A Sigh of Relief

PART ONE

The Anatomy of Calm

By Stephen Porges, Ph.D.

As a culture, we are endowed with the belief that anxiety, packed as it is with worry, is a condition that exists in our head. Decades of psychophysiological research have proved to me that, in fact, anxiety is in our body. It’s even more accurate to say that it is in our nervous system. Like other animals, we humans have a unified nervous system. The body and the brain talk to each other—because they regulate each other. That system of regulation offers a whole new understanding of how we become anxious, how we perpetuate and even justify anxiety, and how we can release it.

Our physiologic state influences how we react to the world and how we make our way through it.

Unfortunately, it is nowhere accounted for in most models of mental health. My perspective differs from the prevailing model in psychology and psychiatry, which sees anxiety as a brain reaction, not a full-body phenomenon. Psychology holds that through cognitive and behavioral technologies, anxiety can be tamed with language. But the evidence demonstrates that certain physiologic states bias us to negativity and others to optimism and social experience, and we need a toolkit that grapples with that fact first.

Anxiety, like other emotions, arises from different bodily states as the neural signals they give off work their way up through the brainstem, where control of our basic states resides. That information also gets relayed to higher levels in the brain, where we make meaning of it—what we call emotions. Anxiety is the response of the body under threat.

One of the first obligations of all organisms is to maintain a means of defense. The ability to detect danger is critical to defense, and acute threat reactions, in which we quickly mobilize resources, are life-sustaining. Chronic threats, however, impose high costs on our physiology, disrupting the homeostatic mechanism that allows us to grow and flourish, not only imperiling our health but constricting our range of experience and, especially, our ability to relate to other human beings.

Every single one of us contends with states of threat, which are our responses to the uncertainty of survival. Threat can emanate from the external world or arise internally from memories. I devised the term neuroception to describe how—below the level of conscious awareness—neural circuits constantly monitor and assess internal and external risks, whether situations or people, as safe, dangerous, or life-threatening.

A potent mechanism that has the potential to down-regulate threat resides in the ventral portion of the brainstem, in an area known as the nucleus ambiguus, where the vagus nerve, the star player of the autonomic nervous system, originates. Vagus means wandering, and the vagus nerve begins at the base of the brain, branches down to the heart, the lungs, and the digestive tract, with stops along the way at the larynx, the pharynx, and the diaphragm, before descending into the abdomen.

The branches of the vagus nerve enable the organs to adjust instantly to the demands of a person’s surroundings. It is the duty of the vagus nerve to orchestrate bodily responses to keep you safe or prepare your body for danger before you are even aware of it or have a chance to think about it. Most of the vagus is composed of sensory fibers that function as our surveillance system, informing the brain of the status of our visceral organs.

In our evolutionary journey to becoming social mammals, the basic reptilian structures underwent modification. In order for animals to become social, there had to be a way to turn off threat reactions—animals had to be able to cue one another that they were safe enough to come close to. As distinct from reptiles, mammals have neuroception not only of threat but also of safety. The vegas nerve responds to cues of safety—detected by higher brain structures—which bring on enough calm to open you up to socially engage with others.

Because information flows both to and from the brain via vagal pathways, the vagus nerve can be thought of as a major mind-body highway. Through the vagus nerve, you react to signals in your environment in ways that calm, alarm, or dysregulate the body, and these states in turn create emotional experience and play out in behavior. It has taken me decades to define how the vagal pathways operate and the control they exert—summed up in what I call polyvagal theory.

Polyvagal theory explains the interconnectedness of body reactivity, cognitive and emotional function, and social behavior. It reveals that we humans are meant to regulate each other, that proximity, social interaction, and intonation of voice are all powerful neural signals.

As states of visceral calm get transmitted up to the brainstem, the information is also relayed to more highly evolved brain structures, allowing full access to the brain’s talents and means of expression and enabling social interaction—which has the effect of perpetuating the state of neural calm. But in potential danger states—such as completely novel
environments—those higher systems turn off; we don’t have access to problem-solving skills, to powers of creativity, to our full intelligence. We become vigilant and defensive. The vagal circuitry narrows our focus, mobilizes our resources, and prepares us to fight or flee, tripping the so-called stress response.

