Here is a copy of the handout I gave my students before I retired:
Understanding and Managing Anxiety, Panic Attacks and Agoraphobia
Anxiety has often been called the “common cold” of emotional disorders. Most people experience anxiety in one stressful situation or another, while many of us have experienced or will experience anxiety at some point in our lives that is intense enough that it interferes with our daily activities.
One of the biggest problems in dealing with anxiety for most people is that admitting that you experience anxiety is not socially acceptable in many circles. Males particularly have trouble admitting to symptoms of anxiety because many of them anxiety as conflicting with their of being “strong” and masculine. Not owning up to symptoms of anxiety, however, does not make those symptoms go away. One simply becomes “anxious about being anxious” and resolving the problem becomes more complicated.
Fear versus anxiety
If you are walking across US-41 from Wads over to Fisher, you slip on some ice in the middle of the road and see a logging truck barreling towards you, what you will experience is fear. Fear is an emotion that is connected to real-life, here and now dangers. The emotion of fear is extremely good and adaptive, in that if you are afraid enough, hopefully you will get yourself off of the road very quickly and that logging truck will miss you by a country mile. We are descended from people who were able to become very afraid and were then able to avoid dangers out there in the real world that would have killed them had they not run away as fast as they could. We are not descended from those people who, in the face of severe dangers that couldn’t be fought off, acted very nonchalantly about it or who put on a macho attitude that then got them killed by the big hairy critter with sharp teeth. Fear then, has two primary attributes: 1) it is based on a realistic assessment of actual, here and now dangers; and 2) it serves to energize us to take effective action to effectively avoid those dangers that are best dealt with by avoidance.
Fear is a healthy and a natural emotion. In its proper place, fear is good.
Anxiety, on the other hand, is by definition an emotional disturbance. An emotional disturbance is any emotional experience that 1) is not primarily based on an actual, here and now situation; 2) tends to be based on catastrophic fantasies of what might occur rather than on a realistic assessment of the actual risks (the possibilities and counterbalancing probabilities of what might go wrong) within any given situation; 3) tends to energize behavior that moves one away from one’s primary goals in life rather than towards those goals; 4) tends to result in highly ineffective and self-defeating behaviors rather than effective and self-actualizing behaviors.
If you avoid crossing US-41 unless it is totally devoid of all traffic simply because five years ago you almost got hit by a car as you tried crossing the street in your home town, then your emotions are not based on actual here and now experience, nor are they based on a realistic assessment of the actual risk of crossing US-41. You are experiencing the emotional disturbance of anxiety rather than fear. If your anxiety is strong enough, you will stand at the curb for 15 minutes and be late to class rather than cross the road when you can see a single car one hundred yards away. In this example (taken from real life), the emotion of anxiety is serving to interfere with your goals of crossing the street and getting to class on time, and is thus self-defeating and disturbed.
If you avoid talking to attractive members of the opposite sex because you imagine them possibly rejecting you and you imagine how awful and unbearable that would be to experience, you are experiencing debilitating anxiety, not fear. Some people experience such intense anxiety that even if an attractive member of the opposite sex gives clear signals that he or she wants to strike up a conversation, these people isolate and avoid such encounters, preoccupied by the fantasy of how shameful and embarrassing it would be to make a verbal mistake and how terribly they would be rejected by this attractive person if they made such a verbal or social slip.
Fear then, is not anxiety. Anxiety is not fear. One is healthy, one is an emotional disturbance.
Reactive anxiety and phobias
Some people are anxious only in certain situations. Many Michigan Tech males, for instance, show no particular fear or anxiety when they engage in sports that carry a realistic risk of injury, such as hockey, rock climbing or skydiving. These same males, on the other hand, can become extraordinarily anxious and avoidant when talking with an attractive woman or talking with a professor about a question they might have on some subject materials.
