Peak Performance for Anxiety Sufferers

Research shows our worries aren't as well-founded as we often think.

Posted Apr 28, 2019

     "Beyond my anxiety, beyond this writing, the universe waits, inexhaustible, inviting." —Jorge Luis Borges, A Personal Anthology

People diagnosed with anxiety disorders are often concerned that they aren’t doing as well as they should be doing. This can be true for people with social anxiety disorder, who fear and often come to believe that other people are judging them harshly, laughing at them, or otherwise finding them worse than worst; for people with generalized anxiety disorder, who chronically ruminate, nagging at themselves day in and day out, and often experiencing physical symptoms, such as muscle tension, headaches, and nervousness; and for people with obsessive-compulsive disorder, who are bound to compulsive behaviors and obsessional thoughts which can take over in the form of time-consuming rituals and routines, strong superstitions, and considerable sadness and frustration.

Can You See the Real You?

Given that anxiety disorders, like other psychiatric conditions, including depression and post-traumatic stress, change the way we perceive ourselves and others—distorting our sense of reality—are those of us who struggle with anxiety disorders really as bad as we think we are? How much do anxiety disorders change the way we function, and is it always negative? Here's a place where self-doubt can be healthy—learning to be skeptical of self-defeating thoughts and critique entrenched, negative self-representations.

As the psychiatrist and founder of Interpersonal Psychoanalysis, Harry Stack Sullivan, noted, people can be seen as having three basic kinds of self-identifications or "personifications": "Good Me," "Bad Me" and "Not Me." If we have a pretty good sense of self, we are usually in tune with the Good Me versions of or variations on ourselves. Greater anxiety biases us for Bad Me, a seductive place where the risk of failure seems more tolerable, because we are pre-judged as lacking. Let's not talk about Not Me, where the existence of whatever it is about ourselves is too troubling to even entertain, kind of like Jung's idea of the Shadow, the Dark Night of the Soul.

How to Separate Truth From Reality

Two recent studies offer optimistic findings for people learning to live with anxiety, recognizing when anxiety is useful and informative, and when anxiety tries to tell us things about ourselves and others which simply are not true. In psychoanalysis, the term "transference" is used to name distortions that cause us to read things into other people which are not there, traditionally a form of identification. A therapist reminds me of my father, and then when the therapist does something my father used to do, I jump to an emotional conclusion that it was for the same reason as my father. 

Our brains process social information as well as self-referential information. The information pathways for these different categories of information overlaps, because we are inherently social. Personal information is mediated by the social context, and how people act toward us can influence how we see ourselves.

In a way, this is similar to the Freudian notion of transference, a kind of noise which makes interpretation of social information in driving self-assessment sometimes ambiguous. Anxiety past a certain threshold, anxiety which begins to affect executive function in the frontal cortex, throws off correction of distorted ideas, sometimes making it seem as if our worst fears were coming true.

Generalized Anxiety Disorder and OCD: Perception Versus Performance

In the first study, researchers from the University of Pittsburgh and Yale University compared healthy controls with patients diagnosed with generalized anxiety disorder or obsessive-compulsive disorder. They wanted to look at how people with clinically significant anxiety might be different both in terms of actual and perceived performance. Would people with an anxiety disorder see themselves as less-than, and would this be reflected in how they actually did on tasks? Would anxiety convey any advantages?

Researchers looked at anxiety through the lens of what psychologists have named the Dual Mechanism Control Theory, a psychologically and neuroscientifically based approach to understanding how two different decision-making systems ideally work together to determine behavior, or clash and cause dysfunction. Dual Mechanism Control Theory focuses on two contrasting features of brain function: proactive control and reactive control.

According to the study's authors, “Proactive control is a form of early selection (i.e., filtering out irrelevant information at earlier stages of processing) and involves the effortful and active maintenance of task goals over time. By contrast, reactive control is a late-stage correction mechanism that is mobilized only after a conflict or other triggering stimulus is detected.”

Proactive control requires long-term thinking, planning, intentionality, allocating of future resources in a thoughtful way, developing contingency plans to be responsive to unexpected events, and so on. Reactive control is in place to fix issues which come up when the proactive elements run out of options. When foresight runs out of contingency plans, reactive systems are ready, willing, and variably able. Variably able because, as we know, reactive behavior doesn’t always fit the situation at hand, especially when we have been pre-conditioned to expect people and the world to be different from how they really are.

