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.

Robin Williams 1951 - 2014

Robin Williams 1951 - 2014

As I was posting my last blog about the problems Experiential Avoidance can escalate into, including suicide and addictions, a heart-breaking drama was playing itself out in the Californian home of the Oscar winning actor and comedian Robin Williams who was 63.

Robin had long been diagnosed with severe depression and had battles with drink and cocaine addiction for which he had famously received treatment for at a rehab centre.

Reporting the death of Robin in the early hours of this morning (UK time) the Marin County sheriff's office stated they suspected suicide by asphyxiation.

Robin's wife Susan Schneider said this morning "This morning I lost my husband and best friend, while the world lost one of its most beloved artists and beautiful human beings. I am utterly heartbroken,"

Robin openly talked about his battles with alcohol and cocaine in the early 1980s, and his relapse in 2006. He appeared to have recovered however last month he returned to rehab in Minnesota.

Suicide is often seen as a selfish act, however as one who had in the past seriously considered such action whilst suffering from depression myself, having dealt with depression and anxiety in many other people therapeutically and having attended suicides and prevented a number of suicides as a police officer, all the individual often wants is relief from the symptoms of the crushing depression.

In an interview in 2010, asked about his depression and had he felt happier, Robin replied : "I think so. And not afraid to be unhappy. That's OK too. And then you can be like, all is good. And that is the thing, that is the gift."

This comes back to the heart of the dangers of Experiential Avoidance.

My heart goes out to Robin's family and friends. We have lost a true talent and extraordinary fellow human being in very sad circumstances.

If you recognise and think you too may be avoiding feelings, thoughts, memories, physical sensations and other internal experiences please get help.


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The Cost of Anxiety

The Cost of Anxiety

It is widely known in the medical research community that anxiety disorders are the most common disorders there is, bar none. Not only are anxiety disorders the most frequently suffered disorder there is, a research paper published in journal Neuropsychopharmacology worked out that in the US alone in 2002 anxiety cost about 100 Billion dollars or £58,326,044,000 per year, which is the last reliable estimate of the general cost of anxiety. Given that this was firstly back in 2002 and secondly just in the US, which only accounts for about 4,44% of the worlds population you can start to get some idea of the size of the problem.

The cost obviously goes way beyond the financial burden, in terms of the incalculable effects it has on people's lives on a daily basis. Especially when you take into account the reduction in opportunities anxiety causes. Right now as I write this I have personal clients who:

  • couldn't go out,
  • wouldn't fly,
  • found it hard to speak at meetings,
  • got flustered and avoided social events, meetings, dating and a whole host of other social situations,
  • couldn't go shopping,
  • wouldn't drive,
  • wouldn't be a passenger in a car being driven by someone else,
  • couldn't go for job interviews,
  • wouldn't take a promotion,
  • avoided public places,
  • avoided intimate relationships,
  • were putting off an operation,

and that is just the start. The cost to these people in terms of the reduced opportunities and social functioning cannot be put into monetary terms. Not only that the emotional cost is almost impossible to articulate. Until you have had a panic or anxiety attack, or found yourself avoiding things or had depression, it is very difficult to understand what this does inside to a person.

The cost does not end there. There is now a growing body of evidence about the direct and indirect health costs of anxiety disorders. For example people with an anxiety disorder are 3 to 4 times more likely to develop cardiovascular disease, and twice as likely to die from some form of heart problem or a heart attack as the people without anxiety. Additionally as I reported in 'People with anxiety are more likely to develop depression' people with anxiety are 50-70% more likely to develop depression than the general population. Further there are a whole host of other health problems associated with anxiety which greatly effect the quality of life like cancer and cost the individual in mental and emotional ways beyond just financial costs.

And yet if you go to the doctors with any anxiety disorder the frequent response is to be put on a waiting list for online CBT or anti-depressants. Whilst I understand the primacy physical illnesses like coronary and cancer ( See 'Links between anxiety and cancer' ) care has, it is about time anxiety disorders also got the attention and priority other illnesses have form the medical professions. Anxiety which often either underlies, predicts or complicates the physical illness or as reported here '(The effects of pre-operation anxiety on the recovery of heart surgery patients') actually exacerbates or worsens the prognosis of the patient.

Anxiety treatment and prevention needs to become a priority for all of the health services. It's not like there is a lack of evidence.




