A complete guide to understanding what anxiety is, how it works, and what to do about it.

Anxiety is a huge topic, often as confusing to understand as it is distressing to experience. The goal of this guide is to present a framework for thinking about what anxiety is and how it works. Specifically, I’ll show how anxiety is unique as a concept, explain why it’s useful to discriminate it from related concepts like fear and stress, and give a brief overview of the clinical categories of and treatments for anxiety. Then, with a basic understanding of the nature of anxiety, we’ll discuss the mechanics of how it works, including the factors that sustain it and make it worse as well as the only strategy you need for unlearning anxiety in any form.

Overview

Click on the links to jump straight to a specific part or section of the article.

  1. What is Anxiety?
  2. How Anxiety Works
  3. Conclusion & Further Reading

Key Ideas and Takeaways

A Summary of the most important points and ideas from the article.

  1. Anxiety is an emotion, related to fear but distinct in that it is typically future-oriented, prolonged, and essentially irrational in nature. It is also distinct from cognitive activities like worry or rumination as well as physical sensations like chest tightness or lightheadedness.
  2. Anxiety reaches clinical levels and become a disorder when it persists for an extended length of time and in some way significantly impairs our functioning. Common anxiety disorders include Generalized Anxiety Disorder, Panic Disorder, Simple Phobias, Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder, Social Anxiety, and Separation Anxiety.
  3. The most common treatments for anxiety include Cognitive Behavioral interventions such as Exposure Therapy or Cognitive Restructuring, Mindfulness-based interventions, relaxation interventions like Progressive Muscle Relaxation and Diaphragmatic Breathing, or various psychotropic medications including some anti-depressants (e.g. Prozac, Paxil), anxiolytics (e.g. Xanax, Klonopin), and beta-blockers like Propranolol.
  4. The amygdala is the brain’s threat detection system and is responsible for keeping you safe from physical danger. Through avoidance habits, it can be trained to flag non-threats as genuine threats, leading to hypersensitivity and the experience of anxiety through the process of Fear Learning. Re-training the amygdala to reduce anxiety involves approaching feared stimuli or situations without responding as if they were threats, a process called Safety Learning.
  5. Regardless of the initial cause, all anxiety is sustained or exacerbated by some form of behavioral or cognitive avoidance; thus, eliminating these habits of avoidance is the key to eliminating anxiety in any of its forms.
The 10 Best Books for Genuine Self Improvement Icon Nick Wignall

The 10 Best Books for Genuine
Self-Improvement

Get this 31-page PDF for free when you join my weekly email newsletter.

Get the Free PDF →

Part I: What is Anxiety?

What’s the difference between anxiety and fear? What about anxiety and worry? How does stress or the feeling of being “stressed-out” fit in? What about Nervousness? Angst? Panic? Terror? Dread?

One of the biggest obstacles to working through anxiety is to simply understand what we mean when we use the term. If we’re not clear on what it is, it makes it awfully hard to figure out where it’s coming from and what to do about it. So let’s begin by defining our terms and clarifying what we mean exactly by anxiety compared to other related concepts.

Defining Anxiety Using the 3 Levels of Experience

When it comes to talking about anything psychological in nature—anxiety, included—it’s helpful to distinguish between three basic levels of our experience: physical, cognitive, and emotional.

Events vs Actions

Note that both physical and cognitive experiences can happen to us—our tummy churns and grumbles, the thought pops into our head that we need to pick up bananas on the way home from work. These are events. But we can also initiate both physical and cognitive experiences directly—waving to a friend, working through the problem 14×8 in your head. These are actions.

Emotional experiences, on the other hand, are strictly events that happen to us—we feel grief after learning that a loved one has passed away or guilt after a transgression. They are not actions we can initiate directly. We can’t simply turn up our happiness dials or switch off our anger.

This distinction between events and actions is important because we get ourselves into all sorts of trouble psychologically when we mistakenly assume that emotions are things we can do or have direct control over. A key tenant of most theories of mental health (and basic neuroscience) is that we can only change our emotions indirectly by means of how we choose to think and what we do or the environments we expose ourselves to.

Now that we have our three basic levels of experience—physical, cognitive, and emotional—and their status as either events or actions, let’s see if we can place anxiety and some related terms within this framework.

