Anxiety and Panic Disorder

By Dr. Bert Pitts

Anxiety is an emotion that serves important preparatory and signaling functions, but which can easily escalate, “derail”, and become disruptive. Anxiety is intended to signal us about impending threat or danger and cause the adrenal or “fight or flight” system to become activated. Unfortunately, the human brain cannot discriminate between real danger and that which does not actually exist (except in the mind of the individual), for example, with unfounded paranoid thoughts or phobias. Thus, even “imagined” fears, if strong enough, cause the brain to activate the adrenal system, eliciting (unnecessary) “fight or flight” responses such as a sudden increase in heart and respiratory rate, shunting of blood flow from core to extremities, cold sweats, sweaty palms and soles of the feet, light-headedness, and so on.

This “false” activation of the adrenal system makes the treatment of individuals with anxiety or panic disorders quite challenging. In other words, it is one thing for a therapist to help “desensitize” an individual to their fearful thoughts (assuming the thoughts are not tied to real or significant threats). However, when the fearful thoughts are occurring inside of a “revved” and adrenalin-charged body, they become much more real, believable, and difficult to release. In effect, an adrenal body tells the person terrorized by, say, a working elevator, that they are right to feel afraid: “Look at yourself! You are panting, and your heart is leaping out of your chest! OF COURSE you are in danger!”

As such, the therapist’s first job is often to teach the client how to relax their body, utilizing what is called relaxation breathing (slow, even, patterned breathing in and out). The latter is often paired with relaxing mental imagery, tensing and relaxing of various muscle groups, and/or “tuning in” to the body (concentrating on the specifics of what is physically felt at the moment, good, bad, neutral, e.g., anything being touched). Only when the client’s body is sufficiently relaxed does it make sense for the therapist to start desensitizing the client to their fearful thoughts. In the case of intense phobias, the behavioral treatment approach of “systematic desensitization” establishes a hierarchical ladder of fears within a certain category of feared objects or events. Starting at a tolerable level of fear on the ladder, the therapist guides the client through an alternation between exposure to the feared stimulus (often beginning with imagined exposure, then progressing to actual exposure) and relaxation, where the latter is reached via relaxation breathing and imagery.

At times, a person’s anxiety or panic is intense enough to be beyond what can be calmed with relaxation breathing and psychotherapy alone. In these cases, a psychiatrist or physician may need to be consulted, to provide medication to reduce the anxiety to a manageable level. These medications fall basically into two groups: (1) minor tranquilizers, also called benzodiazepines, of which the best-known examples are Valium (diazepam), Ativan (lorazepam), Xanax (alprazolam), and the long-acting benzodiazepine, Klonopin (clonazepam), and (2) anti-depressants. (Anti-depressant medications are not only useful for depression, but also anxiety.)

One class of anti-depressants which is particularly helpful with anxiety and panic is the SSRI (selective serotonin reuptake inhibitor). This class includes many well-known medications such as Prozac (fluoxetine HCl), Zoloft (sertraline HCl), Paxil (paroxetine HCl), Celexa (citalopram HBr), and Lexapro (escitalopram oxalate). Between benzodiazepines and anti-depressants, anti-depressants are used more frequently to treat anxiety, as they usually are quite safe, and have no addictive potential. Unfortunately, anti-depressants do not work quickly, requiring around three weeks (at each dosage) to reach their maximum level in the bloodstream. However, as long as the SSRI is well-tolerated, once the person has been on an appropriate (daily) dosage for several weeks, the anti-anxiety benefit can be very significant.

With people suffering from severe anxiety or panic, because of the lack of immediate response with an SSRI, the physician will sometimes start the person on an SSRI and benzodiazepine together. Benzodiazepines work very quickly, within around 20-30 minutes. (This quick and effective action is not without a “string attached,” as benzodiazepines can be habit-forming, especially with higher doses and/or longer use.) However, it is safe for low-dose benzodiazepines to be used early in an SSRI trial, then once the SSRI has built up and is fully engaged, the benzodiazepine can be gradually phased out and no longer used (except in case of a relapse of acute anxiety).

As disabling as anxiety and panic can be at severe levels, at moderate or low levels, anxiety can actually serve good purposes. It helps us to work harder, be more concerned about doing a good job (e.g., “sweating the details”), and/or getting the job done by the deadline. This is part of what it means to be a “Type A” person, e.g., focused, driven, compulsive, self-initiated, (and often anxious!). As a rule, the most successful people in the world have many of these traits, and yes, anxiety is usually part of the fuel that gets them to the top! The anxiety must be kept in check, however. Performance improves with increasing anxiety only up to a point—once the anxiety becomes too high, performance rapidly falls off to near zero. Allowing ourselves to become too anxious also makes us less able to work with or listen well to others, as we become more demanding, controlling, impatient, and just plain noxious at times. The ability to be cooperate with others and work as a team may be the single most important ingredient for life success. Thus, while we benefit from the worries that help put the “polish” onto a good job, we must remember that anxiety is a double-edged sword, that can hurt us if we fail to modulate and channel it.