Posts tagged: Anxiety

Panic

Panic is not a disorder unto itself, and neither is a panic attack.  The modern conceptualization is that panic is a form of anxiety that may or may not include agoraphobia.  This last term is taken from the Greek, and literary means “fear of the marketplace”.  It is a fear of being unable to escape in a crowded situation, fear of bridges, and fear of travel in any kind of conveyance.   Much of the fear is anticipation of having a panic attack in these sort of situations.  The fear is heightened if the person believes the situation is such that no one will come to their assistance.  The agoraphobia is rarely initiated by a specific trauma, as is a post-traumatic stress disorder.  It is also not secondary to a fear of being socially embarrassed, as is a social phobia.  All these anxiety disorders impel one to flee the situation, but for different reasons.  Situations that involve travel or crowds  are feared and consequently avoided.  Many agoraphobics do not experience panic, but most suffer with the disorder.

Many agoraphobics develop anticipatory anxiety of being in public places, then avoid these situations for fear of having an attack.  Phobic avoidance develops over time, which reinforces the avoidant behavior.  The combined disorder of agoraphobia with panic tends to be more functionally debilitating than either disorder in isolation.  Anticipation of a fearful situation reaches the point of panic, and the panic is so startling that a person would do anything to avoid another panic attack.

Many patients complain of panic, but rarely do they meet the criteria.  Most people experience acute unpleasant anxiety and label that as panic.  Several symptoms overlap with generalized anxiety, but a few are better indicators of true panic than the rest.  The onset of panic and anxiety may be sudden, but panic tends to peak within ten minutes and then subside.  Generalized anxiety has less intensity at the onset, and tends to take a long time to resolve-if ever.  There are intense fears of dying or going insane while enduring a panic attack.  It almost seems like a medical problem when the heart beats so strongly.  A miasma of nausea, dizziness, palpitations, chest pains and shortness of breath overwhelm one to the point they fear dying.  Sweat pours forth in buckets.  Generalized anxiety often is accompanied by sweat, but typically not as intense or circumscribed.
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The good news is that most people who believe they are experiencing panic are actually experiencing acute anxiety.  The onset of panic is so strong and unforgettable, that it creates a cycle of fear and avoidance.  Generalized anxiety does not have specific fears that could be avoided.  Many people have agoraphobic symptoms, but fortunately, few will fall prey to the disorder.  It is commonplace for people to fear bridges, especially if they can see through a metal roadbed.  It is also normal to have fear of being trapped while waiting in line, or have a fear of being immobilized in a crowded elevator.  It is rare these mild anxieties develop into a Panic Disorder with Agoraphobia.

Treatment of all phobias is cognitive-behavioral in nature.  The main thrust of the therapy is to gradually expose the patient to the feared object.  The hope is to decouple the feared situation from the biological and psychological reaction. A psychologist will have the person imagine driving over a bridge, and discuss their emotional and cognitive apprehensions.  As the therapy progresses, the psychologist will attempt increased contact with the feared situation until the person masters their reaction.  Another method is to directly expose the patient to the feared situation in an aggressive fashion, which often alleviates the anticipatory anxiety of the next exposure.  There is a greater risk of being overwhelmed or even traumatized by this second sort of treatment, such that it should only be attempted with professional assistance.  Medication is not advised for long-term control of panic, but temporary usage can assist the therapy by lowering the overall level of anticipatory anxiety.  Please leave your comments regarding this article in the space provided below.

Angst

Angst is not a word often used in conversation, yet it lists very highly on web searches.  I could not find it indexed in the Diagnostic and Statistic Manual IV.  This book lists accepted mental disorders and the codes many insurance companies use for claims.  Two medical dictionaries and a prior DSM (III) did not list angst as well.  It’s an uncommon term for a common condition.

The nearest synonym is anxiety, though it does not capture the full meaning of the word.  There are typically feelings of dread and frustration in a fluctuating balance.  Perhaps many people using “angst” as a search word are trying to capture a state of being they experience.  Perhaps there is a perception of something lacking in their existence, and most English words do not capture the essence of their thoughts adequately.

The existential philosophers address the word “angst,” which is actually a German word for “anxiety” or “dread.”  The philosophical use of the term was coined by Kierkegaard to denote a state of anguish we feel as the responsibility or burden of freedom.  There is dread arising from a lack of purpose, meaning or concern in the universe.  We try to impose our values and meanings on an inherently absurd universe.  Their is a constant dialectical tension between the man searching for meaning, and the universe that is conceived as mute and uncaring.

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While a sense of meaning is important, a sense of purpose can truly keep people alive.  In my clinical practice with nursing home patients, a sense of purpose is the single most important factor in turning around many depressive episodes.  Most people do not theorize about the meaning of their lives until something dramatic happens.  A sense of purpose is nearly prerequisite in the average adult, and it has the advantage of being less abstract than the meaning of one’s existence.

The most clinically meaningful use of the term “angst” is anxiety and frustration with an absent or misguided purpose to one’s life.  What makes it clinically relevant is that it captures a broad swath of humanity, and avoids the perception of the universe as absurd.  A sense of meaningless absurdity to one’s existence is often a depressive perception, such that taking it as factual would not be helpful in mitigating a patient’s Major Depression or Adjustment Disorder.  The typical goal of psychotherapy is to adjust someone to their environment, such that a perception of one’s environment as absurd would render the goal absurd as well.

Angst is a handy word to describe something complicated.  A perception that one is on the wrong track in life, that the boat was missed is the precondition of my definition.  The ongoing sense of anxious dread serving out the sentence of one’s life is angst.  The discovering of an ego-syntonic purpose to one’s life is psychotherapy.  Please share your thoughts about this post in the “comments” section below.