Jenny Arthur was living at a pretty hectic pace. Working two jobs while pursuing a graduate degree had her stressed and rushing more often than not. Surprisingly, though, it was a calming weekend away that sent her into a tailspin. Arthur, then 30, had gone to Madison, Wis., to go to a friend, and the two spent the weekend visiting the farmers’ market, taking in films, wandering round the city, talking and drinking coffee — plenty of it.
On the drive toward home, where all of her projects were waiting, Arthur began to feel strange. “My range of vision started getting narrower and narrower. Me was racing, and I felt like I couldn’t breathe,” she recalls. “I had no clue what was happening to me.” She pulled off the freeway and called a friend who drove out and brought her to the nearest urgent-care clinic. “The doctor explained, ‘You’ll be fine. You’ve just were built with a panic attack.’”
Arthur, now 42 and an event planner in Minneapolis, is one of 40 million Americans who have been derailed by what psychiatrists call “anxiety disorders.” It’s a broad medical diagnosis that includes several distinct categories:
Obsessive-compulsive disorder, which consists of intrusive thoughts (obsessions) combined with repetitive behaviors (compulsions), for example excessive hand washing, that the sufferer performs to avoid the obsessive thoughts.
Panic disorder describes recurring episodes of intense physical fear, without an obvious or immediate supply of fear. These episodes, also called anxiety attacks, are commonly characterized by a pounding heart and may be accompanied by chest pains. It might also be difficult to breathe, and you'll feel like you are choking (symptoms which will make the situation even more frightening and further ratchet up anxiety).
Posttraumatic stress disorder (PTSD) follows a severe traumatic event that threatens actual harm.
Social anxiety disorder describes the condition of people who suffer overwhelming anxiety when faced with everyday social interactions.
Generalized anxiety disorder is a catchall category that describes any chronic anxiety or exaggerated worry that lacks an obvious cause.
While these diagnoses, symptoms and distinctions sound clear-cut in writing, in practice they are anything but. In part, this is because separating the typical from the pathological isn’t always easy. The human brain, it seems, is hardwired to worry even underneath the best of conditions.
“Because we humans have prefrontal lobes, we are able to anticipate the future and make up a scenario that's harmful to us,” says Melissa Blacker, MA, a psychotherapist and associate director from the Stress Reduction Clinic at the University of Massachusetts Medical School’s Center for Mindfulness.
Some degree of anxiety and fear are common responses to life. “Healthy anxiety is part of our fight-or-flight response system,” says Jonathan Abramowitz, PhD, director of the Anxiety and Stress Disorder Clinic in the University of North Carolina, Chapel Hill. “Like a basic emotion, it is helpful. In fact, we would all be dead without it, because it protects us from harm.”
So where does a proper emotional response to stress leave off as well as an anxiety disorder begin? “Anxiety is a response to the perception of threat,” Abramowitz explains. “When we’re referring to a real danger, that’s healthy anxiety and stress, but when the perception of threat is dependant on either a misinterpretation of the severity of the threat or the likelihood of harm, then we’re talking about a disorder.”
It can be hard, though, to objectively differentiate between a real threat and misinterpretation. A hostile coworker, for instance, or a rash of burglaries locally, may or may not constitute a genuine threat.
To further complicate the image, the science guiding the treatment of anxiety disorders has been anything but clear-cut, opening the door for pharmaceutical companies to inspire consumers to self-diagnose and to seek out advertised items that may or may not be particularly good at treating the disorders in question.
What’s clear is that the most promising approaches to managing anxiety — from its more acute manifestations to a chronic, low-level presence — involve clarifying both how it's triggered and how the body’s natural stress-coping mechanisms could be harnessed to bring it under control.
The Myth of the Magic Cure
In nov 2007, thousands of people requested more details about a condition known as “Dysphoric Social Attention Consumption Deficit Anxiety Disorder” and Havidol, a drug that promised to combat the disorder.
It turned out that both the disease and also the drug (pronounced “Have-It-All”) were the invention of Australian artist Justine Cooper, who launched the elaborate parody campaign to draw attention to drug companies who have been aggressively marketing their products straight to consumers. Not only did the satire fool the public, but the fake condition was briefly incorporated into medical Web sites as a new condition and treatment.
The Havidol hoax illustrates the complex and controversial reality of modern treatments for mental illnesses — especially those like depression and anxiety, which feature symptoms that overlap with normal human emotions.
Mental disorders are classified and described in the Diagnostic and Statistical Manual of Mental Disorders (DSM), a book written by a committee of doctors to codify psychiatric conditions. Psychiatrists make use of the DSM to diagnose patients and prescribe medication; insurance companies typically require a DSM diagnosis before they approve payment for services.
