According to the National Institute of Mental Health, almost one out of every three US adults will suffer from some form of anxiety disorder at some point in their lives. In addition, among US adults who have experienced an anxiety disorder, around 23 percent report serious impairment and 34 percent report moderate impairment in the normal activities of daily life, work, or school (based on data last updated in 2017).
This makes anxiety disorders the most common group of mental disorders in the US, affecting tens of millions of individuals each year. But that’s not the worst of it; these numbers represent only the reported or documented disorders. Even if we cannot officially classify our anxiety as severe or chronic, most of us will nevertheless face anxiety in some capacity over the course of the year. In other words, virtually everyone can benefit from learning more about the causes and management of anxiety.
In Unwinding Anxiety, psychiatrist and professor Judson Brewer distills into a single volume over 20 years of research and practice in the diagnosis and treatment of anxiety and addiction. It turns out that, while anxiety is highly treatable, most people are taking the wrong approach. Let’s take a closer look at the science of anxiety and how it can be managed more effectively.
Anxiety manifests itself in habits
Dr. Brewer’s first key insight is that anxiety manifests itself in habits, and, as such, some people may not realize they are struggling with anxiety at all. But whether we realize it or not, we all tend to self-treat our anxiety by creating habits, some of which are positive, but most of which are detrimental to our health (e.g., overeating, smoking, or drinking alcohol). The first step to overcoming anxiety, then, is to understand the origin of the habits we want to eliminate or replace, and this requires understanding how the brain works to create anxiety in the first place.
Crudely speaking, the brain can be divided into the older, instinctual part and the newer, higher-level thinking and planning part (prefrontal cortex). Our older brain (in evolutionary terms) is the seat of fear, which is differentiated from anxiety in the immediacy of its response. For example, if a car is barreling down on you, you will experience an immediate fear response and will jump out of the way before consciously thinking about your actions. The fear response is quick and automatic and comes with the standard physiological responses (rapid heart rate, tightening of the stomach, high blood pressure, etc.)
The fear response in the above example comprises three elements: the environmental trigger, the behavior, and the result or reward.
- Trigger: the threat of being hit by a car
- Behavior: jumping out of the way
- Result: avoiding injury or death
Fear is our body’s automatic, evolutionary method to quickly take action to avoid harm. It is therefore quite useful in a variety of situations; problems arise, however, when our newer, thinking brains co-opt the fear response to create longer lasting anxiety about potential future events that could be harmful.
Because our thinking brains can run simulations of the future—and because the future is uncertain—we map out scenarios in our minds about future disastrous events and then worry about the possibility of their realization. This results in the basic formula for anxiety:
Anxiety = Fear + Uncertainty
Because there are a multitude of things to fear, there are a multitude of things to be anxious about, which we can see in the myriad types of anxiety disorders that exist. We each have our own fears and anxieties, and these all manifest in the habits we form as self-treatments. These self-treatments, however, simply create habits based on short-term fixes that often have long-term negative consequences. Then, these habits (smoking, overeating, etc.) become the parts of our lives we most want to change.
But change is, while not easy or quick, within our reach. In fact, Brewer has developed a three-step approach in his clinical practice (and based on his research) that has been shown to be highly effective, and that runs counter to the idea that we can simply use willpower to overcome our urges. In the battle between the old brain and new brain, the old brain usually wins, unless we can learn to leverage how our minds naturally work—using the principles of rewards-based learning—to our own advantage.
Unwinding anxiety in three steps
Briefly, the three steps to the effective management of anxiety are as follows:
- Identify your habit loops
- Update the reward values of the behaviors you want to change
- Replace your old habits with new, healthier habits
Let’s review each in turn.
Step 1: Identify your habit loops
If our anxiety manifests itself in habits, the first step to treating your anxiety is the identification of your problematic habit loops. To see how this works, let’s use the example of smoking, which, by now, almost everyone can agree is a habit that offers no actual benefits and several negative consequences. Smoking is the quintessential bad habit that is both addicting and disastrous for your health.
If you’re a smoker, you might notice that you tend to get cravings most intensely after a stressful event, maybe after a tough day at work, for instance. Here’s what the habit loop looks like:
- Trigger: stressful day at work
- Behavior: smoke a cigarette
- Result: temporary relief of stress and anxiety
Of course, the act of smoking brings only temporary relief. The anxiety will return, which will require another cigarette, ad infinitum. This short-term self-treatment of stress and anxiety is no long-term fix, and, on top of that, it creates its own long-term health consequences.
While identifying the relevant habit loops is a critical and necessary first step, simply recognizing them is not enough to quit. Your new brain cannot outbid your old brain when it comes to updating the rewards of behaviors. You can tell yourself that smoking is bad for you; you can reprimand yourself for every cigarette you smoke; and you can remind yourself that smoking increases your risk of developing cancer. You can even tell yourself that you will never smoke another cigarette again. But it’s just not that easy. Faced with significant stress, the reward centers in your older brain will compel you to reach for that pack of cigarettes and your new brain will have to concede.
As Brewer explains, while a select few individuals have the brute willpower to change habits on a whim, the majority of us require a different approach—one that takes advantage of how our brains naturally respond to rewards.
