Chapter 2 : Anxiety Disorders
Anxiety disorders were first recognised as a discrete group of disorders in 1980 by
the American Psychiatric Association (APA 1980). Anxiety disorders include panic
disorder, social phobia, post traumatic stress disorder, obsessive compulsive disorder
and generalised anxiety disorder.
Many people are surprised when they realise that anxiety disorders represent the
largest mental health problem in the general population. While there is now much
more publicity about panic attacks and anxiety, anxiety disorders are still hidden
within the community. When we begin to develop an anxiety disorder, we feel as if
we are the only one in the world experiencing this level of distress. We are not being
narcissistic. It is more that we can't believe other people could be feeling this
degree of distress and it not be more widely acknowledged in the community.
Anxiety disorders affect people right across the socio-economic spectrum across all
age groups. While many people will develop an anxiety disorder between their late
teens and mid thirties, children can also develop a disorder and so can people in
their forties right through to their eighties.
People often ask me if the increase in the number of people with an anxiety disorder
is due to the escalating pressures and demands of life. While this is a factor, the
main reason for the increase is that, in the recent past, many people were simply not
being diagnosed at all and lived their life suffering from 'nerves'.
There are various theories as to the cause of anxiety disorders. Physiological
research suspects that a chemical imbalance may be involved although researchers
are unsure whether a chemical imbalance is the cause or a result of the panic attack
(APA 1990). Behaviour theories suggest that anxiety disorders are learned
behaviours and recovery means unlearning the previous limiting behaviour (APA
1990). Psychoanalytic theory postulates that anxiety stems from subconscious
unresolved conflicts that began during childhood (APA 1990).
This conflicting information about the cause of anxiety disorders makes it difficult for
us to come to an informed decision about the most suitable treatment. It is possible
that the three schools are thought are each partly correct, and that viewed together
they form a whole picture of cause and effect (APA 1990).
The experience of panic attacks is central to four of the anxiety disorders, with
generalised anxiety disorder the exception. While the disorders were first recognised
in 1980, it wasn't until 1994 that a more definitive understanding of panic attacks
and anxiety disorders emerged (APA 1994). Prior to this no distinction was made
between types of panic attacks and the relevant anxiety disorder. Panic attacks
were seen more as a phobic response to particular situations and places, yet for
people with panic disorder this was not the case. People were not frightened of
situations or places. They were frightened of having panic attack. It didn't matter
where they were or what they were doing, it was the fear of actually having an
attack that was the problem. In 1994 three separate and distinct types of panic
attacks were identified and their relationship to particular anxiety disorders was
defined (APA 1994).
Uncued (Spontaneous) Panic Attacks
The experience of an uncued attack is the central feature of panic disorder. This
type of panic attack is not triggered by situations and places. It occurs
spontaneously, 'out of the blue', irrespective of what the person may be doing at the
time. These attacks can also happen when people are relaxed, reading a book,
watching television, when they are going to sleep at night; or they can be woken
from sleep with an attack. Attacks can feel completely overwhelming, physically and
psychologically, and many people do feel as if they are having a heart attack, or
dying or going insane.
What isn't discussed in any detail in the literature on anxiety disorders is the fact
that the spontaneous panic attack can have a number of distinguishing symptoms
that differ from the other two types of panic attacks. My colleagues and I have
found in our own research (Arthur-Jones& Fox 1994) that the symptoms are, in
many cases, the reason why people panic. That is, the symptoms come first and
people panic in response to them, as opposed to the symptoms being part of the
actual panic. I discuss this in detail below.
Cued (Specific) Panic Attacks
Unlike the experience of a spontaneous attack, the cued attack does relate to, and is
triggered by, specific situations or places. The cued attack can be one of the
components of social anxiety, post-traumatic stress disorder or obsessive compulsive
Situationally Predisposed Panic Attacks
Some people may be predisposed to having panic attacks in some situations and/or
places. The attack is not necessarily always triggered by the particular situation or
place---it may happen on some occasions and not on others. People with
spontaneous panic attacks may go on to develop this type of attack.
