by Jennifer Lee
The more I thought about this, the more it started to seem essential to me that I leave the theater as quickly as possible and get myself to a bathroom, just in case I had to throw up. (Keep in mind that throughout this whole period, I didn’t actually feel nauseous or close to vomiting at all. This was all just because I noticed I was thirsty! This shows the power of panic to make apparently “logical” connections between different fears, even when nothing frightening is actually happening.)
To my family’s surprise and alarm, therefore, I stood up during the midst of the concert and made my way across the other people in the aisle. They had to shift uncomfortably in order to make room for me, and I felt embarrassed. I then got to the bathroom and drank some water out of the faucet, hoping this would reduce my feeling of being dehydrated. I then made my way back to my seat to finish watching the show.
As soon as I was seated, however, the whole thought process started over again. What if that wasn’t enough water? What if I get sick anyway? Where would I go? I’d have to climb all over everybody again.
Even from this small example from the author’s personal experience, we can already see some of the features common to anxiety and panic disorders that we will be examining throughout this book. We see the ways, for instance, in which a variety of quite different fears can build on and reinforce each other, through a seemingly “rational” logical process.
My experience in the theater drew upon a social anxiety (about not wanting to be on display and to embarrass myself), a fear of enclosed spaces (I was worried about what my “escape route” would be, if I had to throw up), and fear of losing control over my physical bodily responses (fear of throwing up) and other individual fears that we will be examining in detail later on in this book.
More importantly, however, my experience can help show us the way in which panic can start from something extremely small, usually a minor discomfort or fear (in this case, feeling thirsty), and grow from there. Above all else, the thing that feeds and reinforces panic is avoidance.
In my case, I thought that by getting up in the theater to get a drink of water, I could avoid the thing I was afraid of (i.e., throwing up). Instead, this only reinforced the panic, because my efforts to avoid the fear opened up a new set of potential fears. Once I had the drink of water, I realized that even drinking water isn’t a surefire guard against the possibility of throwing up. I still wasn’t entirely safe from the possibility.
Minor as it may seem, this one experience in the theater led to four years of struggle with panic and anxiety symptoms. My fear of throwing up in the theater quickly led me to be afraid of other places in which I would be “trapped” for a certain period of time in an enclosed space, and therefore would not be able to get to a bathroom in case I needed to vomit. This led me to begin avoiding airplanes, subways, and even elevators.
In turn, after I had experienced a number of panic attacks in such places, the fear of panicking itself began to be reason enough for me to avoid situations that I associated with my anxiety. Over time, the anxiety began to exert greater and greater degrees of control over my life, and the range of ordinary activities in which I felt “safe” in my life felt ever smaller.
Avoidance of panic triggers often leads to this result, because it is not actually feasible to entirely escape the possibility of panic. The future is always uncertain, and you cannot screen yourself off entirely from the range of possible emotions or bodily responses you might undergo. Avoiding various situations merely serves as a reminder of this frightening truth. As I experienced after my trip to the bathroom in the theater, I realized I could not entirely forestall the possibility that what I was afraid of might actually happen.
The important thing to do, therefore, is not to find a way to avoid the possibility of having a panic attack, because you can’t. The important thing, rather, is to realize that you do not need to avoid it because panic attacks are not dangerous. In the concert hall all those years ago, I was confronted by the frightening fact that I could not foresee all of my future potential bodily responses. None of us can. We do, however, have the power to keep ourselves anchored in the present and to realize that we are perfectly safe, even if we start to panic.
The Samuel Butler Principle
Strange as it may seem then, as you come to accept the possibility of panicking, you will quickly find that a panic event that you fear is far less intense in reality that you thought it would be in imagining the future. Indeed, you may discover that the panic attack never comes at all.
Some people who have dealt with panic disorders have even gone as far as to say that they are not sure they have ever really had a panic attack at all. This is because so much of the panic attack experience itself is often tied up in an anticipatory dread of a future panic attack, or the fear that a panic attack will get worse or go on forever, that telling the difference between a panic attack itself and the fear of a panic attack is often not easy to do. Indeed, it is possible that there is no distinction between the two, and the two experiences are one and the same.
As we will see in the following chapter, anticipating future threats is the essence of anxiety. As most of us know from our personal experience in other contexts, however, we are very often more afraid of something before it comes than we are when we are actually facing it. Think of going on a roller coaster. When do you experience the most fear and trepidation? During the ride itself? Or during the long wait, when you are staring up at the towering contraption and its huge falls? Chances are, it’s the latter.
The same is true with a panic attack: its bark is worse than its bite.
