by Jennifer Lee
Social Anxiety, Claustrophobia, Agoraphobia, and Separation Anxiety, all of which we will discuss in detail in Chapter 3
Generalized Anxiety Disorder (GAD), an anxiety condition that often takes the form of worrying about the implications of normal, everyday decisions. People with GAD often report feeling plagued by anxious concerns about their own health, about money or financial troubles, about their relationships with friends, family members, or significant others, etc. Many struggles with decisions that are, for other people, simple parts of everyday life, such as paying bills on time, making meals, etc.
Obsessive-Compulsive Disorder (OCD), a form of psychological disturbance in which people feel the need to engage in repetitive tasks and become excessively focused on minor details. For people with OCD, these repetitive tasks often become essential to feeling a sense of personal safety, and they can experience severe anxiety when their ability to perform these tasks is interrupted. For this reason, OCD is often considered alongside – or under the heading of – anxiety disorders.
While all of the anxiety-related disorders we have considered above are distinct, it is important to understand that they have a high degree of co-morbidity. This means that they often appear alongside one another, in the same person. People who experience PTSD, for example, or one of the phobias listed above, may also come to exhibit symptoms of panic disorder, because their phobias may lead to panic attacks. By the same token, people with panic disorder may come to exhibit other phobic responses. This happens because their fear of having more panic attacks leads them to become afraid of being in situations they find frightening for other reasons, and which they, therefore, begin to fear might induce a panic response in them.
So too, anxiety disorders often appear alongside with Substance-Abuse Disorder. This happens both because people may seek to self-medicate with drugs or alcohol in order to dull their anxiety symptoms, or – in cases where the line of causality flows in the opposite direction – because consumption of psychotropic drugs disrupts people’s normal neurochemistry and leads to other psychological symptoms.
Finally, anxiety disorders have features in common with depression, bipolar disorder, and related psychological problems. Some of these similarities will be discussed in more detail in Chapter 3.
Good to Know: How Common is Anxiety, Really?
To remind yourself that you are by no means alone in suffering from an anxiety-related disorder, it might be helpful to look at some recent public health surveys of the incidence of various mental disorders. One such recent study shows the relative incidence rates of different forms of anxiety. This survey shows that the most common form of anxiety is a specific phobia (including claustrophobia) and that nearly 14% of people suffer from this condition in the course of a lifetime. The next most common form is social anxiety, which 13% of people reportedly experience in the course of a lifetime.
Overall, nearly 34% of people will experience some form of anxiety disorder in the course of their life, or about one out of every three people. Here is a chart showing the relative prevalence of various kinds of anxiety disorder in the general population:
Source: Data on relative incidence rates taken from the National Comorbidity Survey-Replication, as reported in Bandelow, Borwin & Michaelis, Sophie. (2015). Epidemiology of anxiety disorders in the 21st century. Dialogues in Clinical Neuroscience. 17. 327-335. Chart created for this book.
What Causes Anxiety?
The first and most important thing to know in looking for the causes of your anxiety is that it is not the “fault” of any particular person. You are not to blame for your anxiety, nor is any other person or event necessarily responsible. While some forms of anxiety disorder – such as post-traumatic stress disorder – are often linked to particular triggering events from a person’s past, many other forms of anxiety have no relation to anything that a person experienced before.
Bearing this in mind, there are some habits that seem to be linked to anxiety disorders – at least in some cases. Having frantic, fast-paced work habits, for example, which interfere with a person’s ability to maintain a regular sleep schedule or enjoy sufficient leisure time and quality time with the significant people in their lives, can trigger or exacerbate the symptoms of an anxiety disorder.
So too, prolonged abuse of psychotropic substances (which can include both illegal narcotics and controlled prescription drugs, when these are used excessively and without medical oversight) can also affect a person’s brain chemistry in unanticipated ways.
Just as often, if not more so, however, anxiety is not linked to any particular behavior, habit, or lifestyle. Anxiety symptoms often first begin to manifest during a person’s early adulthood – a time when the brain is still undergoing major biochemical changes, as the pre-frontal cortex finishes developing and a person’s neural system is transitioning from its adolescent to adult form.
Oftentimes, therefore, anxiety symptoms may simply be related to difficulties regulating one’s emotions and making the adjustments to the natural processes happening in one’s brain, and to the lifestyle changes involved in early adulthood.
Genetic factors – that is, traits inherited from the genes of one’s biological parents – may also play a factor in predisposing people to anxiety or related disorders. On the other hand, it is important to remember that even people with a genetic predisposition to anxiety-related conditions are capable of successfully treating and managing anxiety. With anxiety and panic, as in other parts of life, genes are not destiny.
There are also Physical, Neuro-chemical Causes of Anxiety Disorders.