Panic disorder is the fear of having a spontaneous panic attack, fear being the
operative word. It is the fear of having a spontaneous panic attack that is the
driving force in the development of panic disorder.
Some people may only ever have one panic attack while others may have
intermittent attacks throughout their life, in both cases this does not necessarily
mean they will go on to develop panic disorder.
Panic disorder is diagnosed after a person has experienced 'at least two' spontaneous
panic attacks followed by one month of 'persistent concern' about having another
one (APA 1994). It is the 'persistent concern', our fear that not only causes much of
our distress but also makes us more vulnerable to having another attack. And many
of us do. It is not unusual for people to begin to have two or more panic attacks a
day and to experience pervasive anxiety in anticipation of having another one.
Recovery for so many of us has been the loss of the fear of having one of these
attacks. Once we can lose our fear we lose the disorder, and lose our ongoing
anxiety about having another attack.
People with social phobia are frightened of making a fool of themselves or
embarrassing themselves in some way because they fear being judged in a negative
way by other people (APA 1994).
They may fear social occasions or simply talking with other people in day-to-day
situations. They may fear eating in front of other people, signing their name or
writing in front of others. People can suffer extreme anxiety in these situations, or
simply in anticipating them. They may have a panic attack as a result. This panic
attack is specific to their fear that they may embarrass, or make a fool of themselves
in some way.
Post-Traumatic Stress Disorder
Post-traumatic stress disorder can develop following an event or events in which the
person 'experienced, witnessed or was confronted' (APA 1994) with a situation that
was life-threatening to themselves and/or other people. This can include victims of
violent crime, rape, a serious accident, active war duty or being civilians in war zone,
natural disasters such as bushfires, cyclones or earthquakes.
People may have ongoing persistent thoughts about the experience. They may have
flashbacks in which they believe they are actually living through the event again, or
nightmares in which they relive the experience. Many people will have a cued panic
attack in situations or places similar to, or reminiscent of, the actual event.
Panic disorder can be secondary to post-traumatic stress disorder. On occasion
people will seek treatment for their panic disorder but will be too frightened or
ashamed to speak of the traumatic event or events that precipitated it. And this is
especially so in matters relating to childhood abuse. One English study showed that
63.6 percent of young women with panic disorder who were interviewed for the
study came from 'difficult childhood backgrounds', which included 'parental
indifference, sexual and physical abuse' (Brown & Harris 1993).
Obsessive Compulsive Disorder
Obsessive compulsive disorder means being obsessed by 'persistent ideas, thoughts,
impulses, or images that cause marked anxiety or distress' (APA 1994). Unlike
generalised anxiety disorder, which is based on 'real life' concerns, the excessive
thoughts can be fear of contamination by germs or a fear the person might harm
other people, or act in a socially unacceptable way.
Other people may need to have everything arranged in a particular way, or redo
certain jobs a number of times. Some people may feel the need to repeat a name or
number or phrase constantly. Others may continually check to see if they have
locked their house or car, or if they have turned off domestic appliances. Some
people may hoard unwanted or useless items. These compulsions can be so severe
that the person becomes totally restricted by them and is unable to lead a normal
Generalised Anxiety Disorder
Generalised anxiety disorder is diagnosed when a person experiences 'anxiety and
worry' (APA 1994) for at least six months over particular real life events such as
marital or financial problems. Most people with his disorder have been worriers all
their life and feel powerless to stop the endless cycle of worry.
It is not unusual for people to have fears and symptoms from all the disorders.
People with panic disorder usually have ongoing anxiety. They may also have
aspects of obsessive compulsive disorder, social anxiety and, in some instances,
post-traumatic stress disorder.
