Anxiety Read online

  the fact that the forward-thinking, anxiety-arousing propensity of the human mind is more highly developed than it is in lower animals probably accounts for many of man’s unique accomplishments.

  Behaviourism has also informed some of the most successful strategies for treating anxiety problems. The South African psychologist Joseph Wolpe (1915–97), for example, developed behavioural desensitization to tackle fears and phobias. This technique, which involves gradually exposing individuals to the situation they fear – for example, heights or snakes – so they can learn that there’s actually nothing to be afraid of, is still the standard treatment for phobias.

  And the legacy of behaviourism can be seen in today’s most widespread form of psychological therapy, cognitive behaviour therapy, or CBT. At the root of CBT is the insight that unhelpful thoughts, feelings, and behaviour are not innate but learned. And because they are not innate, they can be unlearned – and often surprisingly quickly with the help of a therapist.

  Cognitive theories of anxiety

  The fundamental idea is that emotions are experienced as a result of the way in which events are interpreted or appraised. It is the meaning of events that triggers emotions rather than the events themselves. The particular appraisal made will depend on the context in which an event occurs, the mood the person is in at the time it occurs, and the person’s past experiences.

  Paul Salkovskis

  Behaviourism – with its exclusive focus on those aspects of human life that could be studied in the laboratory – dominated academic psychology in the US and UK for much of the 20th century. But things began to change in 1956 with the advent of the so-called ‘cognitive revolution’. Cognitivism aimed to identify and understand the basic processes underlying how human beings think; behaviourism had declined to study thoughts because they aren’t the sort of thing you can observe directly.

  The new approach was summarized in the ground-breaking Cognitive Psychology, published by Ulric Neisser (1928–2012) in 1967. Its subject was:

  all the processes by which the sensory input is transformed, reduced, elaborated, stored, recovered, and used … Such terms as sensation, perception, imagery, retention, recall, problem-solving, and thinking, among many others, refer to hypothetical stages or aspects of cognition.

  To clarify these processes, cognitive psychologists mapped them out using a metaphor drawn from another boom area of the time: computing. Sensory information was depicted as being received by the brain and then processed via a series of binary yes/no steps, just like the flow diagrams on which many computer programs are based. Today, the models are more sophisticated: rather than a linear flow chart, in which a specified part of the brain deals with inputs one at a time, multiple mental processes occur simultaneously and in tandem across a complex, multi-layered ‘neural network’.

  Cognitivism is now the dominant strand in contemporary psychology. So what does it have to tell us about anxiety?

  Perhaps its key insight is that anxiety – like other emotions – arises from our appraisal of a situation. Initially that appraisal, or interpretation, may not be a conscious process; often, it’s a case of ‘intuition’. Our senses function as an early warning system, picking up on something potentially important and then passing it on to the more rational, deliberative part of our brains to consider. When we detect a threat we’re not confident we can handle, we feel anxiety. These latter, conscious thoughts about threat are crucial, and they’re what modern psychological treatments for severe anxiety set about changing.

  Imagine, for example, that you are woken in the early hours of the morning by a noise downstairs. How you interpret that noise will determine your emotional response. If you decide it’s your cat clattering around, you might feel mild irritation at being disturbed before turning over and going back to sleep. But if you believe it may be the sound of a burglar rather than your pet cat, you’ll almost certainly be gripped by anxiety and lie awake wondering whether you ought to investigate. It’s not the event that determines our emotional state, but rather the way in which we make sense of that event.

  The perceived threat can be either external – like the noise in the night – or internal. For example, panic attacks are very often triggered by the mistaken belief that odd but otherwise normal physical sensations – a tightness in the chest, perhaps, or a twinge in an arm – are symptoms of serious illness, such as a heart attack. Indeed, a vicious cycle can be triggered in which the physical manifestations of anxiety (for example, breathlessness, racing heart beat, queasiness) are taken as confirmation of impending collapse or death, which in turn leads to more anxiety. Again, it is the individual’s appraisal of these internal signals that is crucial. This means that if you change your thinking, you can change your emotion.

  But why is it that one person interprets a little breathlessness after running up stairs as a sign of imminent death, and another scarcely notices it? Why does one person assume a noise in the night is nothing to worry about, and another find themselves paralysed by anxiety? The answer lies in our preconceptions, ideas, and habitual thought processes – what the founder of cognitive behaviour therapy Aaron T. Beck termed ‘schematic beliefs’. These schematic beliefs are forged through our life experiences. And they’re so ingrained and automatic that we’re usually unaware of their existence.

  There’s nothing inherently negative about cognitive schemas: they allow us to quickly orient ourselves to the situations in which we find ourselves. But Beck discovered that people with anxiety disorders typically possess unhelpful schematic beliefs about themselves, the world around them, and the future (what’s known as the cognitive triad). For example:

  • ‘It’s always wisest to assume the worst.’

  • ‘Trouble can strike at any moment; I must always be ready.’

