What does anxiety feel like to you?

Here are a few descriptions I have heard over the years:

From the literal:

• Queasy
• Revved up
• On edge
• Worried

To the metaphorical:

• Like a pit in my stomach
• Like an internal storm
• It’s a sinking feeling

And my favorite: “It’s like a toddler. It never stops talking, tells you your wrong about everything, and wakes you up at 3 a.m.”

The American Psychological Association defines anxiety as “an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure.” Feeling anxious can be a deeply uncomfortable experience. It’s also perfectly normal. Just because it’s awful doesn’t make it a disease that needs to be treated.

The key difference between having an anxiety disorder and normal anxiety is the extent of dysfunction and distress it causes. Generalized Anxiety Disorder, one of the most common diagnoses, is characterized by persistent, excessive, and unrealistic worry about everyday things. This worry could be multifocal such as finance, family, health, and the future. It is excessive, difficult to control, and is often accompanied by many non-specific psychological and physical symptoms. Excessive non-stop worry is the central feature of generalized anxiety disorder.

Diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) aka the “bible” of Psychiatry, include the following:

• Excessive anxiety and worry for at least six months
• Difficulty controlling the worrying
  • The anxiety is associated with three or more of the following symptoms for at least 6 months:
    • Restlessness, feeling keyed up or on edge
    • Being easily fatigued
    • Difficulty in concentrating or mind going blank, irritability
    • Muscle tension
    • Sleep disturbance
    • Irritability
• The anxiety results in significant distress or impairment in social and occupational areas
• The anxiety is not attributable to any physical cause.

Put simply, feeling anxious at a given point in time about something stressful going on in your life does not mean you have an anxiety disorder. High anxiety may be appropriate and even adaptive in certain contexts. For instance, going off to college, switching jobs, or dealing with a break up may fill you with dread but that doesn’t make it pathological. There is plenty of evidence showing that anxiety can be beneficial under some circumstances. It might motivate you to prepare for a test or remind you to check the battery on the fire alarm.

In some situations, such as in Ukraine, anxiety can be protective. As Dr. David Rosmarin recently wrote in The Wall Street Journal since the Russian invasion, residents who experience nervousness and worry, “are probably better off than their neighbors who are less anxious. They are more likely to survive a military attack, since a stress response yields benefits such as greater situational awareness, quicker response time, and even constriction of blood flow in the event of injury.”

Anxiety is not “all bad,” and an absence of anxiety is not “all good.” Unfortunately, the current conversation about anxiety in any form portrays it as something to be minimized, avoided, and treated. By pathologizing anxiety, we miss out on the opportunity to learn and potentially grow from it. Plus, we are making people anxious about being anxious. Because of all the negative implications swirling around anxiety, they are mistakenly led to believe that there is something wrong with them.

I have met many young people who have diagnosed themselves with anxiety because they took an online screening test that only asked two questions — one about feeling nervous and the second about being unable to control worry over the past two weeks. There is no inquiry about context. No nuance is explored. In under a minute they are diagnosed as a likely case of generalized anxiety disorder.

Here are the questions:

Answering “more than half the days,” to one question and “several days,” to the other is enough to screen in. Pretty much anyone going through a rough patch will qualify. The intention behind this simple test is to rapidly identify those in need of treatment. There may be other unintended consequences as well. Labeling oneself as having an anxiety disorder can shift a person’s self-concept. Believing you have a mental illness might impact your response to an awkward social situation or influence a decision to take on a challenge.

Of course, its entirely possible that I am overly anxious about over pathologizing anxiety. These concerns are a perfectly normal and healthy response to something that is stressing me out.

What makes you tick?

This is the question that drew me to psychiatry in the first place. What interested me most was not what people did but why they did it. What I have learned along the way is that there is so much that we get wrong about others. All too often, in an attempt to make sense of someone else’s behavior, we jump to conclusions about their “true self.” Using a few breadcrumbs of information, we are quick to make assumptions and attribute their behavior to a fixed aspect of their personality. The person who cut me off in traffic is surely a jerk. The woman who screams at her child lacks patience. The teenager who breaks the vase is clumsy. The dog owner who doesn’t pick up her dog’s poop is selfish. The coworker who leaves early is lazy.

