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July 2011 Ask the Expert: Anxiety and Depression

During the month of July, Living Beyond Breast Cancer expert Drucilla Brethwaite, MSW, LCSW, OSW-C, answered your questions about how to cope with the complex emotions you may feel after receiving a breast cancer diagnosis and after completing treatment for breast cancer, or if you are at high risk for breast cancer.

You may also be interested in Metastatic Breast Cancer: Facing Feelings and Fears.

I was diagnosed in November 2010 with invasive lobular carcinoma. On my mother’s side of the family cancer runs rampant, but I am the first [to be diagnosed] with breast cancer. Because of this, and the fact that cancer is NEVER a good thing, I am constantly consumed with the fear that cancer is going to kill me. How do I get/find a different mindset, considering how much of a worrier I am?

EVERYONE has at least one deep-seated fear that wakes them up at night drenched in sweat, [one] that is such a tremendous fear that you try as hard as you can NOT to think about it because it’s that bad!!! I’m not afraid of the actual dying part, but I’m SCARED TO THE CORE of the being dead part—always have been!!!!!! I could never quite put my finger on it, but talking about it one day with a friend, she actually put it into words that I could never find, and it explains it perfectly—I WILL NO LONGER EXIST!!!!! The thought that my family, the world, will go on without me there to experience things has just never sat well with me, especially not being with my family anymore. No, I don’t consider myself special as to never die, cause that just ain’t gonna happen. No one gets to pick and choose their fears, and that one is mine. How do I deal with that?

I was diagnosed with inflammatory breast cancer in February 2009. I finished treatment and have made some major changes in my lifestyle since then—improved my diet and added exercise and 10 minutes of meditation daily. I still am so afraid of recurrence. I don't know how to deal with these fears. I want to see my youngest daughter married and want to be around for grandchildren. I have planned a trip to Europe next spring, but am so very afraid something will happen before then. How can I deal with these fears; is it harmful to me to worry so much about these things? I struggle very hard to move forward in my life, but find myself returning to these fears.

Post diagnosis (02/11, bilateral mastectomy, 05/11) and with ongoing treatment with aromatase inhibitors, I sometimes find myself feeling normal, only to be yanked back (almost as though I am on a morbidity/mortality leash) and gripped by uncontrollable terror and helplessness. I then isolate myself. Is this normal, and what would you advise?

I spend every night scouring medical journals. I am not innumerate, but I believe that I am relentlessly looking for statistical hope that is, of course, on an individual basis, absurd. I then become an irrational believer in bad luck. Any advice?

My medical oncologist stressed that the vast majority of metastases were discovered by a physician on follow-up exams, and then, too, there was very little one could do beyond palliation. There seemed to be no reason to discover this progression early, as little or nothing could be done. This grim truth plunges me further into depression. Any tips on combating this? (Oh, other than massive drugs.)

I’m still experiencing considerable anxiety leading up to my yearly follow-up exams, and this summer will be 5 years since my initial diagnosis. Is this normal? I mentioned this to my doctor and he prescribed anti-anxiety medication for just 2 days prior to my appointment, which does help. Is this something I should continue to do, or are there other ways to help relieve my anxiety?

I am taking anastrozole (Arimidex), and changes in my daily life, such as a vacation trip or a road trip for the weekend, cause me great anxiety. These are kinds of things I have done my whole life, and now I can't enjoy them. What can I do to tell myself that it is ok to have a little fun?

I was diagnosed in 2008 with stage I invasive cancer. I had an oncotype score of 21 and chose to have chemo and a double mastectomy. I came through okay, but lately I am backsliding. I have gained 50 pounds, and I can’t seem to find a healthier way to cope with stress. I am very nervous about my three- year anniversary for some reason. And instead of staying on course, I am eating Big Macs and tempting fate. I do not know how to get back on track. How do you trust in that there will be a future and thus make good choices?

I underwent surgery and radiation for stage I breast cancer and am now taking arimidex (Anastrozole). It has been 7 months since my surgery. I am angry and anxious most of the time unless I am drinking alcohol. How to get better?

What can do I cope with fear of recurrrence? I am having a lot of anxiety right now.

Question: I was diagnosed in November 2010 with invasive lobular carcinoma. On my mother’s side of the family cancer runs rampant, but I am the first [to be diagnosed] with breast cancer. Because of this, and the fact that cancer is NEVER a good thing, I am constantly consumed with the fear that cancer is going to kill me. How do I get/find a different mindset, considering how much of a worrier I am?

Ms. Brethwaite: Worry can at times be beneficial as it enables us to be more vigilant or motivates us to be better prepared to keep us safe. However, the unpredictable nature of cancer can result in excessive worry which can affect quality of life and impair effective decision making, adherence to treatment and/or day to day functioning.

From a physiological, brain-based, cognitive approach, consider that your amygdala, located in the middle of your brain, is appraising a thought, word or string of words as a threat and activating the sympathetic nervous system. This causes an emotional reaction of fear and the release of a number of stress hormones that cause physiological responses such as perspiration, increased blood pressure and heart rate, muscle tension and impaired cognition.

