Return to Anxiey and Panic Disorder

Return to Anxiety-Relieving Techniques

Why We Have Generalized Anxiety and Panic Disorder and What We Can Do About It



Dennis B. Kottler, MD



This is the third part in a series looking at major health concerns that affect our society in epidemic proportions.  The current monograph deals with the epidemics of Generalized Anxiety Disorder as well as Panic Disorder, in adults, and offers practical suggestions to combat these major health threats.  Innovative self-treatment approaches are discussed that have proven effective in large numbers of people.    It is hoped that many individuals with these disorders will find this monograph of major help.


What is “Normal?”

Before launching into the discussion of anxiety, as a disorder, it is helpful to consider what is meant by “normal.”  The concept of normal is problematic in the case of many  behavioral as well as physical attributes.  Is a little anxiety normal?  How little?  What about a little obesity?  How do we view slightly elevated blood pressure?   In each of these cases, and many more we could think of, there is probably no precise cut-off.     For practical reasons we often assign a somewhat arbitrary value to the upper limit of “normal” (at least in things we can measure).   Beyond this arbitrary point, quality of life might increasingly suffer or longevity might diminish.    But then again, we could be difficult and ask, “What is normal quality of life or longevity.”   The point here is that most biological traits exist on a continuum, including such behavioral traits as anxiety.  In the total absence of any anxiety, one is probably brain dead.  Extreme anxiety and one is probably functioning well below his potential.   Even in the case of Panic Disorder (see below) some “normal” individuals have some of the symptoms of this disorder occasionally.   Again a continuum exists.   Perhaps a more utilitarian approach than “normal versus abnormal” would be to look at the disorder from the viewpoint of how much distress and impairment of function it causes to the individual, with the goal to maximize function and minimize discomfort.  With this mind, we are ready for launch.


Anxiety:   What is It and Where Does It Come From?

Anxiety in the lay sense may connote just plain “nervousness,” or apprehension about a coming event, such as taking the college boards, getting married, or having a meeting with your boss to discuss your performance.  Most of us can relate to these feelings, which are usually appropriate to the situation.   In the clinical sense, however,  anxiety becomes excessive and “abnormal,” in the sense described above, where there is unwelcome interference with quality of life and daily functioning. 

It is useful to think of anxiety as having a “cognitive,” or thought component, an “emotional” component, and a “somatic,” or physical component.  One or all of these elements may be present to varying degrees.  The “cognitive” component is usually manifest as excessive worry and apprehension.  The emotional component may be experienced as dread or fear or hyper-vigilance.  The somatic component may be manifest in a large array of physical changes, such as increased heart rate, blood pressure, stomach and bowel activity, muscle tension, and  sweating.  There may be a decrease in skin temperature, particularly in the hands and feet (cold feet), and the face may look pale.  These physical reactions, along with the hyper-vigilance, are part of the famous “fight or flight” response we all possess from caveman days.   In those days, it was of great survival value to gear up for a fight or to be able to exit as fast as possible, when the lion was staring you down.   Nowadays, this response may have some value in gearing up for an important test, as long as the response is not too intense, or perhaps to prime the body for a 300 yard dash. 

The problem is we are often “hyped up” in this “fight or flight” response for no useful purpose.   Perhaps some of us are genetically endowed with a stronger “fight or flight” reaction or a more sensitive trigger mechanism.  Perhaps the increasing information and media overload, in which we are exposed to all varieties of extremely distressing news, contributes to activating this mechanism.   Perhaps the problem lies somewhere as yet undiscovered.   Maybe the caveman was equally anxious.    Whatever the causation, anxiety remains a major mental health concern for many millions of Americans


Anxiety Disorders:  The Many Different Types

There are several different types of anxiety disorders.  A correct identification of the problem results in the most appropriate treatment.   It is recommended that a psychiatrist perform the initial assessment to make an accurate diagnosis.  Also this physician may suggest an evaluation by an internist or family practitioner to rule out physical causes of the problem.  

Two of the most common forms of anxiety are Generalized Anxiety Disorder (GAD) and Panic Disorder (PD).   These two conditions can coexist, or exist alone in a given individual.  Although the focus of this current monograph will be Generalized Anxiety Disorder and Panic Disorder, it should be recognized that there are many other disorders that fall under the heading of “anxiety.”  These include Specific Phobias, Social Phobias, Obsessive Compulsive Disorder, Posttraumatic Stress Disorder, and Acute Stress Disorder.   Some of these disorders will be addressed in future monographs.


Description of Generalized Anxiety Disorder

Generalized Anxiety Disorder (GAD) can be thought of as a chronic condition of persistent worry, usually involving cognitive, emotional, and somatic symptoms.  The cognitive (thought) symptoms include repeated rumination and worry and difficulty concentrating.  The emotional symptoms include feelings of dread, often not related to a particular event, a vague sense of uneasiness, and sometimes other difficult to describe sensations.   Some people describe these sensations as, “its like jumping out of my skin,” “my head is going to explode,” or “I feel wired.”  Other descriptors include feeling  “tense,” “tight,” “edgy,” or “irritable.” 

