ANXIETY AND EXISTENTIAL ANGST
“ANXIETY AND EXISTENTIAL ANGST
The existential approach to the understanding of ‘anxiety disorders’”
EVGENIA GEORGANDA, Psy.D, ECP.
Hellenic American University
20 September, 2013
Anxiety is a normal human emotion that everyone experiences at times. Many people feel anxious, or nervous, when faced with a problem at work, before taking a test, or making an important decision. Stressful situations often make us nervous or fearful. Experiencing mild anxiety may help a person become more alert and focused on facing challenging or threatening circumstances.
Freud described anxiety as a signal of unconscious material, related to libidinal drives, that was threatening to break into consciousness. Defense mechanisms were employed in order to avoid the threat.
Yalom used the same idea in his psychodynamic /existential approach but substituted the libidinal forces with the four “ultimate concerns”, death, freedom, isolation and meaninglessness.
We can distinguish three types of anxiety: Normal, Neurotic, and Existential.
What is ‘neurotic anxiety’ and the so called “anxiety disorders”?
Anxiety disorders can cause such distress that it interferes with a person’s ability to lead a normal life. Individuals who suffer from an anxiety disorder experience extreme fear and worry that does not subside. The frequency and intensity of anxiety can be overwhelming and interfere with daily functioning. Fortunately, the majority of people with an anxiety disorder improve considerably by getting effective psychological treatment.
There are several major types of anxiety disorders, each with its own characteristics.
Generalized anxiety disorder, is a common, chronic disorder characterized by long-lasting anxiety that is not focused on any one object or situation. Those suffering from generalized anxiety disorder experience non-specific persistent fear and worry, and become overly concerned with everyday matters. Excessive, unrealistic and recurring fears, worries and tension, even if there is little or nothing to provoke the anxiety is experienced and often there is a persistent sense that something bad is just about to happen. The reason for the intense feelings of anxiety may be difficult to identify. But the fears and worries (such as finances or health issues) are very real and often keep individuals from concentrating on daily tasks. A person may have problems making daily decisions and remembering commitments as a result of lack of concentration/preoccupation with worry. Generalized anxiety disorder is the most common anxiety disorder to affect older adults. Anxiety can be a symptom of a medical or substance abuse problem, and medical professionals must be aware of this. A diagnosis of GAD is made when a person has been excessively worried about an everyday problem for six months or more.
Panic disorder involves sudden, intense and unprovoked feelings of terror and dread. People who suffer from this disorder generally develop strong fears about when and where their next panic attack will occur, and they often restrict their activities as a result. Other symptoms of a panic attack include sweating, chest pain, palpitations (irregular heartbeats), and a feeling of choking, which may make the person feel like he or she is having a heart attack or “going crazy.” These panic attacks, defined by the APA as fear or discomfort that abruptly arises and peaks in less than ten minutes, can last for several hours. Attacks can be triggered by stress, fear, or even exercise; the specific cause is not always apparent. In addition to recurrent unexpected panic attacks, a diagnosis of panic disorder requires that these attacks have chronic consequences: either worry over the attacks’ potential implications, persistent fear of future attacks, or significant changes in behavior related to the attacks. Accordingly, those suffering from panic disorder experience symptoms even outside specific panic episodes. Often, normal changes in heartbeat are noticed by a panic sufferer, leading them to think something is wrong with their heart or they are about to have another panic attack. In some cases, a heightened awareness (hypervigilance) of body functioning occurs during panic attacks, wherein any perceived physiological change is interpreted as a possible life-threatening illness (i.e., extreme hypochondriasis).
Phobias: The single largest category of anxiety disorders is that of phobic disorders, which includes all cases in which fear and anxiety is triggered by a specific stimulus or situation. Between 5% and 12% of the population worldwide suffer from phobic disorders. A specific phobia is an intense fear of a specific object or situation, such as snakes, heights, or flying. The level of fear is usually inappropriate to the situation and may cause the person to avoid common, everyday situations. Sufferers understand that their fear is not proportional to the actual potential danger but still are overwhelmed by the fear.
Social phobia, or social anxiety disorder involves overwhelming worry and self-consciousness about everyday social situations. The worry often centers on a fear of being judged by others, or behaving in a way that might cause embarrassment or lead to ridicule. Social anxiety disorder describes an intense fear and avoidance of negative public scrutiny, public embarrassment, humiliation, or social interaction. This fear can be specific to particular social situations (such as public speaking) or, more typically, is experienced in most (or all) social interactions. Social anxiety often manifests specific physical symptoms, including blushing, sweating, and difficulty speaking. As with all phobic disorders, those suffering from social anxiety often will attempt to avoid the source of their anxiety; in the case of social anxiety this is particularly problematic, and in severe cases can lead to complete social isolation.
