Emotional Resilience Blog from The Fear Course

The latest research, realisations and thinking in the world of emotional resilience, anxiety and fear reduction from around the world.

The emotional impact of internet addiction on our children

The emotional impact of internet addiction on our children

The internet is an amazing resource and social connector and a recent study found that about 90% of school children with internet access use it to get educational information for school work, as well as other activities such as playing games and social interaction for example. Like most things in life, used responsibly the internet is a fantastic resource and can be a lot of fun.

However there have been a rash of recent studies showing that the prevalence of internet addiction, the feeling one needs to go online as a first recourse and as a preference to engaging with other real life activities, especially among children, is growing. The estimations of the growth of internet addiction in academic research studies range from 1.4% up to 17.9% of the adolescent population or 11 - 15 year olds in both western and eastern cultures. With newly published studies coming in at the higher end of this range, this means that somewhere approaching 1 in 6 of our 11-15 year old children may well be addicted to the internet. Given the study I reported on last week, this is likely to get worse as todays internet toddlers grow into adolescents.

Like every addiction, internet addiction carries a cost and a study to be published next month in the journal Comprehensive Psychiatry highlights some of that cost.

The study looked at 2293 11-14 year olds and assessed them for levels of depression, hostility, social anxiety whilst also monitoring their online habits. The researchers then measured the children a year later to see if there were any links. Now a number of studies have already linked internet addiction with depression, particularly in young adults, 16 - 21 year olds.

The interesting thing about this study is the inclusion of social anxiety. There have been a number of studies already which show that people tend to feel less social anxiety whilst online compared to face-to-face interaction. There is strong speculation in the academic world that this effect maybe driving some peoples addiction to the internet as a proxy for live 'in person' social engagement.

Additionally two studies have found that people with depression also have lower levels of anxiety and hostility when socialising online. This sounds like the internet is a good thing for these people, right?

A famous study in 2011 found that chronic online gamers suffered from greater levels of depression, social anxiety, social phobia (complete aversion to face-to-face contact), and aggression / hostility than individuals who either didn't partake of such games or were just light users. The effects of this aren't just mental. Studies have found that people with higher levels of internet derived aggression and hostility also have higher levels of cardiovascular issues as well as other circulatory problems.

Anyway, this study, led by Dr. Ju-Yu Yen an academic, medical doctor and psychiatrist, found that the longer an individual is addicted, particularly in the adolescent years, the slower the recovery, when treatment or an intervention occurs. Basically the sooner internet addiction is found and dealt with the better the outcome and the faster the symptoms of depression, anxiety and hostility / aggression will reduce.

A number of interventions have been tested where internet addicted people with high levels of depression, anxiety and aggression / hostility have their online addiction treated with positive results. The aggression / hostility tends to reduce the fastest after the individuals are no longer using the internet in such heavy doses, with depression levels also dropping as face to face socialisation increases. Anxiety tends to be the last issue to reduce following such an intervention.

I am currently writing a book titled "ADJUSTED: What the research says about how to bring up emotionally well adjusted, resilient and competent children". If you would like to get your hands on an advanced copy just click here.



Chih-Hung Ko, et al, (2014) The exacerbation of depression, hostility, and social anxiety in the course of internet addiction among adolescents: a prospective study. Com- prehensive Psychiatry (2014), doi: 10.1016/j.comppsych.2014.05.003

Other papers

Calles JL Jr. (2007) Depression in children and adolescents. Prim Care 2007;34:243-58.

Constantine MG. (2006) Perceived family conflict, parental attachment, and depression in African American female adolescents. Cultur Divers Ethnic Minor Psychol 2006;12:697-709.

Crutzen R, et al (2011) Strategies to facilitate exposure to internet-delivered health behavior change interventions aimed at adolescents or young adults: a systematic review. Health Educ Behav 2011;38:49-62.

Ferguson CJ, & Kilburn J. (2009) The public health risks of media violence: a meta-analytic review. J Pediatr 2009;154:759-63.

Gentile DA et al. (2011) Pathological video game use among youths: a two-year longitudinal study. Pediatrics 2011;127:e319-29.

Greydanus DE, & Greydanus MM. (2012) Internet use, misuse, and addiction in adolescents: current issues and challenges. Int J Adolesc Med Health 2012;24:283-89.

Ha JH, et al (2007) Depression and Internet addiction in adolescents. Psychopathology 2007;40:424-30.
Kitamura T, & Fujihara S. (2003) Understanding personality traits from early life experiences. Psychiatry Clin Neurosci 2003;57:323-31.

