You or someone you love is exhausted from constantly worrying. You experience unexplained aches and pains, tightness in the chest, and racing thoughts. You have another tab open where you’ve recently typed the words “is this anxiety or a heart attack?” into your Google search. Panic attacks or intrusive thoughts about bad things happening have led you to question if you can even trust your own mind and body anymore.
We all experience stress and anxiety sometimes. It’s part of being human. Other times, anxiety can morph into something so big that it makes it hard to keep it together on a daily basis.
Here’s the good news: there is a way through this, and you CAN feel better with the right support.
Just because you have felt this way as long as you can remember, does not mean you have to keep feeling this way. Learning to effectively manage anxiety is within reach, and I can help you get there.
Prior to starting up treatment for anxiety, it is helpful to understand a few things about anxiety, including what tends to cause it; different types of anxiety disorders; and evidence-based treatment methods.
Where did my anxiety come from in the first place?
While there are many unique reasons that could cause people to experience anxiety, a few common reasons are outlined below:
- Genetic predisposition. Some people are born with a genetic predisposition to experience high levels of anxiety. Anxiety tends to run through the family tree. This may be caused by a combination of inherited qualities and learned behaviors about how to cope with stress.
- Family patterns of coping. People who struggle with anxiety often see patterns in their family of excessive worrying. In these families, there are extreme efforts taken to prevent bad things from happening, including avoidance of feared situations and rumination about all of the possible catastrophes that could occur. Our experiences in early childhood become our foundation for beliefs about the world around us (i.e. how safe/unsafe things are). These experiences also teach us how to deal with threats, and sometimes these methods involve behaviors and routines that inadvertently fuel anxiety.
- Life transitions. Major changes and stressful life circumstances can cause anxiety to ramp up. Examples include: to college for the first time; moving; starting a family; or grieving a loss. Anxiety might be something that you temporarily experience as you work through life changes, or you may experience more long-term struggles.
- Trauma. When you have experienced a traumatic event in your past or present, anxiety can become a very difficult part of life to manage. Trauma undermines your sense of safety, which then ramps up anxiety and hypervigilance.
- Physical or mental exhaustion. Not sleeping enough, not eating well/being nutrient deprived, overworking, and not having enough time for rest can all contribute to a heightened stress response in the body.
- Underlying health conditions. Health problems such as thyroid issues; hormone imbalances; heart conditions; or blood sugar issues can all cause a biological experience of anxiety. Because the root cause in these instances is physical, we work in conjunction with your doctor as they treat underlying physical issues. It is often helpful for clients to have a physical examination done with bloodwork to rule out physical causes at the start of therapy.
Generalized Anxiety Disorder
Generalized Anxiety Disorder (GAD) involves worries about just about any and everything. People with GAD often find themselves wrapped up in worries about a variety of things happening in their lives, and this worry takes a significant hit on overall functioning (trouble sleeping, body-aches, headaches, muscle tension, and a significant amount of time spent lost in thought about worries).
Generalized Anxiety Disorder is typically treated with Cognitive Behavioral Therapy, which involves examining default thought patterns about the world around you and how safe or unsafe things are. People with anxiety experience significant doubt about whether or not something bad might happen and assume that they would not be able to cope if it did happen.
The heart of CBT is about questioning our automatic assumptions and becoming aware of when our imagination is creating anxiety stories. A great deal of our stress in life comes not from the events that actually happen, but the stories that we tell ourselves about what is happening or what could happen. Once you can change-up your automatic thoughts and explore a full range of the possibilities about how something might turn out and consider the resources you do have to cope, you are able to envision more possibilities and solutions.
Before we talk about treatment strategies, it is first important to understand what is going on in your brain when you are faced with an anxiety trigger. When our brains evaluate if something is safe or dangerous, our prefrontal cortex sends information over to our thalamus, which sends a “danger” signal to our amygdala. Our amygdala then sets off the “fight or flight” reaction, which leads our hypothalamus to pump out adrenaline and cortisol.
