Anxiety, Phobias, and Panic

If you purchase this book without a cover you should be aware that this book may have been stolen property and reported as "unsold and destroyed" to the publisher. In such case neither the author nor the publisher has received any payment for this "stripped book."

Note: The ideas, procedures and suggestions contained in this book are not intended as a substitute for consulting with either a physician or psychotherapist. You should regularly consult a physician in matters relating to your health and particularly in respect to any symptoms that may require diagnosis or medical attention. Likewise, if you feel desperate and are unable to cope with stressful events, you are urged to seek help from a qualified psychotherapist.

Warner Books Edition

Copyright © 1988, 1992, 1995, and 2005 by Reneau Z. Peurifoy, M.A., M.F.T.

The circumstances of certain events depicted and the names of individuals have been altered and/or deleted to protect the privacy of the people involved.

This Warner Books edition is published by arrangement with the author.

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First eBook Edition: September 1995

ISBN: 978-0-446-55461-9

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Acknowledgments

There are many people who have made this book possible. First, I would like to thank the clients who have worked with me. Through their struggles with anxiety, they helped perfect the program outlined in these pages. Next, I would like to thank the people who read the various drafts of the manuscript for the first edition. Kris Baxter, Carole Sabo, Joyce Herman, Dorothy Lambert, and Jann McCord labored through the first drafts and offered many suggestions on both content and format.

After the first drafts were revised, Alissyn Link, Lucille De Rose, Jane Fry, Mary Ann Kinyon, Linda Kenney, and my mother, Clara Peurifoy all made extensive suggestions on style and format. Kim and Kevin Thompson managed the actual page layout and production of the first edition. Alissyn Link, Dr. Frank Capobianco, Jane Fry, Nancy Morris-Struben, and Kaaren Smith all helped with the revisions for the second edition. I would also like to thank Shirley Green, founder of ABIL (Agoraphobics Building Independent Lives, which is a large self-help organization in Richmond, Virginia), who has offered much encouragement and support.

In regard to the most recent, revised edition of the book, I'd like to thank the many people who have made it possible. My agent, Barbara Zitwer, worked with my editor, Diana Baroni, to create this update. Melissa Carney, Danielle Seadia, Keiloni Bruner, and Patricia Popp volunteered to read the revised lessons as they were completed and offered many suggestions for improvements. Laura Jorstad, the copyeditor, did a superb job of editing the final text. My greatest thanks goes to God, who has blessed me richly over the years and provided me with the abilities, opportunities, and insights that have allowed me to make this book what it is.

Finally, I would like to thank my wife, Michiyo. Without her support this book would not have been possible. Because her love and companionship have helped sustain me, I dedicate this book to her.

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LESSON 1

What, Why, and How

Congratulations! You are about to start a journey along the path to freedom. During this journey you will meet many people just like yourself. Like most who traveled this path before you, your first questions are probably: "What has happened to me?" "Why me?" and "How can I overcome these anxiety-related problems?" This lesson answers the first two questions and starts you on the path that leads to freedom from anxiety-related problems.

I'm Not Alone

People with anxiety-related problems often feel that they alone suffer from this problem. Nothing could be further from the truth. The National Institute of Mental Health (NIMH) ranks anxiety disorders as the most common mental health problem in the United States. The NIMH has found that more than nineteen million adults suffer from anxiety-related problems. While reliable figures for the number of children and adolescents suffering from anxiety-related problems are not currently available, it is now known that they can also develop anxiety-related problems. Anxiety-related problems will also frequently occur with other issues such as depression, eating disorders, and substance abuse. The following table, based on statistics from the NIMH, shows how common the six basic types of anxiety-related problems are:

NUMBER OF AMERICANS EXPERIENCING AN ANXIETY-RELATED PROBLEM IN A GIVEN YEAR

	Population Estimate(in millions)	Percentage
Panic disorder	2.4	1.7
Obsessive-compulsive disorder	3.3	2.3
Post-traumatic stress disorder	5.2	3.6
Specific phobia	6.3	4.4
Social phobia	5.3	3.7
Generalized anxiety disorder	4.0	2.8

One of the big changes that has taken place since I first began working in this field is that most medical personnel are now familiar with the different types of anxiety-related problems that people can experience. As a result, most of the readers of this book who suffer from an anxiety-related problem will have already been diagnosed and read some literature that describes their specific problem. If you have not been formally diagnosed, however, or if you are reading this book because a friend or relative suffers from anxiety, descriptions of each of the above anxiety disorders are given in Appendix 1.

