We throw the word ‘anxiety’ around a lot these days. 

There’s a lot of chaos in the world, things are unpredictable and it can be tough to feel good about ourselves, and our minds can spin out.  To a degree, this is normal.  It’s normal to struggle with our thoughts sometimes, it’s normal to sometimes feel fear that is  out of proportion to what’s in front of us.  What distinguishes normal anxiety from an anxiety disorder is when it starts to change how we act. When it starts to lead to patterns of avoidance of things we fear. When we start changing how we act with our friends, partners, at work, and what we do in the world to avoid feeling worse.  When these patterns of avoidance start having real impacts on our day to day life, treatment becomes critically important.

Anxiety disorders are fundamentally a result of  neurological design.  The parts of our brain involved in threat detection are old. Millions of years old - they’re designed to rapidly scan the environment for threats and trigger fight or flight responses when they do, leading to a cascade of hormones and neurotransmitters to make us fast, quick, and strong. This is vital for survival. The pre-frontal cortex - the fancy part of our brain in our frontal lobes - responsible for higher order thinking, imagination, and problem solving among other things - is new.  The size and complexity of our pre-frontal cortex is unmatched compared to other apes.  Our ability to create vivid fantasies lets us problem solve to an unparalleled degree, being able to think of dozens of possible problems, and imagine hundreds of possible solutions is in large part the key to our success as a species.  And it creates anxiety disorders.

The mid brain - specifically the amygdala (responsible for threat detection) and the hypothalamus (responsible for triggering the cascade of hormones that activate the sympathetic nervous system - aka our fight or flight response) is so old, it evolved before we developed our incredible imagination abilities. It can’t tell the difference between an actual threat, and an imagined one.  Have you ever had the experience of imagining a scary situation, and your heart rate goes up?  It’s crazy! Your threat response systems are responding with a cascade of biological responses (such as increased respiration and increased heart rate to hyper oxygenate the blood to prepare for the fight) that have real consequences - such as digestion going off line, and de activation of cellular repair process’s - to something that your brain just made up.  And through this fun mismatch in evolutionary neurodevelopment (think a computer from the 90’s trying to talk to one from 2025) we have the origins of anxiety disorders.  Our threat response systems respond to imagined, problem solving oriented thinking as if they were real. Imagine how many times in a day we can go over something that’s bothering us. Hundreds!  And our poor little mid brains are being tricked into thinking we are in a hell realm of BEAR ATTACK AFTER BEAR ATTACK! (Or, break up after break up, or job loss, or social rejection, ect ) And each time, another shock of adrenaline and cortisol - teaching our brains that the world is full of threat, requiring constant guard and constant vigilance.

Before we get to understanding how an anxiety disorder develops, we need to map out the process a bit more. There are four stages in an anxiety response. Stimulus, emotion, thought, and behaviour. Let’s break them down.  Remember - anxiety in itself is not a problem. It’s a perfectly adaptive, healthy, life saving response. But sometimes it gets a bit . . . out of control.

Stimulus - anything in the environment that triggers a sympathetic nervous system (fight or flight) response. This can be a physical threat from humans or animals, environmental, or even relational (stimulus related to people not liking us, or partners leaving us triggers our fight or flight system in humans). Importantly - vivid enough thoughts of threat and danger can count as threat stimulus.

Emotion - Ouch! My feelings!  Down to the most basic multi cellular organism, life on earth is wired to be aversive (to want to move away) to things that don’t feel good. For this reason, when our fight or flight response is activated it’s designed to feel bad, triggering an aversive response (we could get into extreme sports and danger seeking, but that’s a whole other topic).  We call this mechanism experiential avoidance. The desire to avoid uncomfortable internal states.  All creatures have this. For some reason (jury is out, but there is solid evidence for combinations of genetic pre-dispositions for evolutionary advantage, early childhood experiences, and even gut biome) folks with anxiety disorders rate much higher on scales of experiential avoidance. The desire to move away from an uncomfortable feeling is much stronger (or the feeling itself is much stronger, it’s hard to tell sometimes).

