When Anxiety is Not Anxiety

“I’ve tried it all. I’ve tried everything, but nothing seems to work for me. Sometimes I have a bit of a break, but it never lasts long enough. I’ve tried all types of treatments. I’ve even tried alternative treatments like yoga, meditation, exercise, anything—you name it. And sometimes, just when I think everything was going well in my life, I still get anxious. I am tired of this. I need some help. I just cannot continue to let anxiety ruin my life.”

Her name is Carla. She’s 42 years old and presents to her new clinician, Stephanie, with the above narrative. Stephanie, who is seeing Carla as part of a multidisciplinary team, proceeds with a comprehensive assessment using what's known as the Bio-Psycho-Social-Cultural Formulation Model, which assesses a mix of multiple factors to get to the bottom of a client's challenges and formulate the best treatment approach.

The Biological Roots of Anxiety

What are some of the biological factors associated with anxiety that Stephanie ought to rule out in determining why Carla’s anxiety simply persists despite having tried everything? [1] Here are 5 common ones:

1. Genetic predisposition as evidenced by a family history of anxiety
2. Certain physical health conditions, like hyperthyroidism, heart disease, or asthma [2]
3. Medication side effects, including steroid medications, stimulant medications, or medications used for thyroid disease
4. Alcohol and/or substances, like cocaine, marijuana, or caffeine [3]
5. Neuropsychiatric conditions, like head trauma, PTSD, or panic disorder

Psychological Contributors to Anxiety

When Stephanie is done looking at the biological factors that might help explain Carla’s persisting anxiety, she then moves on to the psychological factors that might help explain Carla’s dilemma. What are the psychological factors associated with anxiety? Here are 5 common ones:

1. A history of exposure to a traumatic event
2. A history of an ambivalent or avoidant type of attachment [4]
3. A personality trait, like neuroticism
4. Family dynamics
5. Burnout [5]

Socio-Cultural Factors That Contribute to Anxiety

Lastly, Stephanie looks at the socio-cultural factors that might help explain Carla’s predicament. What are some of these social-cultural factors? Let’s take a look:

1. Exposure to stigma [6] and discrimination
2. A stressful or unhappy living arrangement
3. Limited social support
4. Financial stressors [7]
5. A new job

In response to Stephanie's thorough assessment, Carla says, “This is the first time someone has taken the time to assess me so thoroughly."

She adds, "My mom used to have a lot of anxiety. I used to have asthma and used to take Albuterol. My anxiety did get a bit better after I was asked to stop it. However, my anxiety has returned even though I’m no longer taking Albuterol. I also stopped drinking alcohol, I no longer drink coffee or tea, and I even stopped smoking cigarettes. I did get a break from the anxiety. I thought that was it. But now it’s back, and frankly, it’s been getting worse. I did have some trauma growing up—who doesn’t, right? But I think I’m over that stuff. I barely remember any of it by now.”

Abraham Maslow once said, “I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.” This seems to be what Carla’s previous clinicians had been doing—until Carla met Stephanie.

Yet Stephanie may not necessarily be any more successful than Carla’s previous clinicians. For despite the comprehensive assessment so far, the root cause of Carla’s anxiety has yet to be discovered.

What is the Root Cause of Carla’s Anxiety?

“If I had an hour to solve a problem, I'd spend 55 minutes to understand the problem and 5 minutes to solve it,” said Albert Einstein. While this comprehensive assessment following the bio-psycho-social-cultural model is essential to conduct for every client who presents to a therapist's office, does this model truly provide us with a deep understanding of what really causes anxiety—or does it simply tell us of some associations that exist with anxiety?

In a world where correlation is often mistaken for causation, it is understandable why we may still be missing the point despite how comprehensive our assessment may be. But correlation does not imply causation. Two things may correlate, but it does not mean that one causes the other. In fact, correlations often have a third factor between them that affects both of them. [8]

Anxiety Essential Reads

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How I Quickly Stopped a Panic Attack

What does that all mean for someone who is experiencing and suffering from anxiety? How does any of this help such a person? Here’s how:

1. If you’re experiencing anxiety, make sure your clinician has proceeded with a thorough assessment, using the bio-psycho-social-cultural model.
2. If, despite addressing any of the associated factors, your anxiety persists, consider that what you call anxiety may not be the problem.
3. Work with your clinician to follow Einstein’s principle of “understanding before solving.” In other words, learn to understand what anxiety really is before attempting to address it.

What about starting right now? What is anxiety? What does anxiety really mean? Stay tuned as we address these questions in subsequent articles.