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Chapter 2

Step 2: Breathe

Take a deep breath. Draw air in through your nose and let it out very slowly through pursed lips. Take your time and don’t rush the technique. This breathing exercise can be done one to three times in any situation. People will not even be aware that you are doing it. It will slow your pulse rate and help you calm down and relax.

The way we feel is affected by the way we breathe. When we are upset, we are often told to take a deep breath. But when we are feeling anxious or frightened, we don’t just need to take a deep breath; we need to take a breath and exhale slowly. Breathing out, not breathing in, is associated with relaxation. Deep, slow, diaphragmatic breathing is a behavioral relaxation technique that can be taught to reduce or modify symptoms of anxiety. Watch a baby breathe. You will see its stomach—not just its chest—rise and then fall as the breath is released. Breathing retraining causes arousal reduction. Just as hyperventilation is taken by the nervous system as a sign that the body is under stress, deep diaphragmatic breathing sends a signal to the nervous system that “there is no danger—you can relax.” When you are affected by a stressor, your body goes into the fight-or-flight response. One of the components of this response is an increase in your breathing rate and a move to upper-chest breathing. Diapragmatic breathing can reverse this process. This simple exercise made a great difference in Matt’s life. Let’s look at how and why:

Matt’s Story

“My anxiety is a battlefield. It has both a mental and a physical aspect. I worry and live with various fears on a daily basis. I get nervous when I am in an interview or meeting, a crowd of strangers, while driving (particularly if I am going somewhere new) or anywhere that I feel that I am trapped and can’t escape easily. I feel overwhelmed. The negative thoughts pile up and seem insurmountable. When these feelings last for a while, I start to beat myself up for not being able to get it together and I become depressed. I also start thinking that I am getting physically sick, developing a new allergy or having a stroke. I think that I am losing my mind and will need to check into the asylum. I also get obsessive and start double-checking locks and the stove to see if it is on. My chest gets tight and there is pain on either side of my upper body. My back and neck become tight. My stomach churns. I get bouts of dizziness. I feel like adrenaline shocks are shooting through my body. I sigh a lot.

Sometimes, the physical symptoms can be much worse. I feel the tightness in my neck and back as well as the pain in my chest. As the anxiety grows, I begin to feel that I am not breathing right. I can’t take a full breath. I can’t swallow. Then my heart starts beating faster and I feel tightness and throbbing in my temples. As the anxiety increases and overwhelms me, I hit panic mode. My lips, the sides of my face, hands and feet will go numb and tingle. I feel like I have hive-like blotches on my face. Once my face was so numb and hot that I thought my eyes would be forced shut while driving and that I would crash. Immediately after the stressful situation passes, the numbness starts to go away but leaves my face and lips feeling puckered. I actually feel silly at that moment looking at myself like I just sucked on a lemon.”

When I first met Matt, he was twenty-eight years old. He had had surgery for strabismus (being cross-eyed) and later a gastric bypass which brought his weight down from 430 to 230 pounds. Although his appearance was improved, it did not change his low self-esteem. He complained of feeling lonely. He had a college degree in fine arts and multi-media but in spite of being bright and creative, he only had a low-level technical job. Matt had a history of panic disorder; however, it was his generalized anxiety and low-grade chronic depression that brought him to my office for therapy. His anxiety was persistent, demoralizing and interfered with his functioning. For the most part, he had suffered in silence. The gastric surgery eight years prior had left him with multiple “stomach problems,” including gas, nausea and constipation. He reported that he had been taking an antidepressant that inhibited the reuptake of serotonin and norepinephrine for four years and at top therapeutic dose. Each time that his family physician tried to lower the dose, Matt felt that it caused “pill withdrawal,” upset his digestive system and threw his nervous system into turmoil, giving him increased anxiety, stomach pains and dizziness. He was adamant about not giving up his pills.

Matt was also convinced that many of his anxiety symptoms, particularly the numbness and the facial sensations and manifestations, had a physical cause. The presence of vague physical symptoms, often involving every system of the body, is an important feature of GAD. However, his ill-defined facial symptoms were unusual: they did not seem to be due to drug abuse, caffeine or medication. There was no family history of thyroid disease or diabetes. I was pleased when he told me that his family physician had also referred him to an endocrinologist for evaluation. A few weeks later, I received a report from the endocrinologist. He had ordered hormone studies to try to explain Matt’s symptoms but was pessimistic that the results would give him an answer. He also wanted to rule out an allergic reaction. All the studies came back within normal range.