Cognition - This is when we start spiraling in our heads. Our brilliant brains (specifically, advanced functions in the prefrontal cortex) go to work, trying to figure out how to get us away from this feeling and aversive stimulus.  We have the incredible capability to game-play out hundreds of scenarios, permutations, and variations, all in the quest to find the ideal course of action.  If this is in relation to say - getting away from a bear, great. Or even if it’s how to make more money as we don’t like the feeling of need/lack, again, great. Way more efficient than physically trying out every solution.  This neurological function is a key part of our species' fantastic success. But - what if there is no solution? What if sometimes, the world is just painful?  The way we can so amazingly fix problems in the external world, when applied to our internal world fails miserably.  Sometimes the world just isn’t how we want it to be. This could be our financial situation, social, rejection, whatever.  The constant attempts to fix the unfixable can drive us crazy.  This isn’t meant to be black and white, this stuff is hazy. An old cognitive therapy saying is that anxiety is, “an overestimation of a future threat with an underestimation of our ability to cope with that threat”.  We end up cycling trying to fix the unfixable, desperately trying to avoid what we actually need to accept, all the while triggering our poor threat systems which end up thinking we’re trapped in a hellish realm of constant danger.  Terrible fantasy after terrible fantasy on repeat.

But! Eventually, in this maladaptive cognitive loop, we at least settle onto doing something.

Behaviour - Our brain settles onto some sort of solution. And this is usually . . . avoidance! Just get rid of the stimulus! Again, if the stimulus is a bear, good job! Bears are not for cuddles.  If the stimulus is our broken heart after a break up though . . . There’s nothing our short term fix obsessed brain cant actually do to fix a broken heart. Or immediately make our fears of climate change go away. Or economic disruption or . . Whatever.  In the face of a problem we can’t immediately fix, that hurts us, we reach to direct avoidance.  This could be drugs (drugs can work great for making uncomfortable feelings go away). Or maybe compulsive sex to help us ‘get over’ the feeling of rejection from an ex. Or we stare at our phones to blank our minds out for just a little bit.  And it sort of works. Feelings are numbed, the aversive stimulus isn’t right in our face anymore.  We might begin to avoid things that trigger these feelings. And, back to our bear example, if it’s the third time in a row while on your way to a specific friend's place that you saw a bear meters from their house that growled at you . . . Maybe it’s a good idea to take a different route.  But what if, as you’re struggling after a break up - you start avoiding anywhere that your ex liked to go because it’s to ‘triggering’?

At the start, this can be fine. Not a big deal. But something insidious can start to happen. Remember that experiential avoidance thing from above? We start to sensitize and reinforce this mechanism. We begin teaching our brain, “hey, if I avoid things, I don’t feel as bad!”.  If it’s avoiding your ex’s favourite place to eat, again, not a big deal. But it often starts to expand.  The web expands.

Next you’re not going to the area of the city they lived in. When a friend suggests you start dating, the mere thought of dating sends you into a spiral - dating links to the ex links to pain - and we’ve been learning that avoiding things makes us feel better. So - just don’t date! Easy. No pain that way.  See how this happens?

In fancier psych language - avoidance behaviour is a short term behavioural strategy - it keeps us safe, and keeps us from feeling bad. But it is disastrously bad at long term, value driven behaviour. Or, things that actually make us feel good, that we care about. It’s not our mid brain's fault! It’s whole thing is keeping us safe! It doesn’t understand all these complex concepts like the importance of socialization, and our careers, and keeping our house clean and staying fit . . It’s just doing its avoidance thing. It’s just doing its job.

Short term avoidance leads to long term divergence from core goals, coupled with a cycle of ever re enforcing behavioural patterns endlessly convincing us, “yeah, this avoiding thing works pretty well”.  And now we have an anxiety disorder.

Treatment

Behavioural focused anxiety treatment has a few pieces. Behavioral goals and exposure, cognitive shifts (reframing, self compassion narratives, gentle challenging, etc), mindfulness,  and, the worst part, actually feeling our feelings.  Remembering our four steps in an anxiety mechanism -  and we can’t do anything about stimulus (or we tried to, and we developed an anxiety disorder because of it!). The world has bad things sometimes. But for effective treatment, we want to target the emotions (countering avoidance), the thoughts (thinking in new ways) and behaviors (acting in new ways).

Behaviour  

We need to clearly determine what’s going wrong and how anxiety is changing how you act.. We need to create clear commitments and accountability to start acting in new ways.  For this, a combination of clear goal setting and classic exposure therapy works best.  Exposure therapy means - exposing ourselves to the ‘feared stimulus’, over and over to help our brains re-pattern that we can actually handle it, will be okay, and are not in danger. It’s not a fun approach, but it works incredibly well.

