Are Worry and Anxiety Related?

What is the relationship between anxiety and worry?  Can an individual worry and not feel anxious?  Similarly, can an individual feel anxious but not worried?  The age-old debate of which came first…the chicken or the egg once again applies.  In today’s post, I will discuss anxiety, theories of anxiety’s relationship to worry, its physiological symptoms and its origins.  The next post will discuss treatment options.

WHAT IS WORRY?

Is worry merely a different name for anxiety?  Worry is an integral component of anxiety, although worry is a process that can exist in the absence of anxiety.  Let’s identify worry as a primarily mental (thinking) activity.  When an individual worries, their mind is preoccupied with fear or dread. Often thoughts have a prevailing theme of negativity - rehearsing the worse case scenarios. Worry can range from the nagging little voice inside your head to unrelenting obsessions that can neither be ignored nor quieted.  Depending upon the severity of the negative thoughts and the permanency of those thoughts (statements that begin with never or always) some level of physiological reaction frequently follows.  Ultimately the mind convinces the nervous system to prepare for battle.  This then triggers a fairly predictable sequence of autonomic physical symptoms that characterize anxiety (e.g., fear, racing heart, sweating & tingling sensations).  In this theoretical framework, anxiety is identified as the reactive symptoms an individual feels within their body in response to their mental state of worry.

An alternative theory suggests that when an individual feels a myriad of undesirable physical symptoms that seemingly “come out of the blue” they often question their origin (a mental process) and may begin to either hyper-focus on the severity of the physical sensations or obsess about an ultimately fatal outcome when these symptoms worsen. Worry is the mental process triggered by feeling anxious rather than the cause of the anxiousness. Ultimately when worry sets in the autonomic system prepares either to take flight or to fight.  Some individuals may then experience the very scary physical symptoms known as a panic attack.  Following this logic, a panic attack is an extreme physical manifestation of anxiety. Understand that an individual may feel both worried and anxious and not experience a panic attack.

What conclusions can we draw from this chicken or egg debate?  Both positions identify a relationship between the mental processes and the physical symptoms that define the term anxiety.  Anxiety is neither all bad nor is it always a diagnosable condition!  Historically it has served as an alerting and preparation mechanism to safeguard us from impending danger.  For anxiety to meet DSM-V diagnostic criteria symptoms must be frequent, extreme and a source of ongoing distress (at least six months).

SYMPTOMS

Many symptoms of anxiety can mimic those of a heart attack - if you experience them seek medical attention immediately! Anxiety can present as chest pain or tightness in the chest, numbness and/or tingling in the arms and/or legs, labored breathing (as if an elephant is sitting on your chest), racing heart, cold sweats, dizziness, chills, tightness in the throat, elevated blood pressure, ringing in the ears, restlessness and/or agitation, gastrointestinal distress and most frequently a profound sense of impending doom.

Remember that when we’re anxious our bodies are activated to either flee or fight. A great illustration of this phenomenon has been captured by many National Geographic documentaries that feature hunting behaviors of animals in the wild.  The predator (lion) stalks and takes chase after unsuspecting prey (gazelle).  The gazelle exhibits the flight mode, the lion the fight mode.  Our brains have not yet evolved beyond these basic primal responses!

Additional physical symptoms of anxiety may include a cluster of symptoms characterized by tension: feeling keyed up or on edge, irritability, muscle tension, fatigue and sleep impairment.  Sleep impairment may range from difficulty falling asleep to early awakening to unsatisfying sleep (sleeping but not feeling rested).  Cognitive symptoms of anxiety may often include a temporary inability to recall names, events and previously over-learned information (mind going blank). The best example of this phenomenon is test anxiety-despite knowing the topic, the test appears to be written in a foreign language because the student cannot remember anything.  When a person feels anxious, it can also seem that any attempt to learn or take in new information is impossible.  This is another example of the mind going blank.  Once the anxiety dissipates, cognitive abilities return to their normal level of functioning. In summary, while the symptoms of anxiety are specific to the individual, general themes involve cardiac-like symptoms, tension symptoms and cognitive symptoms. Now let’s look at who, what and where regarding anxiety.

