 Dear colleagues, welcome to this sixth international conference on depression, anxiety and stress management, held in April 2019 in London. Apropos London, Three quarters of all British adults, adults in the United Kingdom, report being overwhelmed by stress and anxiety. One third of all British adults considered suicide the year before. A whopping one third of adults have suicidal ideation. 18% of all adults in the United States suffer from a diagnosable mental health illness. We could trace the sources of this mental health pandemic which centers around anxiety and stress. We could trace the sources, the etiology, to two reasons. One, it is difficult to be seen, it is difficult to be noticed because of the sheer numbers of the population and because of the fierce competition for attention. Being seen, being observed, being noticed is crucial for the regulation of one's emotions and cognitions. In the absence of the gaze of the other, we dysregulate and if dysregulation lasts a protracted period of time, it becomes a mental illness. In the past, we had social institutions dedicated to being seen, dedicated to observing the individual and thus regulating emotions, cognitions and behaviors. We had the family, we had communities, we had villages, we had neighbors. Today, all these institutions are defunded and have disintegrated. Today, in an atomized economic society, individuals have to fend for themselves and in order to attract attention, to attract the gaze of the other, this defining regulating feature of daily life, they have to resort to radical and extreme measures, exhibitionistic measures. This in itself creates a sense of unease, a dissonance which leads to anxiety and later on to depression. It's also very stressful. The second reason is social ranking or relative positioning. Everything from social media to the workplace encourage a competitive, ambitious environment. It accords with the efforts of Anglo-Saxon capitalism, the jungle mentality. The American dream turned an American nightmare is today a global nightmare. It's ubiquitous in every culture, in every society and it's a rat race. It encourages one to measure one's self-worth and to form an identity, to coalesce an identity around one's relative accomplishments. People keep comparing themselves to other people in order to establish the sense of identity and regulate the sense of self-worth which is comprised of self-esteem and self-confidence. This constant comparison, constant measuring against, fosters and engenders only negative emotions such as pathological envy. No wonder we have this pandemic of anxiety, stress and depression. Today I would like to discuss this phenomena, how they are diagnosed, sometimes misdiagnosed and how they are treated in therapeutic settings. But I think it would behoove us to start by defining anxiety. We tend to ignore the fact that anxiety is compulsive, it's uncontrollable. It is a form of excessive apprehension, a kind of unpleasant dysphoric mild fear but with no apparent external reason. Anxiety is drained in anticipation of a future menace, or in imminent but diffuse and unspecified danger. Usually this danger is imaginary, imagined or excessive, exaggerated. The mental state of anxiety and the concomitant hypervigilance, these have physiological complements. Anxiety is accompanied by shorter dysphoria and physical symptoms of stress and tension such as sweating, palpitations, tachycardia, hyperventilation, angina, tense muscle tone and elevated blood pressure. Together we can immediately identify this condition as arousal. It is common for anxiety disorders to include obsessive thoughts, compulsive and ritualistic acts, restlessness, fatigue, irritability and difficulty concentrating. Shift our gaze and let's look at another class of mental health disorders, personality disorders. Patients with personality disorders are often anxious. Narcissists for instance are preoccupied with the need to secure social affirmation, approval and attention, what is called collectively narcissistic supply. The narcissist needs narcissistic supply. He cannot control this need and the attendant anxiety because he requires external feedback to regulate his labile sense of self-worth. This dependence makes most narcissists irritable. They fly into rages and they have a very low threshold of boredom and frustration. So, subjects suffering from certain personality disorders, for example histrionic, borderline, narcissistic, avoidant or schizotypical personality disorders, these patients resemble very much patients who suffer from panic attacks and from social phobia, social phobia being of course another type of anxiety disorder. These patients are terrified of being embarrassed or criticized in public. Consequently, they fail to function well in various settings, social, occupational or interpersonal. So, anxiety disorders and especially generalized anxiety disorders, GAD, are often misdiagnosed as personality disorders. For example, narcissistic personality disorder. Let's consider this specific disorder as an example. Anxiety is uncontrollable and excessive appreciation. We also said that narcissists are anxious for social approval, etc. This conflation means that narcissists resemble very much patients who suffer from panic attacks and social phobia. Equally, narcissists are terrified of being embarrassed or being criticized in public. And most narcissists fail to function well in social settings, in various settings, like social, interpersonal. So, this is very common to narcissists and people with social phobia. The personality disorder patients often develop obsessions and compulsions. Exactly like sufferers of anxiety disorders, narcissists and people with obsessions and compulsions, both of these types are perfectionists. They are preoccupied with the quality of their performance and the level of their competence as judged by others. The Diagnostic and Statistical Manual describes generalized anxiety disorder