The more somatic symptoms of Generalized Anxiety Disorder can include chronic fatigue, headaches, muscle aches, back pain, hot flashes, nausea, diarrhea, abdominal pain, chest tightness, shortness of breath, a “lump” or “tightness” in the throat or neck, rapid heartbeat with or without palpitations (the sensation of feeling the heart beating), frequent urination, exaggerated startle response, shakes and tremors.  A person may have any combination of these symptoms.  Many times the symptoms convince the individual that he must have a physical illness and sometimes repeated medical consultation is sought. 

Generalized Anxiety Disorder is by definition a chronic problem lasting at least six months and occurring more days than not.  If the above symptoms are transient, the condition is more often an acute response to a disturbing event and not Generalized Anxiety Disorder. 


Additional Features of Generalized Anxiety Disorder

In Generalized Anxiety Disorder a stressful event may seem to trigger the anxiety, but the reaction is excessive and continues in a chronic state (greater than six months).   The worry may revolve around everyday life responsibilities, such as job performance, finances, household chores, or taking care of children, but again it is beyond that experienced by the average person in similar circumstances, and it impacts quality of life.

It is important to rule out other causes of  “anxiety” symptoms such as hyperthyroidism, seizure disorder, familial tremor, prescription drug side effects, excessive caffeine use, alcohol abuse, and the effects of various other psychoactive substances.  It is also important to rule out other mental disorders which can present with anxiety symptoms, such as obsessive compulsive disorder or posttraumatic stress disorder, depression, or even psychotic disturbances.   Again medical consultation is necessary.


Demographics of Generalized Anxiety Disorder (the last stop before treatment)

Generalized Anxiety Disorder occurs in both adults and children.  It is generally thought to be somewhat more prevalent in women, perhaps 60% in females to 40% in males, although this figure may be inaccurate, since women may be more open about admitting their symptoms.  Also, in some cultures people openly display their anxiety; in other more reserved cultures, the anxiety may be more manifest as somatic symptoms or internalized as an almost purely cognitive experience, with little obvious emotional component. 

It is extremely difficult to estimate the prevalence of Generalized Anxiety Disorder although it probably is in excess of 5%, involving perhaps 15 million or more Americans!  The disorder is generally chronic, over most of one’s life, if left untreated.   It often begins in childhood, but may also first appear in adulthood.  It is unclear what if any genetic factors are at work, although this disorder, like many psychiatric disorders, seems to concentrate in certain families more than others.   Although environmental factors can aggravate Generalized Anxiety Disorder there also seems to be a neurochemical basis for this disorder.  Some experts have postulated that abnormalities in serotonin availability in the brain may be part of the cause of GAD, other investigators have looked at other neurotransmitters (chemicals that facilitate neural activity in the brain) as being involved.


Treatment Options

The available treatments for Generalized Anxiety Disorder involve techniques that one can apply oneself.   There are also professionally guided treatments available.  The latter include medication and behavioral and cognitive therapy approaches. 

Some of the treatments for GAD also apply to Panic Disorder although there are also important differences related to the nature of the disorder.  Generalized Anxiety Disorder is generally a chronic, less acute disorder, while Panic Disorder (see below) is characterized by very acute episodes of severe anxiety which escalate very rapidly, in minutes or even seconds, and the attack usually resolves in a short time.   


Self-help Step #1 – EDUCATION

Once one is convinced he is suffering from Generalized Anxiety Disorder (and this may require medical consultation to rule out other disorders), the first step is to become thoroughly familiar with the nature of this disorder.  Hopefully what you are reading will help to fulfill this requirement.  The purpose of education in this case (besides the desire to be well-informed in general) is to demystify the disorder and realize that “you are not alone.”   There is usually great solace in this realization.   Solace is a major antidote to anxiety, so you are already well on your way to fighting this problem.  Of course some people may choose to seek their “education” from a healthcare professional rather than obtaining it on their own.   It doesn’t matter which route is pursued as long as the source is reliable. 


Self-help Step #2 – “TEACHING”

Once you have a clear understanding of the disorder, you might elect to share your information with other sufferers.   In this “teaching” you will experience a sense of  “control and mastery” of the problem.  This makes the whole business of anxiety less threatening.    After all, if  I can both understand this problem and inform others about it, I must have a pretty good “handle” on it.  This may not sound like it helps much, but it does.  In fact, this technique of  “educate yourself and inform others,” helps a very wide range of psychiatric disorders.   

Many support groups that get together to deal with psychiatric issues are led by people who have these problems themselves.  The group leaders (or facilitators) derive a sense of empowerment over their problem by being in this leadership role.  Many such groups rotate the leader (or facilitator) so that everyone has a turn to benefit from this experience.

For those not wanting to be part of a live group, there are endless, internet chat groups which address psychiatric problems, including anxiety.  Some of these are quite good and some are quite poor (like many things on the “net”).  Of course attending a support group, “in real life,” is preferable.  (Especially on the net, always be wary of misinformation; check many sources).

