On anxiety and all its states – part I

“Usually people are afraid of the emotions that they have because they haven’t been able to manage them so far and they expect that when they come in, they’re going to come in all at once, and sometimes they can come in all at once. The idea is how do we let them in slowly so that they don’t rush in very hard or end up controlling our lives in one way or another.”

Volunteer: During Mental Health Awareness Month, we spoke to Bianca Vătășescu, clinical psychologist, psychotherapist and career counselor, about anxiety, what it is and how it manifests. Listen to the first part of the episode.

Bianca: Anxiety is a kind of diffuse fear, without a specific object, and that’s somehow the difference between what we mean by anxiety and what we mean by phobia, because usually phobia is when you have a clear stimulus, like a phobia of dogs. It’s clear that the trigger is the dog and you’re aware of that object, whereas anxiety is somewhat diffuse, because you don’t really understand what consciously triggers it. Another definition that the APA, the Association of American Psychologists, has suggested is that anxiety is characterized by feelings of tension, worry, and physical changes. On a cognitive level, all sorts of thoughts, more or less rational, pass through us. Either way, they’re intrusive, in the sense that we can’t really get rid of them when anxiety overwhelms us, such as “I’m not good enough” or “what’s going to happen” or fears about the future. Or, if it’s in the context of social anxiety, it might be something like “I’m going to embarrass myself” or “I’m going to be silly” or “other people will laugh at me”. There would also be difficulty concentrating, because when someone is actually suffering from anxiety, it’s difficult to concentrate, to focus, on the tasks that they have to do, like at school, the feeling that the mind has gone blank, that sort of blankness that we sometimes feel. There could also be the fear of losing control and, unconsciously or, consciously for some, there could be the fear of death. This would somehow be more so when panic attacks also occur, because somehow the fear of death is also quite profound in the physical manifestations that the person experiences. And we’ll get right to that.

Volunteer: Are these thoughts involuntary or triggered by something?

Bianca: Yes and no. In the sense that there can be a trigger, in the sense that someone with, let’s say, social anxiety, has sometimes gone through various contexts in which they felt rejected, or threatened, or bullied, and somehow when they get into a social context, this type of trauma is reactivated or, somehow, their anxiety is activated. There doesn’t necessarily need to be a trigger, because anxiety can manifest itself even without a real trigger, like panic attacks can occur even without a real trigger, in the sense that a lot of frustrations build up

or problems that the person doesn’t take into account and, at some point, they end up having a kind of panic attack and it may be without a real trigger, that is, the trigger doesn’t exist at that moment. It could be, I don’t know, having a chat with friends and everything is flower power and somehow a panic attack is triggered. So the trigger doesn’t necessarily occur.

Everybody thinks of anxiety as fear, except that somehow it’s not just made up of fear, it’s broken on many levels. And one of them would be the feeling of loss of control, because that’s somehow the most prominent in anxiety, like the person feels like they’re losing control of their own body, because you’ll see that there are some changes in the body as well, and of their own mind, because they don’t understand where these thoughts are coming from and what to do with them, and of the emotions that they feel, because if you’re at a party and suddenly you feel a fear that you can’t explain, it’s clear that somehow you feel that you’re losing control. There’s also a state of tension that the person feels both emotionally and in their body, because I’m going to get to the body sensations, and I’ll come back to this, there’s a kind of trembling, both of the hands and the body, which may or may not occur in some people. The feeling of being on the edge, in the sense that you don’t recognize your own emotions, you don’t know what’s going to happen, you don’t know whether you’re going to live or not, and somehow people with anxiety, especially the first time anxiety onset, don’t really understand what’s going on with them. Another level would be irritability, but that somehow comes up more when we also talk about depression.

Volunteer: Depression and anxiety go hand in hand, or can there be one without the other, or does the other come at some point, after the anxiety, let’s say?

Bianca: It can be just one, or it can be both, or it can come one after the other. All the 3 options that you have listed are perfectly ok, in the sense that, as a rule, a person who starts having anxiety or depression, later on may develop the other one, because they are somehow in comorbidity, comorbidity meaning that, somehow, their symptoms are slightly mixed, and I’ll explain why that happens. As a rule, a person who starts having panic attacks, or simple generalized anxiety, slowly slowly starts avoiding all sorts of situations. Avoiding all sorts of situations, they start to withdraw socially, somehow lose their zest for life, and little by little, they may fall into depression. At the same time, a depressed person may think that … what’s happening to them … somehow they don’t find solutions, or there won’t be any solutions, and they may somehow manifest typical anxiety-like behaviors or, why not, even develop anxiety. I mean, somehow these go hand in hand. And yes, there are people who indeed have anxiety and depression, somehow it went much deeper, it may be an affective disorder.

