TWENTY YEARS HAD PASSED, but she can remember it as vividly as a first kiss. She was having lunch with friends at Ristorante della Fontana. The waiter placed the soup tureen near her plate and her friends asked her to serve them. She picked up the ladle. Then her hands began to shake, and the room grew dim and she thought she might die.
If her friends had asked her to shoot herself from a cannon, her response might have made sense. But ladling soup is hardly an act of bravery.That's why the episode was so baffling - and so frightening. How could Mrs. C. trust herself to eat in a restaurant ever again? How could she be sure she wouldn't feel these strange sensations somewhere else? Her mind conjured up the many ways she might suddenly lose control.
Sometimes a situation she hadn't even imagined would present itself. One day she became paralyzed at the thought of signing her name on a check at the supermarket. She abandoned her cart full of groceries and fled. After that, she started bringing cash when she shopped.
For 20 years she has struggled to stay calm. But only in the past year has she sought help. And only now she understands that it wasn't really the restaurant she was afraid of, or the supermarket, or signing her name on a check. Those were only circumstances.
What she was really afraid of, as Franklin Roosevelt said in another time and in another context, was fear itself. AS MANY AS ONE in 20 people suffers some form of "panic disorder," the term doctors now use for the many permutations of anxiety that have fear as their common denominator.
Salt Lake psychologist Hugh Gillilan calls them "the seven flavors": generalized anxiety, panic attacks, agoraphobia, simple phobias, social phobia, obsessive-compulsive disorder and post-traumatic stress disorder.
But more often than not the flavors get mixed up together, like a melting bowl of Neopolitan ice cream. A person with panic attacks, for example, might also have agoraphobia, which essentially is a fear of having panic attacks in specific situations - situations that the agoraphobic then begins to avoid.
Despite the fact that panic disorders are the most prevalent form of mental disorder - estimates are that 9 million Americans, for example, are too afraid to drive - the people who suffer from panic tend to think no one else is as crazy as they are.
The people interviewed for this article, embarrassed by their condition, have asked to remain anonymous.THE DOORBELL RINGS. Mrs. S. gets up to answer it and before she even gets to the door her heart has begun to race. She knows it is just the letter carrier with a package for her; she can see him through the glass. But she is already feeling that floating sensation.
Her parents used to label her shy. Then, one day in the first grade when the other children were out at recess, she suddenly got a thought in her head that wouldn't go away: You need to pour glue all over the floor, the thought said, because robbers might come in to steal the books.
Although she has seen psychiatrists since she was 13, it has only been in the past two years that Mrs. S. has understood that she suffers from social phobia, agoraphobia and obsessive-compulsive disorder (OCD).
While some people with panic disorder experience moderate discomfort in an occasional elevator, Mrs. S. is at the other end of the anxiety spectrum. She spent most of 1988 and 1989 in her house because she was too afraid to go out.
Four years ago, when she was pregnant, her anxieties grew. After her baby was born, Mrs. S. felt panicky even in her own living room.
"It got to the point where I could only stay in the bedroom," she explains. Her hands shake as she tells the story. Her social phobia extends to her husband and her child, she says, which means that life is more or less one constant nerve-wracking experience.
"If I'm sitting alone I'm relatively calm. But the minute someone walks through the door, then I feel panicky. It's like I can't handle other people in my space." It's not that she doesn't like other people, she explains. "I just feel panicky."
Over the past 15 years, she has taken 30 different drugs. But recently her doctor has found three drugs that, in combination, make her feel a little better. She takes Prozac for the OCD; she takes anti-anxiety medication to counter the increased anxiety she feels when she takes the Prozac; and she takes Imipramine for the social phobia.
She still feels panicked, she says. But where before she might have felt physically sick for an hour after the mailman came to the door, now the panic hangover lasts only a few moments.
Recently, Mrs. S. has begun behavioral therapy with clinical social worker Suz Harrington at the Western Institute of Neuropyschiatry. At Harrington's gentle coaxing, Mrs. S. is beginning to enter the world again, a little step at a time.AVOIDANCE IS THE worst thing you can do for panic disorder, says Harrington, although next to being fearful it is the thing that many anxiety-prone people do best. The more you avoid situations that seem to produce panic, the more you send a message to your brain that those situations are indeed scary.
The situations don't cause the panic anyway, says Harrington. What does is the fear that the panic might happen again.
Panic itself is just a set of physiological symptoms: shortness of breath or a smothering sensation, dizziness, heart palpitations, trembling, sweating, numbness, choking, nausea, a feeling of utter loss of control.
People with panic disorder tend to be supersensitive to their bodies' signals, says Harrington. A feeling of dizziness that another person might brush off will make an anxiety-prone person begin a chain-reaction of fear - first a physical symptom, then a catastrophic thought, then escalating symptoms, then escalating thoughts, and on and on.
Most doctors now believe that the catalyst for this self-generating, self-defeating reaction is a neurochemical imbalance most likely associated with the neurotransmitter serotonin.
Most treatment for panic disorder today employs medication, behavioral modification, cognitive therapy or a combination of all three.