patients, especially children, as typically overzealous in seeking approval and require excessive reassurance about their performance and their other worries. They sound suspiciously like narcissists. Narcissists could easily be described as typically overzealous in seeking approval and require excessive reassurance about performance. So, both narcissists and people with social phobia and narcissists and people with obsessive-compulsive personality disorder, both these sets of patients display a preoccupation with social feedback, with social approval, with affirming attention. Both classes of patients, those suffering from anxiety disorders and those tormented by personality disorders, are paralyzed by the fear of being judged as imperfect or lacking or inadequate or failures. Narcissists, as well as patients with anxiety disorders, constantly fail to measure up to an inner, harsh and sadistic critic and a grandiose, inflated ego-ideal or self-image. In my book Malignant Self-Love Narcissism Revisited, I have written the following in 1995. The narcissistic solution is to avoid comparison and competition altogether and to demand special treatment. The narcissist's sense of entitlement is incommensurate with the narcissist's true accomplishments, as we know. The narcissist withdraws from the rat race because he does not deem his opponents, colleagues or peers worthy of his efforts. As opposed to narcissists, patients with anxiety disorders are invested in their work and their profession. To be exact, they are over-invested. Their preoccupation with perfection is counterproductive and ironically renders them under achievers, considered for example procrastination. So this is the difference between narcissists and people with anxiety disorders. It is easy to mistake the presenting symptoms of certain anxiety disorders with pathological narcissism. Both types of patients are worried about social approbation and seek it actively. Both present a haughty or impervious facade to the world. Both are dysfunctional and weighed down by a history of personal failure on the job and in the family. But the narcissist is ecosyntonic, he is proud and happy of who he is. The anxious patient is distressed and is looking for help and away out of his or her predicament, hence the differential diagnosis. And now let's consider yet a third group of patients or clients. Abuse victims. Repeated abuse has long lasting pernicious and traumatic effects such as panic attacks, hypervigilance, sleep disturbances, flashbacks, intrusive memories, suicidal ideation and psychosomatic symptoms, conversion symptoms. The victims of abuse experience shame, depression, anxiety, embarrassment, guilt, humiliation, abandonment and an enhanced sense of vulnerability. Complex post-traumatic stress disorder, CPTSD, has been proposed as a new mental health diagnosis by Dr. Judith Herman of Harvard University to account for the impact of extended periods of trauma in abuse. In the articles talking and overview of the problem in the Canadian Journal of Psychiatry in 1998, authors Karen Abrams and Gail Ehrlich Robinson wrote the following. Initially there is often much denial by the victim. Over time, however, the stress begins to erode the victim's life and psychological brutalization ensues. Sometimes the victim develops an almost fatal resolve that inevitably one day she will be murdered. Victims unable to live a normal life, describe feeling stripped of self-worth and dignity, personal control and resources, psychosocial development, social support, pre-morbid personality traits and the severity of the stress may all influence how the victim experiences and responds to it. Victims stalked by ex-lovers may experience additional guilt and lowered self-esteem for perceived poor judgment in their relationship choices. Many victims become isolated and deprived of support when employers or friends withdraw, often also being subjected to harassment or are cut off by the victim in order to protect them. Other tangible consequences include financial losses from quitting jobs, moving and buying expensive security equipment in an attempt to gain privacy. Changing homes and jobs results in both material losses and loss of self-respect. I think it's very important to re-emphasize one of these points. Many victims become isolated and deprived of support when employers and friends withdraw, after also being subjected to harassment or when they are cut off by the victim in order to protect them. Surprisingly verbal, psychological and emotional abuse have the same effects exactly as the physical variety. See for example, Psychology Today, the September-October 2000 issue. Abuse of all kinds also interferes with the victim's ability to work. Abrams and Robinson describe this in the article Occupational Effects of Stoking in the Canadian Journal of Psychiatry in 2002. They wrote, Being stalked by a former partner may affect a victim's ability to work in three ways. First, the stalking behaviors often interfere directly with the ability to get to work, for example, flattening tires or other methods of preventing leaving the home. Second, the workplace may become an unsafe location if the offender decides to appear there. Third, the mental health effects of such trauma may result in forgetfulness, fatigue, lowered concentration and disorganization. These factors may lead to the loss of employment, with accompanying loss of income, security and status. Still, it is hard to generalize. Victims are not a uniform lot. In some cultures, abuse is commonplace and accepted as a legitimate mode of communication, sign of love and caring, actually, and a boost to the abuser's self-image. In such circumstances, the victim is likely to adopt the norms of society and avoid serious trauma. Deliberate, cord-blooded and premeditated torture has worse and longer lasting effects than abuse mated out by the abuser in rage and loss of self-control. The existence of a loving and accepting social support network