By Al Galves
In its section on Anxiety Disorders, the Diagnostic and Statistical Manual of Mental Disorders (DSM) doesn’t include a state of being that is consistent with what we mean when we use the word “anxiety” in everyday conversation. Rather, it includes disorders which are more extreme than that – Panic Disorder, Agoraphobia, Posttraumatic Stress Syndrome, disorders which can be attributed to specific events or situations – Specific Phobia, Social Phobia, Acute Stress Disorder, or disorders which have very unusual or extreme symptoms – Obsessive-Compulsive Disorder, Generalized Anxiety Disorder.
For a definition of the more “vanilla” type of anxiety which visits all of us from time to time, we have to turn to Webster’s New Collegiate Dictionary which defines “anxiety” as:
A painful or apprehensive uneasiness of mind usually over an impending or anticipated ill.
An abnormal and overwhelming sense of apprehension and fear often marked by physiological signs (as sweating, tension and increased pulse), by doubt concerning the reality and nature of the threat, and by self-doubt about one’s capacity to cope with it.
This sounds a lot like the stress response which was defined by Hans Selye as “the non-specific response of the organism to any demand placed upon it.”
Again, I am assuming that any state of being that human beings can experience must have some survival value, must contribute somehow to our health and happiness. Otherwise, it would have been wiped out by natural selection long ago. So what would be the usefulness of anxiety or the stress response? This, I think, is a relatively easy one to answer.
Anxiety and the stress response tell us that something is threatening us or being demanded of us that is going to be difficult to deal with. Something is getting in the way of our ability to love the way we want to love, work (express ourselves) the way we want to work, enjoy the way we want to enjoy, live the way we want to live. And the symptoms tell us that energy is being built up in our organism to deal with it. The stress response gives us increased stamina, sharpness, strength, pain tolerance and quickness.
It’s easy to see how such a response is useful to us. It gives us the resources we need to deal with the threat or meet the demand. It arms us for battle. Useful, indeed! And there is evidence of its usefulness. Research has found that people who are moderately anxious score higher on the Scholastic Aptitude Test (SAT) than people who are either extremely anxious or not anxious at all. People who react to stress by taking action and trying to exercise some of control over whatever is causing it are healthier than people who avoid it or distract themselves. Gorillas who manage stress well are more dominant and successful than gorillas who don’t.
But more than any other states of being I can think of, anxiety and stress are useful in moderate amounts and intensity and extremely harmful in excessive amounts and intensity. Because, if you don’t use the energy, strength and stamina that anxiety and stress give you, you will get sick and depressed and, in extreme cases, die or kill yourself. Threats and demands such as unhappy marriages which include kids and houses, depressing jobs that must be retained for the time being, the challenges of parenting difficult children, troubling conflict with siblings, parents, co-workers, spouses can cause this kind of danger.
If I could do one thing to increase the health and well-being of human beings, it would be teach them how to use anxiety and the stress response. What are the keys to doing that?
Well, the first step is being aware that you are experiencing anxiety and stress. Some people have been so traumatized that they have shut themselves off from receiving the messages from their bodies. At the first sign of activation they either explode or go off into the fugue of dissociation. Those people would benefit from the kind of trauma therapy that is provided by the Sensorimotor Psychotherapy Institute in Boulder, Colorado.
Once you are aware that you are experiencing anxiety or stress, the next step is to allow yourself to know what is causing it. What is the threat or demand that has brought this on? This may take some time and effort. You may have to sit with the anxiety and stress for some time. It may help to just sit quietly in a safe, comfortable place and allow your mind to reflect on whatever comes up. It may help to take some long walks in nature, pay attention to your dreams, ask yourself “What am I pretending not to know?”
Once you have an idea of what is causing the anxiety and stress, the next step is to decide what, if anything, you want to do about it. If you decide to do something about it, you’ll need a plan that includes getting help from others, finding a way of doing it without making things worse, overcoming the natural fear of taking action, dealing with the potential obstacles to success, etc.
What if you decide not to do anything about it at this time? Now, it’s important to find some good ways of using the energy, strength and stamina in anxiety and stress: vigorous exercise; building, fixing and cleaning things; other kinds of creative activity; talking to friends or therapists; emoting (getting onto the interstate, rolling up the windows and screaming bloody murder for several miles, finding an isolated country road on which you can walk, start talking to yourself and scream bloody murder for several miles, pounding pillows, beating a tree with a stick); journaling, helping others – some way of using all of that energy, strength and stamina that has built up in you.
Note: Sometimes, the anxiety and stress will make you fatigued. Don’t let the fatigue keep you from taking the action described above. Honest. You’ll feel better if you do it anyway.
Notice that these methods of using the energy, strength and stamina in anxiety and stress are the last step, not the first step. You only take this step after you’ve become aware of what is causing the anxiety and stress and have decided not to do anything about it at this time.