The DSM, however, is a flawed document, says Christopher Lane, author of Shyness: How Normal Behavior Was a Sickness. In researching it, Lane conducted an exhaustive study of correspondence and interviews with doctors involved in compiling the 1980 DSM-III. “What I found was, frankly, very disturbing,” he says. “Some of the definitions lack a rigorous scientific rationale. Instead, the thing is capricious decision-making among close friends and colleagues who shared the same approach, while other approaches were left out. Some of the criteria are astonishing when it comes to their carelessness and the lack of empirical justification from field studies.”
This carelessness, says Lane, opened the doorway to drug manufacturers to exploit the DSM categories in marketing many. The United States and New Zealand are the only two countries in which direct-to-consumer advertising of drugs is legal, and pharmaceutical corporations spend millions to press their competitive advantage.
“GlaxoSmithKline spent almost $100 million promoting social anxiety disorder in what they called a public awareness campaign just two or three months once they got FDA approval for Paxil — then, the only pharmaceutical treatment available,” Lane explains. “Meanwhile, the psychiatric community went straight for medication and largely overlooked other kinds of viable treatment.”
While medication can offer immediate relief from anxiety (although in the risk of side effects), long-term pharmaceutical treatment rests on the controversial 1950s-era theory that mental illness is the result of a “chemical imbalance” that can be corrected with medications. Once the brain functions normally, it sends so what can be thought of as a chemical code from one cell to the next using substances called neurotransmitters. When a person is depressed or anxious, amounts of some of these neurotransmitters drop; thus, the notion that correcting the chemical balance corrects the problem.
Although the metaphor of an imbalanced brain persists, now that we know that it’s a biological oversimplification. Neurotransmitters like serotonin and dopamine might be present in higher or 'abnormal' amounts during various emotional states — but that doesn’t suggest they are the primary cause of those states. Actually, they can just as easily be seen as the result or biochemical product of emotional experiences.
Moreover, depression and anxiety are common, predictable responses to certain life events, so any alternation in brain chemistry during these states can’t accurately or continually be described as an “imbalance.” Neurotransmitters often play not only one role in the brain and may act broadly to influence a variety of body functions (serotonin, for example, has been shown to play a role in both mood and appetite), so interfering with their transmission can affect not only mood — sometimes in unpredictable ways.
Drug interactions with brain chemistry are similarly broad: Any drug, whether cocaine or Prozac, affects our mental state by broadly repressing or enhancing our ability to manufacture, release or transfer certain neurotransmitters. Which would be to say that increasing or suppressing the transmission of the selected neurotransmitter increases or suppresses all of the roles that neurotransmitter plays in the brain, not just its one role in, say, anxiety. (For any look at how nutrition affects neurotransmitters and moods, see “Comfort Food for the Brain.”)
But perhaps the most damaging part of the chemical imbalance theory is that it treats the brain in isolation in the rest of the body. In fact, they’re one highly integrated system.
Research indicates that our mental and emotional states really are a complicated mix of brain chemistry and biology, in addition to genetic, environmental and physical factors. Instead of thinking of the brain as some kind of isolated chemical lab that sends directions to the body, scientists now understand our bodily experiences and our environments directly affect the functioning of the brain. Increasingly, doctors are recognizing this connection being an essential element in effectively treating disorders like anxiety.
Mind-Body Connections
The biological processes triggered by anxiety — sweaty hands, shallow breathing, increased heart rate, dizziness — are hardwired human responses to stressful situations. Many of these responses serve some biological purpose, for example preparing our bodies to react (fight or flee), or they are the byproduct of the chemicals, for example cortisol and adrenaline, that such a reaction might require. It’s whenever we perceive a major threat in situations where, objectively speaking, there is little or none — for example, in a crowded elevator (claustrophobia), crossing a bridge (anxiety about heights), leaving the house (agoraphobia) or in an office mixer (social anxiety) — that anxiety is classed as a disorder.
The more frequently or dramatically an unwarranted response occurs, and the more it interferes with a person’s daily life, the more severe that classification is likely to be.
Although pharmaceutical drugs can help moderate our bodies’ physical response to stressful thoughts or stimuli, nonpharmaceutical treatments — like cognitive behavioral therapy (CBT) — are beginning to replace drugs as the preferred strategy to anxiety disorders.
Unlike medications that make an effort to suppress our physiological responses to perceived threats, CBT is aimed at correcting our perception of those threats, and thus encouraging a self-moderating response.
The first goal of CBT is simply education, says Abramowitz. “We teach people regarding their symptoms,” he explains. “We explain that when you feel nauseated, it’s not because you’re going to throw up; when your heart races, it’s not because you’re going into cardiac arrest.” For many, just recognizing the symptoms of anxiety for what they are — and realizing that they do not represent an immediate danger — can prevent an attack from worsening.