Ko CH, et al (2007) Factors predictive for incidence and remission of internet addiction in young adolescents: a prospective study. Cyberpsychol Behav 2007;10:545-51.

Ko CH, et al (2009) The associations between aggressive behaviors and internet addiction and online activities in adolescents. J Adolesc Health 2009;44:598-605.

Ko et al (2009) Predictive values of psychiatric symptoms for internet addiction in adolescents: a 2-year prospective study. Arch Pediatr Adolesc Med 2009;163:937-43.

Lam LT & Peng ZW. (2010) Effect of pathological use of the internet on adolescent mental health: a prospective study. Arch Pediatr Adolesc Med 2010;164:901-6.

Mythily S, Qiu S, & Winslow M. (2008) Prevalence and correlates of excessive internet use among youth in Singapore. Ann Acad Med Singapore 2008;37:9-14.

Norris ML. (2007) Adolescents and the internet. Paediatr Child Health 2007;12:211-16.

Park S, et al (2013) The association between problematic internet use and depression, suicidal ideation and bipolar disorder symptoms in Korean adolescents. Aust N Z J Psychiatry 2013;47:153-9.

Prinstein MJ, et al (2005) Adolescent girls' interpersonal vulnerability to depressive symptoms: a longitudinal examination of reassurance-seeking and peer relationships. J Abnorm Psychol 2005;114:676-88.

Siomos KE, et al (2008) Internet addiction among Greek adolescent students. Cyberpsychol Behav 2008;11:653-7.

Yen JY, et al (2007). The comorbid psychiatric symptoms of Internet addiction: attention deficit and hyperactivity disorder (ADHD), depression, social phobia, and hostility. J Adolesc Health 2007;41:93-6.

Yen JY, et al (2012) Social anxiety in online and real-life interaction and their associated factors. Cyberpsychol Behav Soc Netw 2012;15:7-12.

Yen JY, et al (2011) Hostility in the real world and online: the effect of internet addiction, depression, and online activity. Cyberpsychol Behav Soc Netw 2011;14:649-55.

Young KS. (1998) Internet addiction: The emergence of a new clinical disorder. Cyberpsychol Behav 1998;1:237-44.

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A link found between anxiety and cancer - Research just published

A link found between anxiety and cancer - Research just published

Currently an area of great interest and focus in the medical research and in particular the cancer research world, are a set of types of cell known as regulatory T cells or Treg cells. Treg cells are part of our immune system and in effect, they suppress or stop the immune responses of other cells. Basically what Treg cells do is turn off an immune response once it has done its work of eliminating any invading 'bugs'. This is a vital function, otherwise our predatory immune system cells would stay on the rampage even after the threat had passed.

As you may know, the problem with cancers is that the cells in the body 'forget' to turn off and keep multiplying. These cancerous or non turning off cells then often keep growing out of control, eventually killing the individual concerned. So Treg cells essentially turn off the immune system response to prevent this happening.

It is already known that the immune system of mice and other animals tends to reduce in effectiveness when the animal is subject to chronic stress and anxiety, and in particular Treg cells become less effective and efficient at doing their job.

A study published this week in The Journal of Immunology has made a potential link between anxiety and cancer.

In this study nine patents were measured for their level of anxiety and the number and effectiveness of the Treg cells in their blood, both before and after an anxiety reduction programme. All of the patents were suffering from GAD or general anxiety disorder.
It was found that the patents had much lower levels of Treg cells in their blood, and those Treg cells that did exist were less efficient in the GAD patients.

These patients were then put on an eight week anxiety treatment programme and then tested again.

After the anxiety reduction programme it was found that the Treg cells had returned to normal levels and functioning. In effect the patents immune system had been returned to normal and was therefore allowing their systems to suppress and turn off immune responses as they were designed to do. The researchers state that this should reduce the risk of cancer in these individuals.

Now whilst it is early days yet with this research, and the numbers in this study were small, it is a strong indication about one possible mechanism of the proliferation of cancer.

As a result of this study the researchers from the University of Pennsylvania School of Medicine in Philadelphia and the Department of Pathology and Laboratory Medicine at the Children's Hospital of Philadelphia recommend that anxiety is treated as a matter course wherever it is found to reduce the potential risk of cancer.

This just highlights the importance of learning and developing genuine emotion regulation strategies and anxiety reduction techniques.