  • ‘I’m a vulnerable person.’

  • ‘I must be in control.’

  2. Aaron T. Beck is recognized as the father of cognitive behaviour therapy, the most effective form of treatment for anxiety problems. One of the world’s leading researchers into psychological disorders, he is Professor Emeritus of Psychiatry at the University of Pennsylvania and founder of the Beck Institute for Cognitive Behavior Therapy. Beck has been acclaimed by the American Psychological Association as ‘one of the five most influential psychotherapists of all time’

  If we believe such things, we’re likely to overestimate the threat facing us, and underestimate our capacity to cope with it.

  Anxiety problems, if untreated, can be extremely persistent. But why is this? Anxious people can spend huge amounts of time worrying about events that have never happened to them, and indeed are very unlikely to occur. Why don’t they realize that their anxiety is misplaced? Why don’t they learn from experience?

  This is a question that has received a great deal of attention from clinical cognitive psychologists. One of their key discoveries is that people with anxiety problems adopt a range of strategies – known as safety behaviours – designed to prevent the occurrence of whatever it is they fear. So, for example, a person fearful about social situations will seek to avoid them; if this is impossible, they’ll fall back on other techniques such as ensuring they attend with a friend, dress as unobtrusively as possible, and keep a low profile. These safety behaviours may reduce anxiety in the short term, but they prevent us discovering that our fearful thoughts are unwarranted – and thus end up strengthening our anxiety.

  Researchers have built on Beck’s work to identify other cognitive biases underlying and sustaining anxiety disorders. Like safety behaviours, patterns of thought and behaviour that seem designed to ward off anxiety only end up tightening its grip. For example, people with anxiety problems are extremely vigilant for possible threats. But because their attention is so focused on potential danger, they tend to overlook those events that don’t fit this rather bleak view of the world. This in turn can lead to an overestimation of the likelihood of danger occurring (psychologists call this threat anticipation)
and lots of false alarms – all of which only fertilizes the ground on which anxiety grows.

  There’s a tendency to interpret ambiguous events negatively. This is a particular problem given that so many of the situations we encounter are inherently ambiguous, usually because it’s so difficult to know how other people really think and feel. A telling example of this attentional bias was provided by an experiment that asked participants to spell a series of homophones (words that sound identical but have different meanings), for example: die/dye, slay/sleigh, pain/pane, weak/week, and guilt/gilt. The more anxious a participant was, the greater the likelihood that they would opt for the more threatening spelling of the words. People with anxiety disorders are also prey to unsettling or even downright alarming images, rather than thoughts. An individual with social anxiety may possess an entirely inaccurate mental image of themselves when in social situations. Rather than thinking things through rationally, they use instinctive emotional reasoning. David Clark, the leading cognitive psychologist of anxiety, has explained:

  It seems as though a mental model of the patient’s observable, social self was laid down after an early traumatic social experience and this model is reactivated in subsequent social encounters.

  This matters all the more because research suggests that images exert a much more powerful influence on emotions than do thoughts. As with the other cognitive biases, this susceptibility to mental images enables anxiety to perpetuate and intensify itself.

  Neurobiological theories of anxiety

  When it comes to detecting and responding to danger, the [vertebrate] brain just hasn’t changed much. In some ways we are emotional lizards.

  Joseph LeDoux

  What happens in our brains when we feel anxiety? Until the relatively recent development of neuroimaging technology, which allows biochemical activity in the brain to be recorded and pictured, scientists could only conjecture. But remarkable advances have been made in recent years, as we’ll see in a moment.

  First, however, a word of caution. Neuroscience has come a long way in a short space of time. But even were we to understand exactly how our brains function – and we are still a very long way indeed from that end point – we wouldn’t thereby possess a complete explanation for our experiences. For example, though scientists can now be much more certain than ever about which parts of the brain are involved in anxiety, it is understood that no emotion can be reduced merely to a set of brain events and structures. There are always other levels of explanation, including the behavioural and cognitive aspects we’ve discussed already in this chapter.

  The way in which such levels work has been nicely captured by the neurobiologist Steven Rose:

  The language of mind and consciousness relates to the language of brains and synapses as English does to Italian; one may translate into the other, though always with some loss of cultural resonance. But we do not have to assign primacy to either.

  It’s the same with anxiety; scientists approach the issue from different perspectives, but none of those perspectives has priority and all are interrelated. The best theories join up the different levels, and cognitive neuroscience has begun to do that, as we’ll now see.

  Long before the advent of neuroimaging, scientists had suspected that the brain’s limbic system plays a major role in the production of emotions. The limbic system in humans closely resembles that found in the first mammals around two hundred million years ago. It is part of the forebrain, a relatively recent part of the brain in evolutionary terms, and is arranged in an approximate circle around the much more ancient brainstem (‘limbic’ is derived from the Latin for ‘border’). Its job is to make a rapid and pre-conscious appraisal of a situation in order to help determine which emotion (and therefore reaction) is appropriate.

