This is my story of self discovery. It all began over 20 years ago when I had a panic attack as a result of obsessive self doubt from my first job out of college. I went to college to become a marketing rep and brutally discovered that I did not have the personality or courage to be successful. The attack was very scary. My heart raced, I would break into a sweat and could hardly breathe. I stayed in my bedroom until it was over. I quickly knew what caused it and quit my job the next day.
Ever since that event until present I started suffering from headaches. At work, I ended up getting a job in Personnel Management; I would have very tense days and almost always had headaches nightly. I dealt with this for two years and finally quit, moved back home and went into a deep depression for nine months. Although I did not have anymore headaches, now I was left with no confidence and no direction. I could not understand why I would get so anxious at work and loose all my self confidence. More importantly- why the headaches? Instead of getting help from a therapist or my primary care physician, I just stayed at home and did not want to restart my life out of fear of more headaches and disappointment.
Finally with the help of friends – especially one – I started a new career working with developmentally disabled adults. Eventually I started my own business and became very successful. What happened to my headaches? They came back but only for short time periods and they were not very severe. Only a few times a year during very stressful times they were intense for a period of two weeks. I continued to live my life this way for years not knowing how to eliminate the headaches or a clear understanding of why and when they occur.
About five years ago everything got out of control! I had another panic attack when a key employee in my business left without any notice. This time it was much more intense and long lasting. The headaches were constant, but now they were joined by intense muscle contractions, shortness of breathe, and chills. Unlike the last one, the symptoms stayed around and would not go away. I was so frightened for my health that this time I did go to my Primary Care Physician. She suggested that I see a therapist and start taking antidepressants to help control the anxiety. I tried many different pills. Most of them caused side effects such as dizziness and tiredness and did not help very much with the symptoms. I did go see a therapist recommended by my physician. She agreed that I was suffering from anxiety and recommended weekly sessions. After about the third session I began working on an anxiety workbook to discover what causes my symptoms. When at the next session the therapist was fumbling through the workbook, I cancelled the therapy and lost any confidence in therapy.
Next, I went to a headache clinic where they tried many other medications, physical therapy, and two more therapists who tried using relaxation tapes, listened to my stories, but never got to the bottom of my problems. I lost all hope or desire to search further for the answer. I continued on meds which lessened the symptoms but did not solve the problem. Like most people I was hoping that I could find that magic pill that would solve all my problems. Ha Ha!
My life finally changed when I found a new physician that found a better medication, and referred me to Birmingham Maple Clinic in Birmingham Mi., and Dr. Stephen Pravel. I was very skeptical of the therapy due to the past failures, but quickly discovered I finally found someone who I was comfortable with and was knowledgeable about anxiety. This is where the self discovery began. Dr. Pravel convinced me that my anxiety was caused from my negative thoughts and behavior. Through many sessions we talked about my thoughts and behavior from a young child to present, trying to discover together what causes my anxiety. We determined that I experienced generalized anxiety disorder and social phobia. Here are some of my discoveries through sessions with Dr. Pravel.
First, I would have many of these physical symptoms when put into uncomfortable social or work situations interacting with family, work associates or friends. I would have thoughts of “I have to avoid this”, “what can I say to this person so I am not embarrassed?”, or “I do not match up to this person!” Through the encouragement of Dr. Pravel I used self-talk to boost my confidence before entering these conversations, prepared ahead of time things to say, and became more assertive in the conversations to gain confidence as the interaction progressed.
Second, holding in my negative emotions and feelings instead of verbalizing them caused anxiety and thus the headaches, muscle contractions, etc. When interactions with family members upset me, instead of expressing my anger or disapproving opinions, I would ignore them, walk away from the relationship, or be passive aggressive. I did this most of my life with both of my parents, my sister, and my wife. My mother was very controlling, my father yelled a lot, my sister had no consideration for my feelings, and my wife liked things her way. Instead of addressing these issues I held everything in and eventually my body rebelled. Now I try very hard to always express myself and not hold anything in. It is very hard to change these old habits, but I am making progress.
Thirdly, my anxiety is caused by many thoughts of being powerless to make changes in my life to become happier and to make life more fulfilling. This caused further feelings of hopelessness. Now when I identify that my thoughts are heading in that direction, I yell at myself to knock it off and try to generate ideas for improvement. Then I work to be more assertive in my behavior to make it happen. Things that have worked are: building better and more active relationships with my friends, talking on the phone more often, taking better control of my life direction by telling myself “just go do it” and thus preventing out of control thoughts of disappointment and despair, and lastly being more openly honest about my relationship with my wife and father – overcoming a lot of unresolved conflict with myself about my father and wife.
