new behavior through observation of a model (Bandura, 1977). Four conditions have to take place before the new behavior can be learned (Bandura, 1984):
- Attention to the model. Paying attention to the characteristics of the model such as salience; affective valence, that is to say strong or weak emotions; functional value and prevalence; as well as paying attention to the characteristics of the observer such as perceptual cognitive capability, cognitive set and arousal level.
- Retention processes. The encoding processes of the observer: verbal or imagery, cognitive organization, rehearsal skills and memory skills.
- Motor reproduction processes. The ability to replicate the model’s behavior: physical capability and component sub-skills and observation of feedback.
- Motivational processes. The external, internal, hedonistic, social, moral, or religious incentives that motivate the observer to perform the model’s behavior.
- Exposure methods and systematic desensitization: Exposes the patient to the feared stimulus. Indirect methods use imagery of the feared stimulus. Direct methods involve exposure to the actual feared stimulus. In systematic desensitization patients are gradually exposed to a situation they fear, either in a role-playing situation or in reality. Models are often used in conjunction with the procedure. Research suggests (Meichenbaum, 1971) that peer or coping models are more effective than mastery or expert models.
- Behavioral homework assignments: Homework is assigned to the patient between therapy sessions. For example, have a claustrophobic patient enter and then immediately exit an elevator while a companion keeps the elevator door open.
- Contingency contracting: The therapist and patient develop a written or verbal contract of appropriate behaviors to be increased and inappropriate behaviors to be decreased. Contingent reinforcement and punishment are frequently incorporated in the contract.
- Role playing: The therapist and patient engage in role-playing scenarios that are related to the patient’s anxiety (Kelly, 1955). Various responses are attempted by trial and error and the patient is then given a response to try out as a homework assignment. Subsequent sessions monitor and refine the process. Specific pragmatics or paralinguistic areas to focus on include: response speed, volume, inflection (tone of voice) and dysfluency (such as stammering). Eye contact, facial expression, gestures, and posture (direction of leaning: forward, backward, relaxed or stiff, etc.) are elements that can be practiced as well.
- Flooding: Direct exposure to the anxiety-provoking situation that the patient fears the most (either through mental visualization or real life contact) in an effort to extinguish the fear response.
- Progressive relaxation: Systematic relaxation of the muscles and breathing until the patient reports an absence of bodily tension.
Self efficacy and psychological intervention
Psychologists understand the necessity for determination and resolve as an element of healing anxiety and other emotional disorders. Bandura calls the process self efficacy and defines it as "the ability to develop a program or plan for action to reach a goal" (Bandura, 1986).
Generally people with higher self-efficacy are better able to attain goals. Consequently, psychological interventions that employ self-efficacy are incorporated into the cognitive and behavioral treatment of anxiety disorders. The major variables bringing about self efficacy are:
- Mastery experience: Practicing appropriate concrete graduated actions in respond to fear-stimulus cues. In the case of the claustrophobic patient in the systematic desensitization example above, therapy might focus on the success of entering the elevator rather than exiting. Accomplishing a single step may be viewed as mastering the first of a series of sub-goals that lead to a final goal: riding the elevator alone to the top floor of the building.
- Vicarious experience: Observing a peer model struggling with the same problem of performing an appropriate behavior in response to a fear-stimulus cue. For example, have as a child who is afraid of dogs watch another fearful child approach and pet a dog.
- Prompting: Using key words or phrases as cues to appropriate action, followed by verbal approval as reinforcement (Morelli, 2005). For example, if a child verbalizes, "Ok! Just let me take one step toward the dog," say "Good job!" The child might continue with, “Ok! I did that step, now let me try another one.”
- Perceptions of arousal: Having an accurate understanding of the physiological nature of bodily arousal and knowing that it can be managed. The child attempting to overcome the fear of dogs might monitor his or her arousal at each step and see that it is “endurable.”
In my clinical experience I have discovered that many of the people treated for emotional disorders, including anxiety, have a pattern of unsuccess. Successive failures result in low self esteem and in some cases serious depression that leads to low self-efficacy (Morelli, 2005). Efficacy training, therefore, is an important component in any healing process. The more success an individual experiences, the greater his self-efficacy.
