She's not sure what would trigger her panic attacks--the racing heart, the sweaty palms, the dizziness. "To me," she said, "they just came out of the blue."
"I had a hard time breathing," recalled Tracy, who asked that her real name not be used. "I would hyperventilate, and I'd lose sensation in my hands and feet. My immediate thought was, for sure, I was going to die. I really thought I was going to pass out and stop breathing . . . Imagine the worst way you could ever feel, multiply it by 10, and that's what a panic attack was like."
Seated in a Costa Mesa restaurant, the attractive, outspoken 27-year-old graduate student in business administration was describing her year of living anxiously.
The panic attacks, which lasted from 30 seconds to a minute, hit once every couple of days in the beginning. Then they began occurring four or five times a day. Finally, Tracy said, she reached the point where she was afraid to be alone.
"I wouldn't drive anyplace or go anyplace by myself," she said. "I became totally dependent on my boyfriend. I had to give up all the things I love--backpacking and hiking. I've always liked being by myself, but I couldn't be by myself."
And even when she wasn't experiencing panic attacks, there was little respite: "I was," Tracy said, "anxious all the time."
Anxiety--in all its sweaty-palmed, light-headed, stomach-churning ignominy--has been deemed the No. 1 mental health problem in the United States by the National Institute of Mental Health. A recent NIMH survey shows that 8% of Americans suffer from anxiety disorders--an array of problems that includes generalized anxiety, panic attacks, phobias such as agoraphobia (an abnormal fear of open or public places), post-traumatic stress disorder, and obsessive-compulsive disorder.
In recent years, researchers have begun to focus on biological answers for anxiety disorders--some people may simply have "anxious genes"--and many anxious individuals have sought relief in a variety of anti-anxiety drugs.
Others, however, are finding a more natural way to overcome anxiety's hammerlock hold on their ability to lead a normal life.
It's called cognitive therapy--an approach to treatment that emphasizes the role cognition, or thinking, plays in anxiety disorders.
Simply put, cognitive therapy takes the view that anxiety is an emotional response to the thought that something terrible is going to happen: Anxious people tend to overestimate the degree of real dangers--or see dangers that do not exist--and underestimate their ability to cope with them.
Mary, a 26-year-old hospital admissions counselor from Costa Mesa, has had a lifelong fear of flying. Her anxiety had been manageable until last Thanksgiving when she flew to Philadelphia. On the way, the plane developed engine trouble and had to land in Indianapolis for repairs.
"That really kind of blew it off the roof for me," said Mary. "After taking off again, I was just sure that with every little noise I heard we were crashing. I'd look at the stewardess to see if she was worried. If she was not smiling, I'd think, 'Oh, oh.' It (her anxiety) didn't show on the outside, but inside . . . my heart was beating real fast, my mouth was dry and my hands would sweat . . . I couldn't talk and I was white-knuckling it all the way there."
Once the fear reaction starts, cognitive therapists say, it usually builds on itself. In the months that followed Mary's Thanksgiving flight, for example, she said, "any time someone even mentioned flying I'd get very anxious."
"Anxiety is a signal of danger, just like an alarm," says Dr. Aaron T. Beck, the 64-year-old founding father of cognitive therapy. "But the problem is people often will react to false alarms as though these are true alarms, so we have to teach them to discriminate between false and real alarms. We don't want them to react to a minor danger as though it's a major danger and just fall apart."
Cognitive therapy, Beck said, "is helping people to first think more realistically about the threats that they perceive. And, secondly, it helps them to cope more successfully with the inevitable anxiety that people experience."
The approach--which is also referred to as cognitive-behavioral therapy because it uses the behavioral therapy method of gradually exposing persons to the situations they fear--focuses on having anxious individuals examine their fear-producing thoughts and beliefs, and in correcting their erroneous or exaggerated thinking, they lessen or eliminate their anxiety.
It may take as few as 15-20 weeks to treat a normal anxiety such as a salesman who has started having panic attacks whenever he calls on a customer, say cognitive therapists. For more complicated cases such as a woman who had suffered panic attacks for more than 40 years and would only leave her home if her husband was with her, treatment may last from one to three years.
In the case of Mary's flying anxiety, it took eight sessions and repeated trips to the airport to look at airplanes in order to "desensitize" her and convince herself "the planes aren't going to crash."
"I'm still anxious about it, but it's manageable for me," said Mary, who recently flew to New Orleans on business with relatively little anxiety. "The bottom line was to stop the scary, unrealistic thought I was having and just not let myself think it."
Beck, director of the Center for Cognitive Therapy in Philadelphia and a professor of psychiatry at the University of Pennsylvania School of Medicine, happened upon the role thoughts play in emotional reactions in the late 1950s when one of his patients undergoing psychoanalysis for depression said he had been having negative thoughts and images that he previously had not mentioned.
In questioning his other depressed patients, Beck found that all of them, regardless of their background, had similar pessimistic thoughts about themselves and the rest of the world when they were depressed.
"These thoughts were very fleeting, and they were on the fringe of consciousness," Beck explained in a telephone interview. "The main thing about these thoughts was that they showed that the individual was reacting to the current situation in a somewhat distorted or inappropriate way.
"Up to that time," Beck said, "it was thought that an individual simply reacted emotionally to other people. But with this discovery, we realized it was always a thought that intervenes between the exposure to a situation and the emotional reaction."
Although cognitive therapy initially was criticized for being a superficial approach to treating depression, independent studies conducted in the United States and Britain have shown that depressed people who have undergone cognitive therapy do as well as those given anti-depressant medication. And in long-term follow-ups, Beck said, the people who underwent cognitive therapy had a much lower relapse rate than those on medication.
