Affiliations: Clinical Psychologist
Journal reference: Josette ten Have-de Labije, PsyD. Ad Hoc Bulletin vol 10, 1, 2006, page 35.
Summary: Have you ever felt symptoms of anxiety? Your heart racing, your palms sweating, that uneasy feeling in your stomach. Here Dr. Majdalani describes the different manifestations of anxiety from a therapist’s point of view, and how a psychological assessment can help identify which patients are in need of support to regulate those symptoms.
Many patients who present for therapy suffer from anxiety. That is why the therapist’s first tasks will be to :
- Assess the specific manifestations of anxiety for each patient.
- Assess the patient’s ability to correctly recognize the physical symptoms of their anxiety.
- Assess the patient’s ability to regulate their anxiety.
The assessment of each patient’s particular pattern of functioning should take into account:
- Manifestations of anxiety
The path of anxiety follows a particular pattern:
- Somato-motor manifestations :
Anxiety begins in the muscles of the hand (thumb movements), the mouth (lower lip bite), or the periorbital area (tics), and then moves to the flexor and extensor muscles of the forearms (hand/fist rubbing) and/or the pronator and supinator muscles of the forearm, extends to the muscles of the arms, shoulders, neck, face, then to the vocal cords, the abdominal wall, the intercostal muscles (frequent sighs), and finally to the muscles of the lower back and legs.
- Autonomous and endocrine manifestations :
On the one hand with the activation of the sympathetic nervous system: dry mouth and throat, dry eyes, sweaty armpits and palms, cold hands, blushing, accelerated heartbeat, shivering and sometimes vaginal dryness. On the other hand with the activation of the parasympathetic nervous system: light headedness, dizziness, fainting, constipation, diarrhea, urge to urinate, nausea, heartburn.
- Cognitive and Perceptual Manifestations :
Thought disorders (or cognitive manifestations) are manifested by a disturbance in the thought process (incoherence, delay or acceleration) as well as in its content (spatio-temporal disturbance and confusion about people). Perceptual disorders can be characterized by an alteration of visual and auditory faculties (tunnel vision, tinnitus, hallucinations, dissociation).
- The distribution of the three types of manifestations and their proportion
It is according to the distribution and proportion of the three channels mentioned above (autonomic and endocrine somatomotor, cognitive and perceptual) through which anxiety manifests itself that the therapist can evaluate : i) the degree of regulation of the patient’s anxiety (the higher the degree, the healthier the regulation; the lower the degree, the more dysfunctional the regulation) and ii) the degree of the patient’s ability to regulate his or her own anxiety for the benefit of their health.
When the somatomotor manifestations are proportionally greater than the autonomous and endocrine manifestations, and when the cognitive and perceptual symptoms of anxiety are absent, it can be concluded that the patient is reasonably capable of managing his or her anxiety. If mild symptoms of cognitive and perceptual dysfunction are identified, it can be concluded that the patient is already less able to regulate their anxiety. If the proportion of autonomic system manifestations is greater than the proportion of somatomotor manifestations, it is known that the patient is not able to regulate their anxiety properly. And if the proportion of cognitive and perceptual dysfunction surpasses that of the autonomic and somatomotor systems, we can deduce that the patient is very fragile, unable to regulate his anxiety properly, and very quickly finds themself overwhelmed by their anxiety.
- The speed of rise, duration and speed of fall of these three types of anxiety manifestations
In some patients, anxiety increases and spreads within seconds. In others, the rise and spread of anxiety is slower. It is generally in this second category of patients that the time it takes for anxiety symptoms to subside is faster. In other words, the faster the anxiety rises, the slower it falls and the more difficult it is for the patient to regulate it.
- Assessment of the patient’s ability to recognize and identify the different symptoms of anxiety
Most patients arrive at the therapist’s office with little or no knowledge that they are suffering from anxiety and are therefore unable to describe the symptoms accurately and completely. Some patients are passively aware of only a few symptoms of their anxiety and are able to identify them correctly. Other patients are passively aware of some symptoms of their anxiety but do not recognize them as anxiety symptoms (e.g. dry mouth and throat are only the consequence of thirst). Many patients are completely unaware of the manifestations of their anxiety.
Also, certain defence mechanisms block the processing of information sent by anxiety, either at the stimulus level (e.g., denial of a painful situation) or at the response level (e.g., denial of the physiological manifestations of anxiety or related distressing emotions).
Take home message
If a patient arrives in therapy with anxiety in the forefront, and it is apparent that they are completely or partially inattentive to the manifestations of their anxiety, then the therapist will know that it is because this patient is used to ignoring and denying the physiological manifestations of their anxiety or to observing them with great carelessness and neglect. The therapist can also conclude that the patient is most likely unable to regulate their anxiety in a healthy way.