THREE SOURCES OF ANXIETY
Carl Shubs, Ph.D.
©2008

Kenneth (not his real name) was a 35-year old man who first came to see me for psychotherapy because of panic attacks that were devastating for him. They were interfering with his very responsible and prestigious executive job and with his relationships within his family. They were also undermining and eroding his self-esteem, which then led him to feel both embarrassed and ashamed, each of which set in motion escalating cycles of progressively deteriorating self-esteem and increasingly greater embarrassment, shame, guilt, and panic.

He had to travel for work occasionally, and he would be afraid to fly because he feared that the plane would crash. He would also be afraid that he would fail in his performance in doing the presentation he was traveling to make and that he would therefore be seen to be ill informed, stupid, and foolish.

He was having panic attacks regarding going to work, even locally, because he feared that he would no longer be able to know what to do in his job and that he would be given tasks and responsibilities that were beyond his grasp, although previously he had always performed well and had been highly respected for his significant background, credentials, and accomplishments. Again, he was afraid that his performance would reflect poorly upon himself, would disappoint others, and would leave him feeling humiliated and ashamed. These fears were so out of control for him that he was unable to go in to work and they were jeopardizing his job and his livelihood, which further fueled and escalated his panic.

Similarly, with his family, he felt highly conflicted both in being with them and being apart from them. He felt afraid to leave the safety and security of his family, while simultaneously feeling afraid to be with them because he felt so fragile and feared being unable to live up to his self image with them and to fulfill his roles as provider, strong man, protector-husband, and strong, confident, capable, protective father to his three small children.

As we began to talk together, his primary concerns were, "What do I do when I'm feeling that panic? How do I control it? How can I stop it from happening?" It was as if the panic was a thing that happened to him, coming out of the blue, out of nowhere, like an alien entity that was attacking him, invading him, and taking over him. He definitely felt like a helpless victim to it, and he felt further overwhelmed, subjugated, and defeated by it because he had no foundation for understanding where it came from or why it was happening. He therefore felt confused by it. He felt his intelligence and his highly developed cognitive abilities had been stripped from him and were made powerless and ineffectual by the panic, leaving him without those as resources on which he previously had so strongly relied and had used for coping, support, and reassurance.

Our first course of action was to focus on discovering and developing some new coping mechanisms that could help him address his burning questions of "What do I do? How do I stop it?" We were able to do that, but this left our job only half done. This was helpful to him, and he felt much better as a result. But this concentration on coping was strictly about symptom relief. It didn't address anything about what brought on the panic within him and how we could change that. It's like putting calamine lotion on a poison ivy rash and stopping there, without also seeing that the outbreak happened because he was hiking through the thick brush rather than on an open trail and that he was unaware of how to recognize the poison ivy so he could avoid it in the future.

As I always note with people who are dealing with such issues, our approach has to be focused on a dual track: 1) symptom relief and 2) removing the cause of the symptoms in the first place so that symptom relief eventually will not be needed. To use a medical analogy, if you have an infection or a virus, treating the symptoms is not enough. You must also clean out the infection or stop the virus or else they will continue to fester and wreak havoc. Once they are addressed and treated, there is then no further need for bandages or medication.

As Kenneth and I turned our attention to exploring and examining the triggers for his panic, we came to recognize that they presented themselves in three primary areas: 1) competence, 2) ability to manage feelings, and 3) interpersonal relations. Getting to know and understand each of these realms more clearly opened up vast resources for us in being able to eliminate the foundations of his anxiety so it would not later develop into panic.

The competence arena includes questions like, "Can I perform this task, understand this material, and master this skill?" Maybe math is not your thing, but it's a central part of the job you have to do. Maybe you don't write well, but you have to write an important paper or report.

The issue in the realm of managing feelings relates to experiencing your own normal and natural feelings as being overwhelming and out of control. Some of this concerns the variety of feelings we have, responding to certain ones with fear and/or revulsion, and therefore reacting to a normal occurrence of that feeling as if it were a terrible event. It may come to be experienced as a toxin in the system, like an allergy, and we then react to it by breaking out, like with poison ivy, though here the break out is an emotional one, such as panic.

The result of this, as a trigger (the thing that sets off something else, here being the panic), is that we experience our anxiety or fear as overwhelming and therefore we become afraid of being afraid. We are afraid that we will not be able to manage the fear that we anticipate. This fear grows like a snowball rolling down hill, expanding, until it crashes and wipes out the town. This means that it completely debilitates the person and leaves them emotionally and psychologically paralyzed and unable to function, when it occurs in the extreme.
For Kenneth, this was a significant part of his fear of leaving home, getting on a plane, or doing a presentation. He was afraid that he'd become afraid and that he'd get caught up in the spiraling panic. He therefore felt helpless and powerless in the face of his anticipated and projected inability to manage the anxiety that he expected would come over him.

The third source of anxiety is the interpersonal domain. This concerns how you imagine and expect others to respond to you if the realities of your fears of incompetence and inability to manage your feelings are actually realized. It expresses itself in questions like, "What will they (he, she, the group of them) think of me? How will they feel about me? Will they change how they think and feel about me? Will they still love/like me? Will they have some kind of feeling about me that I don't want them to have? Will they be hurt, disappointed, ashamed, or angry with me?"

These are all crucial questions and concerns that naturally arise as companions to each of the other realms of anxiety, because they all exist as part and parcel of our relationships with other people. Sometimes, the fears emerge concerning the actual flesh and blood people that are in our lives, like our mother, father, spouse, child, or friend. At other times, they surface concerning the significant people in our lives who are represented by those flesh and blood people, such as when we relate to our spouse, child, boss, or friend as if they were our mother or father. Similarly, the fears may arise concerning those significant people who have a place in our minds even when the actual people may be physically absent, of another time and place, or maybe even no longer living. They continue to live in our minds, and we continue to relate to them through our experiences. This may be happening when we become afraid that we'll not live up to the expectations of our mother or father, even though they may know nothing about it or may have died years ago. These relationships, therefore, are a major source of anxieties and must be recognized to play a powerful role in our experiences of anxiety, fear, and panic.

As Kenneth and I continued working together, he found it extremely useful to have these three sources of anxiety: competence, managing feelings, and interpersonal relationships, as reference points to guide him as he would notice feeling overwhelmed, confused, anxious, and panicky. Being able to determine which areas his fears were based in helped him to understand them more clearly, evaluate whether or not there was any reality basis to them, and recognize and reappraise the interpersonal elements they had concerning his past and current relationships. This served as a powerful tool in helping him to feel more in charge of his feelings, more able to manage them, more able to feel safe and secure in his relationships, and more empowered personally. It enabled him to build and progressively expand his sense of confidence and self-esteem instead of spiraling into panic as he had previously done.