Metaphorical models - Anxiety Disorders


Anxiety is adaptive. It drives the athlete, motivating them to compete, to train, to perform and to win. It drives the student to attend lectures, to read boring textbooks, to study and to pass. They may be anxious about failure, about humiliation, about losing self-esteem, losing confidence, losing momentum, about letting others down, or merely anxious to chase success. There are numerous fears that might trigger anxiety that is adaptive as it helps to drive some behaviour that is deemed adaptive for the individual.

Panic attacks

Anxiety may also be triggered by danger, by the fear of death, fear of injury, fear of annihilation. It is also, obviously, adaptive as the individual must survive into early adulthood to reproduce and into adulthood to raise their children and contribute to their family’s (genetic) propagation.

The Lion in the Jungle Metaphor (or The Fight or Flight Survival Program Metaphor)

The patient is walking cautiously through a jungle when a lion jumps out from behind a bush.

The ‘fight or flight’ survival program is automatically activated, triggered by the sudden danger. Anything perceived as threatening the integrity of the body or mind is a danger. The organism is not supposed to ‘think’, just react in a stereotyped physiological manner:

The adrenal glands pump out adrenalin, which acts on various organs. The respiratory rate increases so that more oxygen can be pumped into the blood. The heart rate rises so that more oxygenated blood is pumped: perceived as palpitations. The muscles prepare for action and blood flow is maximised to the muscles: perceived as muscle tension. The blood flow to the brain and gut is minimised: perceived as the mind freezing and butterflies and nausea.

The aim is to maximise the patient’s strength and agility to enable a rapid and automatic retreat. The terror of the attack might provoke a punch in the beast’s nose to stun it and give time for escape, if the individual has been cornered by the beast. Although the patient may not realise it at the time, s/he may be capable of accomplishing extraordinary feats of courage or strength during that moment when they are physiologically at a peak of their endurance.

This is what is supposed to happen, the way Nature (Natural Selection) intended the program to play out. We evolved in an environment where the dangers were consistent: large hungry carnivores, smaller creatures inflicting poisonous bites, heights, strangers, extreme sensory phenomena (dark, bright light, loud noise, rapid movement) and unfamiliar water or land. These are the atavistic fears -- the inbuilt, hardwired danger triggers that are meant to activate the ‘flight or fight’ response.

In a hunter-gatherer, tribal, rural lifestyle, these dangers were diffuse. When encountered, the survival program would save the individual’s life. Those who did not have programs that were activated rapidly would die out. Thus there would have been a natural selection pressure on being reasonably neurotic i.e. having a sensitive, trigger-happy nervous system.

Those who got anxious somewhat too easily (the neurotics) would have had more uncomfortable, less relaxed lives, but they had a survival advantage over those very calm, unconcerned people who didn’t worry about anything. (Perhaps the latter compensated for their reduced neuroticism by being more selfish and antisocial.)

Neurotics are also usually more anxious about how others perceive them and are thus more empathic and giving. Certainly cooperating with others is a good survival scheme, as organising into specialised roles is likely to improve subsistence efficiency and permit rotation of roles. There would be an opportunity to enjoy less stressful assignments alternating with the more dangerous tasks (e.g. hunting), and this might compensate for anyone with higher stress levels.

Individuals living in a tribal community would have been unlikely to encounter dangers alone. Dependency behaviour is adaptive as it improves survival prospects. But it also makes you more dependent on others, which may make you more anxious when not living in closely-knit groups. Modern Western ideology worships the materially successful individual working altruistically in a large anonymous society. A bit of a paradox?

The Tribe-City Metaphor

Our current environment is extremely different to the one we lived in for tens of millions of years, in other words, the environment we had evolved to ‘fit in’ to. In the last few thousand years, we began to congregate increasingly into villages and cities. This progressed further in the past few hundred years, such that it is now the case that we live in densely packed cities. The skyscrapers and swarms of strangers living in the metropolis of Manhattan, New York, is a very alien environment to the rural savannah plains that we had been living in for millennia, as small hunter-gather tribes of kinsmen.

We now live in an environment that our nervous systems find confusing. There is an endless array of triggers that mimic the atavistic fears: heights from buildings, planes, stairways, windows; strangers everywhere; vast stretches of unknown terrain due to the large distances that can now be easily travelled in short periods; unfamiliar sensations and phenomena abound. These are interpreted, incorrectly, as dangerous by the hardy ancestral nervous system within us.

A panic attack usually does not remit quickly, as it has been triggered by a non-serious threat or threat that is not evident to the individual. Without any serious danger present for the individual to escape from or destroy, which signals an end to the danger and activates an end to the panic state, s/he is left continuing to pump out adrenalin, with its end-organ effects, for longer than Nature intended. The ongoing hyperventilation leads to an increased ratio of O2:CO2, which leads to light-headedness, dizziness, headache, myoclonus (muscle jerks), carpo-pedal spasm (muscle spasm) and parasthesiae (pins & needles). Because the symptoms are prolonged (usually 10-30 min), the sufferer is confused and afraid and begins to imagine the worst ...that they are about to have a heart attack or stroke or faint or die from suffocation or heart strain.

