Tackling Anxiety – From Top to Bottom

Read more about Pernille Yilmam at the end of the blog.

Anxiety and depression are widespread mental health disorders, affecting 4% of the global population with only a quarter receiving treatment. This article explores how anxiety manifests in the mind and body and offers strategies for self-management. Cognitive anxiety, characterized by negative thoughts and ruminations, benefits from approaches like cognitive reframing. Somatic anxiety, which presents physically, can be managed through techniques such as Progressive Muscle Relaxation (PMR). Understanding these aspects and empowering oneself with education can significantly aid in overcoming anxiety.

Anxiety and depression are the most common mental health disorders worldwide. According to the World Health Organization (WHO), 4% of the global population experience an anxiety disorder, yet only 1 in 4 receive treatment. In the United States, over 19% of adults and 31% of adolescents are estimated to live with an anxiety disorder in any given year.

While therapy and professional support are crucial in addressing anxiety, empowering yourself through education on its origins and implementing effective self-support strategies can also have a significant impact. This article introduces foundational concepts about how anxiety manifests in the mind and body, and it offers practical strategies to help you overcome it. 

Anxiety lives in our brain and body

Even though many people encounter anxiety, the nature and the intensity of their experience can vary widely. For some, anxiety manifests through dwelling on the past or worrying about the future, while others may feel it as chronic physical symptoms like stomach aches, headaches, or disrupted sleep. Sometimes, people experience a mix of these different symptoms.

If you struggle with anxiety, it can be helpful to understand the underlying neuroscience. This knowledge not only clarifies the root cause but also guides you to the most effective tools for managing it. The first exercise is to figure out if your anxiety is mostly cognitive or somatic. Let’s explore each of them (1, 2). 

Cognitive anxiety

Cognitive anxiety often manifests through negative thoughts, persistent ruminations, and self-doubt. This type of anxiety may involve anticipatory worries about the future and is often accompanied by negative self-talk, such as “I’m not capable enough” or “I’m worthless.” It originates from our thought processes and is a pattern that we are aware of, although we may not always feel in control of it.

Decades of research indicate that cognitive anxiety does not stem from a single gene, brain region, or neurotransmitter; rather, it results from altered brain processing (3). At its core, cognitive anxiety involves a disrupted connection between two key brain regions: the prefrontal cortex (PFC) and the amygdala. The PFC plays a crucial role in regulating our conscious behaviors, thoughts, and emotions, while the amygdala is renowned as the center for our fear response (it’s important to note that the amygdala is involved in much more than fear, playing an important role in our memory formation and motivation).

The PFC and amygdala work in concert with other brain areas, but their connection is particularly vital in managing anxiety. In individuals with anxiety, studies show that the amygdala tends to be hyperactive, and its communication with the PFC is less effective. This imbalance means that those experiencing cognitive anxiety may struggle more to dampen amygdala activity through PFC regulation. This difficulty helps explain persistent rumination about the past or chronic worry about the future—instances where the PFC struggles to exert its usual regulatory “brake” on the amygdala.

Addressing cognitive anxiety often benefits from a “Top Down” approach, focusing on altering thought patterns to engage the PFC actively and thereby reduce amygdala activity. 

Somatic anxiety

In contrast to cognitive anxiety, which manifests in our thoughts and brain, somatic anxiety expresses itself in the rest of our body. Symptoms can include numbness, feeling hot, increased heart rate, headaches, stomach aches, and muscle tension. It is now widely recognized among healthcare providers and researchers that individuals with anxiety disorders are more likely to develop autoimmune disorders (4, 5). If you’ve read The Body Keeps the Score by Bessel Van Der Kolk, Trauma and the Body by Pat Ogden, or In an Unspoken Voice by Peter A. Levine, you’re likely familiar with stories of people experiencing somatic anxiety.

Compared to cognitive anxiety, there is less research on the roots and characteristics of somatic anxiety, which is inherently more complex due to its involvement with multiple systems throughout the body, including nerve endings in our skin and gut. The most challenging aspect is that much of this processing occurs unconsciously, making it difficult for individuals to recognize that their symptoms are anxiety-related. This often leads to untreated cases and negative experiences with gastro-intestinal doctors, dermatologists, and rheumatologists who may not understand why standard treatments are ineffective. If fortunate, these individuals may eventually see a specialized psychiatrist or psychotherapist who can guide them through somatic therapy.

Although the name may not reveal it, somatic anxiety is represented in the brain, albeit differently than cognitive anxiety. Whereas cognitive anxiety heavily involves the cortico-limbic networks (for example the connection between the PFC and amygdala), somatic anxiety is represented in different sets of brain regions, including the insula (which is important for sensing our inner state) and our sensorimotor cortex (important for perceiving sensations and executing movements) (6). Newer research suggests that it’s the hyperactivation of these sensory areas in our brain that lead our body to respond with hypervigilance to sensory input (6). In other words, somatic anxiety is rooted in the brain, but it’s physically expressed in the body.  This means that when we address anxiety, we need to implement methods to change how the brain is responding to and processing sensory input. 

