Anxiety:
Different Experiences, Different Causes,
Same Vicious Cycle
Anxiety comes in many guises. Some people experience sudden panic and might need to leave the situation in which they start feeling uncomfortable. Others experience panic, get preoccupied with body symptoms and feel as if they are about to die, no matter where they are. They stay put but remain vigilant about workings of their own bodies. It is easy to interpret even a small change as indicative of a heart attack or a stroke in waiting. Yet others are subjected to constant worry about what the future might bring. Hours are spent questioning all possible scenarios and their ability to handle situations that might never happen.
Anxiety might be caused by adverse life events, increased life demands or nothing in particular, as something just happens and our attention centers on the feelings of discomfort. When anxious, we feel terrified in absence of actual danger. Anxiety feeds on our very efforts to push it away. Fortunately, irrespective of the initial cause or its shape, anxiety can be understood as a product of interaction between our attention (number 1 in the Vicious Cycle of Anxiety diagram), beliefs (2), physical sensations (3), behaviours (4) and triggers (5). Older diagrams usually begin with a trigger, however research shows that what and how we pay attention is more important than triggers.
When anxious, we don’t just react to our triggers, we actively search for them. Everything feels important and everything can be a trigger, from someone’s facial expression to a random thought to being given an opportunity for a promotion.
This state of hypervigilance is the reason why a worrier stays up at night examining her thoughts least they convey information about possible future difficulties and someone with a panic disorder monitors their breathing for warnings against future pending panic attacks.
The cycle is held in place by the beliefs that we have about our triggers (e.g., that a fleeting thought that the partner might cheat means that the partner is cheating or that a change in breathing signals onset of unending waves of panic) AND by beliefs about the vigilant attention (e.g., If I don’t heed all my warning thoughts, I will be caught unprepared” or “If I catch panic early enough, I will be able to prevent it”). These thoughts might be automatic and difficult to notice or take a form of clear convictions.
Our body responds by activating a fight-flight-freeze response (3) that is an attention grabber of itself. We might feel nauseated, sense pressure in the chest, experience palpitations or feel like the world is spinning while legs refuse to move. When that happens, rational thought is lost, and we search to end this painful experience as quickly as possible. We do things that increase our sense of safety without contributing to actual safety (4). These emotion-based safety behaviours include avoidance, checking, distraction, increased monitoring of symptoms and quest to understand causes of our anxiety. Avoidance confirms our perception that whatever we avoided should have been avoided. Checking tends to create doubt as we search for more and more information, Distraction prevents us from noticing reality. Symptom monitoring serves to accelerate our body response. The quest for the cause leads us through many possible explanatory pathways, none of which feels truly satisfying. We eat healthy, avoid all stress AND feel even more anxious than before. The culprit is the maintenance cycle.
Meet John, Leila, Grant and Anna.
John’s car was hit from behind when he was about to turn into the parking garage at his workplace. Help arrived soon and there were no major injuries, but John was kept overnight at the hospital for observation. He felt frustrated with unpredictability of life as the accident prevented him from delivering an important presentation that was a first step in securing a promotion that he always wanted. John felt ashamed when he returned to work couple of weeks later. The project was time sensitive, so the task was assigned to someone else. He started experiencing panic attacks at work. Initially everyone was quite accommodating. John began feeling more and more frustrated with his situation. He resumed driving. He was even able to drive his family to a weekend retreat but started to take a Go train to work to avoid reliving the panic that he has felt on a few occasions when he drove his car into the garage at work. Anxiety at work continued. John concluded that it has nothing to do with his accident – the workplace is plainly toxic.