Akimova, T. et al (2014) Amelioration in generalized anxiety disorder is associated with decreased Treg number and function
The Journal of Immunology May 1, 2014 vol. 192 no. 1 Supplement 52.27

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Can losing weight reduce anxiety?

Can losing weight reduce anxiety?

I have written a number of times about the effect of diet on anxiety levels (here) for example. However if you are overweight will reducing weight also reduce anxiety levels?

A study just published this week looked at this very question.

It has been found that patients with metabolic syndrome, which is combination of diabetes, high blood pressure and obesity, (and these conditions often go together), also often report higher levels of anxiety as well. The question is are the increased levels of anxiety linked to the metabolic syndrome or in particular, obesity?

There are a set of neurotransmitters or chemicals in the brain, called monoamines which it is believed are connected to anxiety levels. We think monoamines are vital components of our emotional and thinking systems. It has been found that problems with the effectiveness of monoamines in the brain occur in issues like depression and anxiety. Some drugs used to treat these problems increase the effectiveness of the monoamines.

This study examined the levels of anxiety, weight and monoamines levels in a group of patents aged between 40 and 60 who had been diagnosed with metabolic syndrome.

They were tested for weight, anxiety levels and monoamine levels before and after being placed on a 6 month weight reduction diet.

The results were marked to say the least. They found that of the patents placed on the diet and who lost weight, increased their levels of monoamines, and decreased their anxiety levels by almost a third over the same time. In fact the study found that the level of weight loss for these patents paralleled the decrease in anxiety levels suffered by the individuals in the study. So the answer appears to be that weight and anxiety are linked, at least with people suffering from metabolic syndrome.


Perez-Cornago, A. et al (2014) Effect of dietary restriction on peripheral monoamines and anxiety symptoms in obese subjects with metabolic syndrome. Psychoneuroendocrinology May 2014.http://dx.doi.org/10.1016/j.psyneuen.2014.05.003

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The effects of pre-operation anxiety on the recovery of heart surgery patients

The effects of pre-operation anxiety on the recovery of heart surgery patients

A study just released in the Journal of the American College of Cardiology looked at the connection between pre-operation anxiety levels in patients and how well those patients improved during the first year after the surgery.

The study by a group of cardiologists looked at the anxiety levels of patients just before they were to undergo heart surgery. They then tracked those patients for the first year of their recovery after the surgery to see if there was any impact of the anxiety levels on their quality of life during recovery. The study followed 720 patients who were operated on and measured their levels of anxiety just before the operation. They found that almost half (347 or 48%) of the patients had what could be described as high levels of anxiety just before the operation.

The researchers found that both the high and low anxiety groups had similar operation success rates, however the recovery of the high anxiety group was much slower and their quality of life had significantly poorer improvement outcomes.

This level of evidence should be a call to health providers and patients to ensure the patients are equipped to lower their levels of anxiety before surgery. occurs.


Mohanty, S. et al (2014) Baseline anxiety impacts improvement in quality of life in atrial fibrillation undergoing catheter albtion. J Am Coll Cardiol. 2014;63(12_S):. doi:10.1016/S0735-1097(14)60395-8

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How exercising an avatar can reduce anxiety and improve self-body image

How exercising an avatar can reduce anxiety and improve self-body image

Exergaming or video fitness games that require bodily movement of the player to play, and usually drive the movements of an avatar may have more going for them than might at first appear. The Wii Fit and Kinetic are two examples of these types of exergaming. A number of research studies have found that exergames with activities such as dancing, kickboxing and aerobics for example can have a number of beneficial health effects. However a series of previous studies have also found that people who exercise with other people tend to report more positive wellbeing and less anxiety as opposed to those who exercise on their own.

There is a group of people for whom group exercise is not an appealing thought. People with poor self-image perception or put another way, high levels of body image dissatisfaction, tend to find group or social exercise both demotivating and anxiety increasing, for obvious reasons. This especially occurs in situation where the majority other members of a workout group appear to be fitter or look better and in environments which have large mirrors.

So is it really better to exercise with others or on your own?

There is a syndrome known as social physique anxiety, where people have the feeling that their bodily looks are being negatively evaluated by others and as a result they suffer from embarrassment in many social settings. This is actually a subset of social anxiety. As one can imagine in such situations the motivation to exercise in front of others is quite low. In fact in some situations the anxiety can be so pronounced that a complete aversion to exercise can develop with the obvious health consequences.

A study to be published in July looks at the effects of solitary exergaming using avatars in situations where social physique anxiety and high levels of body image dissatisfaction occur.

