Question of the Month:: January 2011 

Question

Subject: Constant state of anxiety

I started having panic attacks a few months ago. Lately though, i am experiencing a constant feeling of anxiety and fear. A feeling that you get when your afraid or very worried. The butterfly sensation in stomach, head tingling, rapid heartbeat, no appetite, sometimes feeling like you cant breathe, feeling like your going to lose it. Its a constant feeling. I have recently had someone move in with me and i'm used to it being me and my boyfriend. I don't like being around other people alot, unless i want to. To have someone in my space is causing me this anxiety. How do you handle something like this when its constantly there? What can i do to help myself with these feelings.

Panic and anxiety often go together but they are not exactly the same thing and it is important to distinguish between them. Both systems are the product of natural selection (evolution) and are designed to help us when we are in danger or at risk. However, they are designed to do different things.

The panic system is the fight/flight response system. It is designed to help us deal with imminent (immediate) danger. This is the system that “fires up” when you open a door and there is a grizzly bear or a lion right on the other side. The system is designed to be “fast on” and “fast off.” It is designed to ignite your physiology (including increased heart rate, increased respiration, changes in blood flow from the core to the large muscles, adrenaline rush, changes in blood chemistry) so your body can do whatever it needs to do to survive (run, fight). Secondary to these massive primary changes in physiology come secondary changes in feeling and sensation (dizziness, numbness, tingling, dry/tight throat, feelings of derealization and/or depersonalization). In addition to be designed to be “fast on” the panic system was designed to be “fast off” because if there is really a lion right in front of you, you need a response that “fires you up” very quickly. However, you don’t need top be “fired up” for very long because whether you survive the encounter or not, it does not last very long.

In addition to these physical symptoms, the psychological symptom most associated with the activation of the panic system is a need to “ESCAPE!.” Why? Because that is what the system was designed to help you do over the course of millions of years of evolution! And what kinds of things was it designed t help you escape? Well, things that for most of the course of evolution were at least somewhat dangerous. So, people, like most other animals have a number of “natural fears” (or fundamental  fears). Like other animals, we tend to be at least somewhat fearful about enclosed or exposed places (being trapped), heights, moving water, insects, spiders and snakes, the dark, being alone, and things with big teeth. That is why, for example, it is easier to teach children to be afraid of spiders than it is to teach them to be afraid of strawberries. In addition to these fundamental fears, people, in general, do not like being the center of attention.

Like most products of evolution (e.g. height) the sensitivity and reactivity of the panic system follows a normal distribution. If you think about it like height, or a smoke detector, most people have a panic system that is moderately sensitive. It goes off when it should, when there is real danger, and it does not go off when it should not, when there is no danger. Like a smoke detector that works properly, it goes off when there is a real problem and does not go off when there is not. Some people have a panic system that doesn’t work at all. That is not a good thing. People who cannot experience fear are in big trouble. A lot of them end up dead early or in jail. On the other hand, other people have a panic system that is a little too sensitive. These are people who are likely to experience “panic” in the presence of things that only make most people a “little nervous.” What kinds of things? Well, natural or fundamental fear kinds of things like enclosed or exposed places (being trapped), heights, moving water, insects, spiders and snakes, the dark, being alone, things with big teeth, and being the center of attention. So, people with “phobias” have a smoke detector that is a little too sensitive and it goes off (panic) in situations where other people might be only a little anxious.

When people have a panic system that is even more sensitive, it seems like it can go off randomly. Unlike people with phobias, who can identify a trigger in the environment for their panic, people with Panic Disorder may have a panic system that goes off randomly. If you cannot identify a trigger for your panic it makes the experience even more scary. If people cannot identify a trigger for their panic they usually think that they are either dying or going crazy/losing control.  What we know for sure is that in Panic Disorder, the experience of physical symptoms becomes the trigger for panic and people tend to be worried, hypervigilant and focus on changes in their bodily sensations.

But we are not quite finished yet. That was just the panic system. The anxiety system is the system most associated with doubt, worry, and obsessive compulsive disorder. In contrast to the panic system which was designed to help us deal with immediate threat (the lion right in front of us), the anxiety system was designed to help us deal with potential threat and uncertainty. So, the panic system was designed to help you deal with the lion in front of you. The anxiety system was designed to help you process and manage information such as “There was a lion sighted in your neighborhood two days ago.”