Panic disorder

The Anxiety Curve Threshold Metaphor

Why would panic attacks consistently occur in response to triggers that are not particularly dangerous (such as a lion attack) or even in anticipation of triggers or situations?

People appear to have a peak performance where anxiety is optimal at driving their performance but beyond which it becomes counterproductive and leads to reduced performance due to the severity of the end-organ symptoms and/or the duration of symptoms. Some people seem to overshoot beyond the peak in certain circumstances. Perhaps they have developed a hypersensitivity to particular stimuli due to past experience telling their brains that they did not cope effectively with that encounter with danger.

Everyone appears to have a different peak height beyond which the anxiety becomes counterproductive. In other words, the same amount of anxiety can be adaptive in one person and undermining in another.

The anxiety-performance peak is determined by an individual's genetics interacting with their lifetime experiences. Most psychiatric disorders' onsets, courses and symptoms are determined in this way. See genes in the Introduction.

The threshold appears to be modifiable. Repeated traumatic stimuli occurring during relevant developmental stages appears to be able to recalibrate the level of arousal that the individual ends up with, for their particular environment.

Even a single traumatic stimulus is capable of permanently re-setting the threshold, bringing it much lower and leading to an individual being in a persistently hyperaroused and anxious state. See Post-Traumatic Anxiety Disorder.

Anxiety of certain quantities and qualities can trigger another computer program called dissociation. This can be defensive, helping the individual deal with an intensely traumatic scenario by changing their levels of consciousness, awareness, pain sensation and responsiveness. It may a program equivalent to a non-human animal ‘playing dead’ to survive an encounter with danger. In this case, the intensity of anxiety may be helpful to the individual in determining when to initiate such a behavioural repertoire. Unfortunately, if remaining for too long in this dissociated state, there will arise distortions and misrepresentations of the world around. These confusing perceptions and sensations may confound the individual and stress them further, setting up a vicious cycle.

We still don’t know much about how different quantities and qualities of anxiety work to influence the individual. Some forms of anxiety seem to lead to increases of arousal and others to reductions. An example of the latter is ‘learned helplessness’ when animals have been exposed to situations where they lose control no matter how hard they try to flee or fight.

Almost any external or internal stressor can trigger the onset of a hyperanxiety state where the threshold to having panic attacks is lowered. Drugs, medications, depressed states and other anxious states, such as OCD, social phobia, separation from a loved one and psychosis, included. Even the anticipatory fear of having another panic attack can trigger panic attacks.

When the individual tried to avoid the triggers this is called agoraphobia. Unfortunately, the more one avoids the triggers and becomes convinced that this is the way to avoid further panic attacks, the more anxious they become and by pushing themselves further along the anxiety curve, they worsen their condition.

The learning to ride a bicycle metaphor

A usually highly effective method of undermining panic attacks is to conduct breathing exercises. This technique involves counting in a 6-second cycle in one's head (1-and-2-and-3, 4-and-5-and-6, 1-and-2-and.... etc), whilst breathing in through the nose during those first 3 seconds, then breathing out through the mouth during the latter 3 seconds (4-6), repeatedly for about 5 minutes.

Because it is difficult to think straight during a panic attack, it is wise to practice this breathing exercise for 5 minutes two-to-three times per day for about a week or more.

This assists the brain to learn how to conduct the exercise, without needing to consciously "think" about how to do it, which is particularly hard to do during a panic attack. This learning process is akin to learning how to ride a bike, which requires wilful concentration until the coordinated activity becomes learnt, and then can be conducted subconsciously. Theoretically, the sufferer will eventually automatically conduct the breathing exercise whenever anxiety climbs and the risk of a panic attack being inappropriately triggered occurs.

Obsessive Compulsive Disorder

The Octopus Metaphor

Obsessions are like octopus tentacles putting the ideas into the sufferer's mind. Of course, the octopus is a chemical creature (the chemical imbalance in the brain) and the thoughts are experienced as originating from within, but as being silly, purposeless and disturbing, but not foreign. Certainly the sufferer does not want the thoughts and would like them to desist.

The sufferer may develop all sorts of elaborate and detailed rituals as a futile attempt to reduce the anxiety that the thoughts are creating.

The thoughts need to be identified as obsessions (abnormal ideas that are the result of the disorder, not realistic ideas to be acted upon, not even with compulsions, which only make the anxiety worse because the obsessions continue or become more elaborate). They need to be seen as the tentacles of the octopus, which must be fought continuously to win control back over the sufferer's mind.