Put simply, we see other people’s behavior as a reflection of who they really are. This is known as “correspondence bias”— we assume that their actions correspond to their personality. In doing so, we disregard all the other reasons that might explain their actions. In the process, we underestimate their intentions and the situation. We ignore external factors and contributing circumstances.

But, when it comes to ourselves, we do the complete opposite—we attribute our behavior to the situation and discount the role of personality. If I cut someone off in traffic, it’s because I am late for an important meeting. If I scream at my daughter, it is because I didn’t sleep well last night and she said something inappropriate. If I break a vase, it’s an accident. If I don’t pick up after my dog, it’s because I ran out of poop bags. If I leave work early, it’s because I have a doctor’s appointment. The only reason my behavior is anything less than stellar is because of external reasons.

We are quick to make excuses for ourselves but tend not to extend the same generosity to others.

Psychologist Kurt Lewin likened this tendency to think that others are as they act to Aristotle’s understanding of the physical world. Aristotle believed that objects behaved according to their inherent properties. Rocks fell to the ground to get closer to the earth and flames rose to the sky to reach heaven. Accordingly, Aristotelian physics held that the heaver an object, the faster it would fall. It wasn’t until Galileo came along centuries later that the role of external forces was considered. His insight that the behavior of objects must be understood in the context of the situation transformed physics. It is said that he demonstrated the role of air resistance by dropping objects from the top of the Leaning Tower of Pisa.

When it comes to judging the behavior of others, we are stuck in an Aristotelian mode—ready to make assumptions about their true nature based on a few observations and limited information. But in explaining our own behavior, we are Galileans—full of understanding and awareness of external factors.

Thanks to correspondence bias, we jump to conclusions and are left with the false impression that we really know someone, that we’ve got their number, for better or for worse. As Harvard psychologist Daniel Gilbert points out in a famous paper on the topic:

We may strive to see others as they really are, but all too often the charlatan wins our praise and the altruist our scorn. Juries misjudge defendants, voters misjudge candidates, lovers misjudge each other, and, as a consequence, the innocent are executed, the incompetent are elected, and the ignoble are embraced.

Correspondence bias is famously hard to overcome.

Even when we’re fully aware of the outside pressures that people face, we still understand their behavior as a reflection of enduring qualities. In a well known experiment, subjects were shown essays that opposed or supported Cuba’s president, Fidel Castro. Even when the subjects were told that the essayists had been instructed by a debate coach to defend a particular point of view, many of the subjects still inferred pro-Castro leanings in the essayists that defended him. As Gilbert observes, the subjects were basically saying:

“Well, yes, I know he was merely completing the assignment given him by his debate coach, but to some degree I think he personally agrees what he wrote.”

Correspondence bias is problematic because it distorts judgments and leads to misunderstandings. I worry that the rise of everyday use “therapyspeak”—prescriptive language describing certain psychological concepts—amplifies correspondence bias. Based on a tidbit of information or unpleasant interaction, we can justify writing someone off as “toxic” or “demanding.” Connections and potential connections suffer as a result.

Jumping to conclusions about what makes someone tick gets us nowhere. What we can do is simple: give everyone you meet the benefit of the doubt. Consider their intent. Resist wound collecting. Think about what else might be going on in their lives. Last but not least, ask yourself, “What would Galileo say?”

Without any experience in retail and very little cash, Sara Blakely founded Spanx when she was 29 years old. How did she do it? Was it her parents’ kind words and doting support? Not exactly. As highlighted in an article Blakely’s parents were not into coddling:

Some parents are content asking their children, “Did you have a good day?” or “What did you learn at school?” Not the Blakely household. The question Sara and her brother had to answer night after night was this: “What did you fail at today?” When there was no failure to report, Blakely’s father would express disappointment.