Efficacy for the Christian
The Church Fathers taught that healing takes determination and resolve. St. Gregory of Sinai, for example, noted: “We energize [virtues] according to our resolve ...” Some of the Fathers taught that determination arises from the incensive power of the soul. St. Nikitas Stithatos wrote: “Our incensive power ... serves as a weapon” that provokes determination and resolve and thus is in accord with the will of God. He continued: “When our desire and our intelligence, in a way that accords with nature, aspire to what is divine, then our intensiveness is for both of them a weapon of righteousness ...” (Philokalia IV). For the Christian efficacy is not only “self efficacy” but ‘God-empowered efficacy.’ The words of the psalmist come to mind: “He who dwells in the shelter of the Most High, who abides in the shadow of the Almighty, will say to the Lord, ‘My refuge and my fortress; my God, in whom I trust.’ For he will deliver you from the snare of the fowler and from the deadly pestilence ” (Ps 90:1–3). The Christian can follow the spiritual wisdom that was gleaned from our holy western Church Father, the Blessed Augustine: “Pray as if everything depends on God, and work as if everything depends on us.”xi
The efficacy of the therapeutic synergy of clinical science and the healing mysteries of Christ is our trust and dependency on the living God who sustains and governs all that occurs in the universe.
Jesus on anxiety
Anxiety challenges the very core of our relationship with God: allegiance confidence, loyalty, and trust. Recall the words of Jesus as recorded by St. Matthew: “O men of little faith? Therefore do not be anxious, saying, 'What shall we eat?' or 'What shall we drink?' or 'What shall we wear?' For the Gentiles seek all these things; and your heavenly Father knows that you need them all. But seek first his kingdom and his righteousness, and all these things shall be yours as well. Therefore do not be anxious about tomorrow, for tomorrow will be anxious for itself. Let the day's own trouble be sufficient for the day.” (Mt 6:30–34) Understanding that anxiety is a separation from God was not lost on the prophets of the Old Testament. Job tells us: “All the life of an ungodly man is spent in anxiety” (The Orthodox Study Bible-LXX).
St. John of the Ladder on fear (anxiety)
Before the advent of modern scientific psychological research, it appears St. John of the Ladder (579–649 AD) (1982), well understood what we today call anxiety. In his Ladder of Divine Ascent, St. John writes: “Fear is danger tasted in advance, a quiver as the heat takes fright before unnamed calamity. Fear is a loss of assurance.”
St. Maximus the Confessor on fear (anxiety)
St. Maximus the Confessor (580–662 AD) likewise had an astute understanding of fear or anxiety. He tells us: “ an evil which is expected in the future is called fear, and one experienced in the present is called distress [a] contemplative [one striving to be a holy Christian], on the other hand remains dispassionate in the face of such evils, since he has united himself with God and is detached from all that happens in this present life” (Philokalia IV).
Faith: A four- (five-) letter word
In today’s secular world faith is a four letter word. The height and measure of intelligence is to be skeptical. Skeptics believe that they believe in nothing, they are skeptical of all. The secular skeptic is really a believer in the religion of secularism. This religion has its own websites.xii Skeptics are the self-proclaimed intellectual elite of those who are not credulous or gullible, and proud of their claim to be able to see things ‘veridically,’ or the way they think they really are. Tongue-in-cheek we can consider the following quote: "A skeptic is a person who, when he sees the handwriting on the wall, claims it is a forgery" (Morris Bender, on www.answers.com/topic/skepticism). This is the only reality.
Is it possible to exist without faith?
Faith is a term filled with surplus meaning. One reason I seldom use the word ‘faith’ or ‘belief’ in my articles (or homilies) is because of the pejorative meaning of the word in popular usage. For secularists and skeptics, faith is imbued with anti-intellectualism, if not downright stupidity. However, I find the core meaning of faith found in the dictionary to be much more helpful. Most individuals do not have a strong intellectual dispute with the dictionary synonyms for faith: allegiance, confidence, loyalty, and trust (American Heritage Dictionary, 1994). In everyday life, for example, can we get along without confidence and trust?
Faith: A practical example
How many individuals who go to work are skeptical that their car will not start up each day? Alternatively, many other examples can be imagined: the airport near our home will not be there, the light in our home will not turn on when we flick the light-switch. It would be almost impossible to live daily life without some sense of trust and confidence (faith) in the events we encounter.
Psychologist George Kelly (1955) said that meaning in life is centered on ‘how we anticipate events.’ That is to say, a person’s conceptualization of the world is directed by a web of expectations if he acts in specific behavioral patterns. Mentally ruminating and being skeptical about such events or the possible outcome of each action we make would in fact be a potential red flag for a mental disorder. Over thinking is not incompatible with obsession type disorders, which gravely attenuate social and occupational functioning. Effective functioning in life almost demands being able to anticipate events, while simultaneously engaging in continual cognitive information processing.