If the danger is so overwhelming that there is no escape or there is a feeling of being trapped, a third circuit of vagal operations engineers a shutdown. In this state of numbness, social contact becomes an intrusion and is aversive. None of the bodily responses are voluntary, and often people are not aware of what triggered them—although they are likely aware that their heart is pounding or their body is trembling.

As a social species, we evolved to neurally regulate and be regulated by those around us. Such co-regulation is perhaps most obvious in early life, when infant caregiving audibly modulates the baby’s state. Think of a mother singing to her crying baby. Vocalizations are a way of broadcasting physiologic state. Universally, low growl sounds are understood as threat signals. Through evolution from reptiles to mammals, the middle-ear bones broke off the jawbone and enabled the hearing of a frequency band that became the channel for social communication. Prosodic voices are in that bandwidth.

How much co-regulation people need varies significantly among individuals. But it is completely mistaken to think that we can manage threat states by ourselves. Sociality is a potent neurophysiological modulator, more potent than pharmaceuticals, more important than surgery. It’s not just nice to be friendly—our nervous system requires it. We can quantify its impact. And we can apply it as an intervention.

People go a long way to make meaning of the agitated physiologic state we call anxiety. There’s a package of negative emotions that get stirred by it. Using higher brain structures—memory, associations, previous learning, contextual learning—we create narratives of worry that attribute the driving force to something external and that literally keep us in this state. Most people find it difficult to separate the worry from the physical disturbance, but it’s possible: Worry is a personal narrative we create in a state of threat to justify why we feel bad.

Polyvagal theory not only explains anxiety as a physiologic state of threat, it also opens a portal of intervention. Applying specific maneuvers affecting vagal pathways, we can use the nervous system to reset physiologic state. Independent of the threshold of reactivity that pitches a person into alarm mode, it is possible to re-educate the nervous system with cues of safety. Removal of the threat isn’t a bad tactic, but it is not what the nervous system demands: It needs cues of safety. Shift state and you change the character of experience.

The most direct way to access the neural pathway that turns off threat is through breathing—exhaling slowly. Our evolutionary journey endowed us with a gift—the ability to extend exhalation; this not only enables us to regulate our state, it also underlies the ability to speak. Neurophysiologically powerful, it acts on fibers of the ventral vagus nerve ferrying signals between visceral organs and the brainstem, where autonomic control of body organs originates. Extending the duration of phrases—even humming and gum-chewing—stimulates the nerve fibers of the muscles of the face, head, and oral cavity and opens the social engagement system, enabling people to respond reciprocally to the invitations of others.

Gaining control of physiologic state through breathing is why some people turn to yoga and meditation. Singing uses the same neurophysiological structures of breathing and facial muscles as the social engagement system. Playing a wind instrument gives you no choice but to exhale slowly. But most anxious people feed the physiologic state of threat by making slow inhalations and rapid exhalations.

Even CBT has breathing components. Breathing sets the stage for the cognitive work. If you shift a person’s state into calm, then cognitive and behavioral therapies can be extraordinarily efficient. But if physiology isn’t supporting calmness, they can’t work. A person is too tightly wrapped in a state of defense.

The job of therapist is to co-regulate a patient. An individual in a state of chronic threat is not capable of dialogue, not responsive to any form of co-regulation. The person expresses negativity—a reliable indicator of physiologic state. While breathing quickly shifts physiologic state from the bottom up, it is also possible to change state from the top down. The anxious person can be asked, What puts a smile on your face? Was there a time when you felt safe, comfortable, secure? Was there a time you enjoyed getting up in the morning? Tell me about that. That exchange initiates a shift of physiologic state.

Once the internal neural dialogue is shifted from threat/defense to safety, physiology shifts, and many systems of the body are downregulated. Cascades of chemical communication dampen down, including cortisol release. Cues of safety coming through the ventral vagus circuit—familiar faces, intonation of voice—shut off the defensive systems. The shift is immediate and global; no rewiring is required. The body goes into homeostatic mode, with use of resources for restoration and repair.