Agoraphobia is the specific anxiety about being in a place or situation where escape is difficult or embarrassing or where help may be unavailable. Agoraphobia is strongly linked with panic disorder and is often precipitated by the fear of having a panic attack. A common manifestation involves needing to be in constant view of a door or other escape route. In addition to the fears themselves, the term agoraphobia is often used to refer to avoidance behaviors that sufferers often develop. For example, following a panic attack while driving, someone suffering from agoraphobia may develop anxiety over dr
iving and will therefore avoid driving. These avoidance behaviors can often have serious consequences.
Obsessive-compulsive disorder (OCD) is a type of anxiety disorder primarily characterized by repetitive obsessions (distressing, persistent, and intrusive thoughts or images) and compulsions (urges to perform specific acts or rituals). It affects roughly around 3% of the population worldwide. The OCD thought pattern may be likened to superstitions insofar as it involves a belief in a causative relationship where, in reality, one does not exist. Often the process is entirely illogical; for example, the compulsion of walking in a certain pattern may be employed to alleviate the obsession of impending harm. And in many cases, the compulsion is entirely inexplicable, simply an urge to complete a ritual triggered by nervousness. The persistent, uncontrollable and unwanted feelings or thoughts (obsessions) are often followed by routines or rituals (compulsions) in which the individual engages in order to prevent or rid himself of these thoughts. Examples of common compulsions include washing hands or cleaning house excessively for fear of germs, or checking work repeatedly for errors .It is only in a slight minority of cases that sufferers of OCD may experience only obsessions, with no overt compulsions and an even smaller number of sufferers who experience only compulsions.
Post-traumatic stress disorder (PTSD) is an anxiety disorder which results from a traumatic experience. Post-traumatic stress can result from an extreme situation, such as combat, natural disaster, rape, hostage situations, child abuse, bullying or even a serious accident. It can also result from long term (chronic) exposure to a severe stressor, for example soldiers who endure individual battles but cannot cope with continuous combat. PTSD is a condition that can also develop following a traumatic event, such as the unexpected death of a loved one, or losing one’s job. People with PTSD often have lasting and frightening thoughts and memories of the event and tend to be emotionally numb. Thoughts, feelings and behavior patterns become seriously affected by reminders of the event, sometimes months or even years after the traumatic experience.
Symptoms vary depending on the type of anxiety disorder, but general symptoms include:
Ø Feelings of panic, fear, and uneasiness
Ø Uncontrollable, obsessive thoughts
Ø Repeated thoughts or flashbacks of traumatic experiences
Ø Ritualistic behaviors, such as repeated hand washing
Ø Problems sleeping
Ø Cold or sweaty hands and/or feet
Ø Shortness of breath
Ø An inability to be still and calm
Ø Dry mouth
Ø Numbness or tingling in the hands or feet
Ø Muscle tension
Although they may begin at any time, anxiety disorders often surface in adolescence or early adulthood.
What is ‘existential anxiety, or angst, or dread’?
The dread of nothingness, of non-being, of annihilation. The angst created by our awareness of our finality and of the uncertainty of being. The dizziness of freedom and the responsibility it implies.
Etiology: There is some evidence that anxiety disorders run in families; genes as well as early learning experiences within families seem to make some people more likely than others to experience these disorders. The causes of anxiety disorders are currently unknown, although research has provided several clues. Areas of the brain that control fear responses may have a role in some anxiety disorders. The role of brain chemistry is also being investigated. Anxiety disorders appear to be caused by an interaction of biopsychosocial factors, including genetic vulnerability, which interact with situations, stress, or trauma to produce clinically significant syndromes.
Treatment: Usually a combination of pharmacotherapy and psychotherapy is used with good results. Research suggests that CBT is the treatment modality of choice. Cognitive and behavioral components of anxiety disorders are very important, especially in phobias and OCD. Anxiety is related to negative thinking and rumination about the future and what the future may bring. As a result there is great difficulty in focusing in the here-and-now. Relaxation techniques, meditation, mindfulness training, as well as the practice of yoga can prove useful, especially for GAD and PTSD.
Existential approach to the understanding of “anxiety disorders”:
Heraclitus: there is nothing permanent except change.
Anxiety is the result of the uncertainty and insecurity that are part of life and of living. As Yalom mentions, it is also a signal of the ‘ultimate concerns’ threatening to break into consciousness and make us aware of our vulnerability. Often anxiety disorders appear in life transitions were major changes are required and old patterns are threatened. Individuals are especially vulnerable during adolescence and early adulthood when one begins to take control over his/her life. Anxiety over responsibility for choices and fear of growing up is intensified by feelings of incompetency and low self-esteem which are often the result of overprotection, authoritarian and critical upbringing as well as lack of sufficient preparation for adulthood.
