Question

I am not sure what is meant by ‘letting the anxiety and the attacks happen’. They are so much a part of my life I don’t know how to separate them from myself.

Answer

When we are feeling happy, we don’t continually monitor our feeling of happiness or think of how happy we are, we just let the feeling of happiness be there as we get on with whatever we are doing. The same applies to the feelings of anxiety and the attacks. We can separate ourselves from them simply by noting them, ‘this is anxiety, this is an attack’. We just let them be there, without concentrating on them. Not concentrating on them allows us to concentrate on other aspects of our lives. The same is true for temporary feelings of depression. We need to be aware of why we are depressed and we let ourselves be depressed, but we don’t become the depression. If we don’t add to it by continually worrying about how depressed we are, it will disappear because we are not fuelling it. Of course, it does depend on the degree of your depression. If the depression stays with you it will need to be treated by your therapist.

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In the early 1980s my colleagues and I found that the symptoms of winter depression could be greatly alleviated by exposing the SAD sufferer to bright environmental light. Many controlled studies have by now demonstrated beyond question that light therapy is an effective treatment for this condition. Light therapy has been accomplished most successfully by means of special light boxes or fixtures. A typical light box is a square or rectangular metal apparatus that contains fluorescent light tubes behind a plastic diffusing screen. The user generally places it on a flat surface, such as a desk or table top, and sits a certain prescribed distance away from it. In order for light therapy to be effective, the user’s eyes must be open, but it is not necessary to stare at the light. Instead, people often choose to read, eat their meals or do anything that can be done while sitting in one place. I used to recommend that people use this time for paperwork or chores, but then I found that they were avoiding doing their light therapy because they associated it with unpleasant matters. So now I advise them to do whatever will succeed in helping them to use their light therapy regularly throughout their winter depressions. Just as with anti-depressant medications, if a person is still in a vulnerable phase, for example during the short dark days of winter, light treatment must be continued even if symptoms are under good control in order to avoid a depressive relapse.

Light boxes may stand upright or be tilted forward, an arrangement that reduces glare and brings the light source closer to the face, resulting in greater amounts of light entering the eyes. Light intensities are measured in units called lux. Average indoor lighting is about 500 lux; modern light therapy fixtures result in levels of approximately 10,000 lux, about 20 times as much light as ordinary indoor lighting provides. Properly designed light boxes include special filters that remove potentially harmful ultraviolet rays from the light source. If used as recommended, light therapy appears to be very safe and, out of thousands of people treated with light therapy over the past 15 years, no evidence of any harm to the eyes has been reported. Even so, if you have any history of eye problems you should have your eyes checked out by a qualified professional before initiating light therapy, as some serious conditions of the retina can be exacerbated by exposure to bright environmental light.

The duration of light therapy needed varies with the time of year and the individual, and depends also on what is convenient and feasible. The worst elements of the depression can often be prevented if the problem is tackled early in the season. During the autumn or early winter, just before the usual time of onset of symptoms, it is reasonable to begin with 15 to 30 minutes of light therapy in the morning. Studies have shown that light therapy can be most effective when given in the morning hours, though many people find it to be beneficial no matter when they use it during the course of the day. I therefore often recommend that people start by using light therapy whenever it is most convenient. As the winter deepens, it is often helpful to add a second dose of light (such as 15 to 30 minutes in the evening) to the morning dose. After using light therapy for some time, people often become skilful at calculating how much works for them. Some people require up to 45 minutes of light therapy twice a day in order to obtain optimal effects. This amount of light therapy might seem like a very burdensome time commitment, but it is important to remember that one is often sitting down in one place anyway, and it is often quite convenient and actually pleasant to have the bright, cheerful light of the box shining down on you while you are doing so.

Just as people often learn how much light they need in order to overcome winter’s doldrums, so they frequently learn to detect when they are being exposed to too much light. Side-effects of excessive light treatment include feelings of restlessness and overstimulation, headaches or eyestrain. These effects frequently respond to decreasing the duration of light exposure or sitting a little further away from the light fixture. Using light therapy late at night may cause difficulty falling asleep, in which case it often helps to move the light therapy to an earlier hour during the evening or late afternoon.

