Neuroscientist Says Anxiety Is An 'Attention Problem'

Anxiety can feel tremendously uncomfortable, unsettling, and discombobulating. Whether one experiences an isolated case of situationally driven anxiety, or whether one’s anxiety is so severe or pervasive that it becomes a diagnosable anxiety disorder, people tend to focus on the strong negative emotions stirred up by their worries, and on the perceived threats that drive those feelings.

Some medications can quickly alleviate anxiety. Talking therapies can aid in regulating emotions over time. However, emotions can be challenging to work with directly. Emotional distress such as anxiety also makes it harder to apply cognitive tools — when you’re overwhelmed it’s hard to think clearly.

An anxious person misdirects their focus in unhelpful directions, which blocks them from attending to, and dealing with, life as it is happening now. Situations don’t force us to be anxious. Anxiety is an individual emotional reaction to what we think might befall us. 

When we feel anxious we unduly fixate on the potential harm of a future event, even if the risk of a bad outcome is low. Once we’re aware of our anxiety we can opt to create better responses to perceived dangers.

In 30 years of helping patients with anxiety, I’ve seen that reframing anxiety as a problem of attention often provides pathways for escape. Strategies that help an individual shift focus away from anxiety, and toward how they want to act and be in the world right now, empower people and alleviate anxiety.

What good are emotions? Evolution has hardwired our emotional responses. A specific, emotionally evocative trigger activates short neural pathways in primitive areas deep in our brain.

 The emotional response induces not just a certain state of feeling, but also elicits facial expressions, changes in blood pressure, heart rate, and other bodily functions, and alterations in muscle readiness that are characteristic of the specific emotion.

Whatever triggered the emotion may also engage slower, lengthier neural paths leading to the cortex of the brain, giving rise to conscious awareness.

 Emotions deliver complicated, automatic responses far more quickly than the ponderous process that involves becoming aware of what is going on, and then consciously selecting and acting on a behavioral option.

This is why we flinch in fear of a spherical object hurtling toward our face, well before we realize it is just a soft foam ball that isn’t going to injure us. Our emotional response of fear is triggered before we can calculate that we’re not in any real danger.

Anxiety is an attention problem and focusing on attentional issues can help alleviate it.

We tend to think of anxiety and depression as emotional problems, schizophrenia as a thought disorder, and ADHD as an attentional issue. 

Even the names for these conditions reinforce how we classify them. But anxiety and depression also affect memory, attention, and how we organize our thoughts. 

Schizophrenia and ADHD alter how emotions are expressed and regulated. Whether at the level of everyday experience or of clinically significant mental health conditions, feelings, and thoughts are continually shaping each other.

Mental health problems don’t tend to fall into tidy categories. Seldom do they distort just a solitary process of the mind. The brain is a vast integrative machine, with multiple networks intertwining and interacting. It is hard to disrupt just one function of the brain in isolation from all others.

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Be afraid, be very afraid — but don’t be anxious

For animals, including humans, the basic emotion of fear is a response to an immediate situation that could cause death or serious injury. For humans, fear triggers also extend to include threats to our social standing or reputation. 

At a physical level, fear opens our eyes, revs our hearts, and increases our rate of breathing. It can cause us to tremble, and if severe enough, to lose control over the bladder or bowels. It poises us to either freeze in place or race to get away from the danger.

Fear is a useful response, priming us to rescue ourselves from severe harm.

Anxiety, on the other hand, is fear projected into the future. The threat is not happening now, but we imagine it may occur at a later date. 

Anxiety causes an overactivation of our sympathetic nervous system and can elicit the full range of physical responses to fear: accelerating our heart, making our breathing shallow, causing our limbs to quake and our voices to quaver, and disrupting digestion and urination.

Anxiety, from everyday worries to full-blown panic, redirects blood flow within the brain, making it harder to execute complex functions, like sustaining attention, planning actions, or initiating tasks. 

Severe anxiety can freeze us into inaction, or cause us to repetitively engage in mindless motions like pacing, fidgeting, or nail biting.

Concern about future threats can be useful. It can lead us to analyze the actual likelihood of a dreaded scenario. It can motivate us to take steps to lessen or completely avoid future disasters. 