Lastly, if physical symptoms do appear, I do not make a catastrophe out of them. If I were to do that, the physical symptoms would only worsen. Instead I work to ignore them and concentrate on changing the thoughts and behavior causing them.
After one year, I feel much better! My body is still very sensitive to my thoughts and outside conditions, but I know now what I need to do to counter these thoughts and what changes I need to make in my life to continue to improve. I know generalized anxiety disorder will always be a challenge, but thanks to Dr. Pravel I now have the tools and confidence to keep battling. — Mark
CLINICAL SUMMARY
Mark’s story is similar to many with an adult anxiety disorder in that he had a history of having been shy and introverted as a child. He also described himself as having been a “worry wort” when he was young. His first panic attack occurred at 23 when he felt overwhelmed by his new job and was confronted with the terrifying prospect that he may be incompetent in the career he had chosen. He did not go on to have repetitive panic attacks as he did not develop the dread fear of further attacks that constitute the “fear of fear” cycle of Panic Disorder. Instead, his anxiety manifested in symptoms that constitute the basis of Generalized Anxiety Disorder (GAD). Since that first panic attack, he experienced many physiological symptoms of anxiety: diarrhea, headaches, muscle tension, chills, numbness and difficulty relaxing. He also experienced the lack of energy and fatigue that can often accompany GAD. His general state of anxiety, physical discomfort, lack of a sense of well-being and limited self-confidence led him to feel uncomfortable, and inadequate, in social situations. This crisis of confidence caused social anxiety which led to social avoidance which then intensified to the point of Social Phobia.
As is usually the case with an anxiety disorder, Mark had a basis for some of his underlying fear. He feared the consequences of his physical symptoms, especially feared that some physical catastrophe may befall him. This fear was related to and intensified by the fact that both of his parents had suffered debilitating strokes, which he believed were at least partially the result of stress and anxiety.
Mark’s history also contributed to his tendency for anxiety. As he summarized it: his father screamed, and his mother was sarcastic. Though his mother was affectionate she seemed to be an angry woman who was very difficult to deal with, who also had a significant degree of anxiety herself. Her anger intimidated Mark and kept him from expressing his negative feelings. His father had little involvement with Mark or Mark’s mother or sister and demonstrated little affection. Mark felt intimidated by his father due to his anger and emotional abuse. His father also had very poor self-confidence, was anxious and often relied on his “nerve pills” to help him cope. Mark recognizes that he internalized many of his fathers traits: anxiety, limited self-confidence and insecurity. Contributing to an environment of limited safety and security – his parents were emotionally alienated and hostile with each other. Most of the families attention went to Marks sister due to her emotional and behavioral problems. As a result, Mark learned to withhold his thoughts, needs and feelings; and he was not able to develop a sense of safety, security and well-being.
A consequence of Mark withholding his thoughts and feelings was a very limited sense of power over his life. He felt limited to control his internal experiences and the external events in his life. This sense of limited power equates to low self-esteem/self-confidence and that automatically causes some degree of anxiety and/or depression. He would not directly express his negative thoughts or feelings, having been intimidated from doing so in childhood. He therefore learned to express those feelings through passive-aggression. That is: expressing anger, negative feelings or opposing opinions indirectly instead of directly. For example, instead of speaking directly with his wife about a disagreement about child rearing, he would seemingly (passively) go along with his wife but would later indirectly express his dissent (aggression) by not following through with their agreement. While this led to the discharge of some anger, it did not make him feel any more powerful to be able to handle something in a straight forward manner, and therefore did not make him feel any better about himself. Mark handled most of his negative feelings in a similar fashion, both with family and in the work place.
Marks therapy began to progress when he explored and identified these early life influences and their impact on him (psychodynamic insight therapy). He was able to see how he had become the man he was, and by putting it into this context not only did it explain things but also helped him not feel that it was his “fault”. He was able to become more forgiving of himself, especially more forgiving of his shortcomings such as anxiety, self-doubt and physical symptoms. By identifying this family history, it helped him recognize anger with both his parents, and by talking about it in therapy he was able to reduce much of that anger. And by talking about his anger he was automatically reducing his passive-aggressive style of dealing with anger. He started to feel like he wasn’t such a deficient, broken person. He began to realize he was to a great extent, the consequence of his environment. That awareness helped him understand one of the most important of lifes lessons: though we are not responsible for the hand life deals us, we are responsible for how we play it.
