The one thing that chronic worriers cannot do is follow the advice they are most often given: "Just stop worrying" (or, worse, "Don't worry—be happy"). Since chronic worries seem to be low-grade amygdala episodes, they come unbidden. And, by their very nature, they persist once they arise in the mind. But after much experimentation, Borkovec discovered some simple steps that can help even the most chronic worrier control the habit.
The first step is self-awareness, catching the worrisome episodes as near their beginning as possible—ideally, as soon as or just after the fleeting catastrophic image triggers the worry-anxiety cycle. Borkovec trains people in this approach by first teaching them to monitor cues for anxiety, especially learning to identify situations that trigger worry, or the fleeting thoughts and images that initiate the worry, as well as the accompanying sensations of anxiety in the body. With practice, people can identify the worries at an earlier and earlier point in the anxiety spiral. People also learn relaxation methods that they can apply at the moment they recognize the worry beginning, and practice the relaxation method daily so they will be able to use it on the spot, when they need it the most.
The relaxation method, though, is not enough in itself. Worriers also need to actively challenge the worrisome thoughts; failing this, the worry spiral will keep coming back. So the next step is to take a critical stance toward their assumptions: Is it very probable that the dreaded event will occur? Is it necessarily the case that there is only one or no alternative to letting it happen? Are there constructive steps to be taken? Does it really help to run through these same anxious thoughts over and over?
This combination of mindfulness and healthy skepticism would, presumably, act as a brake on the neural activation that underlies low-grade anxiety. Actively generating such thoughts may prime the circuitry that can inhibit the limbic driving of worry; at the same time, actively inducing a relaxed state counters the signals for anxiety the emotional brain is sending throughout the body.
Indeed, Borkovec points out, these strategies establish a train of mental activity that is incompatible with worry. When a worry is allowed to repeat over and over unchallenged, it gains in persuasive power; challenging it by contemplating a range of equally plausible points of view keeps the one worried thought from being naively taken as true. Even some people whose worrying is serious enough to qualify for a psychiatric diagnosis have been relieved of the worrying habit this way.
On the other hand, for people with worries so severe they have flowered into phobia, obsessive-compulsive disorder, or panic disorder, it may be prudent—indeed, a sign of self-awareness—to turn to medication to interrupt the cycle. A retraining of the emotional circuitry through therapy is still called for, however, in order to lessen the likelihood that anxiety disorders will recur when medication is stopped.13
MANAGING MELANCHOLY
The single mood people generally put most effort into shaking is sadness; Diane Tice found that people are most inventive when it comes to trying to escape the blues. Of course, not all sadness should be escaped; melancholy, like every other mood, has its benefits. The sadness that a loss brings has certain invariable effects: it closes down our interest in diversions and pleasures, fixes attention on what has been lost, and saps our energy for starting new endeavors—at least for the time being. In short, it enforces a kind of reflective retreat from life's busy pursuits, and leaves us in a suspended state to mourn the loss, mull over its meaning, and, finally, make the psychological adjustments and new plans that will allow our lives to continue.
Bereavement is useful; full-blown depression is not. William Styron renders an eloquent description of "the many dreadful manifestations of the disease," among them self-hatred, a sense of worthlessness, a "dank joylessness" with "gloom crowding in on me, a sense of dread and alienation and, above all, a stifling anxiety."14 Then there are the intellectual marks: "confusion, failure of mental focus and lapse of memories," and, at a later stage, his mind "dominated by anarchic distortions," and "a sense that my thought processes were engulfed by a toxic and unnameable tide that obliterated any enjoyable response to the living world." There are the physical effects: sleeplessness, feeling as listless as a zombie, "a kind of numbness, an enervation, but more particularly an odd fragility," along with a "fidgety restlessness." Then there is the loss of pleasure: "Food, like everything else within the scope of sensation, was utterly without savor." Finally, there was the vanishing of hope as the "gray drizzle of horror" took on a despair so palpable it was like physical pain, a pain so unendurable that suicide seemed a solution.
In such major depression, life is paralyzed; no new beginnings emerge. The very symptoms of depression bespeak a life on hold. For Styron, no medication or therapy helped; it was the passing of time and the refuge of a hospital that finally cleared away the despondency. But for most people, especially those with less severe cases, psychotherapy can help, as can medication—Prozac is the treatment of the hour, but there are more than a dozen other compounds offering some help, especially for major depression.
My focus here is the far more common sadness that at its upper limits becomes, technically speaking, a "subclinical depression"—that is, ordinary melancholy. This is a range of despondency that people can handle on their own, if they have the internal resources. Unfortunately, some of the strategies most often resorted to can backfire, leaving people feeling worse than before. One such strategy is simply staying alone, which is often appealing when people are feeling down; more often than not, however, it only adds a sense of loneliness and isolation to the sadness. That may partly explain why Tice found the most popular tactic for battling depression is socializing—going out to eat, to a ballgame or movie; in short, doing something with friends or family. That works well if the net effect is to get the person's mind off his sadness. But it simply prolongs the mood if he uses the occasion just to mull over what put him in the funk.
Indeed, one of the main determinants of whether a depressed mood will persist or lift is the degree to which people ruminate. Worrying about what's depressing us, it seems, makes the depression all the more intense and prolonged. In depression, worry takes several forms, all focusing on some aspect of the depression itself—how tired we feel, how little energy or motivation we have, for instance, or how little work we're getting done. Typically none of this reflection is accompanied by any concrete course of action that might alleviate the problem. Other common worries include "isolating yourself and thinking about how terrible you feel, worrying that your spouse might reject you because you are depressed, and wondering whether you are going to have another sleepless night," says Stanford psychologist Susan Nolen-Hoeksma, who has studied rumination in depressed people.15
Depressed people sometimes justify this kind of rumination by saying they are trying to "understand themselves better"; in fact, they are priming the feelings of sadness without taking any steps that might actually lift their mood. Thus in therapy it might be perfectly helpful to reflect deeply on the causes of a depression, if that leads to insights or actions that will change the conditions that cause it. But a passive immersion in the sadness simply makes it worse.
Rumination can also make the depression stronger by creating conditions that are, well, more depressing. Nolen-Hoeksma gives the example of a saleswoman who gets depressed and spends so many hours worrying about it that she doesn't get around to important sales calls. Her sales then decline, making her feel like a failure, which feeds her depression. But if she reacted to depression by trying to distract herself, she might well plunge into the sales calls as a way to get her mind off the sadness. Sales would be less likely to decline, and the very experience of making a sale might bolster her self-confidence, lessening the depression somewhat.