I prefer to see anxiety and depression as being on a spectrum, whether we’re talking about early onset tendencies or whether we’re talking about advanced stages, and then clearly a psychiatric consultation is needed because, I know we’re going to get to this discussion at some point, and I’d like to kind of point out right now. Because there are a lot of people who suffer from panic attacks and don’t treat them in any way. And, the idea would be to go to a psychiatrist, because medication is needed, and if you start early, it’s super ok and the person recovers very easily.

Volunteer: So panic attacks can’t be treated with psychotherapy, you have to intervene with treatment?

Bianca: It’s a question I would answer with “it depends”, because some studies say that therapy helps up to 80% and somehow medication would not be necessary, other studies say that medication is more important than therapy, other studies show that just a simple sport would help depression, for example, and you don’t need to intervene very much on the medication side. However, my recommendation would be that people who suffer from panic attacks or who somehow consider themselves to have depressive or anxious tendencies should consult a psychologist or psychiatrist and then follow the recommendations, because from case to case, either medication or therapy is needed, and somehow the best thing would be to combine the two, because I find it hard to believe that you can get rid of panic attacks alone, or only through therapy. Sometimes it’s much more effective to combine these two and try the psychiatrist’s opinion, even if you don’t take medication. I keep hearing various people who keep getting prescriptions that wouldn’t be in their name, and somehow a wake-up call would be in that direction, that it’s not okay at all to have that happen. It’s not okay because the medication produces changes and it would be okay to be under psychiatric monitoring, in the sense that psychiatrists do all kinds of tests and it’s normal for that to happen, that is, they somehow monitor the patient’s condition. Or if the patient is taking medication without a recommendation, he has no way of knowing what the risks are and what changes he is somehow producing on his own, or whether the medication is appropriate or not. It can’t work only therapy or only medication, I mean it depends on the choice of the specialist, somehow also according to the needs of the client, also according to his reluctance to one or the other because I have met many people who are much more open to take medication than to go to therapy and then go for it, I mean it’s ok if that’s in agreement with you, then at least do that.

Volunteer: It seems to me that there is a very big stigma against medication, in high school going to see a psychologist is something taboo, so in this context to take some pills directly seems curious to me…

Bianca: In Romania it is taboo to go to a psychologist and to see a psychiatrist. Things have changed recently and I’m glad they have. However, somehow, Romanians at least are used to taking medication without an informed opinion and then, if they take paracetamol for the simple fact that it’s ok to take it for anything, they will do the same with tablets because the neighbor recommended them. And that’s what I was saying, that somehow it’s easier to accept a medication, not necessarily the specialist behind the medication, than to go to a therapist and talk about all the problems they have. On the other hand, it’s really more comfortable for some people to go to a therapist… than a psychiatrist because there’s not as much stigma associated with it. Somehow, if you go to a psychiatrist, a lot of people still consider themselves crazy, which is not ok, I mean people go to psychiatrists because they want to find a solution to their problems, not because they are one way or another.

Volunteer: If you’ve heard or made comments like “it’s all in your head”, “you can control it”, “it will pass”, “it’s up to you”, it’s important to know that anxiety manifests itself strongly on a physical level. This is not a consultation. If you find yourself in what Bianca said and want to ask for help, at the end of the discussion we have left some helplines and resources on our website, mentalhealthforromania.org.

Bianca: When somehow we are more anxious, we tend to sweat more, the muscle tension is in the form of trembling, in the sense that my hands are trembling or my body is shaking. When anxiety has been going on for a long, long, long time, all sorts of stomach pains, bowel disturbances, which are not necessarily medically caused, occur, and that’s when even doctors recommend a consultation, I mean, recommend that the person go to a psychologist. Another indicator would be dizziness or high blood pressure, rapid heartbeat, which are somehow very recurrent among panic attacks. Those are the main… the main indicators of a panic attack – rapid heartbeat. There would also be shortness of breath and insomnia, which again can also be identified in depression. The difference between depression and anxiety, as far as insomnia is concerned, is that in depression you wake up earlier or you don’t fall asleep, but in the sense that you don’t fall asleep because you have somehow slept all day or you don’t fall asleep because you wake up during the night and you can’t fall asleep, whereas in anxiety the problems related to insomnia are in the first part, that is, you don’t fall asleep in the evening because all sorts of thoughts come into your head and somehow they don’t let you fall asleep. That would be about the difference in nuance between them. Of course, from case to case, the tendencies are different, the signs are different.

