Three in five Americans experience anxiety over world events, family safety, or financial security, according to a recent mental health poll by the American Psychiatric Association. In this edited conversation, clinical psychologist Rachel Zack Ishikawa, who is also an instructor in the Department of Psychiatry at Harvard Medical School, spoke to the Gazette about when anxiety, a normal response to stress, can morph into a mental health disorder, the role of social media in its spread, and how to prevent it from interfering with everyday life.
Feeling anxious can be normal. When can anxiety become a mental disorder?
As humans, we need the capacity to feel anxious. Moderate levels of anxiety actually improve performance on things like taking tests, playing sports, or giving a presentation. It can be helpful because it encourages people to pursue things that are challenging, and it gives them the opportunity to feel the rewards of success.
“Anxiety and avoidance reinforce each other in a vicious cycle.“
The problem with anxiety is that it feels terrible. For some people it can feel intolerable. And this is when it becomes problematic. When we believe that anxiety is bad, we may start avoiding the sources of anxiety to make those bad feelings go away. Anxiety and avoidance reinforce each other in a vicious cycle. It becomes a disorder when it meets diagnostic criteria, causes clinical distress, and interferes with normal functioning. Anxiety disorders are the most common of all psychiatric disorders. About a third of adults will experience an anxiety disorder at some point in their lifetime.
Does that mean that anxiety is increasing?
If you think about anxiety disorders, there is a large genetic component so we wouldn’t expect that to change over time. I think what we are seeing is a real pronounced shift in the acceptability of anxiety disorders; there are more people who self-identify as having anxiety and who seek treatment. If you’re asking someone whether they have symptoms of anxiety, people may be more likely to say yes as the language of anxiety becomes more familiar to them and seeking help around anxiety becomes more commonplace.
What are the best ways to prevent anxiety from interfering with our normal lives?
We can think about managing anxiety in three different ways. One is to target behavioral avoidance, the propensity to avoid the situations or activities that bring on anxiety. The second is to target ruminative worry, or the automatic negative predictions about the future. And the third is to target what we call hypervigilance, the intense attunement to the physiological component of anxiety.
I’m a cognitive behavioral therapist, and CBT clinicians use the term “exposure-based living,” which describes moving toward rather than away from the sources of anxiety. For example, if you can notice the things that you might say no to because they make you a bit anxious and then move toward those situations instead of away from them, that provides an opportunity for new learning. The brain can learn that most anxiety-provoking situations are not actually dangerous, and that creates the opportunity to learn that you can handle the distress that arises when you challenge yourself.
“The brain can learn that most anxiety-provoking situations are not actually dangerous, and that creates the opportunity to learn that you can handle the distress that arises when you challenge yourself.“
The second strategy is challenging the unhelpful thoughts that pop in involuntarily and tell you that things are not going to work out, or something bad is going to happen. What you can do in those situations is ask yourself some questions that can help you develop more flexible thinking such as, “Do I know for certain that this outcome is going to happen?” or “Are there any other possible outcomes other than the one that I’m afraid of?” This exercise can encourage more balanced, realistic thinking and less of the catastrophic thinking that fuels anxiety.
And the last thing would be to target the physiological experience of anxiety: racing heart, shortness of breath, sweating, trembling, nausea, etc. We interpret the physical sensations as a sign of danger, but we can remember that these are just physical sensations; they don’t mean that something dangerous is coming our way. This calms down the nervous system and reduces the activation that comes with the perception of threat. Those three things are key to intervening when you start to notice anxiety building.
What is the role of social media in the rise of anxiety?
Most studies will show a link between social media and anxiety, and although the findings are mixed, they show that problematic social media use is associated with mental health issues, particularly things like self-esteem, negative social comparison, and loneliness. What studies are showing is that the nature of social media use matters; people who passively use social media, scrolling through other people’s feeds and posts without interacting with others seem to have a greater risk of negative outcomes. Whereas people who more actively use social media, by sharing links or communicating through DMs, are shown to be at a lower risk of negative outcomes and sometimes even more likely to report better psychological well-being.
We also are seeing poor outcomes for people who use social media for emotional or social validation or as an escape from reality or a replacement for human connection.
Anxiety disorders increased during the pandemic. What are the levels of anxiety now?
Studies that looked at anxiety in the early years of the pandemic found pronounced increases, which makes sense. People had incredible fears about financial instability, social disconnection, COVID, infection, death. But longitudinal studies that continued after the first years of the pandemic found that the initial increases slowed down. In the last couple of years, we’ve seen that in many cases anxiety has returned to pre-pandemic rates, and this is good news because it speaks to the ability of natural human resilience to help us overcome stress.
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