Kathleen Kawamura, PhD Clinical Psychologist
Kathleen Kawamura, PhDClinical Psychologist

Below you can learn more about anxiety and the specific anxiety disorders that I treat:

  • Explanation of Anxiety 
    • Three component model of anxiety 
    • Normal anxiety vs Anxiety Disorders
    • Relationship to breathing
    • Physical symptoms of panic attacks
  • Treatments for Anxiety
    • Cognitive behavioral therapy
    • Biofeedback
    • Mindfulness Meditation
    • Medications




What do you mean by anxiety?

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 about our children's safety, we watch them carefully. Because we are concerned about our own well-being, we fasten our seatbelts. These kind of concerns help keep us aware and alert but don't interfere with our daily life in any way. In fact, worry on this level means that our internal protective systems are doing what they are supposed to do. 


The three component model of anxiety is often used to understand anxiety. The three components refer to the thoughts, physical feelings, and behaviors that are triggered by a situation and lead to anxiety. 



For example, when an individual is faced with an anxiety provoking situation such as an upcoming flight, he may experience thoughts such as, "The plane is going to crash. I'm going to have a panic attack. I'm going to make a fool out of myself," which leads to physical sensations of anxiety such as heart palpitations and sweating, which leads to anxiety, which leads to behaviors such as pacing and avoiding the flight, which further leads to thoughts such as, "If I went, I would've died. I wouldn't have been able to handle it," which then leads to further symptoms of anxiety and avoidance and so on with anxiety increasing with each cycle until it spirals into an anxiety attack. WIth each repetition, this cycle becomes a habit that is strengthened so that eventually a trigger can rapidly lead to an anxiety attack. 


For many people, problematic behaviors develop as an understandable way of coping with the uncomfortable and distressing symptoms of anxiety. For example, avoidance behaviors are an understandable way of coping with the intense fear associated with anxiety, or compulsive checking is an understandable way of coping with distressing obsessions. Sometimes these coping styles, which may have been helpful in the past, become less and less effective in minimizing emotional and physical pain. These coping styles can also become problems of their own. 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


How do anxiety disorders differ from normal anxiety?

In many situations, such as during a test or before 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 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 distress.



Anxiety disorders develop when levels of anxiety become excessive, inappropriate, or uncontrollable and begins to impair functioning in work, family, school, and social relationships. For some, specific situations can trigger anxiety, while for others, the worries may not seem to be connected to any specific situation and rushes of anxiety can seem to happen "out of the blue" and disappear as mysteriously as they started. Sometimes they can become quite pervasive in one's life (like in Generalized Anxiety Disorder) or they can be compartmentalized (as with phobias). 


What are panic attacks, and how are they related to our body's natural anxiety response? 

For some individuals, anxiety is accompanied by a panic attack, which is a sudden burst of intense fear marked by symptoms such as heart palpitations, chest pain, or shortness of breath. Panic attacks generally peak and subside within 30 minutes. Panic attacks are often “out of the blue” with no obvious triggers as seen in panic disorder, or panic attacks may be situational, meaning it is set off by a specific trigger as seen in social anxiety, phobias, or obsessive compulsive disorder. For those suffering from panic attacks, it is important to understand the physiological explanations of the anxiety response.  

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 related 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:


  • The heart beats faster, pulse rate goes up, and blood pressures increases so that our muscles, heart, and vital organs receive the extra blood and oxygen needed to fight or flight. If we are sitting in our cars and not running away from a tiger, our activity level is not matching the increased activity in our bodies, and we experience these symptoms as heart palpitations or chest pain.
  • Blood is redirected to our essential organs by the constriction of blood vessels in places like our fingers and toes so that our extremities may feel cold and tingly during an anxiety response.   
  • Digestion slows down and immune responses decrease so that our body can conserve energy for more essential bodily functions needed for fight or flight. This can lead to an upset stomach or feelings of nausea.  
  • Respiration also increases in preparation for the extra activity. If no extra activity occurs, we are basically over breathing, or breathing more than is necessary for what we are doing. This over breathing can lead to hyperventilation, which in turn can lead to chest pain, feeling smothered, dizziness, blurred vision, confusion, dissociation from reality, and hot flushes.
  • Sweating protects our body from overheating
  • Other symptoms can include dry mouth, the need to urinate, or muscle tension


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:


  • Going crazy is unlikely as a major mental illness such as schizophrenia has a gradual onset and does not occur suddenly as in a panic attack. Those with schizophrenia also show mild symptoms of the disorder throughout most of their lives and until it manifests in their teens or early 20's. Thus, if an individual has not shown symptoms of shizophrenia by this time, it is unlikely to he will become schizophrenic suddently. An interview with health professionals would also have indicated schizophrenic tendencies if they did exist.
  • Losing control often means becoming paralyzed, running around perhaps yelling obsenities, or a vague feeling of something bad happening.The activation of the sympathetic nervous system makes it highly unlikely that an individual would become paralzyed during a panic attack. The sympathetic nervous system, though, is likely contributing to those feelings of confusion and dissociation. Even so, you are still able to function normally so that often times those around you are unable to tell that you are having a panic attack.
  • A fear of passing out comes from the fear that the sympathetic nervous system will continue to spiral out of control, but in reality, the parasympathetic nervous system is in place to prevent this from happening. The likelihood of passing out is extremely unlikely especially if it has not happened before. If you do pass out, then the sympathetic nervous system will cease and you would gain consciousness.
  • The fear of dying is often associated with the fear of having a heart attack. Unlike a panic attack, pain associated with heart disease is often directly related to physical exertion and the physical symptoms often subside quickly with rest. On the other hand, panic attacks often occur when at rest and do not subside quickly. When symptoms occur at various times and not only during times of physical exertion, then it is likey due to anxiety and not heart disease. Finally, if you have had an EKG and your physician has not identified signs of heart disease, then it would be safe to assume that you do not have heart disease.  


Once our sympathetic nervous system has been activated and adrenaline has been released into our 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 relaxed.  


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.


How does breathing style contribute to symptoms of anxiety?

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:

  • Dizziness
  • Shortness of breath
  • Chest pain
  • Lump in throat
  • Tingling in extremities
  • Nausea
  • Confusion

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, but 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


What causes anxiety?

The BioPsychoSocial model is often used to explain the development of anxiety disorders. 



Biological: There may be a genetic predisposition to anxiety sensitivity, meaning that some individuals may inherit a sensitive anxiety response system. There may also be medical conditions that contribute to anxiety symptoms. All individuals should be seen by a medical professional to rule out conditions such as heart disease, diabetes, hyperthyroidism, asthma and other respiratory disorders, drug use or withdrawal, or rare tumors. Anxiety can also be a side effect of medications or drug use or can be the result of poor sleep and nutrition. For some physical exercise can change brain and body chemistry enough to make significant changes in emotional functioning. For others, the additional assistance of medications may be beneficial.


Psychological: Certain personality factors can contribute to the general ways in which individuals think and respond (cope) when faced with stressful situations. For example, a perfectionistic personality trait can lead individuals to see anything less than perfect as a threat, or a neurotic personality can contribute to a tendency to interpret situations as negative. Another psychological factor is thinking style. Some individuals tend to overestimate the probability of threat or the occurrence of negative events while also underestimating the ability to cope with such threats. This thinking style can lead to an overactive anxiety response system.


Another psychological factor refers to the ways in which individuals think about themselves, others, their environment, and their futures. Anxiety occurs when an individual thinks of themselves as vulnerable or incompetent, others as threatening or uninterested, the environment as dangerous, or their future as doomed. Individuals who tend to avoid or escape from uncomfortable situations are also prone to anxiety in that those particular behaviors strengthen the fears and do not allow the individual to develop confidence in their coping skills. By addressing these personality factors, one may be able to find more peace.


Social: Anxiety responses can be learned from parents, caregivers, and other role models. By watching others, children can learn to be fearful, learn to avoid anxiety provoking situations, and generally, learn to think, feel, and behave in ways that lead to the development and maintenance of anxiety disorders. Stressors in the social environment can also contribute to anxiety, such as an unstable home environment, childhood trauma, or toxic work environment. Strong relationships with close family and friends can help ease the pain of anxiety.


Spiritual: Though not typically part of the BioPsychoSocial model, I believe the spiritual component is an important one that influences the entire biopsychosocial system. For some, a connection to a specific religion or a higher power can provide peace and comfort. For others, life is given meaning through nature, relationships, or acts of service to others. Identifying our purpose and values can help us to tolerate the pain we encounter in life.  


What treatments are there for anxiety disorders?