Shifting physiologic state restores access to your whole self. Memory and higher capacities are available. You become cognitively present to solve problems. The social engagement system becomes a portal to gaining back our human heritage.

PART TWO

Why Are Worriers So Bad at Worrying?

By Graham Davey, Ph.D.

I’m a born worrier.

You’ve heard that phrase before, maybe even uttered the words yourself. Worriers are interesting creatures. Chronic worrying is a prominent feature of many anxiety-related mental health problems and a prominent indicator of someone who regularly suffers stress and anxiety. But worriers seem to be proud of the fact they’re worriers and have no inhibitions about letting others know of their affliction.

If worrying were an Olympic sport, my mother would have had a cabinet full of gold medals. When family members reassured her that the bad things she regularly worried about would actually be fine, she'd respond with You know me, I’m a born worrier. That phrase, which defines many people, reveals a couple of things: that she’ll be worrying about something again in the near future and that she can’t change that.

But there is no gene for worrying. In reality, studies show that it’s an activity developed over a lengthy period of an individual’s lifetime by a variety of complex factors. This complexity of factors makes it difficult for people to understand why they worry so much—so their worrying seems uncontrollable. Their inability to understand why they worry and why they can't stop gives rise to the only credible explanation worriers can think of: I must have been born this way.

But that type of reasoning is fallacious. In fact, I’m a born worrier serves two purposes. It sends the message I have to worry, so don’t try to stop me, and it explains to the worrier why worrying seems so uncontrollable.

Those of us who research such matters are not yet certain about the developmental processes that give rise to chronic worrying, but we do know quite a bit about the psychological processes that maintain it. First, chronic worriers are very good at catastrophic worrying, asking endless What if…? questions that elaborate a whole range of potential negative outcomes. A lot of what they worry about never happens—up to 90 percent, studies suggest. The imagined disasters exist only in their heads and never materialize in the real world. Why do these people worry so much if hardly any of the events actually happen?

Another worry researcher, Adrian Wells, a professor of clinical psychology at the University of Manchester in England, regularly begins conference presentations with a dramatic opener: I wake up every morning worrying about being trampled to death by a herd of elephants. The audience invariably looks bemused. A herd of elephants? In Manchester? After a brief pause, he explains: But I haven’t been trampled to death yet—so my worrying must be working! If you view your worrying as a way to stop something bad from happening, then, when it doesn’t happen, it may seem as if your worrying has been worth it. Worriers develop very strong beliefs that worrying is necessary to prevent bad things from happening—even though there is usually no causal relation between their worrying and the failure of feared events to materialize. Such beliefs turn worrying into a compulsion that the worrier finds difficult to control.

A strong belief in the utility of worrying drives the onset of worrying. But why is it so difficult to stop worrying? For the chronic worrier the off switch seems to have fallen off!

Chronic worriers are actually very bad at almost every aspect of worrying. For example, they beat themselves up during worrying rather than coming up with constructive solutions. In early studies colleagues and I conducted, we found that self-bashing themes—of personal inadequacy, low self-esteem, and lack of control over events—would creep into the worry stream. We even asked worriers to imagine they were the Statue of Liberty and that they were worried about the state of world affairs. Sure enough, the same self-depreciating themes emerged in their worries. Feelings of personal inadequacy are a near-inevitable consequence of worrying, regardless of what's worried about.

Chronic worriers also have poor problem-solving confidence. It’s not that worriers don’t have good problem-solving skills—those skills appear to be as good as anyone’s. It’s that they have low confidence in their ability to solve problems. This means that worriers have problems deciding on solutions to problems and putting possible solutions into practice.

Worriers’ beliefs about worrying drive them to keep doing it—but how do they decide it’s time to stop worrying about a particular problem? Well, because they’re not so good at objectively telling if they’ve actually solved a problem, they’ll usually end up defaulting to their mood.