Ultimately, the things that happen inside the human brain are still somewhat mysterious to us. While enormous progress has been made in neurochemistry in recent years, the precise way in which the chemicals inside the human brain influence our emotions and behavior is still a subject for further investigation and research. We know, however, that imbalances of certain important chemicals in the brain, such as noradrenaline and serotonin, are directly related to anxiety disorders.
Good to Know: The Chemical Side of Anxiety
Noradrenaline chemical structure. Source: Wikimedia Commons. This image is in the public domain.
Noradrenaline, also known as norepinephrine, is – as the name implies – closely related to the chemical adrenaline (which is also referred to as epinephrine). You may have heard of adrenaline since it has entered our everyday language through phrases such as having “a rush of adrenaline.”
Basically, both adrenaline and noradrenaline are chemicals that operate as neurotransmitters in the body. Neurotransmitters are key to performing all muscular and bodily tasks because they are the chemicals that carry messages from the brain to other parts of the body in order to trigger them to engage in certain actions.
The body produces both adrenaline and noradrenaline, specifically when it is engaged in what’s known as the “fight or flight response.” This response evolved in humans, as in other animals, in order to help us respond to imminent danger. It leads to a racing heart rate, hyper-focused awareness, rapid breathing, and other physical indicators that we associate with the emotions of fear, tension, and the need to make rapid, instantaneous decisions concerning our safety (such as whether to fight or to flee).
During a state of anxiety or a panic attack, the body is essentially kicking the “fight or flight response” into overdrive, even though there is no actual threat, and you are not in any danger. This response causes the body to produce noradrenaline, which transmits only to “alpha” receptors, which are located in the arteries, and adrenaline, with transmits to “beta” receptors in the heart, lungs, and elsewhere in the skeletal and muscular structure.
This is why fast-acting medications that halt the immediate effects of panic attacks are called beta blockers. These medications interfere with the effects of adrenaline on beta receptors – in order words, blocking the chemical from having its full impact on the heart and lungs, and thereby decreasing one’s heart rate
and rate of breathing. We will discuss these in greater detail in Chapter 5.
The effects of adrenaline/epinephrine are therefore somewhat more extensive than those of noradrenalin/epinephrine because they affect more parts of the body. By affecting alpha receptors, noradrenaline can cause blood vessels to constrict (which make it a useful chemical for treating low blood pressure, but a potentially harmful one for people experiencing high blood pressure). Adrenaline, meanwhile, can lead to heightened heart rate, rapid breathing, and the other physical indicators we discussed above, which are associated with the “fight or flight response” and which show up during panic attacks.
While the body is often producing too much adrenaline and noradrenaline during a panic attack, however, it is important to understand that these are not “bad” chemicals, and treating your anxiety through medication that “blocks” the effects of adrenaline is only a short-term way to mitigate a panic attack, not a long-term method of treating the causes of anxiety.
Adrenaline and noradrenaline are essential and useful chemicals in the way the body regulates its emotional and physical responses, and it is an imbalance of these chemicals that leads to mental disturbance, not their mere presence. Indeed, low levels of noradrenaline have also been linked to anxiety and depression, even though the body is often flooding you with noradrenaline in the moment of a panic attack.
Serotonin chemical structure. Source: Wikimedia Commons. This image is in the public domain.
Much the same applies to serotonin, which is a chemical often implicated in cases of anxiety and depression. Like noradrenaline and adrenaline, serotonin is a neurotransmitter. This means it carries messages from the brain that help instruct other parts of the body to carry out specific functions. While much about the action of serotonin remains mysterious and a subject of controversy, it is generally understood that the functions serotonin triggers in the body are those related to happiness and well-being, such as social responses, positive feelings, natural sleep patterns, and sexual responses.
Low levels of serotonin, therefore, have been linked to mental disorders associated with feelings of depression and anxiety. Having too little serotonin is also believed to be linked to migraine headaches, as the great author Joan Didion describes in one of her essays, “In bed,” published in her collection The White Album. (This essay is definitely recommended reading for anyone suffering from anxiety and panic attacks, as the symptoms are very similar to the experience Didion describes when treating of her own lifelong struggle with recurring migraine headaches.)
Again, it is important to understand that serotonin is not simply a “happiness” chemical. While low levels of it are linked to anxiety and depression, these conditions cannot be simply treated by infusing large amounts of serotonin into the body, and antidepressant medications operate in far more complex ways than that. As we saw above, the important thing in neurochemistry is maintaining a balance between the various chemicals our brains need to function. Too much or too little of any can cause serious mental disturbances. As the great American author Jack London once wrote, in words that still ring true a century later, speaking of the “laws of organic chemistry” in the body: “One pays according to an iron schedule—for every strength the balanced weakness; for every high a corresponding low.”
