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 Anxiety: The Silent Epidemic Anxiety has been called the “common cold” of mental health and for good reason. According to the Anxiety and Depression Society of America, symptoms of anxiety affect over 40 million Americans at any given time and accounts for a whopping $42 billion dollars in healthcare costs annually. That’s almost one-­‐third of the total cost of healthcare in America. Twenty three billion of those dollars are the result of repeated visits to healthcare providers due to anxiety-­‐related symptoms that mimic physical illnesses. What is not accounted for, because it is impossible to express in dollars and cents, is the emotional cost of anxiety. The number of lives affected by this often times debilitating condition is incalculable. How do you put a price on unhealthy, unhappy, unproductive, and dysfunctional families, couples, and co-­‐workers? Untreated anxiety disorders are a social problem as well. Because we are all part of larger social systems, each of us contributes to the health and wellbeing of local, state, national, and even international communities. Our ability to function in a healthy way affects many of those around us. The human cost of anxiety, in many ways, far outweighs the financial cost. In short, all of us are affected by anxiety. The good news is that hope lies within every anxiety sufferer’s reach. Even very acute anxiety disorders are very treatable and there are many effective treatments readily available. None of these treatments will work, however, if those experiencing anxiety do not avail themselves of the help that is often right around the corner. Unfortunately, almost two-­‐thirds of those experiencing clinically significant anxiety do not seek help. They suffer needless emotional and even physical pain due to untreated symptoms of anxiety. This article is the first in a series of articles examining anxiety; its causes, treatment options, and simple techniques proven to be effective in reducing the symptoms of anxiety. As a mental health professional, who specializes in anxiety disorders, and as one of the 40 million people who experiences clinical anxiety, I feel that I can bring a unique perspective to the treatment of this debilitating condition. More importantly, as one who has learned to fully live with anxiety, indeed one who embraces anxiety as a normal experience, I feel compelled to “shine a light” on what has truly become a silent mental health epidemic in this country. The Anatomy of Anxiety Simply put, what we call anxiety is a natural response to a real (or perceived) threat. Our very existence depends on a sophisticated biological, physiological, psychological, and behavioral system that together make us who we are. Our experiences in life depend on how these systems interact with each other and how they (we) respond to the world around us. An anxiety disorder occurs when these systems respond in such a way that they interfere with our ability to function normally. Normally, our biological, physiological, psychological, and behavioral systems are balanced and, as a result, we function remarkably well most of the time. But, when there is an imbalance in one or more of these systems, disorders can occur. Let’s take a closer look at each one of these systems and see how they contribute to our well-­‐being, and how they can contribute to an anxiety disorder. Biology The biology of anxiety refers to the genetic makeup of our brain. It is our biology that determines what kind and how many chemicals are released by our brain when we encounter a real (or perceived) threat. Of course, not all of our biology is equal. Some of us have brains that naturally release more chemicals than others. This is called our biological “disposition.” We are each born with our own unique disposition and this, by and large, determines our innate (inborn) sensitivity to perceived threats. Indeed it is our innate sensitivity to these threats that contribute to what is perceived as a threat. The chemicals that are released due to this sensitivity reside in a part of our brain called the limbic system (a very old part of our nervous system). This part of our brain is sometimes referred to as the “ancient brain” because it is the part of our brain that belonged to our ancient ancestors. As a matter of fact, it was at one time the only part. Think of the limbic system as our “emotional center.” The limbic system is essential to our survival because, back then, as now, there were indeed threats to our safety. From an evolutionary perspective, those of us who were predisposed to anxiety were far more likely to survive; while those who weren’t were far less likely. So, this predisposition toward anxiety, along with a heightened sensitivity to the environment, was actually a good thing survival-­‐wise. Therefore, according to the laws of Natural Selection, the trait of anxiety was passed on, from generation to generation, to us. As you can see, this predisposition toward anxiety has been going on for a long time, and it set the stage for our automatic responses to threats, as well as our thoughts, feelings, and behaviors in modern times. Physiology The physiology of anxiety is how our physical body responds when these chemicals are released. Many who experience anxiety report a variety of physical sensations: sweating, clammy palms, rapid or irregular heartbeat, difficulty breathing, dizziness, pain, digestive problems, and muscle tension, to name just a few. In many ways, these physical sensations are our normal response to life-­‐threatening events. A popular term