Understanding the mechanisms of anxiety is critical in the treatment of anxiety disorders, and thus this page was created to transfer my expertise to those interested in learning how to manage their anxiety. Long and detailed explanations for anxiety are provided and are meant for clients to read and refer to regularly as we progress through treatment.
TIP: Start by reading through the information and take time to take notes or make an outline or print out this page and review daily until the information becomes automatic. The goal is to practice recalling this information when calm and focused so that you are able to use this information as a way to cope with anxiety even in the moment. Just as with CPR, the goal is to practice, practice, practice so that the information is automatically recalled during an emergency. Do not wait to practice during an emergency.
EXPLANATION OF ANXIETY
Normal Anxiety Vs. Anxiety Disorders
Anxiety is a normal feeling of uneasiness, concern, and apprehension that, when carried to an extreme, can become outright fear, panic, and alarm. Some amount of anxiety and worrying is a normal and necessary part of life. Because we are concerned for our own well-being, we avoid a snarling dog. Because we are concerned for our children's safety, we have them wear seatbelts. Anxiety disorders develop when levels of anxiety become excessive, inappropriate, or uncontrollable and begins to impair functioning in work, family, school, and social relationships.
Reasonable levels of anxiety help keep us aware and alert but don't interfere with our daily lives. In fact, worry on this level means that our internal protective systems are doing what they are supposed to do. The anxiety response system can be viewed as an evolutionarily adaptive mechanism in that those individuals who feared immediate dangers, worried about the future, and planned protective measures were able to survive and pass on their genes. We are the descendants of the scaried and worried.
Anxiety and Optimal Performance
In many performance situations, such as during a test, a moderate level of anxiety, arousal, or stress is optimal in that it leads to heightened attention, energy, and motivation. If stress levels are too low, there may be apathy or boredom, which leads to poor performance. If stress levels are too high, this can lead to a lack of concentration or a complete emtional breakdown, which too can lead to poor performance. There are some situations where a high level of arousal is desired such as when a ferocious dog is charging towards us, but for the most part, high levels of anxiety lead to high levels of unncesssary distress. Because of their frightening experiences with anxiety, those with anxiety disorders have become uncomfortable with even these moderate levels of anxious stimulation and treatment often includes re-learning how to tolerate normal, moderate levels of anxiety.
Three Component Model of Anxiety
The three component model breaks anxiety down into concrete, understandable components which can help the mind view anxiety as less of a vague, mysterious threat. The three components refer to the thoughts, physical feelings, and behaviors (actions) of anxiety that are triggered by a situation.
PANIC EXAMPLE: When an individual is faced with an anxiety provoking situation such as an upcoming flight, he may experience thoughts such as, "I'm going to have a panic attack and won't be able to escape," which leads to physical sensations (feelings) of anxiety such as heart palpitations and sweating, which leads to actions such as pacing or hyperventilating, which further leads to thoughts such as, "Here comes the panic attack. I can't breathe. I'm going to pass out," which then leads to additional physical symptoms (feelings) of anxiety such as dizziness and difficulty breathing which then leads to the action of escape from the airport, which leads to thoughts such as "I knew I couldn't do it. It's too much for me to handle. I'm so weak," which leads to the future action of avoiding airports all together, which leads to future thoughts about fear and failure, which leads to future sensitivity to any feelings associated with anxiety.
STRESS EXAMPLE: When an individual is faced with an anxiety provoking situation such as the daily stress associated with employment, there may be thoughts such as, "I'm going to make a mistake. I can't make any mistakes," which leads to physical feelings of agitation and muscle tension, which leads to behaviors (actions) such as checking an email a dozen times before sending, which leads to thoughts such as, "I'm going to look incompetent. My boss will realize I have no business here," which leads to futher feelings of heart pounding and sweating which leads to actions such asking colleagues for reassurance or apologizing for mistakes not made yet, and when no reassurance is gained, the anxiety spirals and leads to thoughts such as "I'm going to lose my job. I'm going to be a failure," which can lead to stress symptoms (feelings) such as headaches, insomnia, GI distress.
