Are We Thinking About Fear and Anxiety Wrong?

More than 40 million people in the United States have some form of anxiety disorder. But even those of us without a specific diagnosis sometimes feel overwhelmed by anxious thoughts.

My book Anxious is about anxiety, and its partner, fear. It explains what we know about these in terms of brain mechanisms, and uses brain discoveries to suggest why current therapies are not more effective, and how they might be improved. But this is not a self-help book. It is a book about the science of emotion and how this field could benefit from a clearer conception of what emotion is.

In the age of neuroscience, or what some call “neuroporn,” it is common to hear about fear or anxiety centers in the brain, areas that are responsible for these feelings. If we could get a drug that would specifically attack those centers, anxious or sad feelings might be turned off. But this idea reflects a poorly conceived idea about what fear and anxiety, and more generally, emotions, are.

Scientists have often adopted a “common sense” view of emotions as mental states that cause us to behave in certain ways: we run from a bear or snake because we feel fear. But what if the different circuits in the brain are responsible for feeling fear and running from the threat? In other words, what if running and feeling are two different consequences of the threat? That would mean that feelings of fear and anxiety, while correlated with behavioral responses we associate with them, are not necessarily the cause of the responses. If so, feelings of fear, terror, anxiety, dread, and the behaviors we often show when we have these feelings may be vulnerable to different risk factors and require different treatments.

The effort to treat fear and anxiety with drugs is a good case in point. Some major pharmaceutical companies have abandoned the antianxiety medication business—the products being developed aren’t doing the job the companies hoped. But the drugs may in fact be doing exactly what they were designed to do, and the companies simply had the wrong understanding of what they were studying.

For example, drugs used to treat anxiety are developed by placing animals in challenging situations. If they are less inhibited behaviorally, they are said to be less anxious. Then the drugs are given to people. An anxious person may then find it easier to go to a party (be less inhibited), but then still feel anxious while there. The drug changes behavioral inhibition—NOT feelings of anxiety. These are often confused.

What about psychotherapy? I think that the basic idea underlying psychotherapy is correct—that unwanted physical responses (behaviors and physiological reactions) and disruptive mental states (thoughts and feelings) both have to be changed in order to help the person. But existing therapies typically try to change both at once, with the result being that neither is effectively controlled.

Traditional talk therapy is not very effective at controlling ingrained behavioral and physiological responses; these may be better changed by recognizing their implicit (non-conscious) nature in the brain, and may be best altered by procedures that bypass conscious processes to alter implicit memories that control behavior. Cognitive behavioral exposure therapy potentially gets at the implicit processes but contaminates the effort by also engaging at the same time cognitive processes that seek to change thoughts and feelings.

The conscious mind does need to change as well, but this may be best done when the non-conscious systems are better controlled and are producing fewer consequences in the brain that interfere with cognition and consciousness—if your brain is revved up, as is often the case in anxiety, it’s hard to relax and focus on strategies for changing troubling thoughts and memories that are core elements of feelings.

In addition to these changes in the way drugs are developed and used and the way that therapy is done, there are things we can each do ourselves. The ancient methods of breath control and inner mental focus are valuable. Breath control activates the parasympathetic nervous system and shuts down the sympathetic system and the so-called fight-flight responses it supports. And mindfulness training allows the development of cognitive control strategies that help regulate the stream of consciousness.

We may not all be capable of becoming master meditators, but most people can probably benefit from these approaches. It might be especially useful if preschool children learned breathing exercises routinely so that they would have tools to cope with school and social stress. This preemptive approach may prevent or weaken the impact of early experiences that set the brain on the path towards a life of uncontrolled anxiety.