When spring arrives, people naturally find themselves using their light boxes less and not missing them. But spring tends to be an erratic season and it is prudent to watch out for rainy or cloudy days – especially a string of them – and be ready to bring out the light box at a moment’s notice.

An innovation developed to help people who want to move around while receiving their light therapy is a head-mounted light delivery system called a Light Visor. This device is also handy for those who need light therapy while travelling. While many people swear by the benefits of the Light Visor, data from controlled studies of the anti-depressant effects of light therapy are not as convincing for the Light Visor as for the light box.

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1. Check the position of your head and neck and breathe in through the nose as you loosely lift the shoulders, breathe out noisily as you drop them, and go limp in the chair. Try it eight times,.

2. Roll each shoulder first back then forward in a circle

Keep calm when facing an angry boss

(keep the arm limp). After you have circled both shoulders eight times in each direction, try doing both together.

3. Raise arms to the ceiling and stretch without straining, then let them fall loosely towards the floor.

4. Add any shoulder or arm exercises you know and stand up to do a few loose swinging arm movements.

5. To exercise the legs draw eight circles with each big toe, clockwise and anticlockwise.

6. Finish by standing up and loosely shaking the whole body.

Shaking increases circulation and lets fear out. Dogs don’t stop themselves shaking when they are afraid. Don’t try to control nervous shaking. Stand up and encourage it. If it is not suppressed the need to shake (and to cry or be angry) will diminish.

Don’t push yourself to do more exercise than you can manage, but carry on slowly even if it hurts. It may be uncomfortable. Remember the tight arm band previously mentioned? Taking it off the arm would make the hand feel more uncomfortable for a time, but it would be curative. In the same way, some people have held their head and shoulders tight for so long that they need the help of an osteopath to free the joints. In tranquillizer withdrawal it is not advisable to tighten groups of muscles before letting them relax. Because the muscles are not behaving normally it increases spasms. It is better to use your imagination. Pretend that your feet/legs/trunk/arms etc. are being bathed in warm water or sunlight. This allows them to go slack and heavy. Avoid using the word relax. Some people are so frustrated by their unsuccessful attempts at relaxation that the word is a trigger for more tension.

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This can happen as aside-effect and withdrawal reaction. When it happens whilst you are on tranquillizers it could be what is called the paradoxical effect. Instead of feeling calm and relaxed the user may feel disinhibited and full of rage. Mothers are often afraid they will hurt their children during these attacks. Losing your temper out of all proportion to the situation is distressing and very common. Help the people around you to understand this is temporary and not your real personality. Give them any literature you have about withdrawal, and take them to the support group where they will see other people with the same problem.

Your personality may have temporarily changed whilst you were on the pills. So often the cry is ‘I just want to be the person I used to be.’ Your old self is still there. It will come back. Some users have suppressed their emotions for so long that when the pills are taken away, they temporarily become aggressive and hard to live with. It is difficult for you and your family, but necessary for a while, to get you in touch with normal feelings again.

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Here is another extract from the Oxford Textbook of Psychiatry (1983):

This shows again the importance of attention to correct breathing. Over-breathing is breathing in a rapid and shallow way which results in a fall in the concentration of carbon dioxide in the blood. The resultant symptoms include dizziness, tinnitus (noises in the ears), headache, a feeling of weakness, faintness, numbness and tingling in the hands, feet, and face, carpopedal spasms (severe cramp in hands and feet), and precordial discomfort (area of the chest over the heart). There is also a feeling of breathless-ness which may prolong the condition. When a patient has unexplained bodily symptoms, the possibility of persistent overbreathing should always be borne in mind.

The anxious person tends to overbreathe, whilst the depressed person often takes a short in-breath and has a long sighing out-breath.

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This could take most of the fear of the illness away, and hasten your recovery. You will recover—but there may be times when you need to be constantly reassured about this. Talking with someone who has been through withdrawal, or a sympathetic doctor, is the first step on the road to recovery. Try to overcome feelings of guilt, or of being a nuisance. It often only takes a two-minute telephone call to allay a fear, or explain a symptom. As you recover, your confidence will grow, and as you become more independent, reliance on your helper will disappear.

If you feel that the pills have stopped working and you have to increase the dose to get the same effect, or if you feel ill when you do not take the pills, then you could be dependent.

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