(A skippable anecdote follows which, however, illustrates the value of education and “teaching” in extreme form): 

 I am reminded of a very successful psychiatrist I once knew.  He suffered from severe social phobia (severe anxiety when in a social situation, especially when  performing before other people).  This individual, in fact, dropped out of medical school in the first year because he trembled and “froze” when called upon by the professor to answer a question before the class.    However, this individual did not give up and become an internet billionaire.  No, he still wanted to become a physician, social phobia notwithstanding.  This young man educated himself thoroughly about social phobia, reading everything he could get his hands on in the library (this was before the internet).   When he was suitably armed with knowledge he plotted his next step.  He joined Toastmasters to confront his fear and delivered a speech or two, on social phobia, no less.   So far, he had followed steps one and two.   He learned and then he taught.   After a while he was feeling pretty good about this social phobia business, in fact he prided himself on being an expert of sorts.   With this renewed confidence, he announced to all his friends and anyone else who would listen that he would be giving a “talk” on social phobia at the next meeting in the community room of the local hospital.  He had flyers printed (and this was before desktop printing) announcing the “talk.”  He made everything look very professional.  The flyer urged others with similar anxiety problems to attend the meeting.

On the day of the meeting there was, in fact, a huge crowd.  The young man assumed that many of these people had similar anxiety problems, hence their attendance.  How could he look and feel foolish, he decided, when most of the audience was in worse shape than he was.   (This is probably part of the reason some of us become psychologists and psychiatrists).   The speech was an incredible success.    Some initial anxiety gave way to a free flow of information; he really got into it.  He got a standing ovation.   Others in the audience who would admit to anxiety problems were invited to share their experiences with the room.  Many people volunteered and did surprisingly well in talking before the large group.  Many people heard about this event and contacted this “social-phobic-turned-educator” to learn how he had managed to overcome his anxiety so well.

This young man eventually went on to finish medical school, and he is now a very successful psychiatrist whose favorite professional activity is forensic psychiatry and especially making court room appearances!

Educate yourself and then spread your knowledge.  It works.


Self-help Step #3 –  THE RIGHT TOOLS

Tools, of course, are essential for accomplishing almost anything.   The tools in this case, overcoming Generalized Anxiety Disorder,  consist of such things as:


A steady diet of self-reassurance

Relaxation exercises

Self-Guided imagery

Yoga stretching exercises

Proper sleep (see e-matter monograph “Why We Can’t Sleep and What We Can Do  

            About It”)

Proper diet, avoiding caffeine and other stimulants

A support group or suitable internet chat group

A supportive family or friends (find one or create it out of what you have)


Self-reassurance, seemingly obvious, is often neglected.  You must remind yourself to remind yourself that the anxiety will diminish with time if all of the other techniques are followed.  This self-reassurance itself, of course, is a major part of diminishing the anxiety. 

Relaxation exercises should be tailored to the individual.   Some exercises work better for some people than others; some exercises might actually create anxiety.  It is trial and error to see what works best.   These exercises include muscle relaxation activities such as “tense and relax.”    In “tense and relax” the individual plans a series of exercises starting usually at the head and working down to the toes.  For each muscle group under voluntary control, one first tenses that muscle (or group of muscles, since some muscles work together), holds the tension for a few seconds and concentrates on that sensation, then slowly releases the tension, so that the muscle(s) is as relaxed as possible.   With practice the degree of muscle relaxation will increase.  One might start, for example, with the brow (knitting it tightly for a few seconds and releasing), then the lower face (tight pursing of lips), then the neck muscles, then raising the shoulders, then the same with the arms (all muscle groups), then fists, then abdomen, then buttocks, then thighs, then calves, then shins, and finally toes.  It is very helpful to practice this several times a day during a convenient time. 

Along with this muscle relaxation it is helpful to periodically “scan”  the various muscles, from head to toe, to search out any muscles that have tensed up, and to do a “tense and relax” on them.  Over a period of several weeks, the muscles will achieve a more relaxed resting state and, at the same time, improved muscle conditioning will result from the tensing phase of the exercise. 

Another extremely important relaxation exercise involves breathing.   In the typical breathing exercise one concentrates on taking in a deep breath, holding it for a few seconds, and then very slowing exhaling through pursed lips, maybe to a slow count of 5.   During this breathing  exercise it is important to do abdominal breathing, like a baby does (it hasn’t gotten anxious yet) versus the usual chest breathing we customarily do as adults.  To make sure you are doing abdominal breathing, place a hand on the abdomen and feel the abdomen balloon out on the inhalation and sink back in on the slow exhalation.  Keep the hand there for several repetitions of the breathing.  It is a good idea to practice this breathing exercise several times a day, whether feeling anxious or not.  It is good anxiety prevention as well as treatment when one is feeling anxious.   Be careful not to hyperventilate.  This will be prevented by breathing slowly, taking a longer time to exhale than to inhale.  As you exhale, imagine the tension leaving the body with the departing breath.  Do several of these slow breathes in a series.   It works.

In another form of relaxation technique, take yourself on a mental journey to someplace where the air is pure, the weather is beautiful, there is no electricity, etc.  You get the idea.    This imaginary scene is highly personal.  Some people can actually smell the surf as well as see the beach, if that is where you choose to go.  What is quite relaxing for one individual could trigger anxiety in another.  Experiment with different “mental vacations.”  Spend several minutes a day in these retreats.

 Another form of self-guided imagery involves feeling sensations in your body as opposed to the more visual images described previously.   In one such exercise, the person imagines his hands getting heavy or warm, or both heavy and warm.   When one does this exercise, there is actually a physiological warming of the hands which can, in fact, by measured, that corresponds to increased blood flow going to the hands.  The same exercise can be done with the feet instead of the hands.