Anxiety and Related Concepts

What follows is a list of the most common anxiety-related terms and my take on how they are distinct. There’s no official party line that defines these terms, so they’re certainly open to interpretation. But for the purposes of this article, I want to define them up front so I at least can be consistent.

Stressors, Stress, and “Stressed”

A stressor is anything in our environment that’s perceived to be threatening or challenging (e.g. a tiger chasing you or an upcoming exam).

Stress is your body’s physiological reaction to a stressor. It’s characterized primarily by the release of adrenaline and activation of the fight or flight response. The most common sensations associated with a fight or flight response are rapid breathing, increased heart rate and blood pressure, muscle tension (especially chest tightness), stomach tightness/butterflies/nausea, dizzy sensation, perspiration, lightheadedness, and numbness or tingling in extremities like toes or hands or sometimes face. These sensations are all manifestations of your brain trying to prepare you to effectively manage a threat by either running away or fighting (more on this below).

Stressed or Stressed-out are the casual terms we use to describe how we feel physically when we are in a chronic or long-term state of elevated stress. Note that all of these occur on the physical level, even though we sometimes (mistakenly) use the terms stress or stressed-out to describe how we feel emotionally.

Fear

Fear is an emotion that usually arises as a response to a perceived threat or danger. We see a dark, curvy shape on the hiking trail in front of us and we feel fear because we consider the possibility that it might be dangerous snake. But as we get closer, we realize it’s merely a fallen tree branch, our fear subsides, and we keep on hiking. Fear tends to be present-oriented, temporary in duration, and based on a reasonable evaluation of danger.

Anxiety

Similar to fear, anxiety is an emotion that comes about in response to the perception of a threat or danger. But while fear is typically a response to realistic threat in the present that quickly subsides, anxiety is usually a response to an unrealistic threat—often one that is imagined or could hypothetically happen in the future no matter how unlikely—and it tends to persist in frequency and intensity. For example, after watching a National Geographic documentary about the most venomous snakes on the planet, we begin to decline invitations to go hiking, imagining that we could encounter and get attacked by a lethal snake. Soon, we avoid remote areas of the park, golf courses, lakes, even zoos. We find ourselves spending a lot of time planning our days so as to avoid even the possibility of running into a snake.

Panic

Panic is a sudden burst of intense anxiety that peaks within a few minutes and often subsides after 10-20 minutes. Panic is typically triggered by a catastrophic interpretation of symptoms associated with the fight or flight response (E.g.:“I’m going to have a heart attack and die because my heart’s beating too fast”). In people who have repeated episodes of sustained panic (i.e. a panic attacks), panic is often triggered by worry about having a panic attack. In a sense, panic is anxiety about anxiety.

Terror, Dread, Angst, Nervousness, etc.

These are all emotional variations on fear or anxiety. Dread, for instance, is similar to anxiety but is often more vague and pervasive, more intense, though perhaps not as acute, and slightly more existential in nature.

Quick experiment: Set your phone timer for 60 seconds and see how many variants of anxiety you can list (e.g. fear, terror, nervous, etc.). I had a client come up with 18 once, which I thought was pretty impressive.

Worry

Even though we casually use the term worried to describe how we feel emotionally, worry is best thought of on the cognitive level and is a form of problem-solving that tends to be repetitive, fast, negative, and self-evaluative, but is generally unproductive or unhelpful. Worry is almost always the primary factor that sustains anxiety and stress or causes it to recur frequently. It is similar to but distinct from problem-solving or planning.

Hopefully this brief discussion has helped clarify how anxiety is related to but distinct from many similar concepts. Two important takeaways from this discussion are:

  1. It’s important to be as specific as possible about how we feel. I think a good framework for doing this is to figure out, for any given experience, is to ask: A) Is it primarily physical, cognitive, or emotional in nature? and B) Is it something I’m doing (action) or something that’s happening to me (event)?
  2. I said before that emotions are harder to define because they are mixtures of the physical and cognitive levels. Specifically, emotions are the result of a specific interpretation of something that happens to us or is perceived by us. The essential word here is interpretation. You literally can’t have an emotion without taking some kind of cognitive action first. This is good news because even though we can’t change our emotions, we can change how we tend to think and interpret ourselves and the world, even if these cognitive tendencies are longstanding habits. This idea, by the way, is the basis for both cognitive therapy and it’s philosophical predecessor, stoicism.

