- Pathological anxiety is defined by its intensity, disproportionality, and functional impact.
- When it comes to anxiety, doing what feels most self-protective often just reinforces our fears.
- Exposing ourselves to our fears and learning how to tolerate anxiety is the key to its extinction.
If you strike me down, I shall become more powerful than you can possibly imagine.
—Obi-Wan Kenobi, "Star Wars"
Like many psychiatric symptoms, anxiety can be conceptualized along a spectrum that ranges from the normal to the pathological. At the normal end, anxiety represents an adaptive human response that's part of the body's warning system that alerts us to dangers. It often manifests as transient fear, causing us to step back from threats—like snakes and heights—that could cause us serious harm or death. And it can also take the form of more persistent worry about potential or ongoing threats, ideally providing the kind of motivation we need to take action to safeguard ourselves against the real possibility of danger—like when we purchase insurance or install smoke alarms in our homes.
When anxiety becomes pathological, it's often because of its intensity, disproportionality, and functional impact. For example, when anxiety and fear intensify to panic and when worries blossom into disproportional mental ruminations about imagined rather than actual threats, the result is that we often freeze up or get stuck in our heads to the point of immobility. And since normal anxiety is a necessity for survival, not having any anxiety would also put us in harm's way. So, whether it's too much or too little, the outcome is much the same—pathological anxiety prevents us from taking the necessary action to figure out how to deal with the issues that lie at its root.
Wanting to Escape the Source of Our Fears
Because excessive anxiety is so visceral, including not only mental panic but physical symptoms including a "nervous stomach," chest discomfort, or trouble breathing, it's often experienced as intolerable. As a result, our natural response isn't to problem-solve, but to avoid—we tend to be more focused on "flight" than "fight" and will often try to do whatever it takes to escape the source of our fear.
Sometimes that can be helpful—if we're in danger of being bitten by a rattlesnake, then running away is a good idea. But when we're afraid of potential threats rather than actual threats—like when we face situations that trigger our trauma-based fears—running away isn't always the best option. And it isn't always possible—when the source of our fear is the worry that's in our heads more than anything else, often the only imagined escape is to turn off our minds by doing something like drinking alcohol or using other drugs. While the term "self-medication" is sometimes invoked in this context, the reality is that such attempts at pharmacologic avoidance are usually more counterproductive than therapeutic.
The paradox of anxiety is that what feels most instinctual and self-protective—escaping from the source of our fears or trying to ablate intolerable anxiety with a drink or a pill—often just reinforces it by teaching us that our fears are too powerful to face. It also primes us to monitor for its return when we are able to find temporary relief, but if we're constantly scanning the environment for threats or our bodies for evidence of fear, we're certain to find it.
Evidence-based interventions to treat pathological anxiety typically involve the opposite of avoidance. Medications like selective serotonin-reuptake inhibitors (SSRIs) don't dampen anxiety in the moment the way that something like alcohol or a benzodiazepine like lorazepam (Ativan) or alprazolam (Xanax) can; they more optimally diminish ruminative thinking and cut pathological anxiety off at its source.
Psychotherapies like acceptance and commitment therapy (ACT) encourage us to sit with our anxiety, compassionately acknowledging its presence, and letting it go in the moment through mindfulness meditation. Cognitive-behavioral therapy (CBT) involves challenging the cognitive distortions that might be causing undue anxiety along with a component of gradual or graded exposure to what we're afraid of. Psychodynamic therapies explore the conscious and unconscious roots of our anxiety, getting into the weeds of our fears.
The Power of Exposure
Whatever the therapeutic intervention for anxiety, it's exposure that's most likely to lead to extinction. In other words, treating pathological anxiety often requires allowing ourselves to feel anxious. That doesn't mean "white-knuckling" it or subjecting ourselves to terror; it's more about engaging with and confronting our fears "one step at a time" in a safe and therapeutic setting with someone at your side. Through that process, we can do the work we need to do to shift from being immobilized by fear or from incessant worrying to problem-solving.
Of course, that's easier said than done, but that's the paradox of anxiety. What comes most easy for us when we're anxious is often the last thing that we need.