Anxiety can make life hard to enjoy. Learn about the types and symptoms of anxiety, how it works, and what helps. Treatment is available in various forms, including anxiety therapy here in NYC.
What is anxiety?
Anxiety is something we all experience at times. However, for some of us it affects us in ways that can be debilitating. Anxiety can take many forms including panic attacks, obsessive thinking, compulsive behavior, phobias, excessive worry, difficulties in social situations and difficulties following traumatic events. The therapists at the Manhattan Center for Cognitive Behavioral Therapy are extensively trained in the treatment of these difficulties.
Typically, cognitive-behavioral therapy (CBT) for these problems involves learning new ways to deal with anxious thoughts and anxiety-provoking situations. By learning to change the way we think and what we do, we can reduce the impact that anxiety has on us. One important part of how CBT accomplishes this is through the use of personalized exercises. Often a CBT therapist will assign these as “homework” designed to help a client develop new habits and behaviors. Through practice, the new skills and behaviors become more automatic and more comfortable. Positive change happens most often through this type of practice.
Anxiety vs. Fear: What’s the difference?
Is anxiety different from fear? Yes. Fear is a reaction to a present and immediate danger. We experience fear if we encounter a mean-looking unleashed dog, or if we think someone has broken into our home while we are there. Anxiety, by contrast, centers on future events such as I won’t be able to pay my rent next month, or what if I get sick next year? or she’s going to get mad when I start talking to her. These worries often reflect discomfort with our inability to control these future scenarios.
Types of anxiety
We all worry at times. When worry becomes clearly excessive or disproportionate to the actual risk, it can be a sign of a condition called generalized anxiety disorder (GAD). Worry in GAD is typically about future events and outcomes. A prominent theory about excessive worry is that it functions as a way to help us reduce unpleasant feelings of uncertainty. In cases of GAD, however, this effort creates more problems than it solves.
People with GAD tend to interpret information in ways that produce a sense of threat. This threat can lead to further worry and can eventually affect their view of the world.
Panic attacks (see blue info box below) are one of the most unpleasant parts of having anxiety. Not everyone with anxiety has them, of course. But for those who do, they can be very impactful. Panic attacks are sometimes due to a condition called panic disorder. Panic disorder involves a history of panic attacks and fear of (or efforts to avoid) future panic attacks.
A panic attack is a period of intense fear or discomfort that typically includes elevated heart rate; shallow, quick breathing, or the sensation of having trouble breathing; dizziness; fear of dying or having a heart attack; fear of passing out, fear of going crazy, or other symptoms.
Panic attacks can either happen “out of the blue” or can happen in specific situations, e.g., when flying, in crowds or on trains or subways. Panic attacks are sometimes accompanied by an urge to leave the place you’re in.
The most common phobias involve animals, insects, heights, blood, needles, enclosed spaces and flying. These phobias respond well to behavior therapy. Other problems commonly thought of as phobias (e.g., fear of flying, fear of germs or contamination) are actually more likely to be related to different anxiety disorders.
Social anxiety involves anxiety that happens in specific social situations. Common settings where social anxiety arises include: giving a presentation, conversations with an authority figure at work, or going to parties where you don’t know many of the guests. People with social anxiety tend to avoid these situations or endure them with difficulty.
Post-traumatic stress disorder (PTSD)
Sometimes anxiety symptoms that affect our lives are related to a distressing event from our past. Often, the link between the symptom and the event isn’t obvious. For example, one symptom of PTSD is an exaggerated startle response — reacting strongly when something unexpectedly scares you. It might not be easy to recognize this as a symptom of anxiety. Even if you do, you might not realize its link to a specific past event. However, other symptoms of PTSD might be easier to recognize. For example, it’s not hard to spot the link between a traumatic event and symptoms like nightmares, unwanted memories, or changes in thinking.
Obsessions and compulsions: OCD
Obsessive-compulsive disorder (OCD) occurs when someone has either obsessions or compulsions or both.
Compulsions are repeated behaviors such as cleaning, washing, checking, reviewing or counting things. Typically, someone with OCD will perform compulsions repeatedly and has trouble stopping.
Obsessions are thoughts that produce immediate, significant anxiety and often an immediate urge to figure something out. Obsessions are typically unrealistic fears. For example, the fear that you ran someone over when driving earlier today, or that you will bring harm to a loved one if you don’t recite a sequence of numbers out loud.
How anxiety works: Mechanisms
Factors that create and sustain anxiety are known as anxiety mechanisms. Some are emotional, some are biological and some are behavioral. These mechanisms are what treatments target in order to reduce anxiety.
