Anxiety: Part One, “What It’s Like”

“In the time of chimpanzees,
I was a monkey.” - Beck


Emotions are tricky - they’re like colors. Understanding facts about colors doesn’t seem to give us all the information. I can be raised in a darkened room and be taught about wavelength of light, additive color theory, subtractive color theory, the history of the use of color and pigment in art and photography. Yet, once I leave the darkened room there’s still information in what it’s like to experience the color. Philosophy calls these individual bits of subjective experience “qualia.”

Discussing the “what it’s like” of experience activates the self-observer and works to increase self-awareness. Bernard Beitman describes increasing the capacity for self-awareness as one of the core processes of psychotherapy. Cognitive Behavioral therapists call it identifying thoughts, feelings and beliefs. Psychoanalysts call this development of awareness “insight.” The development of self-awareness is not circumscribed to psychotherapy. Buddhists see it as a practice called mindfulness. The Stoic philosopher Marcus Aurelius described self-seeing and self-analyzing as a virtue of the rational soul.

There is a well of knowledge to be gained in exploring what it’s like. This is not information we can quickly teach or transfer. I sometimes like to think this kind of knowledge is difficult to transfer because we find it hard to remember what it’s like to not know. But it’s actually that this knowledge is experiential, a posteriori knowledge that can only be gained by having a number of experiences which contrast with each other. Experiential knowledge can be large and conceptual, making it difficult to transfer because “concept shaped holes can be impossible to notice.”

If I were anxious, would I know it? Perhaps I notice some parts of anxiety but not others. It’s also possible that I can go without naming my experience “anxiety” due to a conceptual bucketing error. I could be misconstruing anxiety as something only people with more serious problems experience. Fear, stress and anxiety are music that every human mind performs. Since everyone experiences them, it can be difficult to tell what it would be like if I was experiencing these more often, more intensely, or for longer periods of time than others. When we don’t notice anxiety, we are acting like the proverbial fish who incredulously asks, “what the hell is water?”


When I instruct people to look for anxiety, it often feels counter intuitive to even begin this exploration. “Didn’t I learn this in kindergarten? I saw the poster with the drawings of the feelings! Since then, I’ve been commander of my ship. I sit at the control panels of my mind and have a perfect readout of the quality of my mind. Accurate. Clear. Discrete.”


And yet, we observe again and again that it is possible to be unaware of one’s emotional experience. I’m sure you’ve met someone who is unaware of their present emotions. They sound like this: “ANGRY? I’m not ANGRY!”

This occurs because our attention tracks a limited amount of our conscious perceptions and thoughts. We do not and cannot keep track of all the things which contribute to our emotional states. In The Feeling of What Happens, neuroscientist Antonio Damasio puts it like this,

“[W]e often realize quite suddenly, in a given situation, that we feel anxious or uncomfortabie, pleased or relaxed, and it is apparent that the particular state of feeling we know then has not begun on the moment of knowing but rather sometime before. Neither the feeling state nor the emotion that led to it have been "in consciousness," and yet they have been unfolding as biological processes.” (p 36)

It is possible to be unaware and it is possible to gain awareness. This ability of monitoring and discerning feelings in ourselves and others is referred to as Emotional Intelligence (EI) or Emotional Competence (EC). These research programs are tied to the idea that it’s possible for us to be unaware of what we’re feeling. And while most therapists probably accept the concept of Emotional Intelligence/Competence uncritically (it’s one of the things we all try to cultivate in psychotherapy), there are interesting claims and controversies that I will have to leave to explore in another series of posts.


Anxiety is a fear, worry or dread about what might occur. The quality of anxiety can be similar whether the threat is physical, social or emotional. It’s an internal tension and uneasiness. It modulates our behavior in a complicated way. It can help us avoid frightening situations, it can motivate us to work on our goals, or it can impair us from being able to move and act in the world. It becomes a problem when it feels out of control, overwhelming, out of proportion to the situation, and interferes with living.