Anxiety and Fear

Anxiety and fear are normal responses to a perceived threat. For the purposes of this program, anxiety and fear are considered as opposite ends of a spectrum. Anxiety is usually triggered by a vague or ill-defined threat, while fear is usually triggered by a well-defined threat, such as a car skidding on wet pavement. This relationship between anxiety and fear can be diagrammed as follows:

Both anxiety and fear trigger unpleasant mental symptoms such as a sense of helplessness, confusion, apprehension, worry, and repeated negative thoughts. Both also trigger physical symptoms ranging from simple muscle tension to a pounding heart. The full range of possible symptoms is listed in the description of panic attacks that follows. (The next two sections describe the different symptoms that characterize anxiety along with some of the medical causes of anxiety. Some find that reading about anxiety-related symptoms makes them overly anxious. If this is true for you, you have been diagnosed by a therapist who understands anxiety-related problems, and you know the specific type of anxiety-related problem you have, feel free to skip ahead to the section titled The Fight or Flight Response.)

Panic Attacks

A panic attack is an intense state of fear that occurs for no apparent reason and is characterized by four or more of the following symptoms:

•  Shortness of breath (dyspnea) or smothering sensations.

•  Dizziness, unsteady feelings, or faintness.

•  Palpitations or accelerated heart rate (tachycardia).

•  Trembling or shaking.

•  Numbness or tingling sensations (paresthesias), usually in the fingers, toes, or lips.

•  Flushes (hot flashes) or chills.

•  Chest pain or discomfort.

•  Fear of becoming seriously ill or dying.

•  Fear of going crazy or of doing something uncontrolled.

•  Sweating.

•  Choking.

•  Nausea or abdominal distress.

•  Feelings of unreality (depersonalization or derealization).

An attack with fewer than four of the above symptoms is called a limited symptom attack. Panic attacks can build gradually over a period of several minutes or hours or strike very suddenly. While they can last from a few minutes to several days, most do not last longer than half an hour.

When anxiety or panic is felt regardless of where one is, it is called spontaneous anxiety or spontaneous panic, depending upon the degree of intensity. If the anxiety or panic occurs only in a particular situation, it is called situational or phobic anxiety or panic. If anxiety or panic is triggered simply by thinking of a particular situation, it is called anticipatory anxiety or anticipatory panic.

Medical Causes of Anxiety

The first step in overcoming any anxiety-related problem is to rule out possible medical causes by having a complete examination by a physician. There are many medical conditions that can cause one or more of the symptoms associated with anxiety such as cardiovascular problems, asthma, seizure disorder, diabetes, hypothyroidism, and problems with the inner ear. Medications such as stimulants, thyroid supplements, cold medications, tranquilizers, sleeping pills, certain blood pressure medications, steroids, and, ironically, antidepressants can also cause anxiety symptoms. Sometimes anxiety symptoms are due to unsupervised experimentation with or withdrawal from a medication. Finally, common legal and illegal recreational drugs, such as caffeine, alcohol, and marijuana, provide yet another potential source of anxiety symptoms.

While identifying possible medical sources of anxiety is important, you may find that resolving the medical issue by itself will not end your anxiety-related problems. As you will see later in this chapter, anxiety that starts out as a medical condition often takes on a life of its own and continues long after the medical condition is no longer present. It is essential, then, to work both with any medical condition that might be triggering anxiety as well as with the thinking patterns and behaviors that can keep anxiety active without the initial medical condition.

