Therapy for Anxiety
Psychologist, Brad Peters, is experienced working with anxious clients. Anxiety involves psychological and physiological symptoms that signal the presence of a real, perceived, or anticipated threat (APA, 2000). Although anxiety is usually an adaptive response, it becomes problematic when it operates beyond the presence of a genuine threat, or if it overgeneralizes to non-threatening situations. When this happens, the individual may find themselves psychologically restricted, in how they think, feel, and act: thoughts can become plagued with worry, dread, or obsessive planning; behaviours can become inflexible or rigid, through avoidance of people, places, or anxiety-provoking situations; even emotions can become restricted, if the body associates emotional experience as threatening, thus triggering tension and discomfort, in the place of genuine feelings like sadness and anger.
Since psychological and behavioural avoidance is a key part of what maintains anxiety, nearly every therapy for anxiety will involve a combination of exposure to a tolerable level of anxiety, along with anxiety regulation strategies.
Fears and Phobias
Psychologists often distinguish fear from anxiety. While each can produce similar physiological responses, they can be experienced quite differently, depending on the broader context. With fear, the individual is facing a known or identifiable threat, such as being mugged in a dark alley, or encountering a bear while on a hike in the woods; we are fearful of the mugger and the bear, respectively.
Most fears are justifiable and adaptive. However, for various reasons, we can develop irrational fears, or, justifiable fears may overgeneralize to other objects or situations. It is quite common that even thinking about the feared object can cause distress, which may lead to psychological or behavioral avoidance. Unfortunately, the ‘relief’ we experience through avoidance, only reinforces the fear response, and increases the likelihood of developing a genuine phobia. Such patterns can become reflexive and very difficult to control, leaving one stuck in a vicious cycle of anxiety and avoidance. In these situations, psychologists work with clients to help them understand avoidance patterns and potential roadblocks, while helping them gradually face their fear, eventually leading to a dissipation of the fear-response.
Anxiety: Three Kinds
Anxiety, in contrast to fear, involves either an unknown threat, or one that is vague or poorly defined. For instance, a student might experience anxiety about being asked a question in class, even though there seems to be no rational basis for it – they like their teacher and their classmates, and believe themselves capable of answering questions that could be asked of them. In this case the threat is ambiguous – is it the teacher, the other students who might judge, the feeling of vulnerability, or something else? The response that the situation calls for, is also ambiguous, which can lead to a kind of psychological paralysis, or, behavioural avoidance.
There are, perhaps, a few different categories or ‘types’ of anxiety that are worth distinguishing. The first, and arguably most well-known, involves physiological responses driven primarily by dominance of the somatic and sympathetic nervous systems. Somatic signs of anxiety, can include (Frederickson, 2013):
- muscle tightness in the hands, arms, legs, shoulders, and neck
- tension in the chest (often relieved through frequent sighing)
- tight stomach muscles (e.g. stomach knots).
Activation of the sympathetic nervous system is often characterized by:
- increased heart-rate & blood-pressure
- increased respiration
- possible hyperventilation & fainting
- dry mouth and eyes, dilated pupils
- cold hands, shivering, and blushing
Frequently referred to as the ‘fight-or-flight’ response, this form of activation is arguably the most adaptive or flexible, since it prepares the body to act. It provides the metabolic resources to either engage the threat, or flee from possible harm.
Importantly, the symptom profile of somatic and sympathetic-dominant anxiety, is such that there are usually noticeable signs of anxiety. As a result, others are less likely to doubt whether an individual is anxious, since they can visibly see signs of discomfort, exhibited in fidgety mannerisms, rapid speech, laboured breathing, and so on.
The second, and less known/understood form of anxiety, involves smooth muscle activation and dominance of the parasympathetic nervous system. The parasympathetic nervous system is typically associated with the ‘rest-and-digest’ response (states of relative calm and relaxation). However, neuroscientist and distinguished university researcher, Dr. Stephen Porges, has challenged this simplistic picture with his Polyvagal Theory (2011). As the name suggests, Porges found evidence suggesting that there were two branches of the vagal nerve, and that they served very different functions.