It’s common to discover anxiety problems in children, who don’t have the same practice naming their feelings, by observing their expression of the somatic symptoms associated with anxiety:

“They appear uneasy, seeming at times to be uncomfortable inside their own skin. Commonly, these youngsters report profuse sweating, light-headedness, dizziness, muscle tension, stomach distress, increased heart rates, breathlessness, and bowel irregularities. … They may say that they feel “fluttery” "or “jittery” or “jumpy.” We have heard youngsters report anxiety by saying they feel “yucky” or “weird” inside.” (Clinical Practice of Cognitive Therapy with Children and Adolescents, p 218)

In adults the altered quality of thoughts that comes with anxiety is more frequently noted: rumination, a mental focus that’s hard to tear away from the distressing thought; perseveration, mentally revisiting the same worry over and over; cogitation, obsessive consideration about what could happen. These qualities of anxiety are part of what leads to having difficulty concentrating or functioning in certain situations or during certain periods.

Adults still have the physical symptoms of anxiety but describe them differently than children. Anxious adults have muscle tension and feel keyed up or on edge in ways that leave them exhausted and sore. They sometimes complain of digestive problems and headaches. They may have a hard time turning off the thoughts to get to sleep. The unpleasantness of anxiety symptoms contribute to the development of avoidance of the subject of the worry.

Since anxiety is an emotion that everyone can and does experience to varying degrees, it’s easy to lose track of just how unpleasant and disabling anxiety can be. Anxiety disorders are common mental health issues, affecting ~10% of the population of western countries but they are highly treatable.

There’s a big question regarding what’s psychologically normal and what’s a problem. In the US, the nosological manual we use to divide up and categorize pathology is the Diagnostic and Statistical Manual of Mental Disorders. The Fifth Edition (DSM-5) of this manual was released in 2013 and its Anxiety Disorders section covers phobias, social anxiety, generalized anxiety and panic. The various anxiety disorders are united by feelings of anxiety or fear but distinguished by the particularities of how these feelings present. Some are related to exaggerated fear, as experienced by those coping with phobias and social anxiety. Other presentations, like generalized anxiety, involve a sort of continuous “anxious misery,” while panic disorder is characterized by discrete, short attacks of anxiety that can become a subject of fear themselves.

I find one of the criteria for Generalized Anxiety from the DSM strangely comforting in its brevity: “[I find] it difficult to control the worry.” (DSM-5 p 222)

The DSM-5 makes the distinction between fear and anxiety by stating, “Fear is the emotional response to real or perceived imminent threat, whereas anxiety is the anticipation of a future threat.” (DSM-5 p189) That is to say that fear requires a cue, but anxiety does not. The two states are qualitatively similar, both involve responses to threats, increased tension in the body and similar changes to qualities in our mind like attention, but we can be anxious with little but our own thoughts. Pensive regret and feelings of foreboding that lead my body to freak out can happen when I’m all by my lonesome. These negative emotions and autonomic arousal is what is presenting in an exaggerated form in generalized anxiety and panic disorder. So while there’s disagreement about how to divide them up and clump them together, for the purposes of exploring anxiety, we’ll start with clumping.

These disorders are related through underlying brain circuits, physiological responses, behavioral responses, and qualitatively similar subjective experiences. It’s helpful to distinguish these factors as they do not necessarily all act in perfect concert. In follow up posts, I’ll be discussing theories of emotion, neurobiology, personality, epidemiology, historical perspectives, adaptiveness, and treatments in the hopes of gaining a deeper understanding of what it’s like and how to cope with being an anxious ape like myself.

“Insofar as we're smart enough to have invented this stuff and stupid enough to fall for it we have the potential to be wise enough to keep the stuff in perspective.” - Robert M Sapolsky

Recommended by SlateStarCodex's Psychia-List

Scott Alexander is a psychiatrist on the west coast who blogs about science, medicine, philosophy, politics and futurism. His blog is one I’ve followed for a few years now and I find it to be one of the best sources for dispassionate and well informed takes on difficult subjects which do not admit to easy answers. His writing demonstrates how to approach questions in a way that improves the accuracy of our beliefs and the application of our values.