But before we get into strategies for changing how we think and working through our anxiety, let’s briefly run through what anxiety looks like when it reaches a clinical level and becomes a disorder.

Common Anxiety Disorders

Anxiety reaches a clinical level and become a disorder when it persists for an extended length of time and significantly impairs our functioning. In other words, anxiety is a disorder when it becomes a habit and impacts your life in a serious way. Note, though, that anxiety should not be diagnosed if it is better accounted for by another mental or physical health issue or the effects of some kind of drug, medication, or other substance. In other words, before you can diagnose an anxiety disorder, you have to rule out hyperthyroidism, cocaine abuse, ADHD, etc.

Below are some of the most common anxiety-related diagnoses/disorders, along with a brief description.

Generalized Anxiety

Persistent anxiety marked by excessive worry about a variety of topics (E.g.: failing a test, not being able to sleep, what happens when you die, etc.). People with generalized anxiety are often described colloquially as “the worried well.” Although it’s counterintuitive at first blush, people with generalized anxiety actually use the mental act of worrying as a way to temporarily distract themselves from the emotions associated with whatever it is they’re worried about. Unfortunately, in the long run this habit of worry leads to persistently elevated levels of anxiety and stress (more on this below).

Panic Disorder

A panic attack is technically defined as a sudden surge of intense fear or anxiety that peaks within minutes and is typically characterized by symptoms of a fight or flight response such as sweating, rapid heart rate, chest tightness, feeling lightheaded, etc. A person has panic disorder when they experience repeated panic attacks with persistent anxiety about having future panic attacks or their consequences (e.g. going crazy, dying).

Specific Phobia

Anxiety related to a specific situation or object such as flying, snakes, confined spaces, etc. True specific phobias are relatively rare. Much more common is panic disorder that looks like a specific phobia. In other words, people are irrationally afraid that a specific thing or situation will lead to panic, not that the specific thing or situation itself is dangerous.

Social Anxiety

Social anxiety1 is anxiety in social situations, typically when a person is exposed to the real or imagined scrutiny or judgment of others. Often social anxiety manifests as excessive worry and concern about how others are perceiving or evaluating you.

Obsessive-Compulsive Disorder (OCD)

OCD is defined as the continued presence of obsessions, compulsions, or both. Obsessions are recurrent and intrusive thoughts, images, or urges that cause significant anxiety or distress (E.g.: imaging your house exploding because you forgot to turn off the stove) which the person attempts to suppress or ignore. Compulsions are repetitive behaviors or rituals that an individual performs in order to alleviate the anxiety associated with an obsession (E.g.: washing your hands seven times before drying them, counting the number of steps in every building you enter, etc.). The key idea with OCD is that people treat intrusive mental activity (an event) as something dangerous or bad because they assume that either they are responsible for it or that it means something (i.e. they treat it as thought it is an action).

Post-Traumatic Stress Disorder (PTSD)

PTSD occurs when a person is exposed to an actual or threatened trauma (e.g. rape, murder, etc.) and it results in the persistent experiencing of:

One way to think about PTSD is that it’s like a phobia of memory. People become afraid of something in their environment triggering a memory of a traumatic event and the negative thoughts, feelings, and sensations that may go along with it. As a result, they become preoccupied with avoiding any kind of cue or trigger for their trauma. This avoidance can easily lead to isolation, depression, and substance abuse, not to mention higher levels of anxiety.

Separation Anxiety

Separation anxiety is age-inappropriate distress regarding separation from an attachment figure, typically a parent. It’s generally seen in childhood (e.g. school refusal behaviors), but can also occur in adults (e.g. anxiety when a spouse leaves town for business).

