Before resorting to medication as a cure for anxiety,
there are other ways to consider in the effort to overcome this rather difficult condition.
We all become anxious from time to time. Examples include when we’re about to have a meeting with an important person, changing to a new job or concerns over a new relationship.
All these create anxiety as the person is concerned about the future – fearing what could go wrong and mulling possible consequences and repercussions, instead of also considering probable positive outcomes.
Hence, it is natural that the terms ‘fear’ and ‘anxiety’ are commonly used interchangeably. However, there is a distinction between these two terms.
Fear refers to an innate, almost biological-based alarm response to a dangerous or life-threatening situation. Anxiety, in contrast, is a more future-oriented and global concern – it is sometimes referred to as panic attacks.
The term anxiety is about someone feeling inordinately apprehensive, tense, and uneasy about the prospect of something terrible happening. Anxiety becomes a clinical concern when it interferes with the ability to function in daily life as the person enters a maladaptive state, characterised by extreme physical and psychological reactions.
According to the Diagnostic and Statistic Manual of Mental Disorder (DSM-IV-TR), a panic attack is a period of intense fear or discomfort, during which a person experiences four or more of the following symptoms, which develop abruptly and reach a peak within 10 minutes:
palpitations, pounding heart or accelerated heart rate;
- trembling or shaking;
- sensations of shortness of breath or smothering;
- feeling of choking;
- chest pain or discomfort;
- nausea or abdominal distress;
- feeling dizzy, unsteady, light-headed. or faint;
- derealisation (feelings of unreality) or depersonalisation (being detached from oneself);
- fear of losing control or going crazy;
- fear of dying;
- paresthesias (numbness or tingling sensations); and
- chills or hot flushes.
There are three categories of panic attack – unexpected panic attack, situationally-bound panic attack and situationally-predisposed panic attack.
For unexpected panic attack, there is no situational cue or trigger. The second type of panic attack occurs where a person has a tendency to have a panic attack in the situation but does not have one every time.
For example, when one of my friends hears an ambulance siren, she begins to experience the symptoms of a panic attack. She could not work in a hospital – especially in accident and emergency department. So, she finally settled herself in the area of public health.
The last category of panic attack is situational predisposed panic attack where a person will have situational panic attack but not every time. For example, when you are standing in a closed and dark room, the panic attack does not appear all the time but it occurs randomly.
In trying to understand the cause and strategy to fight panic disorder, we should discuss both biological and psychological perspective. However, in this article, I will focus more on the psychological perspective.
In the biological perspective, panic attack is associated with excess of noreponephrine in the amygdala, a structure in limbic system involved in fear. Besides, the disorder derives from defects in gamma-aminobutyric acid (GABA), a neurotransmitter with inhibitory effects on neurons.
According to anxiety sensitivity theory, people with panic disorder tend to interpret cognitive and somatic manifestation of stress and anxiety in a catastrophic manner. For example, they feel that they cannot breathe even though others feel the situation is normal. This false alarm mechanism causes the person to hyperventilate and the person is thrown into a panicked state.
Turning to psychological perspective, we focus on conditioned fear reactions as contributing to the development of panic attacks. This person relates bodily sensation with memories of the last attack, causing a full-blown panic attack to develop even before measurable biological changes have occurred. Over time, the individual begins to have panic attacks before the trigger event happens.
David Barlow and his colleagues proposed in a cognitive-behavioural model that anxiety becomes an unmanageable problem for an individual through the development of vicious cycle. The diagram shows the cycle of panic attacks.
Stress management techniques help in the treatment of a panic disorder. In this approach, the client learns to systematically alternate tensing and relaxation of muscles all over the body, starting from the forehead down to the feet.
After stress management techniques, the client should be able to relax the whole body when confronting a feared situation.
However, I like to use panic control therapy (PCT) developed by Barlow and his colleagues. This technique consists of cognitive restructuring, the development of an awareness of bodily cues associated with panic attacks and breathing retraining.
I found that clients treated with PCT show marked improvement, at levels comparable to improvement shown by clients treated with anti-anxiety medication. I would propose that the combination of both anti-anxiety medication and PCT should give a marked improvement among patients.
During my training in counselling and psychotherapy, International Islamic University Malaysia Professor of Psychology, Malik Badri, explained the more comprehensive interventions involving cognitive techniques.
He recommended in vivo exposure when treating individual with panic disorders, especially those with agoraphobia (which loosely means being afraid of open spaces). He taught the use of graduated exposure, a procedure in which clients expose themselves to increasingly greater anxiety-provoking situations.
For example, Mr X finds visiting large shopping malls to be emotionally overwhelming. I would recommend that his exposure to such stressful environments to begin with a small shop in which he feels safe and relatively anxiety free. Step-by-step, Mr X would progress to environments that are higher on the list of anxiety-provoking settings.
I have just completed attending training in counter-conditioning. This technique is used to treat hyperventilation, a common symptom in panic attacks.
In this approach, the client hyperventilates intentionally and begins slow breathing, a response that is incompatible with hyperventilation. In this training, the client can begin the slow breathing at the first signs of hyperventilation. Hence, the clients learn that it is possible to exert voluntary control over hyperventilation.
If the recommended psychological approach is not able to control the anxiety of a person, the use of medication can help alleviate symptoms, with the most commonly prescribed being anti-anxiety and antidepressant medication.