More than Just Jitters: A Harvard Professor Examines Anxiety Disorder

From a Lecture Series Presented by Professor Ronald D. Siegel, Psy.D.

No matter what you call it—misgivings, nerves, apprehension, unease—we’ve all experienced a form of anxiety at some point in our lives. But when “jitters” don’t go away or turn into something more substantial, you may have an anxiety disorder.

illustration of person hiding under desk for article on anxiety disorder

There is almost always some baseline of anxiety happening in the body and in the mind. Sometimes it is little fears, and sometimes it is big ones. Our tendency is to want to avoid painful experience, and in the process of avoiding it, we end up stuck in a loop that keeps us trapped for a long period of time. In some people, this can become a debilitating issue—one that is difficult to understand or relate to.

Learn more: Befriending Fear, Worry, and Anxiety

Creating an Anxiety Disorder in Just a Few Simple Steps

Most anxiety disorders develop through what is called escape-avoidance learning. You can create an anxiety disorder in just a few simple steps:

First, you must enter a situation. Let’s call it the supermarket, for example. And let’s say that you’re walking down the cereal aisle. Now the strict biological determinists or some behaviorist will say anxiety tends to arise at random. Other mental health professionals say, you know, I don’t really believe it’s so random. But I think the process is often unconscious.

Mental health professionals believe anxiety is an unconscious process not random. Click To Tweet

Let’s say I am walking down the cereal aisle. And let’s say something happened when I was five or six years old with my brother at the kitchen table involving Cocoa Puffs. It’s long since been repressed because it was a painful experience as a young child. But here I am walking down the cereal aisle and unconsciously I just happen to spy, out of my peripheral vision, the Cocoa Puffs. And that’s enough to bring up a little bit of anxiety because this is how associational memory works. It just takes a little trigger to be able to connect us back to something that has been difficult.

So, anxiety is going to arise. Now, we find anxiety unpleasant, so most of us try to take steps to get rid of it. Especially if we have misattribution, for example, I start to think, uh-oh, maybe I’m having a cardiac problem. Or, uh-oh, I’m getting short of breath. I may have trouble breathing. Or, uh-oh, I’m going to have a real anxiety episode.

I’m going to want to flee the situation. And chances are I’ll leave the cereal aisle. In fact, I may even leave the supermarket entirely and go out into the parking lot.

Once I get into the parking lot that’s going to feel better. The anxiety is going to abate. And this reduction in anxiety is called negative reinforcement.

Learn more: Anxiety and Mood Disorders

Negative Reinforcement

Negative reinforcement is a principle in learning theory about the reinforcement that comes from removing an unpleasant experience. Like, if I’m being hit over the head with a hammer and I do a certain behavior and I stopping being hit over the head with a hammer, I’m going to be more likely to do that behavior the next time, because it feels good to have the negative experience stop.

So, once this is negatively reinforced, what do you think is going to happen the next time that I enter the supermarket, even if I don’t go near the cereal aisle? I am going to have a thought that goes something like, gosh. I hope I don’t feel the way I did the last time I was here.

And that’s going to be enough to get a little bit of anxiety going in my mind and body. And once a little bit of anxiety starts going, I’m going to have another thought. I’m going to think, uh-oh. It’s happening again. And chances are I am going to get into the same loop, leave again, receive more negative reinforcement for fleeing, and after a while, I might start avoiding the supermarket entirely.

And then this can extend to other things. Then I could start avoiding the post office and other locations. This can work its way into full-blown what is called the agoraphobia, which is fear of the marketplace, fear of going out into the world. But even if it doesn’t get to that state, most of us develop these patterns, in little ways, around things that we’re afraid of and we start to avoid.

Closeup sad young man with worried stressed face expression, anxiety disordersWhy Therapy May Not Help

There is a little-known fact about anxiety problems, and that is that people with anxiety disorders are often more accurate at appraising risk than people without anxiety problems. Let me explain—give you an example of how this works.

A person with an anxiety disorder might be driving down the highway and a thought might occur to them:

Hm. I am hurtling through space at 60 or 70 miles an hour in a tin can. This is an inherently risky position. One moment’s inattention on my part, on the part of another driver, on the part of my mechanic, or even the highway crew, and I am going to be killed or maimed. You know, this feels scary. I think I will take the side roads.