There are many techniques available--that take practice--which can mediate the sympathetic nervous system response. Meditation, even if it is a simple breathing practice or progressive muscle relaxation, can reduce the heart rate and muscle tension. Making a list of your strengths using affirmations such as “I am getting good medical care” or “I believe in the future and plan for it,” or imagery such as imagining a pleasant or safe place, can also relieve distress, provide a sense of well-being and build resiliency.

Question: EVERYONE has at least one deep-seated fear that wakes them up at night drenched in sweat, [one] that is such a tremendous fear that you try as hard as you can NOT to think about it because it’s that bad!!! I’m not afraid of the actual dying part, but I’m SCARED TO THE CORE of the being dead part—always have been!!!!!! I could never quite put my finger on it, but talking about it one day with a friend, she actually put it into words that I could never find, and it explains it perfectly—I WILL NO LONGER EXIST!!!!! The thought that my family, the world, will go on without me there to experience things has just never sat well with me, especially not being with my family anymore. No, I don’t consider myself special as to never die, cause that just ain’t gonna happen. No one gets to pick and choose their fears, and that one is mine. How do I deal with that?

Ms. Brethwaite: Your question puts you in the company of great philosophers, theologians and songwriters who have struggled with this concept throughout the ages. As these kinds of thoughts can have a way of blocking you from living your life, I would like to offer two comments.

One of my favorite life philosophies is, “We are all who we meet.” Meaning that with every encounter with one another, we each take something away...we are changed...even if in a most insignificant way. My guess is that you have touched the lives of countless people, some of whom you are not even aware. Engaging in some storytelling of your life, not necessarily your trauma story, can be a way of understanding the purpose and meaning your presence has in this life and after. Taking pen to paper and rereading your words out loud uses additional areas of the brain that can reinforce your sense of existence.

My other comment is to manage distressing thoughts by engaging in a mindfulness practice. Find a quiet place, settle in, begin to breathe deeply and focus on your breath. As each thought comes, acknowledge it and then without judgment, let it go and return to your breath.

Question: I was diagnosed with inflammatory breast cancer in February 2009. I finished treatment and have made some major changes in my lifestyle since then—improved my diet and added exercise and 10 minutes of meditation daily. I still am so afraid of recurrence. I don't know how to deal with these fears. I want to see my youngest daughter married and want to be around for grandchildren. I have planned a trip to Europe next spring, but am so very afraid something will happen before then. How can I deal with these fears; is it harmful to me to worry so much about these things? I struggle very hard to move forward in my life, but find myself returning to these fears.

Ms. Brethwaite: A breast cancer diagnosis can challenge one’s assumptions about life and make one feel less safe or secure. For many women, fears of recurrence tend to ebb and flow. I would be interested in your description of what “so afraid of recurrence” and “worry so much” looks like? How is it affecting your day-to-day functioning? How does your meditation practice and exercise help when you have thoughts that make you fearful?

It seems like you are doing a great job at moving forward with your life. You have changed your lifestyle, are engaged with family and set goals ... wedding, grandchildren, Europe ... how wonderful!

It might be helpful to make a list of your short-term goals (and yes, include some that you have already accomplished), mid-range goals and long-term goals. When you find yourself “returning to these fears,” acknowledge the fears and then try reviewing your accomplishments, including all the steps you have taken, as this might make you feel more secure in your life.

Questions: Post diagnosis (02/11, bilateral mastectomy, 05/11) and with ongoing treatment with aromatase inhibitors, I sometimes find myself feeling normal, only to be yanked back (almost as though I am on a morbidity/mortality leash) and gripped by uncontrollable terror and helplessness. I then isolate myself. Is this normal, and what would you advise?

I spend every night scouring medical journals. I am not innumerate, but I believe that I am relentlessly looking for statistical hope that is, of course, on an individual basis, absurd. I then become an irrational believer in bad luck. Any advice?

My medical oncologist stressed that the vast majority of metastases were discovered by a physician on follow-up exams, and then, too, there was very little one could do beyond palliation. There seemed to be no reason to discover this progression early, as little or nothing could be done. This grim truth plunges me further into depression. Any tips on combating this? (Oh, other than massive drugs.)

Ms. Brethwaite: I like your sense of humor and your style of expression ... you obviously are a resilient lady considering you are only a few months out from the initial onslaught of this disease.

So what makes you so resilient? Besides your humor and gift for writing, you obviously are an information seeker; you have great insight and personal assessment skills. The behaviors and emotions you describe sound fairly typical, so let me offer a few concrete ideas that you might want to explore to see what might work for you.

As long as it is not prolonged, isolation can be an opportunity to center yourself and reduce the number of stimuli that can increase anxiety. A key piece here is to have a practice to center yourself, such as using breath work, meditation or journaling. These kinds of activities can calm the amygdala, that fear center in the brain, and activate the parasympathetic nervous system, the rest and digest state.