An “if you’re not failing, you’re not growing” approach may seem harsh by today’s standards. It’s essentially the opposite of how parents and educators think about learning:

From an early age, children are taught that success means having the right answers, and that struggling is a bad sign, the sort of thing you do when you’re not quite “getting it” or the work is too hard. Throughout much of their education, students are encouraged to finish assignments quickly. Those who don’t are sent off to tutors. After 12 years of indoctrination, it’s no wonder that so many of us view failure the way we do: as something to avoid at all cost. In reality, it’s only by stretching ourselves that we develop new skills.

As Blakely reminds us, frustration is part of the learning process. Failure, (dare I say the unsayable “f-word”?”) is something to be learned from rather than avoided. Without struggle and failure, we end up with “perfect” children who are terrified of making mistakes. They are fragile teacups—ideal for display but easily broken.

I recently heard about about a new and rather unusual form of therapy designed to help conquer fear of rejection and failure called Rejection Therapy. The idea is to make a game out of rejection by creating situations where you get rejected each day.

Here are a few examples:

• Request a lower interest rate from a credit card provider
• Sit beside a stranger and strike up a conversation
• Ask for a discount before purchasing something

You get the picture. By forcing yourself to do the thing you fear, you de-fang it. The focus is on process not outcome.

Rejection Therapy may have a place at the dinner table. In addition to asking your kids what went well in the day, consider channeling the Blakelys. If the question, “What did you fail at?” seems a little harsh, consider asking “What was hard or challenging for you today?”

It may save years of (Rejection) Therapy in the future.

Too soon?

It may only be August but pumpkin spice season is officially upon us. Brands are already rolling out their fall-inspired offerings and Christmas merch is popping up too. Apparently this is known as “Christmas Creep.” Long before a leaf hits the ground, retailers are telling us the summer is over. Thanks but no thanks.

Autumn anxiety may not be an official diagnosis but the annual experience of increased stress at this time of year is very real.

As seasons go, fall is cited by many of my patients as the most stressful. The end of summer, a new school year, a more rigid schedule, and the impending holidays (likely amplified by Christmas Creep) all contribute to the end-of-summer blues.

My son once described August as the Sunday of the summer. The thought of homework, going to bed early, and having to wear shoes again made him shudder. When a back-to-school commercial played on the television, he would leave the room. The countdown was painful. The closer Labor Day loomed, the harder it became to think about anything else. One late August evening, feeling a chill in the air, he said, “I almost wish school started tomorrow. I just want to get it over with.”

What my son was experiencing was dread. Dread is it’s own unique form of misery. Defined as an “extreme reluctance to meet or face,” dread conjures impending doom. Unlike anxiety which is characterized by uncertainty and generalized worry, dread is more specific. The cruelty of dread is its inevitability. Anxiety is imagining there might be a hungry monster under the bed. Dread is knowing there is a hungry monster under the bed who is about to come out.

Here’s why dread can be so devitalizing

Anticipating something horrible can be horrible in itself. Or as Tor Wagner of Columbia University observed, “expecting an emotional event is an emotional event.” A 2014 study underscores the discomfort of dread. When given the choice of receiving an immediate strong electrical shock versus a milder one in the future, most participants opted to receive the more intense shock right away. Anticipating unpleasantness was so unpleasant that they would rather receive more voltage than have to endure the torment of waiting for it.

Dread is a catalyst for catastrophizing. Instead of imagining the most realistic outcome, dread distorts our thinking so that the worst case scenario becomes the only possible scenario. In addition to warping our perception of the future, when we’re awash in dread, the present becomes purgatory, a prelude to the dreaded event. It’s hard to enjoy anything in the moment when we’re preoccupied with the thoughts of imminent misery.