The one thing you want to avoid doing is seeking comfort and avoiding discomfort. Because, if you do those things, you won’t be finding out what is causing the threat or demand that is beneath the anxiety and stress and deciding what, if anything to do about it.
So far we’ve been looking at the anxiety and stress response that everyone experiences from time to time. But what about more extreme forms of anxiety. Let’s take a look at panic disorder.
Panic attacks are very uncomfortable and scary. All of a sudden you notice your heart beating faster and stronger. You notice some sweating, or a tightness in the head or some jumpiness in your stomach. You start thinking “Uh-oh, what’s going on? Something is wrong.” Your heart is beating faster. You notice some numbness in your fingers and toes. You’re having trouble swallowing. You feel short of breath, can’t get a good deep breath in. Now you’re really spun up. “Is this a heart attack or a stroke?” You begin to feel faint and are afraid that you’re going to lose consciousness. You’re heart is beating faster and faster. You can’t catch your breath. You’re afraid of blacking out. You’re in a vicious feedback loop. The stronger your symptoms, the more scared you get and the more scared you get the stronger your symptoms become.
This extreme experience keeps you from doing whatever you were doing before the symptoms started. If you were driving a car, you pull over. If you’re at work, you escape from wherever you are to find a place away from other people. If you’re at a party, you rush outside or find a bathroom. It’s easy to see how a person who is suffering from frequent panic attacks would not want to leave the house or do much of anything.
So the question: what is the cause of the panic attack? What is underneath it? How might it be useful or functional? Here’s my first reaction to that question.
The most clear thing about what is going on is that there is a lot of energy in the bodymind. The body is revving up, gearing up for action. What is the body wanting to do? There must be something important that the body is wanting to address, to do something about. There must be some problem, threat, dilemma that is demanding action.
That is what I think is going on. I think people who are experiencing panic attacks are facing a dilemma that is so difficult and intractable that they don’t even want to know what it is. I worked with many patients who came in complaining of panic attacks. At some point in our relationship, I would ask them if they could think of any problem or dilemma that could explain them. Hardly any of them were able to identify one. I pressed some of them fairly heavily. Still, they wouldn’t believe that there was a problem or dilemma behind them. They felt as if they were coming out of the blue, just showing up in a random kind of way.
There was one patient who did get in touch with what was causing the panic symptoms. And her experience is instructive. She came in complaining of the classic symptoms I have described above. She was with her husband, who seemed quite supportive and understanding. I asked her if she could think of anything, any situation or concern that could account for the attacks. She couldn’t. We kept on talking. About ten minutes into our conversation she said,”My son is in the Army Reserves. He’s going to be involved in the invasion of Iraq.” When she said that she broke down and cried for quite a while. The invasion of Iraq was scheduled to begin in two weeks. Her son was going to be in it, squarely in harm’s way. Apparently in an effort to bear up, to not be a burden, to not upset those around her, she had pushed her fear and concern down so far that others couldn’t see it and, perhaps, she wasn’t acknowledging it. But the body knows. The body is smarter in many ways than the mind. The mind can try to do its tricks and make believe. But the body isn’t fooled by that kind of dissembling. It gets revved up and cries out for action.
When the woman calmed down, we spent some time talking with her and her husband about ways in which she could manage her fear and concern and ways in which he and other family members could support her. They left and I never saw them again.
This is consistent with my experience of panic attacks. I’ve had panic attacks at various times of my life. It has always seemed as if they were coming out of the blue. When they were happening, I didn’t know what they were about. Now, when I look back on them, I do know what they were about.
I was 19 years old sitting in a college classroom. There was a young woman in the room who was very attractive, very sexy, exuding her animalness. I began noticing my heart palpitations. I was having trouble swallowing, afraid that I was gong to pass out. I managed to get through the attack by focusing on something in the room and gutting it out. Once it passed, I didn’t make much of it and didn’t put any effort into understanding it. I didn’t know what it was about. Now I do.
What I wanted to do more than anything else back then was learn how to be intimate with boys and girls. That was what I cared about. But I didn’t let myself know it. I was making believe that the most important thing was going to class, studying and living the life of a pursuer of knowledge. Of course, much of my actual behavior was focused on being with boys and girls but I never acknowledged the fact. So here was the dilemma I was facing. I had a very powerful desire to learn how to be intimate with boys and girls but I was not consciously aware of that desire. I needed a lot of help in learning how to do that and I wasn’t going to ask for any help. I was in a big bind. My body knew what was important and wanted to do something about it. So it got revved up and ready for action. Unfortunately I never got the message and spent a fairly miserable four years in college.
Here’s another example from my life. I was 36 years old, married, with two children and a job that I enjoyed a lot and that fit my talents and temperament fairly well. But, in order to do my job, I had to do some things that I thought were wrong. I imagine this happens to lots of people. I was working for a group of other people. They were good people but we had some major differences over what our organization should be doing and those differences would not be easy to resolve.