Deflecting thinking about, and planning for possible bad outcomes leads to avoidable tragedies. However, anxiety is maladaptive because it decreases our ability to effectively address those upcoming perils.

The range of anxiety problems — and their connection to attention

Genetics influence the likelihood that we become anxious. Some children are timid and avoidant, while others boldly explore and interact with their worlds. 

But our natural inclinations can be shaped by how we are raised. Supportive, but not overprotective, adults can help even fearful children to be more comfortable with their world.

Our world is a dangerous place. Healthy individuals will display some moments of anxiety. However, anxiety that disrupts normal functioning could be a sign of an anxiety disorder. 

Anxiety disorders are the most prevalent mental health conditions in our modern world — and rates are increasing.

Anxiety is either the central feature or a common accompaniment, of all of these conditions:

• general anxiety disorder
• social anxiety
• specific phobias
• Post-traumatic stress disorder (PTSD)
• depression
• ADHD
• Obsessive-compulsive disorder (OCD)

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To oversimplify, imaging studies indicate that in anxiety states a brain structure called the amygdala tends to be overly active, generating an excessively strong fear signal. 

Meanwhile, the prefrontal cortex is abnormally quiet, failing to dampen down the signals from the amygdala. Those same prefrontal cortex regions are responsible for directing attention to important events in our world, sustaining attention when appropriate, and shifting our focus to new information when that would be helpful.

When we’re stuck in anxiety, we activate our default mode network (DMN), a system intimately involved with mind wandering, and a focus on the self, including our past, present, and imagined future experiences.

 Activation of the DMN inhibits, or disconnects, the frontoparietal network that engages when we are involved in goal-oriented tasks, and cognitive effort.

Focusing on attentional biases

Some anxious people fixate on scanning their environment for danger. Some anxious people avoid looking directly at the threats that scare them. Psychologists call these largely unconscious propensities “attentional biases”. 

The tendency for constant scanning is labeled attentional vigilance while deflecting from danger is labeled attentional avoidance. Not all studies have found attentional biases in individuals with anxiety.

By examining a subject’s eye movements when they look at computer screens with neutral, threatening, or pleasurable images, researchers can measure attentional vigilance and avoidance.

 A little over a decade ago, psychologists began to use such computer set-ups to intentionally alter these attentional biases. They hoped that by decreasing an individual’s attentional vigilance and avoidance they would thereby reduce anxiety.

Attention bias modification (ABM) treatments can, over time, change attentional biases. However effects tend to be small, and it is not clear how long the benefits might last. Some evidence indicates that ABM might be more effective for PTSD than for social or generalized anxiety.

While focusing on attentional vigilance and avoidance, ABM neglects another form of attentional bias called attentional capture. This refers to the difficulty in pulling oneself away from immersion in anxiety-driven worry about a threat and the difficulty of redirecting focus to other tasks. 

Attentional vigilance and avoidance influence the likelihood of falling into an episode of anxiety, but in my clinical experience, attentional capture is the source of most of the dysfunction and distress for patients.

Many anxious individuals know that it is counterproductive to stay mired in their anxiety, but feel that they just can’t extricate themselves.

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What does and doesn’t help anxiety

Telling someone not to think about pink elephants encourages further thoughts about rose-colored pachyderms. Trying to suppress an idea often makes it more prominent. 

Telling someone “Just don’t worry about it.” doesn’t dispel anxiety, it’s likely to increase it, because of the Pink Elephant Paradox. It’s also likely to increase the worrier’s anxiety because they think that they are the only responsible person paying attention to some horrible threat.

Simply asserting that “Everything will be okay.” also usually fails to staunch anxiety. While it may briefly quell anxiety, it trains the worrier to keep seeking reassurance from others. An effective anti-anxiety strategy helps people reassure themselves.

Cognitive behavioral therapy (CBT) involves retraining people’s ideas and actions to change their emotions, thoughts, and behaviors. CBT helps with even the most intense form of anxiety, a panic attack. 

CBT for panic initially shortens the duration of panic attacks, and for weeks, makes them less easily triggered, so reduces their frequency, and often makes them go away completely. Effective CBT for panic results in actual changes in brain chemistry and circuitry.