Common Treatments for Anxiety

While they can be extremely distressing and problematic, anxiety disorders are actually among the most treatable mental health conditions. And because the psychological processes that govern the acquisition and extinction of behaviors is fairly well understood, treatment can often be rapid when delivered by a competent provider.2

Exposure Therapy

Considered the gold standard treatment for most forms of anxiety, exposure therapy involves deliberately exposing oneself (usually in a progressively difficult or graded fashion with the help of a therapist) to an irrationally feared stimuli (e.g. airplanes, contamination, panic attacks, public speaking, etc.) in order to experientially learn through repeated trials that the feared outcome will not in fact take place.

Most effective forms of exposure therapy also involve response prevention, which means that in addition to deliberately seeking out the feared situation or object, you also prevent yourself from engaging in any activity that would lessen your anxiety, such as reassurance-seeking, distraction, checking, etc. Exposure therapy generally is divided into three types: Imaginal, In-Vivo, and Interoceptive.

The Atlantic has a good article on exposure therapy called When Pain is the Best Therapy.

Cognitive Restructuring

A core technique in cognitive behavioral therapy, cognitive restructuring is the process of noticing and becoming aware of chronic irrational beliefs or self-talk that lead to unhelpful emotional states or behaviors. Then learning to challenge those thoughts and beliefs while subsequently generating more realistic alternatives. While initially developed for the treatment of depression, it can be equally useful with anxiety. Lifehacker has a surprisingly good quick overview of the technique. The classic self-help book on the topic is David Burns’ Feeling Good.

Mindfulness

Mindfulness is cognitive technique that emphasizes better control over one’s attention, specifically the ability to shift the mind from an analytical and problem-solving mindset oriented toward the future or past into a more observational mindset oriented toward the present moment, typically some aspect of the body like the breath. Mindfulness-based techniques such as mindfulness meditation are often used as a part of cognitive behavioral or acceptance and commitment therapy. For a good overview and useful guide to implementing the technique for anxiety specifically, see The Mindfulness and Acceptance Workbook for Anxiety.

Relaxation Training

Medication

Most professional mental health organizations consider medication for anxiety as a second line treatment. This means that the above treatments should probably be tried first, especially since cognitive and behavioral approaches are generally shown to be more effective than medication for anxiety disorders and also to have fewer side effects and certainly no withdrawal effects. What’s more, while medications may mask the symptoms of anxiety, they never correct the underlying cause.

Below are some of the most common types of medication prescribed for anxiety, starting with the most powerful (and potentially dangerous):

Part 2: How Anxiety Works

We’ve talked about what anxiety is (and isn’t), how it’s conceptualized clinically, and what the most common treatments for it are, but why do we have anxiety at all? Why do we get irrationally afraid of things and stay afraid? In other words, how does anxiety work, exactly? And how can we use that knowledge to our advantage?

I’m going to let the cat out of the bag right off the bat and suggest that the single most important concept when it comes to anxiety is avoidance. More specifically, the reason clinical levels of anxiety persist is because we try to avoid our anxiety in the first place. I get that that statement sounds counter-intuitive at best and maybe just nonsensical (Of course we should avoid it—it feels awful!) so let me break it down a bit.

At their core, all anxiety disorders are basically the same. Even though they may look and, to some extent, feel very different, from a mechanical perspective the same dynamics are present. That is, people with anxiety disorders have trained themselves to be afraid of the thoughts, sensations, and emotions associated with anxiety. And they’ve done this quite on accident. In fact, the very thing they do to try and make their anxiety better—avoiding it—is the thing that’s counterintuitively making it worse. To explain how all this works, we need to start with the brain, specifically, a little chunk of neurons in the middle of the brain called the amygdala.3

Your Amygdala and You: A User’s Guide

The amygdala’s main job is to keep us safe from danger—specifically, physical threats to our survival. To do this, it’s A) always on the lookout for potentially threatening things, constantly scanning the environment for suspicious suspects. If it spots something that it thinks might be a threat, it B) sounds the alarm and prepares our bodies to deal with the potential threat. It does this by stimulating the release of adrenaline and activating our fight or flight response. Our breathing gets faster, our heart rate goes up, muscles tense, and blood flows quickly out of our torso and head and into our extremities so that we can more efficiently deliver oxygen4 to our arms and legs to either fight or flee.5

Now, all this is great if you’re being confronted with a genuine physical threat to your survival—a thug pulls a knife on you in a dark alley, or a saber tooth tiger jumps at you. In that case, you’d better hope your little amygdala gives you a lot of adrenaline to get out of there or fight back. Obviously, adrenaline and our fight or flight response can be extremely helpful when confronted with an true threat to our survival.