Increased peripheral blood flow correlates well with the relaxed state.  Conversely, in the anxious, “fight or flight” response, the blood leaves the skin, hence we describe a person as having a pallor, having cold feet, or having cold clammy hands.   In an appropriate situation, such as facing a lion, this may have adaptive value (if you are a caveman for example).   The blood leaving the skin allows the circulation to redistribute to the muscles which are needed a lot more than the skin to “get out of there.”   Fighting is probably out of the question in this case.  

In one study, it was shown that people who have trouble sleeping, most likely due to an overanxious mind, had significant success in falling asleep when they found a way to warm their feet.  In this case, heavy socks seemed to do the trick rather than mental imaging.   The redirected blood flow back to the periphery probably resulted in sufficient relaxation for the individual to fall asleep.

Yoga Stretching Exercises are probably best learned in one of the many exercise classes available in most communities.  If one is not available, there are numerous self-help Yoga Books available that cover these stretching exercises quite well.  In addition to “stretching” Yoga there is meditative Yoga which many people also find quite helpful in achieving a state of relaxation.

Proper sleep is a given to reduce anxiety levels.  For most people, running a “sleep debt” results in increasing irritability, daytime fatigue, and depression, and creates a general feeling of edginess and nervousness.   After several good nights of proper sleep, anxiety levels are often noted to decrease significantly, especially in those people where insomnia has been a problem.   Good sleep hygiene involves many different techniques, such as setting a consistent bedtime and following a bedtime “ritual.”  For further detailed treatment of this subject I refer you to the monograph entitled: “Why We Can’t Sleep and What We Can Do About It.”  This is also available from  “FatBrain e-matter.”

Proper diet should pay careful attention to avoiding stimulants such as caffeine or the stimulants found in chocolate and cocoa.  Some people are very sensitive to these psychoactive substances and feel “wired.”  Other times the effect is more subtle but nonetheless a significant contributor to anxiety.  For some people the high L-tryptophan content of milk can help diminish anxiety, but be careful about “lactose intolerance.”  This latter condition is quite common in adults, especially those of “Mediterranean” background.    (Symptoms of lactose intolerance, caused by a deficiency of the lactase dehydrogenase enzyme, include bloating, cramping, and diarrhea).  L-Tryptophan used to be available in pill form in health food stores but had to be withdrawn due to impurities.

A support group or quality internet chat group is extremely helpful in feeling, what else, support, and also in providing one with the comfort that he is not “alone.”  Please see my detailed discussion of the therapeutic benefits of this above.

Supportive family and friends are of obvious benefit to anyone.  However they are  particularly important when one is struggling with an anxiety disorder.  Such individuals can be taken into the “inner circle.” Perhaps they can   read educational materials about the nature and treatment of anxiety.   This is important not only so these individuals can render emotional support and encouragement, but also so they will understand the other elements of the treatment plan, and be supportive of them as well.  


Self-help Step #4 –  REDUCE SPEED AHEAD!!!

Many people with Generalized Anxiety Disorder, but not all, have a speeded up tempo to their lives.  The may talk fast, move in an abrupt and propulsive manner, and demonstrate constant impatience.  Some of these people have trouble letting someone finish a sentence.  They jump in and finish the sentence for the other person or just trample over it.   When the other person is talking, these people are not listening but anxiously waiting to talk, often sitting forward on the edge of the seat.  They make the other person feel uncomfortable and rushed. 

If any of these descriptions sounds familiar, try practicing slowing down.  Enlist the help of a trusted friend or spouse to help you “catch” yourself.    No doubt the tendency will remain to keep speeding up again, but work at it.   “Fast” often equals agitated in the anxiety world; “slow” equals calm and relaxed.   It is possible over a period of time to reset the tempo.   The increased feeling of relaxation will be the reward. 


Panic Disorder

As we move on to the next subject, Panic Disorder, keep in mind the principles described above.   In many cases these same techniques will help with this disorder also.  A major difference however, is that Panic Attacks come on rather quickly, usually in considerably less than 10 minutes, and often in a matter of seconds.   To deal with the immediacy and acuity of this problem, additional techniques are given, which should be combined with the above.


Description of Panic Disorder

Panic Disorder can be thought of as characterized by the intense and sudden occurrence of anxiety attacks which appear periodically and are often accompanied by characteristic physical, emotional, and mental symptoms, as opposed to the usually lower grade anxiety in Generalized Anxiety Disorder.   The attacks of anxiety in Panic Disorder occur in discrete episodes and the anxiety escalates rapidly, usually within ten minutes, and often much quicker than this.   At the peak of the anxiety the person often feels like he will die, or that he is about to have a heart attack, stop breathing, or have some other catastrophe occur.  

Between panic attacks there is usually apprehension that an attack will occur and frequently there is avoidance or dread of placing oneself in a situation where an attack has occurred previously.  People with Panic Disorder thus frequently avoid going to public places or driving on the freeway.  They fear they would have trouble getting help in these situations or they would embarrass themselves.  These very concerns tend to increase anxiety in these settings and this can, indeed, precipitate a panic attack.  