It had been a long and difficult week. Carolyn was glad she now had some time to
herself. She curled up on the lounge with a book she had been wanting to read. As
she relaxed she felt the tension ease from her body and she felt herself drifting into
sleep. Without warning, she felt a wave of incredible energy surge through her
body. As it moved through her, her heart rate doubled, she had difficulty breathing,
she felt light headed and dizzy, a wave of nausea swept over her and she began to
perspire. She jumped up and ran outside to her husband. 'Help me,' she cried.
'Something is happening to me, I don't know what, but something is very wrong.'
Alex disliked staff meetings and social get-togethers and did what he could to avoid
them. He felt more comfortable just doing his job and avoiding personal interaction
with other staff. Now the new owners of the business had arranged a dinner for all
staff and their partners and, like it or not, Alex had to go. He had been feeling
uncomfortable all day and he knew his anxiety levels were very high. As he and his
wife sat down at their table the people next to them began to make conversation.
Alex's heart began to race, his breathing became short and shallow, he began to
perspire heavily and his hands trembled violently. As he tried to control it, he
thought to himself, 'I shouldn't have come. This always happens every time I am in
Jessica turned on the ignition of her car. She was feeling very anxious. Is it going
to happen today? As she pulled out of her driveway she tried to rationalise with
herself for the hundredth time. She wasn't frightened of driving---in fact, she used
to enjoy driving before she began to have spontaneous panic attacks. But there was
one set of traffic lights where she would sometimes have an attack. There was no
pattern to it. Sometimes it happened, sometimes it didn't. Sometimes she would
have an attack after she had driven through the traffic lights; on other days there
were no attacks at all. Someone had told her she was frightened of that particular
intersection, but she thought that was ridiculous. She was frightened of the attacks
and their unpredictable nature, it had nothing to do with the intersection.
If you haven't been diagnosed as having panic attacks
or a panic-related anxiety disorder but think this may
be what you are experiencing, speak to a doctor. Don't
self diagnose. You need to know exactly what it is you
are trying to recover from.
Many of our symptoms are a direct result of the 'fight and flight' response. This is an
automatic response within the body that is activated in times of danger. It assists us
either to stay and fight the danger or to run away from it. The problem is, we are
not in actual danger. The 'danger' is being created by the way we think and our
body responds accordingly.
The symptoms of anxiety can be quite varied, with any
number of symptoms being experienced at the same
time. A panic attack is diagnosed when we experience
four or more of these symptoms (APA 1994). The most
common ones are a rapid or pounding heartbeat,
palpitations, 'missed' heartbeats, chest pain,
hyperventilation, difficulty in breathing, and an
inability to take a deep breath, a feeling breathing will
stop altogether, a choking sensation, a tightening of
the throat, indigestion, churning or burning in the
stomach, dizziness, giddiness, feeling faint, light
headed, nausea, pins and needles, diarrhoea, shaking,
trembling, dry mouth, excessive perspiration, neck
ache, headache, flushed face.
People with panic disorder can also report left arm pain and jaw pain. Most
experience a number of dissociative symptoms such as depersonalisation (the feeling
of being detached from the body), derealisation (when nothing appears to be real, or
feeling as though looking through a white or grey mist), other visual disturbances
including stationery objects appearing to move, tunnel vision, intolerance to sound
and intolerance to light (Arthur-Jones & Fox 1994).
Sometimes these symptoms are our constant companion. Not just for a few minutes
or hours at a time, sometimes they can be chronic for months or years. To confuse
the issue further, people may experience different symptoms and sensations in their
anxiety and with each panic attack (Arthur-Jones & Fox 1994).
Many people experience a number of effects as a result of their anxiety disorder.
These can include fatigue or overwhelming exhaustion, loss of concentration, loss of
appetite, loss of libido and, in some instances, loss of feeling towards family and
Another theory my colleagues and I have been investigating is the role played by
dissociation in spontaneous panic attacks. From my research and experience, the
ability to dissociate is extremely common in people who experience spontaneous
panic attacks. In fact, as they begin to understand their ability to dissociate, they
become aware that it is their dissociation that triggers the feeling of panic (Arthur-
Jones & Fox 1994).