The second phase of CBT focuses on exposure and response protection. Some CBT therapists actually put the sufferer in the situation that causes him or her fear — whether that situation is external, like playing with a large dog, or internal, like experiencing an accelerated heartbeat. “When a person repeatedly confronts their fears, they learn that the outcomes they worry about aren’t as likely as they think,” Abramowitz explains.
Moreover, they discover the initial fight-or-flight response is transitory; anxiety eases when you’re in a position to stay in a situation and your fears aren’t realized.
It can take 10 to 15 sessions of CBT to produce lasting results, says Abramowitz, and the success rate is fairly high — as many as 70 percent of patients conquer their anxieties. (To locate a cognitive-behavioral therapist near you, visit the National Association of Cognitive-Behavioral Therapists at http://nacbt.org/.)
Anxiety as a Physical Condition
The physical aspects of anxiety — our fight-or-flight response — are controlled by the sympathetic nervous system. CBT functions by essentially reprogramming our involuntary activation of this system. But other treatment approaches focus on the body’s parasympathetic nervous system, which regulates the healing, recharging part of the nervous system and helps shut off the fight-or-flight response.
Patricia Gerbarg, PhD, MD, a clinical psychiatrist at the New York Medical College and coauthor of methods to Use Herbs, Nutrients, and Yoga in Mental Health Care, is studying how to activate the parasympathetic central nervous system to quiet anxiety. She and her colleagues have found that some ancient practices are highly effective.
In particular, yoga breathing induces a really calm, clear-minded state — the opposite from the anxious fight-or-flight state of the sympathetic nervous system. “When you change the pattern of breathing,” explains Gerbarg, “it changes what happens in your emotion centers and thinking centers,” slowing the fight-or-flight actions of the amygdala and quieting the areas from the cortex that process worry.
Gerbarg and her colleagues happen to be able to quantify the effects of breathing techniques around the parasympathetic nervous system, and they are using what they’ve learned to coach patients to interrupt anxiety with breathing. “We have seen some very rapid effects,” she says. “In five minutes, people may go from severe anxiety to accomplish relaxation.”
Gerbarg still prescribes medications at the appropriate interval to help relieve acute, debilitating symptoms and provide alternative interventions a chance — but her long-term goal would be to build the strength of the parasympathetic system, instead of to suppress the sympathetic.
Psychotherapist Kathryn Templeton, who spent Two decades working with soldiers suffering from PTSD in the National Center for Posttraumatic Stress Disorder at the U.S. Department of Veterans Affairs and today works with abused children, uses breathing and yoga extensively in her own treatments. She has her patients start by inhaling slowly for three counts and exhaling for six counts, an exercise that cultivates awareness of their breathing patterns. “Breathing creates resiliency and releases tension,” she explains. It's physically impossible to breathe deeply and feel anxious simultaneously.
The power of breath to reduce the signs of anxiety helps illustrate how anxiety resides in both brain and body. Because anxiety is as much a physical condition as a mental one, a variety of physical activities can offer relief. Exercise particularly, writes Edward Hallowell in Worry: Hope and Help for a Common Condition, “is a terrific antidote for worry.”
Exercise quiets the anxiety response, not by changing the situation that is causing anxiety, he explains, but by changing “the vessel of the worry, the physical state of the body and brain.” He notes that exercise creates a variety of chemicals, such as endorphins, corticosteroids and neurotrophins, as well as various neurotransmitters like serotonin that will help soothe the worried mind.
If you begin to feel anxiety welling up and you have even just a few free minutes, a few treks up and down the stairs or perhaps a brisk walk around the block can work wonders, says Hallowell. You won’t always have the opportunity to break into a sprint when you feel your anxiety spiking, but, he continues, “A regular exercise program — exercise three or four times per week — will almost always cut down on worry. Exercise ought to be incorporated into any plan to reduce anxiety and control worry.”
Finally, no method of anxiety management can be optimally successful unless it is supported by proper nutrition. Our brains require certain fats, proteins and nutrients to manage mood and function normally — and no amount of yogic breathing or CBT can compensate for a mineral or omega-3-fat deficiency. (To learn more about what to eat to reduce anxiety and stabilize mood, see “Comfort Food for the Brain.”) It is also important to limit your intake of stimulants such as caffeine, which prime your body and brain for heightened anxiety.
Mix Your Own Cure
After her first panic attack around the freeway in Wisconsin, Jenny Arthur went on to experience several more. Next, she says, “I started recognizing this vicious-cycle pattern. I would start to feel anxious after which I would think, ‘Oh God, can i have a panic attack?’” In turn, her increased concern with having one would fuel the onset of an actual panic attack.
This cycle was finally interrupted when her general practitioner recommended CBT treatments. CBT taught Arthur to calm her mind and set her physical reaction to stress in context. “I still use exactly what the therapist taught me,” she says.