In some cases the person with Panic Disorder develops a secondary agoraphobia, a fear of  leaving home and being out in public.  Lifestyle can become severely limited.  

Many people with Panic Disorder feel relatively safe when they are with a trusted spouse or friend and when they are at home, although the panic attacks occur at home also.  In these situations people feel that if an attack does occur there is someone present who can  help or that they will be able to call for help.   These feelings, of course, are not completely rational, since the trusting spouse or friend may have no idea what help to afford.  However, from the very beginnings of our life, most of us associate some concept of “home” with relative safety.   

According to the Diagnostic and Statistical Manual of Mental Disorders – 4th ed., the generally accepted “bible” of mental health disorders, the panic attacks which occur in Panic Disorder are characterized by some combination of thirteen somatic and cognitive symptoms.  The DSM IV requires the presence of at least 4 of these 13 symptoms, otherwise the event is considered a “limited symptom anxiety attack” or “partial anxiety attack.”  The list from (DSM IV) is as follows:


1  – palpitations, pounding heart, or accelerated heart rate

2  – sweating

3  – trembling or shaking

4  – sensations of shortness of breath or smothering

5  – feeling of choking

6  – chest pain or discomfort

7  – nausea or abdominal distress

8  – feeling dizzy, unsteady, lightheaded, or faint

9  – derealization (feelings of unreality) or depersonalization (being detached from


10 – fear of losing control or going crazy

11 – fear of dying

12 – paresthesias (numbness or tingling sensations)

13 – chills or hot flushes


Again the presence of  4 of these 13 symptoms is required for a technical, anxiety attack, while the presence of  fewer than 4 symptoms represents a partial attack, although for a given individual, the partial attack can feel just as frightening.

It should also be noted that anxiety attacks can occur in the context of other types of anxiety disorders, including posttraumatic stress disorder, obsessive compulsive disorder, specific phobia, social phobia, and acute stress reaction.   Panic attack-like symptoms can also result from various physical illnesses, such as hyperthyroidism, excessive caffeine intake, or the use of restricted substances such as marijuana or cocaine.   Initial consultation with a psychiatrist or other physician is highly recommended. 


Demographics of Panic Disorder

Panic Disorder occurs in both adults and children. It is diagnosed two to three times as often in women as in men.  This figure may be inaccurate, since women may be more open about admitting their symptoms and reaching out for help.   Since our culture tends to be biased against men showing anything that could be construed as “weakness,” perhaps under these conditions men find ways to “suppress” anxiety symptoms.  One means of suppression used (it does not work well and, of course, creates other problems) is alcohol.   An unknown number of alcoholics are self-medicating anxiety disorders.

(Skippable but an interesting tangent:  It is interesting to wonder just how much influence changing social attitudes have had on psychiatric disorders.  Thus, disorders described in Freud’s time, such as hysterical conversion syndromes, in which people, often women, presented with pseudo-paralysis or other such symptoms, are rarely seen today.  What happened to this disorder?   On the other hand, various disorders seem to be much more common today, such as borderline personality disorder.  Does society influence which disorders manifest themselves, or is it just a matter of better diagnosis.    There are many possibilities involved.   One intriguing hypothesis involves the effects of “suggestion.”  As we hear and read more about psychiatric disorders it is possible that certain genetically predisposed individuals begin to increasingly experience symptoms.  Physicians have long experienced this process themselves.    In medical school more than one budding young doctor becomes convinced he has a brain tumor or other life-threatening condition.   In fact, I knew one medical student, who by the time he graduated, had experienced at least one serious affliction from each of his clinical rotations.  Perhaps similar forces are at work in the general public).

The prevalence of panic disorder is very difficult to estimate, but probably runs at least somewhere between 2 and 3 percent worldwide.   No doubt this disorder is often mislabeled in some parts of the world.   For example, among certain societies the symptoms of panic attack are interpreted as demon possession and the treatment involves some form of exorcism.   And sometimes this works!

As with many psychiatric and physical disorders, there is evidence based on studies of families and also on twin studies, that panic disorder has some genetic contribution.  Nonetheless, many individuals with panic disorder do not report any occurrence of this in family members, when questioned. 


Treatment Options

I refer the reader back to the treatment options discussed above under Generalized Anxiety Disorder.   All of these techniques are helpful for those suffering Panic Disorder, since they serve to lower the baseline level of anxiety and thus decrease the anxiety Panic Disorder people experience between panic attacks.   This lowering of anxiety will help decrease the probability of a panic attack as well.

In addition to these Generalized Anxiety Disorder treatment approaches, there are additional specific techniques which are extremely helpful to those suffering from Panic Disorder.  These techniques involve cognitive and behavioral approaches.  They are as follows:


1 - Put the “Magic” Back in Your Life

This may sound like a very strange treatment approach but the reasoning goes like this (besides the fact that it works).  Many people who experience panic attacks experience some form of breakdown in their usual everyday confidence that “things will work out.”  For some reason, they become acutely fearful not just of having a panic attack, but of a number of catastrophes, such as dying of a heart attack, having an accident on the freeway, dying in an airplane, fainting in public.  These fears predispose to the emergence of the panic attack.   In the past (and for some people in the present) reassurance was found in religion.  It was assumed that some “higher power” would look after us.    Whatever one’s religious bias, this was often a very comforting thought and probably quite effective in decreasing anxiety levels.  However, our “sophisticated” scientific society has eliminated this support for some people.   