In both examples, the spiral of anxiety becomes a habit that is strengthened with time and repetition so that eventually a trigger can rapidly lead to an anxiety attack or to stress symptoms.
IDENTIFYING THE THREE COMPONENTS
The first step in treatment is to identify the situation, thoughts, physical feelings, and actions (behaviors) associated with anxiety. The following descriptions of each component can assist in that process.
A situation refers to events or objects that trigger an anxiety response. Some triggers such as snakes, spiders, heights, and water seem to be preprogrammed in our brains so that there is, at the very least, a sensitivity to those objects and situations.
Other triggers are learned when a previously neutral or safe situation is paired with a negative event that naturally causes pain, discomfort, or a negative response. In a classic psychology experiment, a young child who was not previously afraid of rats was shown a rat while being startled by a loud noise which made him cry. Because the rat was paired with the loud noise, eventually just the sight of the rat elicited a fear response in the child. In psychology literature, this is called classical conditioning.
For some individuals, there are no readily identifiable triggers to panic attacks. This may be because the trigger is an internal, physiological sensation such as shortness of breath or heart palpitations. A fear of these physiological symptoms may have developed when these symptoms were paired with a panic attack which caused intense fear. Previously, these symptoms may have caused discomfort and unease, but after the initial full blown panic attack, any sensations associated with a panic attack are now met with intense fear. In addition, after having a panic attack, it is common to start hyperscanning the body for even the most subtle physical symptoms that may be associated with a panic attack, so that even the slightest changes in breathing or heart rate can trigger a panic attack.
For other individuals, there may not be a specific event that led to a situation becoming a trigger. For example, it is thought that in OCD, the brain spontaneously generated a thought, image, or impulse that the individual interpreted as meaningful and dangerous, which then caused the experience of fear. Therefore, a client with OCD who is afraid of contracting meningitis from touching a door knob may not have had any previous negative experiences with door knobs, but rather, it is the spontaneously generated thought of contamination from door knobs that led to fears of illness and death, which then led to door knobs becoming triggers.
TIP: Try to identify the situations that trigger anxiety. On a scale of 0-100 with 0 being no anxiety and complete calm and 100 being total panic, rate how much anxiety you experience in each situation. Then rank them and write them in order from least to worst.
An important part of the treatment of anxiety disorders is to identify the thoughts that are igniting and maintaining the spiral of anxiety. This process can take some practice. To become aware of the thoughts related to anxiety, it can be helpful to ask yourself questions such as:
"What was I thinking right before I became anxious?"
"What am I afraid will happen, and if that happens what might happen, and if that happens what might happen..."
"What is the worst thing that can happen?"
"What am I afraid this means about me, the world, or the future?"
"What images come to mind when I'm feeling anxious?"
Thoughts that contribute to the anxiety spiral often have to do with:
1) Overestimation of the probability of the feared event. ("If I don't make all my sales calls, I'll lose my job. For sure.")
2) Overestimation of the "awfulness" of the feared event. ("If I lost my job, that would mean I'm a total failure as a father and husband, and I could never face my family again.")
3) Underestimation of the ability to cope if the feared event happened. ("If I lost my job, I would fall into a deep depression and wouldn't be able to get back on my feet again.")
TIP: Try to become aware of the thoughts that you are having when you are feeling anxious. Write them down and become familiar with them.
For many people, when faced with an intensely fearful situation that the mind perceives as dangerous, the understandable reaction is escape or avoidance. Individuals struggling with anxiety disorders may escape from or avoid all together situations such as elevators, classrooms, airplanes, public bathrooms...anything that causes anxiety. Other avoidance behaviors can include drinking alcohol to avoid feelings of anxiety or performing compulsions to escape the feelings of anxiety. Anxiety can also lead individuals to engage in safety behaviors such as only driving with a companion or never leaving the house without anxiety medications. Another common coping behavior is reassurance seeking where individuals may seek the reassurance of family, experts, or the internet about their fears.