Using the previous example, if a person had trouble starting his car the evening before work, then this information should be considered in anticipating (faith: trust and confidence) whether the car will start the next day. If the car has had a near perfect history of instant startup, anticipating a startup would be quite normative.
The Understanding of the Church Fathers
The Church Fathers see anxiety as a problem of attachment to the world and what we really treasure. St. Neilos the Ascetic (Philokalia I) tells us: “Detachment is the mark of the perfect soul, whereas it is characteristic of an imperfect soul to be worn down with anxiety about material things.” The good saint cites the words of Jesus Himself: “And why are you anxious about clothing? Consider the lilies of the field, how they grow; they neither toil nor spin; yet I tell you, even Solomon in all his glory was not arrayed like one of these” (Matthew 6:28–29).
Overcoming anxiety by detachment is echoed by St. Simeon the New Theologian: “ acquire freedom from anxiety with respect to everything whether reasonable for senseless – in other words, you should be dead to everything” (Philokalia IV). St. Gregory Palamas continues the same theme: “When a person bids farewell to all things, to both money and possessions, either casting them away or distributing them to the poor according to the commandment (cf. Luke 14:33), and weans his soul from anxiety about such things his intellect withdraws untroubled into its true treasure-house and prays to the Father ‘in secret’ (Matthew 6:6). And the Father first bestows upon it peace of thoughts then he makes it perfect in humility” (Philokalia IV). As Jesus Himself counseled: “Let not your hearts be troubled; believe in God, believe also in me” (John 14:1).
St. John of the Ladder (1982) links anxiety with attachment and, conversely, its spiritual cure: detachment. Consider his words: “I have observed many men in the world assailed by anxiety, by worry, by the need to talk, by all night watching, and I have seen them run away from the madness of their bodies.” The cognitive psychologists that linked anxiety with the ‘tyranny of the shoulds’ stand in the tradition of St. John who points out the way of psycho-spiritual healing: “No one can enter crowned into the heavenly bridechamber without first making three renunciations. He has to turn away from worldly concerns, from men he must cut selfishness away; and thirdly, he must rebuff the vanity that follows obedience.” The saint goes on to say “Detachment is good [the one] withdrawing from the world for the sake of the Lord is no longer attached to possessions.”
The words of St. John of he Ladder share the spirit of St. Paul’s council to the Hebrews (13:5–6): “Keep your life free from love of money, and be content with what you have; for he has said, ‘I will never fail you nor forsake you.’ Hence we can confidently say, ‘The Lord is my helper, I will not be afraid; what can man do to me?’” The individual who works at being reliant on God also works at trusting in Him.
The Prophet Isaiah (26:3) tells of the relationship between the absence of mental stress and serenity when we rely on God: “Thou dost keep him in perfect peace, whose mind is stayed on thee, because he trusts in thee.” St. John of Karpathos specifically links eradication of anxiety with trust in God: “We should on no account wear ourselves out with anxiety over our bodily needs. With our whole soul let us trust in God: as one of the Fathers said, ‘Entrust yourself to the Lord, and all will be entrusted to you.’ ‘Show restraint and moderation,’ writes the Apostle Peter, ‘and be watchful in prayer casting all your care upon God, since He cares for you” (1 Pt. 4:7; 5:7; Philokalia I).
The anxiety-challenging questions, developed by Beck and Emery (1995), as noted above, can be compared to the Spirit-inspired wisdom of St. John, for those who are still coping with anxiety because they are doubtful God really cares for them. St. John counsels: “ think of the spider and compare it with a human being. Nothing is more weak and powerless than a spider. It has no possessions, makes no journeys overseas amasses no savings does not meddle in the life of others living in this quiet fashion always hard at work—nothing could be more lowly than the spider. Nevertheless the Lord, ‘who dwells on high but sees what is lowly’ (Ps 113:5–6, LXX) extends His providence even to the spider, sending it food every day, and causing tiny insects to fall into its web” (p. 309).
St. Paul counseled having trust in God as the way to overcome anxiety. He tells the Philippians (4:6–7): “Have no anxiety about anything, but in everything by prayer and supplication with thanksgiving let your requests be made known to God. And the peace of God, which passes all understanding, will keep your hearts and your minds in Christ Jesus.”