You can have the best therapy sessions in the world, have perfect insight into your patterns, how the anxiety is rooted in childhood patterns and how it developed. But if you’re still avoiding things in your life and it’s still controlling you, people don’t get better. At least not quickly.  We do this through making a thorough inventory of anxiety triggering environments and stimulus, and then creating ways (starting small, controlled, and time limited) practices to start challenging them. The idea isn’t just to do things that scare us for the sake of it. We target specific things that are in line with how we want to actually be living, but are avoiding because of feelings of anxiety.  There are various techniques we can layer on to make this easier (breathing, grounding, mindfulness, but at the core, it’s going to be hard).

Thinking

We learn to gently challenge the ways our anxiety loops tend to think. Reassessment of the situation, building up our sense of strength and resilience, focusing on the present and what is good - there are many ways we can practice thinking in ways that help us feel better, and counter the sometimes vicious, dark, and repetitive thinking that is paired with anxiety disorders.  This isn’t about lying to ourselves and telling ourselves that we are the most amazing rainbows of light and everything is perfect. It’s not. The world is chaotic and often full of danger.  This is about building ways of thinking that help us be successful, that help us navigate a world full of unknowns.  Anxiety spirals and avoiding everything certainly isn’t it.

Emotions

At the core, we’re trying to avoid our feelings. Pema Chodrun, a Buddhist Nun, says “We are trying to find ground in a groundless world”.  We have hurt. We see the unknown in the world, the lack of safety, and we scramble to find safety. Sometimes this is good. When we get into anxiety disorder land, it isn’t, and can destroy us.  We need to learn to come into contact with our core feelings. Sometimes this is fear, sometimes hurt, sometimes just pain.  Learning to see these parts with compassion and acceptance is incredibly difficult, and incredibly important.  When we start to figure this out, it undercuts the whole cycle. We don’t need to be lost in our anxiety thoughts (which remember, are driven by avoidance of core feelings) if we can accept the core feelings at the root of our pain. I know this can seem vague.  It is.  We start to drift into experiential practices, learning to slowly touch into the parts of ourselves that hurt.  Simply acknowledging our hurt and our pain is the most deeply loving, compassionate thing we can do for ourselves. We don’t need affirmations, we don’t need to tell ourselves we love ourselves. Just sitting, being present, and saying ‘Okay, this is here’ is enough.

Nervous System

Our theory here is that anxiety disorders are rooted in an over activated fight or flight system.  Learning how to immediately down-regulate our nervous system in these moments of triggering is incredibly helpful.  Learning techniques like structured, slow breathing, sensory awareness and shifting, and lifestyle interventions like exercise, nature time, and cold immersions can help us physically change the state our body is in, making all this other treatment stuff much easier.

Mindfulness

Mindfulness and meditation tends to be pretty badly understood these days.  For all the things we’re talking about above to work, you need to be able to remember to do them! And when we are panicking and highly anxious, it can be incredibly difficult to remember, “Oh yeah, I’m supposed to do x and y the therapist said!”.  The purpose of meditation (at least when it comes to anxiety treatment) is to train our brains. Not clear our minds, not feel peaceful and calm, and not to make us happy.  Through putting our brains in boring situations (sitting still), and focusing on a something specific (like our breath) it triggers our brains to go all over the place and get incredibly distracted. This is the point. Every time we get distracted, we have the opportunity to become aware that we’re distracted (which is what we call mindfulness) and bring our  minds back to the present moment.  Every time we do this, we strengthen a key part of our brain called the Executive Function centers(EF). This part of our brain is responsible for impulse control, concentration, and the literal ability to direct where our minds are focused.  Meditation literally exercises this part of our brain and makes it larger. Every time we become distracted is another repetition, literally no different than weight training.  This directly translates to the ability to go, when stuck in anxiety, “Oh! I’m doing the anxious thing. Right. Let’s focus on my breath instead, or practice the thing the therapist said”. And then, little by little, we start creating new ways to respond to anxiety.

Getting better from an anxiety disorder is a lot of work.  I can’t emphasize this enough. We’re talking about re-patterning the way your brain responds to adversive stimulus. Countering tens of thousands of anxiety driven repetitions of mal-adaptive patterns.  Be highly suspect of anyone promising a quick fix.  My role as a therapist is to guide you, stay with you, teach you skills,  help you see the good in yourself and understand the roots of your issues, and have a zoomed out view to help you avoid the pitfalls (luckily, they’re pretty predictable).  However, my role isn’t to fix you.  Getting better is dependent on the work you put in.  I know this might sound ominous. But the neat thing, and what I love about being a therapist, is that we know these things work.  Not always. Not 100% of the time. But the interventions we’re talking about above are based on solid, empirical evidence, and decades of research into the underlying mechanisms of the interactions between the body, mind, and heart.  It’s worth it.