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who has seen active combat duty and witnessed a fel-
low soldier be blown to shreds; or any child who has
witnessed her parents regularly beating one another.
An individual s world might never feel safe again
because once these events have taken place, they
become forever etched in the banks of emotional and
anxious memory. Inasmuch as these events color the
ability to be intimate with others, to feel integrity
within one s own skin, or to access and actualize the
human ability to use freedom of choice, the costs are
incalculable.
Notes
1. American Psychiatric Association. (2000). Diag-
nostic and statistical manual of mental disorders (4th
ed., text revision). Washington, DC: American
Psychiatric Association.
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2. Barlow, D.H. (2002). Anxiety and its disorders. New
York: The Guilford Press.
3. Freud, S. (1959). Inhibitions, symptoms and anxi-
ety (1926 (1925)). In Strachey, J. (Vol. Ed.), The
standard edition of the complete psychological works of
Sigmund Freud: Vol. 20 (pp. 77 178). London: The
Hogarth Press and the Institute of Psycho-Analy-
sis.
4. Freud, A. (1946). The ego and the mechanisms of
defence. New York: International Universities Press,
Inc.
5. Vaillant, G. (1995). Adaptation to Life. Cambridge,
MA: Harvard University Press.
6. LeDoux, J. (1996). The emotional brain: The myste-
rious underpinnings of emotional life. New York:
Simon & Schuster.
7. Freud, S. (1959). Remembering, Repeating, Work-
ing Through. In Strachey, J. (Vol. Ed.), The stan-
dard edition of the complete psychological works of
Sigmund Freud: Vol. 12 (pp. 145 156). London:
The Hogarth Press and the Institute of Psycho-
Analysis.
8. Schmidt, M.D., Leonard J., Warner, B. (2002).
Panic: Origins, insight, and treatment. Berkeley, CA:
North Atlantic Books.
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9. Ellenberger, H. (1970). The discovery of the uncon-
scious: The history and evolution of dynamic psychia-
try. New York: Basic Books.
10. Nesse, G.W. & Williams, G.C. (1994). Why we get
sick: The new science of Darwinian medicine. New
York: Times Books.
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Reprinted with permission from The Cartoon Bank, a division of The New
Yorker magazine.
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PART TWO
The Many
Faces of
Anxiety
What is performance anxiety?
What causes a panic attack?
Can anxiety really keep me up all night?
More . . .
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20. What is performance anxiety?
We all commonly experience performance anxiety when
taking a test, speaking in public, or acting on stage.
Patients report all kinds of medical, physical, and psycho-
logical symptoms, which range from sweating, nausea,
and palpitations to an overwhelming sense of doom to a
heightened sense of tension about the potential outcome
of their project. This might also happen to accompany an
activity which the patient really loves to do (playing her
favorite instrument or speaking about the topic which she
most enjoys). There often seems to be a history of trauma
in these patients. For example, a child made too much
noise when practicing a performance and was terrified by
the yelling and beating which ensued, thereby feeling
threatened by and afraid of his parents. It may take a
while working with any particular patient to get to these
memories, but it seems that using medication to control
the symptoms more immediately while helping the
patient to understand that his or her symptoms are not
coming out of the blue (as they first seemed), he or she
can achieve a greater sense of control. In the case of the
child mentioned earlier, this type of understanding pro-
vides the now-adult patient with the realization that he
does not have to respond to the performance at hand as if
it were a time of stern punishment from childhood, when
he really did have no control over the overwhelming fear.
Patients also talk about another kind of memory con-
nected to their anxiety surrounding performance: the
fear of loss of love from their families. They fear that
love in their particular family depends upon perform-
ance; hence, a test or other performance becomes not
just about delivering the information that they know
or communicating the material of the presentation, but
rather an assessment of whether they are lovable. This
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feeling can leave patients feeling angry and hurt that
their self-worth has become tied up in a performance
rather than simply in a sense of self. In more compli-
cated cases, parents do more than just become critical;
they beat their children if the performance is not per-
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