Anxiety is about the future, in the sense that the worries go into the future, and that somehow I’d like to differentiate between anxiety and depression, because whereas anxiety goes into the future, depression is about the past. That is, I’m worrying about something that I haven’t changed, in the past and that’s following me into the present, whereas anxiety is, I’m worrying about something that might happen sometime in the future. Usually people with generalized anxiety avoid all sorts of behaviors that they used to be okay with, that are not okay now, like going out socially or, I don’t know, going on vacation or going on a plane or all sorts of behaviors that normally wouldn’t be anxiety-provoking but now may be a trigger for a possible panic attack.

How depression differs from anxiety is that depression somehow hides an anger because as I said it’s more on irritability. An irritable person can have depressive tendencies, a melancholic person, a sad person. But it’s not just sadness that makes a person depressed. Convictions like “there’s no point” or thoughts of suicide that somehow that can be as a typical behavior of depression or not and as I said anger or absence of anger because sometimes in depression there’s an anger that the person didn’t express adequately when it was appropriate.

Volunteer: Another question and concern was whether shyness is the same as anxiety.

Bianca: A shy person really can be anxious, in the sense that they can be afraid of a lot of things and then they are perceived by others as shy. At the same time, this shyness hides a lack of self-confidence, which, yes, can lead to anxiety or depression, but it doesn’t necessarily mean that it’s associated with depression or anxiety.

Volunteer: In a consultation, when you tell these things, does a specialist decide where you fit in and what treatments to follow?

Bianca: Let me tell you what the clinical psychologist does. Usually, if the client comes in with a story, he doesn’t really know what’s going on, he doesn’t know if it’s depression, anxiety, but he knows that something is not ok. The clinical psychologist does an interview, in the sense that we talk about the problem, we see what the problem is made up of and we see if, I don’t know, for example, if there are irrational thoughts or fears or we see what the nuances are. After that, there is usually also a testing part, in the sense that there are standardized tests that measure something specific, in the sense that there are anxiety tests, there are depression tests, there are tests that measure anxiety and depression and stress, because sometimes we tend to think that we are anxious, when in reality we actually have a very high level of stress that affects us and it might just be stress and not necessarily having already developed anxiety. And somehow it’s important to be quite clear, I mean to have some appropriate and valid measurements at the same time and that’s why somehow the clinical psychologist has to measure, beyond the actual discussion. Of course, intuition and experience and all the information he or she has helps, but there are several pieces of the puzzle that have to be put together piece by piece. Then recommendations are made, in the sense that if the person needs to see a psychiatrist, recommendations are made to a psychiatrist or a report is given with which the person goes to the psychiatrist and only then the psychiatrist decides what the real diagnosis is and whether or not medication is needed.

Volunteer: What is a panic attack and what causes it?

Bianca: Panic attacks are somehow episodes that occur either much more often, in the sense that in a month a few episodes occur or once a year, two years. Somehow the person having panic attacks the first time they have them doesn’t understand what’s going on. They often go to the emergency services or to hospital because they feel the sensation in their body much too deeply and it is associated with a deep fear and a feeling that they could die at any moment, in the sense that, as I said just now, there is this sensation of deep palpitations, loss of breath or shortness of breath, chest pains. A lot of times, people who have had panic attacks have thought they’ve had a heart attack, I mean somehow that’s how intense the sensation is, plus they can either have thoughts that something might happen or they can stop thinking at all at that moment. There would be hot flushes or chills during this time, but either way, it’s much more intense than anxiety. Not every anxiety leads to panic attacks and these two should not be confused because not everyone who has anxiety also has panic attacks.

VOLUNTEER: Do these symptoms come in a pack, meaning does a panic attack have an overwhelming wave of panic, a feeling of loss of control? Does a panic attack always have the same intensity, or do they also differ?

Bianca: It differs, the intensity and the symptoms that each individual person has differs. In the sense that as a rule, the first one is stronger, then the panic attacks are smaller or maybe bigger, it depends on each person, it depends on the trigger that triggered it or not. As I was saying, it can exist in the absence of a conscious trigger, it can be an unconscious trigger like “everything’s ok, no stressor is coming in, instead I see something that reminds me of something that happened 10 years ago when I felt something”. And then I can have a panic attack. Sure, not to exaggerate and be very paranoid now that we can have a panic attack at any time, but in the sense that they often occur unexpectedly and people don’t understand what triggered them. But no, it depends on the individual, I mean, as a rule, hyperventilation and hot flushes are more common, palpitations again are common, but it depends on the individual. Either way, the sensation is not exactly comfortable for the person experiencing it, which is why they also need to control things one way or another and seek specialized help. Of course there are a lot of people who start living with panic attacks and realize that it’s only going to last a few minutes and then it’s going to be ok, it’s just that à la longue, not treating it is not ok at all because it affects a person’s life quite a lot, in the sense that you can’t enjoy the same things you used to enjoy, you live always with a fear that you might start having a panic attack and ideally you should treat it when it’s appropriate and not afterwards.