Nonetheless people must believe in something.  If nothing else they must believe, for example, that they will survive the coming day.  They must believe they will awaken from sleep, not have a heart attack in the morning, not crash in a fatal accident on the way to work or wherever, not faint in public and embarrass themselves, and on and on.  They must also believe that the world will not end in some major nuclear mishap and that they will not be the victims of some horrendous natural disaster.  While there are no guarantees, people must rely heavily on the overwhelming probabilities that these things will not happen. 

Unfortunately, many forces in our society conspire to destroy our sense of security.  We are bombarded in the media by every disaster occurring anywhere in the world.  We read about every manner of serious and fatal disease.  We are overwhelmed by frightening information.   It becomes hard to believe the world will go on, let alone one’s own life. 

Nonetheless, in our own personal microcosm, we must believe that we exist in some bubble of security.   We must have faith in this, or we are walking anxiety time bombs.  In fact it is often the bursting of this bubble that can lead to the beginning of a pattern of anxiety attacks.

(Another skippable, but interesting anecdote illustrating loss of confidence in a previously courageous individual): 

I once treated an ironworker who prided himself on being able to walk on I-beams, 30 stories above the City of Los Angeles.  He did this for years and never gave it much thought.   There was no safety net, mind you.   One day he learned about a coworker who slipped and fell to his death.   My patient became a psychological “invalid.”  Not only did he become unable to pursue his occupation, he developed panic attacks on the freeways and in large warehouse stores.   He had lost his bubble of security, his faith had been punctured.  The road back was long and involved all of the elements discussed in this monograph, but this man is now back walking on I-beams.  End of story. 

The “magic” in one’s life can center around a comforting saying, such as a prayer or inner words of reassurance (“everything will be all right”).   Choose whatever inner thoughts seem the most appealing.   This technique is simple and it works. Some people choose to carry around a comforting item in their pocket or purse.  This can range from a lucky marble to a “lucky” extra pill of Xanax (an anti-anxiety medication).  Many times there is no more need to swallow the Xanax than to swallow the marble.  Just having it available helps.  Some people carry around a small pocket-sized book of prayers or one-line “feel good” statements.   You can even create your own such aid.    Reading from this several times a day is very reassuring.


2 -  Imagine the Worst Scenario

This technique may sound like anything but comforting, yet paradoxically it can be.  A worst scenario may go like this:   Imagine you are on the freeway and you feel an anxiety attack coming on.   The worst scenario is you pull off onto the shoulder.  You try to do the breathing exercises and other techniques of relaxation described above.   It doesn’t work.  You reach for your purse for a Xanax (an anti-anxiety, anti-panic attack medication) but you find you have none left.  You reach for your cell phone to call your husband, even though he is 40 miles away at work.    The cell phone battery is dead.    You are frantic.  You sit in the car for what seems an eternity.  Your face is numb, your heart is pounding against your chest, you have the sensation you can’t get enough air (it’s just a sensation, you are probably hyperventilating).  At this point, either the anxiety attack eventually subsides on its own (at some point it will and often much sooner than it seems) or eventually someone will see you stopped and call Highway Patrol on their cell phone.  Either way you will get help.  You didn’t die, although you felt you would and you didn’t go crazy, another common fear.  You learned something:  that a panic attack is eminently survivable. 


3 - Reassurance, Reassurance, Reassurance

When you do have a panic attack, realize that it is not the end of the world, although it may feel like this.  The attack will pass even without particular treatment, such as medication, and you will feel your normal self again.  The body does not have the energy to maintain a level of acute anxiety for very long.  If it did, all panic attack sufferers would look anorexic from the huge number of calories consumed.


4 – Recognize Interoceptive Signals for What They Are

Interoceptive signals are the internal signals that cross your consciousness, in the case of anxious people, more than they should.  For example, that slight stuffy ear becomes larger and larger on the mental “radar.”   You start feeling slightly disoriented or dizzy.  You may even start hearing a buzzing or high pitched squeal.   You have become so sensitive to internal signals, that they are overwhelming and frightening.   Similarly, the conscious mind becomes acutely aware of the heartbeat and the heart responds to this anxiety by beating faster (via the autonomic nervous system and the adrenaline in the bloodstream).  In another scenario, the minor, normal cramping sensation in the gut becomes magnified and “gut-wrenching” so to speak.    Unfortunately, not only does the conscious mind start feeling these signals with much increased intensity, as though the amplitude is turned on high, but the mind interprets these signals in the most frightening way.    A minimal chest twinge becomes a major chest pain and the harbinger of the inevitable heart attack.  The beating heart feels like it is about to explode.  The minor cramping in the gut feels like a huge wrecking ball has crashed into the abdomen and disaster is sure to follow.    The trick is to recognize these harmless signals for what they are, normal physiological events of no particular consequence.  Get back to work, it was a false alarm, invented by the overactive, anxious mind.    Next time the sensation occurs it won’t be frightening, with this new insight you have developed. 


