Almost Anxious: Is My (or My Loved One's) Worry or Distress a Problem? (The Almost Effect)

"This long overdue book will be invaluable to people who are 'almost anxious' and their loved ones. It presents many effective methods for dealing with anxiety. Very practical and vibrant read! Bravo!"
--Sabine Wilhelm, PhD, Professor, Harvard Medical School

"This book is a wonderful resource for anyone who has ever wondered if they are 'a bit too anxious' and if there is anything they can do to feel more at peace. The text offers clear, scientifically-based information about adaptive levels of anxiety, anxiety disorders, and that 'almost anxious' space in between. The use of diagrams, self-assessment tests, and self-help treatment forms guide the reader in a search to gain understanding of his or her symptoms, and the means to lessen their severity and impact. The best thing about this book, however, is Dr. Marques' voice, energy, and engaging personality. You never feel as though you are stuck in an advanced psychology seminar. Rather, reading this book is like sitting with Dr. Marques in her beautiful office, overlooking the Boston skyline, and having a lovely, personal chat."
--Risa B. Weisberg, PhD, Associate Professor (Research) Brown University

"This is simply a great book. It brings together so much information about anxiety and worry, even if it is 'just' almost, and it does so in a way that is easy to understand and apply to one's own life. The techniques presented for coping with anxiety and worry are practical, pragmatic, easily applied, and likely to be very helpful. This is an important book for persons troubled by anxiety and worry."
--Richard G. Heimberg, PhD, Professor of Psychology, Distinguished Faculty Fellow, and Director of the Adult Anxiety Clinic of Temple University

"Whether you are almost anxious or suffer from a full-blown anxiety disorder, this book provides concrete and proven cognitive and behavioral strategies for effectively dealing with the debilitating problems of anxiety. Dr. Marques, an expert clinician, wrote a masterful book that provides the reader with the knowledge and skills to turn the scary anxiety monster into a harmless pet. It is a must-read for any consumer."
--Stefan G. Hofmann, PhD, Professor of Psychology, Boston University, and author, An Introduction to Modern CBT (Wiley, 2012)

"One of the main goals of effective therapy for individuals with anxiety disorders is to 'give away' as much of the treatment as possible--to have the patient themselves take over the role of therapist. In Almost Anxious, Dr Luana Marques, herself a master clinician and researcher, provides patients and their family members with critical insights and important tools that they can use to more effectively help themselves on the road to better health."
--Mark H. Pollack, MD, The Grainger Professor and Chairman, Department of Psychiatry, Rush University Medical Center

"Almost Anxious is an engaging, informative, and evidence-based book. Accessible to the general reader, it provides an abundance of useful tips for people struggling to cope with symptoms of anxiety."
--Richard J. McNally, PhD, Professor, Harvard University author, "What is Mental Illness?"

It’s only human to worry about problems in our lives―but for some of us, obsessing for weeks and months, or avoiding social situations due to feelings of panic, can become regular habits. If any of these describe you or a loved one, it could be “almost anxiety.”

Those of us who are “almost anxious” may never address the issue because we don’t fully meet the diagnostic criteria for an anxiety disorder. In Almost Anxious, Luana Marques, PhD, describes the spectrum of these symptoms, from normal situational anxiety on one end to a full-blown diagnosable anxiety disorder on the other. Drawing on case studies and the latest research, she gives you the tools to

assess whether your or a loved one’s worry is a problem

gain insight on how to intervene with a loved one

discover proven strategies to change unhealthy feelings of distress

gauge the physical, psychological, and social impact of your anxiety symptoms

determine when and how to get professional help if needed

Chapter 1: What is "Almost Anxious"?

One hot afternoon in the middle of July, I learned a lesson on how to keep a healthy perspective on anxiety. I was near the end of the Half-Dome trail in Yosemite National Park in California. Since 4 a.m. I'd been hiking uphill through forest. So far the hike had been extraneously uphill, but the terrain was covered by beautiful trees.

