It’s midnight and I’m convinced I’ll be dead of a brain tumor by first light.
How I even know about brain tumors is a mystery. I’m six years old and no one in my small world has ever had one. Still, I’m panicking, gulping at the air, trembling beneath the covers. My mother tries to hold me and talk me down, but I’m too far gone to be comforted. Finally, near tears herself, she phones an old family friend who happens to be a world-famous neurosurgeon. Fifteen minutes later he shows up at our house and puts me through the paces of basic neurology tests—close your eyes and touch the tip of your forefinger to the tip of your nose, walk heel to toe in a straight line across the room—then he promises me I don’t have a brain tumor. I believe him—for now.
The Brain Tumor Episode was not the first—or last—time I believed I was at risk of imminent death. Worries over nuclear war, fire, kidnapping, and tse-tse flies had all come before. In college, I found my way more than once to the emergency room, certain I was dying of an MI. (I was up on the lingo for myocardial infarction, aka heart attack, and many other conditions after spending countless hours watching doctor shows.) Inevitably, the ER doc would tell me I was having a panic attack and shoot me up with valium.
I can’t remember a time when I wasn’t prone to anxiety. I can’t remember a time when I haven’t wrestled with fear. In a sense, fear and anxiety have been my greatest teachers, moment by moment prompting me to come to grips with living in a body, living in the world.
So many of us are plagued by insecurity, dread, persistent stress, irrational fears. When this many people have anxiety, is it really a disorder?
The Latin root of anxiety is angere, to choke or strangle—just the sort of sensation felt during a panic attack. According to the National Institute of Mental Health, anxiety disorders affect about 40 million American adults aged 18 years and older—about 18% of the population. Women are 60% more likely than men to experience an anxiety disorder over their lifetime, and a large national survey of adolescents reported that about 8% of teens ages 13-18 have an anxiety disorder, with symptoms commonly emerging around age six (Hello!). And these are only the folks who get a formal diagnosis of anxiety in one of its recognized forms: generalized anxiety disorder, obsessive-complusive disorder, social phobia and other phobias (snakes, airplanes, heights, you name it), panic disorder, and post-traumatic stress.
But what about everybody else? The worried well, the high functioners plagued by insecurity, dread, persistent stress, irrational fears? People without a formal diagnosis? People like me?
“When this many people have anxiety, is it really a disorder?” asks Phillippe Goldin, Ph.D., an assistant professor at UC Davis who also directs the Clinically Applied Affective Neuroscience Research Group at Stanford University. A major thrust of Goldin’s research is the effect of mindfulness on clinical anxiety. “No,” he says, answering his own question. “Anxiety is normal in many, many cases. From an evolutionary perspective, anxiety has been preserved in the human animal over millions of years. If everyone came in chilled out and calm, that would be the death of humans.”
What is changing radically, though, is how psychologists and neuroscientists view not just anxiety, but depression and other mood disorders as well. “The labels come from psychiatry, with the blessing of the pharmaceutical industry, but mounting evidence shows that the basic neural circuits are consistent across all these disorders,” Goldin explains. “The push now is to identify core psychobiological mechanisms that help us understand what cuts across human experience without using these labels. What core mechanisms turn anxiety and distorted self-views from on to off?”
Remarkably, negative emotional states and self-perceptions can be seen clearly in functional MRIs of the brain. What’s more, Goldin says, “The common understanding is that the prefrontal cortex down-regulates the amygdala [i.e., it’s less aroused]. Anxiety reduces. That’s oversimplistic. The data suggest that some people depend on the energy arousal of the amygdala for greater cognitive and emotional control, while in others the amygdala is overly aroused and needs to be quelled. What’s really needed is individual and context-dependent modulation of brain circuitry.”
The research sounds exciting. Still, I wonder, how might it help people whose brains aren’t being mapped by neuroscientists? How do we form those new neural pathways we hear so much about? How do we, in Goldin’s terms, become Jedi masters of up- and down-regulation of our amygdalae as needed?
Not surprisingly, he says there’s no one-size-fits-all solution. “The Holy Grail now is treatment matching. There are several potentially helpful components.” These include mindfulness meditation: either non-judgmental awareness of the present moment, or focused attention on an object, usually the breath. Mindfulness-Based Stress Reduction (MBSR) has shown great promise in regulating mood states. So has Cognitive-Behavioral Therapy (CBT), in which clients learn how to identify and work directly with the thoughts that influence their emotions and behavior. Also in the toolbox are other forms of psychotherapy, medication, and aerobic exercise, as well as changes in diet and behavior.
“But we know that each of these interventions works for less than 50% of people studied,” says Goldin. “What will amplify the effectiveness of any one or combination of treatments is creating an individualized learning experience that gets adjusted over time.” Still, he cautions, “To maintain the gains, you have to keep practicing.” Even if you do two months of MBSR, there will be longer term benefits if you stick with it. But for that to happen, you need the ongoing reinforcement of a teacher and a community.”
True confession: Although I’m powerfully drawn to mindfulness practice—and have done many retreats over the past 30 years—I’ve often had trouble meditating. Times when I’ve been too anxious, too restless, my thoughts too rambunctious, my body too wired to sit quietly and follow my breath. This is my dirty little secret.