When someone struggles with clinical anxiety, there is a biological process going on in the brain that is different from the brain of a non-anxious person – the amygdala tends to be overactive, which is thought to be due in part to a deficit of the neurotransmitter serotonin. The amygdala actually measures larger on brain scans in people with clinical anxiety due to a highly overactive fear-response system.
Here’s the thing about our amygdala – we should be thankful for it, because it protects us from danger! We need it to survive. However, our amygdalas are wrong all the time when assessing whether something is a true threat, and they do not respond to logically telling them, “Hey! no need to panic, we’re safe.”
For a person with anxiety, an overactive amygdala is like a smoke detector going off every time you burn popcorn. Even though you can logically assess after the fact that there was no fire and no need for your heart to jump out of your chest, you simply can’t tell your nervous system to not panic when you hear that alarm going off. This is why it’s not helpful when people say, “just don’t worry so much!” and why spending too much time disputing your thoughts tends not to be very effective.
Your amygdala learns through experience – It cannot just be told. We need to give your amygdala new experiences by changing the ways in which you relate to your thoughts when you are anxious. You can reason all day long about the evidence as to why something probably won’t happen or isn’t true – but with this approach, there is always going to be that bit of doubt that creeps back up and convinces you that you’ve missed something; that you just need to research a bit more; think about the situation for a few more minutes; or ask for reassurance one more time.
These compulsive behaviors fuel anxiety and reinforce the idea that the imagined threats are real and need your attention. You might feel better temporarily when you Google repeatedly, get that reassurance, or mentally review that conversation just one more time – but the reality is, these things will never fully satisfy the demands of anxiety.
So what do we do about this? How do we train our amygdala that we do not need to urgently respond to every false alarm?
First, we get very clear on your values. What matters most to you? We want you to be living life each day according to your values. Even when you feel fear or anxiety, I’ll teach you about a mindset that drives you toward your values first and foremost, regardless of what fear is telling you.
Through CBT and mindfulness strategies, you learn skills to help you orient yourself to this moment using your five senses to figure out what is true right now. When you can attend to life as it is happening right in front of you, you are adopting a solution-focused attitude about what needs your immediate attention, as opposed opposed to getting lost in worries about all of the “what ifs.”
We work on the acceptance of uncertainty that all of us face in our lives. Our goal here is NOT to argue with irrational thoughts or spend too much effort on disputing them or trying to answer the questions that anxiety plants in our minds.
We work on increasing our tolerance of the fact that life is hard, and that there are things we don’t have control over. However, instead of automatically assuming that the worst-case will happen, we explore other possibilities of how things could go. Maybe the situation goes better than we think; more neutral than we think; or maybe it isn’t our best case scenario, but it’s manageable.
We work on exposing ourselves to things we fear in order to retrain our amygdala. Cut back to the smoke alarm example. If your smoke alarm went off at the same time every day with false alarms and you come to experience that these are not real threats, you are no longer going to experience the same intensity of fear each time that false alarm goes off. Exposing yourself to things that you fear allows your brain and body to habituate to the fear, to the extent that it no longer creates distress for you. Another process that happens here is inhibitory learning, which means that when you are exposed to a fear repeatedly but the worst case doesn’t happen, your brain learns that things are more safe than you might initially think and the feared situation is no longer seen as threatening. The key here with exposures is that you have to change your behaviors first (approaching fears) and the anxiety relief will come second to that.
As the saying goes, “everything you’ve ever wanted is on the other side of fear.” This is so true! There is so much life to be lived, and anxiety treatment can help you get there. You are capable of more than you can imagine, and we all have untapped bravery and courage inside of us that can be unlocked with the right support and tools in your toolbox.
(Disclaimer: According to the DSM-5, Obsessive-Compulsive Disorder has been removed from the Anxiety Disorder category and placed in its own category. I am including OCD in my anxiety page because I frequently meet clients who initially reach out for help with anxiety who actually meet criteria for OCD).