Blessed are the poor in spirit, for theirs is the kingdom of heaven (Matthew 5:3)
St. Ephraim the Syrian (1997) puts this Beatitude of Jesus into his own words, reflecting the connection between attachment to the wants and needs we think are the essential to our living in this world and fear and anxiety resulting from the threat of their loss. He states: “Blessed is he who has in the Lord become completely free of all earthly things in this troublesome life, and who has loved the good and merciful God.”
In discussing this, the good saint reflects, “Blessed is he who in the Lord has become free of all the affairs of this vain life.” His counsel makes us think that the things evoking anxiety the most are those things we are most attached to in our own lives.
Solomon, the son of King David and writer of the book of Ecclesiastes, in the wisdom of his old age and under the inspiration of the Holy Spirit states:
vanity of vanities! All is vanity. What does man gain by all the toil at which he toils under the sun? A generation goes, and a generation comes, but the earth remains for ever. The sun rises and the sun goes down, and hastens to the place where it rises. The wind blows to the south, and goes round to the north; round and round goes the wind, and on its circuits the wind returns. All streams run to the sea, but the sea is not full; to the place where the streams flow, there they flow again. All things are full of weariness; a man cannot utter it; the eye is not satisfied with seeing, nor the ear filled with hearing. What has been is what will be, and what has been done is what will be done; and there is nothing new under the sun” (Ecclesiastes 1:2–9).
If I may be permitted a personal reflection, most of the major threats (events) in my life that I handled somewhat well (admittedly a subjective and possibly biased self observation) are not the major thornsxiii that I have had to deal with. Rather, I get “nervous” about the little things. When traveling to the airport, I arrive at least three or four hours before my flight. On Sunday, I get to the parish two or three hours before the start of Orthros and Divine Liturgy. During Holy Week, for evening services, I make sure to arrive at the church before 3:00 p.m. My homilies are completed by Monday or Tuesday of the prior week. I constantly tell myself the popular mantra: ‘Let go and let God.’ In other words, I have to constantly remind myself to “have trust in God.” For me, humanly speaking, this is not easy. But all of us are called to this challenge of placing all our trust in God. The specifics may be different but the overall process is the same.
The holy apostle Peter as ‘psychologist’
In his epistle of encouragement to the churches in Asia Minor, Peter wrote: “Humble yourselves therefore under the mighty hand of God, that in due time he may exalt you. Cast all your anxieties on him, for he cares about you.” (1 Pt 5:6–7) This is exactly our task in overcoming the anxieties we have in our lives. To be humble before God is to acknowledge our dependency on Him and on His Church and its Holy Mysteries which He has given to us for the healing of our diseases and infirmities.
This was told to us by Jesus who St. Matthew records: “And he called to him his twelve disciples and gave them authority over unclean spirits, to cast them out, and to heal every disease and every infirmity.” Thus with the use of our intelligence, we work at disputing and restructuring the distorted cognitions that accompany anxiety; we use practice pro-social behaviors that compete with anxiety related behaviors, but in addition, by God’s grace, we attend Divine Liturgy, partake of the Eucharist—the very Body, Blood, Soul and Divinity of Our Lord, go to Holy Confession, and receive the anointing of Holy Unction for the healing of our body, mind, and soul (Morelli, 2006f).
St. John of the Ladder (1982) points out: “Fear starts sometimes in the soul, sometimes in the body, and the one communicates the weaknesses to the other. But if your soul is unafraid even when the body is terrified, you are close to being healed.”
We end again reflecting on the words of St. John of the Ladder: “The servant of the Lord will be afraid only of his Master, while the man who does not yet fear Him is often scared by his own shadow.” As Jesus said: "With men this is impossible, but with God all things are possible." (Mt 19:26)
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- Morelli, G. (2006a, February 4). Smart Parenting Part II: Behavioral Management Techniques. www.orthodoxytoday.org/articles6/MorelliParenting2.php.
- Morelli, G. (2006b, March 16). Smart Parenting Part III: Developing Emotional Control. www.orthodoxytoday.org/articles6/MorelliParenting3.php.
- Morelli, G. (2006c, March 6). Asceticism and Psychology in the Modern World. www.orthodoxytoday.org/articles6/MorelliMonasticism.php.