Thankfully, there are some research-based strategies to make dread a little less devitalizing:

1. Define it

To prevent dread from hovering like an amorphous ever-expanding cloud, casting dark shadows over every aspect of your life, find the exact words to describe how you’re feeling. Be as precise as you can. Whip out a thesaurus if necessary. The more precisely you can define how you’re feeling, the easier it will be to manage your uncomfortable emotions.

2. Distract yourself

Sitting around waiting for the dreaded event can be as painful as the dreaded event itself. To combat the paralyzing effects of dread, actively draw your attention from whatever you’re dreading. Physical activity, breathing exercises, and spending time outdoors are excellent antidotes for dread.

3. Distance yourself

To break the cycle of overthinking—or rumination—about the dreaded event, imagine the worry-provoking event from a distance. Visualizing it from afar facilitates better coping strategies and reduces emotional reactivity.

Dread is powerful but need not be all powerful. Use the 3 Ds to defend against it and perhaps even lean into it.

As Pulitzer Prize winning novelist Barbara Kingsolver observed:

“The changes we dread most may contain our salvation”

After all these years, the movie Jaws still haunts me. I love to swim in the ocean but lurking in the back of my mind is the possibility of a man-eating monster lurking just below the surface. Apparently, I am not the only one. According to a survey, 43 percent of people who have seen Jaws have lingering fears of the ocean.

Consider the following:

• You have a 1 in 63 chance of dying from the flu and a 1 in 3,700,000 chance of being killed by a shark.
• Over 17,000 people die from falls each year. That’s a 1 in 218 chance over your lifetime, compared to 1 in 3,700,000 of being killed by a shark.
• In 1996, toilets injured 43,000 Americans. Yes, it is more likely I will come face to face with a hostile toilet bowl than with an angry shark.

Sharks inspire terror but the mosquito should make our knees quiver. No other species, including our own, is responsible for the loss of as many human lives each year as mosquitos that kill 725,000 people annually. Humans murder around 475,000 other people each year. Snakes kill around 50,000 while dogs (mainly from rabies) claim another 25,000 lives. Some of the most feared animal (sharks, wolves) kill fewer than 10.

When it comes to fear, logic and reason fly out the window. Barry Schwartz explains:

People have great difficulty understanding risks. The weight a person gives to a scenario—flood, fire, winning the lottery—should depend on its likelihood. In fact, it depends on how easily it can be envisaged. People will pay more for air-travel insurance against “terrorist acts” than against death from “all possible causes.”

That said, fear serves an important function.

It alerts us to danger and enables us to act quickly. Think of swerving out of the way of an oncoming truck—you turn the steering wheel before you even register you are afraid. It is instinctive.

We see this all the time in the animal kingdom. When a gazelle is chased by a lion, her body goes into survival mode—stress hormones flood the bloodstream, the heart goes into overdrive, extra blood is shunted to muscles to facilitate running, awareness intensifies and vision sharpens as the body devotes all its energy to escaping the beast. If the gazelle outruns the lion and survives, she returns to the watering hole with her fellow gazelles and resumes her routine hanging out and eating grass. Stress hormones return to normal, along with blood pressure and heart rate. She doesn’t dwell on how upsetting it was to be chased by a lion, nor does the fear of another attack consume her.

People are not like gazelles. Problems arise when we are in fight or flight mode all the time. It isn’t quite as easy for us to flip back into relaxation mode. Those with chronic stress and anxiety experience the equivalent of the lion chase throughout the day, placing them at risk for a number of mental and physical problems.

My advice:

• Ask yourself: what are the odds of this terrible thing really happening?
• Know what you can control and what you cannot.
• Personalize a strategy to calm your mind. Meditation, exercise, listening to music, spending time outdoors, reading a book, visiting a museum, spending time with friends, volunteering, and cooking are all examples of ways to quiet an unquiet mind.

Find the one that works for you to channel your inner gazelle.

Bottom Line: Remember, FEAR has two meanings. Forget Everything And Run or Face Everything And Rise. The choice is yours.