for this reaction is the “fight or flight” response. Part of what is so distressing about this is, for many of us, there is no obvious threat. It’s as if our nervous system is all dressed up, but with nowhere to go! Psychology The psychology of anxiety is what and how we think about the threat—how we mentally perceive and evaluate our experience. Through millions of years of evolution, our brain became more than just a bundle of nerves that responds to threats. It eventually developed other bits and pieces that greatly affected our experience as humans. One of these bits is called the pre-­‐frontal cortex. This little miracle of evolution is at the front of our brain, just above our eyebrows. It allows us to think abstractly—to use judgment, plan ahead, make tools, write poetry, build bridges, and dunk basketballs (assuming we have the physiology to do so). The pre-­‐frontal cortex does this by manipulating symbols into coherent ideas that help us interpret what the heck is going on around us. We call the process of manipulating and organizing symbols thinking. Our brain thinks (constantly), and what our brain thinks are called thoughts—pretty simple right? Okay, so our brain thinks thoughts, so what? Well, indeed some of our thoughts are random noise; they mean nothing at all. Many of our thoughts are conversations we have with ourselves about what’s going on, what we are doing, what we did, what we are going to do, etc. This is called “self-­‐talk.” However, not all thoughts are equal. Some thoughts are considered more important to us than the others. We call these thoughts our beliefs. We call them that because they are thoughts that we evaluate as being true. It is this collection of beliefs that define our world, gives us our perspective, and create our experience as human-­‐beings. To some, this collection of beliefs is like a mental picture of our reality. We call this picture our world view. This view is the filter through which all we sense (see, hear, touch, smell, taste) in the world flows. With respect to anxiety, the philosopher Epictetus said it best two thousand years ago when he said “We are disturbed not by things, but by the view which we take of them.” It is this view—our psychological response to events in our life—that is key to resolving anxiety disorders. Behavior Finally, our behavior refers to how we act—what we do—when we become anxious. We may pace, fidget, wring our hands, twitch, tremble, run or walk away, or even panic. This is our attempt to dissipate the chemicals that are coursing through our body; our physical attempt to alleviate the anxious feelings. We do this by acting on our impulse to do something to reduce the anxious feeling. Essentially we feel compelled to act out our fight or flight response. We literally try to escape the feeling of anxiety. So there it is, the “anatomy” of anxiety. In the next article, I will examine how this works in our day-­‐to-­‐day experiences. Next: Anxiety in Action. Anxiety in Action: A Walk in the Woods It’s a cool fall day and you are taking a leisurely walk through a densely wooded area in your favorite local park. You are feeling good—calm and relaxed. The crisp cool air is invigorating and your thoughts are on the approaching holiday season. Thanksgiving and Christmas are have always been stressful times of the year for you. Maybe this year will be different. In thought, you find yourself on a secluded stretch that winds its way down to a small creek. It is growing dark, but you can still make out objects ahead and along the trail—just not very well. Suddenly, as you approach the creek, you sense (see, hear, or even smell) an activating event—a large shape just off the trail ahead (I call this event activating because it activates your limbic system). Immediately, and without conscious thought, your limbic system kicks into gear. Your mind goes completely blank and in a flash a warm feeling flows over your body. Your ancient brain has already dispatched chemical neurotransmitters through a network of nerve cells, from your optic nerve to other parts of your brain. Your brain responds by releasing a slew of chemicals that cascade down to organs in your body. These signals cause physiological changes to occur. You freeze and remain very still (the first behavior triggered by innate anxiety). You are suddenly aware of your heart pounding in your ears and chest. Your muscles become tense, your breathing becomes shallow, and your digestion slows to a crawl. On the plus side, your eyesight and hearing become more acute—you actually see and hear better! Your body’s core and large muscle groups also get lots of blood flow, but at the expense of your extremities (hands and feet). They turn stone cold as your arteries narrow to divert blood-­‐flow elsewhere. What is happening? Your body is on autopilot—
preparing you to fight—or to run for your life. This process is called a primary response. This primary response occurs very quickly (as it should) and essentially bypasses your pre-­‐frontal cortex. This makes sense because when this process began to evolve, there was no pre-­‐