Dissociation can also be described as altered or
discrete states of consciousness or trance states.
Dissociation can be an 'accepted expression of cultural
or religious experience in many societies' (APA 1994).
A leading expert in altered or discrete states, Dr
Charles Tart (1972), comments that many other
cultures 'believe that almost every normal adult has
the ability to go into a trance state '.
Individuals in some societies induce trance states not only by meditation but by
fasting, sleep deprivation and other forms of physiological stress. For those of us
who have the ability to dissociate, major stress can make us more vulnerable to
these states. Or stress can be a cause of our not eating properly or of losing sleep,
which in turn increases our vulnerability to them.
The ability to dissociate is not harmful in itself, but our lack of understanding of the
phenomenon can lead to acute anxiety and panic. Although some people with panic
disorder report they are not frightened of these sensations, others are and the fear
contributes to the feeling of going insane or loss of control.
Dissociation and Spontaneous Panic Attacks
It has been assumed that dissociation is an effect of a panic attack and that some
people use these states as a form of 'escape' from the anxiety or the attack itself.
While I have seen this in a few cases, most people are aware it is the dissociation
itself that triggers the panic (Arthur-Jones & Fox 1994).
Some people experience depersonalisation or derealisation or other dissociative
symptoms first, and panic as a result of these sensations. Others report these
sensations together with the feeling like an electric shock, or an intense burning and
tingling sensation, moving through the body. Some report a feeling like a wave of
unusual energy surging through them (Arthur-Jones & Fox 1994). This wave is
usually experienced as beginning in the feet, surging through the body, over the
head and back down through the body again (Arthur-Jones & Fox 1994). Or it is
likened to a white hot flame, starting 'just below the breastbone, passing through the
chest, up the spine, into the face, down the arms and even down to the groin and to
the tips of the toes' (Weekes 1992).
One psychiatrist quotes a description of a panic attack by one of his patients. The
attack begins with 'a tingling feeling going up my spine which enters my head and
causes a sensation of faintness and nausea. I feel I'm going to lose control or lose
consciousness. I thought I was going to die and started to panic...' (Hafner 1986).
Notice how his patient separates the attack from the feelings of panic. This is
Another psychiatrist describes the attack as being associated to a 'rushing sensation
of a hot flash surging through the body'. People may experience a sensation that is
'sometimes associated with a sick of feeling and a sensation of fading out from the
world'. This faintness is more like a 'whiteout' than a 'blackout' and the head may
literally 'feel light'. The fear of this attack is then followed by the fight and flight
response (Sheehan 1983). Again, notice the separation between the precipitating
sensations and the fight and flight response.
From my own experience and those of my clients, the rushing sensation, the hot
flash, the tingling or the electric shock sensation happen as part of the overall
dissociative experience, and we panic in reaction to this.
For those of us who do dissociate, learning to see this separation from the feelings of
panic is an important step in recovery and I will return to this point shortly.
People who do dissociate 'may display high hypnotisability and high dissociative
capacity' (APA 1994). The dissociative sensations are the effects of an alteration of
consciousness which can be similar to the alteration of consciousness when deeply
relaxed or meditating or in a hypnotic state.
Many people report they can be fully relaxed when they have an attack and one
research study confirmed this. The study looked at EEG activity in people with panic
disorder and found, to the researchers' surprise, a ' paradoxical positive correlation
between increases in slow wave EEG and increasing anxiety' while the patient was
the at rest (Knott 1990).
'Slow wave activity' indicates a very relaxed state. The question is how can we be
relaxed and anxious at the same time? The study concluded that 'replication of
increases in slow wave activity in further studies would suggest psychobiological
disturbances in panic disorder are not merely normal emotions expressed in
inappropriate contexts'. (Knott 1990). This study indicates that our overall
experience of an attack is more than the spontaneous arousal of the fight and flight
response, normally viewed as the reason for a spontaneous panic attack.