So I was facing a very difficult dilemma. I liked my job but it required me to do things I didn’t think were right. It was not a good time to look for another job in view of my being married with two young children. My mind was trying to find some way of reconciling the situation. But my body wasn’t cooperating. So on the way to meetings, I would suffer panic attacks, have to pull off the road and manage my symptoms until they subsided.
I think all panic attacks are about this kind of difficult dilemma, situations that don’t have any good solutions, only better ones. With many of my patients it seemed clear to me what the dilemma was. Often, it involved a difficult, unsatisfying marriage that, for various reasons, was not going to be resolved. Hardly any of my patients were able to clearly identify the dilemma and address it. It appeared to me that they were dealing with dilemmas that were so difficult they didn’t even want to know what they were.
In such cases, I would help them learn how to manage the symptoms. That involved teaching them how to do self-talk and to focus their attention on something outside of themselves. The self-talk would include messages such as: “I know what this is. This is a panic attack. I’ve been through them before and I’ll get through this one. This is not a heart attack or a stroke. I’ll just focus my attention on something outside of myself and this will be over in a minute or two.” Most patients were successful in learning how to do this. But the attacks were still very uncomfortable and often were disrupting influences in their lives.
For readers who want to read a very thorough and helpful workbook on anxiety and panic, I recommend Map of Anxiety and Panic by Barlowe and Kraske.
Perhaps the most troubling and perverse of the anxiety disorders is Obsessive-Compulsive Disorder (OCD). Here are the DSM’s diagnostic criteria for OCD:
A. Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and (4):
1. 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
2. the thoughts, impulses or images are not simply excessive worries about real-life problems
3. the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action
4. the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)
Compulsions as defined by (1) and (2):
1. repetitive behaviors (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
2. the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive
B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children.
C. 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.
Again, assuming that all states of being and behavior must somehow be meaningful, must have some survival value, what might be the meaning or usefulness of this kind of experience?
Here’s a possible answer. This kind of excessive hand washing, ordering and checking may be a way of dealing with the uncomfortable truth that we don’t have any control over the things that we really need to be afraid of. We don’t, for example, have control over other drivers whose behavior may maim or kill us, over other kinds of accidents and disasters that are outside of our control, over the safety of an airplane flight when we are on one, even over dangerous illnesses such as heart attacks, strokes, cancer and diabetes. So the repetitive behavior may give us the illusion of having control over things so that we don’t have to experience the discomfort of realizing that we actually don’t.
As for the intrusive thoughts, perhaps they are useful in that they enable us to avoid having to take responsibility for making decisions and addressing the difficult, real problems of everyday life – dealing with love relationships, jobs, co-workers, bosses, children, financial difficulties, moral dilemmas, competing priorities. Since we deal with these kinds of problems all the time, perhaps we lose sight of how difficult they can be. They often involve conflict with other people. They often require us to make decisions and choices that involve necessary losses and understandable regret. Carl Jung one time defined mental illness as “the avoidance of suffering.” Some human beings will go to great lengths to avoid dealing with the difficulties of the real world. They don’t choose such states of being and shouldn’t be blamed for them but it may be helpful to know what they are about.
What about Post-traumatic Stress Disorder, perhaps the most debilitating of the anxiety disorders? What might be its meaning and usefulness?
Here are the symptoms of Posttraumatic Stress Disorder (PTSD):
Recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions.
Recurrent distressing dreams of 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 people that arouse recollections of 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.
Exaggerated startle response.
These symptoms appear to be designed to help the person avoid the psychic and physical pain of the traumatic experience and to avoid a reoccurrence of trauma. They also appear to urge the person to relive the experience. It makes sense that people would want to relive traumatic experience. Typically, people who suffer trauma carry some (usually irrational) guilt about it, believing that they somehow contributed to it happening or that they could have done something about it. Reliving the experience holds out the possibility of resolving the guilt or imagining a different outcome, somehow making more sense out of the incident and coming to a more realistic appraisal of it.
James Pennebaker has done this research numerous times. He gives a group of students a writing assignment. Half of the students are assigned to write about the most traumatic experiences of their life. Half are assigned to write about what they are going to do during the summer vacation, where they are going to graduate school or some similar impersonal topic. They write for 30 minutes a day three days in a row. For the next six weeks, their immune systems are evaluated through blood assays and their trips to the health clinic are counted. Every time he has done this research, Pennebaker has gotten the same result. The students who write about the most traumatic experiences of their lives have stronger immune functioning and make fewer trips to the health clinic. The reason for this outcome is not clear. However, one explanation is that, as the students write about their traumatic experiences, they begin to make more sense of them, develop a more realistic appraisal of them and better integrate them into their lives. This explanation is based on a review of the writing which indicates a progression each day in this direction.