Suddenly, the landscape shifted and I found myself clambering up open rock, surrounded by empty space. My body immediately responded to the perceived threat of falling. My heart pounded, my sweat increased, my body tensed up, and I slowed down my pace. All I could think about was "What if I slip and fall?" The more I focused on that thought, the more my body reacted. I began scanning around for rocks with edges that I could hold on to in case I stumbled. My sense of apprehension increased. My friend, who was hiking with me, asked if I was okay. I answered, "I'm not sure; I might have a height phobia." "And you choose now to tell me?" he responded. We both laughed. It was an unfortunate time to discover that I might be afraid of heights, given that in a few more minutes our hike would culminate at the steep, 4,800-foot climb arriving at to Half Dome.

Does this mean I have a diagnosable phobia of heights? Am I "almost anxious" about heights? Or was I just exhausted from hiking several hours and had normal protective physical sensations? Examples like my hike at Yosemite and the fears, anxiety, and worries that many of my patients face can help you better understand natural responses to anxiety compared to a diagnostic disorder, and the almost anxious space in between.

Maggie's Story
As I mentioned in the introduction, anxiety is helpful, up to a point, but most of my patients' anxiety is a signal of something being wrong. However, anxiety is not necessarily the problem, but rather how my patients manage their anxiety level that gets them into trouble. Take the example of Maggie, who came to see me after having a severe panic attack during her freshman year of college.

Maggie was 19 years old, originally from South America, and was studying abroad for the first time. You might not have known that Maggie was a foreigner had she not told you, since her spoken English was remarkable and she was very knowledgeable of American culture. Maggie experienced her first panic attack while walking to class mid-semester in her freshman year. She could not pinpoint anything that led to the attack, which had truly come out of the blue.

"I was walking to class when suddenly I noticed my heart started to pound, I started to feel nauseous, and had some difficulty breathing. My mind started to race and I had trouble focusing. I started to sweat and it felt like someone was sitting on my chest. I really believed I was having a heart attack. I nearly went to the emergency room but I thankfully was able to reach my mom on the phone. She distracted me from my anxiety and helped me calm down enough that I was able to go to class," she told me.

Overall, Maggie described herself as happy, with many friends, and very lucky to have gotten a scholarship to study in America. At our first meeting, however, she was still scared. Maggie decided to seek help right away because she noticed that she was changing her behavior in response to her fear of panic attacks and at the recommendation of her mom, who had battled panic disorder for most of her life. For example, she decreased her coffee intake to morning only because she noticed that coffee would make her heart speed up and remind her of her panic attack. Similarly, she had been an avid runner but was now only running short distances with friends just in case she would have another panic attack.

Maggie is a great example of someone who is "Almost Anxious." Although her anxiety is interfering in some aspects of her life, mostly daily life style things, she is still engaging in life. In fact, Maggie's avoidance, at the time I first met her, were very limited to a few things, and she was still managing to engage in classes, see friends, and enjoy most aspects of her life. Yet, if Maggie did not seek help, it is probable that she might go on to develop panic disorder.

Is my "anxiety attack" severe enough to be considered a "panic attack"?
What do people mean when they say they had an "anxiety attack"? Often my patients are referring to what psychologist call a panic attack. A panic attack is defined as having an intense surge of anxiety and fear, combined with the experience of at least 4 of the following symptoms:

To find out if your anxiety attack is in fact a panic attack, think back the last time you had a lot of panic and anxiety and check the following boxes if the symptoms happened at the same time and bothered you significantly.

• Palpitations, pounding heart, or accelerated heart rate
• Sweating
• Trembling or shaking
• Sensations of shortness of breath or smothering
• Feelings of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, lightheaded, or faint
• Chills or warm sensations
• Numbness or tingling sensations
• Feelings of unreality, like things are happening in slow motion or not in real time
• Feeling detached from your body, as if you were having an "out of body experience
• Fear of losing control or going crazy
• Fear of dying

Evolutionary Benefits of Anxiety
Walking through a forest hundreds of years ago, our ancestors had to be alert, sharp, watchful, and ready to attack a prey for dinner or to fight off an enemy to stay alive. People learned that adrenaline--or the anxiety that resulted--was essential to their survival. But centuries later, modern humans have come to interpret anxiety and its emotional consequences (like a sense of dread, doom, and fearfulness) as well as its physical symptoms (like pounding pulse, sweatiness, dizziness, difficulty concentrating) as the enemy.