Obsessive-Compulsive Disorder is similar to GAD in the sense that there is chronic and intense worrying happening. GAD and OCD can both include intrusive thoughts and even compulsions. OCD is sometimes different from GAD in regard to the typical content material of the intrusive thoughts. OCD thoughts can cast a wider net than GAD typically does and often includes some bizarre and scary content (i.e. harm fears) that are not related to any true threat or factual experience happening in your environment. These thoughts are egodystonic – meaning they do not align with what you actually feel, think, or desire to do.
(You’ll notice I emphasized that the content of OCD can sometimes be more bizarre or less realistic than GAD – because often, your OCD could actually about “real” or more “normal” stuff! OCD can be about ANYTHING. It can be about relationships, or fears around real things like COVID, or health in the face of a true health problem. Many people with OCD are improperly diagnosed with GAD because there content is not about stereotypical things like cleanliness, or it’s not “out there” enough. However, a true OCD specialist can recognize that OCD is really about the PROCESS – not the content).
People with OCD experience intrusive thoughts and compulsions.
Intrusive thoughts are unwanted thoughts, images, impulses, or urges – and everyone has them sometimes. 99.9% of people will have an odd or scary thought that pops into their brain (i.e. “what if I accidentally run someone over while I’m driving?”) This is just your brain having a meaningless electrical blip.
Someone without OCD can experience this thought and let it go rather quickly without thinking too hard about it or feeling particularly distressed by it. On the other hand, someone with OCD will tend to latch on to this thought and experience a high degree of distress. They can’t stop thinking about it and feel compelled to engage in a compulsion to get rid of the thought and bring down their anxiety. These obsessive thinking loops and compulsions take up a lot of time and energy and interfere with work, your relationships, and other domains of life.
OCD is thought to occur because of a faulty stop/start signal in the brain, which is thought to be related to serotonin production. The part of the brain that filters what information is important or unimportant is wide open in people with OCD, leading many unimportant, meaningless thoughts to make their way through.
Some examples of common intrusive thoughts are listed below:
“What if I accidently fall on a knife while I’m unloading the dishwasher and get hurt?”
“What if I lose control when I’m cooking dinner with my family and a stab someone?”
“What if I hit someone while I’m driving?”
“If I don’t fold this towel *just so* or walk in and out of this doorway three times, something bad is going to happen to me.”
“What if I don’t really love my partner and it’s all a lie?”
“What if I have cancer and don’t know it?”
“What if I’m a terrible person and everyone hates me?”
“What if I picked up a serious illness from touching that doorknob?”
Compulsions can be either occur on the outside (behavioral) or the inside (internal).
Some examples of behavioral compulsions include: handwashing, rewriting notes, doing an activity a certain number of times, repeatedly checking, asking for reassurance, or Googling about health.
Internal compulsions are mental processes that involve excessive analysis about the meaning of thoughts. Some examples of internal compulsions include: mentally reviewing a situation repeatedly to gain certainty about what occurred; silently praying or counting; or mentally reassuring yourself that certain thoughts will not occur.
While compulsions may provide temporary relief, the anxiety comes back even stronger later on. Compulsions keep the anxiety spiral going.
The gold standard for treating Obsessive-Compulsive Disorder Exposure and Response Prevention (ERP), which is a form of CBT. Traditional talk therapy alone does not work – which is sadly why people with OCD go years without symptom relief, even when they regularly go to therapy. The key to successfully reducing OCD symptoms is through behavioral learning. You have to first change your behaviors (face the fears head on without doing compulsions) and then the anxiety reduction comes afterward. If you wait until you feel sure that the bad things won’t happen, you will be waiting forever! ERP requires a leap of faith and learning to trust yourself that you can handle your fears.
In addition to the behavioral work, you also learn ways to become more aware of your thoughts through mindfulness training and new ways to respond to these thoughts that will stop fueling your anxiety. While worrying tend to feels automatic, it is actually a habit that involves choices over what you pay attention to and how meaningful you make your thoughts out to be (so many thoughts truly mean NOTHING at all, even the scary ones! They are just random thoughts). The good news is that habits can be changed, and that you can learn new ways to relate to intrusive thoughts so that you do not experience anxiety anymore when they pop up.