Uncertainty is inherent in life. How well we tolerate uncertainty goes a long way toward determining our likelihood of having problems with anxiety. Uncertainty intolerance has been linked with various types of anxiety disorders, but most prominently with GAD and OCD. For sufferers of obsessions in particular, uncertainty intolerance is at the heart of the problem.
A big part of what’s behind a lot of anxiety problems is how we see ourselves. People who see themselves as quite capable, likeable, and independent are less likely to have anxiety. On the other hand, people who see themselves as lacking in competence, likeability and independence are more vulnerable to various types of anxiety. These ways of seeing oneself are known as self-schemas,
Biological factors play an important role in determining whether someone is likely to have anxiety problems. One such factor is genetics. Genetic factors significantly impact the likelihood that someone will develop an anxiety disorder. There is an emerging body of research finding links between individual genes and specific anxiety disorders. So does this mean that if you have anxiety, you’re destined to have it forever? Like having a certain eye color? No! Research also shows that anxiety disorders respond quite well to specific treatments (see below).
The physical structure and dynamics of the brain play a role in anxiety as well. There are several parts of the brain that are responsible for anxiety. Anxiety is associated with various networks in the brain that involve different neurophysiological structures. Perhaps the most well known such structure is the amygdala. The amygdala is an almond-shaped structure in the temporal lobe of the brain. It participates in various aspects of emotional processing. It is the amygdala’s communication with other parts of the brain that occurs when we are anxious or afraid.
One compelling model for understanding how anxiety maps onto brain function is to think of the brain as having two components — the cognitive brain and the emotional brain. When the cognitive brain, associated primarily with the frontal cortex, overrides fear coming from the emotional brain, we can calm ourselves. At other times, the fear network of the emotional brain drives our experience and behavior. The interplay between these two systems can explain how anxiety affects us in any given situation.
We often ask if a condition is caused by genetic or environmental factors. But does that work, exactly? Conditioning is the mechanism by which the environment exerts its influence on anxiety.
A good illustrative example of this is the case of “Little Albert.” Little Albert was a child who researchers conditioned to fear rats by making a loud noise when he was shown the rat. The child had no prior fear of rats. By making the loud noise repeatedly, he eventually associated the rat with the unpleasant emotion produced by hearing the loud noise. (This experiment was conducted over 100 years ago before the adoption of minimum ethical research standards. It would certainly not be allowed today.) The experiment illustrated how one type of conditioning (classical or respondent conditioning) can lead to anxiety.
Another type of conditioning called operant conditioning is also an important mechanism of anxiety. Operant conditioning refers to the ways in which things we do are sometimes rewarded or punished by our environment. These rewards and punishments do not have to be the intentional actions of someone else, but they do affect our behavior. For example, if we feel lousy after every time we eat walnuts, we will soon stop eating walnuts.
The principles of operant conditioning help us understand how the anxiety developed and how it can be treated. One example would be this: a woman has social anxiety and doesn’t like going to parties. When she is invited, she starts to feel anxious. She anticipates that she won’t like it or that the partygoers won’t like her. As the party approaches, her anxiety increases. Then shortly before the party, she makes an excuse and says she can’t make it. The relief she feels when making this decision functions as a reward, or reinforcer, of her decision. As a result, she will be more anxious the next time she’s invited to a party and more likely to make an excuse not to go. This brings us to one of the most important factors that sustains anxiety disorders — avoidance.
Avoidance refers to the tendency of people with anxiety disorders to avoid things that make them feel anxious. This is an understandable habit, and it’s one that we likely all have to some extent. However, for people with anxiety disorders, avoidance can become a way of life. As described in the paragraph above, avoidance creates “rewards” for staying away from the object of our anxiety. This is true whether that object is a person, a situation, a place, a thing, or even a feeling.
Unfortunately, although avoidance helps us dodge anxiety in the short term, it ends up worsening it in the long term. It can also wreak havoc on our relationships, careers, and personal lives.
Our thinking can cause anxiety, and anxiety can also affect our thinking. Regardless of the nature of the relationship between the two, we know that working to change some unhealthy thinking patterns can reduce anxiety. Some types of cognitive-behavioral therapy strive to do just that.
For example, some people with health anxiety will have frequent thoughts about being highly likely to contract a rare disease. The name for this is “probability overestimation.” It can affect our physiology and our behavior.
