ANXIETY & PHOBIAS

Anxiety is a set of psychological and physiological symptoms that signal the presence of a real, perceived, or anticipated threat. We generally see anxiety as a bad thing, but we can also imagine that it would have been very adaptive for our bodies to be able to signal to us that there is a potential threat and prepare ourselves for action. These systems are so ingrained within us, that they can often get triggered without us even needing to think. This would have been adaptive, because thinking takes time, and time can sometimes be a matter of survival.

Let us take some time to explore what is happening within our bodies that cause us to be anxious. Basically, the body's nervous system consists of several parts, including something called the "Autonomic Nervous System," which serves to control and regulate our level of physiological arousal. You can also think of it as the "Automatic" nervous system, because it coordinates a lot of bodily actions "automatically," without us needing to think about it. This system is then divided further into two complementary systems: the "Sympathetic" and "Parasympathetic" systems. When the "Sympathetic Nervous System" is activated, it triggers a cascade of internal events that essentially increase our physiological arousal and energy expenditure. In comparison, when the "Parasympathetic Nervous System" is activated, it triggers the complementary responses of decreasing our physiological arousal and promotes energy conservation. In a nutshell, an unbalance of these two systems, involving excessive Sympathetic arousal, is the cause of our physical symptoms related to anxiety. Have a look at the divisions below to see how these different systems compare:

It is important to keep in mind that these systems do not get switched "on" or "off," but rather work in harmony with one other, like the swinging of a pendulum, or a teeter-totter that is often balanced near the middle, but sometimes swings toward one side or another. If the balance swings too far toward Sympathetic activation, we experience symptoms of anxiety. Remember that this would be adaptive in many situations and probably contributed to our species surviving as long as it has. For example, imagine that you find yourself on a hiking trip and suddenly encounter a wolf. Without even needing to think, your sympathetic system will kick into action:
 

1. Your pupils dilate (get big) so that your body can take in more information about the threat.
2. Blood vessels constrict and your heart rate accelerates to pump blood to fuel your core muscles (i.e. your torso and quadriceps), giving them energy to move. Blood that is not needed in the extremities (i.e. hands, feet, & head) is also directed toward the core of the body, which is why some people will experience a "tingling" or "pins & needles" sensation in their limbs.
3. Breathing becomes laboured and heavy to provide oxygen to these same core muscles.
4. Adrenalin is secreted to amplify the sympathetic response and boost the supply of oxygen and glucose to the brain and bodily muscles.
5. Non-emergency functions within the body (i.e. digestion) are suppressed so that this energy can be directed toward managing the threat at hand.

These coordinated actions prepare us to either challenge the threat or to run away from it. As a result, sympathetic activation is sometimes referred to as the "fight or flight" response, while the parasympathetic system is sometimes referred to as the "rest and digest" response.

Types of Anxiety

Most people would agree that accidentally stumbling upon a wolf in the woods (as in the above example) would cause most of us to experience anxiety. If you have read this far, we can see how our body's natural response to this event would be adaptive. It gives us a sudden burst of energy that we can use to fight off the wolf (if it looks hungry) or to run or climb up a sturdy tree. Even the fact that our body reacts without thinking would be extremely adaptive because it saves us valuable time. Most of the time, we know what we are anxious about. We can scan the environment, or even our thoughts, to determine the source. Yes, as most of us know, even our thoughts can cause us to be anxious. This is worth taking some time to explore.

Humans did not always have the ability to think in the complex ways that we often take for granted. While our sympathetic nervous systems developed early in our evolutionary history, the ability to think abstractly using complex symbols and ideas and think in terms of time and space evolved much later. With these new developments, the "fight or flight" system became much more sophisticated, though it also presented new problems for us humans. Not only do we experience anxiety when facing a physical danger or threat, but with these new abilities, we can become worried or anxious about things that have happened in the past, are yet to happen in our future, or may never happen at all. While we know we are just thinking or imagining a potential threat, the rest of our body and our sympathetic system cannot tell the difference between what is real versus imagined. Our bodies often act "as if" the threat in our mind is actually present in the here-and-now. Our thoughts therefore have a huge part to play in managing our anxiety response or this sympathetic nervous system reflex.

This leads us to one of the major ways that anxiety can be treated. If our "worry thoughts" can trigger an anxiety response, then we want to make sure that such thoughts are realistic, adaptive, and make sense given a person's individual situation. Sometimes however, our thoughts can become slightly distorted in logic, excessively rigid, over or under emphasized, and so on. It is extremely hard for us to notice when this begins to happen, because our thoughts are our own; we treat them as facts or absolute truths and seldom take time to question them. Another problem arises when we discover how hard it is to even identify what our thoughts are; especially when we are anxious! These thoughts might be so quick and fleeting that it can be difficult to put them to paper. Therefore part of doing therapy with anxious clients can be to help them identify thoughts that could be triggering or worsening an anxiety response. Once these thoughts are identified, the clinician can collaboratively help the client challenge these thoughts to see if they are worth believing or whether they can be "replaced" with thoughts that are more realistic or adaptive.