Over time, ERP can lead to a significant reduction in anxiety and can truly help you get your life back. Instead of spending all of your time paying attention to intrusive thoughts and doing compulsions to get rid of them, you learn not to engage with the intrusive thoughts, resist compulsions, and to focus your attention back to your values and things that matter to you.
ERP treatment is pretty amazing – research shows that it can biologically rewire your brain circuitry. You truly can recover and get your life back!
Panic attacks are a terrifying experience. They can occur with or without an obvious trigger, and it feels as though the walls are closing in. Your heart races and your fingers get tingly. You feel a sense of impending doom or like you might die, and it is hard to breathe. You might even get nauseous and throw up.
Once you have your first panic attack, it is common to live in fear of having more, which can lead people to avoid situations that could cause this to happen. Your life can start to feel smaller and smaller, and the constant fear of panic symptoms can actually lead these symptoms to happen more.
Panic attacks often occur for the first time when you experienced symptoms of heightened anxiety (heart racing, sweating, tunnel vision, etc.) and then your brain misinterpreted that experience of anxiety as being life-threatening. Your body is actually meant to respond to stressful events with all of the symptoms mentions above – that is a sign of a well-functioning body! However, where things went wrong here is that your brain misunderstood these symptoms as meaning something was terribly wrong (insert Googling about heart attack), and you then developed a fear of being afraid.
Once this fear of being afraid has been established, you are in such a hypervigilent state of constantly analyzing your body that this tends to being on more panic attacks. It can be challenging to function because every twinge in your body continues to be misinterpreted as a threat.
Panic attacks feel completely terrifying – but they are actually NOT dangerous! They involve symptoms that are very uncomfortable, but they can’t actually hurt you. Learning that panic attacks are inconvenient and uncomfortable, as opposed to life-threatening, is a key foundational piece of treating panic disorder.
Treatment for panic disorder is essentially about retraining your brain out of the habit that has been established to fear your natural anxiety response.
In order to train your brain that you are safe and in control, we have to expose you to different situations that could lead you to feel panicked so that you can experience new learning. These exposures involve intentionally experiencing physical sensations that remind you of a panic attack (i.e. jumping jacks to bring up your heart rate) and also progressively facing situations that might trigger panic (i.e. if you have medical anxiety or phobias, you would intentionally do things like go to the doctor). A key part of this is actually learning to ride the wave of panic symptoms without trying to avoid them and come out on the other side learning that you can handle it.
Once we identify some of your unique triggers that contribute to panic attacks, we work on coping strategies that will help you cope with anxiety on a daily basis. These include things like paced breathing, progressive-muscle relaxation, visualization, and examination of your daily habits (sleep, exercise, nutrition, alcohol and caffeine intake, work/life balance, and restoration and self-care opportunities). If we can set your physical body up for success by taking down your stress response a notch, you can feel more equipped to face hard things with courage, as opposed to giving in to avoidance and making your life smaller and smaller.
Can I be “cured” from anxiety?
Treatment for anxiety or OCD can significantly reduce your symptoms. Active participation in treatment can lead to being largely symptom free. Overall, you can sleep better; worry less; and fully participate in your life again.
That being said, anxiety tends to come and go throughout your life, and episodes of higher anxiety can be re-triggered by a variety of factors. There is not an end point where you will never experience anxiety again; this is due in part to the fact that we need our anxiety response in our lives to help us function to a degree and respond to true threats! Utilizing CBT and ERP strategies is a lifestyle you maintain on a daily basis, and this will help you handle challenges with more confidence and less overwhelm.
We can’t control what thoughts pop into our heads. If you’ve struggled with anxious thoughts or intrusive thoughts, you will probably have these come and go throughout your life. However, you can learn ways to react to these thoughts differently so that they do not cause you distress and to the extent that you may experience very minimal anxiety about them anymore.
