Kathleen Kawamura, PhD Clinical Psychologist
Kathleen Kawamura, PhDClinical Psychologist 

Understanding Anxiety

TIP: Start by reading through the information one section at a time, taking time to take notes, make an outline, or print out the information 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. 


  • Explanation of Anxiety
    • Normal anxiety
    • Anxiety and optimal performance
    • Three component model of anxiety
      • Panic example
      • Stress example
      • Anxiety cycle 
  • Identifying the Three Components
    • Situations/Triggers
    • Thoughts
    • Behaviors
    • Physical symptoms of anxiety






Anxiety is an automatic and protective mechanism where feelings of uneasiness, concern, and apprehension lead to behaviors that keep us, our loved ones, and our environment safe from harm.


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. Because we are worried about our environment, we recycle.


Some amount of anxiety and worrying is a normal and necessary part of life and indicates 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 scared and worried - we are the survivors. 


Not only is anxiety normal, it can be related to positive characteristics. Those with anxiety can be incredibly sensitive to the thoughts and feelings of others. This acute awareness of others and of the environment may lead to anxiety but it is also what leads to compassion.


In addition, through the lens of your own struggles with anxiety, you may be better equipped to feel empathy for the struggles of others.


Anxious and worrying brains can also be seen as creative brains. This creativity that conjures up worst-case scenarios and anxiety provoking images can also be seen as over activity of the part of our brain that generates new thoughts and ideas. It is this creative vision that helps us progress as a society and that creates art, music, and poetry.  


Anxiety is also related to bravery. Bravery is often defined as the ability to face a situation despite danger, fear, or difficulty. Thus, it's not necessarily that you don't feel fear, it's that you enter a situation despite fear. Anxiety may make you feel weak, but in fact, it is an act of strength and courage that you are able to face situations each and every day that cause you fear.


Anxiety disorders develop when levels of anxiety become excessive, inappropriate, or uncontrollable and begin to impair functioning in work, family, school, or social relationships.


Therefore, the goal in therapy is not to eradicate anxiety completely but to return anxiety to normal and functional levels. This is done by managing anxiety when it shows up and not letting it interfere with your pursuit of life and happiness. This can only happen when you are able to change your relationship with anxiety and become more flexible in how you react to it.


There are strategies in therapy that can help you with this process. 




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 emotional 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 unnecessary distress.


Because of their frightening experiences with anxiety, those with anxiety disorders have become uncomfortable with even these moderate levels of anxiety, and treatment often includes re-learning how to tolerate normal, moderate levels of anxiety. 



The three components of anxiety refer to the anxious thoughts, physical feelings, and behaviors (actions) that are triggered by a situation. 


By breaking anxiety down into concrete, understandable components, it will not seem like such a vague, overwhelming threat. You may even see patterns in your responses to anxiety that give you an understanding of your own cycle of anxiety.


Monitoring your anxiety as three components also allows you to step outside of your anxiety, even if for a moment, and view it from a different perspective. This starts the practice of learning to observe your anxiety without immediately reacting to it in habitual patterns of responding.


Another benefit of breaking down anxiety into components is that it can help you develop a plan for managing each component so that treatment is not so overwhelming. 


Panic Example: 


When an individual is faced with an anxiety provoking situation such as a dreaded upcoming flight, he may experience an automatic fight or flight fear reaction, such as the physical feelings of heart palpitations, sweating, and a feeling of terror, which are quickly accompanied by a rapid series of thoughts such as, "Oh no, it's happening. I'm having a panic attack. I'm going to pass out. I'm going to have a heart attack. I'm going to make a fool out of myself."


This is the primary, or automatic, fear response. This individual may have little control over this automatic fear reaction. What follows is another set of anxiety reactions - the secondary anxiety response.


The secondary anxiety response might include thoughts about the initial whoosh of anxiety such as, "Oh this is definitely bad. This is definitely happening. I have to control this," which leads to an increase in the intensity of physical symptoms (feelings) and perhaps additional symptoms such as dizziness and difficulty breathing, which then leads to actions such as pacing or hyperventilating.