If you hear that there was a lion sighted in your neighborhood two days ago, what should you do? Well, panic doesn’t make much sense because the lion isn’t right in front of you. However, anxiety and worry does make sense. So, under conditions of uncertain threat we get a different kind of physical sensation. We feel tense, nervous or “on edge.” We feel that something is “wrong” or “not right.” Unlike the panic system this system is “slow on” and “slow off.” The feeling often starts out small and grows. I think of it as being like an electric coil on an electric stove. When it glows red hot we have a feeling of dread or doom or a feeling that something terrible is going to happen. Unlike the panic system, that tells us to speed up and escape, when the anxiety coil starts to heat up it tells us to slow down, be careful, and “think things through.” It tells us to wash and check and clean. It tells us that something isn’t quite right or not good enough.

So, the physical sensations associated with the anxiety system running hot are feelings of anxiety, tension, nervousness, nervous stomach, muscle aches and pains, insomnia, and agitation. The thoughts associated with the anxiety system are worries, the “what ifs.” As people, we are “meaning making “ machines. When we feel that something is “wrong” or “not right,” we cannot help but start to ask ourselves what could be wrong (what if?). If there is a real threat the system works pretty well. If there really is a lion in the neighbourhood, the system works really well. I hear the news, the coil starts to heat up, I get a bad feeling, I slow down and start to risk manage: What if the lion is still around? What if my kids are on the way home from school and don’t know? What if it is in my back yard?

People do not have big teeth or claws. However, we do risk mange better than any other animal. It is our competitive advantage. However, like the panic system, the anxiety/worry system can be too sensitive, be activated when it doesn’t have to be, or stay too hot for too long. When that happens people can have problems with doubt, worry or obsessions and compulsions. In summary, the two things that make us most human, our ability to risk manage and our need to make meaning out of everything, can get us into trouble.

Like the panic system, the anxiety/worry system is product of evolution. Most people have an anxiety/worry system that works the way that it should. Their anxiety/worry system starts to heat up under conditions of uncertain threat and they worry “some” or “enough.” Some people have an anxiety/worry system that doesn’t work well at all. These people are in big trouble. They do not risk manage well and they do not think things through. Such people are often considered “not very smart.” They are often end up dying young or in jail. Other people have an anxiety/worry system that is a little more sensitive or runs a little more “hot” than average. Such people tend to worry a little more. We tend to call these people perfectionists and perfectionism seems to be really quite adaptive. So, there may be even selection pressure for “more worry.” Unfortunately, at some point “even more worry” starts to get you into trouble. Anxiety causes us to slow down and anxiety and worry start to cause distress (What is wrong? What is wrong with me? Why can’t I stop thinking about it?”) and get in the way of making decisions and getting things done. Somewhere around here people can meet diagnostic criteria for an anxiety disorder such as Generalized Anxiety Disorder, OCD, Health Anxiety, Body Dysmorphic Disorder, Eating Disorder, or even Panic Disorder based on the content of the worry.

So to (finally) get around to answering your question the panic system and anxiety/worry systems are two separate but related systems. They are both related to evaluating and managing threat and danger, so it makes sense that when one gets activated the other may start to heat up. So, for example, when the anxiety/worry system is running really hot, people generally have a feeling of doom or dread, a feeling that something terrible is about to happen. Under those conditions, it makes sense for the panic system to be activated because it “feels like” your life is in immediate danger. On the other hand, when the panic system is really sensitive, people are usually experiencing a lot of panic attacks, even random panic attacks, and it makes sense that under those conditions the worry/anxiety system would get heated up. After all, random unexpected panic attacks are a potential and uncertain threat. Interestingly enough, it is possible for someone to have a “pure panic” problem and experience panic attacks and not worry about them. It is an interesting kind of problem because experiencing random panic attacks without worry about experiencing panic attacks is much less of a problem. In fact, in order to be diagnosed with Panic Disorder, people have to be worried about having panic attacks. So, usually people start experiencing panic attacks and then start to worry about them. So, the panic system starts the problem and the anxiety/worry system gets activated and helps to maintain it. That is why CBT for Panic Disorder targets worry about having panic attacks in a number of ways, including interoceptive exposure. It is also possible for someone to have a “pure worry” problem without experiencing panic attacks and they may be diagnosed with Generalized Anxiety Disorder, OCD, Health Anxiety, Body Dysmorphic Disorder, or an Eating Disorder, based on the content of the worry.

If you have a worry problem, there are a number of techniques outlined in the Panic Program that include relaxation techniques, controlled breathing, regular aerobic exercise, worrry time and cognitive exposure.