If Maggie were facing a lion in the jungle, her body's first response would be to go into a fight or flight. As a result, several of the symptoms Maggie was experiencing as a "panic attack" would have actually increased her chances of survival:

• Her heart would speed up, as she would need more blood moving through her body to get ready to either fight the lion or flee. A stronger heartbeat leads to more blood circulation, which in turn would raise Maggie's body temperature.
• She'd get sweaty, which has two primary functions: to decrease her body temperature (this is important to keep her brain cool!) and to make her body more slippery, which would in turn make it harder for an enemy to grab her in a fight.
• Her muscle tension would increase--much like it would have done if she had been on one of her normal jogs. But during an encounter with a lion, her muscles would be ready to help her flee
• If Maggie had just eaten prior to seeing the lion, she likely would start to feel nauseated. In an extreme circumstance, she might even feel the pangs of diarrhea, since her body would stop digestion to ensure blood was instead utilized for running.

These symptoms were familiar to what Maggie experienced during her panic attack late that fall. Physical sensations like these can be scary when you're having them. But if you keep in mind that they're simply tools that evolution has hard-wired into our bodies for a good reason--much like a fire alarm in a home--you can change the way you think about them so they're not so bothersome.

Anxiety: From Fight-or-Flight to a False Alarm
People can experience panic attacks even without having a full-fledged panic disorder. A national survey suggested that, even though 15 percent of people might experience a panic attack during their lifetime, only 1 percent of those individuals would meet criteria for panic disorder in the past month. So, why do some people develop panic disorder, while millions of other people are able to disregard their experience of a panic attack?

One of the reasons people go on to develop panic disorder is their misinterpretation of the consequences associated with their physical sensations. It's easier to understand this with an example. Imagine that you are at the mall, shopping for a book at Barnes and Nobles, when you notice that everyone in the store starts to run towards the door?

What is the first thought that comes to mind? Fire, perhaps! What do you feel? Most of us would start to feel a little anxious, our heart might start to pound, and we might experience the fight or flight we talked about. What would you do? Well, I know I would run if I thought it was fire, likely fast and without questioning it. How about you?

But, suppose that, before running off, you were to stop someone and ask: "Hey, what is going on"? And the person's response is, Britney Spears arrived at the mall! How would this piece of information change your natural fight or flight response? I guess, for the true Britney fans, they might still run, but I would assume they are now running with a smile on their face and the hope of seeing their muse. For others, like myself, our bodies might just relax and we might just go on to keep browsing the books.

As you see, your body is wired to respond in a particular way, but at times that response is not appropriate given that there is no real danger, it is merely a "false alarm." As such, being able to change your interpretation of the situation (e.g., I am dying of a heart attack versus I am experiencing a false alarm) is likely to change your chances of developing panic disorder.

In short, higher anxiety allows a mother to jump and catch her baby daughter before she falls from a chair, or a student to concentrate harder while taking an important exam. But when does normal anxiety cross the line until it starts approaching a full-fledged anxiety disorder, which is the region known as being almost anxious?

A concept called the Yerkes-Dodson Curve offers an easy way to understand the importance of maintaining anxiety at just the proper level.

The Yerkes-Dodson curve--A better life with just the right amount of anxiety
In 1908, a pair of psychologists, Robert M. Yerkes and John D. Dodson, conducted a series of experiments with mice to learn about the relationship between arousal (in other words, anxiety) and performance, which led to the so-called "Yerkes-Dodson Law." These experiments showed that an increase in mental and physiological arousal is directly associated with an increase in performance--but only up to a point. This is easy to understand if you think about that first cup of coffee that you have in the morning, which raises your body's level of arousal and helps you focus a little better.

But drinking more and more coffee doesn't send your performance levels higher in a straight line. Eventually, the coffee has an unintended effect. Imagine having a few too many cups of coffee on an empty stomach because you hadn't slept much the night before. For most people, this would lead to jitters, possibly a pounding heart, less ability to focus, and an overall decrease in productivity.

Similarly, the Yerkes-Dodson Law suggests that the increase in performance related to the increase in arousal only goes so far. Moderate levels of arousal are associated with an increase in mental and physical performance. Yerkes and Dodson showed that there was an optimum level of anxiety that supported optimum performance, about mid-way through the curve. For decades, psychologists have discussed this as "adaptive anxiety." This is like being "in the zone," often related with increased focus, creativity, problem-solving, and multi-tasking.