Additional thoughts such as "If I don't get out of here, I'm going to have a panic attack. I can't take this anymore," then lead to even stronger physical symptoms (feelings) and urges to escape, which then end with the action of escape from the airport.


These behaviors can then lead to thoughts such as "I knew I couldn't do it. It's too much for me to handle. I'm so weak. That can't happen again," which leads to the future action of avoiding airports all together, which leads to future thoughts about fear, danger, 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 an anticipatory thought that pops up automatically such as, "I'm going to make a mistake. I'm going to look incompetent. I could be fired," which lead to physical feelings of agitation and muscle tension, which leads to behaviors (actions) such as checking an email a dozen times before sending or avoiding the email altogether.


Additional thoughts may occur such as, "I can't make a mistake. I can't look incompetent. I have to figure this out. I can't handle this." These thoughts can lead to further feelings of heart pounding and sweating which leads to actions such asking colleagues for reassurance or apologizing for mistakes not made yet.


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. I'm going to end up destitute and alone," which can lead to stress symptoms (feelings) such as headaches, insomnia, or GI distress.


Anxiety Cycle:


In both examples, thoughts, feelings, and behaviors become habits that are strengthened with time and repetition so that eventually a situation can trigger a terrifying jolt of fear. This unconscious, automatic, conditioned fear response (primary anxiety response) and the thoughts, feelings, and behaviors that follow (secondary anxiety response) create an intensifying spiral of anxiety.


Therefore, the goal in therapy is to address both the thoughts, feelings, and behaviors associated with the fear of a particular situation or trigger AND the follow-up thoughts, feelings, and behaviors associated with the initial fear response. 




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.




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, "Little Albert," 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. The child's fear of white rats also generalized into fears of a white rabbit, a white dog, and a mask with a white beard. 


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 experienced as dangerous, painful, or intolerable.


After the first panic attack, the body then becomes conditioned to react automatically to any of these physical sensations with intense fear, and the brain starts to hyperscan 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 now automatically trigger a panic attack.


For other individuals, there may not be a specific event that leads to a situation becoming a trigger. For example, it is thought that in OCD, the brain spontaneously generates a thought, image, or impulse that the individual interprets as meaningful and dangerous, which then causes the experience of fear.


Therefore, a client with OCD who is afraid 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. Then, just the sight of door knobs may elicit an automatic, conditioned fear response.


With anxiety disorders, it is not necessarily that specific situations or objects elicit the fear response, but rather it is the physical sensations, thoughts/images, or memories associated with the situations or objects that trigger the automatic fear response.


The triggers, though, are not the central problem; it is the secondary anxiety response - the response to the automatic fear response that fuel and maintain anxiety.


For example, you may have an automatic startle response when you walk into a room with a large spider sitting in the middle of the floor, but it is the follow-up thoughts ("The spider is dangerous, looking at it is intolerable") that lead to intensifying physical sensations and the behaviors (run away) that lead to the maintenance of anxiety.


The goal in therapy then becomes learning to tolerate the conditioned, automatic fear response, addressing anxiety-provoking thoughts, and learning to sit with the discomfort until your brain and body learn that the situation is not dangerous and that you can cope with it. Then, over time, your body will react with less intensity to the triggers that initiate the fear response.


TIP: Try to identify your triggers. 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. The initial fear response may be automatic but the follow-up thoughts may be adding fuel to the fire.


These thoughts happen quickly and automatically and for the time being may be beyond your conscious control, and therefore, it can time and practice to become aware of the thoughts related to anxiety.


It can be helpful to ask yourself questions such as:

  • "What thoughts are going through my mind? What am I telling myself"
  • "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 about this bothers me most?"
  • "What am I afraid this means about me? Or about my future?"
  • "What images or memories come to mind when I'm feeling anxious?"
  • "What will happen if I become anxious? How am I wanting to respond to this anxiety?"
  • "Are there any themes or patterns in my thoughts?"

