On BBC Radio Nottingham’s Morning Show with Frances Finn today 12th April, we discussed anxiety and panic attacks.

Anxiety stems from fear, in response to danger; the flight part of the Flight/Fight or Freeze response, sometimes called the Stress response.

Everyone feels fear from time to time – could be a near miss situation: you are just about to overtake a lorry when it pulls out in front of you and you brake in the nick of time; or you lose sight of your child in a busy shop….. and we can feel angry afterwards! Anger and anxiety are closely connected.

Fear triggers a bio-chemical response in the body, like tripping an alarm:

1. The hypothalamus in the brain stimulates the pituitary gland to secrete a hormone which in turn releases cortisol from the adrenal cortex
2. Glucose stored in the liver is released for extra energy
3. In the core of the adrenal glands, above the kidneys, the medulla secretes adrenaline (and noradrenaline, raising blood pressure)
4. The sympathetic branch of the Autonomic Nervous System launches into action:

• heartbeat and breathing become more rapid so that blood carrying oxygen and glucose for energy can get to the muscles faster
• we sweat to make cooling more efficient
• digestive processes go ‘on hold’ so as not to waste energy
• all the senses sharpen for greater efficiency (eg eysesight, pupils dilate to let in more light)          

In the appropriate circumstances, this can be really valuable – say you had to dash into the road to save your child from being run over – or defend yourself when no escape was possible…

Typically we use memory and personal experience – filtered through our belief system/values/life rules – to identify whether a threat requires fight or flight. Sometimes, however, we may NOT be able to escape from situations which we find threatening or lash out in anger, because this is socially unacceptable in today’s world, bringing unpleasant consequences – eg it’s not ok to run out of a business meeting/presentation, or physically attack someone who has carved us up whilst driving. But the Autonomic Nervous System is still firing away!!

We often describe this as stress. Sometimes the fear response happens only occasionally, in reaction to particular events, eg taking an exam or getting results of medical tests, and we can usually cope with this type of situation and reason ourselves into controlling the feelings.

Often people limit their own exposure to things they find stressful, or reward themselves if it’s been a stressful day. (Not always in a healthy way – eg by self-medicating with alcohol…)

However, if the same sort of things which ‘stress’ us keep occurring and are unavoidable, we become anxious This can develop, over a long period of time, into chronic anxiety; (The sympathetic branch of the Autonomic Nervous System can’t keep going, and the para-sympathetic branch takes over with slower heartbeat and breathing rate, even though the stressors are still present, sending confused messages through the body, and inducing a range of illnesses: eg depression, allergies, ulcers, heart disease and many others…)

The brain can also deceive us into thinking that there is danger, when this is not so; how does this happen? Sometimes we may have an experience in a situation which was uncomfortable; perhaps we were in a meeting or doing a business presentation and we were asked a question which we couldn’t answer or we got a bit stuck on…..when we replay the situation in our mind later, it might make us cringe and wonder what people were thinking of us – maybe they thought we were stupid, maybe the boss was disappointed in our performance…And so we associate the experience with threat to our well-being. We avoid meetings etc, because we fear this could happen again; our negative thinking contributes to distortion of memory, bigging up the unpleasantness/threat of the experience. Anxiety builds as we contemplate not being able to avoid the next occasion. Faced with the situation, the sensations of the flight response, listed above, intensify, we misinterpret these as harmful to us:

• My heart is beating so fast I must be having a heat attack
• I’m gasping for air, I can’t breathe, I’m going to die
• The room is closing in, I feel so dizzy, I’m going to faint
• My mouth is dry, my throat is constricting, I’m going to choke
• My legs have turned to jelly, I’m going to collapse
• My stomach is heaving, I’m going to be sick
• I need to go to the toilet, I’m going to lose control
• It feels unreal, like I’m not in my body..

As we know, all these sensations can be explained by the activities of the body’s alarm system, but as anxiety escalates, we sometimes panic, and what is called a panic attack occurs. This lasts just a few minutes but feels terrifying. We can dread a repeat experience, and the fear of this makes them more possible. They can sometimes occur ‘out of the blue’ for no apparent reason, eg in the middle of the night. This is usually as a result of underlying ongoing high levels of anxiety. People often think they are going to faint, but this is impossible because blood pressure is HIGH and fainting occurs when blood pressure is low.

Note: it is important to check with your GP whether you are experiencing anxiety, or whether you have a (rare) medical condition which may require treatment. As a general guide, if the sensations disappear when you are relaxing, at home, or enjoying yourself, they are unlikely to be signs of physical illness.

There are a number of different types of specific anxiety, with various origins:

Social anxiety  – people avoid social contact because they fear negative judgements by others, considering themselves inadequate, stupid. This arises from self-esteem problems

Health anxiety – people constantly monitor themselves for signs of illness, fearing developing a terminal illness, dependancy on other whilst in pain or helpless, death. This arises from a need to control uncertainty in an uncertain world which is perceived as threatening.

Performance anxiety – people dread that they may not live up to the expectations of themselves or others in situations where they are being observed, have deadlines to meet etc. This arises from issues of self-identity, and a fear of not being as competent as ‘supposed’ to be, or ‘should’ be.

Separation anxiety – people fear being away from home or close relatives. This arises from difficulties in  attachment in (usually early) relationships.

Generalised anxiety- people are anxious about a range of things, replacing one thing with another as problems resolve and being in a constant state of alertness watching for the next source of anxiety. There are a number of factors producing this kind of mind-state, and it is often associated with obsessive-compulsive behaviours.

Agoraphobia – people fear being away from a place of safety (usually home), and of being trapped somewhere in a public place, eg cinema, restaurant, meeting, bus, where escape opportunities are controlled by other people or circumstances. This can arise due to control issues, as in health anxiety.

TREATMENT

1. Getting to the bottom of what the anxiety stems from – what was the trigger incident, why did it have specific significance to the person? Challenging a person’s learned beliefs about themselves, the world and others. Developing self-awareness and acceptance of self/
2. What is the function of the anxiety, what would this person have to deal with/face, if they were not so preoccupied with this fear? Dealing with unfinished emotional business.
3. Psycho-education on understanding how the anxiety shows itself in the body, the bio-chemistry of the fligh/fight response. A hyperventilation exercise is sometimes used to demonstrate the process.
4. Facing the fear, with graded exposure step by step to the feared situation to prove that the anxiety will naturally reduce by itself when tolerated without avoidance or safety measures.  A different approach is to desensitise the person to the feared experience by creating a new, more positive association, using strategies like slowed breathing.