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Worry, Anxiety and Panic

Very common reasons for coming to see a psychologist are worry, anxiety and panic. The reason anxiety is so common is that we are all born with the capacity to become anxious - at heart, anxiety is a survival mechanism which is designed to save our lives. Sometimes, however, worries, anxiety and panic occur in situations which are not actually life threatening - for example, a person may experience panic symptoms in shopping centres, or begin to experience anxiety in crowded places. Because the physical sensation of anxiety is so unpleasant, people learn to avoid situations in which they believe they may become anxious. Eventually this avoidance can interfere greatly in a person's life, restricting their activities and making them feel helpless against their anxiety.

Anxiety is a normal and healthy reaction. Anxiety is a physical response that allows you to deal with threat or danger. These changes are vital when it is necessary to respond to threat or danger very quickly - for example, when you are being mugged, or when you need to get out of the way of a speeding car.

Physical Anxiety

Any threats that occur in day to day life (e.g., being chased by a large dog; being involved in a car accident; being pulled over by the police when driving) cause a series of changes to occur automatically in the body. Once the brain becomes aware of danger, hormones are released. The involuntary nervous system then sends signals to various parts of the body to prepare the body to 'fight' or to flee ('flight'). This response is called the 'fight-or-flight' response and is associated with the following physical and mental changes:

Symptoms associated with the fight-or-flight response

• The mind becomes alert
• Blood clotting ability increases, preparing for possible injury
• Heart rate speeds up and blood pressure rises
• Sweating increases to help cool the body
• Blood is diverted to the muscles which tense ready for action
• Digestion slows down
• Saliva production decreases causing a dry mouth
• Breathing rate speeds up - nostrils and air passages in lungs open wider to get in air more quickly
• Liver releases sugar to provide quick energy
• Sphincter muscles contract to close the openings of the bowel and bladder
• Immune responses decrease (which is useful in the short-term to allow massive response to immediate threat, but can become harmful over a long period)
• Fear and apprehension
• Trembling or shaking
• Restlessness
• Cold and clammy hands
• Hot flushes or chills
• Feeling sick or nauseous
• Butterflies in the stomach

The fight-or-flight response is useful in the short term, especially if the source of danger can be avoided by physical exertion. However, the fight-or-flight response is of no use in the long term and is certainly of little use in most stressful situations. It is not helpful to run when the police pull you over and it is not helpful to fight physically when you are threatened by your boss. However, because the fight-or-flight response was useful in the distant past when humans had to deal with physical dangers, this response is still part of our bodily make-up.

The anxiety response is very good in dealing with physical threat, but it's not so good when we are dealing with psychological threat.

Reversal of the response can be produced by the use of breathing control. While anti-anxiety medication will reduce anxiety, breathing control is the preferred method since individuals can use breathing control all their lives without any of the risks associated with anti-anxiety medication. Another way that the cycle can be interrupted is by preventing activation of the fight-or-flight response. Prevention involves attempting to reduce the stressful nature of life experiences. Stresses can be reduced with relaxation, slow breathing, or by learning how to solve problems more effectively.

Anxious Thinking

As well as being a physical response, anxiety is also characterised by a style of thinking which is threat related. Remember that when the fight-flight response is activated, the person's mind begins to think in a threat related way, that is, the brain scans the environment to see where the danger is. During anxious periods, people do not think in the same way that they do when they are relaxed. How can they, when their body is telling them that they are in mortal danger?

Anxious people have thoughts, beliefs, and attitudes which support the anxiety. For example, a person who experiences anxiety in enclosed places may think of going to the theatre in the following way "It'll be full of people. I won't be able to get out. I'll be trapped!"

Common Types of Anxiety Problems:

Panic Attacks

A panic attack is defined as a discrete period of intense fear or discomfort in which 4 or more of the following symptoms develop abruptly and peak within 10 minutes:

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, light headed, or faint
9. Derealisation (feelings of unreality) or depersonalization (feeling detached from oneself)
10. Fear of losing control or going crazy
11. Fear of dying
12. Parasthesias (numbness or tingling sensation)
13. Chills or hot flushes

Agoraphobia

Agoraphobia is defined as anxiety about being in places or situations from which escape might be difficult (or embarrassing), or in which help might not be available in the event of having a panic attack or panic-like symptoms. Agoraphobic fears usually involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line, being on a bridge, and traveling in a bus, train, or car. These situations are avoided (e.g., travel is restricted), or else are endured with marked distress or with anxiety about having a panic attack or panic-like symptoms, or require travel with a companion.

