the opening session, I took a psychiatric and medical history (a habit I always practice), asked Judy about her family, her education and her job history. I did a mental status examination which confirmed my initial impression that she was suffering from generalized anxiety disorder (GAD). At the end of the hour I said to her, “Judy, I had a job to do today. I had to make a diagnosis and formulate a treatment plan. Now, I have to ask you two things. Did you feel comfortable talking to me today? Did everything that I said to you seem to be relevant to you as a person or did you feel that I was trying to put you into a square hole in which you did not belong?” She answered that she had felt comfortable and that she felt that everything that I had said to her was about her and resonated with her. I stood up, smiled and shook her hand. “Then we have made a start.”
Judy was not wrong in her assumption that she had inherited her anxiety from her mother. Research studies on twins have long hinted that anxiety-related personality traits such as worry, harm avoidance, tension, fear of uncertainty, fatigability and pessimism are 40 to 60 percent inherited. Human genetic studies have proven this premise to be true.1 In 1996, Science Magazine reported evidence of a gene (the functional unit of inheritance) linked to individuals prone to these anxiety traits.2 According to Gregor Mendel’s genetic model of inheritance, two alternative forms of a gene, which carry a delivery system for the brain chemical serotonin, influence human “neuroticism” (anxiety and associated traits). One form results in more protein, more serotonin uptake and more neurotic behavior. The second form results in less protein, less serotonin uptake and fewer neurotic symptoms. An offspring exhibits one or the other of the genes but not a mixture of the two.3
It soon became apparent that Judy definitely also had issues concerning time pressure that added to her tension and stress. She told me that her father was in a long-term care facility and frequently needed to be hospitalized due to falls. In spite of having two sisters, she was the designated caregiver and took care of most of his needs. Her son had dropped out of college, lived at home and was not working. Her live-in boyfriend, although she said that he was emotionally supportive, didn’t seem to do much around the house and was not always there physically or emotionally. She demanded an intense level of performance from herself, at work and everywhere else. These demands meant that she had no time for herself to unwind and relax. She constantly had too much to do and too little control over the time and manner in which things were done. This was aggravated by her inability to establish boundaries between her work and personal life.
Many times during our sessions, I said to myself, I wish that I could just get Judy to learn to relax for a moment. I tried to teach her a breathing exercise to slow her down and allow her to calm down. I illustrated the exercise myself. I took in a deep breath through my nose and let it out very slowly. I placed my hands flat on the top of my chest and moved them down slowly as I exhaled through pursed lips. This took me about fifteen seconds. I asked Judy to try it. She did it in two seconds flat as if she was blowing out birthday candles. I said, “Try it again and do it more slowly.” By the fourth try, she had it up to eight seconds.
Judy often complained of feeling that she was going from one pressure cooker at work into another pressure cooker at home. I asked her to pause for a moment and allow her rational brain to seek a solution rather than responding with anxiety and irritability while under stress. I suggested that she try to think of a way that she could unwind and reduce her tension between the time that she left work and returned home. She answered, “Another therapist taught me a trick to help me stop bringing my job home. He suggested that when I leave work that I stand outside for at least ten seconds and tell my mind, ‘work is over, no more thinking about it.’ This is harder than it sounds. However, with practice, it works.” I suggested she do the same thing before she entered her home, which she agreed was a good idea.
As I have gotten to know people who are anxious, I have noticed that there are certain themes that continually crop up in our conversations during therapy. Like many anxiety-prone people, Judy was also a perfectionist with high expectations of herself and others. Anything less than 100 percent was seen as failure. This is one reason that she hesitated to delegate some of her father’s care to her sisters, because “They don’t do it right.”
She valued control and predictability. Any loss or threatened loss of control made her feel helpless and subsequently anxious. She had a need for too much control to feel secure and calm. Like other anxious people, she was overly concerned with what “should be.” She felt that there was only one “correct” way to do things. She tended to see things as either black or white. This also made her more prone to anxiety. She would often say, “They should have done it this way.” I would counter by saying “According to whom?” She would laugh because she saw my point. The word “should” reflected her need to do things according to her rule book. These rules allowed her to feel more in control but restricted her flexibility and spontaneity.
During one session, Judy went on and on about her mother. She spoke about how her mother had been hard on her and was big on guilt: “She was the disciplinarian in the family and beat the crap out of me. She was very hard to please. She felt that her increased anxious energy was productive but she felt that mine was non-productive. Mom worked all the time and was not there for me. She had a high-pressure job. Like me, she thrived under the pressure but hated it at the same time. I remember saying to her, ‘This is a new generation, mom. I will never do all you do.’”
At this point, I asked her, “Did you like it when your mom acted that way?”
She answered with a loud and emphatic, “No!”
“Then why do you act that way toward your family members?” I asked. I could see the light bulb go on in her head.
She went on to talk about her sisters: “My twin sisters were born when I was two. When my parents brought the baby girls home from the hospital and I saw them for the first time, they told me that I took a bag of oranges and threw them one at a time at the two of them. I don’t know how mom did it. She had to learn to cook, find a babysitter for my two younger sisters and me in the summer and maintain the house. Mom pushed me off to my grandmother, who died when I was twelve years old. My aunts were there for me, but basically I was alone. My father worked full time and belonged to a lot of organizations. He came home at six and expected dinner on the table. He spent time with us only on the weekends.”
Judy’s Opinion of What Helped Her Anxiety
“My mother dropped dead at sixty-eight years old (burst an artery in her brainstem). Stress kills! That’s when I went to therapy for the first time. The rug had been yanked from beneath me. My rock was gone. Dr. Zal is the third therapist I have had. He does ‘talk therapy.’ Sometimes you just can’t see yourself and need that outside professional opinion to point things out to you. He can zero in on what I call my ‘bad behaviors’ in dealing with anxiety. He is honest and direct. He calls me on my crap, as I call it. We are getting to the root of my anxiety. He is helping me deal with the stress caused by taking care of my dad, who is in a long-term care facility. He is teaching me how to say no! I have trouble saying no to anyone who asks me to do something for them (even people I don’t consider close to me) and it just adds to my stress. I get upset if people don’t like me. He helps me by asking easy questions such as, ‘Do you like everyone?’ I answer, ‘Of course not.’ He adds, ‘Then why does everyone have to like you?’ His query stops me dead in my tracks.
“I used to handle stress by eating poorly, drinking too much coffee, smoking more. It didn’t work. I still felt increased pressure, felt overwhelmed and couldn’t get things done. I had trouble concentrating and making decisions. I worried constantly. I had ‘stress eczema,’ headaches, insomnia and muscle tension and spasms. In therapy, we have discussed better ways to handle stress. I have learned new coping skills. I am exercising more, have decreased my caffeine and take time to sit down and eat right. I do meditation and yoga. If I can’t sleep, I get up and do something constructive