I’m delighted to have been recommended on his list of mental health professionals! You can find the list here:

Frequently Asked Questions About Drugs and Addiction

Is it normal to use drugs?
We see the drive to alter consciousness across time and cultures. Every culture has norms and rituals for preparing and using psychoactive substances. As a Human Universal, it’s hard to say that altering consciousness is not normal behavior.

Is alcohol a drug?

What is addiction?
The mental health field in the United States is moving away from the term “addiction” and towards discussing “substance use disorders.” Substance Use Disorders are when someone experiences some negative consequences like loss of control, changes in social behavior, and health consequences related to a substance. About 1 in 9 people who use substances meet the criteria for a substance use disorder.
Many people can use substances in an acceptable way and cut back when their use negatively affects them. Addiction is when someone finds they continue to use despite negative consequences and despite the desire to stop.
Please also check the American Society of Addiction Medicine’s page on the definition of addiction as it is an excellent resource.

Why can't people just choose to stop?
Addiction is a disease of the brain that affects its ability to interpret and recall pleasure and pain. The misinterpretation of pleasure and pain affects the part of the brain that makes choices. Over time, the faulty recollection of pleasure and pain leads to lack of motivation to change and a belief structure that supports the addictive behavior.

Why is addiction treatment important?
Addiction treatment isn't there for people who are comfortable with their substance use. Addiction treatment is there for people who find they struggle to cut back on their own and need help. Studies have found that spending money on evidence based addiction treatment is far more effective at reducing costs to society than trying to stop the inflow of drugs or enforcing punitive drug laws.

Can anyone become addicted?
There are many genetic and environmental factors that contribute to addiction. It is possible that with repeated exposure to addictive substances or behaviors that anyone can become an addict.  So while having family members who deal with addiction is a good sign you may experience addiction, not having family members who deal with addiction is not a guarantee that you will not experience addiction.

Isn't calling addiction a disease just an excuse?
We know addiction is a disease because it comes from predictable stressors, causes predictable symptoms, and benefits in predictable ways from treatment.  Calling addiction a disease explains the behaviors we see as symptoms of a substance use disorder, but doesn't excuse them.
No one chose whether they are susceptible to addiction.  But almost everyone dealing with substance use problems have moments of clarity where they notice their behavior around their use is a problem.  Recognizing that addictive behavior has become a problem entails being responsible for getting appropriate help.

Are addicts just bad people?
No. The fields of medicine and health have only recently begun to view addiction as a problem within their scope - we are still in the early stages of recovering from a century of viewing addiction as a criminal justice problem.  Because it's a long-stigmatized problem, a large majority with addiction problems do not seek out treatment.
People dealing with addiction often behave badly when they are actively in addiction.  The drug has become their brain's survival priority.  With their brain sending overwhelming emotional signals to "get the drug, it’s the most important thing!" many people behave in reprehensible ways and do things against their moral codes. 
The more we understand addiction as a disease, the more we will understand the behavior of people suffering from addiction as symptoms.  The behavior of addicts typically goes away with predictable treatments, which lends credence to the notion that they are patients dealing with symptoms, not bad people suffering from moral failings.  If we can discuss addiction in a way that brings less shame to those suffering from it, we allow more people to get help.

How do I know if I have a problem?
If you’re bothered by how preoccupied you are with drinking or getting high or struggle with reducing negative behaviors related to substances that lead you to be defensive to others and latch onto stories to justify your use to yourself then it may be wise to discuss your experience with someone who has experience diagnosing and treating substance use disorders.

What if I’m interested in changing my relationship with some substances but not interested in abstinence?
We can have different relationships with different substances. Abstinence is the right option for some people at some points but it certainly isn’t the only option. Others may want to be completely sober from one substance but not from others. Some find that they are able to achieve their goals by moderating. Treatment is helpful for people in various situations with various goals.

Is recovery from addiction possible?
Recovery from addiction is about changing the beliefs, attitudes and behaviors that led to and maintained the problem. Recovery is a long-term process. There are no quick cures nor is there just one way to get into recovery but those who have the desire and willingness to put in the work do recover.