Later, when you are experiencing a relaxation response and you are better able to process cognitively, think about what the thoughts may be that are triggering you to scour those medical journals. What besides statistics says “future” to you? Make a wellness plan: When was the last time you did something for the first time? Answer the question, “I need…”

The numbers of cancer survivors are growing. A “Survivorship Care Plan” (many institutions and organizations offer them), which is recommended by the Institute of Medicine, may also enable you to feel more confident as it provides guidelines for monitoring and maintaining health. Make sure you select a plan that has both a medical and psychosocial section.

Question: I’m still experiencing considerable anxiety leading up to my yearly follow-up exams, and this summer will be 5 years since my initial diagnosis. Is this normal? I mentioned this to my doctor and he prescribed anti-anxiety medication for just 2 days prior to my appointment, which does help. Is this something I should continue to do, or are there other ways to help relieve my anxiety?

Ms. Brethwaite: Triggers for anxiety come in many forms (dates, places, smells) and in varying degrees of intensity and frequency. Some individuals use distraction or mind-body techniques to tolerate these uncomfortable feelings as they know they will pass. However, sometimes patterns are built up that can make a trigger more distressing and less tolerable which may motivate an individual to seek a counselor who can help reframe or restructure the thoughts.

In your particular situation, you have already demonstrated very effective problem-solving skills. You identified the issue and sought advice from a trusted professional, and the suggested solution works. As you have found, medication for these kinds of limited triggers can be very effective.

Question: I am taking anastrozole (Arimidex), and changes in my daily life, such as a vacation trip or a road trip for the weekend, cause me great anxiety. These are kinds of things I have done my whole life, and now I can't enjoy them. What can I do to tell myself that it is ok to have a little fun?

Ms. Brethwaite: Anxiety is a common theme for women diagnosed with breast cancer. What does your personal anxiety look like? What are the thoughts that activate your amygdala, the fear center in your brain? Thoughts such as, “If I make plans, I might get sick and then I would lose my deposit or family and friends would be mad at me” or “If I go, I might get sick and not have access to care.” Sometimes you may use avoidance to suppress the fear of being placed in a potentially unpredictable situation—the “what ifs.”

You sound like someone who engaged in life and had an adventurous spirit. It can be difficult to deny your nature. One strategy might be to list all the steps necessary to achieve a goal—that is, ALL the discrete steps, not just “call and make a reservation.” List those “what ifs” and write down a plan A and a plan B to address them, should they occur. Having a plan in place often reduces anxiety that blocks us from engaging in life.

Question: I was diagnosed in 2008 with stage I invasive cancer. I had an oncotype score of 21 and chose to have chemo and a double mastectomy. I came through okay, but lately I am backsliding. I have gained 50 pounds, and I can’t seem to find a healthier way to cope with stress. I am very nervous about my three- year anniversary for some reason. And instead of staying on course, I am eating Big Macs and tempting fate. I do not know how to get back on track. How do you trust in that there will be a future and thus make good choices?

Ms. Brethwaite: Backsliding can offer us a renewed perspective on what is important to us, and we all engage in behaviors that are not always healthy. It takes an individual with self-confidence to admit it and a motivated one to make the necessary changes to get back on track.

Backsliding is part of being human. Sounds like you had some good skills that got you through those first 3 years—can you identify what they were? A survivorship care plan could be a good tool for you to track where you are physically, emotionally and spiritually, where you want to be in the future and strategies to reach those goals, making you feel more in control.

Question: I underwent surgery and radiation for stage I breast cancer and am now taking arimidex (Anastrozole). It has been 7 months since my surgery. I am angry and anxious most of the time unless I am drinking alcohol. How to get better?

Ms. Brethwaite: Most everyone has engaged in behavior in order not to “feel” at some point. Alcohol is often the drug of choice because with initial use, it is great at temporarily reducing anxiety. However, keep in mind that with prolonged use alcohol can make anxiety worse.

Anxiety is a normal reaction characterized by such things as tensing of muscles; shallow, increased respiration; feelings of fear or dread and impaired cognition. Anger is a trigger emotion. It is a cue to alert us that we are being overwhelmed. It can push us into action. What would it be like to experience those sensations without numbing yourself?

There are a lot of tools available to help you cope with stress and behaviors that are not in your best interest. Cognitive behavioral and mind-body techniques have been shown to be particularly effective for managing both anxiety and anger so you are able to engage in more productive problem solving.

My other comment is related to how to get better. How do you define that state, and what does it mean to you? Understanding your expectation in regard to “getting better” might also help minimize the anxiety and anger that you are experiencing.

Question: What can do I cope with fear of recurrrence? I am having a lot of anxiety right now.

Ms. Brethwaite: Connecting to others in a similar situation is a common strategy that women use when they are diagnosed with breast cancer. Sharing stories and possible approaches to manage the physical and emotional aspects of being a survivor are often the most powerful. You have found an incredible link to others at lbbc.org—-how can you continue to use LBBC resources and others in your community to identify tools to better manage your fears?

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