These coping styles, which may have been helpful in the past, can become less and less effective in minimizing emotional and physical pain. Old coping styles become problematic when:
1) They do not directly address the source of the problem.
2) They cause more problems in the long-run.
3) They no longer work as well in relieving distress for any significant amount of time.
Physical Symptoms of Anxiety
Imagine that you are walking through a jungle, and suddenly, a tiger pounces in front of you. Luckily, your body is equipped with an instinctual, safety mechanism that rapidly prepares itself for action in the face of danger. Your body has already set off its protective emergency response system before you were even fully aware of the danger in front of you. This is the "fight or flight" response which evolved as a way to either fight the source of danger or take flight away from the source of danger. When the fight or flight response is engaged, the primitive and reactive parts of our brain immediately send messages to the rest of our body to create powerful emotions and physical reactions that are difficult to ignore, thus, ensuring our safety. It is important to remember that the purpose of this anxiety response is to protect us from danger, and anxiety is necessary to keep us safe and aware of the challenges ahead.
The flight or fight response is initiated by the part of our brain called the amygdala (more on that later). The amygdala responds immediately by sending an alarm to the rest of our body which leads to the activation of our sympathetic nervous system. The sympathetic nervous system is part of the autonomic nervous system, which controls functions in our body that our essentially automatic and outside of conscious awareness such as heart rate, respiration, and digestion.
The autonomic nervous system is made up of the sympethetic nervous system and the parasympathetic nervous system. The sympathetic nervous system rapidly activates our stress response while the parasympathetic nervous system gradually restores calm to the body. When activated, the sympathetic nervous system sends a signal to the adrenal glands to dump epinephrine (adrenaline) into the bloodstream which then immediately leads to a variety of physiological changes that are meant to protect us from immediate life-threatening danger:
Fear of the above symptoms can lead to additional fears of going crazy, losing control, passing out, or dying, usually by heart attack. It is important to recognize that:
Once the sympathetic nervous system has been activated and adrenaline has been released into the blood stream, it can take some time for the physical symptoms to subside. The anxiety response eventually diminishes when the adrenaline in the blood stream is used up or is destroyed by the body, or when the parasympathetic response kicks in.
As compared to the sympathetic nervous system, the parasympathetic nervous system is a slow acting, dampening system that counters the effects of the sympathetic nervous system by promoting a relaxed feeling. The parasympathetic nervous system has been referred to as the “rest and digest,” “tend and befriend,” or “feed and breed” system in that it is associated with behaviors that occur at rest.
The parasympathetic nervous system works to prevent the anxiety response from spiraling out of control. It is important to note, though, that the anxiety dampening system takes time to engage, meaning you may feel on edge for some time after the sympathetic nervous system has stopped responding while the chemicals continue to float around in your body. This is thought to protect our bodies by keeping it in an alert state in case the source of danger returns.
The sympathetic and parasympathetic nervous system responses were likely developed to protect our bodies from immediate life threatening dangers, but in modern times, threats come in more complex and subtle forms. Therefore, instead of the tiger in the jungle, we may now fear heart palpitations that may trigger a heart attack which may trigger death which may cause our children to be left without a parent. The same response is triggered whether we see an actual tiger or whether we perceive in our minds a threat to our livelihood.
With an actual threat, our bodies fight or flee which uses up the energy released by the sympathetic nervous system. With a perceived threat, the body remains idle and thus chemicals from the sympathetic nervous system remain active in the body. This leads to the persistent and uncomfortable symptoms associated with anxiety attacks. Rather than feeling protected, we are left feeling exhausted, fearful, and uncomfrotable. Fortunately, you can learn to activate the parasympathetic nervous system by engaging in activities that make you feel at ease.
Click here for more thorough information regarding panic attacks, panic disorder, and treatment.
Click here for a more thorough explanation of the biological components of anxiety.