Leila always wanted to be a mother. She did dread pregnancy or labour. The first time she held her newborn daughter in her arms, she felt incredible love and joy and …fear. This little bundle of life was now fully dependent on her. What if she misses something? What if she is not attentive enough to be a good mother? What if she inadvertently hurts her baby or worse, becomes neglectful and the baby dies? After all, sudden infant death is a thing. Laila could not sleep. She would stare at her newborn to ensure that everything was OK. She became so exhausted and tense that she would occasionally snap at her daughter, a confirmation that she was not fit to be a mother. Breastfeeding was an ordeal for both and quickly abandoned. Leila retreated into her mind, constantly thinking about how much she wanted to protect her daughter and yet unable to even take care of the basics.
Grant felt very proud after securing his admission into a highly competitive program. He moved into the residence and was ready for his frosh week. He was very impressed with his classmates. Everyone seemed so talented, so self-reassured. How did they do that? Grant’s work was good, but it took so much effort to produce. He began feeling that he did not belong and that whenever he talked, his replies were lame. He sounded too needy, too eager, not cool enough. Grant tried to formulate some clever quips ahead of time and frequently lost track of the conversations, a new source of embarrassment. Eventually he started feeling othered. Couple of times he has experienced morning palpitations and decided to skip classes and stay in bed. Catching up became difficult. Assuming that people would think that he was weird and stupid, he felt too embarrassed to ask for help. He was about to fail his first semester.
Anna began feeling queasy at the grocery store. She felt that something was really off, left her shopping card behind and drove herself quickly back home. She made herself a cup of tea and settled in bed. The experience was weird and rather intense. Anna run through a series of explanations: Not eating enough? Not enough sleep? Too much caffeine? Surely the feeling will not come back after a good rest. Anna relaxed, had a nap and decided to do some evening chores. At bedtime, Anna mentally reviewed again what happened to her. Just in case, she scanned for symptoms and noticed that she still felt a bit queasy and that the beating of her heart was not just right. She tried to sleep but couldn’t. Next day, sleep deprived, queasiness, irregular heart rate returned. As Anna examined her symptoms, she became progressively more agitated. She started having trouble with her breath. Something was definitively off. Anna felt that she was about to collapse and called 911. After running a series of tests, Anna was told that she likely experienced a panic attack. Just in case, she was asked to see her family physician. Frustrated, embarrassed but reassured, Anna returned home. She made herself a bedtime tea and wondered if the panic symptoms would return…. The cycle started again.
These stories seem very different from one another and yet they share many commonalities: active search for triggers (attentional bias or focus), highly emotional thinking (beliefs), powerful body sensations and a host of coping strategies (behaviours) that only serve to reinforce the vicious cycle. The outcomes of our efforts become new triggers.
John, the young executive, developed anxiety following a car accident and yet is able to drive just fine with the exception of driving to work. He is preoccupied with workplace toxicity that he assesses based on his body responses (panic attacks). Have a look at John’s cycle of anxiety.
The diagram shows us that John’s core fear is about being caught off guard, like he did during the accident. Returning to the place of the accident activated the fight-flight-freeze reaction that increased John’s emotional response when he has learnt that his project was assigned to someone else. This might have created a one-tack mind with John’s missing out on other opportunities. The diagram offers a roadmap for John’s treatment: we can start by challenging John’s beliefs about workplace toxicity by creating behavioural experiments.
For example, if John were to volunteer for a new project, would he be given a chance? If John were to join his coworkers for lunch, would they act friendly towards him? If reduced checking himself for signs of panic, would that increase or decrease his panic attacks at work? Does perception of workplace toxicity increase or decrease depending on whether John drives himself to work or not? This last experiment would allow John to understand the impact his body reactions have on his thoughts, reduce emotional thinking and serve as a good exposure to help him tolerate physical symptoms of anxiety in a safe manner.
Leila, the young mum, is preoccupied with monitoring of her own worries and wellbeing of her baby while the worry symptoms make her too exhausted to take care of and bound with her daughter. Mapping her anxiety cycle shows that our first intervention target would be excessive monitoring of thoughts. We can do so by working on Leila’s beliefs that such monitoring is protective to the baby. Leila might be asked to do some thought records. She would also be asked about many other things in her life that are very important, but she does not monitor excessively with no ill consequences. We can also ask Leila to play with her baby while allowing some weird thoughts to enter her mind without doing anything about these thoughts. It is important for Leila that a thought is just a thought. Instead of fighting the thoughts, we guide Leila stay grounded to help her notice that she might have a thought that the baby is in danger while she is safely playing with her at her own home.