You can probably see where this research is going, however there is an interesting twist in this study and it's called the Proteus Effect.

The Proteus Effect refers to a phenomenon noticed years ago in the online gaming world. It was found that people often tend to take on the attributes of the digital persona or avatar or character they are operating with. Studies have found for example, that people who use tall lean avatars in games tend to close the physical space between themselves and other people's avatars more than if they are using short fat avatars. Other studies have shown shifts in a range of persona attributes including general attitude, confidence, aggression levels, empathy, communication style, problem solving style etc. Researchers have been finding that it's not just online behaviour that can change as a result of the Proteus Effect. There have been a number of successful therapeutic interventions using avatars in areas such as weight loss, addiction, aggression / anger and confidence problems using avatars as role models.

The term Proteus Effect comes from the Greek sea god Proteus who is mentioned in Homers 'Odyssey'. Proteus, who lived in the sea, knows everything, everything that has happened, everything that is happening and everything that will happen and consequently was much valued. The only problem was that Proteus was somewhat of an elusive god and didn't like to give up his secrets. If approached Proteus would hide by transforming himself into other sea creatures so you couldn't work out who he was and get hold of this powerful knowledge.

The proteus effect refers then to the taking on of the attributes and persona of the avatar by the game player.

Not only can the shape, attractiveness and general attributes of an avatar change our online behaviour, but it also affects how we feel about the game or activity, other people and ourselves. Game designers have known for some time that people with more attractive and successful hero type avatars tend to build deeper affiliations with the game and other players and consequently tend to stay with the game longer. Avatar based games such as the ever popular Warcraft and online environments such as Second Life measure player engagement in terms of years as a direct result of this effect.

The thing to note here are these are emotional reactions. Emotions such as enjoyment, attachment, confidence and even grief are experienced whilst operating through an avatar. Not only are these emotions real for the participant but they are being altered as a direct result of the percieved personality of the avatar. In effect we tend to take on the personality projected by the character we are in effect role playing.

This study (remember that?) looked at three research questions:

1. How do body image dissatisfaction and exercise context affect individuals' (a) enjoyment, (b) mood, and (c) perceived exercise accomplishment during exergame play?
2. In the group context, will social physique anxiety be reduced during exergame play?
3. What is a role of self-presence in predicting perceived exercise accomplishment?

They had 732 people attend both group exercise classes and do solitary exergaming. Half of the population reported suffering from some form of body image anxiety.

  • The researchers found that all the participants significantly improved their enjoyment of solitary exercise using an avatar over doing the exercise in a live group situation. People with high levels of body image dissatisfaction had even greater levels of enjoyment than those with less of an issue about their body image.
  • When it came to an increase in positive mood, people with high body image dissatisfaction reported a significantly elevated effect on their mood as well whilst using an exergaming programme.
  • Again when it came to the perception of having accomplished something, everyone reported a significant increase whilst engaging in solitary exergaming over group exercise. This effect I assume is quite likely to be down to the progress bars and the like such games produce.
  • The big win from the research was that everyone saw a significant decrease in body image anxiety during exergaming when compared to social exercise and the effect was significantly more pronounced for those with higher levels of body image dissatisfaction than those with lower levels of body image anxiety.
  • Finally for the last question the researchers found that the role of the avatar was significant in these results. Basically what happens is that people identify emotionally and physically with their avatar and begin to experience the world through the percieved avatars personality, what scientists call self-presence. In other words, when playing such games we tend to experience the game as the avatar might rather than from our own perspective. The Proteus Effect in action.

So you can get into or more into exercise, reduce body image anxiety and feel better about the whole exercise thing by exercising an avatar!


Ball, K., Crawford, D., & Owen, N. (2008). Obesity as a barrier to physical activity.
Australian and New Zealand Journal of Public Health, 24, 331–333. http://

Belling, L. R. (1992). The relationship between social physique anxiety and physical
activity. Unpublished master's thesis, University of North Carolina, Chapel Hill.

Ersner-Hershfield, H., Bailenson, J. N., & Carstensen, L.L. (2008). Feeling more
connected to your future self: Using immersive virtual reality to increase retirement
saving. Paper presented at the Association for Psychological Science Annual
Convention, Chicago, IL.

Fox, J., & Bailenson, J. N. (2009). Virtual self-modeling: The effect of vicarious
reinforcement and identification on exercise behaviors. Media Psychology, 12,
1–25. http://dx.doi.org/10.1080/15213260802669474.