We might call this important insight the “Samuel Butler principle,” after the famous British author because he once summarized it in a, particularly pithy way. To paraphrase slightly, he wrote: “Life is so much more often an affair of being frightened, that it is of being hurt.”
So it is with panic attacks. They are very often frightening. But they do not have the power to harm.
***
Four years after the incident in that concert hall, I now live my life largely without anxiety, and without limits, it once imposed on my range of life options. I travel routinely for work on planes and the subway, I ride elevators, I go to concerts, and a whole range of other activities that once felt as if they were next to “impossible” for me. Moreover, I reached this point without the use of medication. In Chapter 6 of this book, we will discuss some of the simple methods I used to begin to regulate my panic responses and to reach this result.
Chapter 2: Understanding Anxiety
Anxiety, by Edvard Munch (1863-1964). Source: Wikimedia Commons. This image is in the public domain.
“What’s wrong with me? I never used to be this way.”
If you are struggling with anxiety, the chances are that this is a thought that has occurred to you in the past. Anxiety can strike people at many different stages of their lives, and some reach their early adulthood, or even later, without noticing any symptoms of anxiety. When people do first start to experience anxiety, it can feel as if it “came out of the blue.” Things that used to be extremely easy for them to become difficult – or even come to seem “impossible.”
People who were immensely sociable in the past, for instance, and had no trouble going to parties and meeting new people, may suddenly start to experience forms of social anxiety or phobia that keep them at home. (See Chapter 3 for a further discussion of social anxiety.) So too, people who have flown around the world or across the country without any concern throughout their lives may develop a terror of flying that prevents them from setting foot on an airplane.
This can lead to a frightening sense that one’s horizons are shrinking, or that one is losing abilities that one used to have in the past. In the classic novel by Nobel Prize-winning author V.S. Naipaul, A House for Mr. Biswas, he describes this feeling in the context of his protagonist’s struggle with symptoms that we would now recognize as an anxiety disorder. He notes that his protagonist
is unable to imagine how he could have interacted socially with other people in the past when he now finds it so terrifying. “His whole past became a miracle of calm and courage," writes Naipaul.
Naipaul knew whereof he spoke. A House for Mr. Biswas – considered by many to be his masterpiece – is based on his father’s life story. Toward the end of the novel, Mr. Biswas – the stand-in for Naipaul’s father – realizes that his son is experiencing the same symptoms of anxiety and depression he once went through and sends him a book in the mail (perhaps a book much like the one you now hold in your hands) that will help him manage the symptoms. All of these events correspond to things that actually happened in Naipaul’s life.
As Naipaul’s example suggests – and as we will see throughout this book – many famous people who have achieved important things in the world have grappled with anxiety and its associated disorders. There is nothing “bad” or strange about you for going through the same, and it is not your fault that you are experiencing this form of mental illness. You are simply experiencing the same anxiety symptoms that people have dealt with throughout history.
Moreover, while it can be very disconcerting to find that you feel “incapable” of doing things that used to come easily to you in your past – because you feel blocked by your anxiety – you can also use those memories to remind yourself that it is possible to live without anxiety. You used to do things without being blocked by anxiety, and you can do so again, you just need a little help.
The first step is simply to reduce the feeling of mystery and stigma around the disorder itself. Familiarizing yourself with the typical symptoms can help you recognize and treat your anxiety for what it is.
What is anxiety?
Throughout this book, we will be using the terms “fear” and “anxiety” as interchangeable, following their everyday uses. Clinicians, however, recognize a technical distinction between them, pointing out that fear really refers to one’s reaction at the moment to a perceived threat, whereas “anxiety” has an element of anticipation to it. We are anxious for the future – for what we think may be coming up ahead.
It is helpful to consider this distinction because it can enable us to understand the way anxiety disorders operate. As we will discuss more fully below, anxiety disorders often function through anticipatory fears that prevent us from putting ourselves in situations where we feel me may be at risk. Many people who have overcome anxiety disorders describe a realization after doing so that they often experience far less fear – maybe even no fear at all – in the moment of facing what they feared, than they did during the period when they were anticipating, waiting for, and dreading that fear (see the section on the “Samuel Butler principle” above).
In the case of people who overcome a fear of flying, for example, many states that the hardest part of the process was convincing themselves to get on the plane. Once they were aboard and their seatbelts were fastened, their fear largely abated.
This can be hard for many people with anxiety to believe until they experience it directly. The sense of being “past the point of no return” and of having “no way out,” is often precisely the thing that people with anxiety fear the most. Yet once the doors of a plane are closed, and there is truly no turning back, people surprisingly relax.