Relationship to Breathing: As mentioned above, when our mind perceives danger, we begin to breathe rapidly and shallowly from our upper lungs in preparation for physical exertion. This style of breathing is normal when we are running or fighting, but if our bodies are idle, this style of breathing can lead to hyperventilation, or breathing more than is necessary. When hyperventilating, we are dumping out carbon dioxide, which lowers the carbon dioxide levels in our blood, which leads to symptoms such as:
These breathing patterns can further contribute to uncomfortable symptoms of anxiety, which can lead to anxious thoughts about the symptoms, which can then lead to more anxiety. In addition, when we experience chronic stress, we may be consistently hyperventilating on a small scale, leaving our bodies vulnerable to a panic attack.
A study by Meuret et al (2011) showed that for those who experienced "out of the blue" panic attacks, significant changes in their breathing and heart rate occurred a full hour before their panic attack, and that these symptoms were largely outside of conscious awareness. Wilhelm and Trabert (2011) also showed that individuals with panic disorder evidenced instability in measures of respiration even at rest. These findings point to the importance of stabilizing respiration in those who suffer from panic attacks.
Because of the relationship between breathing and anxiety, many treatments for anxiety disorders involve breathing retraining. Breathing retraining refers to teaching clients how to breathe from their diaphragm, or from their bellies, vs their chest. Breathing retraining also involves learning how to slow the breath cycle to about 6 breaths per minute, or 10-second breaths. Often, this can be done by imagining breathing through the nose (smelling the flowers) and then breathing out through pursed lips (blowing out the candles) and imagining that you are breathing into your belly, filling up a balloon that expands and pushes up your belly.
It is important to note that there have been mixed findings regarding the efficacy of breathing retraining in the treatment of panic disorder. This may be because "correct" breathing becomes another source of anxiety or the breathing is used as a way to stop or control a panic attack tthat has already been triggered. It is important to remember though that the key to treating panic disorder is learning to tolerate the uncomfortable physical symptoms associated with anxiety and to learn that they are not harmful, can be tolerated, and will pass. Therefore, when implementing this strategy, it is important to use it as a preventative measure that decreases overall physiological arousal to reduce the likelihood of panic attacks but once a panic attack is triggered, the breathing should be used as way of sitting with the anxiety and allowing it to pass.
Click here for more information about breathing and anxiety.
Click here for more information regarding breathing retraining
Anxiety and the Brain
Over thirty years of scientific research has supported the efficacy of cognitive behavioral therapies in the treatment of anxiety disorders, but it is only recently that technological advances have shed light on the neurological explanations for how anxiety disorders develop and why cognitive behavioral treatments are so highly effective. An understanding of the brain can be extremely helpful when learning to manage uncontrollable, excessive anxiety, and therefore, this section will attempt to describe in general the brain mechanisms related to the experience of anxiety.
One of the most relevant findings of the brain is regarding our abilities to change brain structures and patterns of responding in the brain. This is referred to as neuroplasticity. Changing the way we think and changing the way we respond, can change the brain’s circuitry by strengthening certain connections while weakening others. This new and improved circuity can lead to long lasting changes in the brain making it more resistant to anxiety.
Another important finding is regarding the structures of the brain that are associated with the fear response. Imaging techniques that examine activity in the brain have found that the amygdala is the part of the brain that is most active during the fear response. The amygdala is an almond-shaped structure in our brain found on each side of our brain. The amygdala seems to attach emotional significance to experiences and memories and is responsible for initiating the fight or flight response in the rest of the body. Without the amygdala we would not be able to have a fear response, and in fact, studies have shown that animals and humans with compromised amygdala functioning no longer have normal, adaptive fear responses to dangerous situations.
The amygdala can be automatically activated even before we have had time to think. This is why we can jump out of the way of a car before our thinking brain has even registered the danger. The amygdala acts as a protector that seizes control and sends an immediate alarm that drives us to safety. Once the amygdala has initiated a fear response, it takes time for the body to settle down, even if the threat is no longer present and even if we tell ourselves that we are safe. This means that we may need to ride out the experience while trying not to ignite a secondary fear response.