Matt’s initial evaluation showed much “grist for the mill” for therapy. I decided to follow my gut reaction that his facial symptoms were due to anxiety. Education is a crucial part of the initial treatment process. Knowledge allows perspective, reduces feelings of helplessness and increases a sense of control over frightening symptoms. I decided to go back to basics and taught Matt to do a breathing exercise to see if that would help his symptoms. I told him to take in a deep breath through his nose and then let it out very slowly through pursed lips. Remember, it is the slow letting out of air that lowers the pulse rate and encourages relaxation. Most likely, Matt hyperventilated when he became anxious. This rapid breathing caused a decrease of carbon dioxide (CO₂), which upset the body’s acid balance and caused physical symptoms such as muscle spasms and contractures. The deep breathing exercise helped bring this balance back to normal. The same effect can be gained by having the client breath into a paper bag, thus rebreathing CO₂. I hoped that this exercise would allow Matt to consider anxiety as a causative factor in his distress, offer him a new coping skill and help us form a therapeutic alliance.

Matt’s biggest challenge was trying something new, particularly if it was geographically outside of his comfort zone. As with many anxiety-prone people, two of his stumbling blocks were his difficulty with change and his fear of the unknown. Change is difficult for anyone; for nervous people, because they value control and predictability, change is a haunted house filled with dark rooms. Any loss or threatened loss of control like a new job, a move to a new location, meeting new people or even trying new things causes them to feel helpless and subsequently anxious. They catastrophize and anticipate a negative outcome. It is difficult for them to relax and just go with the flow.

Anxious inner voices from the past often act as roadblocks to action for these individuals. When they are planning a trip, they may hear an internal voice saying, “That’s awfully far from home.” The inner voice may stem directly from parents, grandparents, teachers or older siblings who may have been anxious themselves and significantly influenced the clients’ lives. Unfortunately, people who are anxious seem to accept these internal warnings as dictums rather than as a sign of the other person’s own anxiety and fear. I try to help my clients step back from these warnings and consider their own desires and choices. I offer encouragement by saying, “Do you really need all that protection? You do not have to listen to the committee in your head. Think it through yourself and use your own judgment to decide what is right for you.”

Matt faced a double problem: There was a history of anxiety on both sides of his family. He described his mother as intelligent, warm and affectionate but also overbearing, anxious and overprotective. She had multiple health issues and often stayed in bed for a week. “Pills and doctors—she had a fix for everything,” Matt said. His maternal grandmother also got attention by complaining about physical things. His mother was the disciplinarian in his childhood home and often threatened him with a wooden spoon. His father, a draftsman, was “cold and unemotional but also anxious and a worrier.” His father could be sarcastic and had a rule book about what was appropriate. He worried constantly about his father’s reaction. At the beginning of therapy, I always ask clients to describe the people who raised them. Looking back at their descriptions often gives me clues to better understand how they became who they are and how they may see other people. Insight often comes from these connections.

These themes all played out in Matt’s life. Anxiety, particularly about being away from home, had been an issue with him for some time. His dream growing up was to go to New York and become a musician. His mother told him, “Go to college. That’s what I need from you.” She told him to be “the best.” Feeling great pressure, he went to a university in New York to study music technology. He became depressed and anxious and often couldn’t stop crying. Feeling worthless, embarrassed and ashamed, he took a semester off, returned home and worked for a title company. Then he attended college in Philadelphia and majored in multi-media. He wrote music and recorded voiceovers. He still speaks of New York as “the scene of my failure.”

Admitting that he needed to seek praise and approval his whole life, Matt was very sensitive to the remarks of others. “I didn’t think I had done a good job unless someone told me.” He easily felt rejected. He hated going to a private school with religious connections. He talked of how a teacher in seventh grade put him down and how he subsequently became depressed, had stomach problems and wet his bed. “She told us we were bad if we didn’t do things perfectly,” he said. His anxiety and stomach problems increased when he started a “real job” and kept him from doing things. He spoke of how his father and grandmother called him “a fat pig.” Once, in his twenties, he dated someone who went to another church and he contemplated converting. His mother said, “You’re giving up your family?” and made him feel guilty, thus putting an end to his religious exploration.