Evidence Based Wellness Choices to Make Life Better

1.    To Best Understand The Role of Diet, Exercise and Sleep Begin with a Detailed Journal. Using an app like MyFitnessPal is a quick way to start a food journal.  Documenting is an excellent way to learn calorie and nutrition content and gain insight regarding what your choices really entail.  Keeping track is the best way to learn what gets in the way and what actually works for you.

 2.    Eat Real Food. Comparisons of diets have discovered there is no one solution to “the best diet.”  However comparative diet researchers, Katz and Meller, conclude that, “A diet of minimally processed foods close to nature, predominantly plants, is decisively associated with health promotion and disease prevention.”[1]  Processed food is food that is changed in any way before it’s made available to eat including freezing, canning, salting or drying. 

Processed Food Continuum.jpg

3.    Control Appetite by Eating Nutrient Rich Sources of Protein. Eating carbohydrates can make you feel hunger sooner than eating more nutritious food.[2] Eating foods that make you feel full is an important aspect of maintaining a healthy diet.  A major study determined, “protein generally increases satiety to a greater extent than carbohydrate or fat and may facilitate a reduction in energy consumption.”[3]


4.    Engage in Vigorous Physical Activity. Find or pick a physical activity that captures your interest.  It can be as simple as a daily walk or a complicated as competitive fencing.  Keep yourself involved by making it a habit, making it part of your routine or commit by signing up for groups or classes.  Schedule when you’re going to do it throughout the week and commit to going beforehand rather than leaving the decision up to the moment. 

 5.    Manage Sleep with Consistent Routine and Schedule. Limiting daytime naps to 30 minutes, avoiding caffeine for at least 6 hours before bedtime, and engaging in 10 minutes of daily exercise has been shown to improve quality of nighttime sleep.  Get out in the sun during the day to encourage a healthy sleep-wake cycle.  Develop a bedtime routine such as taking a bath, stretching, or reading.  Avoid screens and emotionally stimulating material in the evening.  Taking too long to fall asleep at night is a sign you should evaluate your habits as you approach bedtime.[4]


Brazilian Jiu Jitsu and Mental Health

One of the biggest milestones in my own mental health journey was beginning Brazilian Jiu Jitsu.  Ten years ago I was struggling with depression and anxiety and found that joining this community had surprising benefits.  Finding a gym I was excited to go every night changed my everyday experience.  Jiu jitsu became a source of enjoyment, belonging, meaning and confidence.  While it’s been a huge source of wellness for me, I’ve long been reluctant to recommend it to others because my experience seemed specific just to me. I figured other people would find “their thing” which might provide similar benefits.  But after a decade in the sport I’ve started to notice specific factors that make Jiu Jitsu particularly suited for enhancing mental wellness.

Jiu Jitsu isn’t a small phenomenon.  It’s a rough estimate but there are about 500,000 Brazilian Jiu Jitsu practitioners in the US. The international organization, IBJJF, has 670,000 likes on facebook at the time of this writing. It’s a martial art and a sport that looks like wrestling in pajamas. It's a game with simple rules: without striking your opponent, place them in a position where they are forced to “tap out” lest they be injured or rendered unconscious or otherwise unable to continue fighting.  The most common strategy to win this game is to wrestle to a superior position then use your arms and legs to control your opponent while you place pressure on the arteries in their neck or hyperextend one of their major joints.  You can do this again and again because it’s easy to tap out when it begins to hurt but long before you are injured.

It sounds insane! It sounds risky! I was curious about the actual level of risk so I looked up some data.  My friend, Ethan Kreiswirth wrote a study on incidence of injury at the 2009 World Jiu Jitsu Championship. At this high level of competition, the rate of injury was 24.9 per 1000 Athlete-Exposures (A-Es).  To compare, college football games have a rate of 35.9 injuries per 1000 A-Es, college wrestling matches a rate of 26.4 injuries per 1000 A-Es, and college soccer games a rate of 18.8 injuries per 1000 A-Es. So competing in Jiu Jitsu is about as risky as wrestling, which is more dangerous than soccer but less than football.  And practice in all these sports is significantly less risky than actual competition.

