The Nature of Anxiety and Panic: The Importance of Fear We all know and experience anxiety on a daily basis. It's as natural an emotional experience as happiness or sadness. However, if asked to define the term, we struggle for a clear and accurate definition. The signs and symptoms of anxiety take the form of fearful thoughts, physical sensations, and avoidance or escape behaviors.

For example, when anxious "what if...[something terrible happens]" thoughts routinely race and repetitively cycle through our head. In response our bodies react, often times in extreme and rapid fashion. Physical symptoms might include: rapid breathing, increased heart rate, sweating, dizziness, nausea, trembling or shaking, shortness of breath, chest pressure, chest tightness or discomfort, dizziness, lightheadedness, unsteadiness, tingling sensations or numbness, chills, or flushing. Without question, the physical symptoms of anxiety can be both confusing and frightening, routinely resulting in fears of "going crazy", "losing control", "dying by heart attack, stroke", or other physical problems, or "being embarrassed". The end response is usually escape or avoidance in an effort to relieve the symptoms and facilitate recovery.

Let's say you're in a grocery store, it's crowded and you start to feel warm, sweaty, and notice your heart racing. You've had a panic attack in the past, you might immediately think "oh no.... here we go again... I'm going to have another panic attack." In an effort to get relief you might run out of the store, retreating to the safety of your car, or you might simply hold on tight to the arm of a loved one or friend.

Regardless of the specific fearful thoughts you have, physical sensations experienced, or the steps you take to feel better, there is a consistent cycle to panic. At the heart of it are fears such as "dying," "going crazy," "losing control," or "being embarrassed." The problem with our fears is that they're simply inaccurate and most often catastrophic. At the time, however, the physical sensations of anxiety and panic are so severe and overwhelming that you can easily be convinced that "something terrible is going to happen." As a result, you may find yourself doing things that provide immediate relief but only serve to make the panic worse in the long run and severely restrict your lifestyle. More about that below.

Identifying and Understanding Your Panic Cycle

The first step in understanding your particular panic cycle is to monitor your fearful thoughts, physical sensations, and your behavioral responses. This is actually pretty easy to do. You can simply keep a daily log, making note of the times in which you felt anxious or panicky. Be sure to answer the following questions: a) what were you doing at the time, what was going on around you? (the situation or circumstance), b) what were you afraid of happening? (the thoughts that race through your head), c) what were you feeling at the time? (the physical sensations), and d) what did you do to feel better or get relief? (escape or avoidance behaviors). If you can answer these questions then you can identify and map out your particular panic cycle. It's important to know how your panic cycle works because it determines the steps you'll take for recovery. Although at times panic seems to come "out of the blue," you can identify your cycle with careful monitoring. Using your monitoring log, here are the steps you need to take:

1. Identify your panic trigger(s). This is the first step. These are the things that start your panic cycle. If you look at your panic log, these are external things like places, situations, circumstances (such as driving a car), objects/substances (drinking something with caffeine), or people (someone you have a conflict with). You can also have internal triggers which include thoughts (such as a thought of dying, having another panic attack...), upsetting mental images (such as seeing yourself having a panic attack, fainting, dying...), strong emotions such as anger, or physical sensations (such as chest tightness, dizziness, sweating, racing heart).
2. The next step in the cycle is the emergence of fearful thinking. As a result of getting triggered, you're going to try to make some sense of how and why you're feeling what you're feeling. What are your afraid of...what do you think is going to happen? Are you afraid of dying, passing out, losing control, being embarrassed? In other words, how are you misinterpreting your anxiety symptoms?
3. As a result of being afraid, your body's reaction is going to intensify. You're going to get anxious and the physical symptoms of anxiety listed above are going to get worse. The problem is that your fear is unfounded, even though it seems real.
4. Since your physical symptoms are getting worse, the natural response is to monitor them closely. For example, you might take your heart rate or check your breathing. However, when afraid we tend to "selectively attend" to the worst aspects of the experience. In essence, you're saying to yourself "I've got to watch my heart rate because I really could have a heart attack." A nice example of selective attention is if you've ever had a bug bite or poison ivy. The more you thought about not scratching it, the worse it itched. This selective attention only intensifies and escalates your symptoms further.
5. Your symptoms will continue to intensify, your fears will cycle through your head until one of two things happens, either you'll have a panic attack or you'll do something to get relief. This is usually some form of escape or avoidance behavior. Most often people will simply stop doing the things that trigger their panic cycle. Sometimes it is as straightforward as deciding not to drive on the highway, not going to a crowed place alone, or stopping the use of caffeine. But often times it is very subtle things such as walking close to walls in case you were to fall, holding on to the arm of a loved one, trying to imagine yourself "someplace else" when your anxious. Although subtle, all are forms of avoidance and escape and prevent you from overcoming your underlying fear(s) and, as a result, your panic.