Participants in the study were evaluated using standard diagnostic interview tools and several clinical research-standard scales for anxiety, stress, worry, depression, OCD, and related conditions, as well as the Attentional Control Scale (a self-report assessment of how well a person can direct their attention). They took tests measuring their actual performance on tasks requiring cognitive control, using the AX-Continuous Performance Task, to look at proactive and reactive strategies for deciding how to deal with a challenging situation involving split-second decisions about whether or not to press the right key, depending on how changing sequences of letters are presented on a computer screen. Finally, participants’ task effort was estimated by looking at how often they selected more draining proactive control strategies over those who chose the path-of-least-resistance reactive strategies by looking at which AX-Continuous Performance Task sequences they favored (some being more proactively and other more reactively biased decisions).

And here’s the first piece of good news. Even though the average person in the anxiety disorder group saw themselves as performing more poorly, on actual performances measures they were as good as the control group. They felt like they weren’t able to pay attention, but they actually focused well. The anxiety disorder group even showed a tendency to perform faster and with greater effort than the healthy control group on proactive tasks. Clinical participants tried harder than healthy controls overall, while the healthy controls made a greater effort in association with less worry. 

Be Chill

In the second study, researchers from the University of Greenwich, London wanted to find out if higher levels of social anxiety would impair social performance in actual social situations. They recruited people for the study and had them participate in two different socially demanding tasks. In the first, they had three minutes to put together a speech either arguing about it being OK to lie or that any crime can be justified. They then delivered the speech to a few other people, whom they thought were other study participants, but were actually secret-agent researchers rating their performance. In the second task, participants had to meet someone new (again, an undercover researcher) and get to know them as much as possible during a three-minute conversation. Public speaking and meeting someone new, both situations which can be challenging and even seem impossible when social anxiety is high.

Participants completed a self-assessment Social Phobia scale. Their baseline level of anxiety and anxiety during the task was measured, and how well they did socially was evaluated using the Social Performance Rating Scale, looking at five elements: Gaze—quality of eye contact; Vocal Quality—the sense of clarity and connection conveyed in tone and manner of speech; Length—how much they mumbled and droned on; Discomfort—how much they looked physically out-of-sorts, fidgeting or looking stiff, etc.; and Flow—how well they spoke and included what the other person was saying into the conversation.

The second piece of good news is that people with higher levels of social anxiety were good when it came to communication—they spoke smoothly and were free to hold a good conversation. They looked more nervous to observers, but did fine in the interaction. Don’t pay too much attention if you feel physical anxiety, perhaps mentally tag it as a symptom but then move on—even if your body feels off, or your voice shakes a bit. It may be helpful to remind and reassure oneself that it isn't as bad as anxiety leads us to believe, with research to back it up. For others, however, even "knowing" that it isn't as bad as we think has little impact. The emotional reality trumps what we know to be objectively (so to speak) true.

Anxiety, friend or foe?

Listening to anxiety is a tricky business. Threat, fear, and stress responses serve important functions for us, changing the way the brain works to better match a more challenging environment. Anxiety helps direct attention and prepare the brain and body for dealing with a potentially tough situation. Stress responses prepare us for action, shunting resources away from non-essential functions. Anxiety can motivate us, making us aware of a problem which needs to be addressed. How do we know when to obey anxiety and steer clear of something, or make a note of anxiety's alarm and move forward into the anxiety provoking situation?

There's an unclear tipping point after which adaptive, moderate anxiety levels trail off, and higher anxiety levels start to cause distortions. Anxiety can tell us that the environment is more challenging than it actually is, magnifying our sense of worry about negative outcomes and causing us to doubt our competence. This defensive response can protect against the emotional risk of failure, while also making it more likely one will fail by undermining our sense of self-efficacy and making us feel like we can do it.

The present research shows that when people persevere in the face of anxiety, we do perform as well on cognitive and social performance metrics (at least those used in these studies) as do people without clinically significant anxiety. Knowing this is the case makes it easier to counter self-defeating inner voices, choosing "yes" over "no," steering clear of self-fulfilling prophecy land, and moving forward with confidence.

Author: Grant H. Brenner, MD, FAPA