That understanding facilitated the Cognitive-Behavioral Therapy (CBT) component of Marks therapy. CBT is a process of identifying, challenging and modifying anxiety provoking thoughts and beliefs. Mark began to identify some of his irrational beliefs and fears. In social situations Mark realized he had the irrational, anxiety provoking belief that: it was a disaster and evidence of his fear if there is a moment of silence; that other people know when he is anxious and that is a disaster; and that other people are as critical of him as he is of himself. Armed with this awareness, he began to experience social situations as much less intimidating, and he actually began to enjoy being around other people. One experience of greater ease and self-confidence quickly led to a second experience, which further helped him decrease those old negative and unrealistic ideas.
A significant part of CBT is identifying old, irrational and negative core beliefs about the self. These beliefs fall into two main categories: Powerless and Unlovable. Mark had some beliefs that he was unlovable due to a childhood of having received limited or conflicting messages as to his worth and value. But the more troublesome negative core beliefs for Mark were those regarding his feeling powerless. He had very limited self-esteem and self-confidence and held in most of his thoughts and feelings. This combination increased his negativity and passivity, which contributed to ineffectiveness in dealing with his environment, and therefore caused him to feel powerless. In other words, his powerlessness was a self-fulfilling prophecy. Since he felt powerless, he acted powerless, and therefore was powerless in improving his life. The secret was that he could change that — as he is very powerful to change how he handles life.
When Mark came to understand this self-fulfilling sense of powerlessness, and came to understand how he can act otherwise, he came to discover that he was in fact powerful. He was powerful to: express himself, to effect outcomes on the job and at home, to handle himself in social situations and especially powerful to start changing his negativity into a more appropriate positive mindset.
Another facet of Mark’s CBT was his learning about the relationship between emotional feelings and physical feelings. Whenever we feel an emotion, we experience corresponding physical sensations. When we’re happy, we feel ‘light-hearted’. When we feel sad, we feel tired and ‘down’. When we feel anxious we feel ‘butterflies’ in the stomach. When we get angry our heart races, we get flushed and feel ‘hot’. These are but a few examples of the numerous physical manifestations that accompany all our emotions. For people with anxiety disorders, there is often a tendency to be more aware of and focused on the physical sensations than on the emotions themselves. This was a most central issue for Mark: instead of being aware of his anger, frustration, fear or sadness, he was only aware of their physical manifestations.
Mark’s complaints of headaches, muscle aches and fatigue were nothing more than the physical side of his emotions. Unfortunately, he was not very aware of the emotion side of his emotions. CBT helped him come to better recognize those emotions and begin to more effectively express them. This facilitated his becoming more assertive and effective in responding to events and issues causing his emotions. When he wasn’t aware of his emotions, he couldn’t effectively respond to them. With CBT, he started to feel more powerful to respond to events in his life that he used to feel so powerless to deal with. But more importantly, he came to understand the concept: verbalize or somatize. The mind = Psyche, the body = Soma. When Mark has a strong feeling he needs to identify it, express it, and respond to it or he will only feel it physically (somatically). Mark came to recognize that the main negative feeling that caused him problems was anger. He came to realize that it was even a bigger problem for him than anxiety. He had great difficulty directly expressing anger and was therefore often passive-aggressive. But it was that unexpressed, and unresolved anger that caused most of his physical (somatic) symptoms, which in turn caused him to be anxious. When Mark became more assertively and appropriately expressive of his unhappiness, he discovered two things: 1- he felt empowered, and 2- he did not have the physical sensations of anxiety. Instead, he felt great!
As a result of understanding how his childhood contributed to the formation of anxiety and low self-esteem, and learning to identify and express himself in appropriate ways, Mark has made dramatic progress in reducing the frequency and intensity of the anxiety symptoms of GAD. His increased sense of personal power and competence has led to self-confidence and self-esteem. In other words, Mark now likes himself. This has therefore caused him to feel much more confident and secure in social situations with the result of the remission of his Social Phobia.
Mark has now completed therapy, but he is well armed with the insights, knowledge and strategies that can help him better manage his emotions. He has also had several months of experiencing relief from anxiety and a boost in self-confidence that has developed out of his therapy. The more time that passes with this successful new approach to life, the greater the likelihood he can continue this for the rest of his life. Congratulations Mark!