Cognitive and somatic anxiety can happen to anyone with any kind of anxiety disorder

It’s important to recognize that everyone can experience somatic and cognitive anxiety, regardless of their type of anxiety diagnosis. While certain experiences, such as childhood sexual abuse, are more likely to result in somatic anxiety (7), it’s impossible to strictly categorize anxieties into somatic or cognitive groups. For instance, one person with post-traumatic stress disorder (PTSD) might predominantly experience somatic symptoms, while another might experience more cognitive symptoms.

Therefore, it is crucial to approach your symptoms with an open mind and seek out experts and support groups that can help you identify and implement techniques most effective for your specific symptoms. 

Different anxieties require different tools

If the mechanism of anxiety resides in different parts of the brain, then we need to lean on distinct strategies that can target each of these. While Cognitive Behavioral Therapy (CBT) is an effective method for all types of anxieties, it may be less beneficial for those who experience somatic anxiety symptoms (8). CBT focuses on engaging and changing thought patterns, and because somatic anxiety manifests in the body, often outside of conscious awareness, CBT’s “Top Down” approach may not be effective. Instead, somatic therapy approaches emphasize (re-)engaging the mind-body connection, which can be particularly helpful in the context of somatic anxiety (9). When seeking a therapist, it’s important to consider whether they have experience in treating your specific type of anxiety. Below, I provide insights into two evidence-based techniques to help you manage your unique expression of anxiety. 

Cognitive reframing through Thought Records

If you are dealing with cognitive anxiety, cognitive reframing is likely a method that’s useful for you. Cognitive reframing involves “interrogating” your recurrent anxious thoughts and replacing them with an alternative, more balanced thought pattern. This technique can be aided by using Thought Records, an integral tool in CBT that you can easily use on your own.

The purpose of Thought Records is to identify patterns of thinking that contribute to emotional distress, and to challenge and reframe these thoughts, and a typical Thought Record includes the following sections:

1. Situation: Describing the context or event that triggered the negative thoughts.
2. Automatic Thoughts: Recording the spontaneous, often negative thoughts that arose in response to the situation.
3. Emotions: Noting the feelings experienced as a result of the automatic thoughts, often with an intensity rating.
4. Evidence for the Thought: Listing the evidence that supports the automatic thought.
5. Evidence Against the Thought: Identifying the evidence that contradicts the automatic thought.
6. Alternative/Balanced Thoughts: Formulating more balanced or realistic thoughts based on the evidence.
7. Outcome: Recording any changes in emotions or behaviors after reframing the thoughts.

A completed Thought Record might look like this:

1. Situation: I flunked a work presentation in front of the top leadership and my supervisor.
2. Automatic Thoughts: I feel like a total failure. I don’t understand why they haven’t fired me. I don’t deserve to be in my current role.
3. Emotions: I’m frustrated (8 out of 10), sad (7 out of 10), embarrassed (8 out of 10), and angry with myself (9 out of 10).
4. Evidence for the Thought: I have been late to a few meetings lately, I felt overwhelmed with my responsibilities, and I have not been as prepared as usual.
5. Evidence Against the Thought: The recent death of my mother made me feel sad and hopeless. Before her death I was typically always timely and prepared. I’m doing the best I can to navigate work and grief.
6. Alternative/Balanced Thoughts: Right now, I’m going through a difficult time. My performance will improve as I process the grief. I’m a responsible and capable person, but right now I need to focus on grieving and cut myself some slack.
7. Outcome: I’m less frustrated (3 out of 10), sad (0 out of 10), embarrassed (1 out of 10), and angry with myself (0 out of 10). I feel more relaxed (7 out of 10) and capable (8 out of 10).

Regularly practicing this exercise can help you shift your “automatic” thought patterns, making you less likely to engage in negative self-talk, catastrophizing the future, or ruminating on the past. It also serves as a valuable tool for increasing self-awareness and promoting healthier thinking patterns overall. If you find that Thought Records haven’t worked for you in the past, you may benefit from fine-tuning your approach, as discussed in this blog.

Researchers have discovered that after undergoing CBT, which heavily utilizes cognitive reframing and Thought Records, brain areas in the cortical and limbic networks exhibit altered activity consistent with reduced anxiety. This change supports the notion that CBT helps us better regulate our negative thoughts and feelings (10, 11). 

Increasing Parasympathetic Activity through Progressive Muscle Relaxation

Cognitive reframing requires us to be aware of and engage with our thoughts and feelings. An alternative strategy is to tackle anxiety from “Bottom Up”, which focuses on connecting your mind and body without delving into the triggers, thoughts, and behaviors.