Bardeen, J.R. etal (2014) Exploring the relationship between positive and negative emotional avoidance and anxiety symptom severity: The moderating role of attentional control. Journal of Behavior Therapy and Experimental Psychiatry. Volume 45, Issue 3, September 2014, Pages 415–420

Chalmers J, Quintana DS, Abbott MJ and Kemp AH (2014). Anxiety disorders are associated with reduced heart rate variability: A meta-analysis. Front. Psychiatry 5:80. doi: 10.3389/fpsyt.2014.00080

Fagundes, C.P. etal (2014) Attachment Anxiety is Related to Epstein-Barr Virus Latency. Brain, Behavior, and Immunity (2014), doi: http:// dx.doi.org/10.1016/j.bbi.2014.04.002

Jacobson N.C. & Newman, M.G. (2014) Avoidance mediates the relationship between anxiety and depression over a decade later. Journal of Anxiety Disorders. 28 (2014) 437-445.

Kessler, R. C., & Greenberg, P. E. (2002). The economic burden of anxiety and stress disorders. Neuropsychopharmacology: The fifth generation of progress, 67, 982-992.

Kravitz HM, Schott LL, Joffe H, Cyranowski JM, Bromberger JT (2014) Do anxiety symptoms predict major depressive disorder in midlife women? The Study of Women's Health Across the Nation (SWAN) Mental Health Study (MHS). Psychological Medicine [2014:1-10] DOI: 10.1017/S0033291714000075

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

Rubertsson, C et al. (2014) Anxiety in early pregnancy: prevalence and contributing factors. Archives of Women's Mental Health June 2014, Volume 17, Issue 3, pp 221-228

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Problems caused by anxiety during pregnancy

Problems caused by anxiety during pregnancy

Around 3-17% of pregnant women suffer from some form of antenatal depression during pregnancy and up to 40% suffer from heightened anxiety.

A rash of studies have shown that this can have a number of negative effects not just on the mother to be but also on her social, personal and marital relationships as well as later mother and infant interactions and of course the infant. Now there is a growing body of evidence to show that anxiety also increases the fear of the birth which results in increases in elective caesarian section and also predicts a range of obstetric problems and also pre and post natal depression.

A study just published today, looked at the prevalence of increased anxiety during the first trimester (gestation weeks 8-12) and the problems associated with anxiety during this period.

The researchers found that 15.6% of women reported significantly increased levels of anxiety during the first trimester. Additionally they found that women under the age of 25 are at an increased risk of contracting problematic anxiety. Further they discovered that additional risk factors include being pregnant in a country where the the mothers native language isn't primarily spoken, lower levels of educational attainment, unemployment, smoking (obviously) and previous bouts of depression or anxiety. Not only that, women who have these risk factors are more likely to develop either or both pre and post natal depression unless the anxiety is successfully treated.

The researchers conclude that all women in the risk category groups and any pregnant women who develops anxiety should obtain treatment for the anxiety (i.e. learning emotion regulation techniques) as a matter of course.


Conde A, Figueiredo B, Tendais I, Teixeira C, Costa R, Pacheco A, Ceu Rodrigues M, Nogueira R (2010) Mother's anxiety and depression and associated risk factors during early pregnancy: effects on fetal growth and activity at 20–22 weeks of gestation. J Psychosom Obstet Gynecol 31(2):70–82

Heron J, O'connor GT, Evens J, Golding J, Glover V (2004) The course of anxiety and depression through pregnancy and the postpartum in a community sample. J Affect Disord 80:65–73

Rubertsson, C et al. (2014) Anxiety in early pregnancy: prevalence and contributing factors. Archives of Women's Mental Health June 2014, Volume 17, Issue 3, pp 221-228

van Bussel CHJ, Spiz B, Demyttenaere K (2009) Anxiety in pregnant and postpartum women. An exploratory study of the role of maternal orientations. J Affect Disord 11:232–242 CrossRef

van den Bergh BRH, Marcoen A (2004) High antenatal maternal anxiety is related to ADHD symptoms, externalizing problems, and anxiety in 8 and 9 year olds. Child Dev 75:1085–1097

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Different types of control predicts depression

Different types of control predicts depression

Following on from the research articles reported in last week's blogs (here and here) about the links between anxiety and depression and the finding that people who avoid the object that is causing their anxiety are much more likely to have their anxiety turn to depression if the anxiety continues for some time, a third article just published sheds more light on the situation..

Largely there are three types of control that people use to cope with negative emotions: primary, secondary and disengagement control.
Primary control coping is based on changing and influencing our environment in order to cope. Choosing which friends to go out with based on who makes us feel good, problem solving to deal with the situation and engaging in emotion regulation techniques.
Secondary control is coping by adjusting ourselves to the environment, for example accepting the situation.
The third form of coping people engage in is to disengage completely or avoid the object or situation that is causing the negative emotion.