Enough about the risks. I’m interested in talking about the benefits. There are five major domains where Jiu Jitsu has specific, significant benefits that contribute to mental wellness:

Immediate Somatic: Jiu jitsu looks a lot like the natural play of many animals. It’s an inherently enjoyable physical activity.  This playful, engaging activity is an excellent source of exercise.  Physical contact with others fulfills a human need.  Touch sends a powerful message: “you’re okay to touch and I’m okay touching you.”

Immediate Psychological:  People who train know they feel markedly different after training than they did before.  Jiu jitsu as stress relief is similar to but distinct from the catharsis that can be had while training.  If you’re holding on to anger or resentment, training jiu jitsu can be an excellent way to get those feelings out. Jiu jitsu is also a source of flow, a state of being where sense of self is lost and one's mental process becomes seamlessly identified with the activity.  Flow is marked by the absence of boredom, anxiety, and self-doubt and the presence of an energized focus.  Psychology research on flow states is ongoing but suggests that there is a relationship between time spent in flow states and an increase in positive feelings and behavior as well as a reduction in negative feelings and behavior.

Long Term Psychological:  People who train experience increased confidence and assuredness. Because of their connection to the martial arts community they have an excellent resource to develop connectedness to others. The stress we experience when training exposes us to serious anxiety and learning to manage that helps us learn to cope with stress and anxiety outside of jiu jitsu as well.  The practice of jiu jitsu is an excellent outlet for aggression – we should not seek to eliminate this drive, but to find appropriate boundaries and outlets for our aggression.  Training also helps develop focus, as growing our skills in jiu jitsu demands that we hone our skills through concentrating on tasks at hand.

Community: Training is an excellent form of socialization. For people in recovery from substance abuse, a jiu jitsu gym can be a place where you’re accountable to show up sober every evening.  The gym is a place to experience the positivity that comes from having shared goals with other people that you develop through a shared culture.  But jiu jitsu is larger than just the gym you join, it allows you to connect to a global sport.

Long Term Skill:  Training is an opportunity to learn from people who have mastery in a skill. The transparent process by which we see others gain mastery leaves us with a solid pedagogy, a methodology for teaching and refining a skillset. Part of that pedagogy is critical thinking, a skill we have to utilize and grow in jiu jitsu in order to test ourselves and test techniques in a fast-moving problem solving task. Many jiu jitsu schools accept fights from all comers because these tests force us to confront the reality of our skills, something jiu jitsu practitioners take great pride in.  The fundamental hypothesis of martial arts is this: with training, a smaller, weaker person can defeat a larger, stronger person.  One of the best parts about Jiu Jitsu is the bang for your buck you get in proving this hypothesis.

Brazilian Jiu Jitsu is more than just a fighting style. It is a source for play, catharsis, growth, connectedness, and learning. As part of my work in mental health, I look forward to continuing to be a voice in the larger conversation about the particular ways Brazilian Jiu Jitsu is suited to enhancing mental wellbeing.  

What We Know About Preventing Adolescent Substance Abuse

There's a wealth of information available online about substance abuse.  The results of massive, government funded studies are available at places like  The results of these studies are available for free, which makes my job a lot easier.  The tricky part is interpreting the results.  When we collect data for studies, we try to do so impartially as possible, removing all human bias.  However, when we look at that hard data and try to make sense of it, human bias comes back into play and it's easy to lose track of what's really going on.  So let's look at the results of the National Survey on Drug Use and Health (NSUDH) and try to make sense of some of it.

The results of the 2013 NSUDH mostly cover prevalence, ie. how many kids of each age group are using which drugs. But one section of the study is devoted to "Youth Related Prevention Measures."  The study had questions which measured the correlation between kids answers to questions like, "do your parents help you with your homework" and "have you used marijuana in the last 30 days."  And they found some interesting correlations that let us know specific things we can do to help adolescents avoid falling into substance abuse!