The DNA of the Soul: Developmental milestones can be observed in the spiral of the DNA. During the first years the development of insufficient trust and security, the development of shame, doubt, fear and guilt lead to feelings of insecurity and low self-esteem. Thus, poor self-image accentuates anxiety and uncertainty over individual’s capability to deal with life stressors.
Anxiety and especially existential anxiety cannot be ‘treated’. Anxiety is part of life and can be very useful as an awakening call; a way of making our life more authentic. ‘Treatment’ has to do with the improvement of our self-image and self-esteem.
The case of Vera:
Vera is a 25 y.o. woman who is finishing her studies at the Greek University. I first saw her when she was 18. Her father called because he was concerned for his daughter. Although she was an adult I accepted to make an appointment with him for her sake, something which I usually do not do. The first time she came she arrived with both of her parents who waited for her in the waiting room. She looked much younger than her age, was very thin and looked fragile. She was simply but carefully dressed, was well kept and good looking.
Initially it was difficult for her to speak but during the first session she related she needed help because she was extremely anxious and tense. It was very difficult for her to relax and to do many of the things that most people can do. When I asked her to explain what she meant she said that it was very difficult for her to go to most places by herself and even when she went out with a friend she was unable to order. She related she was unable to go to the subway and buy her own ticket, or to call on the phone and order pizza because she was afraid she would make a mistake and people would ridicule her. She was extremely concerned and worried about what others would think of her and had trouble going out to new places or with people she didn’t know. She was concerned about how she was going to go to the University which she had just entered but where she knew no one. Leaving the security of her old school where everything was familiar and safe was extremely difficult and she was afraid she would not be able to adjust to the new environment.
Vera had a boyfriend from school but no female friends. As she explained it was very difficult for her to be open and share how she felt with others (even her parents or her sister), except her boyfriend. Other women were viewed as competitors and she often felt they had betrayed her in the past.
We agreed to meet once a week and for all the time we worked together Vera was never late or missed an appointment. Initially she was brought by her father who waited for her in the car but after the first three months she was able to come by herself with the subway. As time passed and our relationship became more solid she was able to express more openly her feelings. In one of her outbursts she wrote to me:
“Καλησπέρα..Αποφάσισα να σας στείλω μειλ γιατί νιώθω ότι χάνω τον έλεγχο και πραγματικά δεν μου έχει μείνει κανένας να μιλήσω..Με το γιάννη είμαστε πάλι τσακωμένοι και δεν μου μιλάει και με το γιωργο τα πράγματα είναι πολυ άσχημα..Είμαι πραγματικά σε απογνωση..¨Ολη μέρα έχω φάει ελάχιστα,το κεφαλι μου ποναει,ωρες ωρες δυσκολευομαι να αναπνευσω και κλαιω σε καθε ευκαιρια που θα βρεθω μονη μου..Δεν ειναι μονο σημερα,γενικα η κατασταση ειναι περιεργη αλλα σημερα ηταν το αποκορυφωμα και νιωθω οτι δεν μπορω να αντεξω αλλο..”
Slowly she was able to go to the university, get her driving license and start going to the gym by herself. She went shopping by herself and she even went by train to Thessaloniki to visit her younger sister who was studying there. Their relationship had improved and Vera could talk to her about her fears.
The earliest memory she related was being lost in the flea market at the age of 5 or 6, where she went with her father. She was scared and stood at a corner waiting for him. She was relieved when she saw him but did not cry because she tried to hide the way she felt. He was often critical of her, especially when they did math together, and she didn’t understand or made mistakes. The more he asked her questions the more she froze and could not respond. Her father had often anger outbursts for no apparent reason and Vera was scared and felt intimidated.
She was the first born not only in her family but in the extended family as well. As the first grandchild she was often spoiled but also had high expectations from everyone. She felt she had to be perfect and make no mistakes and she was often scolded by her mother who was quite demanding and critical. When she made ‘something wrong’ and was scolded she felt very guilty and incompetent. Vera was shy and reserved as a child and became even more so when she went to school where she felt left out from other kids. She was of course a very good student and the favorite of teachers which did not help her with her relationship with classmates.
Overall she felt very insecure and unsafe. She dreamt of being independent, self-sufficient and very popular but at the same time she felt incapable of achieving these goals. The idea of growing up was both very attractive and very scary. The work we have done has primarily focused on her low self-esteem and her unrealistic expectations of herself. Her feelings of insecurity are less intense and she realizes she can cope, and has coped, successfully with many situa
tions she previously experienced as threatening or catastrophic. She is ready to graduate in November, to leave the security of the identity of a student and to go out to the adult world. She is very popular with men and she is able to do most of the things she could not do when she first came to see me, except order pizza over the phone.