A positive mood says, You’re OK, so you can stop worrying. But a negative mood says You’re not OK, so keep on worrying. Most worrying occurs during negative moods, such as anxiety, depression, tiredness, and stress—moods that are telling the chronic worrier to keep on worrying. Be clear: This is not a conscious process, and that’s one reason why it’s so difficult for chronic worriers to understand why they can’t seem to control their worrying.

Worrying and anxiety are uncomfortable bedmates. Both are responses to the threats and challenges that occur during our daily lives. Anxiety is that visceral feeling you get when you’re confronted with these threats and challenges. In contrast, worry is just one of the cognitive processes we deploy to help us understand the threats and challenges and evolve solutions for them. However, high levels of anxiety often thwart successful problem-solving because they’re associated with poor problem-solving confidence, poor perceived personal control, taking responsibility only for negative but not positive outcomes, an increased tendency to define events as threats, and the deployment of avoidance or emotion-focused coping strategies. Quite a list!

This is why we often feel even more distressed at the end of a worry bout than when we began: Our anxious brain has successfully steered our thoughts down a better-safe-than-sorry route, identifying even more potential threats for us to be wary of and failing to solve problems to our own satisfaction.

For the chronic worrier, worrying is not just about solving problems. It’s not just about a driving need to identify future problems. It’s not just a desire to deal with anxiety-provoking threats and challenges. Chronic worriers tend to be ineffective worriers because, for them, worrying triggers core issues with self-confidence, self-efficacy, and self-esteem—all issues that can be addressed successfully in treatment for chronic worrying.

PART THREE

Six Lessons Anxiety Teaches Us

By Steven C. Hayes, Ph.D.

Almost 40 years ago, I sat on a shag carpet in the middle of the night dying of a heart attack. Or so my mind told me, until I realized that what posed as heart failure was just a new, more horrifying form of a panic attack.

Already years into a “life and death” struggle with anxiety, that was the last straw for me. Nowhere was safe. Even simple tasks like sleeping, breathing, walking, or talking could become impossibly difficult. I saw no way out.

As I sat cross-legged, bouncing on the bottom of absolute despair for who knows how long, I suddenly realized that my struggle with anxiety was orchestrated by a voice within me. The voice said it was me—but it couldn’t be “me,” because I was hearing it. Instead, now seeing a way in (not out), I turned on it and declared my independence, saying aloud to an empty room: Apparently you can make me hurt; you can make me suffer. But I’ll tell you one thing you cannot do. You can’t make me turn from my own experience. I stood up swearing a solemn oath: Never again. I will not run from me.

In the four decades since, I’ve learned a lot about anxiety and how our thoughts and emotions can combine in toxic and psychologically inflexible ways. The intervention method I originated and codeveloped, acceptance and commitment therapy (ACT) is by now one of the most researched and broadly applicable interventions in behavioral science. When I look back over those decades and that body of empirical work, six lessons stand out.

1. Let Go of Evaluations. When we experience an emotion, we quickly evaluate it as good or bad, as something we want or as something we do not want. These evaluations often overshadow our emotional experience. We dive into “anxiety is bad” before we even know what we are feeling or where we feel it. Anxiety can present itself in all kinds of ways: from trembling hands to a churning stomach, to electricity flowing through our body. We might feel uneasy, restless even, with a sense of impending doom. Thoughts and fragments of memory flitter through our minds. Odd as it may sound, there is a richness to anxiety as a whole experience that we deny ourselves by immediately labeling this experience as “bad” and rushing to escape from it.

That “voice” I heard on the shag carpet was not a hallucination; it was the expression of my inner evaluation and problem-solving that told me I had to run, fight, freeze in place, or hide from “bad” emotions. You probably have your own version of this experience. If you slow down, however, and respectfully decline that command, you can learn from your emotions. You can observe the anxiety. You can ask yourself questions like Where do I feel my anxiety? What is it encouraging me to do? Is it moving? What else am I feeling? Describe the experience of anxiety, appreciate it, and then grow stronger because of it.