CBT acknowledges the validity of worry arising but tries to switch the response from anxiety to one of concern. It also embraces that life contains uncertainty, which means that perfect safety is not an attainable goal. CBT manuals document how to employ these techniques, and research verifies that many are effective at lowering anxiety.

Tools for escaping attentional capture

Sometimes CBT techniques are delivered in a way that feels too dry, or cerebral, or that fails to meet a patient where they are when amid distress. On the other hand, in controlled studies, the more closely therapists adhere to standard techniques, on average, the more effectively they help patients.

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These are tools I use with patients to deal with anxiety. In some cases, they deviate from standardized CBT, but I’ve found them to be effective. They help people move from anxious, default mode processing, to productive engagement in the real world.

• Anxiety is an attention problem. Similar to the CBT approach to panic, I remind people that despite how horrible it may feel, they are stuck in anxiety. And anxiety means that their attention is misdirected away from living life right now. Many people mired in anxiety will say “You’re just trying to distract me.” But that has it backward. Anxiety itself is a distraction from life. Virtually anything that pulls you out of anxiety and redirects attention elsewhere is good.

• Quest not test. Life is an exploration, not a set of future tests for you to potentially fail at. You may face adversity or challenges, but if you switch your focus away from those barriers, to thinking about what you are trying to achieve or attain at this moment, and how to do that, you’ll find ways to continue acting and striving.

• Set aside time to worry. This counter-intuitive CBT tool recommends setting aside time each day, anywhere from ten to thirty minutes, to focus on all of the things that are worrying you. Then, if worries arise at any other time of the day, you remind yourself that you do have time and energy and your life to devote to those anxieties and that you don’t need to engage them now. You may need to remind yourself of this dozens of times a day, but almost everybody improves with practice.

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• The one adjustment I make is to not even call it “worry time”, which I think reinforces that there are benefits to being anxious. I recommend calling it “problem-solving time.”

• Life is about getting back on track, not whether or not you got derailed. All of us get off track. Certain conditions, particularly ADHD, and anxiety, lead to much more frequent derailments. Anxiety itself is a derailment. If you focus on the derailment, you stay off track. Those who succeed are the ones who get back on track.

• Engage your senses and your body. The meandering, introspective mental space of the default mode network shuts you off from external input. Redirecting attention to what you can see, smell, or hear in your world engages salience networks that deactivate the DMN and move you out of anxiety. Or focusing on breathing the air on your skin, or other bodily sensations can also help redirect attention out of anxiety.

• Life will keep giving you chances. Human brains need repetition. Lots of it. Over and over again. Reiterated until we are sick of it. Many people have an initial success in getting out of their anxiety, only to find themselves back in their anxiety moments later, and then give up, feeling they have failed. We need to repeat simple things over and over before they are ingrained behaviors. Don’t worry if you didn’t “get it right” the first or forty-third time. Every time you move out of anxiety is a victory and means that you are more well-practiced and proficient at that skill.

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• Perfection is not an option. Anxiety is often closely tied to a need for certainty. Don’t expect the future to be free of uncertainty. Absolute safety is unattainable. That doesn’t mean to not strive for improved safety or greater certainty, just a reminder these are ideals, not actual destinations. Perfect knowledge of the future, or even the present, is not simply difficult, it’s impossible.

• Real security comes from knowing that you’ve done what you can to minimize risks and prepare yourself and that when adversity arrives, you will find some way to deal with it.

• Recite mantras. Most of the previous approaches involve redirecting focus from the anxious/DMN towards the prefrontal task-engagement circuits. An alternative network that also silences the DMN is the meditation network, representing a third way to be present in the world. 

• But launching into a mind-clearing meditation can be extremely difficult, almost impossible if anxiety levels are high enough. One of the most simple and easy ways to access a meditative mind is through chanting mantras. Particularly a mantra that you have rehearsed ahead of time.

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John Kruse MD, PhD is a psychiatrist, neuroscientist, and author. He writes regularly about mental health on Medium.com, as well as talks weekly on YouTube channels about adult ADHD and related issues.