ORIGINS

Recent statistics indicate as of 2011, anxiety surpassed depression as the primary complaint identified by patients to their general practitioner.  Historically, women have been twice as likely as men to present with symptoms of anxiety.  Recent literature also suggests that men may be closing this gap as anxiety becomes less stigmatized within the general population.  Anxiety appears to be more prevalent in developed countries and spreads across lifespans.  The differentiating factors are age-related concerns.  For example, children may exhibit anxiety regarding school concerns while adolescents may be more likely to report anxiety regarding dating, school and independence.  Adults may report anxiety regarding advanced education, professional growth, marriage, families and aging parents.  The elderly may exhibit anxiety regarding their declining health status, grief from significant losses and their own death. 

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, cites “childhood adversities and parental overprotection” as risk factors for developing anxiety.  Also reported in this edition is that one-third of the risk of developing a diagnosable anxiety disorder may be related to genetic transmission.  This is roughly equivalent to the genetic factors associated with a diagnosis of major depression. The balance of the contributing influences may be related to personal temperament.  This means that certain individuals who are harm avoidant, behaviorally inhibited and display negative affect may be more susceptible to developing an anxiety disorder compared to individuals who are more comfortable with risk, are behaviorally extroverted and display positive affect.

CONCLUSION

As I stated earlier in this post, if you intermittently worry and feel anxious, that may simply be a reaction to specific life events and completely normal: life can be stressful!  To meet diagnostic criteria, symptoms must be extreme, chronic and incapacitating.  The presence of panic attacks, symptoms that necessitate frequent emergency room visits and symptoms that render an individual unable to maintain appropriate daily self-care and social relatedness are of significant concern to both behavioral health and primary care professionals. In these instances, after a thorough evaluation, a diagnosis of anxiety may be warranted.

Stay tuned for Part II where I will discuss treatment options.  Specifics regarding panic attacks will be discussed in a dedicated post on that topic.

Are Children Who Underachieve Lazy?

Do your child’s academic reports contain comments such as “not working up to potential?” What does that mean?  I receive many “emergency” calls from parents once they receive progress reports and report cards.  They are confused and scared.  A common question is whether their child is lazy. Parents often tell me how their children did well for a period only to then demand more and more of their parents’ time to supervise, assist and even complete their homework and projects.  Is this a common occurrence in your household?

I do not believe that children decide to become lazy.  I do believe that children mask feelings of fear, embarrassment, anger and sadness as apathy. They can develop a fairly sophisticated set of behaviors to defend against those feelings. They may come across as lacking interest, may begin “forgetting” books, turning in poorly done or sloppy assignments, barely passing exams, blaming teachers and their parents as being too demanding, and sometimes, completely refusing to engage at school.  These behaviors tend to surface in transition years: third/fourth grade, middle school/junior high, high school and college. 

In the next several posts, I will focus on alternative explanations for “laziness” drawing on medical, cognitive, neuropsychological, academic/achievement and psychological perspectives. 
 

Medical Considerations:

Generally the child’s pediatrician is the first point of call for many parents seeking explanations for their child’s changed behavior, and rightfully so:  general health significantly impacts our ability to learn and retain information.  Vision and hearing deficits are a possible explanation for a perceived lack of interest.  Diet, exercise and sleep also may impact learning.  Before considering any other probable cause, a medical clearance is highly recommended.

Overall Intelligence:
 
Assessing a child’s overall level of cognitive functioning is an excellent next step.  Cognitive assessments provide a foundation for performance expectations and reveal relative intellectual strengths and weaknesses. 
 

Neuropsychological Considerations:
 

Neuropsychology refers to the relationship between the nervous system, especially the brain, and cerebral or mental functions such as language, memory, and perception. Determining your child’s learning style is an essential tool in determining the fit between a teacher’s instructional style and the ability of the child to assimilate what is being presented.  Is your child a visual, auditory or combined modality learner? Individual differences in working memory and long-term memory storage, as well as issues related to attention, focus and hyperactivity also are included in the neuropsychology category.  Some or all of these processes may impact your child’s motivation as well as their academic success.

Academic/Achievement Considerations:
 

What has been your child’s academic history?  Were there remarkable differences during their transitional years?  To what types of educators did your child most enthusiastically respond?  What was the student to teacher ratio when your child seemed to flourish?  Grades are not the only benchmark of academic proficiency, nor are the annual standardized STAR or IOWA basic skills testing administered by the schools. There are specialized testing protocols that can help assess everything from reading comprehension to math fluency and writing mechanics. 