One effective “Bottom Up” strategy is Progressive Muscle Relaxation (PMR), a powerful technique for those struggling with relaxation. This method involves actively contracting muscles to create tension, then progressively releasing it. You repeat this routine for every muscle group in your body, until you achieve a state of relaxation. While more research is needed, studies have found that intentional muscle contraction engages the sensorimotor cortex, and the gradual release of tension activates brain areas important for sensing our body’s state. (12, 13).

You can find various YouTube videos and podcasts online providing you with guided PMR. Below is an example of what the script may sound like:

• Start with taking five deep breaths. Make sure you can feel your belly expand with every breath.
• Squeeze your feet for five seconds. Release the tension and relax.
• Squeeze your calf muscles for five seconds. Release.
• Squeeze your thigh muscles for five seconds. Release.
• Squeeze your stomach muscles for five seconds. Release.
• Shrug your shoulders up towards your ears for five seconds. Release.
• Squeeze your upper arm muscles for five seconds. Release.
• Squeeze your lower arm muscles for five seconds. Release.
• Squeeze your hands into fists. Release.
• Open your jaw as much as you can and hold it for five seconds. Release.
• Squeeze your eyes closed for five seconds. Release.
• Tighten your forehead muscles for five seconds. Release.
• Take five deep breaths. Make sure you can feel your belly expand with every breath.
• Continue this routine until you feel more relaxed.

Ideally, you’ll be sitting comfortably in a chair or lying down on a soft surface as you move through this sequence. If you struggle with anxiety-induced insomnia, then PMR is an excellent tool for pre-bedtime routines. 

Empowerment through Education

Navigating anxiety can be challenging and overwhelming. You may have experienced judgment from loved ones, discrimination in the workspace, or bullying by healthcare providers. While these experiences are neither comfortable nor uncommon, they do not reflect your opportunity for recovery and betterment. Anxiety, whether cognitive or somatic or both, can be managed and even treated entirely with the right support.

A first step that many people find empowering is to educate themselves more about the roots of their challenges, enabling them to better understand what they need to improve and articulate that need to the people around them. Sometimes, simply sounding more confident can get you a referral from a resistant healthcare provider, or feeling confident about sharing the science of anxiety can help you push back against bullies. Moreover, keep in mind that over 19% of adults and 30% of adolescents in the US have an anxiety disorder, and many more have experiences with anxiety either currently or in the past. You are not alone, and chances are that the people around you understand more than you think.

References:

1. Schoen, C. B. and Holtzer, R. “Differential relationships of somatic and cognitive anxiety with measures of processing speed in older adults”, Neuropsychology, development, and cognition, 2017.
2. Ree, M. J., et al.  “Distinguishing Cognitive and Somatic Dimensions of State and Trait anxiety: Development and validation of the State-Trait Inventory for Cognitive and Somatic Anxiety (STICSA)”, Behavioural and Cognitive Psychotherapy, 2008.
3. Martin, E. I., et al., “The neurobiology of anxiety disorders: brain imaging, genetics, and psychoneuroendocrinology”, The Psychiatric clinics of North America, 2000.
4. Siegmann, E. M., et al., “Association of Depression and Anxiety Disorders With Autoimmune Thyroiditis: A Systematic Review and Meta-analysis”, JAMA psychiatry, 2018.
5. Amiri D, Brizziarelli L , “The Association Between Anxiety and Autoimmune Diseases: A Systematic Review and MetaAnalysis of 16 Studies”, J Vaccines Immunol, 2023.
6. Bouziane, I., et al., “Enhanced top-down sensorimotor processing in somatic anxiety”, Translational psychiatry, 2022.
7. Eilers, H., et al. , “Childhood Trauma and Adult Somatic Symptoms” Psychosomatic medicine, 2023.
8. Otte C., “Cognitive behavioral therapy in anxiety disorders: current state of the evidence”, Dialogues in clinical neuroscience, 2011.
9. Tamaren, A. J., et al. , “Predictive validity of the cognitive vs. somatic anxiety distinction”,      The Pavlovian journal of biological science, 1985.
10. Yuan, S., et al., “Neural Effects of Cognitive Behavioral Therapy in Psychiatric Disorders: A Systematic Review and Activation Likelihood Estimation Meta-Analysis”, Frontiers in psychology, 2022.
11. Steiger, V. R., et al. , “Pattern of structural brain changes in social anxiety disorder after cognitive behavioral group therapy: a longitudinal multimodal MRI study”, Molecular psychiatry, 2017.
12. Toussaint, L., et al. , “Effectiveness of Progressive Muscle Relaxation, Deep Breathing, and Guided Imagery in Promoting Psychological and Physiological States of Relaxation”, Evidence-based complementary and alternative medicine, 2021.
13. Kobayashi, S., and Koitabashi, K., “Effects of progressive muscle relaxation on cerebral activity: An fMRI investigation”, Complementary therapies in medicine, 2016

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