He started to understand how angry he’d been since childhood. He seldom said anything negative or stood up for himself or his thoughts due to his fear that others would not like or approve of him. By talking about his feelings in therapy, he realized that not everyone might be judgmental like his family. He realized that his childhood world was different from the larger outside world that he now inhabited. Gradually, he started to take risks and verbalize his feelings and desires more often outside of the therapy room. Although scared at first, he soon found that the results were positive and liberating.

Matt carried his insecurities and anxieties into his personal relationships. He was emotionally needy, had trust issues and could easily become jealous. He had had several significant relationships since age nineteen. Most recently, Matt had been dating David for several months, whom he described as intelligent, stable and mature. One of the main problems was that David lived one hundred miles from Matt’s home. At first, David drove and they went out in the Philadelphia area. Gradually, as the relationship became more serious, there was pressure on Matt to visit David. There was also the issue of doing new things together, such as attending the theater, seeing family members and going to social functions. This meant driving on strange roads and to new places, which brought his anxieties to the forefront. He often used stomach pains or other physical complaints to avoid going.

Eventually Matt showed improvement with therapy. As he learned things about himself, he felt a little more confident and started taking more risks. He did better with change and the unknown and began to see how his anxiety and avoidance kept him from reaching his goals. At first, he would not drive alone and only drove to Harrisburg when David came to his house and went with him. Therapists call this using a “phobic partner.” Finally, Matt took the chance and drove himself to Harrisburg, sometimes using side roads to avoid the expressway and turnpike. He slowly drove greater distances and tried more new things, much to David’s pleasure.

Several months into therapy, he decided to see an Akashic healer, who told him about “The Book of Life” (a belief in universal memory and interconnection) and taught him meditation. At first Matt told me about the healer as if I wouldn’t approve. When I said that anything he did to help himself was okay with me and that really his healer and I were both trying to help him feel more in control but in different ways, he relaxed and became less defensive. He had found two people whom he respected and who accepted him unconditionally. He started to gain perspective in his relationship. He realized that David’s need for “alone time” was not a sign of rejection. He started to ask for more responsibility at work and looked for new employment. With great trepidation, he went on several job interviews and obtained a much more significant position.

Matt’s Opinion of What Helped His Anxiety

“With the help of Dr. Zal and spiritual practices, I have learned several methods to lessen my anxieties. The best tool for an acute anxiety attack is the breathing exercise. This alleviates the tightness and numbness in my face and hands (and gets rid of the blotches on my face) pretty quickly. It is hard to think of and practice in the moment of stress. But it works.

“I learned a lot about myself in therapy. I understand that I use health issues to feel more in control and avoid things that I am afraid to do. I also learned that part of my anxiety is created by holding back emotions. I used to use crying to release a lot of physical and mental symptoms (particularly feeling upset or angry). I fought crying for a long time as it is not considered “manly.” It is not always appropriate in all situations, but if alone in a safe place, I say let it out. I have learned that my feelings can also be let out safely just by sharing them with someone I trust. I also try to use what I call ‘The Zal Method’ of dealing with my anxiety. I ask myself what anxiety or feeling is underlying my physical symptom. I don’t always buy it but I at least give it a chance. Often, he is right and I think of something that I’m anxious or upset about. Now, I bulldoze through my worries. I can’t waste my time.

“My antidepressant medication has been slowly reduced. I still will not give it up entirely. Perhaps it is my ‘last parent’ or security blanket. Perhaps it is my safety net that I can turn to in time of need. I am learning that I have been standing on my own two feet for a long time and doing quite well. Maybe I do not need a safety net.

“My involvement with Siddha Yoga practices has taught me how to meditate. Every morning, I spend at least ten minutes focusing my breathing and clearing my mind of all thoughts. It is tough to learn and does not happen instantly, but over time I have gotten to the point where I can clear my mind in five minutes and actually not feel anxiety for that time in meditation. I also feel it affects the stress level of the rest of my day in a positive way. My spiritual leader also taught me that ‘We are all alone. God is inside us.” This idea has helped me be less dependent on others.

“After taking a class from a Reiki Master, I learned to perform Reiki on myself. Reiki is the movement of spiritual energy or Qi through the body. It is meditative and whether it is a placebo effect or not, it aids in relieving my stress physically and mentally.

“Finally, one of the most important steps in lessening anxiety over time is positive self-talk. I consciously make an effort to recognize my accomplishments in fighting my anxiety and refuse to beat myself up if I fall short of my own expectations in the battle. I compare how I handled a situation in the present to how I would have handled it a year ago or two years ago and realize how far I have come. I recognize that there is no magic answer or instant fix, but each little step I take further into the battlefield is a win.”