5 – Filter out the Environment by “Divide and Conquer”

Some people report that certain settings commonly trigger panic attacks.  Common examples are the freeway and the huge warehouse stores.  In both cases, the person seems overwhelmed by external stimulation.  The sensitivity to certain stimuli is greatly increased during these times.  Perhaps this is a throwback to the hyper-vigilance of the cavemen who had to “take everything in” lest an adversary take him unawares.  On the freeway, the witnessing of cars rushing by can create a sense of feeling overwhelmed, like a herd of stampeding elephants to use the caveman example.  But there you are trapped in your car with no where to run, your only hope, that the “elephants” don’t trample you.   The big “truck elephants” are particularly frightening. 

The warehouse store presents a different form of over-stimulation.   One is use to having a certain feel of the environment.  Usually this environment consists of modest sized spaces (the rooms in your house) or open areas outdoors that don’t intrude much.   In the warehouse store you have a scale factor that can feel overwhelming to some people.  The extremely high ceiling, with large boxes piled thirty feet high, the harsh fluorescent lighting, and the buzz of people scurrying around, not to mention the forklifts that sometimes whiz by are sometimes too much stimulation.  

The “trick” in both these cases is to break the environment down into more manageable pieces.   You essentially “divide and conquer.”  On the freeway, detune the mind to the havoc around you.   Filter out the “noise.”   Focus on your own driving.  Think about where you are going or what you have to do that day.  Don’t worry about peripheral vision, it works by itself, in the background so to speak. .  The normal mind is constantly monitoring the environment, the problem occurs with the sensitivity to this environment becomes too acute. 

Similarly, in the warehouse store, focus on the list you may have taken with you, or think about the items you came to get.  Look at all the interesting things at eye level.   That is what we are meant to do.    Forget about the high ceiling and don’t stare at the bright, hanging lights.  Focus on your little micro-space where you travel with your carriage in front of you and your child (maybe) at your side.   See, the place is really not all that bad. 


6 - Use Distraction

Although panic attacks can feel all consuming, try to redirect your mind to some other focus in the midst of the attack.  If you are in a store, go over to some product and become engrossed in reading the label.  In you are in your car, turn on the radio and sing to the music.  If you are with someone else, start up a conversation.   Do whatever activity is available to refocus your mind.   The mind is not very good at doing two things at once.  The panic attack will lose out, if you can successful divert your attention away from it.


7 - Use Cues to Return to Normalcy

I learned this pearl of wisdom from a patient, who after my failed attempts at helping her (actually I did help her a little), discovered that when she rubbed her shoulders (alternate hand to alternate shoulder) the panic attack seemed to slowly go away.  She tried this each time she had a panic attack, and each time it worked.  She had discovered a key, a cue leading back to normalcy.  I congratulated her on her success and felt a little dumb for not having been the one to have suggested this.  So now I can use this knowledge, now that I have confessed the source. 

Actually any number of “devices” can work as a cue to abort a panic attack.   Some people find that if they massage their thighs this helps.  Other people squeeze a ‘stress” ball.   Slowly rubbing the hands together (pleasant rubbing not mad wringing) can sometimes help.

This technique probably works both by providing a distraction as well as by the activity acquiring a special meaning for that individual.    The activity becomes associated with aborting the anxiety attack and this association can remain indefinitely.  I recommend developing a repertoire of more than one such activity, just in case, for some reason, an activity is not available (example, the dog ate the stress ball).


8 – Rehearse Panic Attacks 

 After having “mastered the panic attack,” by application of all the techniques reviewed in this monograph, you might choose to rehearse occasionally.  This can be done either by imagining all the symptoms, something that will produce some anxiety but often not a complete panic attack, because these things are difficult to summon up at will.  In the context of this imagined panic attack go through the various relaxation techniques until you feel perfectly relaxed.  Do this periodically to reassure yourself you still have control of your condition.


9 – View the Actual Panic Attack as an Opportunity

As you begin to develop some confidence in your ability to abort or at least mitigate the panic attack, you can begin to look at each actual panic attack (and they will be fewer and fewer) as an opportunity to practice what you have learned.    This can give a tremendous sense of empowerment.   You deserve it. 


10 – Develop a Healthy Bravado

Boast to yourself and others who might listen (spouses are good, they have to listen) that you are finally conquering a major problem, the Panic Disorder.  You will look back and wonder at the “hold” this disorder once had on you.   Furthermore, you can then become an inspiration to others who still suffer from this disorder.  Who knows, you might feel so good about having solved the panic attack problem, you might decide you want to become a therapist and help others as well. 


Alternative Treatments:   Generalized Anxiety and Panic Disorder

Professional Cognitive/Behavioral Therapy and Group Therapy

There are times when the self-help techniques discussed in this monograph just don’t quite do it for some people.  These individuals often benefit more when they are guided in the treatment by an outside mental health specialist.  Perhaps this is somewhat analogous to the difference between people who learn best from books and those who learn best from professionals in a face to face format.  Furthermore, the outside specialist can supply an added dimension of support.   The cognitive and behavioral techniques employed by most therapists/psychiatrists generally will be similar to those discussed in this monograph, as self help techniques.  Nonetheless, the presence of an expert is often required to keep one on “target.”  Additionally, the specialist may have an added twist on these techniques that might just do the trick.  