Nocturnal Panic Attacks
The theme of Knott's study is also demonstrated in the literature on nocturnal panic
attacks. Many of us are woken at night by these attacks. Research suggests the
'sleep' panic attack occurs 'during the transition from stage two to stage three sleep'
(Uhde 1994). The research also stipulates that the attack is not a result of dreams
or nightmares (Uhde 1994), but happens on the alteration of consciousness.
'Sensory shocks' that accompany the hypnagogic (first) stage of sleep or the
transition from dreaming sleep were first noted in 1890. Researchers describe them
as 'an upward surge of indescribable nature, an electric sort of feeling ascending
from the abdomen to the head sometimes followed by bodily jerks or of a violent
explosion and/or a flash of light'. The researchers also note that a sense of alarm,
together with a cold sweat, laboured breathing and tachycardia, often follows
And for many of us this sense of 'alarm' can be the 1990s definition of our panic!
Our attacks are usually interpreted within the biological model, as the fight and flight
response. Within the psychological model it is thought that people have more time
to think about their anxiety symptoms when they are relaxed, thereby actuating the
fight and flight response. The possibility we may be dissociating first is never
considered. As one researcher points out, the transition into the trance states can
occur in a split-second (Putman 1989) and it is in that split-second that we can go
from feeling relaxed to total panic.
Inducing Dissociative States
Inducing dissociative states when we are vulnerable to them is incredibly easy. The
most common way is by staring---at the computer, at the television screen, at a
book. We stare while driving---at the traffic lights, the car in front of us, at the road
ahead. We stare at people when we are talking to them, we stare ahead when we
are out walking, we stare while we are waiting for an elevator. When we are
vulnerable we can induce a trance state very quickly and without realising it.
Without warning we can fill the sensations of dissociation.
In Eastern traditions, open-eyed meditation is an advanced meditation technique,
usually taught only to skilled practitioners (Brunton 1965). Yet many of us
unconsciously practice a similar method of ' meditation'. In many cases we induce a
dissociative state and panic as a result of the sensations. Our self absorption can be
absolute, and this self absorption is similar to other meditation techniques. We need
to be aware that our self absorption can be significant enough to also induce
Some people report that fluorescent lighting can also induce a dissociative state
(Arthur-Jones & Fox 1994). This is one of the reasons why people can have so much
difficulty in shopping centres. The sheer brightness, the glare of the lights can be
overwhelming and can induce a dissociative state. Some people can actually see the
moment to moment flickering of the lights which can also induce trance states.
Fight and Flight Response
Many of us who experience dissociative sensations know they are not part of the
fight and flight response. We have all been in situations where the fight and flight
response has been activated---perhaps a near miss with another car while driving, or
waiting for surgery, any situation that can produce fear. People with a background
of abuse know all to well the feelings of fear and the accompanying symptoms of the
fight and flight response. Even if the fight and flight response were activated
spontaneously we would be able to recognise it. We would not react with total fear if
our experience was simply that of the fight and flight response.
The description of panic disorder is 'the presence of recurrent unexpected panic
attacks followed by at least one month of persistent concern about having another
panic attack' (APA 1994). Our persistent concern triggers the fight and flight
response and adds ferocity to our overall experience. Once the attack subsides, the
fight and flight response is continually activated by our fear of having another attack.
It is the fight and flight response that creates our anxiety symptoms.
For me and other people, recovery means that we may occasionally experience an
attack. In other words, we may dissociate when we are tired or stressed but,
instead of reacting with fear and panic, we can now break the dissociated state and
allow any physical effects---the 'indescribable surge' ---to happen. When we do this,
the attack disappears as quickly as it comes. Recovery is a matter of learning to
change our perception of these particular attacks, learning to see them and control
them without fear. When we can do this, we are able to think 'So what?' instead of
'What if?' I discuss this further in Chapter 9.