The Ventral Vagal Complex (VVC), roughly corresponds to the ‘rest-and-digest’ response, and works to counterbalance and regulate the sympathetic ‘fight-or-flight’ response. In contrast, the alternate branch, called the Dorsal Vagal Complex (DVC), was associated with more crude survival strategies, presumably evolved from primitive vertebrates, reptiles, and amphibians (e.g. freezing, death feigning, conserving resources). Parasympathetic anxiety, resulting from DVC activation, may cause the following symptoms (Frederickson, 2013):
- decreased heart rate & blood pressure
- decreased respiration
- salivation, teary eyes, & constricted pupils
- increased gastrointestinal motility (nausea, vomiting, diarrhea)
- relaxed bladder sphincter (urge to urinate)
- migraines (due to vasodilation)
- “jelly legs” or unsteady gait
- dizziness & foggy thinking
These findings have been supported by many sources, including trauma researcher and therapist, Peter Levine (2010), and the newer clinical psychodynamic literature (e.g. Abbass, 2015; Frederickson, 2013).
Unlike the sympathetic-dominant anxiety, this parasympathetic form of anxiety involves symptoms that may have very little outward signs. In fact, someone may look completely calm, while their internal experience is one of nausea, muscle weakness, and difficulty thinking. As such, it can be difficult for supportive others to notice or understand what is happening; even an attentive therapist can sometimes fail to notice that a client is becoming quickly overwhelmed during a session.
This last ‘category’ is closely connected to the one just described. So much so, that one might consider it a sub-class of the parasympathetically-dominant anxiety response. Despite the overlap, the panic/grief response appears to have a distinct enough ‘feel’ and ‘appearance,’ to warrant saying a few things about it.
Much of the work here, is drawn from the late affective neurobiologist, Jaak Panksepp (Panksepp & Biven, 2012), who characterizes the panic/grief response as one that includes typical parasympathetic symptoms, such as “feelings of weakness and depressive lassitude” (p. 190). However, the most prominent symptoms include “a strong urge to cry, often accompanied by tightness in the chest and the feeling of having a lump in the throat” (p. 190). Indeed, to a third-party observer, the panic/grief response may appear indistinguishable from a sudden burst of sadness or extreme emotional vulnerability. Still, when one asks the individual about their experience, their first-person reports will often include adjectives such as feeling ‘panicky’ or ‘overwhelmed’ (as opposed to ‘heavy,’ ‘upset,’ or ‘sad’). Panksepp claims that this response will often prompt “thoughts about lost objects of affection,” and hypothesizes it to be intimately connected to attachment-related feelings of interpersonal loss or abandonment.
Individuals who suffer from anxiety know firsthand how debilitating it can be. Your therapist should be able to distinguish which type of anxiety you are experiencing, as it may call for different kinds of intervention. Our Halifax-based psychologists have experience in cognitive-behavioral, interpersonal, mindfulness, psychodynamic, and existential approaches that can often be helpful in understanding and treating anxiety, fears, and phobias.
Things Might go Terribly, Horribly Wrong: A Guide to Life Liberated from Anxiety (K. Wilson & T. DuFrene)
This is not your typical '10-step' or 'quick-fix' kind of self-help book - and that is in part its greatest strength. Rather than viewing anxiety from a medical model and as something to be superficially managed or avoided at all costs, the authors challenge their readers to begin exploring the meaning of their anxiety while confronting it from a mindfulness and acceptance based perspective. An excellent supplement to individual therapy for anxiety, readers may come away from it will a different way of looking at anxiety, stress, and maybe even life.
Abbass, A. (2015). Reaching through resistance: advanced psychotherapy techniques. Kansas City, MO: Seven Leaves Press.
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision). Washington, DC.
Levine, P. (2010). In an unspoken voice: How the body releases trauma and restores goodness. Berkeley, CA: North Atlantic Books.
Panksepp, J., & Biven, L. (2012). The archaeology of mind: Neurodevelopmental origins of human emotions. New York, NY: Norton.