Anticipatory Anxiety: Bleeding Before You Are Cut

Anticipatory Anxiety: Bleeding Before You Are Cut

Sally Winston, PsyD

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Dr. Sally Winston is a clinical psychologist and co-director of the Anxiety and Stress Disorders Institute of Maryland. She is nationally recognized for her expertise in the treatment of anxiety disorders. Dr. Winston has been active with ADAA for over 30 years. She has served as chair of the ADAA Clinical Advisory Board and was the first recipient of the ADAA Jerilyn Ross Clinician Advocate Award.

Martin Seif, PhD, ABPP

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Dr. Martin Seif is a master clinician who has spent the last thirty years developing innovative and highly successful treatment methods for anxiety disorders. He helped found ADAA and has served on its Board of Directors and Clinical Advisory Board.  Dr. Seif has offices in Manhattan, NY and Greenwich, CT. For the last 18 years, he has been Associate Director of the Anxiety and Phobia Treatment Center for White Plains Hospital Center. He also trains therapists and psychiatric residents at New York-Presbyterian Hospital.

Anticipatory Anxiety: Bleeding Before You Are Cut

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Anticipatory Anxiety: Bleeding Before You Are Cut

In our newest book, Overcoming Anticipatory Anxiety, we target anticipatory anxiety as a component of most anxiety conditions—including phobias, social anxiety, and panic. It drives the compulsions and ruminations that define OCD.  It is the worry about the future, the fear that bad things can happen, or that you might be unable to accomplish what you set out to do.  It can be the haunting dread of the return of an unwanted thought. or terror while waiting for a medical test result and imagining the worst. This book is the third in a self-help trilogy, beginning with Overcoming Unwanted Intrusive Thoughts, followed by Needing to Know for Sure. 

Anticipatory anxiety can also come in the form of physical symptoms like hyperventilation, insomnia and gastrointestinal distress, or it can just look like the ongoing parade of worries of GAD. Anticipatory anxiety precedes difficult decisions, actions, and situations. It is how our bodies and minds feel when we buy into catastrophic thinking and anxious imaginings.  

Alongside this discomfort comes the strong urge to prevent the imagined problem from occurring: we mistake anticipatory anxiety as red flags indicating danger or a credible prediction of failures, mistakes or regrets. We create an imagined catastrophic story and buy into that narrative. Then we try to figure out a way for that not to happen, often spending hours, days or weeks planning escape routes, analyzing “why?” or ruminating about our lack of confidence.  We oscillate in indecision, trying to choose whether to commit to a course of action.    

Anticipatory anxiety is the third layer of fear—what we call the avoidance layer.  First, we can be afraid of something: “I am afraid of giving talks”. Second, we can be afraid of being afraid: “I am afraid I will get so anxious I will faint or freeze and humiliate myself”. Third, we can be afraid of being afraid of being afraid: “I am so freaked out by the misery I will feel while waiting for and constantly imagining next month’s scheduled talk that I think I have to cancel it”. 

Anticipatory anxiety can involve expectations not only of anxiety or panic, but also of disgust, anger, shame, regret, humiliation, becoming overwhelmed, or any other unwanted emotion. The urge to avoid emerges from the expectation of unwanted feelings or outcomes from some dreaded failure, loss, or disaster. 

If you are worried that you might have a panic attack feeling trapped in an MRI machine, anticipatory anxiety can start weeks or even months before the appointment. If you believe that you “would not be able to stand it” if something went wrong with a choice you made, or that you might die if you let yourself ignore an odd sensation, then you will tend to focus your attention on seeking safety and avoiding even reasonable risks.  Similarly, if you believe that you could somehow “lose control” and do something crazy and against your own wishes, you may spend inordinate amounts of time and effort trying to convince yourself you would never do anything like that. 

Anticipatory anxiety can develop by getting hijacked by an overactive imagination or from automatic conditioned responses to memories. It can be driven by a trait called anxiety sensitivity—the fear of manifestations of anxious arousal. It can also emerge from a depressed and withdrawn mood state. Or it can find its origins in beliefs about one’s own inability to cope with novelty or challenge. Anticipatory anxiety is common in people with sticky minds. 

Effective treatment of anticipatory anxiety—like all forms of anxiety—is targeted at the factors which maintain it. As always, too much thinking is not solved by more thinking.  The path towards recovery has several components: a shift in metacognitive perspective, a change of attitude towards one’s own mind and experience, and an abandonment of avoidance behaviors and the kinds of self-talk that inadvertently reinforce the anticipatory anxiety. It is also important to gently re-direct attention to the present sensory experiences while allowing for and not struggling against the experience of anxiety, 

Changing the metacognitive perspective includes a better understanding of what anxious thoughts do mean and don’t mean, what they can and can’t do,  and that thoughts are neither facts nor warnings. Worrying can be mistakenly valued as if it indicates love or loyalty, or misidentified as productive planning.  This perspective highlights the fact that one’s anxious imaginings are just thoughts.  

When a person understands that obsessive doubts arising from memory or imagination cannot be solved with reassurance or checking, it leads to a willingness to let uncomfortable thoughts simply pass through without examination, disputation, or entanglement in the content.  

A shift in attitude towards anxiety from struggle to acceptance is supported.  People are encouraged to give up the urgent demand to feel sure and the harsh self-judgments which empower continuing distress. The antidote to avoidance is commitment–undertaken without guarantees and with curiosity and good humour.   

We foster a willingness to stop the effort to control the future, and instead, actively allow whatever appears in the imaginative mind while attending to and proceeding forward in present reality. 

The acronym DANCE is an integration of the metacognitive, behavioral and attitudinal shifts that create resiliency and growth in the face of anticipatory anxiety. 

  • Discern that you are experiencing anticipatory anxiety and disentangle yourself. 
  • Accept doubts and discomforts willingly 
  • No struggling, avoiding, reassuring, or overthinking 
  • Commit to proceed with action or choice 
  • Embrace the present as it is and proceed 

When you practice the steps of this DANCE, you will open the door to flexibility, challenges, and the excitement of new opportunities.  


Overcoming Anticipatory Anxiety - Drs Winston and Seifs new book - May 2022

Sally Winston, PsyD

headshot

Dr. Sally Winston is a clinical psychologist and co-director of the Anxiety and Stress Disorders Institute of Maryland. She is nationally recognized for her expertise in the treatment of anxiety disorders. Dr. Winston has been active with ADAA for over 30 years. She has served as chair of the ADAA Clinical Advisory Board and was the first recipient of the ADAA Jerilyn Ross Clinician Advocate Award.

Martin Seif, PhD, ABPP

headshot

Dr. Martin Seif is a master clinician who has spent the last thirty years developing innovative and highly successful treatment methods for anxiety disorders. He helped found ADAA and has served on its Board of Directors and Clinical Advisory Board.  Dr. Seif has offices in Manhattan, NY and Greenwich, CT. For the last 18 years, he has been Associate Director of the Anxiety and Phobia Treatment Center for White Plains Hospital Center. He also trains therapists and psychiatric residents at New York-Presbyterian Hospital.

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