The problems start when our amygdala gets confused about what types of things are truly threats to our survival—and therefore worthy of a fully blown fight or flight response—and things that maybe look or feel like threats but aren’t actually dangerous or capable of hurting us. To better illustrate things, let’s use our example from earlier about going for a hike out in nature.

How Avoidance Leads to Fear Learning and More Anxiety

Most of us would agree that hiking is not typically a very dangerous activity. And while there’s always the risk of falling of a cliff or getting attacked by a dangerous wild animal, in most scenarios going for a hike is a pretty safe thing.

And yet, many people are too anxious to go hiking. They turn down any invitation to hike, no matter from whom; they only go for walks in well-know paths or areas; they even avoid movies about hiking and traveling through nature. But how can this be? Why doesn’t Aunt Shirley believe me when I tell her that it doesn’t make sense to be afraid of something as innocuous as hiking because it’s perfectly safe!?

The trouble is, it’s not a matter of what they believe; what matters is what their amygdala believes. And to a large extent, our amygdalae tend to believe what we teach them.

People with anxiety disorders have most likely triggered a process called Fear Learning which has taught their amygdala to be overly sensitive to potential dangers and fear things that are not actually threatening. To unpack this, let’s imagine that you’re an average Joe out for a hike in the foothills on a beautiful spring day.

After being out for 20 or 30 minutes, you notice something up ahead of you—a dark, curvy line on the trail. Chances are your amygdala fires up a bit, warning you of a potential threat. (It could be a poisonous snake!) You feel your heart beat a little faster and your muscles tense a bit. Maybe your chest feels a little tight. What you end up doing next is crucial when it comes to anxiety.

In addition to A) scanning the environment for potential threats and B) releasing adrenaline in order to prepare you to fight or flee if it is in fact a threat, your amygdala has an error correction mechanism built in that allows it to learn when it has correctly or incorrectly flagged something as dangerous. This mechanism is to watch how you respond to the potential threat and use your behavior to either confirm or deny its initial threat assessment. Specifically it watches to see whether you try to avoid or approach the potentially dangerous thing.

If you avoid the thing the amygdala singled out as a danger—by either fighting it or running away from it—you are engaging in Fear Learning. In effect, you’re telling your amygdala, “Yes, that thing you thought was dangerous is a genuine threat to my safety and survival. Remember it for next time and shoot me up with lots of adrenaline so I can run away faster.”

If you choose to try to avoid the potential threat—in this case running away from the dark line back down the trail—your anxiety goes down initially because the perceived threat is eliminated. But your amygdala interprets this action as confirmation that it’s initial assessment of the potential threat was accurate and that it is an actual threat—that dark curvy lines on hiking trails are really dangerous! Consequently, your long-term levels of anxiety around hiking actually start to increase now. The next time you go hiking your amygdala will be even more on the lookout for dangerous snakes in the form of dark curvy lines and that much faster to trigger a fight or flight response.

Pretty soon, you’re likely to start going on less adventurous hikes and possibly just avoiding hiking all together because just the thought of a hike triggers so much anxiety. And each time you constrict your range of activities, you’re teaching your amygdala that hiking is an extremely dangerous activity. Before you know it, you’ve got a snake/hiking phobia or panic disorder because you’re afraid that hiking will cause too much anxiety and cause you to have a heart attack in response. Yikes!

To sum up, Fear Learning occurs when, through your behavior, you confirm your amygdala’s initial assessment of threat by trying to avoid or eliminate the potentially dangerous and frightening thing. Of course, often times Fear Learning is a good thing. If a there truly is danger present in a situation, you want your amygdala to remember it. But anxiety develops when the Fear Learning process is applied to things that may look or feel dangerous but in reality are not.

Thankfully the same mechanism the amygdala uses for fear learning can be applied to achieve the opposite, Safety Learning, which is the key to undoing an anxiety you may have developed.

How to Use Safety Learning to Decrease Anxiety

If avoidance behavior (e.g. running away) leads to Fear Learning and then anxiety, approach behavior is what leads to Safety Learning and a lessening of anxiety.