This is because a great deal of anticipatory anxiety is related to an exhausting sense of needing to make a decision all the time (a sensation linked to the natural hormonal “fight or flight response,” discussed below). People with anxiety often spend enormous mental energy, trying to figure out how to avoid the situations they fear. Some describe this as a constant sense of trying to figure out their “escape route.” In situations in which these decisions are out of their hands, and in which they must simply trust the pilot and crew of the plane they are flying, many people report feeling a sudden sense of calm. They are able to let go of the need to make decisions – which is another way of saying, they are able to abandon the quest for control over a situation. Once they do so, their fight or flight response diminishes.
In the sense of an anticipatory fear about future threats, anxiety is an entirely normal part of life. We all experience some amount of anxiety when we are not fully sure of what the outcome of a situation will be. Likewise, related feelings of stress are often linked to a sense that events are occurring outside of our control. While no one likes feeling stress or anxiety, these emotions serve a healthy evolutionary function in our emotional psychology. They help us foresee and plan for future threats to our safety so that we can keep ourselves whole and well.
The important thing, then, is to recognize when a normal amount of anxiety is starting to tip over into pathological anxiety, meaning anxiety that has become a form of mental illness, for which you may need to seek professional help.
Some of the signs that your anxiety may be pathological in the form are if your anxiety is:
preventing you from doing the things you would otherwise like to do with your life,
preventing you from performing the tasks that others around you are able to perform in the ordinary course of living, and not as any special feat (such as traveling, working a regular schedule, sleeping regular hours, etc.)
becoming something you are afraid of in itself, rather than just a feeling that accompanies something else that is causing you to fear.
To give an example, if you feel anxiety before giving a presentation at work, that is a normal and healthy response. However, if your anxiety is so great that you pretend to be sick in order to avoid the presentation, or if part of the reason you want to cancel the presentation is precisely because you are afraid it will make you anxious, or afraid you will panic in the midst of it – and, more importantly, if these kinds of responses are becoming more and more prevalent in your life, these might be signs that you are suffering from a pathological form of anxiety.
The physical symptoms of anxiety will be familiar to anyone who has suffered from various kinds of fear in the past. We will be confronted with a very similar list in Chapter 3 when we come to consider the symptoms of a panic attack. These symptoms include:
Heart palpitations, Arrhythmia, Pain in the chest. We will discuss arrhythmias and anxiety disorders that center around fears of heart trouble more fully in Chapter 3. The important thing to keep in mind, for now, is that panic and anxiety may make your heart race or lead to other feelings of discomfort, but they will not hurt your heart, nor are they linked to heart disease or any physical heart condition.
Lump in the throat, Shortness of breath, Digestive problems, Sweating, and other physical symptoms. As with the heart-related effects in the previous bullet point, it is important to keep in mind that while these physical symptoms may be uncomfortable, they are not dangerous. Your body is not capable of “choking” itself, and you will always continue breathing, even in the midst of a severe panic attack. Many people with anxiety or panic disorders describe a sensation in which they feel their throat is constricting, or in which they cannot get enough air to breathe (this feeling can come from hyperventilation, discussed below). The famous novelist John Updike reportedly suffered from such a choking sensation periodically in his young adulthood. The good news is that this did not prevent him from breathing comfortably until his death at the ripe age of 76. Your body’s respiratory, or breathing, an involuntary function, and would continue even if experienced panic, or even if you passed out. You do not need to worry about maintaining it.
Difficulty sleeping, also known as Insomnia. Some peoples with anxiety report periodic feelings of being “jolted awake” in the middle of the night. Many people describe their anxiety thought patterns as most difficult to escape during the periods when they are trying to get to sleep because there are fewer external and social stimuli during this time of day to distract them from these thoughts. We will discuss later in the book some of the ways people have found to manage and overcome the sense of being haunted by recurring thoughts, which can occur in both anxiety disorders (where they are a
ssociated with panic) and depression (where these recurring thought patterns are known as rumination).
Throughout this book, we will be referring to anxiety loosely as a “disorder,” and we will at times describe it alongside panic, to which it is closely related. From a clinical standpoint, however, anxiety is really a larger umbrella category that includes a number of distinct anxiety-related disorders. Many clinical references, for example, speak in general of “Anxiety Disorders,” and give specific examples of the problems that fall within this category.
Such specific anxiety disorders include:
Panic Disorder, often characterized by recurring experiences of high-intensity feelings of anxiety or panic, known as “panic attacks,” which we will discuss in detail throughout this book;
Post-Traumatic Stress Disorder (PTSD), which we mentioned above and which we will discuss again in Chapter 3;