A study just published in Anxiety, Stress & Coping looked at the coping mechanisms of people who had previously been depressed and compared them with the coping mechanisms of people who have never been depressed
They found that people who had never had depression and who tend to use fewer primary coping skills in preference for avoidance coping strategies are significantly more likely to develop depression.
People, whether they had previously had depression or not, who develop secondary coping strategies, accepting the situation and their emotions (which is different to resignation), tend to see a decrease in their depressive symptoms.
They also discovered that people with greater levels of mental flexibility also tended to suffer from less depressive symptoms and recover more quickly from depression than people with less cognitive flexibility.

The researchers recommend that people at risk of depression should either be helped to develop emotion regulation strategies (primary control coping) or acceptance strategies (secondary control coping). Obviously learning both would be better, significantly reducing the risk of depression regardless of whether you have had it or not before.



Morris, M.C. et al (2014) Executive function moderates the relation between coping and depressive symptoms. Anxiety, Stress & Coping: An International Journal. 2014 June DOI: 10.1080/10615806.2014.925545

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One of the reasons anxiety turns into depression - new study

One of the reasons anxiety turns into depression - new study

As reported in Thursdays blog, more and more evidence is being found that long term untreated anxiety is likely to turn into depression. The study quoted on thursday found that this was likely to happen to about 50% of the population of anxiety sufferers. Another study also published recently suggests that untreated long term anxiety is likely to turn into depression in up to 77% of cases.
It has also been found that those that develop depression following long term anxiety, tend to get more severe forms of depression compared to those who develop depression without first suffering bouts of anxiety.

These are sobering findings and really highlight the importance of dealing with anxiety in its early forms and of learning the tools and techniques of proper emotion regulation.

However a question arises as to what is causing the anxiety to turn into depression. Surprisingly only three studies have looked look at the potential causes of this phenomenon. The first research study from 1999 looked at whether specific negative life events or reassurance seeking behaviours could be what transforms anxiety into depression, however the researchers could not find the expected connections. The second study from 2009 looked at the hypothesis that a lack of problem solving skills or individuals with anxiety who perceive that they have little or no control over the things that happen to and around them might cause, in part at least, the anxiety to turn to depression. Like the 1999 study, this study was unable to find such a causal effect.

However a study published a few weeks ago does finally shed light on this transformation. The study by researchers at The Pennsylvania State University in the United States used a large scale sample between 1994 and 2008 in four waves of observation with between 6504 and 4834 people to try to find what might be one of the causes for depression with people suffering from anxiety.

A prominent feature of anxiety is avoidance or flight. If an individual is anxious about something, say meetings, or public speaking or flying for example, they will tend to avoid engaging in that activity as a method trying to regulate the anxiety. As members of the free course will know this is one of three primary responses to what is known as the 'fear of the fear' phenomenon.

The researchers tested the hypothesis that avoiding the anxiety inducing subject, e.g. flying, public speaking etc. was a factor in the onset of depression. If this hypothesis were to prove to be correct one would expect that the greater the level of avoidance the greater the chance the individual has of becoming depressed. Indeed this is exactly what the researchers found.
The more someone avoids the anxiety promoting stimulus the greater their chances of becoming depressed.

There is now a hunt ongoing to find why this might be the case.


N.C. Jacobson & M.G. Newman (2014) Avoidance mediates the relationship between anxiety and depression over a decade later. Journal of Anxiety Disorders. 28 (2014) 437-445.

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People with anxiety are more likely to develop depression

People with anxiety are more likely to develop depression

A central question that has been argued over for years in the anxiety - depression field is, are anxiety and depression linked and importantly does can anxiety lead to depression?

A study published in the journal Psychological Medicine recently helps to answer this issue. The research by scientists at the Departments of Psychiatry and Preventive Medicine, Rush University Medical Center, Chicago conducted a long term (12 years) analysis of the metal health of 425 women (278 Caucasian and 147 African American) women in america. The women were measured annually for symptoms of anxiety and depression to see if where any depression manifested itself, anxiety tended to be a precursor to the depression.

Firstly they found that women with anxiety were more likely to suffer from a major depressive disorder than those who did not suffer from anxiety in the first place. In fact they discovered that if you suffer from anxiety for a year you are almost 50% more likely to suffer from depression than people without anxiety. If you have already suffered from a bout of depression you are even more likely to suffer a recurring episode of depression.

The researchers recommend people with anxiety are closely monitored for signs of the onset of depression during the year. Obviously it would be better to treat the anxiety and reduce the chance of depression significantly.



Kravitz HM, Schott LL, Joffe H, Cyranowski JM, Bromberger JT (2014) Do anxiety symptoms predict major depressive disorder in midlife women? The Study of Women's Health Across the Nation (SWAN) Mental Health Study (MHS). Psychological Medicine [2014:1-10] DOI: 10.1017/S0033291714000075

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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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