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Understanding these and other potential causes of anxiety can be helpful in deepening your awareness of what is happening inside your mind. At the end of the day, however, the causes of anxiety are a lot less important than what we can do about it in the future. Always remember: regardless of where a particular person’s anxiety came from, or how it started, many of the same methods for treating and managing anxiety will still apply.
In the earlier days of the practice of clinical psychology, psychotherapists often devoted much more attention to discovering where particular mental disturbances came from, and how they originated in a given person’s case (in medical terms, this is known as the etiology of an illness). Influenced by Freudian psychoanalysis, many earlier practitioners of psychotherapy believed that it was important to isolate particular triggering events or symbols in a person’s past that first induced them to develop a mental disorder (or neurosis, in Freudian terms).
Over time, however, these methods bore little fruit. Modern clinical experience has shown that tracing mental illnesses back to earlier events in a person’s biography often has little impact on their ability to recover from them in the present. Human memory, moreover, is extremely malleable, meaning it is subject to change, and the events of one’s past do not determine one’s present and future.
Finally, dwelling on earlier occurrences can even be counter-productive; as it can lead to people feeling trapped by the past and can reinforce the memory of traumatic events.
Meanwhile, modern clinical practice has often shown that enormous progress can be made even when a patient has no knowledge of any earlier event that could have led to symptoms of anxiety, panic, or related phenomena.
Contemporary psychotherapists are therefore a lot less concerned with a person’s past than they are with the future. Modern-day professionals do not go looking for “recovered memories” through hypnosis; nor do they interpret dreams or sexual symbols from a person’s childhood, or look for “archetypes” in a supposed “collective unconscious.” Indeed, many clinical psychologists today would consider those practices to be forms of pseudoscience.
Many of the clichés associated with mental health professionals in our popular culture, in other words, are badly out of date.
Contemporary clinical psychology focuses on how people can get well in the here and now. In particular, it is interested in how people can alter their thought processes and behavioral patterns in ways that help them achieve greater happiness, freedom, and autonomy in their daily lives. Many of the methods used most often by psychotherapists today fall under the heading of cognitive behavioral therapy, which we will discuss more fully in subsequent chapters.
Chapter 3: What is a Panic Attack?
In technical term used by most mental health practitioners – and found in such important reference works as the Diagnostic and Statistical Manual of Mental Disorders, or DSM – anxiety, and panic disorder are distinct. Specifically, panic disorder is one particular form of a variety of conditions that fall under the heading of anxiety disorders.
As we saw above, however, the various forms of anxiety disorder often overlap and can bleed into one another. A person may experience a specific phobia or fear – such as a fear of dying, social phobia (a fear of being on display, of making a fool of oneself, etc.), fear of losing control of their actions, etc. – which causes them to experience a panic attack in a particular situation. They then become afraid of having another panic attack, and so they start to engage in avoidant behaviors so as to escape the kinds of situations that originally provoked the attack.
Having an occasional panic attack in the course of your life is not necessarily a sign of a disorder or a larger problem. Moreover, it is completely normal to experience times of fear, anxiety about the future, and stress in the ordinary course of living. If panic attacks are becoming a recurrent feature of your life, however, and if you are engaging in behaviors to avoid them that are preventing you from living your life fully or are blocking you from the things you would like to do, then it might be time to seek help from a therapist or other mental health professional.
Why Do I Get Panic Attacks?
In the case of anxiety disorders in general, the reasons why some people and not others develop panic disorders are not easy to pin down. Your panic attacks may be related to other anxiety or depression-related disorders; if you suffer from PTSD, these attacks may have been triggered by a past traumatic event; they may be the result of genetic factors or elements of your current lifestyle; they may be due to nothing more than your individual personality traits.
Prolonged stress of any kind has been linked to panic disorder, and it is important to understand what I
mean by “stress” in a therapeutic context. Many of us refer to being “stressed out” loosely in contexts where we are working hard and feel very busy.
What stress really is, however, is not just a sense of putting in a lot of effort at something, but the sense that something in our lives is beyond our control. When people spend large parts of their lives without a sense of basic control over what is happening to them, this can lead to what physicians call toxic stress. This can be very bad for your overall mental wellbeing because it holds the brain in a state of constant “fight or flight” response and prevents you from performing the other cognitive tasks that are essential to higher functioning and human happiness. (For this reason, children who experience poverty, hunger, abuse, or other forms of deprivation often have a harder time concentrating at school than their peers, and may fall behind their classmates, compounding the other difficulties they face.)
Prolonged or toxic levels of stress may be caused by poverty or financial difficulties, conflict or instability in core interpersonal relationships, abusive or controlling partners or ex-partners, unhealthy and exploitative work environments, and similar situations in which we feel we are losing control of our lives.