The Body Remembers

So far we have covered normal sympathetic activation in response to an actual threat or danger and how our thoughts can sometimes trigger or worsen this anxiety response. Even more mysterious is when we feel anxious and cannot identify a cause. There are several ways in which this can occur. One thing to understand is that our bodies can "learn" or "remember" without us being consciously aware. Take riding a bicycle, for example. When you begin to learn how to ride a bike, it takes a lot of cognitive effort to do so. You have to think about balance, body position, how to move your feet, and so on. However, once we learn how to do it, our bodies just "remember," often to the point where we do not even have to think about it. This particular example describes "muscle memory."

The sympathetic or anxiety response works in a similar way. For example, if someone was attacked by a vicious dog at three years of age, there is a good chance that even as an adult, they could be weary or anxious around dogs, even though the individual might not have a conscious recollection of the initial attack. The body remembers what it should sense as a threat and it will automatically trigger our bodies into "fight or flight" action based on our past experiences. Our bodies naturally want to avoid pain and discomfort and will act to move us away from these potential threats. As many of us know, anxiety itself can be quite uncomfortable and we tend to avoid things that trigger it. A problem then arises if the anxiety we experience causes us to avoid the thing that causes it. Our bodies never learn that there might not be anything to fear after all. If a person avoids dogs because approaching them causes anxiety, their bodies never "learn" that there is nothing to fear. One of the most powerful ways to undo this kind of physiological learning is to essentially approach the threatening [object, thought, feeling] and "ride out" the anxiety until your body is able to "unlearn" what has been learned. In therapy, this might mean helping a client manage or cope with the anxiety and by taking small steps toward approaching the [object, thought, feeling] until the anxiety eventually dissipates.

Readers might have recognized that in the preceding paragraphs, I am alluding to ways in which our bodies can "remember," without us even being aware of it. It all happens unconsciously. It makes sense then, that we can be anxious about something and not even know the cause. Again, our bodies remember, even if we do not. I also suggested that we might even experience anxiety in response to a threatening thought or feeling. For example, a child who grew up in an abusive home might have "learned" to avoid negative feelings of hurt and sadness because these feelings might have led to further physical or emotional hurt by their primary caregiver. If situations arise later in life where the person might otherwise experience hurt or sadness, the individual instead experiences anxiety. Here is why: the anxiety signals a threat, and in this case, the body has learned that it is threatening to experience or express hurt and sadness. It is important to keep in mind that the individual is only aware of the anxiety; not the reason for the anxiety or the thoughts or emotions that might be underneath it. If the cause of anxiety is not evident, it is the task of the both the client and therapist to explore potential causes. For this reason, I will often ask my therapy clients about their family upbringing and attachment history, traumatic events, and the quality of their interpersonal relationships (both past and present).

Treating Anxiety

As we have seen, anxiety can originate from numerous sources and its cause can operate at multiple levels of awareness. I believe a good psychologist needs to have a sophisticated theoretical background in order to understand the different ways that anxiety can present itself. If a clinician is then flexible in their approach, this knowledge provides an intuitive sense that can guide an intervention to best suit the individual patient or client. A good therapy for the treatment of anxiety needs to provide more than "symptom management" skills. It should be more than just positive thinking, breathing techniques, or other "band aid" solutions. As a Psychologist, my goal in working with anxious clients is to first help them identify the true cause(s) of their symptoms and to then support them in slowly confronting the [object, thought, feeling] that triggers the subjective experience of anxiety until the anxiety dissipates. In my experience, once a client is able to do some of this difficult work, they find themselves no longer a slave to their anxiety, but now open, flexible, and adaptive in how they experience themselves and the world.

PDF Handouts

Recommended Reading

There are a lot of "solution-focused" or "cognitively-based" approaches out there for dealing with the symptoms of anxiety - some are modes of therapy, while others can even be packaged into a self-help book, such as the ones mentioned below. While these approaches are often helpful in improving anxiety symptoms, I tend not to recommend them before exploring the root cause of the anxiety, which may operate, at least in part, on some level just outside of our awareness. While a purely cognitive approach may help in the short-term, in the long-run I believe it can often do more harm than good, since it may allow the person to intellectualize about their issue, which distances them further still from what may be the underlying cause. After a person has some depth of insight about the origins, causes, or triggers for their anxiety, I can safely recommend the following books to assist in managing the symptoms.

The Anxiety and Phobia Workbook, 5th Ed. 
(2011; Author: E. Bourne)

The Shyness and Social Anxiety Workbook: proven, step-by-step techniques for overcoming your fear, 2nd Ed. 
(2008; Authors: M. Antony, R. Swinson)

What to do When you Worry Too Much: A kids guide to overcoming anxiety. 
(2005; Author: Huebner)