Sometimes it suffices simply to pause and take deep breaths, expanding the inbreath and slowing the outbreath—a technique that helps during 2 a.m. flopsweats.
I take comfort in knowing I’m not a total outlier. “Everyone has to custom design their own pathway of soothing the nervous system,” says Tara Brach, Ph.D., a clinical psychologist and founding teacher of the Insight Meditation Community of Washington, DC. “There’s a reason it’s called a nervous system.” For people who have difficulty staying put on a cushion, Brach recommends alternating short periods of sitting meditation with mindful movement—combining stretching or yoga and walking. Sometimes, it suffices simply to pause and take five deep breaths, expanding the inbreath and slowing the outbreath—a technique that helps me during 2 a.m. flopsweats.
Brach also urges practicing with others. “We frequently frame meditation practice as a solo thing, but what’s true in practice, as in life, is that we’re interdependent,” she says. “Often the best way to soothe our nervous system is with others. When we practice mindfulness in a group, we see that most people feel anxious to some degree. We see that anxiety is not just our personal pathology, it’s part of being human.”
When we observe our life moment to moment—as opposed to spinning around inside our thoughts like a hamster trapped in a wheel—we create a gap that allows us to notice what’s happening instead of completely identifying with it.
It’s for this reason—practicing with others—that I sign up for a daylong workshop: “Mindfulness and Anxiety” at Spirit Rock Meditation Center in Woodacre, CA. There are about 200 of us, from 20-somethings to 70-somethings, with most people falling somewhere in between. The crowd looks as ordinary as an audience at the local multiplex. Yet, when Lee Lipp, Ph.D., a psychotherapist and meditation teacher who is co-leading the workshop with David Zimmerman, a Zen priest, asks participants to describe in one word why they’ve come, the answers illuminate every nuance of anxiety: “Nervous. Fearful. Stressed. Disassociated. Overwhelmed. Unsettled. Unsafe. Agitated. Worried. Uneasy. Insecure. Unlovable…” The list goes on.
“Mostly we don’t tell each other or ourselves what’s happening, but in here we can say what our experience is really like,” says Lipp. The sense of relief that ripples through the room is palpable.
“Anxiety is not our fault, it’s the consequence of causes and conditions in our lives,” she explains. “How we relate to anxiety is what matters. It can lead to more suffering or become an opportunity to free ourselves from suffering. By familiarizing ourselves with the habit patterns of our minds and bodies, we interrupt our reactivity and over time it starts to lessen.” In other words, when we pause to observe the actual process of our life moment to moment, as opposed to spinning around inside our thoughts like a hamster trapped in a wheel, we create a tiny gap in our awareness that allows us to notice and name what’s happening instead of completely identifying with it. We see that our thoughts, emotions, and physical sensations come and go like bubbles in a pot of boiling water.
“This helps to calm our anxious, wild mind while increasing our capacity to be present with the truth of our life in just this moment, whatever that may be,” says Lipp. “Our body, with all its senses, tells us everything we need to know.” Many are feverishly taking notes when she asks us to please put away our notebooks. “I want you to experience what it feels like to pause, not write about it.”
Throughout the day, Lipp and Zimmerman lead us through guided meditations, and we break into small groups. Martha, a woman in my group, says she hopes the workshop will help her become more conscious—unlike her mother. “I think anxiety is in my wiring,” she adds. “There’s a raging battle between my primitive brain and my prefrontal cortex.” Leslie confides that whenever a strong emotion comes up, her knee-jerk reaction is to push it away. “This is not working for me,” she says. For each of us, I think, hearing each other’s stories helps break down the isolation we feel inside the cages of our own fear.
It’s no accident that Lipp is leading this workshop. About ten years ago she was asked by her meditation teacher to help others deal with depression. “I saw that lurking beneath depression is anxiety,” she tells me over lunch a few weeks before the workshop. In fact, she doesn’t like either label. “The words anxiety and depression aren’t helpful. They just give a name to transient mood states.” Mood states that Lipp became all too familiar with in childhood, given her absent father and a mother diagnosed as paranoid-schizophrenic. “There was no one to take care of me. I was worried all the time. But at a certain point it became counterproductive to tell my story over and over,” she says. “Mindfulness practice has helped me untangle my story and discern the thoughts that have perpetuated it. When we become really quiet and settled, even the story itself falls away.”
Value of therapy
There are times, though, when digging through the contents of our story may be necessary. Talk therapy or some form of body-centered therapy may help us to better understand the source of our anxiety, as well as help us tolerate it when it arises. The deeper I’ve gone in various forms of therapy, the greater my capacity to maintain awareness when storms and squalls rip through my mind and body.
“The problem is that mindfulness has been so inspirational and demonstrably helpful for so many people that there’s been a big push to replace psychotherapy with it,” says Mark Epstein, M.D., a New York City psychiatrist and author of several books on mediation and western psychology. “That’s a shame. Mindfulness can’t do what therapy does. There’s no one foolproof treatment for anxiety.” What’s more, he adds, “Anxiety is like the tip of an iceberg poking up out of the sea. It points toward something unacknowledged that needs to be understood.”
