023 Anxiety – Part 1

Anxiety is a feeling of worry, nervousness, or unease about something with an uncertain outcome. At low levels it prepares us for an experience with low predictability in case the outcome is not good for us and we need to act quickly and decisively to become safe. This is a good thing.

Video link to the video this is a transcript for

Anxiety heightens our perception of change and harm so that we can better prepare for emergency action. That action is usually driven via the fear reflex – freeze, flight and fight.

Anxiety is supposed to be short term, and give us a clear idea about what we need to be cautious about, even if you can’t see it. Anxiety is generally about known situations that should pass.

Ongoing anxiety keeps you at a level of alertness all of the time. It drives hyper vigilance, hyper reactivity and can cause misperception of the circumstances, leading to poor decisions.  

At higher levels, anxiety can incapacitate one’s quality of life, as the anxious person is frequently enacting the freeze and flight fear response, and less commonly the fight fear response.

If you are responding to a simple problem, like a wild animal, then freeze, flight and fight are excellent responses. These often don’t work well with modern civilisation, where it is rare that you need to fight off animals or act in an emergency situation. In modern civilisation you need more nuanced and subtle solutions to life.

The difference between a fear response and an anxiety response is that with fear, the threat really is there and the consequences are that bad. An anxiety response is in the absence of a tangible threat, after the tangible threat has passed, or the response is in excess of the threat.

It is natural to feel anxiety when entering into a new situation, or where the outcome of an action is perceived to be very important to one’s future. It is not normal to feel anxious in the absence of such a situation. If someone is feeling anxious most of the time, there may be a disorder involved. 

The word “disorder” is a medical term we use to describe when something has got in the way of living your life.

We are going to take a whirlwind tour of a few different types of anxiety disorder.

General Anxiety

General Anxiety describes how someone can feel anxious in most places – whether it be the privacy of their own home, safely in their own room; or at work/school; or at a peaceful park. The feeling of anxiety is independent of the location. If this level of anxiety is a core component of your decisions to or not to do tasks, it is likely going to be called a disorder and be labelled General Anxiety Disorder, or GAD for short. It is frequently positively responsive to a class of medications called “SSRI”, which stands for Selective Serotonin Reuptake Inhibitors and generally benefits from talking therapies. If you experience general anxiety and it is interfering with your life, please talk to your doctor about this.

Social Anxiety

Social Anxiety describes how someone can feel anxious in the presence of strangers, acquaintances, friends and family. While not all people will necessarily trigger anxiety for a person with social anxiety, the feelings of anxiety diminish when alone and not thinking about other people’s judgments, reactions or negative experience of the person with social anxiety. In essence, in the absence of others, there is little to no anxiety. 

Social Anxiety is usually a side effect of some other category of problem and is commonly found with autism, ADHD, PTSD or trauma. For some of these, medication can help reduce the symptoms, for some talking therapies are more effective, often a combination of both. Once it has been established that the type of anxiety is social, the therapist should check to see if one of these other conditions (Autism, ADHD, PTSD or trauma) are also present and better explain the anxiety experience.

OCD

OCD stands for Obsessive Compulsive Disorder. Many people mistake OCD for other psychological traits. Let us debunk a few of those.

A person who can’t stand a tile being out of place in the bathroom, for example, or some other broken pattern has a keen Sense of Correctness or Sense of Pattern. While a Sense of Correctness is common in with Autistic people, it is not exclusive to Autistic people, and is quite helpful when accuracy is needed in your job. It is not OCD.

Someone who hyperfixates on a particular interest, or person, or object, can seem obsessive, but this is not OCD either. Again, this is not uncommon with Autistic people, and again this character trait is not exclusive to Autistic people. 

Ritualistic behaviour is a trait in common with OCD, but is not exclusive to OCD. Consider people who follow a particular religion that has specific set of rituals involved, or someone who just really likes the milk poured in their coffee first, not second, or maybe the other way around. Familiar patterns are commonly found with Autistic people, and again are not exclusive to Autistic people. 

I have mentioned autism a few times in connection to OCD. That is because in my experience, autistic people are frequently mistaken for having OCD. While it is possible to be Autistic and have OCD, the OCD diagnosis has to be carefully done by not assuming a sense of correctness, fixation on details or comfort in patterns/rituals means OCD.

OCD is a combination of Obsessive and Compulsive traits that are either beyond the control of the individual or very difficult to resist. Here, obsessive describes a thought or idea that seems to intrude upon the person’s mind and seems like it comes from elsewhere. It is not a pleasant thought or idea; and compulsive describes actions or rituals taken that are repetitive and perceived to prevent an unlikely or disconnected event, generally of a catastrophic nature. As mentioned before, it is a disorder because the thought intrusion and the requirement to do the action interfere in one’s life.

I have included OCD here because of the anxiety component involved. The person will feel very anxious about the future catastrophe and extreme anxiety and fear in the absence of doing the ritual that staves it off, or if the ritual is incomplete or no longer effective.