There is hope. You can feel better. It also gets SO much easier in time with practice and the right support!
I hear about mindfulness for anxiety all the time – what is mindfulness, and how can it help my anxiety?
Contrary to popular belief, the goal of mindfulness is not to force ourselves into a state of calm by sitting and meditating (although this is a bonus with repeated practice).
Mindfulness is about learning to observe thoughts, feelings, and sensations in our minds and bodies exactly as they are.
When we are fully present for this moment without trying to change it or escape it, we are able to increase our tolerance for a full range of emotions with less reactivity and fear. If you suffer from anxiety or panic attacks, you know reactivity and fear all too well. Mindfulness is a key part of learning to face our anxiety with courage, rather than further avoidance of root problems that are causing us pain.
Learning mindfulness practices are key for people who struggle with anxiety, because brains on anxiety are very imaginative and can create vivid narratives about how terrible things are or could become. When we get stuck in this anxiety fog, it can become very challenging to feel clear about what is true and real in our lives, and what is a product of our anxiety.
Mindfulness allows us to collect real-time, accurate information about what is happening through our sensory experience (what you see, smell, hear, taste, and feel). For example, if you struggle with fears about your health, here is a step-by-step example of how you might use mindfulness to work through an anxiety moment:
- Name the emotion. “I am anxious right now because I am fearful that I have an undiagnosed heart condition and that I could die from it.”
- Identify what you know to be true using your senses. “In this moment, I feel good. My heart is beating. I smell the lemon in my tea and this lets me know that I am alive and present. I feel the breeze coming through the window. At this moment, my body is giving me signals that I am okay and there is no emergency.”
- Remind yourself of the facts you know to be true about what is within your control. “I get a yearly physical, and last month everything checked out well. There were no concerns in my bloodwork and all of my vital signs were great.”
- Get closer to the uncertainty and make a radical acceptance statement. “No one can ever know for the sure a complete status of their health, because this changes moment to moment. I radically accept that I can’t know for sure, but that if things take a turn, I can solve that problem when it arrives here. Right now, there is no problem to solve.”
When we learn to live right in our bodies instead of in yesterday or tomorrow, anchored by controlled breathing, we can find our way back home to a sense of safety within ourselves. When we feel safe within ourselves and learn to accept all aspects of the ups and downs of life, we feel less anxious and more in control of our lives.
How does physical health relate to anxiety? Are there ways to better support my physical body in an effort to reduce my anxiety?
Modern medicine once considered the mind and body as two separate entities. If you were struggling with your mental health, you went to talk therapy and the buck stopped there. Research has evolved and we now know that the mind and body are inextricably tied.
We are living in an exciting time where we are learning a ton about how the mind and body are connected, and how focusing on how physical health can impact mental health. What you eat, how much sleep you get, how much you exercise, how much water you drink, how much time you spend on a screen, and how much time you rest- ALL of these things play into how your anxiety manifests.
The physical symptoms of anxiety are very real and occurring at a cellular level in the body. When feeling anxious, our breath becomes shallow and rapid, blood rushes to the extremities as we prepare for flight or fight (which can lead to dizziness and tingling in the hands), our pupils dilate, and we start to sweat. A brigade of stress hormones rushes through our bodies.
If we are chronically anxious and stressed, these stress hormones are constantly bombarding our nervous system. This overloaded stress response leads to other physical health problems, such as insomnia, physical tension, headaches, and more.
Careful consideration of our physical health allows us to set our bodies up for success with the work we are doing in anxiety treatment. When we are intentional about stress-reduction and physical health, we can holistically treat symptoms.
There are many holistic strategies to improve mental health: nutrition, being in nature, yoga, acupuncture, massage, chiropractic care, float therapy, etc. You name it, I’ve probably tried it! While I am not an expert in all of these disciplines, part of my job is to connect you to other professionals who can help support all aspects of your health. What helps your mind and body feel better will be unique from what helps someone else, so learning about how to best take care of yourself is an individualized experience. We can also spend time making a plan for organizing your daily habits to best support your mental health.
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