Anticipitory Anxiety
Helping Yourself to Overcome Your Anxiety Disorder:

Anticipatory Anxiety is the anxiety that we experience in anticipation of exposure to our frightening triggers.  If you are claustrophobic, when you worry about taking an elevator later in the day, that is anticipatory anxiety.  If you have a fear of contamination, when you worry about having to sit in a dirty seat tomorrow, that is anticipatory anxiety.  And if you have a fear of public speaking, when you worry that your anxiety will ruin your presentation next week, that is yet another example of anticipatory anxiety. 

This simple phenomena plays an enormous role in creating and maintaining virtually all anxiety disorders.  Anticipatory anxiety drives our desire to avoid contact with our sources of anxiety.  It pushes us to stay away from our phobias, worries, and obsessions.  It is extremely powerful and difficult to eradicate.

The irony here is that, like every aspect of anxiety, anticipatory anxiety is entirely paradoxical.  Our attempts to avoid the anxiety makes it stronger. We feel like we are avoiding in order to reduce anxiety, but the truth is that anticipatory anxiety generates additional anxiety.

Some Facts About Anticipatory Anxiety

First, anticipatory anxiety is not a true predictor of how much anxiety we will feel in the actual situation.  Although it is impossible to predict with total accuracy, the fact is that 95% of the time, anticipatory anxiety is much greater than the anxiety we experience when we actually make contact with what frightens us.

This fact flies in the face of our common sense.  Here is a typical way we experience anticipatory anxiety:  Suppose you are frightened of flying.  Despite these fears, you schedule yourself to fly in a week.  When you imagine yourself flying, you think catastrophic thoughts about the flight and your anticipatory anxiety soars.  You think to yourself, “Here I am a week before the flight and just thinking about the flight in the comfort of my living room brings my anxiety up to a level 8.  If I am that anxious just thinking about the flight, imagine how freaked out I am going to be when I am actually on the airplane.  I have to cancel that flight.”

But our anticipatory anxiety gets it all wrong. In truth, we encounter the majority of our anxiety before and at the very beginning of our contact with anxiety producing situations. If you can stay in the situation past that surge of anxiety, you will remain relatively comfortable for the remainder of the time.   In the case of flying, I tell my patients that--if they have a good understanding of the phobic process and have some solid tools for coping with their anxiety--by the time the plane has reached level flight, they will have experienced 80% or more of all their anxiety.  By that time, anticipatory anxiety will have largely passed, and they will begin to benefit from the therapeutic effects of exposure.

Second, anticipatory anxiety is real anxiety, but it is very different from the anxiety we experience in the triggering situation.  There is considerable evidence that anticipatory anxiety and situational anxiety are generated in different parts of our brain. 

We know, for example, that different classes of medications have significantly different effects on these types of anxiety.  SSRI’s (selective serotonin re-uptake inhibitors)  significantly reduce panic, phobic and obsessional anxiety, but have little effect on anticipatory anxiety.  Conversely, the Benzodiazepine class of medications (Valium, Xanax, Klonopin, etc.) can reduce anticipatory anxiety greatly, but have relatively little impact (except at impractically high dosages) on panic, phobias, and obsessional disorders.

Third, anticipatory anxiety is quick to appear and slow to go away.  It is this persistence that makes it one of the most difficult parts of an anxiety disorder to get over.  For example, there are many people who have worked on their phobia or other anxiety disorder to the point that they can make contact with their feared triggers and experience virtually no anxiety.  However, these same people can feel considerable fear when anticipating contact with these same triggers.  In other words, thinking about exposure to the previously feared situation creates anxiety, while making contact with the same situation creates none.

Here is an excellent example, and it is a true story.  Some years ago I was working with a man who was afraid of driving over bridges.  More specifically, he was afraid of getting stuck in traffic while driving over a bridge.  He feared feeling trapped on the bridge, becoming panicky and then doing something impulsive or dangerous , like jumping out of his car or causing a motor accident.  (By the way, these are common “what if” thoughts.  The anxiety makes the thoughts feel like they can really happen, but they never occur in reality.)