Step 2: Disenchant your old habits
We saw in step one that it is nearly impossible to override the reward centers of your brain. If cigarettes temporarily relieve severe stress and anxiety, the temptation is too great for your thinking brain to override. You can’t simply think yourself out of old habits; instead, it’s far more effective to use two critical tools that can help you update the reward value of the behavior you want to change: mindfulness and curiosity.
Using our smoking example, instead of reprimanding yourself for smoking a cigarette, instead pay close attention to the actual experience of smoking. You might notice, for example, how the act of smoking makes your lungs feel contaminated and short of breath, or how the smell or taste is very unpleasant. Rather than mindlessly smoking as a way to relieve stress, you can focus instead on the negative aspects of the experience itself, including any associated negative feelings you experience during and after smoking.
As a quick recap, if you’re a smoker, remember that in step one you identified your habit loops. You will have mapped out the environmental triggers (most commonly stress) that create cravings. In step two, you become curious about the way your mind works and about the actual experience of smoking. You’ll identify smoking as an ineffective means of relieving anxiety, and will further recognize that the experience itself is not rewarding. Over time, the negative aspects of the habit will be internalized, and the behavior will become disenchanted. Here’s what your new habit loop can look like:
- Trigger: stressful day at work
- Behavior: smoke a cigarette
- Result: Feel contaminated and short of breath; experience the unpleasant taste in the mouth, foul smell, etc.
The same process can apply to any habits. If you struggle with overeating, focus on the full and bloated feeling you get when you’re done eating. Force your old brain to relearn and re-associate negative feelings with the habits you want to change, and over time your brain will come to stop seeing these behaviors as inherently rewarding. That’s when you can move on to step three.
Step 3: Replace your old habits with new, healthier habits
Continuing with the smoking example, now that you’ve disenchanted the act of smoking, you can begin to deal with the anxiety itself. But first, a word of caution.
You’ll notice that Brewer is not recommending immediately replacing one habit with another in step one or step two. Several of his patients that went the replacement route directly have either failed or simply established new habits that need replacing. For example, if you substitute eating candy for smoking, you’ve just replaced one bad habit with another. Even if you successfully quit smoking, you now have a candy addiction you need to resolve.
The more effective approach—confirmed by several of Brewer’s own patients—is to first spend time mapping your habit loops and working on the process of disenchantment. That way, when your old habits become less rewarding, they also become easier to replace with newer, healthier ones.
But again, not just any habits will do. What we’re looking for are habits that are readily available, inexhaustible, and capable of reducing anxiety in the long-term, rather than just in the short-term. Two behaviors fit the bill, and are the very same things we encountered in step two: curiosity and mindfulness.
If you think about it, there really is no escape from the things that cause your anxiety. The habits we typically create (smoking, drinking, avoidance) in response to our anxiety provide temporary relief, but even if we replace them with other habits (eating candy), this doesn’t resolve the underlying source of our anxiety. We have no choice but to face the things we fear. The alternative is to suffer from constant anxiety due to the possibility of their eventual realization.
Let’s take social anxiety as an example. If this is the reason we smoke or drink or overeat, none of these habits have the capacity to resolve our fear of social events in the long-term. There is only one way to overcome the source of your anxiety in this situation: retraining your brain to view social situations as rewarding rather than threatening. We know that social situations themselves are not inherently threatening, or else everyone would suffer from social anxiety. The fact that some people seek out socialization and some do not tells you that the problem is psychological.
How can we overcome social anxiety in this situation? Only through mindfulness and exposure to social situations. While it won’t be easy, there really is no alternative, other than medication (another bad habit?)
So instead of running away from our fears and anxieties and coping with them through unhealthy habits, we face our fears with full awareness and the motivation to overcome them directly through repeated exposure. This is the basis of exposure therapy. Patients focus on the situation and its positive aspects through mindful awareness and curiosity rather than dwelling on their internal anxieties and fears.
Overcoming our fears feels good, and over time, this consistently positive feeling, if we pay attention to it, updates the reward centers of our brain. Using the brain’s natural reward-based learning process, we can begin to associate social situations (in the case of social anxiety) with positive outcomes.
The benefits of mindfulness and curiosity
We’ve seen the benefits of mindfulness and curiosity throughout the three-step process. We used mindfulness in step one to analyze how our brains work and how to map out our habit loops. We then used mindfulness in step two to focus on the negative aspects of the behaviors we wanted to change, in the process disenchanting them. Finally, in step three, we used mindfulness to confront our underlying fears through exposure, focusing on the positive aspects of the situations we fear and the positive feelings that come with having overcome our fears.
Since mindfulness is the key to all steps, training the brain to become more aware is an important step in the process. That’s why meditation—which is effectively mindfulness training for the brain—has been shown to be so effective in reducing anxiety. But we should remember that we can’t just practice meditation and expect our fears to vanish—we must also have the motivation to conquer them, and we must seek out challenging situations as tests to overcome. Only then can we rewire our brains to remove the fear once and for all.
Unwinding Anxiety: New Science Shows How to Break the Cycles of Worry and Fear to Heal Your Mind is available on Amazon.com