The Fight or Flight Response

Like all of your body responses, the various anxiety-related symptoms described above are controlled by your nervous system. This system is divided into two parts: the voluntary nervous system and the autonomic nervous system. The voluntary nervous system, also called the somatic system, is composed of the nerves that connect to the muscles that control movement and your various senses. This system sends information from your eyes, ears, and other senses to the brain and controls actions that require thought, such as raising your arm or walking. The autonomic nervous system is composed of all the nerves that connect to your internal organs and glands and controls all the automatic activities that occur in your body, such as digestion and breathing. The autonomic nervous system is itself broken down into the sympathetic and parasympathetic divisions. The sympathetic division, responsible for what is commonly referred to as the fight or flight response, is designed to activate the body quickly and prepare it to fight or flee from danger almost instantaneously. When the danger has passed, the parasympathetic division quiets the body and returns it to normal functioning. These two divisions of the autonomic nervous system can be diagrammed as follows:

Sympathetic division: regulates your fight or flight response Autonomic nervous system

Parasympathetic division: regulates the "resting" functions in your body such as growth, digestion, relaxed breathing, etc.

When triggered, the sympathetic division of the autonomic nervous system suspends all nonessential activity in the body and increases activity in any system necessary to either fight or flee from an external physical threat. This response involves many complex reactions in the body. Some of the most noticeable changes that take place include the following:

•  Accelerated heartbeat: This pumps more blood to the muscles for the impending struggle.

•  Deeper and more rapid breathing: This ensures a large supply of oxygen and is the basis for the panting associated with strong excitement.

•  Increased muscle tension: This prepares the muscles for any upcoming action.

•  Cold sweat: This is in preparation for the warm sweat of actual muscular activity.

•  Constriction of peripheral blood vessels near the surface of the body: This raises blood pressure and is the basis for "blanching with fear."

•  Shivering and raising of hairs: This conserves heat and protects the body from the increased threat of cold caused by the constriction of the peripheral blood vessels.

•  Dilation of the pupils: This permits a better view of threatening dangers and is why eyes are said to be "wide with fear."

•  Suspension of digestive activity: This provides additional blood for the motor muscles.

•  Dry mouth due to decreased flow of saliva: This accompanies the decreased flow of gastric juices in the stomach as digestive activity is suspended.

•  Tendency toward voiding bladder and bowels: This frees the body for strenuous activity.

•  Suppression of the immune system and pain response: This prevents swelling and discomfort, which could interfere with a quick escape.

When the fight or flight response is triggered, it releases increased amounts of adrenaline (epinephrine) and related chemicals into the bloodstream. This response provides the added strength, stamina, and ability to respond quickly that helps soldiers survive in battle, athletes perform better, and people facing dangerous situations respond more effectively. Fortunately, in our modern technological world, we face fewer physical dangers requiring strenuous action than did our ancestors.

The most common threats we face today are psychological threats such as the loss of love, status, prestige, or our sense of belonging and significance. Usually, these losses do not require an immediate physical response. Unfortunately, our bodies respond to any threat as if it does require an immediate physical response. So when you are embarrassed and feel threatened by what others think, your body triggers the fight or flight response and begins gearing up to physically run away or to fight. If you experience a panic attack in this situation, you are actually experiencing an overreaction of the fight or flight response. If you compare the above responses to the list of symptoms of a panic attack given earlier, you will see that each of the symptoms characteristic of a panic attack is simply an exaggeration of one or more of the normal body responses triggered by the fight or flight response.

Brain Circuits That Manage Fear

Information coming into the brain from the senses is processed in two different ways, cognitively and emotionally. Cognitive processing involves conscious thought about what we are experiencing. Emotional processing is designed to alert us to events that are important, whether positive or negative. One of the exciting things that is occurring in research is the pinpointing of the brain circuits where cognitive and emotional processing take place. One of the key structures for processing danger signals at this unconscious, emotional level is the amygdala, two small, very complex almond-shaped structures on either side of the brain. When you experience something fearful or unpleasant, a memory of this is stored in the amygdala. When you encounter this object or situation again, an immediate fear response is triggered. This fear response causes you to experience anxiety and triggers the fight or flight response.

The amygdala is designed to overreact to possible signs of danger. For example, a person living where there are poisonous snakes will quickly learn to associate snakes with danger. The amygdala will then immediately trigger the fight or flight response whenever anything that might be a snake is perceived. After all, if you are walking in the woods, it is better to mistake a stick for a snake than a snake for a stick. Keep in mind that this all occurs very quickly at an unconscious level. This circuitry allows you to react very quickly to danger without the need to consciously think about what is occurring. Unfortunately, events and objects that pose no threat can become associated with danger and trigger a fear response when you encounter them. This unconscious interpretation of harmless everyday situations as danger plays a major role in anxiety-related problems.