Social anxiety shows us another example. Consider someone who, when he doesn’t hear back from a friend he texted, thinks “she must be mad at me.” This is an example of a “mind reading” or “jumping to conclusions” thought. Such a thought raises anxiety levels, despite the fact that it may not be true. For this reason some types of cognitive therapy refer to “irrational thoughts” as important mechanisms of anxiety.
Some common types of anxious thinking
As popularized by David Burns in Feeling Good, 1980:
Catastrophizing: Anticipating and then dwelling on the worst possible outcome of a situation. I can’t find my keys — I’ll never see them again and will have to sleep outside for a month!
Fortune telling: Thinking that a certain future possibility is a certainty. I’m definitely getting a D on that project.
Overgeneralization: Seeing a negative trend where there may not be one. This date didn’t go well, none of my dates go well.
Anxiety treatment options
Treatment for anxious people has improved substantially in the past 40 years. We now have a solid scientific understanding of which types of therapies work best for various types of anxiety. We also have medications that were not available decades ago.
Cognitive-behavioral therapy (CBT)
Extensive research studies of various psychotherapies have shown cognitive-behavioral therapy (CBT) to be the most effective therapy for anxiety. CBT refers to a family of therapies that focus on helping you change your thought patterns, your reactions to situations, and your choices in the service of reducing anxiety. Therapies like exposure therapy, acceptance and commitment therapy, cognitive processing therapy and habit reversal training are all types of CBT.
Exposure therapy is an effective treatment for phobias and related disorders. This form of therapy (sometimes referred to as graduated exposure) involves gradually and purposefully coming into repeated contact with something that causes anxiety. This can be a feeling, emotion, or thing. Exposure therapy is used for OCD, panic disorder and PTSD. Aspects of it are often part of CBT for other types of anxiety such as social anxiety and generalized anxiety disorder, and emotion regulation problems
Acceptance and commitment therapy
Acceptance and commitment therapy (also known as ACT) is a type of cognitive-behavioral therapy. It is effective for many emotional difficulties. It teaches people to create a different relationship with their thoughts. This helps with problems that are driven by unhealthy thinking. It also helps people to examine whether their actions and choices are consistent with what they value.
Cognitive processing therapy
Cognitive processing therapy (CPT) is a treatment for PTSD. CPT helps PTSD sufferers examine their thinking about the traumatic event, about themselves, about the world and other people. In so doing, the therapy creates powerful change that can drastically improve PTSD. Recently, a journalist brought attention to this therapy by recounting CPT’s effects in a recent NPR podcast.
Habit reversal training
Habit reversal training (HRT) is a type of therapy used for tics and for hair pulling and skin picking. HRT systematically teaches people to become more aware of the tic or hair pull, e.g. Then it gives them behavioral strategies to then prevent the tick or other behavior from occurring. This type of treatment is quite effective for tics, hair pulling, and skin picking.
For any type of CBT, the first step in treatment is diagnosis. An evaluation with a CBT therapist will provide this information and determine the best treatment options for your type of anxiety.
Research has shown that for many types of anxiety, medication can be almost as effective or as effective as CBT. Perhaps the most commonly prescribed type of medication for anxiety disorders are called selective serotonin reuptake inhibitors (SSRIs). SSRIs cause more serotonin, a naturally occurring chemical in the brain, to have a greater impact on the cells of the brain. Prozac, Luvox, Celexa, and Zoloft are all examples of SSRIs.
A related class of medications called serotonin-norepinephrine reuptake inhibitors (SNRIs) is less commonly used. Effexor, Cymbalta, and Pristiq are all examples of SNRIs.
Benzodiazepines are quite different from the medications described above. They are fast acting, so their effects are typically felt in less than an hour. They are also potentially habit forming, unlike SSRIs and SNRIs. Examples of benzodiazepines include Valium, Xanax, Klonopin and Ativan. Benzodiazepines are not a good long-term solution for anxiety. However, when combined with other treatment they can be a helpful short term solution.
Anxiety therapy and other treatments: Summary
There are pros and cons to using CBT vs. medications to treat anxiety. CBT requires more time and effort. However, the skills you learn will help for a long time. Although medications affect your brain chemistry, they do not fix the processes and habits that led to the anxiety. Hence, their benefits last only as long as you take the medication.
We are fortunate to have various options available for help with anxiety, each with their different advantages and disadvantages. Remember that there are several different types of anxiety; make sure that the treatment you choose works well for your particular type of anxiety.
Learn more on this topic from our anxiety blog posts from this site.
Last updated: May 25, 2020