Grant’s diagram helps us appreciate his intense fear of humiliation paired with assumptions that others are highly judgmental and that quivering voice will meet with derision. Grant suffers from social anxiety and a temporary blow to his self esteem which is very common among first year students. Persons who gain admission to highly recognized schools have very good skills. Grant is one of them. However, until starting college, Grant was likely the best in his class as otherwise he would not have been accepted into his program. He derived his sense of pride from being the best in his peer group and that has changed. Grant is a victim of his own all-or-nothing thinking. With Grant, we would start by helping him reframe his experience as a challenge (walking to the top of a hill) as opposed to a competition (being first to reach the top of the hill). We would help Grant pay attention to the topic under discussion instead of thinking about what others might think about him. We might even ask Grant to have his voice quiver on purpose to notice that conversations usually continue uninterrupted and even if getting slightly tongue-tied might lead to temporary embarrassment, it is all manageable and he can remain accepted by his peer group. Return to lectures is a must but Grant would be armed with the knowledge that the initial few lectures would feel very uncomfortable as avoidance breeds anxiety. This is a very different from the “common sense advice” to wait to feel less anxious before returning.
Anna’s panic disorder just happened. Everything was great until one day she felt dizzy at a store and the spiral of panic started. Panic is typically understood as anxiety about anxiety. We would show Anna how easy it is to induce panic just by thinking about it. Other induction methods, known as interoceptive exposure, include breathing through a straw or hyperventilating. If Anna were to experience panic attack at the office, she could be asked totally irrelevant questions about her favorite show or a good restaurant. Most people look surprised but get involved in an easy going conversation only for panic to subside. This is a great way of demonstrating the role of attention in maintaining panic. Water never boils when you watch it, panic doesn’t go away when you monitor it. Anna perceives herself as weak and in need of urgent medical attention. We would encourage exercise – it’s great for the body AND another great way to engage in interoceptive exposure. Moreover, Anna would be asked not to search health information on Google and to have regular appointments with her family physician but to keep these appointments spaced apart more and more as symptoms of anxiety decrease. Panic attacks are not medically dangerous, however panic attacks are not a protective factor against other medical conditions. If there is some underlining medical condition, eliminating panic disorder makes diagnosis easier.
CBT for anxiety starts with case conceptualization or building an understanding of your own anxiety cycle that keeps you stuck and in pain. This typically takes away some of the confusion about anxiety attacks and helps us identify the best point for initial intervention. Then, we work on:
-
Ensuring that your thoughts reflect reality instead of painful assumptions. Initially we do so by using thought records to examine the evidence for and against our beliefs.
-
Testing new behaviours to learn what is effective (behavioural experiments).
-
Facing triggers through exposure exercises to learn that many of the dreaded experiences are temporarily distressing but not dangerous of themselves.
-
Using mindfulness skills to help train your attention, build patience, stay grounded in here-and-now and consequently reduce physical symptoms of anxiety.
Ultimately, we learn to live with anxiety. Just imagine that this is your first time walking on the glass floor at CN Tower. You observe how others are doing it. Some are tentative, others walk without hesitation. You might try using a thought record or slow your breathing and yet you will very likely shake at least a little when taking your first step. Things get easier once you have walked across. You are learning that the floor is quite stable. Walking on the same floor with your eyes closed would not work. The moment you open your eyes, you would start trembling. Accepting to live with anxiety means facing our lives, as they are, with our eyes fully open. We might not like how we feel or what we see, but we are on the way of building more engaging lives and becoming better problem solvers. We develop willingness to try.