Psychological Considerations:
 

The final category for consideration is psychological.  Low self-esteem, fear of failure and social embarrassment are all-too-common causes of performance issues.  Significant life events like births, deaths, divorce and relocation also greatly affect children.  Occasionally your child may even be suffering from depression or anxiety, both of which may appear very different in children than what we would expect to see in adults. 

Psychological factors are complicated and can be difficult to isolate. The good news is that most of these issues can be successfully addressed through a period of professional counseling.  

The categories are now outlined.  Does your child fit one and only one category? Not likely.  Frequently the causes are multi-dimensional.  Uncovering what may be impacting your child’s lack of motivation does not necessarily result in a diagnosis!  The main concern is that parents label their children “lazy” or “unmotivated” and then levy stricter punishments or restrictions prior to determining whether they are warranted.  The quality of your relationship with your child, a more chaotic home environment and a source of contention between you and your spouse may be at stake!  This is a situation that requires qualified professional intervention.   Assuming you see value in exploring alternatives to the label of “laziness,” stay tuned…. my next post will explain how to proceed. 

Life Lessons From March Madness

Since last Thursday many of us have been glued to our televisions, our computers and our brackets engaged in the cultural phenomenon known as March Madness.  Why?  I believe that we watch for very personal reasons – a love of collegiate sports, reliving dreams of our long lost youth, the excitement of competition, a social outlet and a renewed connection to regional loyalty.  This post will discuss some parallels between the underpinnings of March Madness and life transitions.  Hopefully it will add yet another dimension to your viewing experience, and if you have not yet become a fan, will encourage you to pick up the remote as the Sweet 16 is fast approaching!

An overwhelming concern of many of my clients in mid-life (40-50’s) is an absence of passion in their lives.  Their dreams have been realized; established and loving relationships, successful careers and nearly grown children. They are floundering about the next step.   Many cannot identify the last time they felt passion about anything. A lack of passion is also an overwhelming concern of my emerging adult (19-24) clients.  Their struggle differs in that they worry whether they will ever feel passion.  Their journey is about initial discovery, the mid-lifers is about rediscovery. 

 

Let’s look at the players on any team in the NCAA tournament.  Certainly they possess immense technical talent, the benefits of world class coaching, equally talented teammates and a love of basketball.  That being said each and every day teams with significantly lower seeds upset teams considered to be more elite.  Bad luck or poor calls by the refs cannot be the only explanations for the upsets.  One could contend that the lower seeds experience less performance anxiety because they enter the game as underdogs.  Therefore, they are less cautious and so are less likely to make errors based upon nerves.  I would suggest that teams are equally matched in the areas of felt anxiety and the resultant adrenaline rush when engaged in a heated battle.

The agony of defeat is also equally felt regardless of the seed, especially in a one or two point game.  When the higher seed loses, there is a sense of disbelief and embarrassment.  The lower seeds although disappointed, expected that outcome. However, I have observed a visible difference in the thrill of victory demonstrated by the underdog turned victor.  Their victories represent a dream realized rather than an expected stepping-stone to the playoffs.  I would like to suggest that March Madness undisputedly exemplifies the magical power of dreams! Dreams fuel the passion that drives the discipline and tenacity required to make them a reality.  Initially, the lower seeded teams feel victorious just to be asked to the dance whereas the higher seeded teams expect the invitation.  Their expectation is winning it all.  The difference is that the lower seeded teams enter tournament play hungry for a victory.  Temple led into the final seconds of the game, as did Iowa State, Butler and CAL.  Often when their dreams neared reality, high anxiety set in and their games faltered.

In adulthood we often become our own worst enemy.  We become so involved in leaping over the next steppingstone to success that we frequently forget to dream. A life without passion is a life without dreams to fuel the emotions.  We forget how it feels to hunger for the seemingly unattainable.  Based upon our successes, we expect to excel and therefore the anxiety that keeps us alert and productive often wanes.

The emerging adult so fears the embarrassment of the “missed shot” that they convince themselves that “shooting” is overrated.  That precludes them from ever being invited to the dance because they do not enlist the discipline required to prove the technical competence that would ensure an invitation.

Many authors are now focused on effective teamwork as the pivotal lessons learned from March Madness that need to be applied to the corporate arena.  I believe that long before focusing on teamwork, disruptive innovative thought that morphs from dreams and its concomitant passion needs to be harnessed.  A team without a mutual goal is merely a set of individual superstars. 

