Fighting Fear

Confronting phobias and other fears

The Evolution of an Anxious Feeling

Panicky feelings and panic disorder.

Feelings, even very unpleasant feelings such as fear, serve a purpose (See my blog post, “The Purpose of Feelings.”) They are a goad to action. For example, someone who is being treated rudely—or frustrated in any other way—is supposedto get angry. The subjective sense of being angry shows outwardly in a raised voice and an angry expression. A message is communicated of a particular kind of distress, and along with it a demand for attention. Other people respond, to a greater or lesser extent, by refraining from doing whatever was objectionable. Those who have trouble getting angry have trouble influencing  the people around them. Every other feeling can be shown similarly to be useful. Joy and affection serve to tie people together, especially families. Sadness, such as homesickness, represents loss and is a reminder to make up that loss in some way. Grief occurs when the loss is too extreme to redress.

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Anxiety is a kind of continuing fear. It is the price paid for anticipating difficulties. It serves to preserve the individual, just as sexual feelings serve to preserve the species. Fear is perhaps the easiest emotion to understand. In the face of an Immediate danger, animals, including human beings, demonstrate a “fight or flight” reaction. Along with the subjective sensation of fear, there occurs a complicated physiological response that serves to prepare the individual for immediate action: muscles tense, respiration and heart rate increase, blood pressure rises. Other hormonal changes occur. And this same complicated reaction takes place whether someone is threatened by an angry boss, a gang of toughs in an alleyway, or a charging elephant. A dispute with a spouse, a school examination, a scary movie, or a sudden injury—all circumstances that are frightening—set in motion the same train of physiological changes, although to a varying extent depending on how threatened the person feels. Each of these bodily changes contributes to an ability to handle stress. They include a heightened alertness and a physical readiness to respond decisively and promptly. They are normal. Tranquilizers, or other substances that interfere with their appearance, also interfere with the ability to react. Someone who is chronically frightened is said to be anxious.

But can anxiety become so severe that it interferes with the ability to cope? Is that panic? Yes. Fear, like any other emotion, is a helpful response to an ordinary circumstance; but in a situation where it is not possible to fight or to run away, the body’s reaction to danger seems exaggerated and prolonged.  Panic occurs when a danger seems imminent and overwhelming—and unavoidable. In the case of a soldier responding to combat, it is more the situation itself that is abnormal than the individual’s emotional response to it. 

However, there are times when the circumstances are ordinary and the person’s response is abnormal. Such is the case in panic disorder. Someone standing in line at a bank or driving across a bridge or through a tunnel-- in no apparent danger even by his/her own account-- suddenly feels terrified and experiences all the physiological changes that accompany fear. For this remarkable phenomenon there are two different possible explanations: 

  1. Such a person is born with a special sensitivity, mediated perhaps through some limb of the central nervous system or endocrine system, and so overreacts, somewhat in the way a loudspeaker gives off a screech if the volume is set too high. The fact that panic disorder, and the agoraphobia that usually accompanies it, runs in families might seem explainable if the underlying disability turns out to be genetic

It is possible some such definable hypersensitivity will be found some day, but the evidence for it now is unconvincing. Neither would such a built-in weakness explain why someone would live into his mid-twenties or thirties without giving any sign of it, enter into a period of four or five years of being grossly symptomatic—feeling anxious most of the time and panicky at least once every day—and nevertheless, after proper treatment, continue the rest of his or her life without any symptoms.

2. The second possible explanation—more credible to me-- is that panicky persons on some fundamental level misunderstand their circumstances and feel themselves to be in acute danger when there is no objective danger, none even that they can see. Along the way of growing up they have learned, usually from parents, that the world is a dangerous place. Even physical health, taken for granted by everyone else, is seen as precarious. Therefore, in order to ward off calamity, it is necessary to be always on guard. As a result, certain places, even certain feelings, become frightening. After a while even the feeling of being frightened becomes frightening. The panic attack appears at a particular time, perhaps, because of a particular stress —unfortunately usually too subtle to be recognized immediately. From then on the generalized wariness such people have of the world centers on a fear of the panic attacks themselves, on the effect they have on physical and mental health and on the possibility of losing control in the wake of such an attack and doing something that is dangerous or embarrassing.

By this explanation, then, a phobia is an avoidance response to a nonexistent danger. It is the result of a mistaken belief. Treatment, therefore, is a learning, or relearning, process. The phobic must learn, first, that the panic attacks are not in and of themselves dangerous and second,  that the illusion of being trapped and helpless, whether in a tunnel or an airplane, is no more than that—an illusion. Nothing else is required for the cure of a phobia. To achieve that cure, the phobic person must develop an active stance in responding to the panic attack, rather than waiting passively and helplessly for that feeling to subside. Being active mentally tends to turn off the panicky feeling. It is not possible to prevent the panic attacks from coming—even with the use of tranquilizers—but it is possible to learn how to drive them away. There are tools that can be used to direct the attention of the panicky person away from that feeling, after which the feeling disappears.

A panic disorder can be said to be cured after the fear of the panic attack is gone. When patients tell me –ten or twelve times—that they were in a phobic situation and experienced a really bad panic attack without leaving I know they are finally better. Then the panic attacks may recur briefly at increasing intervals, but they are no longer feared. They are simply one more feeling. There comes a time when patients cannot remember their last panic attack. (c) Fredric Neuman Excerpted from "Rising Above Fear: an 8 week treatment for phobias." Follow Dr. Neuman's blog at fredricneumanmd.com/blog/ or ask advice at fredricneumanmd.com/blog/ask-dr-neuman-advice-column/

 

Fredric Neuman, M.D. is the Director of the Anxiety and Phobia Center at White Plains Hospital.

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