We practiced by repeatedly driving across a major bridge that connected Manhattan to other parts of New York City.  Two things were very fortunate for us that day.  First, the traffic on the bridge was extremely heavy in BOTH directions.  My patient was driving and I sat next to him.  The traffic was so heavy that he had to drive a few feet, stop for a minute, then pull up another few feet when the car ahead of him moved up.  It was literally bumper to bumper.  It was a cloudy, overcast day, and we could see a sea of red brake lights ahead of us crossing the bridge span.  Although I was pleased about the chance to practice anxiety management techniques, my patient was horrified.  He said  to me, “Well, you may be happy, but I’m freaking out here.”  So the word “fortunate” needs to be looked at in the context of creating a great opportunity to practice.

The second fortunate aspect was that the span of this particular bridge is curved in such a way so that you can see the entire row of cars coming at you as you drive over the span.  Remember that there was stop and go traffic in both directions.  So here is the picture:  we are going over the bridge span bumper to bumper, looking at the sea of red brake lights in front of us.  And, by shifting the view a little to our left, we can simultaneously witness the mass of bright headlights coming over the bridge towards us.  Red lights ahead of us leaving Manhattan.  Headlights to the left of us, entering Manhattan.

In the middle of the span, my patient said to me, “Marty, I’m really shocked.  This stop and go traffic is my worst nightmare.  I thought I would be totally freaked out, but my anxiety really isn’t that bad--maybe a 2 or a 3.  I can’t believe it.”   Then there was a silence and my patient continued, “Now you’re going to think I’m really crazy.  I told you when I look at the traffic ahead of us, my level is maybe a 2 or a 3.  But--listen to this--when I look at the traffic coming back into Manhattan, and I think to myself that pretty soon I’ll be part of that line of cars, my anxiety level goes up to a 7 or an 8.  How weird is it that? I’m much more frightened of thinking about what I have to do, even though I’m doing that exact same thing right this minute!”

Actually, this wasn’t weird at all.  It turned out that this particular practice situation allowed my patient to “switch” quickly between phobic anxiety and anticipatory anxiety.  When he looked at the line of cars in front of him, he was exposing himself to phobic anxiety.  When he looked a little to the left and noticed the cars coming back into Manhattan, he was experiencing anticipatory anxiety.  By switching back and forth that way, he was able to isolate and clarify the difference between these two forms of anxiety. 

Besides highlighting the differences, we were able to put a spotlight on the persistence of anticipatory anxiety.  My patient was experiencing very little fear while going over the bridge--his phobia was slight.  But he felt a great deal of anxiety while anticipating the exact same activity in the reverse direction.  We will return later to this point when we look at ways of managing anticipatory anxiety.

The fourth fact about anticipatory anxiety is that it increases with our indecision.  Anticipatory anxiety generally becomes more pervasive as we get closer to the feared activity, as we find it harder to just “put off” thinking about it.  The anxiety we feel often makes us waiver in our determination to pursue the activity.  So, for example, suppose you are afraid of heights and you have to go to meeting on the 43rd story of a building.  As the day of the meeting nears, you will become ever more aware of your anticipatory anxiety.  You might start to waver about attending the meeting.  Can you reschedule the meeting to an office on a lower floor?  Could you call in sick that day?  Could a colleague take your place in the meeting?  This sort of “should I or shouldn’t I” wavering will drive up your anticipatory anxiety even more.  However, as soon as you commit yourself to either bailing on the meeting (which, in the short term, would be a great relief; in the long term, however, you are reinforcing your fear and feeling less able to manage it) or attending it no matter what the anxiety, you will start to experience some relief in your anticipatory anxiety.

I’m not saying that it will go away.  But the internal debate that drives up your anticipatory anxiety will be turned off, and you will notice at the very least a leveling off of it’s intensity.  By freeing yourself of the “should I or shouldn’t I?” debate going on inside of you,  you will be more able to stay connected to the present and focus on manageable tasks. 

Anticipatory anxiety gets you coming and going.  Let’s say that you are afraid of taking public transportation and you are booked on Amtrak from New York to Boston.  You are frightened of the upcoming trip--that is your anticipatory anxiety.  However, sometimes you don’t feel that familiar anxiety prior to a trip.  When that happens, you worry whether something is wrong, and that maybe the absence of fear right now means that you are going to get super-anxious when you are on the train. That is what I mean when I say that it gets you coming and going.