Reactive anxiety is understood as that kind of anxiety that is localized to a few particular situations and which might have been initiated by painful experiences in the individual’s past. Many males, for instance, report having been severely teased or made fun of when they were in elementary school after they experienced their first infatuation with a girl. Now, ten or more years later, these same males imagine the same feelings of shame and humiliation might occur to them now as they felt at age ten if they talk to an attractive Tech female and end up being rejected by her. Many students report feelings of test anxiety based on poor performances during an exam weeks, months or even years earlier. The test anxiety is not based on a realistic assessment of how one might do on this particular exam and how one might deal with a poor grade, rather it is based on catastrophic fantasies of how doing poorly will be awful, terrible, something one can never truly recover from, and how socially humiliating such a poor grade will be and how helpless one would be do deal with the social reaction of others in such a situation.
Phobias tend to be much more specific than reactive anxieties. Some people are phobic of bugs, mice, spiders, crossing bridges, riding in elevators or flying in airplanes. In other areas of their life, they are fine. Phobias tend to be a little more difficult to resolve than a reactive anxiety response. We at Counseling Services have a pretty good success rate working with students who have obvious phobias.
Generalized or “free floating” anxiety
Some people feel anxious all the time and cannot pin down the source of their anxieties to any one particular situation, person or thing. This kind of anxiety is called generalized or “free floating” anxiety.
At the psychological root of all anxieties is a mental phenomenon called catastrophizing or negative possibility thinking. In everyday life, we all occasionally think about what “might” happen that could be unpleasant or unfortunate. We could slip on the ice today and break our arm. We could get hit by a bus or a logging truck. The Russians could be initiating a nuclear attack on us this very moment. The sun might go supernova today. We might have a heart attack and die after lunch.
While considering these possibilities, most of us also conduct a quick probability check on the things we think about and conclude that, while yes, I could slip on the ice today, probably I won’t. While the Russians might have just launched their missiles, probably they haven’t. While I might die of a heart attack today after eating lunch, in all likelihood I’ll be just fine. Chances are, I won’t be hit by a logging truck today. After we probability check the things we think about that are certainly possible today, we settle down, relax and then go about our business, content in the probability that today will hold no major surprises for us other than the ones we planned for.
The catastrophizer doesn’t do this.
The person caught up in catastrophizing gets “stuck,” thinking that the possibility of something happening is almost the same thing as the certainty of that thing happening. “If it’s possible that I might mess up this test, it’s certain I’m going to mess up this test. If it’s possible this attractive stranger will scorn me if I try and strike up a conversation, then it’s certain that he or she will. If I’m thinking I might have a heart attack this afternoon, then the fact that I’m thinking it must be a clear and accurate premonition that the heart attack is on its way—otherwise I wouldn’t be thinking about it.”
In addition to thinking that the existence of a possibility makes for a certainty, the person caught up in catastrophic thinking also tends to exaggerate the discomfort that a negative outcome will involve. The catastrophizer also tends to him or herself as totally helpless to deal with the negative outcome, imagining it to be catastrophic and not simply unfortunate or a frustration that can be handled.
Instead of seeing a poor grade on an exam as disappointing and unpleasant but something that can be handled by studying harder and trying again the next time, the catastrophizer a poor grade as “awful,” “terrible” and something that “I can’t stand!!”. The catastrophizer tends to make global conclusions based on only a few experiences: if he or she gets a bad grade on a calculus exam, the catastrophizer too readily assumes “I’ll never get it, I’m just stupid in math” and gives up trying. If turned down by an attractive stranger for a date, the catastrophizer too readily concludes “I’m just a loser with women” or with men and stops approaching potential dating partners and mopes inside his or her residence hall room wondering. In this fashion, generalized or free-floating anxiety often precedes or is accompanied by some form of depression.
Generalized anxiety rarely resolves itself on its own, yet is one of the conditions most successfully treated in a therapy or counseling setting.
Few events in the realm of human experience are as terrifying as a full-blown panic attack. Combat veterans who have experienced a panic attack for the first time have said that they would have preferred combat all over again to another panic attack.
One of the worst features of panic attacks is that the individual experiencing them typically becomes sensitized after the first attack. In other words, after experiencing a panic attack once, you become much more vulnerable to experiencing them again and again. After about ten panic attacks, you are exceptionally vulnerable to experiencing panic attacks on a daily or even on a multiple times per day basis.