Phobias

A phobia is defined as:

• A marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).
• Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a panic attack.
• The person recognizes that the fear is excessive or unreasonable.
• The phobic situation is avoided, or else endured with marked distress.
• The avoidance, anxious anticipation, or distress in the feared situation interferes significantly with the person's normal routine, occupational or academic function, or social activities or relationships, or there is marked distress about having the phobia.

Social Phobia

Social phobia is defined as:

• A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he/she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.
• Exposure to the feared social situation almost invariably provokes an immediate anxiety response, which may take the form of a panic attack.
• The person recognizes that the fear is excessive or unreasonable.
• The feared social or performance situations are avoided, or else endured with marked distress.
• The avoidance, anxious anticipation, or distress in the feared social or performance situation interferes significantly with the person's normal routine, occupational or academic function, or social activities or relationships, or there is marked distress about having the phobia.

Obsessive-Compulsive Disorder (OCD)

OCD occurs when a person experiences either obsession or compulsions:

• Obsessions, defined as:
- Recurrent and persistent thoughts, impulses or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress.
- The thoughts, impulses or images are not simply excessive worries about everyday problems.
- The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action.
- The person recognizes that the obsessional thoughts, impulses, or images are a product of his/her own mind (not imposed from without).

• Compulsions, as defined by:
- Repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.
- The behaviours or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviours or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

• At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable.
• The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships.

Post Traumatic Stress Disorder (PTSD)

PTSD occurs when a person has been exposed to a traumatic event in which the following were present:

• The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
• The person's response involved intense fear, helplessness, or horror.

As a result of the above, the person re-experiences the traumatic event in one or more of the following ways:

• Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.
• Recurrent distressing dreams about the event.
• Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated).
• Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
• Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma) as indicated by three or more of the following:

• Efforts to avoid thoughts, feelings or conversations associated with the trauma.
• Efforts to avoid activities, places, or people that arouse recollections of the trauma.
• Inability to recall an important aspect of the trauma.
• Markedly diminished interest or participation in significant activities.
• Feeling of detachment or estrangement from others.
• Restricted range of affect (e.g., unable to have loving feelings).
• Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span).

Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

• Difficulty falling or staying asleep.
• Irritability or outbursts of anger.
• Difficulty concentrating.
• Hypervigilance.
• Exaggerated startle response.

The duration of the above is more than one month, and the disturbance causes clinically significant distress in social, occupational, or other important areas of functioning.

Generalised Anxiety Disorder (GAD)

GAD is characterised by:

• Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
• The person finds it difficult to control the worry.
• The anxiety and worry are associated with three or more of the following six symptoms, with at least some symptoms present for more days than not for the past six months:
- Restlessness or feeling keyed up or on edge.
- Being easily fatigued
- Difficulty concentrating or mind going blank
- Irritability
- Muscle tension
- Sleep disturbance

Cognitive Behaviour Therapy for Worry, Anxiety & Panic

Cognitive behaviour therapy for anxiety problems targets both the physical and the cognitive aspects of anxiety. It also targets the avoidance which so often occurs. Cognitive behaviour therapy is recognised as the most effective form of treatment for anxiety disorders. Cognitive behaviour therapy works - you do not have to live with the anxiety!

Self Essentials offers clients individually tailored cognitive behavioural programs for the treatment of worry, anxiety and panic. These comprehensive programs include management of the fight-flight response through breathing control and relaxation techniques, as well as identifying and changing fear and anxiety producing thoughts. Self Essentials treatment programs also target the avoidance often associated with anxiety. If you are suffering from an anxiety or worry problem, take heart - effective help is at hand. Life can be very different.

If you are interested in learning more or to make an appointment, call Self Essentials on (02) 9555 4810 or send an email to essentials@self.net.au