Medication helps make the behavioral and cognitive therapy easier, says Harrington because it reduces the physiological symptoms to the point where the patient can comfortably try new situations. People with less severe panic can usually skip the drugs.
Behavioral therapy works on the principle that what you know won't hurt you - the more you expose yourself to a fear-producing situation, the less fear it will produce. Harrington teaches her clients "fear management" skills such as deep-breathing and self-talk (see box).
For Mrs. S.'s social phobia, she will begin by just driving around with Mrs. S. in her neighborhood. Later, when Mrs. S. feels more comfortable, they'll walk around the neighborhood. Later still they'll go door to door for the Heart Association or something.
For another of her clients, who had a fear of anything associated with death, Harrington worked up a desensitization strategy at the cemetery. Clients who are afraid of heights take rides on the glass elevator at the Park Hotel. PSYCHOLOGIST MARK E. Owens of the Western Institute of Neuropsychiatry takes a different approach to panic disorder. No elevator rides. No desensitizing trips to the mall. Just talk. Anxiety, in Owens' view, is an outward clue of inner conflict.
In fact, since people with panic disorder often don't feel much emotion other than fear, the panic attacks are actually a "breakthrough," he says.
Although most people prefer to just get rid of the bad feelings that panic evokes, Owens sees anxiety as "a call to a great journey inward."
Whatever their approach, therapists find that people with panic disorder tend to feel like failures, ashamed by their fear of freeways or shopping malls or telephones or neighbors. Depression is often a secondary problem.
"It's important for them to know that they aren't to blame," says Harrington. "They just have bad chemistry."
And who's to say what bravery really is. If you aren't afraid of jumping out of an airplane, does that mean you're fearless? If your brain chemistry causes your knees to get weak when you ladle soup in a restaurant - and you learn to do it in spite of that - maybe that's real courage.
Some of the bravest people he knows, says Mark Owens, are his patients.
Talk provides best medicine when fear strikes
A FEAR OF SHOPPING MALLS is irrational. So is a fear of signing your name on a check. But personally I don't think being terrified to ride on a ski lift - dangling 40 feet above the ground in a chair - is irrational at all. I suppose the psychiatric community thinks otherwise. I know my children do.
So last week I asked Suz Harrington, a therapist at the Western Institute of Neuropsychiatry, to ski with me at Solitude. Maybe, I thought, she could help me overcome the panic that always attacks me as soon as I feel the earth drop away and I realize I'm making my ascent over the Wasatch.
Usually what I try to do when I'm on a chairlift is pretend I'm on a bus. But that's not a good idea, it turns out. "You need to burrow into your fear," Harrington explained as we buckled on our ski boots. "It doesn't work to fight it."
Trying to hide your panic only makes you more panicked. Talking about it in great detail, on the other hand, makes the panic disappear. She wanted to know exactly how I felt, from the very first hyperventilating moment. "I feel dizzy," I said. "And my legs feel paralyzed." Good, she said.
A person prone to panic attacks is usually supersensitive. So when that person's heart begins to pound and she feels dizzy as she moves her head to look at a skier 60 feet below, she becomes frightened. "But you could re-create the same sensations even if you were flat on the ground," Harrington said. "You need to recognize that the feelings will pass."
I wasn't sure. We were dangling 100 feet in the air over a particularly scary section - an open area not protected by the embrace of trees - and I could feel my internal organs getting tense.
But Harrington was reassuring. "You can live through feelings. Once you learn you can lower your anxiety in the situation - that you can handle the feelings - then you can handle the situation."
The worst thing you can do is escape (not likely 200 feet off the ground) or avoid the thing that scares you, she said. Escaping and avoiding reinforce the fear. What what would really be great, she said, would be for the chairlift to break for at least an hour, with us trapped on it. We were about 400 feet above the ground at that point.
"The color has drained out of your face," she said. Then she gave me some advice: "Take a deep breath. Now try assuming a confident posture." Anxious people tend to hunch their shoulders and collapse their chests, making it even more difficult for them to breathe.
"This time when we go up, I want you to pull the bar down," she instructed as we got on the lift again. I threw my shoulders back and reached up for the metal restraining bar and immediately felt dizzy. But the next time it was easier. I even got so I could look around without clutching onto her. And she was right; the more I said "My body feels tense" - rather than tensing my body while I pretended to be calm - the less tense my body felt.
"The whole idea is to get through the experience successfully with less and less anxiety," she said as the lift reached the top and we skiied off.
Harrington does similar therapy with people who are afraid of malls and elevators and freeways. If the panic is especially severe and long-standing, she usually has them begin by just imagining they're in the panic-producing situation. Another day they might walk up to the door of the mall or the elevator. It might take several sessions before they ever get inside.
Harrington, who once was so fearful of public speaking that she crashed her car on the way to an important speaking engagement, has used these desensitizing techniques on herself.
Repetition is important, she told me. "I know if you did this five or 10 times in a row, all day, you'd be completely over it."
I think she's right. I'm excited, in a nervous kind of way, to try it again. I'm sure if my boss would give me a week off to go skiing I'd be cured.