The amygdala appears to respond in a preprogrammed way to certain fears such as snakes, spiders, and heights, but fears can also be learned. Amygdala activation is necessary to learn new fears, and the amygdala also seems to learn through experience, not logic, and through pairings or associations. Thus, the amygdala is the brain structure involved in the classical conditioning of fears. To learn a less fearful response to a trigger, the amygdala must be activated and then presented with a new learning experience where there is no danger despite uncomfortable, distressing feelings of anxiety.
Techniques to Calm the Amygdala: Though some people seem genetically prone to having overly sensitive amygdala responses to danger, there are still techniques that can dampen the amygdala activation system. Diaphragmatic breathing, aerobic exercise, and yoga can lower the intensity of the amygdala response. Regular aerobic exercise, yoga, and adequate sleep are also helpful in decreasing the overall sensitivity of the amygdala response. For long term rewiring of the amygdala circuitry, the most effective intervention is repeated, prolonged exposure to the feared events, objects, experiences, or memories without any dangerous outcome.
As described above, sensory experiences (sights, sounds, smells, tastes, physical feelings) can travel directly to the amygdala immediately igniting an anxiety response even before we have had time to think about what we've experienced. The part of the brain that does the thinking or the interpreting is the cortex. The cortex is what people typically think about when we think about the brain. It is the thinking brain, the logical brain, the planning brain. It is the part of the brain involved in obsessing, worrying, ruminating, and dwelling. The pathway from our senses to the cortex and then to the amygdala is slower and more thoughtful than the pathway straight to the amygdala.
The cortex takes in information from our environment and interprets the world around us, and if it senses danger, it can send information to the amygdala which can then activate the fear response. For example, while on a hike if you see a long, slender shape on the path, the amygdala immediately makes a rough assessment of the situation and interprets this threatening shape as a snake (better safe than sorry), and the body reacts automatically by jumping out of the way before the cortex has had time to register the shape as a stick. Once the cortex interprets the object as safe, it sends a message to the amygdala but the amygdala response takes some time to terminate and furthermore adrenaline has already been dumped into your body system. Thus, the anxiety response may continue for several minutes to an hour depending on the initial level of amygdala activation.
The cortex is also capable of igniting anxiety by generating its own thoughts and images without any stimulation from the environment. Worries and obsessions are essentially being created from within the cortex itself. The cortex also has the ability to dwell and ruminate on these thoughts and images which then activates the amygdala which then activates the fear response.
The cortex can also plan ahead and foresee anxiety provoking situations in the future which leads to anticipatory anxiety. In addition, the cortex can worry and ruminate about fearful situations in the past. In a sense, the cortex is capable of worrying about the past and the future, scaring the amygdala in the present.
Techniques to Calm the Cortex: As with the amygdala, neuroplasticity is seen in the cortex, meaning it is capable of change. The cortex responds to education, reason, logic, debate, and experience, and thus fears can be explored and challenged and new beliefs can be developed and practiced. The most effective way to rewire the circuitry of the cortex is to practice thoughts and interpretations that allow for a new, stronger, pathway to be developed in the brain. This is referred to as the “survival of the busiest,” where the circuitry or pathway in the brain that is used the most becomes the strengthened whereas those that are not being used as much become weaker.
Therapy techniques that might help rewire the cortex (the thinking brain) are those that identify and challenge thoughts and interpretations that induce anxiety. Logical approaches that use scheduling, planning, and problem solving also seem to help calm the cortex. Understanding where these beliefs came from can also help diffuse some of the power behind the thoughts. For some, the cortex may have fallen into the habit of generating anxiety provoking thoughts and then gets stuck on this “anxiety channel,” which activates the amygdala. The realization that these thoughts are not dangerous and are not productive and that it is not helpful to listen to these anxiety provoking messages can provide great relief. Mindfulness techniques can help to develop the ability to allow thoughts to pass by so as to not activate circuits that induce anxiety.