Additionally, generalized anxiety and panic disorder can both be addressed through the use of group therapy.   Panic Disorder, with and without agoraphobia, often responds particularly well to this format.    Again the support of the group as well as the realization that one is not alone helps greatly.   Self-help groups are also quite valuable as discussed above. 


Psychodynamic Psychotherapy and Family /Relationship Therapy

There are situations when the cognitive/behavioral approach just doesn’t seem to produce the desired results, even in the hands of a competent mental health specialist.   This suggests the possibility that there might be additional factors at work which are preventing the disorder from resolving.   At this point, a trial of psychodynamic psychotherapy is in order.   The goal of this type of treatment is to uncover psychological forces which might be at work to maintain the disorder.  Although it is hard to imagine that someone would consciously wish to continue to feel anxious or experience panic attacks, there are unconscious motivations which could be at work.   For example, the symptoms might be the only connection a person has to their spouse, who otherwise ignores the sufferer for the pleasures of the computer screen.    This is known as “secondary gain” from the disorder.   If the prolongation of the symptoms is a deliberate, conscious attempt to keep someone else involved, the condition is known as malingering.  This is not a bad word, it is only an indication that something is amiss in a relationship. 

In another example, a person might have unconscious fears that actually feed the anxiety. These fears could involve almost anything.  Or perhaps, powerful, repressed rage could be driving the anxiety symptoms. A skilled psychotherapist can be of invaluable help in uncovering these unconscious forces, putting them to rest, and thus allowing the person to move on to health. 

When the psychotherapist feels than the prolongation of symptoms, whether consciously or unconsciously driven, involves another individual in the sufferer’s life, the therapist might suggest additional family or relationship counseling. 



Lastly we come to medication.  This does not reflect a bias against medication and in some cases medication can be a primary intervention in Generalized Anxiety Disorder and Panic Disorder.   In cases where the symptoms seem particularly extreme or frequent and render the patient unable to participate effectively in other forms of treatment, medication should certainly be considered.  Generally, when medication is used, the goal is to mitigate symptoms to the point where they can then be effectively addressed by other interventions, such as those described above.  At some point, usually when a person is feeling sufficiently confident of success, medication should be tapered off to see if the symptoms remain in remission.   The person is reassured that medication can always be resumed as necessary.   In many cases of Panic Disorder a person can get to a point where there is no need for the regular use of medication.    However, keeping a few Xanax (an anti-panic, anti-anxiety medication) in the pocket or purse acts like “insurance” and gives the patient great psychological comfort.  What’s the harm?

There are many medications which are effective in treating Generalized Anxiety Disorder and Panic Disorder.   These include such anti-anxiety agents as alprazolam (Xanax), lorazepam (Ativan) and clonazepam (Klonopin).  These are short acting medications which take effect quickly, often 15 to 20 minutes after ingestion, and they can be given on a routine basis or as needed according to a treatment plan worked out with a psychiatrist.  One caveat is that these medications do have an addiction potential, both psychological dependence as well as physical dependence, and they must be carefully monitored by a physician.  When they are stopped, they should be tapered to avoid withdrawal effects.  Another medication, buspirone (Buspar) is effective in treating generalized anxiety and the anticipatory anxiety that can occur between panic attacks.  It is said to be non- addicting.   This medication needs to be given on a regular basis to be effective rather than on an as needed basis. 

Another group of medications, antidepressants, are also quite effective in blocking the emergence of panic attacks as in Panic Disorder or in other conditions where panic attacks are a problem (such as social phobia, specific phobia, and posttraumatic stress disorder).   The older, tricyclic antidepressants included such medications as imipramine (Tofranil), amitryptyline (Elavil), doxepin (Sinequan) and other members of this group.  These medications were often effective but frequently resulted in such side effects as dry mouth, constipation, blurred vision, light-headedness, sedation, and weight gain. Other, newer medications, the selective serotonin re-uptake inhibitors (SSRI’s) are also very effective in blocking panic attacks and are generally well tolerated.  Nonetheless, they also have side effects (every medication does in varying degrees for different people).  The SSRI’s include such household names as Prozac, Zoloft, and Paxil.  Common side effects of these medications are headaches, dizziness, impaired sexual functioning, and in some cases insomnia and weight gain (or weight loss sometimes with Prozac).  Other medications in the antidepressant class which are sometimes useful include nefazadone (Serzone) and also trazadone (Desyrel).

Unfortunately, the choice of medication to use involves trial and error.   We have no test to administer which can predict the response to a given medication.  Sometimes a positive response in a biologically-related family member will effectively guide the choice of medicine.  Sometimes this does not work.  The decision to administer medication in these disorders is best left in the hands of a psychiatrist experienced in treating these disorders.



Now that you have made it this far, you are well on your way to conquering your symptoms of anxiety or to assisting your friend, spouse, or co-worker in his conquest.   I strongly recommend you look over the areas covered in the material you have just read and circle (in red of course) the sections that most apply.   These are the trouble spots.    Re-read these sections and apply the suggestions given.   Don’t give up.   Generalized Anxiety Disorder and Panic Disorder are conditions that are eminently treatable.   With perseverance I am sure you will be successful.   


Dennis B. Kottler, MD 

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