2. Open Up to Your Anxiety. Underneath anxiety are often other emotions that ask for attention. There may be sadness, loneliness, regret, jealousy, or even anger. And when we fail to address these other emotions appropriately, more anxiety is likely to follow. The healthy way forward is to open up to anxiety and these other hidden emotions. This means taking a moment to notice and feel the emotions inside of your body. Observe them. Feel them. And then breathe into them and allow them to expand inside of you. You can ask yourself, What else am I feeling right now? and What else is inside of these feelings?

When I began to feel my anxiety willingly, to my surprise I discovered a profound sense of helplessness and sadness lying underneath—stemming from the domestic violence I witnessed at home as a young child. It took years, but gradually these suppressed parts of my history reached the surface as I learned to create a safe place to experience emotions.

Letting go of evaluations and opening up to your experience is not a one-and-done event. It’s more like an ongoing conversation with someone important to whom you haven’t spoken in a long while. Metaphorically, instead of shutting the conversation down at the earliest possibility, stay curious and learn more.

3. Let Go of Control. A dozen years into my ACT journey, I was giving an important talk to a small group of some of the world’s leading scientists. I had not had a panic attack for years. Anxiety attacks were now behind me.

Not.

As I stood up to speak, I almost fell to my knees with an overwhelming pounding and visceral sense of an oncoming panic attack. For a brief second, I shrieked inside, No! Not here! Not now! No! This wasn’t just a thought; in that instant I chose “no” as my mindset on my anxiety.

And then…I stopped. I turned and looked at the screen as if to ponder my talk. In what felt like an eternity, I changed my choice. I found my way back. I recall thinking If I have a panic attack, it will be their problem—I will not make it mine.

The talk went well, but those brief moments of “no” caused several months of familiar mind chatter: You need to take a pill! Panic is back! You will humiliate yourself!

I had learned a humbling lesson. Yes, emotional openness often produces peace of mind, but it’s a mistake to assume that means that you can control the content of your emotions. Stay with what you can control: your relationship to your emotions.

4. Look at the Other Side of Anxiety. One reason why it’s so important to open up to our emotions is that underneath difficult emotions are our deepest yearnings. We hurt where we care, and we care where we hurt. I’ve never met a socially anxious person who doesn’t want to be with people. If you are struggling with an emotion, stop and flip it over. What does this emotion suggest you deeply care about? For me I yearned to connect with others but feared I was not good enough. Oddly, when I admitted that more openly, those connections came.

5. Listen to Your Body. Human cognition is likely only several hundred thousand years old. By contrast, the ability of our animal ancestors to feel and learn by experience is half a billion years old. When you put your problem-solving mind on a leash, you can begin learning from your anxiety and other emotions more intuitively. Focus less on solving challenges and more on experiencing them within your body. This is about what you are feeling. The mindset of observing, describing, and appreciating emotions and sensations goes beyond interpretation. It starts with your own body as your history affects it. Taking time to feel fully and without needless defense goes beyond your evaluative mind.

6. Don’t Cling to “Good” Feelings. In our culture, we are often told to be happy, to feel confident, and to have pride. But for emotions to do their work, these cannot be fixed in place. They must come and go—like a flowing river over ever-changing features of our current situation. A person who is clinging to “happiness” is not really happy. The very act of clinging says, This cannot go away or else! which in itself causes unhappiness (very much as with the emotion avoider who has a mindset that says, This cannot show up or else!). In the world of emotion, if you’re not willing to lose it, you’ve lost it.

It’s common to think that mental health concerns only the one out of five with a diagnosed disorder. Nonsense. Mental and behavioral health involves developing psychological strength and flexibility. This means being in touch with the ebb and flow of your internal experience—your thoughts, emotions, memories, urges, and sensations—yet holding all of them lightly enough that you can still direct your energy and actions toward your goals, values, and aspirations. That combination of strength and flexibility applies to five out of five of us, 24/7.

This is the core of what my colleagues and I have learned since that night on the carpet 40 years ago. Challenges such as anxiety ask us to develop the psychological skills needed to be who we really are, taking on board the difficult parts of our own history and carrying these forward into a life worth living. It begins now and will never end. Your own experience will guide you, but modern behavioral science now knows enough to facilitate that journey of discovery.

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