Some OCD is a learned behaviour, where a person fears an outcome that is generally beyond their control. They perform some kind of unusual action and in so doing, find a feeling of relief. As the fearful outcome has not actually been effected by this relieving action, the anxiety mounts again, so the action is repeated again with a soothing outcome. This cycle repeats and the training of the behaviour becomes stronger.

Most OCD has a neurological component and some medications are quite effective at relieving the symptoms. 

Generally a combination of talking therapies to address the perception of fear and find non-ritualistic methods to self sooth combined with pharmacological treatment are the best solution.

PTSD

PTSD stands for Post Traumatic Stress Disorder. It is one of the best initialisms in the psychiatric part of medicine as it literally tells you what it is in plain language. This is the Stress one feels after a traumatic situation, where that stress has reached the level of a disorder – that is, it interferes with your quality of life.

One person’s bad experience can be another person’s trauma, and that other person’s bad day can be the first person’s trauma. What I am trying to say here is that trauma is personal. Most of us would agree on some common themes of what should be a traumatic experience for most people, such as war, death, pain etc; but not everyone will agree on uncommon themes, such as a long term adversarial experience with a parent, or workplace bullying, or being misnamed. 

PTSD is generally diagnosed after a person has had a reasonable time to process an experience and adjust, but hasn’t. PTSD is characterised by flashbacks, difficulties sleeping, avoidance of certain stimuli related to the traumatic event, decline in mood, hypervigilance, disassociation and a number of other traits. Not all of these need to be present in the person’s post trauma stress. 

I have included PTSD here as a common aspect of the condition is anxiety about when symptoms are going to occur, anxiety regarding a recurrence of the traumatic event and the avoidance of certain stimuli. 

PTSD can be exaggerated by untreated and undiagnosed ADHD, various Personality Disorders and/or anxiety disorder. Sometimes a traumatic event can exaggerate the symptoms of these and be mistaken for PTSD. For those who are assessing, it is important to do a careful investigation of when traits first appeared and not stop looking when a traumatic event has been identified. In my experience, it is not uncommon that behaviours and traits pre-date the traumatic event, and the traumatic experience has dysregulated a management method.

Treating PTSD requires talking therapy and is frequently supported by medications, especially if there is a background condition identified that was not previously being treated.

Phobia

Phobia comes from the greek root word Phobos, meaning “fear” and is used to refer to an avoidance or running away from that which we irrationally fear. Most people have a thing that they are more uncomfortable around than most, and when that level of discomfort drives the individual to an action or makes other actions near the object of fear difficult, the discomfort is considered to have become a phobia. Generally there is little to no logic behind the source of fear. There are long lists of things that people irrationally fear and we are not going to list them.

Earlier I outlined that anxiety is a fear response to thing that is not present, but is anticipated to cause potential harm, and that an anxiety disorder is where that anxiety is either persistent, or disproportional to the event or object.

With phobia, the anxiety is disproportionate to the object that inspired fear. The person with the phobia will frequently try to justify their fear of the thing so that it seems reasonable and rational. However if no one else (or very few) fears it, even when comprehending it, then the likelihood is that the fear is disproportionate or misattributed to a thing that does not deserve it.

Sometimes the fear is secondary to a disgust reflex, where the individual has learned at some level that “that is wrong” and is thus disgusted in the presence or thought of the thing. This disgust is hard to reconcile, so the feeling is quickly changed to fear. This fear can then be hard to socially demonstrate, and so it is then transformed into anger. When we append the word “phobe” to the end of a noun describing a particular group of people, we are often referring to people that are aggressive about that group. When we look at the source of that anger, it is fear, and when we look at the source of that fear, it is disgust. This disgust is irrational and hard for someone to reconcile.

Phobias and phobes can be managed via talking therapies, which will frequently use various forms of exposure therapy after upskilling the person to manage their mood around the source of fear, and upskilling the person’s mind frame about the thing. This may include some careful use of sedatives to decrease the feelings of anxiety such that the lack of consequence from the thing is observed and internalised. Because the phobia is often based on a fundamental illogical disgust reflex, refreshers of exposure may be needed for many years.

It is important to note the difference between a phobic response to a stimulus and a pain response to a stimulus, such as what Autistic people experience. You can desensitise from the fear / aggressive response to a thing, but you cannot desensitise from a pain reaction to stimulus (such as loud noises). That pain response can trigger aggression and avoidance, and can easily be mistaken for anxiety or phobia. This pain response requires a different method of management, which may include some of the same tools as noted before – reframing and exposure, but will often implement sensory aids such as earphones, gloves and tinted glasses, depending on the source of the sensory overload.

Conclusion

While this is not an extensive list, we have covered some of the more common forms of anxiety, why they are different to each other and some of the common errors in diagnosis and treatment.

These forms of anxiety respond well to talking therapies and some benefit from medication. Most of the talking therapies will use similar methods to address the anxiety component.