- Morelli, G. (2006d, May 8). Orthodoxy and the Science of Psychology. www.orthodoxytoday.org/articles6/MorelliOrthodoxPsychology.php.
- Morelli, G. (2006e, October 5). Overcoming Depression: Cognitive Scientific Psychology and the Church Fathers. www.orthodoxytoday.org/articles6/MorelliDepression.php
- Morelli, G. (2006f, December 21). The Ethos of Orthodox Christian Healing. www.orthodoxytoday.org/articles6/MorelliHealing.php.
- Morelli, G. (2009, July 15). Smart Parenting XVII: Love and Worship in the Domestic Church—of God or Idols. www.orthodoxytoday.org/articles-2009/Morelli-Smart-Parenting-XVII-Love-And-Worship-in-The-Domestic-Church-Of-God-Or-Idols.php.
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iii. The major neurotransmitters are:
- GABA: Produced in the cerebellum part of the brain and spinal cord, where its effects are generally inhibitory. GABA may be deficient in people subject to anxiety.
- Acetylcholine (Ach): Associated with several of the body's systems in a resting or normal, non ‘fight or flight’ state. It decreases heart rate and contraction strength, dilates blood vessels, increases digestion, decreases bladder capacity, and increases voluntary voiding. It also affects normal breathing and stimulates secretion by all glands that receive parasympathetic nerve impulses.
- Norepinephrine and epinephrine: Secreted by the adrenal glands, as well as at nerve endings, these neurotransmitters chemically resemble adrenaline and in actions on the body initiate the ‘flight or fight’ state. It increases heart rate and contraction strength, constricts blood vessels, decreases digestion, increases bladder capacity, and decreases voluntary voiding. It also increases breathing rate.
- Serotonin: Produced by about nine pairs of neurons along the brainstem and around the brain reticular activation system. Serotonin is related to mood levels: increased levels produce a placid quieting effect, attenuating depression, insomnia, and agitation; extreme elevated levels induce lethargy and the early onset of fatigue; decreased levels are associated with wakefulness and greater pain sensitivity.
- Dopamine: Found and distributed in the brain and spinal column. Through enzyme action it is converted to norepinephrine and then epinephrine. It is essential to the control of body motion. Disintegration dopamine-producing brain cells result in Parkinson’s disease.
- Endorphins: Proteins produced in the brain and pituitary gland that reduce pain. Endorphins bind onto opiate receptors in the brain and trigger the analgesic effect of morphine. Endorphins are released in response to pain or sustained exertion ("runner's high") and can be stimulated by acupuncture.
vii. Basic autonomic nervous system reactions: increase in breathing rate, heart rate, goose bumps, etc.
ix. An analogy may help the reader to understand pre-activation or hypervalence. Think of a light that is on a dimmer switch. Under normal, non pre-activating or hypervalent conditions the switch is completely off. To turn the light on to full brightness, the knob has to be turned from completely off to full on, possibly a 180° half turn. If the light were on dimly (analogous to pre-activaton or hypervalent) a 90° quarter turn would only be needed to full brightness. Person’s with pre-activated anxiety, depression or anger carry around with them a semi-lit (so to speak) semantic-imagery network to interpret events that occur by the particular cognitive set that is always partially turned on.
x. For a more detailed explanation, also see: www.orthodoxytoday.org/articles8/Morelli-Smart-Parenting-XII-The-Time-Out-Tool.php and www.orthodoxytoday.org/articles8/Morelli-Smart-Parenting-XIII-Tools-for-Smart-Punishing.php.
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V. Rev. Fr. George Morelli Ph.D. is a licensed Clinical Psychologist and Marriage and Family Therapist.
Fr. Morelli is the Coordinator of the Chaplaincy and Pastoral Counseling Ministry of the Antiochian Orthodox Christian Archdiocese and Religion Coordinator (and Antiochian Archdiocesan Liaison) of the Orthodox Christian Association of Medicine, Psychology and Religion.
Fr. Morelli is a Senior Fellow at the Sophia Institute, an independent Orthodox Advanced Research Association and Philanthropic Foundation housed at Columbia University and Union Theological Seminary in New York City that serves as a gathering force for contemporary Orthodox scholars, theologians, spiritual teachers, and ethicists.
Fr. Morelli serves on the Executive Board of the San Diego Cognitive Behavior Therapy Consortium (SDCBTC)
Fr. Morelli serves as Assistant Pastor of St. George's Antiochian Orthodox Church, San Diego, California.
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