An accomplished violinist finds that his fingers become stiff as he starts to play in front of an audience. A student taking an oral examination finds that her mind has gone blank and she is unable to talk. A medical student participating in his first operation starts to faint. Each of these mishaps is characteristic of the condition commonly labeled anxiety. One of the paradoxical features of acute anxiety (or fear reaction) is that a person seems to bring on unwittingly what he fears or detests the most. In fact, fear of an unpleasant event seems to enhance the probability of its actually happening To understand how the anxiety (or fear) reaction seems to produce just those things that an individual most abhors, reflect on this report by a college professor with fears of public speaking: As I stand talking to the audience, I hope that my mind and voice will function properly, that I won’t lose my balance, and everything else will function. But, then my heart starts to pound, I feel pressure build up in my chest as though I’m ready to explode, my tongue feels thick and heavy, my mind feels foggy and then goes blank, I can’t remember what I have just said or what I am supposed to say.
Then I start to choke. I can barely push the words out. My body is swaying; my hands tremble I start to sweat and I am ready to topple off the platform. I feel terrified and I think that I will probably disgrace myself. We see from this passage that, in a fear episode, practically every system of the body is affected:
(1) the physiological system is manifested in sweating, increased heart rate, and dizziness;
(2) the cognitive, in the anticipation that “I will probably disgrace myself”;
(3) the motivational, in the wish to be as far from the traumatic situation as possible;
(4) the affective or emotional, in the subjective feeling of terror;
(5) the behavioural, in swaying and in inhibited speaking or thinking.
In this example, the total psychobiological reaction is disturbing and involuntary and takes partial control of the individual until it has abated Nature has provided us with a nervous system that functions exquisitely under ordinary circumstances. Why should this system start to work against us in those very instances when we most want it to work effectively? Part of the answer may be that, up to a point, the symptoms associated with anxiety are adaptive and pose a problem only under certain circumstances.
Another explanation is that symptoms that may have been adaptive in our prehistoric ancestors are no longer so. Finally, our tendency to exaggerate the importance of certain situations-believing them to be a matter of life and death overmobilizes our apparatus for dealing with threats and thus overrides normal functioning. It has been said that “evolution favours anxious genes.” It is better to have “false positives” (false alarms) than “false negatives” (which miss the danger) in an ambiguous situation. One false negative-and you are eliminated from the gene pool.
Thus, the cost of survival of the lineage may be a lifetime of discomfort. To unravel the mystery of anxiety or fear reactions, a clinical example of acute anxiety will allow us to see what factors besides subjective anxiety may be present: A forty-year-old man had gone on a skiing trip near Denver and, while on the slopes, had begun to feel shortness of breath, profuse perspiration, faintness, and weakness. He also felt cold and had a feeling of instability.
He had difficulty in focusing on any object and had waves of severe anxiety. Over all the symptoms hovered a sense of unreality. He was in such a state of collapse that he had to be taken from the slopes in a stretcher and rushed to a hospital. When no physical abnormalities were found, he was told he had an “acute anxiety attack.” What psychological disturbance could have been so strong as to produce a complete derangement of this man’s physiological and psychological systems?
The clue is found in his thoughts and imagery, Prior to the episode on the ski slope, he had the thought several times, “If I should have a heart attack up here, it would be almost impossible for me to get emergency care.” Later when he started to have shortness of breath and other symptoms, he thought, “This must be a heart attack. .. this is what it’s like to be dying.” He then had an image of himself in a hospital bed, with an oxygen mask firmly placed on his face, intravenous infusions running through his arms, and doctors in white robes hovering over him.
Each time he had this image, he experienced an acute increase in his symptoms. Thus, the missing piece in this puzzle is his cognition his interpretation of normal physiological responses to exercise in a cold environment and a rarefied atmosphere as indicating a life-threatening disorder.
A more complete understanding of this man’s misadventure must be sought in his total life situation. It appears that, since all of the tests showed there to be no organic disorder, the profound reaction occurred in the setting of some psychological predisposition. It is important to note that he had skied many times before on high mountains and had experienced symptoms that initially were similar to those described previously. When he was skiing in this air, he would start off with shortness of breath, which would often be accompanied by chest pain, particularly after he had been skiing for some time. He generally would feel cold and sweaty. In this particular instance, however, his episode on the slopes was coloured by a recent bereavement in his family. His brother, who was ten years older, had died several weeks previously from a heart attack.
This man’s thinking seemed to go something like this, “If it could happen to my brother, it could happen to me. .. . My brother got his heart attack after exercise and so could I.” Hence, instead of making the most plausible explanation of his symptoms (as due to skiing in a cold, rarefied environment), he interpreted them as what he feared the most-namely, a fatal coronary attack. When I saw the patient one week after the episode, he stated that he found his experience on the ski slope completely incomprehensible. To pinpoint precisely the nature of his thoughts, I asked him what went through his mind just before his full-blown attack. At first he had difficulty recovering the memory.
Then he recalled having had a “flash” when he became aware of the chest symptoms: This could be a heart attack just like my brother’s.” Then he had an image of himself in an intensive care unit and another of himself receiving cardiac massage. The crucial element in anxiety states, thus, is a cognitive process that may take the form of an automatic thought or image that appears rapidly, as if by reflex, after the initial stimulus (for example, shortness of breath), that seems plausible, and that is followed by a wave of anxiety. When the missing link is identified, then the “mysterious” arousal of anxiety can be understood. Of course, a specific thought or image is not always identifiable. In such cases it is possible, however, to infer that a cognitive set with a meaning relevant to danger has been activated.