Song, H et al (2014) Virtual vs. real body in exergames: Reducing social physique anxiety
in exercise experiences. The journal of Computers in Human Behaviour. July 2014. http://dx.doi.org/10.1016/j.chb.2014.03.059

Yee, N., & Bailenson, J. (2007). The proteus effect: The effect of transformed self-
representation on behavior. Human Communication Research, 33, 271–290.

Yee, N., Bailenson, J. N., & Ducheneaut, N. (2009). The proteus effect: Implications of
transformed digital self-representation on online and offline behavior.
Communication Research, 36, 285–312. http://dx.doi.org/10.1177/0093650

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Sleep and anti anxiety drugs increase your risk of dying - new study

Sleep and anti anxiety drugs increase your risk of dying - new study

A study of the effects of anti-anxiety and sleeping drugs published in the British medical Journal by researchers from the universities of Warwick, Keele, and two health trusts in the UK earlier this month have alarmed the health profession with results which are worrying to say the least.

Drugs to help people sleep and deal with anxiety are prescribed widely around the world, and are relied on by many on a regular basis. This collection of drugs, known as psychotropic medicines have already been the subject of a series of studies that have shown that they are addictive. However this study, has shown a direct link between these drugs and increase risk of early death.

The study looked at the death or mortality rates of people prescribed either anxiolytic (anti-anxiety) or hypnotic (sleep) and a control group who were not taking any prescribed medicines. Overall the records of 34,727 patients taking one of these drugs were compared to the records of 69,418 patients not taking them over a 7 and a half year period. What the researchers found was that there were 4% more deaths in the psychotropic drug taking group than in the control group over a 7 year period. The study also found that the more of these types of drugs you take the greater the risk of death becomes.

There are other issues with this collection of drugs. Studies have found that people taking these drugs are at 6 times the risk of hospitalisation due to car accidents, and also have increased risk of stroke, heart problems, birth defects, suicide and cancer.

Another issue from my perspective is that these drugs hide rather than deal with the underlying problem. Anxiety and sleep issues are largely cognitive or psychological issues which can successfully be dealt with as such, rather than reaching for what is turning out to be a quick fix. A fix that doesn't really solve the problem on a long term basis and as these studies are showing, can be dangerous.


Weich. S., (2014) Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study. BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g1996 

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You think too much....

You think too much....

One of the things that appears to separate us from the rest of the animal kingdom is our ability to know we are thinking, what is known as meta-cognition.

Connected to this meta-cognitive ability is our capacity for reflecting on things that have happened. This ability to remember at will, and in effect go over things again, lie at the heart of one of our learning systems. Because we can go back and 're-live' a situation, we can also come to conclusions about an event and then plan what to do the next time something like this event occurs again. So image you have just had a conversation with the boss about a job he or she gave you and the boss got angry during the conversation. Under normal circumstances when we are well balanced and have things in perspective we should be able to go over the events again and work out what went wrong, even to the extent to realising that maybe we should have handled things a bit differently and it's not surprising the boss got angry, or what ever conclusion we come to.

This ability to reflect on things is a vital part of our reflexive learning processes (exploring the relationships between cause and effect). If you reflect, come to a conclusion and make a plan, and maybe even put it into action, you have engaged in learning.

This is normal and you will move on. What can occur for many people however is that they get stuck in a cycle between reflecting on what happened, or worse still on what hasn't but could happen (a projection) and coming to a conclusion. So the individual goes from reflection, to conclusion to reflection and so on, without breaking out of the reflective process and never reaching a final conclusion. This can occur in some individuals many many times where they find it hard to let go of the reflective phase of the process. This rumination particularly occurs when there are negative emotions present in the scenario and is the hallmark of depression and episodes of anxiety.

So given the situation above, the individual would keep coming back to the conversation with the boss in their head and start to feel the uncomfortable feelings of embarrassment, anger, anxiety or whatever. The emotion then blocks the progression of thinking (to conclusion) and the individual goes back to reflection and so starts another (vicious) cycle of reflection or rumination.

The problem with rumination is that every cycle of reflection can intensify the negative emotion and make the next cycle of reflection even more likely and emotionally worse.
These ruminative traps are more likely when we are feeling anxious, depressed or even stressed. OCD is also based on this process, but has become more of a habit or trait for the individual. Rumination keeps us stuck in the emotion.

Like the conclusion of my blog yesterday, going and doing/focussing on something else is the way out of this cycle, and getting some help from stress, depression or anxiety of course.

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