is another mitigating factor. Finally, the ability to express negative emotions safely and to cope with them constructively is crucial to gilling. Typically, by the time the abuser reaches critical and overvasive proportions, the abuser had already, spider-like, isolated his victim from family, friends and colleagues. She is catapulted into a neverland, a cult-like setting where reality itself dissolves into a continuing nightmare. When she emerges on the other end of this warm ball, the abused woman, or more rarely men, feels helpless, self-doubting, worthless, stupid and a guilty failure for having botched her relationship and abandoned her family. In an effort to regain perspective and avoid embarrassment, the victim denies the abuse or minimizes it. No wonder that survivors of abuse tend to be clinically depressed, neglect their health and personal appearance and succumb to boredom, rage and impatience. Many end up abusing prescription drugs or drinking or otherwise behaving recklessly. Subvictims even develop post-traumatic stress disorder, as we mentioned. Contrary to popular misconceptions, post-traumatic stress disorder, PTSD and acute stress disorder or reaction are not typical responses to prolonged abuse. They are the outcomes of sudden exposure to severe or extremely stressful events. Yet some victims whose life or body have been directly and unequivocally threatened by an abuser react by developing these symptoms. Post-traumatic stress disorder is therefore typically associated with the aftermath of physical and sexual abuse in both children and adults. And this is why another mental health diagnosis, CPTSD, has been proposed, as I said, by Dr. Hermann of Harvard University. Once looming death, violation, personal injury or powerful pain are sufficient to provoke the behaviors, cognitions and emotions that together are known as CPTSD. Even learning about such mishaps may be enough to trigger massive anxiety responses. The first phase of PTSD involves incapacitating and overwhelming fear. The victim feels like she has been thrust into a nightmare or horror movie. She is rendered helpless by her own turf. She keeps relieving the experience through recurrent and intrusive visual and auditory hallucinations known as flashbacks or even dreams. In some flashbacks, the victim completely lapses into dissociative state and physically reenacts the event while being thoroughly oblivious to her whereabouts. In an attempt to suppress this constant playback, with the attendant exaggerated startled response, jumpiness, the victim tries to avoid or stimuli associated, however indirectly, with a traumatic event. Many victims develop full-scale phobias, agoraphobia, claustrophobia, fear of heights, aversion to specific animals, objects, modes of transportation, neighborhoods, buildings, occupations, weather events and so on. Most PTSD victims are especially vulnerable on the anniversaries of their abuse. They try to avoid thoughts, feelings, conversations, activities, situations, or people who remind them of the traumatic occurrence, triggers. These constant hypervigilance and arousal, sleep disorders, mainly insomnia, the irritability short-fuse and the inability to concentrate and complete even relatively simple tasks, erodes the victim's resilience. Artically fatigued, most patients manifest protracted period of numbness, automatism, and in radical cases, near-catatonic posture. Response times to verbal cues increases dramatically. Awareness of the environment decreases, sometimes dangerously so. The victims are described by their nearest and dearest as zombies, machines, robots or automata. The victims appear to be sleepwalking, depressed, disforing, unhedoning, not interested in anything, find pleasure in nothing. The victims report feeling detached, emotionally absent, estranged, and alienated. Many victims say that their life is over, and expect to have no career, family, or otherwise meaningful future. The victims' family and friends complain that she is no longer capable of showing intimacy, tenderness, compassion, empathy, and of having sex due to her post-traumatic so-called fragility, hyposexuality. Many victims become paranoid, impulsive, reckless and self-destructive. Other victims somatize or convert their mental problems and complain of numerous physical ailments. They all feel guilty, shameful, humiliated, desperate, hopeless, and hostile. CPTSD does not need to appear immediately after the harrowing experience. It can, and often is, delayed by days or even months. It lasts more than one month, usually much longer. Sufferers of PTSD report subjective distress. The manifestations of PTSD are ecodistonic. They're functioning in various settings, job performance, grades at school, sociability, deteriorates, marketing. The diagnostic and statistical manual criteria for diagnosing PTSD are far too restrictive. PTSD seems to also develop in the wake of verbal and emotional abuse, and in the aftermath of drawn-out, traumatic situations such as a nasty divorce. Hopefully the text will be adopted to reflect this sad reality. But what about therapy? What's the role of therapy? Victims of abuse in all its forms, verbal, emotional, financial, physical, legal, sexual, are often disoriented. They require not only therapy to heal their emotional wounds, but also practical guidance and topical education. At first, the victim is naturally distrustful, even hostile. The therapist or caseworker must establish a rapport, confidence, painstakingly, patiently. The Therapeutic Alliance requires constant reassurance that the environment and treatment modalities chosen are safe and supporting. This is not easy to do, partly because of the objective factors such as the fact that the records and notes of the therapist are not confidential, and partly because the offender can force their disclosure in a court of law simply by filing a civil lawsuit against a survivor. The first task, therefore, is to legitimize and validate the