frontal cortex and waiting for a secondary response would take too long. If indeed the threat was real, these events would happen too quickly to evaluate and respond. No time to think, just act! So there you are, frozen in your tracks as a result of a primal response to a perceived threat. But is this really a threat? In a matter of seconds, your secondary response system kicks in. Mentally, you consider your circumstance—you evaluate the threat rationally. “Think man! Think!” The newest part of your brain (the pre-­‐frontal cortex) quickly catches up with your ancient brain. Your hippocampus, where memories are organized, is activated and the process of evaluating (filtering) all the evidence begins. Your vision, due to the primal response, is sharper now. You watch the shape carefully. It is not moving—at all. Ten seconds, twenty, thirty seconds; nothing, no movement. Then you begin to notice small things, branches and leaves fluttering in the breeze, the tangle of roots extending into the evening sky. Ah…your pre-­‐frontal cortex has finished its evaluation—conclusion: It is the stump of a fallen tree. Whew! You exhale loudly, an indication that your parasympathetic system is engaging (this is a part of your nervous system that counteracts the primal response). Your physiology begins to return to normal. Your heart-­‐rate slows, your muscles relax and breathing returns to normal, your hand and feet get a little warmer as you shake them vigorously to get blood flowing again. The danger has passed, but it still takes about twenty minutes to calm down completely. Soon though, you will forget all about this encounter with a stump in the woods; or perhaps store it in your hippocampus for story-­‐telling later, or for the next time you encounter a large, dark shape in the woods. The vignette above illustrates how our two response systems (primary and secondary) not only work together to protect us, but prevent us from immediately responding to everything as if they were a threat. On the other hand, if we were to evaluate this situation as a real threat, our primary physiological response is still activated and has prepared us to fight or flee. That is why it takes several minutes for our body to return to normal. Understanding these mechanisms and how they interact with each other is a key part of treating anxiety. There is a variety of interventions (therapies) that aim to interrupt the process we call anxiety. Remember, each one of these sub-­‐systems (biological, physiological, psychological, and behavioral) is part of a larger system called “human-­‐beings.” Each sub-­‐system “communicates” with the other systems in order to modulate the others. It may also be useful for us to think of the pre-­‐frontal cortex as a mediator—a conscious way for us to negotiate between the other systems so they don’t run amok. It is important to understand that our primary response to activating events (perceived threats) is difficult to modulate consciously. Remember when we talked about dispositions and sensitivity? Our individual primary responses are essentially biological and physiological, so we are each pretty much hard-­‐
wired to automatically respond in a certain way to activating events. However, our secondary response can be consciously controlled, and can therefore be “trained” to intervene in cases where our primary response is not appropriate. Because we are all different, exactly how each of us consciously responds when we become anxious, is where treatment can be effective. Popular Treatment Options Treatment methods (or modalities) are distinguished by their respective approaches to a problem (or symptom) and I will list a few here: Cognitive Behavior Therapy (CBT)-­‐According to founder Aaron Beck, Cognitive Therapy (and successor Cognitive Behavior Therapy) is based on the idea that thoughts, feelings and behavior are all connected, and that individuals can overcome and resolve their difficulties by identifying and changing unhelpful or inaccurate (irrational) thinking, problematic behaviors, and distressing emotional responses. So as we look at the systems involved in anxiety, we can see that CBT focuses on our psychology, but also recognizes the importance of our behavior as well. Techniques and exercises are developed to interrupt distressing thoughts, consciously reduce distressing physical sensations, and extinguish problematic behaviors (escaping, pacing, compulsive actions, and others). CBT has a large body of evidence to support its effectiveness in treating anxiety disorders and should be considered when seeking treatment. Solution-­‐Focused Brief Therapy (SFBT)-­‐This therapy was developed in the 1980’s by The Brief Family Therapy Center in Milwaukee, Wisconsin. SFBT is based on the idea that focusing on the problem only gives it more power and focusing on a solution is the key to overcoming adversity. Practitioners help the client identify and use resources they already have in order to solve their problems. They do this by identifying instances where the client has already solved their problem, but (because they are so focused on the problem) has not noticed that they have. The client is then encouraged to build on existing “exceptions” to their problem toward a solution. Psychodynamic Therapy-­‐This form of therapy traces its roots back to the late 19th century, owing itself to popular figures such as Sigmund Freud and Carl Jung (pronounced Yoong). Psychodynamic Therapy is based on the idea that the unconscious mind plays a significant role in our difficulties and that unresolved experiences in our past offer clues to our present-­‐day responses to activating events. Most counselors and therapists use a combination of techniques to assist their clients in resolving problems. These counselors will endorse an eclectic approach, meaning several approaches may be used at once or when appropriate to the situation. Counselors who specialize in anxiety disorders are no different. The rule of thumb for most therapists these days: Do whatever works best for the client. Next: Effective techniques to reduce the symptoms of anxiety.