Personality Traits That Can Contribute to Anxiety

Research into the personality traits of people who suffer from the various anxiety disorders has had mixed results. There is no welldefined set of personality traits that can be said to produce a particular anxiety-related problem. Instead, there are a variety of ways in which people can develop a wide range of anxiety disorders. With obsessive-compulsive disorder (OCD), physiological factors seem to be far more important than personality or childhood factors. The triggering of post-traumatic stress disorder (PTSD) and specific phobia also seems to be much more dependent upon outside influences than on personality traits. Personality and childhood factors seem to play a larger role in the development of panic disorder, social phobia, and generalized anxiety disorder. In addition, when the traits noted below are present in a person with OCD, PTSD, and specific phobia, they can intensify symptoms and make recovery more difficult.

Several traits that can complicate anxiety-related problems are compiled in the following list. As you read through it, you will probably find that many do not apply to you, or that they describe people you know who do not suffer from anxiety-related symptoms. These are fairly common traits. Still, it is likely that you will find that some do describe you. When this is the case, place a check next to it; this may be an area you need to work on to overcome your anxiety-related problem.

High-Anxiety Personality (HAP) Traits

•  High level of creativity or imagination: People suffering from severe anxiety are often very creative with the ability to imagine things vividly. Unfortunately, this creativity can become a powerful force behind negative anticipation or what-if thinking. The more creative a person is, the easier it is for him or her to think of a host of frightening things that could occur in a given situation. A creative mind can also help a person imagine these frightening possibilities in vivid detail.

•  Rigid thinking: Rigid thinking is the tendency to perceive life as a series of either–or alternatives. Events are either right or wrong, fair or unfair. Another characteristic of this type of black-and-white thinking is the presence of many rigid rules. There is usually a "correct" way to do things, and it is upsetting when things are not done in that correct way. In addition, there are often many things that "should," "must," or "can't" be done by oneself or others.

•  Excessive need for approval: The excessive need for approval is often referred to as a fear of rejection. A person with this trait depends on others for a sense of self-worth, tends to have a heightened sensitivity to criticism, and often finds it difficult to say no to the demands of others. An excessive need for approval can also create the tendency to take responsibility for the feelings of others and to be overly sensitive to their needs. A person with this trait often makes it his or her responsibility to keep friends and relatives happy.

•  Extremely high expectations of self: There is often the expectation of a much higher level of performance and accomplishment from oneself than would ever be expected from others.

•  Perfectionism: Perfectionism is actually a combination of three things: the excessively high expectations mentioned above; the tendency to use all-or-nothing thinking when evaluating one's actions; and a tendency to focus on small flaws and errors rather than on progress or overall achievement. This can cause the perfectionist to consider any less-than-perfect achievement as a failure. He or she then tends to personalize the poor achievement so that both the task and the person become failures. One common way in which this is expressed is the "but" habit. A perfectionist often says things such as, "Overall this project was done well, but…." The perfectionist then dwells on what was wrong.

•  Competent, dependable doer: The interaction of all the above factors often creates a person who is not only competent, capable, and dependable, but also a real doer skilled at getting jobs done and done well.

•  Excessive need to be in control: A person with this trait places a high value on being calm and in control. Often there is also a need for events to be predictable. Unexpected changes in a predetermined schedule cause distress because it is harder to be in control when one is not sure what will happen. There may also be a tendency to try to control the feelings and behavior of others. This is not done with the intention of hurting others, but out of fear of losing control.

A person with the need to be in control can experience fairly intense anxiety symptoms but appear normal to the casual observer. Since a person like this usually presents a "proper" image to the world even when there is tremendous self-doubt and turmoil inside, he or she may be considered to be very strong by friends and relatives.

•  Suppression of some or all negative feelings: A person with the above traits often suppresses feelings that "shouldn't" be felt because they might cause loss of control or disapproval from others. Anger and sadness are two common examples.

•  Tendency to ignore the body's physical needs: This trait is commonly reflected in the attitude that the body is unimportant. Signs that the body is tired, in pain, or in need of rest or care are ignored or given low priority. A person with this trait is frequently only aware of fatigue when the symptoms of exhaustion are present.