victim's fears. This is done by making clear to her that she is not responsible for her abuse or guilty for what has happened. Victimization is the abuser's fault. It is not the victim's choice. Victims do not seek abuse, although admittedly some of them keep finding abusive partners and keep forming relationships of co-dependence within comfort zones. Facing, reconstructing and reframing the traumatic experiences is a crucial and indispensable first phase. The therapist should present the victim with her own ambivalence and the ambiguity of her message. But this ought to be done gently, non-judgmentally and without condemnation. The more willing and able the abused survivor is to conform to reality of her mistreatment and the offender, the stronger she would feel and the less guilty. Typically, the patient's helplessness decreases together with her self-denial, her self-esteem as well as her sense of self-worth, stabilized. The therapist should emphasize the survivor's strength and demonstrate how they can save her from a recurrence of the abuse or help her cope with it and with her abuser. Education is an important, crucial tool in this process of recovery. The patient should be made aware of the prevalence and nature of violence against women and of stalking. Of the emotional and physical effects of the warning signs, red flags, legal redress, coping strategies, safety precautions, everything she needs to walk, she needs to be taught. The therapist or social worker should provide the victim with lists of contacts, health organizations, law enforcement agencies, other women in her condition, domestic violence shelters and victim support groups both online and in her neighborhood or city. Knowledge empowers and reduces the victim's sense of isolation and homelessness. Helping the survivor regain control of her life is the overriding goal of the entire therapeutic process. With this aim in mind, she should be encouraged to re-establish contact with family, friends, colleagues and the community at large. The importance of a tightly niche social support network cannot be exaggerated. She needs to weave herself back into the social fabric. Ideally, after a period of combined tutoring, talk therapy and anti-exiety or anti-depressant medications were needed, the survivor will self-mobilize. She will emerge from the experience more resilient and assertive and less gullible and self-deprecating. And so, this is the idea, but therapy is not always a smooth ride. Victims of abuse are saddled with emotional baggage, which often provokes, even in the most experienced therapists, reactions of helplessness, rage, fear and guilt. Counter-transference is common. Therapists of both genders identify with the victim and resent her for making them feel impotent and inadequate, for instance, in their role as social protectors. Reportedly, to fend off anxiety and a sense of vulnerability, the therapist tells himself it could have been me sitting here. So, to fend off this anxiety and a sense of vulnerability, female therapists, usually involuntarily blame the spineless victim and her poor judgment for causing the abuse they tend to re-victimize or pathologize the victim. Some female therapists concentrate on the victim's childhood rather than her harrowing present and accuse her of overreacting or provoking the abuse via, for example, projective identification. Male therapists, on the other hand, may assume the mantle of the chivalrous rescuer, the knight in the shining armor, thus inadvertently upholding the victim's view of herself as a mature, childlike, helpless in need of protection, vulnerable, weak and ignorant. The male therapist may be driven to prove to the victim that not all men are animals and that they are good men like himself. If he is conscious or unconscious, overtures are rejected, the therapist may identify with the abuser and re-victimize or pathologize his patients. Many therapists tend to over-identify with the victim and rage at the abuser, at the police, at the system. They expect the victim to be equally aggressive, even as they broadcast to her how powerless, unjustly treated and discriminated against, she is. So, this is a mixed signal, a mixed message. If she fails to externalize aggression and show assertiveness, they feel betrayed and disappointed, they feel that they had failed. Most therapists reacting patiently to the victim's perceived co-dependence, clingy, unclear messages and on-off relationship with her tormentor. Such rejection by the therapist may lead to a premature termination of the therapy, well before the victim has learned how to process anger and cope with her low self-esteem and learned helplessness. And finally, there is the issue of personal security. Some ex-lovers and ex-pousers are paranoid stalkers, you know, erotomaniacs for example, and therefore dangerous. The therapist may even be required to testify against the offender in a court of law. Therapists are human, well, most of them, and they fear for their own safety and the security of their loved ones. This affects their ability to help the victim. This is not to say that therapy invariably fails. On the contrary, most therapeutic alliances succeed to teach the victim to accept and to transform her negative emotions into positive energy, and to competently draw and implement realistic plans of action while avoiding the pitfalls of the past. Good therapy is empowering, restores the victim's sense of control over her life. At this stage, the only tools we have against this tsunami of anxiety and depression are talk therapy, the human connection, even if it is a both human connection, and some medications who are, in the best of cases, controversial. We are not equipped to deal with this emerging, dangerous, life-threatening type of disorders, partly because we tend to conflate and confuse, and partly because our therapeutic tools are so limited. It's time to wake up to this crisis of unprecedented proportions. Thank you for listening.