Dr Jonathan Haverkampf, M.D.
Anxieties can cause incredible suffering, especially in combination with panic attacks, which are usually a short-lived but more intense form of anxiety.
Anxiety disorders are a group of mental disorders characterized by feelings of anxiety and fear.  Anxiety is a worry about future events and fear is a reaction to current events. These feelings may cause physical symptoms, such as a fast heart rate and shakiness. There are a number of anxiety disorders: including generalized anxiety disorder, specific phobia, social anxiety disorder, separation anxiety disorder, agoraphobia, panic disorder, and selective mutism. Often the same individual has more than one anxiety disorders, but in many cases, there might only be one type.
The first panic attack can occur as from nowhere and the sudden sense of imminent death or literally going crazy usually comes as an enormous and sudden shock. In many cases, it has five stages:
- An ominous feeling of an imminent panic attack. A heightened sense of self-consciousness with beginning hyperventilation and other symptoms.
- The sense that there is no way to avert the full-blown panic attack.
- The panic attack with hyperventilation, heart palpitations, the sense of imminent doom and/or death.
- Alternations in the intensity of the panic attack, leading to a decline after about ten minutes.
- A post-panic phase in which there is a sense of exhaustion and sometimes elation that it is over.
Since the first panic attack often occurs in adolescence or young adulthood, the individual might not know what a panic attack is. In older people, panic attacks often lead to visits to the hospital emergency admission.
A feature of many anxieties and panic attacks is that they go largely unnoticed by the environment. Anxieties and panic attacks can lead to the inability to leave the house and interfere with almost every sphere of life, professional, social, and one’s relationships. When anxiety reaches into all areas of life and no longer seems specific to certain situations and locations, we call it ‘generalized’. It is then the pure form of a disturbing feeling that no longer is attached to specific object, but ‘floats freely’.
Loss of Control
Anxiety and Panic Attacks do not seem to be so much a fear that something happens to the world, but that one loses control somehow. Often patients mention the sense of loss of control. But it is important to turn this around. The question is why is there such a need for control in the first place? It is because there is probably a loss of something stabilizing on the inside. After all, patients usually describe the sense of losing control over themselves. This is also what maintains the vicious cycle of fear of fear, felling anxious that the anxiety might mean a total loss of control. It is important to mention that I have never seen a single case, in which someone was seriously harmed who suffered from this fear of losing control. But the feeling is there and it needs to be looked at more closely.
A Signal of Change
But anxieties are actually something quite interesting because they signal a necessary change if someone is willing to go a new route. The necessity for a more global change lies already in the definition of anxiety. It is not a fear of something specific, but of uncertainty itself. Communication which binds humans together is no longer felt as something really stable.
Fear of Imminent Death: Somatic (Body) Reaction
Panic attacks often trigger thoughts of an imminent death, such as not being able to breathe anymore or a heart attack. They frequently go along with bodily ‘fear’ reactions, such as heart palpitations and dizziness. In general, there is a general sense of a loss of control over one’s body and even one’s mind, which further worsens the panic attack. Often panic attacks start in adolescence and young adulthood and frequently they are triggered by relationship events and social situations. But if they remain untreated, they can spread out and become ‘generalized’. They can reach a point where they even occur when someone is at home lying in back or after waking up at night. In the extreme, this can lead to a situation in which a patient is not only house but also bed bound.
Certainty and Security
Under the surface of the symptoms of anxiety and panic attacks there often is a fear of losing a fundamental feeling of losing of certainty and security in one’s life. As babies and small children learn to rely on their interactions with others, especially primary caretakers, to meet their needs, they build up a sense of safety in regard to the world around them and a secure sense of self. As we figure out the ‘rules of daily life’ as children we learn to be reasonably in the world. Things might still be unpredictable at times, but in a caring and supportive environment surprises are seen as a fact of life that one might not be able to control, but one can learn from them and the world moves on anyway, for oneself and for everyone else.
However, if this process does not work properly for a number of reasons, a greater sense of uncertainty and a greater susceptibility to anxiety develops, especially if anxieties, OCD, panic attacks and other conditions of elevated anxiousness vis-à-vis the world and other people run in the family.
Society has developed a number of ways to deal with anxiety and reduce uncertainty. Many human endeavours aim to provide a greater sense of safety. Laws and scientific progress deal with both, uncertainty in people and uncertainty in the natural world. However, in generalized anxiety and panic attacks, it is less a certainty in the outside world than in the inside world which is really what individuals with anxiety strive for, and it is here that therapy needs to begin.
Meaningful social interactions and meaningful relationships are effective against anxiety, where it is the quality rather than the quantity which counts. The reason is that meaningful communication reconnects the individual with others, but it also aids in self-regulation and gives the individual a greater sense of being effective in taking care of oneself through the interactions with others.