On the advice of her CBT therapist, Arthur also reduce significantly on caffeine. “The way in which he put it is, if I’m at a normal anxiety level of 30, then I’m stressed by work or school to level 60, then that café au lait puts me as much as level 90 — that’s a great deal closer to a panic attack at 100,” she says.
Arthur also uses yoga and controlled breathing to help keep herself calm. “I find that yoga keeps my anxiety at a baseline so I don’t have to really think about it much. If I start to feel anxiety building, I actually do some yoga breathing and it goes away. I’m much more likely now to intervene quickly to keep it in a manageable level.”
Ultimately, regardless of whether or otherwise you choose to treat your anxiety with medication, it seems sensible to avail yourself of the full spectrum of other interventions, too — from good nutrition and physical exercise, to yoga, deep breathing and psychological approaches like CBT.
“Not every person will use every [approach],” writes Hallowell. “But every [approach] should a minimum of be considered in order to achieve the best results.” That’s because, he notes, in almost all cases, no single approach alone will give you optimal results. Every individual needs to find his or her own right mix.
In any life, anxiety is likely to come and go. But when it comes on strong enough to impede our health and happiness, it’s comforting to understand that the remedies of modern science, ancient wisdom and simple self-care can all offer relief — and smart ways to keep future anxieties at bay.
This article has been updated. It originally appeared in the November 2009 issue of Experience Life magazine.
The Big Chill-Out
Common indications of an anxiety attack include rapid heartbeat, sweating, shaking, shortness of breath, nausea, dizziness, heart problems, numbness in limbs or face, difficulty thinking clearly, and anxiety about losing control.
Whether or not you're currently experiencing any of these symptoms, here are some top techniques for quickly and effectively reducing anxiety if this rears its ugly head:
Take a deep breath: Perhaps the single best approach you can get your anxiety under control quickly is to breathe deeply and slowly into your diaphragm. Start simply by closing your eyes, breathing in deeply for a count of three after which exhaling for a count of four. Do it for a minute or two at any given time, repeating until you feel calmer.
Pay Attention: Worries and anxieties have a tendency to grow more powerful when we allow them to accumulate in our subconscious. You can interrupt the accumulation of anxieties by bringing them into the forefront of your mind and acknowledging their presence. Don't be concerned about trying to talk yourself too much of your worries. Just take one minute to step back and observe yourself being anxious. Note any physical symptoms (clenched muscles, shallow breathing, racing heartbeat) and get yourself: Are my fears appropriate to my current actual level of danger? Simply taking stock of your anxiety and consciously seeing uncomfortable sensations for which they are (vs. indications that you are in physical danger) can make them feel less intense.
Get a Move On: If you feel anxiety rising, quit what you are doing and take a quick walk, perform some pushups, or climb several flights of stairs. It may be enough to clear your body of accumulating stress chemicals and provide your mind a chance to reframe troubling thoughts. Going forward, build some exercise time into your schedule. Regular exercise (most experts recommend vigorous activity 3 to 4 times a week to help keep anxiety symptoms away) helps your body balance its way to obtain neurochemicals and hormones and also helps increase your overall resilience. Many people find that yoga provides special anxiety- quelling benefits.
Connect With Nature: If you're able to step outside, or even focus on a tree, cloud or horizon line you can see from your window, do it. Clinical studies have shown that exposure to natural scenes and environments, even painted views of landscapes, measurably lowers anxiety and reduces perceptions of pain. Spending some time in nature also improves mood and reduces reactivity in lots of people. So make a point of regularly getting outdoors, allowing images, scents and sensations of nature to help you calm your jangled nerves prior to them getting out of control.
Resources
WEB
Anxiety Disorders Association of America (www.adaa.org) provides details about anxiety disorders, treatments, how to choose a therapist, self-tests and much more.
The National Association of Cognitive-Behavioral Therapists (www.nacbt.org) provides information about CBT and how it works.
The Midwest Center (www.stresscenter.com/mwc) is really a leading provider of self-care and training programs for people who suffer from stress, depression and anxiety.
BOOKS
Natural Relief for Anxiety: Complementary Strategies for Easing Fear, Panic & Worry by Edmund J. Bourne, Arlen Brownstein and Lorna Garano (New Harbinger, 2004)
When Anxiety attacks: The New, Drug-Free Anxiety Therapy That may Change Your Life by David D. Burns, MD (Broadway, 2007)
Living Well With Anxiety: What Your Doctor Doesn't Tell You That You Need to Know by Carolyn Chambers Clark (HarperCollins, 2006)
Worry: Hope and Help for any Common Condition by Edward Hallowell, MD (Random House, 1998)
The Relaxation & Reducing stress Workbook by Martha Davis, Matthew McKay and Elizabeth Robbins Eshelman (New Harbinger, 2008)
Panic Attacks Workbook: A Guided Program for Beating the Panic Trick by David Carbonell, PhD (Ulysses Press, 2004)