Panic attacks quickly become debilitating, in that they sharply interfere with the average individual’s performance of everyday life activities. Persons experiencing multiple panic attacks in the course of a week are at extreme risk of developing an even more serious anxiety disorder known as agoraphobia. The person becomes so afraid of experiencing yet another panic attack that he or she refuses to leave his or her apartment, dorm room or house.
The symptoms of a panic attack
The symptoms of panic attack are often felt as strange and are usually interpreted as catastrophic:
- A sense of impending death or insanity
The individual experiencing the beginning of a panic attack usually feels as though he or she is on the verge of dying or of losing his or her sanity. The ability to concentrate is severely impaired, and the variety of other symptoms that begin to arise are so unusual that the individual experiencing them typically concludes they are catastrophic. Unfortunately, this sense of impending doom usually makes the panic attack much worse and more intense.
- Pronounced shakiness in the hands and legs (rubber legs)
As a panic attack progresses, the individual may notice extreme difficulty writing, handling small objects or even holding a cup of coffee without spilling it. There is oftentimes a feeling of extreme weakness and instability in the legs and a fear that they might not hold you up. Attempting to relax using the standard relaxation techniques usually doesn’t work at all, and simply serves to heighten the feeling that something truly dreadful and probably fatal is going on.
- Rapid heartbeat (tachycardia)
As the individual experiences the panic attack intensifying, he or she may suddenly notice his or her heart beginning to beat at a very rapid pace. Heart rates of 140, 160 or even 180 beats per minute are common during the course of some individual’s panic attacks. Noticing this, this individual may logically but incorrectly conclude that he or she is having a heart attack. Unfortunately, this conclusion usually makes the panic attack even more intense.
- Skipped or extra-strong heartbeats (extrasystoles)
As the panic attack gets underway, many individuals experience what they describe as their heart “beating so hard it feels like it might explode” or “beating irregularly, like it’s about to stop.” Experiencing extrasystoles often convinces some individuals that they are having a heart attack, especially when extrasystoles are accompanied–as they frequently are–with tightness in the chest and sometimes even pain shooting down the left arm. Again, believing one is on the verge of a heart attack intensifies all the symptoms of a panic attack. Many individuals experiencing both tachycardia and extrasystoles go to an emergency room fearing they’ve had a heart attack. In some cases, emergency room physicians who were not knowledgeable about panic attacks belittled their patients after an electrocardiogram (EKG) showed no signs of cardiac disease. More frequently these days, however, emergency department personnel are better informed about the symptoms of panic attack and can make some helpful interventions to the individuals reporting there.
- Intense pressure in the chest, or a sudden intense feeling of “my heart jumping out of my throat” (antiperistalsis)
When these symptoms are accompanied by the rapid heartbeat, especially if it skips beats a couple of times, the individual quickly reaches the frightful conclusion that he or she is experiencing a heart attack. Not understanding the true nature of the symptoms, the individual tries to make sense of them as best he or she can.
- Suddenly very cold or sweaty hands or feet
The individual who notices cold hands or feet might try to “warm them up” and become increasingly anxious when they don’t warm up. The individual experiencing sweaty palms might try repeatedly to wipe his or her hands off, only to fail to dry them. This experience often leads the anxious individual to mistakenly conclude something catastrophic is happening medically.
- An intense “pins and needles” feeling in the hands, feet or face (paresthesias)
Persons who become acutely aware of the “pins and needles” or “face falling asleep” feeling easily reach the mistaken conclusion that they are having a stroke or other neurological catastrophe. Some fear they are on the verge of becoming paralyzed. Frequently the pins and needles sensation begins in the hands or cheeks, and begins to intensify and progress to the feet, earlobes, up the arms and up the legs. As the sensations progress, the individual panics even more.
- Loss of focal vision and focal hearing; a “darkening” of the field of vision
Individuals experiencing panic disorder frequently describe losing the ability to read. They frequently describe a loss of three-dimensional vision, describing their field of vision as “flat” or “as though everything is being projected on the inside of a ball where I’m floating in the middle of it”. The individual’s sense of vision is sometimes reported as simply “weird” or “unreal”, yet unusually vivid and intense. Sounds are frequently reported “as though they are coming from inside a barrel or from inside a conch shell”. Occasionally sounds are described as exceptionally clear and distinct, while overall, everything seems peculiarly and intensely quiet. In intense situations, the individual might have the sensation that “everything is going dark”, and may have the fear that he or she is about to lose consciousness. People who have fainted in the past are aware of the sensation of “the lights going out” that preceded their fainting episode. Persons experiencing panic attack have exactly that same experience, except they usually do not know what is going on.