I would like to emphasize that the above traits are not necessarily undesirable. This is easiest to see when looking at the opposites for each of the above. Here are a few examples. When used in a positive fashion, creativity is the source of all effective problem solving. The opposite would be someone who is dull and unimaginative. The need for approval is essential for healthy relationships; the opposite would be a person who has no feelings about others. A moderate degree of perfectionism, high personal expectations, and dependability creates a valuable member of society. The opposite would be someone who has little concern about how well a job is done. The ability to maintain control of self and emotions helps a person function well during emergencies and in the midst of chaos. The opposite would be someone who is overly emotional.

As with any given trait a person can possess, there is a healthy range for each of the above. For each trait, some people will be at the low end, some in the middle, and some at the high end. A particular trait creates problems only when it is exaggerated and outside this healthy range.

The key to success is learning how to moderate these traits so they are in the normal range and tap into them only during times when they are appropriate. Learning to use them in this way, and minimizing them during the times they interfere with your life, transforms these traits into valuable assets. In the weeks that follow, much of your time will be devoted to accomplishing this task.

Childhood Experiences That Can Contribute to Beliefs and Traits Associated with Anxiety

Your personality developed from the interaction of seven factors:

•  The values and beliefs of the family in which you were raised.

•  The methods of discipline used to train and socialize you.

•  The role models presented by the adults in your life when you were young.

•  Your place within the family constellation (your birth order; the sex of your siblings; and whether or not you had siblings that died, were handicapped, or joined the family as a result of remarriage or adoption).

•  The social and cultural influences present while you were growing up.

•  Your biological inheritance.

•  The meaning you gave to each of the above while growing up.

There are many ways in which these seven factors can interact to produce the HAP traits described in the previous section. In addition, they shaped your beliefs about yourself, relationships, and the world. Experiences and events that can contribute to the development of anxiety-related problems are listed below. Check any that apply to you.

Childhood Contributors to Anxiety

•  Substance abuse in the family: Many of the coping skills that help children survive in the home of a substance abuser can interfere with their lives as they enter into the adult world. The tendency to rely on their drug of choice to avoid feeling the pain associated with normal life problems can be summarized by the saying, Don't look; don't feel; run away. While children of drug users may lead drug-free lives as adults, they often still cope with problems by avoiding them. This is especially true when problems arise in interpersonal relationships. Instead of acknowledging and dealing with interpersonal problems directly, they often use work, hobbies, sex, or activities to avoid such problems.

•  Child abuse: There are six types of child abuse:

a. Physical abuse: Any nonaccidental injury of a child. This is usually the result of being hit, pushed, whipped, bitten, punched, slapped, or burned.

b. Sexual abuse: Any kind of sexual contact with a child by either an adult or child through the use of coercion, threat, or force.

c. Neglect: The failure to provide basic necessities such as clothing, shelter, medical attention, or supervision.

d. Cruel and unusual punishment: A punishment that is extreme or inappropriate for a child's age or ability to understand. Examples include corporal punishment that results in injury, locking a child in a closet, forcing a child to toilet train at six months, and sitting a child in a corner for hours at a time.

e. Emotional neglect: Failure by a parent to be emotionally available to take an interest in, talk to, hold, or hug a child.

f. Psychological abuse: Any form of recurring communication that causes extreme and unnecessary mental suffering. Examples include name-calling or belittling, blocking a child's efforts to accept himor herself, and threats of abandonment.

People with anxiety who have also experienced any of the above forms of abuse often find that the habit patterns and beliefs that developed as a result of the abuse contributed to the development of their problem and also hinder recovery.

•  Anxious parental role model: When a parent suffers from severe anxiety, has fearful beliefs, or has many of the personality traits listed above, a child can develop many of those beliefs and traits as a result of modeling after the parent.

•  Critical parent or family member: Excessive criticism often comes from a perfectionistic parent with unrealistic expectations. A parent like this often demands adult behavior and capabilities beyond the child's ability. Sometimes excessive criticism or teasing can come from a jealous brother or sister. The result for the child is often a poor self-image and the belief in his or her inadequacy.