Now, there are a couple caveats here before we dive into what the findings.  First caveat: correlation doesn't imply causation. If a kid is less likely to report marijuana use when he reports his parents frequently help him with his homework it doesn't mean those two things are directly related. It's possible they are indirectly related through a third factors like a feeling of connectedness that comes from having good family relationships.  Second caveat: we only know the connections that this particular study asked specific questions about.  If the study did not ask (or did not analyze) questions about exercise or number of close friends then we cannot use its results to examine the relationship between those factors and substance abuse.  Science is hard: sometimes we miss out on the most important connections because they're difficult ones to measure.

So what prevents youths from abusing substances? Here's the short list from the 2013 NSUDH:

  • Perceived Risk of Substance Use

  • Perceived Availability

  • Perceived Parental Disapproval of Substance Use

  • Attitudes toward Peer Substance Use

  • Fighting and Delinquent Behavior

  • Religious Involvement and Beliefs

  • Exposure to Substance Use Prevention Messages and Programs

  • Parental Involvement

Seems to make sense. If a kid believes drugs are bad, mom and dad would be mad if you did them, and drugs are hard to get, then that kid wouldn't do them.  Kids with high perceived risk, perceived parental disapproval, religious involvement, parental involvement, and exposure to substance use prevention messages were less likely to report substance use in the past month.  Kids with negative perception of drug users and lower engagement in fighting and delinquent behavior were less likely to report substance use in the past month as well. 

Let me focus on a few areas of the findings: Perceived Risk of Substance Abuse, Perceived Parental Disapproval of Substance Use, and Parental Involvement.  I think these are the most important aspects of youth prevention for parents because they highlight specific things that parents can work on.

It can be hard for parents to communicate specific and accurate information on the risks of substance abuse to their teens because there can sometimes be conflicting information. And some of the best information is relatively new. Dr Frances E. Jensen released a book called The Teenage Brain last month. You can listen to hear speaking about the findings in her book on NPR here. In The Teenage Brain, Dr Jensen discusses recent studies in neuroscience that demonstrate the long-term risks of drug use on the developing teenage brain.  She strongly encourages parents to use her book to gather accurate information about the risks of adolescent drug use and then discuss them with their teenagers.  She also speaks at length about the planning part of the brain that anticipates risk and consequences, the prefrontal cortex, and how it isn't fully connected in the teenage brain.  She encourages parents to help teenagers plan for and weigh risks because their brains aren't yet fully able to do so.

How should parents talk to their teens and tell them they would disapprove if they found out they were using drugs? Calmly and directly.  If a parent is emotionally overwhelmed by the idea of drug use it's likely the message might get lost in all the emotional charge.  If mom screams, "Don't ever let me find out you're using drugs!" then she'll get what she asks for. If her kids use, they will hide it.  It's important to leave the communication lines open with a calm and direct statement like, "I know there are going to be kids drinking, smoking pot, and using other drugs at your high school and I know there's a chance you might end up trying these things as well. I really hope you don't.  At this age your mental development can really be thrown off by even a little drug use, so even if you think you might try it, I hope you choose to put it off for now." Being able to make that statement without an emotional charge leaves your kids with the nonverbal message, "If I am ever in trouble with drugs, I know my parents won't just freak out on me. I know they'll be there to help me."

Being involved in your kids life is a huge factor in preventing substance abuse.  The NSUDH study looked at specific things like whether the kids reported that their parents helped them with their homework, whether they had a curfew on school nights, and whether their parents let them know when they did a good job.  In kids who reported parental supporting and monitoring, tobacco, alcohol and drug use rates were cut in half.  And that relationship gets at an incredibly important and very new idea in the realm of addiction treatment.  Connectedness is a key factor in preventing substance abuse and addiction.  Old studies that seemed to that cocaine was universally addictive in lab rats are being challenged by new studies that show rats living in communities will only become addicted in the absence of healthy social interaction.  You can read an excellent description of recent studies on this in this recent article in The Huffington Post. But the takeaway message is to communicate, connect, participate and be involved with your kids if you want them to lead lives free from substance abuse issues.