Now, a person without anxiety problems gets into a car and thinks:

I am in a well-engineered automobile. I am certain that the designers and engineers at the manufacturing company were thinking about my safety at every juncture and not letting concerns about profit or loss or expense get involved in their decisions about design features.

And that fellow over there in the next lane screaming red-faced into his cell phone, he’s paying attention. He’s thinking about my welfare. My mechanic, I trust fully, and that sweet, pungent, smoky aroma that I get must be incense that he burns in the garage that helps him to pay better attention.

Furthermore, I know from my own experience, as well as talking to others, that substance abuse is extremely rare in my culture, so it would be very unlikely that any other drivers might be impaired at this moment. I’m enjoying my drive.

The problem is that people with anxiety disorders notice that life is fragile and it’s dangerous to be alive, that at any moment bad things can happen very readily to good people.

This becomes an issue in psychotherapy, because often what happens is a psychotherapist will hear a person with anxiety talking about their difficulties and the therapist, being well-meaning, will try to talk the person out of it, will try to point out that, well you shouldn’t really worry about this. It is a low-probability event and you should be OK.

The person with the anxiety disorder, if they have a good relationship with the therapist, they think, oh my therapist is a nice man or lady. Obviously, he or she is in denial. I will just go along until we can change the topic and talk about something more interesting and useful to me.

Learn more: Emotion Regulation Disorders

Components of Anxiety

Given this, how can we possibly help people with anxiety problems? Well, we can start by examining the basic components of anxiety. And researchers and clinicians alike have identified three of these components.

  • First, there is a physiological arousal, what happens in our body when adrenalin starts pumping around. We are going to discuss that in more detail in the next lecture, when we talk about psychophysiological disorders specifically.
  • Second, there is a cognitive and emotional part. There is all the future-oriented thinking and fear, and the accurate and inaccurate risk appraisal that we have just discussed.
  • And finally, perhaps most importantly, there are the behavioral aspects. There are the avoidance and rituals, the things we do to try to not feel anxious.

So how might we treat this? What would the answer be? Well, the general answer in modern psychology is exposure and response prevention.

Let me give you an example of how this works. It has been said that by the mid-1980s, there were no seniors left at North American universities with untreated snake phobias. This is because they had all been recruited for studies in the psychology department.

The Snake in the Office

The students would be invited to come into the lab and they would sit them in an office and just talk to them. They would tell the student that there was a snake locked in a cage down the hall.

In the early days, they used to think that it was necessary to do something called reciprocal inhibition—in other words, to train the student to do something so that they should feel less anxious. So, when the student starts going uh-oh, what kind of snake? they would start teaching them relaxation training and things like that.

They have since learned that it’s not actually necessary to teach the student relaxation training. All you must do is stay with the experience long enough until the anxiety abates by itself.

So, what you do is you talk to the student, describe the snake, answer their questions, and wait it out. Wait until nothing happens and eventually the anxiety starts to abate.

Then, you move the snake a little bit closer. And you tell the student, well, now it’s in the next office. They get anxious again, you wait for it to calm down. The essential thing is to get to the point where you can bring the snake into the office.

So, you have the snake in the cage and the student sitting in front of it. The next step, which of course is the hardest, is you must remove the lid of the cage, take out the snake, and have the student handle the snake.

Picture of a Reticulated python. It looks its crawling towards the viewer.

And if, as a researcher, you’ve had sufficient foresight as to choose a non-venomous species, if you do this several times, the student loses their snake phobia. Basically, the fear response becomes extinguished because they experience that nothing terrible happens.

Learn more: Anxiety and Fear

Mind(fulness) Over Matter

Now when people are coming into therapy for anxiety problems, they are not actually interested in handling the snake, by and large, or whatever the equivalent might be. People want us to eliminate the anxious feeling. Instead, what we’re going to do, in a mindfulness-oriented approach, is to increase their capacity to bear it, to change their relationship to the experience.

Doing mindfulness practice regularly allows opportunities for anxious feelings and impulses to be accepted and integrated so that we no longer fear and resist them. Then, the source of anxiety abates.

Keep reading:
Why Are We Stuck in the Future? A Harvard Professor Examines Anxiety and Mindful Thinking 
Stress Management: Arousal and Value Judgement
Raising Your Emotional Intelligence – The Torch with Jason Satterfield

From the lecture series: The Science of Mindfulness: A Research-Based Path to Well-Being
Taught by Professor Ronald D. Siegel, Psy.D.