15 insights into anxiety and how to manage it
Anxiety disorders, both social and general, can be highly distressing and debilitating conditions. Dr Harry Barry explains why they occur and how to manage them
1 fear versus worry
It is extremely useful to divide the world of anxiety into two - the world of 'fear' and the world of 'worry'. Fear relates to a perception that there is some immediate danger present in our environment which presents itself as an extreme threat to our safety. It is also associated with major physical bodily responses. Fear is the key to panic attacks and phobias.
Worry is where we begin to reflect on and become anxious about possible dangers or unpleasant possibilities that might happen in the future. And this too can be accompanied by associated secondary physical responses. Worry is the key to general anxiety and social anxiety.
2 What is a Panic Attack?
A panic attack is when a person develops a sudden bout of acute anxiety with some, or all, of the following physical symptoms:
• Profuse sweating
• Palpitations (fast heartbeat)
• Dry mouth, stomach in knots
• Weakness, feeling faint
• Headache, muscle tension
• Chest pain
• Hyperventilation (rapid, shallow breathing)
• Trembling or shaking
• Fear of losing control or going mad
• Sensation of choking
• A feeling one is going to die.
They usually occur in bursts, are unexpected and have, at first glance, no obvious cause. They are frightening and more common in women than men. They may be singular events but, in most cases, are recurrent in nature.
3 Why are Panic attacks a problem?
People with panic attacks fail to understand that they are simply having a bout of acute anxiety. The person assumes that the physical symptoms they are experiencing are indeed precursors to some serious potentially life-threatening illnesses, such as heart attacks or strokes.
Many with panic attacks cannot understand why there is no obvious trigger. The pattern of attacks may continue for a long time, until the person is convinced by somebody that the symptoms are simply due to panic attacks. Even when they do believe this to be the case, they remain constantly anxious that the panic attacks will recur. They may feel that they are either going mad, or going to lose control, if the symptoms keep happening.
4 What is the amygdala?
The amygdala is an ancient little organ in our emotional brain whose job it is to see or sense danger and 'fire'. It keeps us alive when faced with danger by firing our stress system to pump out, for example, our fear hormone, adrenaline. It is this hormone that makes us feel our stomach in knots, our heart going quicker, our breathing faster, our mouth dry, muscles feeling tense and general feelings of dread. These were the symptoms this author felt when he met a leopard at night while running a hospital in rural Tanzania!
5 Why do we call it the 'gunslinger'?
We call the amygdala the gunslinger of the stress system - as it shoots from the hip often without thinking and does not really worry about the consequences. The gunslinger is not particularly smart, has a long memory, does not respond to normal talk therapies and regularly disregards instructions from head office, or our logical brain.
In general, if the danger is seen as major, as in panic attacks, it fires at maximum capacity and the physical symptoms generated by our stress system will be full on but of shorter duration. If the danger is lesser, as in general and social anxiety, it will fire less and the physical symptoms we experience will be lesser but more persistent.
6 Why is the amygdala the key to understanding panic attacks?
Panic attacks are due to an adrenaline rush created by the gunslinger firing inadvertently and seemingly without warning. This causes all the physical symptoms of the attack. It does so because we are assigning danger to the initial physical symptoms experienced at the start of the attack.
We now know that the amygdala or gunslinger only responds in panic attacks to a concept called 'flooding'. This involves learning how to go with the physical symptoms caused by the adrenaline rush. This resets the amygdala and the gunslinger settles down. Panic attacks become a thing of the past.
7 What is General Anxiety Disorder?
People with general anxiety live in a world of constant worrying about what might happen in their lives. This is associated with a stream of physical symptoms such as fatigue, difficulties with concentration, irritable bowel, tension headaches, teeth grinding, sighing constantly, sleep difficulties and constantly being on edge. It can also be associated with procrastination, avoidance of tasks; trying to do everything perfectly and trying to self-manage the physical symptoms with alcohol or tranquillisers.
8 What is going on in our minds in General Anxiety?
At the heart of general anxiety is a demand for complete control in our lives and a tendency to rate ourselves as failures when we cannot achieve this impossible demand. This leads us to a fruitless search for certainty, order and perfection which makes us constantly anxious and leads to all of the typical avoidant and safety behaviours.
We end up worrying and catastrophising as to what might or might not happen. The difficulty lies in the power of our inner emotional mind to completely overpower our more logical mind.
9 What goes on in our brain in General Anxiety?
Two parts of our brain are causing the cognitive difficulties: the right prefrontal cortex - the catastrophiser - is the part of the logical brain which creates the catastrophic visualisations that are so common in anxiety. Meanwhile, the left prefrontal cortex - the worrier - is the part of the logical brain creating all the worrying possibilities of what might happen in the future, for example, where I am excessively worrying about developing some major illness with little or no evidence to back this up. Both cause the amygdala (particularly the catastrophiser) to fire.
10 How can we reshape our anxious mind and brain in General Anxiety?
Apart from the usual lifestyle changes of exercise, nutrition, alcohol moderation, yoga and mindfulness, some simple CBT (cognitive behaviour therapy) exercises can teach us to challenge our demands for control and our tendency to rate ourselves. It can also help us to completely change our behaviours when we do get very anxious. This will involve challenging avoidance, procrastination, seeking perfection and avoiding Dr Google.
11 What is Social Anxiety?
In social anxiety, we are anxious and embarrassed in case people will pick up some signs that we are anxious and end up judging us as inferior as a result. Once again, it is associated with very distressing catastrophic visualisations in our mind and with physical symptoms which are very uncomfortable.
12 What is going on in our mind in Social Anxiety?
Typical thoughts/beliefs might be:
• 'I have nothing interesting to say and I am boring'
• 'I will make a fool of myself. They will all notice and judge me'
• 'I will be paralysed with fear'
• 'They will see me blushing or sweating'
• 'They will see in my eyes I am anxious'
• 'They will see me fidget with my hands or feet'
• 'They will see that I am an anxious person because of the above signs and judge me accordingly as weak and socially inept'.
13 What are the typical behaviours in Social Anxiety?
The list of possibilities can be extensive:
• Trying to remain anonymous by saying nothing controversial
• Staying close to the exit door
• Trying to cover up blushing or excess sweating
• Avoiding eye contact
• Checking you are coming across well - constant self-monitoring
• Gripping glasses or cups tightly
• Continuously rehearsing what one is going to say before an event
• Doing a post-mortem when home from a social gathering.
14 How to reshape our anxious brain and mind in Social Anxiety?
Again, the two key players are our catastrophiser and our amygdala. We can use specific CBT exercises to reshape the thinking and behavioural difficulties in social anxiety.
By challenging many of the catastrophic visualisations and in particular the erroneous beliefs that we can be rated or that people can see the physical symptoms of anxiety, we lay the groundwork for challenging the negative behaviours which drive this condition.
We can reshape our socially anxious mind and brain in around six sessions if the person is committed to real change.
15 What is a phobia?
A phobia is where we become acutely fearful or panicky when exposed to a particular situation or thing. Good examples are fear of motorways, fear of flying, fear of crowded spaces, fear of blood, fear of open spaces and so on.
Once again some simple CBT exercises and hard work can teach a person how to deal with these phobias.
* Dr Harry Barry's book 'Flagging Anxiety and Panic - how to reshape your anxious brain and mind' (Liberties Press) is available now
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