The case of Martha:
“Η στεναχώρια αντικαταστάθηκε από άγχος, σύγχηση, πανικό, απελπισία. Δεν μπορώ να ηρεμήσω. Νιώθω αβοήθητη και νιώθω και τις πιέσεις εξωτερικών παραγώντων όπως των άλλων, του χρόνου. Είναι η χειρότεροι μήνες της ζωής μου αυτοί. Και δεν περνάει, δεν φέυγει. Νιώθω πως άνοιξα τόσο πολύ σε όλα και τώρα είμαι εκτεθιμένη όσο ποτέ. Νιώθω πως δεν έχω δέρμα πως δεν εχω πανοπλία, προστασία. Αδυνατώ να κάνω ένα βήμα τη φορά γιατί κάθε βήμα μου φαίνεται λάθος ή φοβάμαι μην αποδειχθεί λάθος. Νιώθω ανίκανη, ανύμπορη, ακατάρτιστη. Και μετά λέω που να καταρτηστώ αφού δεν ξέρω τι θέλω να κάνω και σε ποια χώρα. Σε ποια σχέση να επενδύσω αφού δεν ξέρω ποια θέλω και σε ποια χώρα. Πως να στηρίξω τον εαυτό μου όταν τον έχω χάσει και νιώθω πως δεν τον βρίσκω πουθενά. Νιώθω θολή, χαμένη, χαοτική. Περνάνε οι μέρες, περνάει ο χρόνος και μου φεύγει μέσα από τα χέρια. Θέλω μόνο να έρχεται το βράδυ να κοιμάμαι να μη σκέφτομαι. Να μην καταλαβαίνω τι μου συμβαίνει. Δεν αντέχω τους άλλους ανθρώπους δεν τους καταλαβαίνω. Θέλω να ζήσω κανονικά νιώθω σαν εξωγήνος, νιώθω τα πάντα αφιλόξενα. Και την ίδια τη ζωή. Δεν μπορώ να θυμηθώ πως ήμουν πριν που ζούσα κανονικά. Η καθημερηνότητά μου περνάει αργά σαν όνειρο που δεν το καταλαβαίνω και ταυτόχρονα ο χρόνος τρέχει τόσο γρήγορα που τον χάνω. Δε θέλω να ζω άλλο έτσι. Νομίζω πως δεν θα περάσει ποτέ. Τι έπαθα ρε γαμώτο; Τρελάθηκα, αυτό ήταν; Δε χωράω πουθενά, δεν περιμένω τπτ, ένα χάος. Θα περάσει η ζωή μου θα φύγει και εγώ ακόμα θα μαι έτσι.”
> Μία ψυχολόγος περπατούσε ανάμεσα στο κοινό της όση ώρα τους μιλούσε για την διαχείριση του άγχους. Την στιγμή που ύψωσε ένα ποτήρι με νερό, όλοι σκέφτηκαν ότι θα έκανε την κλασική ερώτηση “είναι μισογεμάτο ή μισοάδειο;”.
> Αντί για αυτό όμως, εκείνη, με ένα χαμόγελο στο πρόσωπο της, έκανε την ερώτηση: “Πόσο βαρύ είναι ένα ποτήρι με νερό;”
> Διάφορες απαντήσεις ακούστηκαν με διακύμανση από 100 ως 300 γραμμάρια .
> Εκείνη απάντησε: “Το απόλυτο βάρος του δεν έχει σημασία. Εξαρτάται από το πόση ώρα το κρατάμε. Αν το κρατήσω για ένα λεπτό, δεν είναι πρόβλημα. Αν το κρατήσω για μία ώρα, θα μου πονέσει ο ώμος. Αν το κρατήσω για μία ημέρα, θα μουδιάσει ο ώμος μου και θα παραλύσω.
> Σε κάθε περίπτωση, το βάρος του ποτηριού δεν αλλάζει, αλλά όσο περισσότερο το κρατήσω τόσο πιο βαρύ θα γίνεται.”
> Και συνέχισε: “Τα άγχη και οι ανησυχίες στη ζωή είναι ακριβώς όπως αυτό το ποτήρι νερό. Αν τα σκέφτεστε λίγο δεν θα συμβεί τίποτε. Αν τα σκέφτεστε κάπως παραπάνω, θα αρχίζουν να σας ενοχλούν. Και αν τα σκέφτεστε συνεχώς, θα αισθανθείτε παράλυτοι – ανίκανοι να κάνετε οτιδήποτε”.
> Να θυμάσαι να αφήνεις το ποτήρι κάτω.