Thoughts that contribute to the anxiety spiral often have to do with assumptions that are made such as:


1) Probability overestimation - overestimation of the probability of the feared event. ("What if I make a mistake...if I make a mistake, I'll lose my job.") 


2) Catastrophizing - 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.")


It is important to remember that these thoughts are not necessarily wrong or bad, but rather, the brain is rigidly fixated on thinking in a way that is meant to keep you safe from imminent danger by driving you away from the source of danger.


This way of thinking may have been adaptive in the past, may have been learned from childhood, or as in OCD may seem as if it is neurological in nature. When you consider how they developed, the thoughts often make sense.


The problem is that if anxious thoughts continue even after the situation is safe, a false alarm will continue to sound, keeping your mind and body in a state of anxious arousal. This emergency mode that was once life-saving in dangerous situations becomes an obstacle for day-to-day living.


The goal in therapy becomes learning how to recognize anxious thinking, seeing it as protective, and recognizing that it is but one way to view the situation and that this perspective may not be helpful or accurate for the current situation. It may be a false alarm and you may feel a sense of danger and fear harm but you may actually be safe to go on with your life.  


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. These behaviors are adaptive and protective in that they can keep us safe from harm. They also lead to an immediate reduction in symptoms of anxiety, which is often experienced as "relief."


The problem is that these behaviors are meant to keep us safe from imminent harm, but many of the dangers of the modern world that cause anxiety are often complex situations that are not necessarily life threatening in the moment, even if they feel that way.   


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 safety behavior is reassurance seeking where individuals may seek the reassurance of family, experts, or the internet about their fears.


Avoidance/escape and safety behaviors can be behavioral (actions that are meant to avoid distress) but can also be cognitive and emotional. Cognitive and emotional avoidance can be distracting oneself from experiencing the fear, singing a song to drown out the thoughts and feelings, or thinking positive or superstitious thoughts to make the fear go away.


These coping styles may have been helpful in the past and the rapid decrease in anxiety provides temporary relief, but eventually individuals find that escape and avoidance: 


1) Do not directly address the source of the problem

2) Cause MORE anxiety and other problems in the long-run

3) No longer work as well in relieving distress for any significant amount of time


4) Do not allow baseline levels of anxiety to return to original levels 


Every time a situation is avoided, an opportunity to build new connections in the brain and to create a new learning experience is missed, and instead, avoidance and escape behaviors confirm to the mind that you are helpless and the situation is in fact dangerous, or why would you have reacted in such a way?


Over time, because of the relief they provide, escape and avoidance become persistent habitual responses and the anxiety worsens so that you're left walking around with a high level of general anxiety and anticipatory anxiety.


Learning to approach rather than avoid anxiety-provoking situations becomes a critical component of learning to manage excessive anxiety. This is done in therapy with exposure exercises where you learn to tolerate and get used to reasonable levels of anxiety and by practicing new ways of managing anxiety when it comes.


With enough repetition and practice in anxiety-provoking situations, your brain will eventually learn to respond with less intensity to the feared triggers. New less fearful reactions will then be able to inhibit or override older more fearful ones.    



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 brains automatically send messages to the rest of our body to create a powerful cascade of 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, that anxiety is necessary to keep us safe and aware of the challenges ahead, and that the anxiety response is automatic and immediate.


The flight or fight response is initiated by the part of our brains called the amygdala (See Anxiety and the Brain). When the brain perceives danger, the amygdala responds automatically by sending an alarm to the rest of our body which leads to the immediate 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 sympathetic 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 experienced as a whoosh of anxiety and 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 schizophrenia by this time, it is unlikely to he will become schizophrenic suddenly. 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 obscenities, or a vague feeling of something bad happening. The activation of the sympathetic nervous system makes it highly unlikely that an individual would become paralyzed 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 likely 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 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.


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 uncomfortable. 


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.