My Opinion of What Helped Matt’s Anxiety

I have seen the simple breathing exercise calm people. However, some of Matt’s physical symptoms of anxiety, particularly those involving his face, were far worse than average. I taught Matt the deep breathing exercise, hoping for the best. After two weeks he returned and told me that he drove a longer distance than usual and his anxiety grew progressively worse with each mile. His lips, the sides of his face and his hands and feet became numb and tingled. Hive-like blotches appeared on his face. He did the deep breathing exercise. After three tries, he looked in the car mirror and the blotches were gone. He was astonished. Seeing this technique work allowed him to have greater trust in therapy and my view of the nature and cause of his anxiety.

When I first saw Matt, I felt that, although he was unhappy, frustrated and had a history of depression, he was no longer clinically depressed. He had GAD and a history of panic disorder. Although his medication was an antidepressant, it was also helpful for insomnia and anxiety. Matt was not wrong when he said that he got increased anxiety, stomach pains and dizziness when he tried to get off his medication (which is known to have withdrawal symptoms). I suggested that we gradually decrease his dosage and place him on an antianxiety medication that would help his anxiety and prevent his panic attacks from returning. It took him five months to try this for the first time.

Matt incorporated yoga, meditation and other alternative therapies as well as spirituality into his treatment plan. He felt that his association with a spiritual leader was very helpful. This involvement allowed him to bring religion back into his life in a way with which he felt comfortable. It gave him something to hold on to during times of stress. He had come back to religion but in his own way.

In therapy we addressed many issues. Matt’s mother and maternal grandmother were both role models who put much emphasis on physical problems and believed that a pill was the answer to everything, even though it sometimes isn’t. This revelation moved Matt to allow me to slowly reduce his antidepressant medication. Matt internalized feelings of anger and guilt and denied his need for support and dependency. All of these issues got in the way in his new relationship with David. As time went by I was able to get him to verbalize these feelings. In any new relationship, we project our early wishes onto the other person just as the client projects them onto the therapist. As we get to know the person better, we start to see flaws and limitations. Gradually, Matt was better able to accept David, “warts and all.”

Therapy helped Matt with his self-esteem and allowed him to feel better about himself. He had a distorted perception of himself, particularly his body image. Some of this was due to the message that he received in childhood that he was “a cross-eyed fat pig.” I helped him reduce feelings of shame and guilt, stay away from self-pity and begin to like himself more. He started a diet. I also helped him see that he did not have to give others so much power over him. As Eleanor Roosevelt said, “No one can make you feel inferior without your consent.”

To reduce his need for control and predictability, I pointed out that his life history showed no evidence of loss of control. There was no family history of psychosis. If anything, his problem was too much control. I tried to teach him that his personality probably would never allow him to lose complete control.

The most significant gain in therapy for Matt was his gradual willingness to travel greater distances, take risks and still feel in control. At first, he traveled to another city to see his lover and visit people in the area. Then, he took another job in a location that was outside of his comfort zone. Finally, with his dependency needs and anxiety in better focus, he was able to leave therapy and take an advanced position in a neighboring state. His anxiety battle had, at last, been partially won.

After several months had passed since I had last spoken to Matt, I called him to check his progress. He seemed happy and confident; his first words were, “I’m doing well. I just graduated from school with a master’s degree in instructional technology. I gave my dissertation presentation in front of thirty people.”

Matt told me that he was still working for the same firm: “It’s been rough—a lot of management changes—but I stuck in there. I am doing consulting work on the side with a young firm. I’m handling stressful situations better. It’s been good, especially with driving. You would be proud. I drive all over now, even across bridges. It’s amazing. At first, I did it with my partner and then started to drive myself. Now I’m cruising on the highway. We are still together. If the fears do come up, I do the breathing exercise. I no longer need to be tethered to home. We will see how it goes from here. My anxiety is manageable. If it does present, I have the tools to handle it and it’s just a bump in the road. Sometimes I just say to myself, what is the worst thing that can happen?”

What surprised me the most was what happened when I read him the first line of his vignette, where he compared his anxiety to a battlefield. Although he remembered writing the words, he could no longer relate to them because so much had changed in his life. I could see that he had come a long way from that insecure, upset and anxious young man whom I had met years ago. I was happy for him.