The value of reliving the traumatic experience in a safe, non-threatening way is also congruent with some of the recently developed approaches to helping trauma victims. In one approach, victims learn how to notice and follow their bodily sensations. They are then helped to go in their imaginations to the moment just before the traumatic experience and to shift their attention from their imagination to their bodily sensations. As they notice and follow their bodily sensations, the energy that was trapped inside of them begins to dislodge and process through and eventually discharge. They are then encouraged to go back into their heads and see if they can develop a more realistic appraisal of the event. Eye Movement Desensitization (EMDR) therapy helps people go into an altered state and relive the trauma in a state which sometimes enables them to integrate the trauma in a healthier way.
I’ve described some of the ways in which the symptoms of anxiety disorders might be meaningful. But that leaves the question of how a person might use the symptoms to become healthier.
For the “vanilla” anxiety that was described at the beginning of the article, that’s a relatively easy one. Anxiety gives a person the energy and sharpness needed to deal with the threat or take the action that needs to be taken.
What about panic disorder? A panic attack is a sign that there is a very difficult dilemma confronting the person. So it provides an opportunity to work hard at becoming aware of what the dilemma is. It’s a sign that the person should be asking himself that wonderful question: “What am I pretending not to know?”
We’ve seen that the symptoms of Obsessive-Compulsive Disorder may be an attempt to embrace the illusion that one has control over the things that can hurt one and a way of avoiding having to deal with the everyday problems of life that can be very frustrating and difficult. Perhaps this person can work at becoming more comfortable with the fact that s/he has no control over the things that can really hurt her or him and at learning how to live with the anxiety involved in dealing with the problems of everyday life.
The symptoms of Posttraumatic Stress Disorder can be a sign that the person would benefit from getting some help in developing a more realistic and self-affirming appraisal of the traumatic event by reliving it in a state in which s/he won’t be re-traumatized and will be able to integrate it more effectively into his or her life.
Al Galves has also written this popular piece on depression.
Al Galves is a retired psychologist who lives in Las Cruces, New Mexico. He is the author of Lighten Up. Dance With Your Dark Side. You can find him on his website here. His email address is: firstname.lastname@example.org
One more thing … or two … vestibular disorders have also been connected to OCD and other anxiety states. Also …
“We don’t, for example, have control over other drivers whose behavior may maim or kill us, over other kinds of accidents and disasters that are outside of our control, over the safety of an airplane flight when we are on one, even over dangerous illnesses such as heart attacks, strokes, cancer and diabetes.”
YES, we often DO have control over diseases like heart disease and stroke as well as diabetes and cancer. And we know this already with certainty. Heart disease and stroke risk can be nearly eliminated, as can adult onset diabetes, through lifestyle changes (in other words, heart attack and stroke along with diabetes are CAUSED by what we do … when we stop doing it, the risk or even existing disease goes away) … and cancer can be greatly diminished.
I spent many, many years with panic attacks and some level of agoraphobia, escalating into severe agoraphobia when on benzos and especially while tapering. I went along assuming that it was certainly psychological, because everyone said so … and if only I could analyze myself enough or learn to let go enough or trust myself enough or whatever, then I would learn to handle it better and it would go away. I looked to my past to see what had made me a “fearful person” and what was keeping me a “fearful person” now.
BUT, I’m not and never have been a fearful person. No one who knows me would ever describe me that way, even when I’m housebound. I’ve never shied away from confronting and experiencing emotional or physical discomfort or danger, ever. I’ve had trauma, like everyone, but confronted it and dealt with it many years ago have no trouble confronting it now.
I’ve struggled with agoraphobia for years, assuming it was one thing (psychological) even if it didn’t make sense, when I now believe it’s been almost entirely physical, which has always made sense.
I stumbled across a book recently that connects agoraphobia to vestibular disorders. Bingo. There it was. That’s exactly what I was experiencing all this time. It finally made sense. We have 2 inborn fears … one of them is of falling. So when someone has a vertigo attack or other type of loss of balance or dizziness, the fight or flight response is sometimes triggered. Once I stopped assuming it was psychological and looked elsewhere, I found a massive amount of research connecting vestibular disorders to panic attacks and agoraphobia. And the connection goes far back into medical history. Up until fairly recent history, agoraphobia was known as the dizziness disease. Also, benzo use causes vestibular issues … so does benzo withdrawal.
There’s not a whole lot of wisdom to be found in vertigo. Well, maybe there is … there’s wisdom to be found in anything. But it’s not the wisdom people assume is there when something is judged to be “psychological.”
In fact, I’m starting to think “psychological” is a label we use when we refuse to see the true nature of something. A catchall term for a *variety* of diverse conditions and situations that are actually unrelated.