Preliminary results of studies on the use of cognitive therapy to treat anxiety or panic disorders show results similar to those of the depression studies, according to Beck, who began using cognitive therapy to treat anxiety in the late '60s.
Now Considered Mainstream
With each new study over the past 10 years, Beck said, cognitive therapy has garnered increasing acceptance. It is now considered one of the mainstream psychotherapy approaches.
Today there are 16 independent Centers for Cognitive Therapy (so-named to show they follow Beck's approach) throughout the United States, including those in Newport Beach, Los Angeles and Palo Alto. The centers provide both treatment and training in cognitive therapy, and private therapists throughout the United States and around the world have participated in training workshops.
Other psychotherapists have learned cognitive therapy from one of several books Beck has written on the subject--his most recent is "Anxiety Disorders and Phobias" (Basic Books, 1985) which he co-wrote with Gary Emery, director of the Los Angeles Center for Cognitive Therapy, and psychologist Ruth L. Greenberg.
But Dr. Dennis J. Munjack, director of the Anxiety Disorders Clinic at USC-Los Angeles County Medical Center in the department of psychiatry, expressed concern that some therapists may be overemphasizing cognitive therapy in treating anxiety disorders.
"While the medications and behavioral exposure (desensitization) treatments have been established in many studies both nationally and internationally, no study of cognitive therapy alone on severely anxious patients has yet been published. Therefore, I hesitate to dilute established therapies of proven value with those that have not been established."
At his clinic, Munjack said, "we use cognitive therapy as part of an overall, comprehensive treatment package, which includes drugs, exposure and practice in feared situations and some cognitive therapy. We might give cognitive therapy more emphasis in some patients and less emphasis in others. It depends on the problem."
Drugs Most Reliable?
"The biggest area of conflict," Munjack added, "revolves around which is the most effective therapy for panic attacks, and there is now very good evidence that the most reliable way of stopping panic attacks are with specific anti-panic medications such as imipramine and alprazolam. Of all the anxiety disorders, panic attacks seem to be the ones with the strongest biologic component."
Although Munjack said the "preponderance of evidence" shows that drugs are effective in treating spontaneous panic attacks, Beck takes a different view on the use of drugs in treating anxiety disorders.
"Medication does seem to have some good results initially, but a study in Britain found people who were on medication for over six months actually had more anxiety than a group who were given a placebo for that period of time," he said. "So it seems in the long run, dependence on medication may actually make the anxiety worse."
"The psychological approach," Beck maintains, "starts to work right away and when it is effective, it's not necessary to give medication."
According to Beck, the most common anxiety disorder is generalized anxiety. "That includes people who seem to experience anxiety throughout the day and it does not appear to be related to specific situations," he said.
Beck noted that "some people are more prone to anxiety than others, and this tends to fall into families. Research studies find that twins who are reared separately tend to have the same levels of anxiety."
Christine Padesky, director of the Center for Cognitive Therapy in Newport Beach, believes several factors contribute to anxiety being the nation's No. 1 mental health problem.
More Internal Pressure
"I think people are putting more internal pressure on themselves to succeed," she said. "And along with that kind of drive for success goes a lot of anxiety because you start judging or evaluating yourself. Plus, being real attuned to how people see and evaluate you is fertile ground for anxiety. And to that you add living in urban areas where there is additional anxiety and stress."
Padesky observed that "in anxiety, there is always physical arousal--rapid heart beat, increased sweating, red face, jitteriness, dizziness. The physical arousal in and of itself can be good or bad. For example, if you're going to give a speech or perform in an athletic event, studies show that a certain amount of being keyed up actually improves your performance.
"Where it starts causing problems is if you start interpreting your physical arousal as dangerous or . . . something to be ashamed of. Then you've added a component that's self-defeating."
People suffering from anxiety, she continued, "often have low self-esteem and are perfectionists. It kind of goes together because if you're perfectionistic, then there are these chances of failing every single day."
Padesky said some people develop anxiety as a result of experiencing some sort of trauma--they may have been in a car accident or they were assaulted.
In Tracy's case, her panic attacks were so overwhelming that when she first visited Padesky, she recalled, "I still thought I was going to die of a heart attack."
Padesky said she broke down the treatment into three phases.
"Initially, I got a history of her anxiety symptoms and panic attacks and other major events in her life that might be contributing (to her anxiety)," Padesky said, noting that it quickly came out that a close relative had recently died of a heart attack and Tracy feared the same thing would happen to her.
Padesky reviewed the facts with Tracy: The relative who died of a heart attack had had a history of high blood pressure and hadn't been taking her medication; she was an older woman and had been a two-pack-a-day smoker. Tracy was in her early 20s, didn't smoke or have high blood pressure.
Padesky said she also taught Tracy three simple techniques to control her anxiety symptoms.
- Distraction: While driving on the freeway, for example, she would turn on the radio and sing along with the music.
- Relaxation: She would breathe slowly and relax her muscles.
- Cognitive restructuring, or adjusting her thinking to be more realistic: She would control her fears by countering them with facts.
By the end of two weeks of therapy, Padesky said, Tracy's panic attacks had become less frequent, and when they did occur they lasted for shorter periods.
Padesky said, however, that although Tracy understood the concept behind cognitive therapy, she was still disturbed by the fact that her panic attacks seemingly came "out of the blue."
"So in phase two," Padesky said, "I had her start to track her stress and arousal level every hour during the day for a week or two. What happened was she began to see that while not one big thing was making her have panic attacks, there were stresses throughout the day that made her get increasingly tense and that her panic attacks always followed periods of tension."
At the end of phase two--about five months into treatment--Tracy was no longer having any panic attacks at all, said Padesky.
The final phase of therapy consisted worked on getting her to start going out and doing things she previously had avoided, said Padesky.