Tools and weapons to use against the OCD octopus are anti-obsessional medications (selective serotonin reuptake blockers like Prozac), cognitive behavioural strategies and behavioural tricks to undermine or ward off the anxiety symptoms, such as breathing and relaxation exercised. Above all, the obsessions and compulsions must be resisted at all times. Never give in to the obsessions or compulsions. Ward the tentacles off with your mental shields and swords. Cut them short by ignoring them ...they will always eventually abate if they see they are not getting a reaction. This is called exposing your brain to not performing the compulsions, which leads to confidence and increased emotional strength to remain in control.

It might be helpful for the sufferer to imagine the octopus as 'the enemy' who they must 'fight', using tricks, tools and weapons such as active resistance, ignoring, distraction, special behavioural strategies and medication to weaken the octopus, shrink its tentacles and reduce its control over their brain and behaviour.

The Regional Overactivity (or Too-much -is-not-necessarily -a-good-thing) Metaphor

In OCD, genetics appears to play a large part in the development of regional overactivity in the circuits that evolved to assist people in avoiding contact with or ingestion of harmful agents.

A PET scan of a sufferer's brain shows a circumscribed area of overactivity. This represents the source of generation of the obsessions, which then lead to compulsions being performed. Anxiety can fuel the circuit. Therefore, anti-anxiety measures greatly assist. Selective serotonin reuptake blockers work here to shrink the degree of overactivity in these neural circuits.

The circumscribed area may also be considered the body of the octopus (combining with the previous metaphor), sending obsessions through tentacles into the surrounding brain tissue.

The genes can be switched off with medications, which also dilute the hot spot. Behavioural strategies can be used to fight and compensate for the symptoms that the hot spot fuels.

Post-Traumatic Stress Disorder

The Overheated Circuit Metaphor (or Regional Overactivity Metaphor)

A massive emotional stressor can lead to local, regional overactivity in certain neural circuits in the brain. This is the classical disorder where an environmental stressor is considered necessary for the psychiatric disorder to occur. In other words, the environmental stressor is seen to be more important than genetic vulnerability in the causation of the disorder. Whereas in other psychiatric disorders, the interaction of genes and environmental experience is seen as the route leading to onset, here the environmental experience itself directly causes the onset.

However, genetics presumably play a large part in the development of the neural circuitry (perhaps a 70% say in it) suggesting that perhaps some people may be more vulnerable to developing PTSD if their circuitry is more vulnerable to getting overheated the same way that certain types of plastic coating electrical wires may be more likely to allow heavy currents to lead to heat leakage and a fire than others (due to different insulation levels).

The overheated circuit is overactive and the images and emotions that have been imprinted by the colossal stressor keep intruding into the sufferer's consciousness in the form of flashbacks, dreams and re-experiencing, especially when triggers occur that re-activate that circuit. The sufferer recognises which triggers do this and they may begin to avoid any situations where those triggers occur. Taken to extreme, they often become agoraphobic and housebound.

It may well be beneficial to spend some amount of time 'resting' the overactive circuit by avoiding triggers. Once it has cooled down, then it might be reasonable to begin to re-expose the jumpy circuit to the triggers, gently, gradually increasing the amount of time in contact with triggers and exposing the circuit to increasingly specific and stronger triggers in a step-wise progression. It is important that this is done slowly and cautiously, allowing the circuit to cool down sufficiently after each re-exposure so that it can learn to be less jumpy and sensitive.

It is important to give the sensitive circuit adequate time to rest between exposures, and to activate other circuits during these periods that are as disconnected and as far from the sensitive circuits as possible. Thus, relaxing, pleasurable and restful experiences (which do not activate the sensitised circuits) must be undertaken regularly. In other words, activation and strengthening of diametrically opposed circuits may be necessary. This will lead to relative weakening and decreased sensitivity of the overheated circuits that give rise to the PTSD symptoms.

The Imbalance between passion and reason metaphor

Trauma-Induced pruning of cortical brain circuits in childhood may predispose to there occurring an over-activation of limbic circuits in response to a serious life-threatening threat later in life. This occurs due to reason circuits inadequately compensating for the excessive fear response, or perhaps over-excitability of the passion circuitry. It is normal for post-traumatic symptoms to occur following a serious life-threatening threat, but the over-activation of limbic circuits usually gradually dissipates as reason circuitry becomes activated and gradually neutralises this limbic over-activation. If the reason circuitry is less likely to fully activate, an imbalance results between it and the passion circuitry, with a resultant ongoing activation of the fear circuitry.

The False Alarm Metaphor

The tap metaphor

A water drop causes ripples that progressively decrease in intensity and frequency

The voice of reason metaphor

The weight lifter metaphor

A weight lifer must gradually increase the weight of barbells when training to improve muscle strength because if he progresses too quickly by overworking he will cause a muscle strain or injury that will undermine his course of training. Similarly, if he uses steroids he may cause unwanted side effects.

The fast to slow lane metaphor

The soldier on guard metaphor

Being in a state of high anxiety is like being a soldier on guard.

The haunted library metaphor

PTSD is like being haunted by a ghost living in your mind's library of memories, such that the autobiographical books come flying off the shelves.

The metaphor

PTSD is like .