Suggestions for Coping With Anticipatory Anxiety

Let’s face it.  By now you must realize that there is no easy way to get rid of anticipatory anxiety.  But there are a few suggestions for making that anxiety more manageable.

First, label your anticipatory anxiety as just that--anticipatory anxiety.  It is real anxiety, but it is different from the anxiety you will experience when you make contact with what frightens you. Remind yourself that anticipatory anxiety has a life of its own, and can remain a potent source of fear even after you have otherwise conquered your phobia.

Second, remember that anticipatory anxiety is not an accurate indicator of how anxious you will be when you encounter your anxiety triggers.  Stay with the fact that 95% of the time your anticipatory anxiety will be much greater than the anxiety you experience when you are in the situation. As you practice exposing yourself to your fears, you will see that a pattern begins to emerge:  anticipatory anxiety will generally be much higher than your situational anxiety.  Make note of this patterns as they emerge, and try to use these facts to anchor yourself.

Third, you can use judicious amounts of benzodiazepines (minor tranquillizers) to help you manage anticipatory anxiety.  This class of medications seems to target this sort of anxiety quite specifically. There is a down side to this, however.  Studies have shown that in addition to reducing anticipatory anxiety, these medications also reduce the therapeutic effectiveness of exposure.  So you will have to weigh benefits against the negative.

Fourth, try to commit yourself to the activity you are worried about.  Remember that your “should I or shouldn’t I?” debate will intensify your anticipatory anxiety, while a commitment to follow through will allow it to stop increasing.

Fifth, try to turn your anticipatory anxiety into a learning experience about the power of your brain to affect your feelings.  Again, remember that while anticipatory anxiety is real anxiety, it a type of anxiety that is 100% generated by images in your mind.  There are no physical or behavioral triggers to this anxiety.  It is independent of external causes.  You will usually think of worse case scenarios when anticipating how terrifying your future experience will be; these scenarios sometimes have nothing to do with external reality.  Observing your own anticipatory anxiety will help you grasp how powerfully your brain can create it’s own version of reality.

Here is an example.  One of my patients had a severe phobia of vomiting, and was so terrified about it that she limited her life enormously.  She avoided anyone whom she believed might be ill, since that person might pass on a stomach virus and cause her to throw up.  She lived in an apartment with a roommate with whom she was friendly, but not very close.  Each of them had their own bedroom and their own bathroom.  One morning she and her roommate lingered over breakfast, and both went to work at the same time.  That evening she returned home to find that her roommate’s door was shut and she could hear definite signs that her roommate was coughing, retching, and throwing up.  “What if,” she thought, “she caught her roommate’s stomach virus and would soon start getting nauseous and vomiting herself?”  That night was a horror.  She was afraid to knock on the door and contact her roommate.  She couldn’t sleep, and spent most of the night with intense anticipatory anxiety, waiting for her own nausea and vomiting to begin. Finally, out of exhaustion, she fell asleep until the morning.  When she awoke, she saw her roommate walking around the apartment, smiling pleasantly, sipping coffee, eating breakfast, and reading the paper. “But I thought you were sick last night, my patient asked?  “How did you recover so quickly?”  Her roommate looked a little surprised, then laughed a bit, and said that she had been fine all night, but saw the movie “Detroit Rock City”  on a CD before going to bed.  There was a scene in the movie where someone throws up, and she guessed that my patient had overheard that scene.

My patient immediately realized that her roommate had never been ill, and she, my patient, had never been in danger of catching her stomach virus.  The entire experience was based on mis-information, and entirely generated in the mind of my patient.  For her, it was the beginning of a profound realization that her phobia was based on images in her brain, and not on the external reality. 

Sixth, and finally, the best way to overcome anticipatory anxiety is to understand that this anxiety bluffs you into believing that you won’t be able to handle your fear in the upcoming situation. Once you gain confidence that you can handle the anxiety that arises there, you will be able to treat anticipatory anxiety for what it is--real anxiety that has it’s own life, but has nothing to do with the fears you are anticipating. 

So, for example, suppose you are overcoming your fear of flying, and you have had many flights under your belt with minimal anxiety each time.  When you purchase your tickets, you might still feel high levels of anticipatory anxiety.  But, if you can tell yourself that you feel confident of coping with any anxiety that might arise during the flight, you can put this anxiety in the background of your awareness, where it will become gradually less intense.