Several important things happen when you go through this panic cycle repeatedly. First, you can't disconfirm your fear belief(s). As a result they start to determine what you do everyday. For example, you may stop exercising if you think you have a heart defect. Second, your tolerance for the physical sensations of anxiety diminishes greatly, often times to the point that normal, everyday symptoms of anxiety are upsetting. Third, you become too aware of how you're feeling, always monitoring yourself, actually triggering fearfulness and escalating your anxiety. Fourth, you start to use avoidance as your primary coping strategy, which only serves to maintain the panic cycle. Fifth, your self-esteem and self-image take on a strong negative quality as you lose confidence in your ability to cope. And finally, your lifestyle is inordinately restricted, the places you can spontaneously go and the people with whom you can interact gradually dwindle.

Seven Steps to Recovery

If you take the following steps, you'll begin the process of overcoming your fear(s), improve your ability to tolerate and cope with anxiety sensations, expand your level of functioning, and enhance your self-esteem.

1. Identify and map out your particular panic cycle answering the questions listed above.
2. Identify your central fears (such as dying by heart attack, losing control, passing out) and develop a hierarchy of triggers, going from least frightening to most frightening.
3. Expose yourself to the triggers in a gradual and methodical manner in order to disprove the fear beliefs that you've developed. Only move up the hierarchy after you've mastered each step.
4. During the exposure exercises work on attending to all the information possible that disconfirms your fear(s). Don't distract yourself from your fear! You want to prove it's wrong. If you distract yourself, you'll miss all the information that is vital to full recovery. Make a mental list each time that you can access for the next exercise. For example, if you believe that you are going to have a heart attack, review everything you know that negates that belief (e.g., you've felt that way before and survived, you've had a physical which was unremarkable, you've been an avid jogger with no problems).
5. Work on building your tolerance for the physical sensations of anxiety. If a racing heart is upsetting, get on a treadmill for 30 minutes a day. If dizziness is a problem, spin in a chair. If chest tightness is upsetting, stack books on your chest while lying flat on the floor. Be creative! Not only will this improve your tolerance for the physical sensations of anxiety; it will help you confront your fear(s).
6. Practice improving your coping skills only after confronting your fear(s). This really is improving your recovery ability. Don't use relaxation, mental imagery, or deep breathing as avoidance. Practice these skills after you've proven your fear wrong!
7. Challenge yourself each and every day. Recovery is both a physical and mental process to which consistency is the key.

Overcoming panic can be a frightening process, making it difficult to do alone. Although these steps will help you in the process, don't hesitate to get professional help.

8/13/98

M. David Rudd, Ph.D. , ABPP is Chief of the Psychotherapy Section, Department of Psychiatry, Scott and White Clinic & Hospital. He is also an associate professor in the Department of Psychiatry & Behavioral Sciences, Texas A&M University Health Sciences Center. He has a Diplomate in Behavioral Psychology from the American Board of Professional Psychology. Scott & White Clinic and Hospital Attention: Psychiatry, 2401 S. 31st Street, Temple, Texas 76508.