  Also located within the forebrain are two other key components of our emotional system. The frontal lobes of the cerebral cortex lie directly behind the eyes, and handle many of the tasks we tend to regard as quintessentially human, such as planning, decision-making, language, and conscious thought. It’s the frontal lobes that consciously think through and regulate our emotional responses.

  3. Joseph LeDoux (b. 1949) is a US neuroscientist and Director of New York University’s Center for Neural Research. LeDoux’s ground-breaking research has highlighted the central role played by the brain’s amygdala in the experience of anxiety and other emotions. LeDoux is also vocalist and guitarist with The Amygdaloids, a rock band who specialize in ‘songs about love and life peppered with insights drawn from research about mind and brain and mental disorders’

  In this, the frontal lobes are assisted by the hippocampus, which helps form and store contextual memories – vital benchmarks as the frontal lobes figure out how best to react in a given situation.

  Joseph LeDoux has been foremost in identifying one particular region of the limbic system as the brain’s ‘emotional computer’, and as especially important in relation to fear and anxiety. That region is the amygdala, two small pieces of tissue shaped, in the view of early scientists, like almond seeds (amygdala is the Latin for ‘almond seed’). The amygdala seems to be responsible for fear reactions in all species that have one, including reptiles and birds as well as mammals. It houses a store of unconscious fear memories, meaning that we can become anxious without knowing why. And it is extremely well connected to other parts of the brain. LeDoux has written:

  The amygdala is like the hub of a wheel. It receives low-level inputs from sensory-specific regions of the thalamus [another area of the forebrain], higher level information from sensory-specific [areas of the cerebral] cortex, and still higher level (sensory independent) information about the general situation from the hippocampal formation. Through such connections, the amygdala is able to process the emotional significance of individual stimuli as well as complex situations. The amygdala is, in essence, involved in the appraisal of emotional meaning.

  The amygdala’s connections don’t end there. Through the hypothalamus, it can influence the basic processes that comprise the autonomic nervous system (for example, breathing, blood pressure, and body temperature). As we saw in Chapter 1, changes to the autonomic nervous system when we’re anxious can lead to a wide range of physical effects including elevated heart rate, dilated pupils, and altered breathing. Prefrontal cortex

  4. The brain, showing the location of the amygdala

  The amygdala is able to make an appraisal of a potentially threatening situation extremely rapidly – so rapidly, in fact, that we may not realize why we’re suddenly feeling afraid. LeDoux has suggested that the amygdala offers a ‘low road’ to fear responses, supplying a ‘quick and dirty’ reaction to events that is designed to save our life first and ask questions later. The ‘high road’, by contrast, involves sensory information being processed by the frontal lobes (the part of the brain responsible for thinking things through) before it reaches the amygdala. The high road is more accurate, but slower. As you might imagine, both routes have their advantages and disadvantages.

  Important though the amygdala seems to be, we shouldn’t forget that anxiety – just like any other emotion – is the result of an extremely complex process involving multiple regions of the brain. As we’ve mentioned, these regions include the frontal lobes and the hippocampus; also involved is the insula, a part of the cerebral cortex that helps us become aware of internal feelings, and several neurochemicals. Among the most significant of these neurochemicals are:

  • Corticotropin-releasing hormone (CRH), which is triggered when the amygdala detects danger and in turn sparks the release of stress hormones to ensure that we’re ready for action in the face of danger; and

  • Gamma aminobutyric acid (GABA), which calms us down when we’re anxious.

  Given that anxiety is the result of a system rather than one element, what happens when that system malfunctions? LeDoux and others have speculated that people with anxiety disorders may possess:

  • An overactive amygdala, and/or:

&
nbsp; • insufficiently active frontal lobes, and/or:

  • a hippocampus that doesn’t pinpoint exactly which elements in a situation on the basis of past experience signal danger, meaning that they may become anxious unnecessarily.

  The amygdala, as we’ve seen, is a kind of rapid-response unit, triggering ‘just in case’ fear reactions that are then appraised by the more deliberative areas of the brain. But if the frontal lobes, for example, can’t make themselves heard over the noise emanating from the amygdala, we’re likely to experience unnecessary anxiety over what are essentially false alarms.

  There’s evidence that persistent anxiety (through the effects of stress hormones) can alter the way in which the brain functions, for example, by impairing short-term memory or even shrinking the size of the hippocampus. These effects are usually reversible, but in the long term they can become permanent.

  In the next chapter, we’ll look at two more perspectives on anxiety. How much of a role do life experiences play in making us vulnerable to anxiety, and how significant are genetic factors?

  Chapter 3

  Nature or nurture?

  ‘Murder, like talent, seems occasionally to run in families’, quipped the Victorian writer G. H. Lewes. Had he been discussing anxiety, Lewes could have allowed himself a little more certainty. Anxiety really does appear to run in families. For example, a person prone to severe anxiety is likely to have a parent – and even a grandparent – with the same problem.