Though anxiety can cause significant impairments, hopes for long-term recovery are very good. Through rigorous research studies, the National Institute of Mental Health has identified cognitive behavioral therapy as being highly effective in treating anxiety disorders. There are usually four parts to the cognitive behavioral treatment of anxiety disorders: education, cognitive skills training, behavioral strategies, and somatic management skills. Education regarding the causes and treatments for anxiety can provide peace of mind, a sense of control, and motivation for treatment. There should be no mystery or complexity in the explanations and treatment. Cognitive skills training involves identifying and challenging the thoughts that increase anxiety and can include self-monitoring thoughts and developing an alternative perspective regarding feared outcomes. This is why the education component is important. Behavioral strategies include exposing you to situations that induce anxiety in a controlled manner allowing you to challenge your fears and develop confidence in your coping skills. Somatic management skills refers to relaxation, breathing, and mindfulness meditation strategies that are used to calm general physiological arousal or to help you tolerate the discomfort of the situation. The specific strategies will differ depending on the source of your anxiety. 


Click here to learn more about CBT in the section the Process of Psychotherapy & CBT



Biofeedback is a therapeutic technique that can be used to help manage symptoms related to anxiety, stress, insomnia, and chronic pain. By using a specialized heart rate monitor, you will be able to see a visual representation of your heart rhythm patterns and learn how to create heart rhythms associated with focused attention, calm relaxation, and positive emotions. Biofeedback is not a cure or a treatment but rather a training technique that is, in a sense, a short-cut to learning deep relaxation and meditation. By getting immediate feedback on a monitor, you will quickly learn how your body responds to stress so that in the future you are more aware of your internal sensations association with stress allowing you to catch it earlier in the cycle. In addition, you will be able to learn how to implement various relaxation techniques and get feedback that it is having a positive impact on your body system. 

Essentially, your heart rate speeds up and slows down in a rhythmic pattern leading to variability in your heart rate (HRV). Heart rhythm patterns associated with stress, anxiety, and anger are shallow, jagged, and irregular whereas heart rhythm patterns associated with calmness, focused attention, and positive emotions are smooth and wave-like indicating that your heart rate is increasing and decreasing in a rhythmic fashion. These smooth waves appear when your breathing and your heart rate (two powerful systems in your body) are in coherence with each other. This in turn, leads to more coherence in your other physiological systems, particularly the autonomic system that is associated with the stress and relaxation responses. The smooth waves have also been found to be an indication of health and wellness, particularly cardiac functioning. In my practice, I utilize a simple heart monitor attached to your earlobe to give you feedback about your heart rate patterns and to optimize breathing techniques.  


Click here for a more detailed explanation of heart rate variability biofeedback.


Click here for research publications on the relationship between heart rate variability and both physical and mental health.


MINDFULNESS MEDITATION Mindfulness refers to the nonjudgmental acceptance of one's thoughts, feelings, and physical sensations. Mindfulness meditation can help increase awareness and appreciation of the present moment, improve clarity of thinking, and calm physiological arousal. Mindfulness teaches us to sit with and observe our thoughts and feelings with compassion and prevents a secondary anxiety response where we become anxious about our anxiety. Mindfulness also allows anxiety to dissipate on its own via the parasympathetic nervous system and gives the prefrontal cortex (our thinking brain) the opporunity to calm our amygdala (feeling brain). MIndfulness meditation is a skill that can be improved with practice. Mindfulness meditation often starts with a focus on the breath. By learning to shift your attention to your breath, you can learn to sit with your anxiety which will allows your breathing to become slow and rhthmic which will then encourage your body to engage in a relaxation response as opposed to a stress response.


Click here for a thorough description of mindfulness based cognitive therapy for anxiety disorders.



A medical professional should be consulted regarding the use of medications in the treatment of anxiety, but an understanding of the pros and cons of the medications would be helpful. 


Click here for information regarding the use of medications for the treatment of anxiety

Click here for information regarding the use of medications for specific anxiety disorders. 



There are many wonderful self-help books out on the market, but most people seem to benefit from the individualized coaching they receive in therapy.


Click here for more information on anxiety disorders from the National Institute of Mental Health

Click here for more information on anxiety disorders from the Anxiety Disorders Association of America


Click here for a workbook that is used by many therapists in the treatment of panic disorder

Click here for a workbook that is used by many therapists in the treatment of chronic worrying

Click here for a workbook that is used by individuals more as a self-help workbook.