Our meditation seat can serve as a sort of base camp, a safe space to which we return, while also availing ourselves of other ways of coping with anxiety. In this regard, my friend Matthew is an inspiration. With a diagnosis of bipolar disorder and proneness to severe anxiety, Matthew benefits from just about every possible approach: medication, psychotherapy, daily aerobic exercise, a strong bond with a meditation teacher and regular practice. “I make the effort even if I’m wired and flooded with fear,” he says. “If the experience is a wild roller coaster ride, so be it.” At such times, he finds that simply following his breath helps. But at other times, he says, he’s able to let the part of him that’s afraid tell its story, which he tries to meet with curiosity. “Sometimes the content is as important as the process. When I’m able to name my fear and see it as just one aspect of myself, I get some space around it and it softens a bit. Then I try to converse with the fear, the way you’d speak to a child, and hear what it’s telling me.”
But for some people, such as those with obsessive-compulsive disorder and other forms of severe anxiety, meditation practice simply may not be possible, says Lobsang Rapgay, Ph.D., a psychologist who directs the clinical training program at the Mindful Awareness Research Center at UCLA (MARC). “We all have some level of anxiety, but crossing the border into a disorder is a whole different thing.” Nevertheless, he says, people who have difficulty meditating can benefit from process-oriented therapy, which encourages them to monitor their awareness of what’s taking place in their mind and body in the presence of a therapist. In his own practice, Rapgay explains, “I might say, ‘When you mention such-and-such, you speak fast and look tense. I wonder what that’s about? Next time we talk about this, try to be aware of what you’re experiencing in your muscles.”
“In people with generalized anxiety disorder, there’s an underlying misguided assumption that if only they can be 100% safe, they can let go of their anxiety. But that’s impossible,” he says.
“MBSR and CBT help promote a state of tranquility and offer a good starting point, but it’s also very important to help people deal with the overarching problem of uncertainty in life. Doing more focused practice that enhances insight is the way to get there. The affective state we want is one of resilient calm, so when your inner or outer world becomes filled with turmoil, you have an inner anchor.”
Hardwired or not?
Like Martha in my group at the Mindfulness and Anxiety retreat, I, too, have always sensed that anxiety is hardwired into me. So often it’s felt as if my whole nervous system is rigged to remain on high alert, as if at any moment the Cossacks will break down the door. This fear reflex feels cellular, genetic, ancestral—I come from a long line of nervous women. As it happens, my grandmother was stoned by Cossacks when she was six, the age at which my anxiety first bloomed.
Interestingly, the age at which someone starts to struggle with intense fear is often not random. Therapist Mark Wolynn, director of the Family Constellation Institute in northern California says there can be “a link between our issues and what happened in a previous generation.” Case in point, from Wolynn’s practice: Ben felt increasingly suicidal as his 40th birthday approached. He had a happy family life, a satisfying job, a strong meditation practice. But as the date of his birthday neared, his agitation became intolerable. It wasn’t until he learned the real story about the father he never knew, a man who was murdered at age 40, that Ben’s panic finally eased. “In therapy he was able to develop a positive inner image of his father and stopped being on a collision course to relive his death,” Wolynn says.
Far-fetched? Maybe not. Mounting evidence in epigenetics reveals how inherited information—in addition to DNA sequence—can affect gene expression. In several studies, mice have exhibited trauma residues without having experienced trauma. Moreover, one recent study of mice at Emory University found that traumatic memories could be passed down to at least two generations as a result of chemical changes in DNA. Researchers Kerry Ressler and Brian Dias suggest that a similar phenomenon may influence anxiety in humans.
The epigenetic research furthers what we already know from studies of twins and experiments related to temperament. According to Susan Smalley, Ph.D., a behavior geneticist and founder of MARC, many studies have shown a strong genetic component to our susceptibility to anxiety, especially generalized anxiety disorder and panic attacks, as well as ADHD. “Roughly 40-50% of people with these disorders are genetically predisposed,” Smalley says. She stresses, however, that just as there is no one surefire coping mechanism for anxiety, there is no single cause for it either.
Still, the notion that my lifelong anxiety is due, at least in part, to genes and family history is comforting. It’s not just me! There are reasons. There are always reasons. As Lee Lipp says: causes and conditions. And though my fear reflex has mercifully diminished over the years, it remains akin to a sleeping tiger that springs awake at the slightest hint of danger—often imagined danger.
This, too, seems to circle back to what we know about the brain.
Smalley talks about two networks by which the body encodes fear: The reactive low road, which is unconscious and linked to the hippocampus and amygdala, and the high road—the famous prefrontal cortex—which makes conscious connections and is more malleable. “With mindfulness practice and various cognitive processes,” she says, “you can make a big dent in the high road. The low road is more primitive, more resistant.”
Which accounts for my sleeping tiger. The Cossacks with their stones. The phantom brain tumor. My uninvited but faithful companions who demand to be seen and heard. “Oh, it’s you again,” I say now more often than not when they start banging at my door. “It’s only you.”
This, more than anything, gives me hope.