Values and Interests
The other important element is finding not only the strength in oneself but also the direction to proceed in the life. Often there are many paths that can be taken, which confuses people and causes anxiety. Without a sense of one’s trues values, interests and aspirations it is more difficult to make the relevant decisions in life that lead to greater happiness. If one’s sense for one’s own values and fundamental interests and aspirations is compromised because of a loss of connection with one’s thinking and emotional self, stress, anxiety and burnout can ensue. It is like running in place without getting anywhere, while having a strong desire to get somewhere.
True values, part biology, part social learning from other human beings, means a fundamental belief that acting according to these values and interests and attaining one’s aspiration will really mean happiness in the long run. In anxiety, these values and fundamental interests are out of sync with our lives.
Anxiety is caused by inner conflicts, which in the cognitive behavioural therapy tradition are assumed to be conscious or ‘near-conscious’, while the psychodynamic or psychoanalytic psychotherapy traditions see most of it in the domain of the unconscious. This largely explains the differences in treatment times between the two approaches, but on a theoretical level both can actually complement each other quite well. Fundamentally the causes are difficulties in communicating one’s underlying needs and wishes in a way that subjectively strengthens rather than weakens a relationship out of a fear of further loss. This also makes the internal conflicts persist. Our communication with the people in our lives has an impact on how we talk to ourselves, because they provide crucial feedback to us. When our social interactions become meaningless, our sense of shaping our world in a way that makes us feel secure and happy suffers.
When I refer to ‘talking to oneself’ I do not mean literally talking to oneself in the street but bouncing back and forth thoughts in one’s head, observing one’s thought process and reflecting on it. This requires the exchange of highly complex information in even more complex webs of networks of nerve cells in the brain. Since our brain is a highly complex network of ever smaller networks of nerve cells it allows the brain to process information in parallel. This is the reason why we can ‘listen’ to our own thoughts. Brain cells are in contact with other brain cells and they can alter the properties of their own connections depending on the information they transmit. Medication can alter certain types of transmissions in this system, but if we want to be more specific, we have to expose ourselves to meaningful information which the brain can use to refigure itself. This is essentially what psychotherapy does. As many empirical studies have shown, psychotherapy can bring about changes in connectivity and activation of the brain, which in turn can have a lasting effect on certain conditions, such as anxieties and panic attacks.
The first step is to become aware of situations that trigger anxieties and panic attacks, such as relationship problems or work-related stress. But these problems might not always be obvious, and they might not even explain the anxiety. Problems in a relationship or shyness in social situations are normally not the ultimate explanation for anxiety or panic attacks. We need to analyse in the specific case why losing a relationship causes such threatening fears as anxieties or panic attacks suggest. Sometimes it is worthwhile taking a look into one’s past and reconstruct how an individual dealt with his or her environment as a child or adolescent and how the environment dealt with the individual. At other times it may be important to ‘dissect’ the thought patterns in the here and now and to try to find out what they could mean. “If I leave the house I might have to figure out what I really want to do in life. “If this relationship breaks up I might have to figure out what I need and what I want, who I am, who I want to be with …” and so on. This step is about better understanding one’s needs, values and aspirations, and thus oneself.
The second step is to determine if the current approach, such as avoidance or negation, is the best strategy. It always never is. But this does not mean that one has to radically alter one’s current lifestyle or social life, though in special cases it might. The actual life we have starts in our head, so it is first and foremost about determining the questions that matter and how to approach them. This is actually easier than most people think, because it is not so much about having certain answers but about learning how to think and communicate in novel ways. Change usually means widening one’s mental repertoire, not narrowing it. The more effective tools are in our toolbox and the more meaningful information we have access to, the better will be our answers and decisions.
The third step is to act according to this novel information. This might sound like a tall order in the face of fears, anxieties and panic attacks, but once someone reaches this stage, the hurdles are often diminished or gone altogether. The fears usually disappear during the first and the second step. The reason is that we are usually more afraid of an uncertain ill-defined event than a certain defined event. When you are facing a threatening event, the uncertainty about an unlikely ill-defined outcome can be more painful than the certainty about a certain well-defined event. The certainty of death does not disturb people nearly as much as not knowing how they will die.
The goal is not absolute certainty in life but the attainment of happiness. Anxiety does not necessarily mean a shift in the balance between happiness and writing a meaningful story for one’s life, rather, it often is a wake-up call for us to re-evaluate who we are and what we really want in life to make us happier.
Most people want to lead lives which feel true to themselves for the simple reason that they believe it will make them happy. The only certainty that really helps against anxiety is the certainty that one follows one’s own path. To help a patient reach this path and follow it with confidence is an important objective of psychotherapy and counselling.
 Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association (5th ed.). Arlington: American Psychiatric Publishing. 2013. pp. 189–195. ISBN 978-0890425558.
Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at firstname.lastname@example.org or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.
This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Trademarks belong to their respective owners. No checks have been made.
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