 

To my clients, present or potential, I challenge you to pick up your remotes and witness the possibility of dreams coming true.  The players’ passions are contagious, their tenacity inspiring and their emotions are laid bare on the court.  Allow yourselves the opportunity to dream and passion will soon follow.  Invest the time and energy to that end by removing the barriers that prevent this process from occurring. 

 

Every year I am excited for March Madness…don’t miss out on a great live opportunity to experience a renewed spirit and a healthy dose of inspiration! 

Confusion -The Hidden Gem of the Emerging Adult

Many emerging adults ages 16-24 are anxious and confused yet feel isolated in their suffering. Anxiety attached to feeling confused has become the dirty little secret that replaced emergent sexuality and underage drinking of generations past. Who fits this profile? This post explains that confusion is an essential element of this life stage that functions as a catalyst for growth. Therefore, it is the anxiety attached to feeling confused rather than the confusion itself that actually inhibits this process of healthy development. 

The young adults of whom I speak are often very accomplished, having been groomed since elementary school to excel in at least one sport, a fine art and boasting stellar academic records replete with the maximum possible number of Advanced Placements units. Many have equally impressive records of community service, maintain full social calendars and are considered Ivy League college candidates. 

A difference emerges among these candidates with respect to their parents. In one camp are young adults walking in the footsteps of their professional parents; in another are young adults carrying the added burden of setting a new standard for their families when it comes to academic and intellectual achievement.

Parents are not the singular force behind creating young adults who feel enormous pressure to embrace what lies before them. Certainly the practice of creating a resume has been either initiated or reinforced by well-intentioned educators and guidance counselors. These are cultural norms developed by adults who want to streamline the process for their children. Yet most adults can recall key missteps that created for them significant opportunity. Why deny the next generation this life experience? 

Erik Erikson, an infamous psychological scholar identified eight psychosocial life stages that form a healthy personality. Two salient stages in this discussion are Identity versus Role Confusion (ages 13-18) and Intimacy versus Isolation (ages 18-40ish). These stages have specific expectations for growth: exploring who we are and what we believe and then branching out and connecting deeply with a mate or through significant friendships. My clients appreciate knowing that what they are feeling has been identified as healthy in Erikson’s theory. 

Many of my young adult clients feel significant amounts of anxiety when the path that heretofore was finely crafted becomes an anchor cementing them to the past. They have often discovered a passion that better fits who they have become. Frequently they need to change majors, or perhaps transfer to a completely different academic institution. Socially, they may feel less connected to their established circle of friends who may have not questioned their path and are seemingly content. As a result, they either become isolated or assume the façade that life is great. One path is active isolation, the other - equally damaging - is emotional detachment.

How do young adults admit to their parents that they may feel confused and/or that they have deviated from the course they jointly crafted? Some young adults avoid the topic; others sabotage themselves by failing; some become physically ill in anticipation of the backlash; and a few, especially if they are rounding out the developmental stage of Identity versus Role Confusion, confidently lay their cards out on the table. The act of exposing their situation is of great value in establishing their identity and autonomy. Parents, on the other hand, often call my office and accuse me of undermining their authority! 

My suggestions to the young adults are two-fold. Rejoice in your confusion because how would you arrive at certainty without it? Understand that it is a component of a vital developmental stage. Also understand that remaining confused is equally as detrimental as following a preordained path that doesn’t fit! You will not magically arrive at the next stage of your journey. You must stay actively engaged in the process of not only exploring options, but also trying them on for size! That feeling is better labeled excitement, rather than anxiety generated from dread or boredom!  My second suggestion is to break the silence with your peers! That is how your relationships transcend the superficial and become significant – your next developmental challenge. 

Allow your parents the opportunity to understand the underpinnings of your angst. It is unfair to blame and dump your anxiety and anger in their laps and then smugly walk away. Engage in many conversations through SKYPE if you are away at school or face-to-face if you are local. This conversation would not ideally be had over the phone or through email. Engaging in self-sabotage through failing, illness and/or avoidance diminishes the credibility of your assertion to pursue your chosen path. Parents want their children to be happy and successful. Extend to them some time to shift gears and embrace your journey. In the meantime, continue to address your anxiety through self-care (diet, exercise, & adequate sleep), doing the difficult work in therapy and nourishing your friendships. You ultimately are responsible for your life choices so honor the process!