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
by
Dennis B. Kottler, MD
Introduction
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
oneself)
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.
Medication
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.
Conclusion
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
Please e-mail the author with your
feedback at: doc@psychiatrix.com