Back to hiking. You initially see a dark curvy line ahead of you on the trail and feel a tad nervous. The though even crosses your mind that you could just turn back or maybe find a different path. But this time you just wait and watch. After 20 seconds you notice that the line hasn’t moved so you take a few steps closer. You feel a bit more afraid, but you’re curious and willing to check things out a little bit further.

You can now see that the line is moving a little, but in a strange way, not at all like a snake would. It looks like it’s swaying. A few more steps and you now realize the dark shadowy line is actually a shadow from an overhanging tree limb. Not only does your fear immediately go down, but you’ve also taught your amygdala a valuable lesson: Sometimes while hiking, what looks like a snake from a distance is often just a shadow. As a result, the next time you’re out hiking, your amygdala will be a little more relaxed and your fight or flight response a little less likely to be triggered—all of which mean you’re more able to have fun and enjoy your hike. This is Safety Learning.

The moral of the story is that while avoiding things that look and feel like threats is often anxiety relieving in the short term, it reinforces unrealistic beliefs in the long term that lead to both unnecessarily high and persistent anxiety as well as an increasingly restricted (and much less fun) life. On the other hand, when we simply pause and observe, we get the chance to learn and get new information. If it turns out that the amygdala was right, then we can fight or flee appropriately. But if we learn that it was incorrect, it gets smarter and we get less anxious—a win-win!

One last point: I’ve argued that avoidance is the key factor in sustained and intense levels of anxiety because it mistakenly teaches the amygdala to respond to non-threats as though they were real threats, leading to ever-increasingly levels of anxiety. I want to point out, however, that behavioral avoidance—running away from a dark curvy line—is not the only way we avoid things. In fact, most of the time our anxiety is actually sustained or exacerbated by cognitive avoidance. And the most common form of cognitive avoidance is worry.

But how is worry avoidance? It almost seems like the opposite—going over and over the scary thing in your mind…

The distinction is that we like to think of worry as problem-solving (gives us the illusion of control and the hope that we can make things better), but really it serves a different purpose—distraction. Worry keeps our mind off the feelings (emotional and physical) of anxiety. It let’s us avoid them by thinking about the (perceived) problem. Unfortunately, by avoiding the feelings of anxiety (the symptoms of fight or flight) we are teaching our amygdala that they are dangerous and threatening to our survival!

This is the anxious person’s dilemma: It’s hard enough to be irrationally afraid of a genuinely harmless situations; but to also be irrationally afraid of our own emotions and feelings makes daily life a constant struggle since our thoughts and feelings are always close at hand. And this irrational fear of our own feelings is maintained and even made worse by the myriad sneaky avoidance strategies we’ve developed over the years—everything from downright isolation and behavioral avoidance to more subtle distraction techniques like worry and “positive self-talk.”

If it seems hard to tell whether something is actually avoidance (and therefore making your anxiety worse in the long run) or approach, just ask yourself this one question: What am I teaching my amygdala?

Conclusion and Further Reading

I’ve tried to give a general overview of anxiety and some of the most common and important ideas related to it. While there’s much more to say on a lot of these topics, I hope this has will be useful as a starting point if anxiety is something that you or someone you love struggles with.

If you want to learn more about anxiety and some of the ideas discussed above, the following are some of my favorite resources:

If you feel like anxiety is a serious problem, talk to your doctor or mental health professional about it and get some help6.

Notes

  1. The technical term is Social Phobia. ↩︎
  2. The following is a good relatively recent paper summarizing the efficacy of CBT for anxiety: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584580/ ↩︎
  3. Technically we all have 2 amygdalae, one on each side of the brain. But for convenience, I’ll refer to it as The Amygdala. ↩︎
  4. We need oxygen to turn glucose into fuel for our muscles. ↩︎
  5. You don’t, by the way, lose all the blood and oxygen in your torso and head during fight or flight—the proportions just get rebalanced in favor of your extremities. ↩︎
  6. Not sure how to find a good therapist or mental health professional? You’re in luck. I wrote a book about how to do just that. ↩︎

#

Leave a Reply

Share
Tweet
Pin
Share