Panic attacks are typically misinterpreted according to the person’s past experiences
Often, people who are especially aware of their loss of focal vision and hearing, or who have experienced a “darkening” during their panic attack start to conclude that they are having either a stroke or the beginnings of a “nervous breakdown.” Those individuals who have experimented with hallucinogenic drugs in the past such as LSD, mescaline
(“shrooms”), psilocybin or marijuana frequently conclude they are having a drug “flashback” that is a sign of permanent brain damage.
In the past, unfortunately, there were many psychiatrists and mental health workers who agreed with both those individuals who were afraid they were having a “nervous breakdown” or psychotic decompensation, as well as those individuals who feared they were brain damaged and suffering from flashbacks.
Panic disorder is much better understood professionally nowadays
Nowadays, however, as the symptoms of panic disorder are much better understood than they used to be—even in the mental health profession—inaccurate and inappropriate diagnoses are much less frequent, and help for the underlying panic disorder is more readily made available.
Panic attacks are extremely treatable! Martin Seligman, one of the foremost researchers in the field of psychotherapeutic effectiveness, writes that panic attack is one of those conditions that best responds to counseling. It is extremely important, if you have experience panic attacks, for you to come into Counseling Services and begin talking with a counselor. This is one of those conditions that usually just gets worse if you try and ignore it or try and deal with it all on your own. At the same time, it is also one of those conditions that starts to clear up rather quickly when help is sought right away and the underlying physiology of panic attacks are better understood and experienced for what they are. Relaxation techniques, done in the knowledge of what a panic attack is, are then very effective.
Individuals who have experienced repeated panic attacks frequently risk developing agoraphobia. While the literal meaning of agoraphobia is “fear of the marketplace,” a better working definition is “a morbid fear of going out in public.”
The individual with agoraphobia classically has the intense fear that if he or she has a panic attack in front of other people, that those other people will mock, judge or humiliate that person to the point where that person’s social image and reputation will be ruined forever. Sometimes agoraphobia takes another tack: some people who have experienced panic attacks fear that they will “have a heart attack” or some other catastrophic medical event while out in public and fear the public loss of control associated with such an event. This is especially true if the individual is called upon to make some kind of public presentation, such as a speech, or is required to voice his or her in an open forum. Frequently agoraphobia is also associated with public claustrophobia. The individual is afraid to go on elevators (for fear the elevator will get stuck and that they’ll have a panic attack and be “trapped” inside unable to get relief) or fly on an airplane (because they might have a panic attack in flight and again be “trapped” until landing).
As a result of their fears of having a public panic attack, the agoraphobic individual soon restricts his or her movements until they typically refuse to leave their home or apartment. They frequently rely on parents, spouses or friends to do their shopping for them, and restrict their movements increasingly until they are completely isolated.
Clearly, agoraphobia is a debilitating condition, one that can easily subvert a Tech student’s studies and academic career.
Fortunately, the early stages of agoraphobia are correctable if the person receives counseling. If the agoraphobia progresses to the point of near or complete isolation, however, the student is probably best advised to withdraw from school at the present time, go home and, in his or her home environment, receive intensive professional help.
Students who are in the early stages of agoraphobia can readily be helped by coming into Counseling Services and working on their condition. Frequently this condition can be resolved without any significant disruption of the given student’s studies. Students who are already experiencing full-blown agoraphobia, on the other hand, probably need to take time off from college and work with a professional near home to resolve the condition to the point where they can return to Michigan Tech and have a reasonably optimistic chance of success. Students recovering from agoraphobia can benefit immensely from coming into Counseling Services for follow up, confident that by teaming up with one of the CS counselors there is minimal chance of a relapse.
- A sense of impending death or insanity