The anxious brain and how to rewire itby Donna Chisholm
As researchers close in on the secrets of the anxious brain, Donna Chisholm asks if young people, especially, are becoming increasingly maladjusted to the pressures of modern life.
The phenomenon became “official” in February, according to the media, anyway, with an American Psychological Association study that found millennials – those born in the 20 years from 1981 – are the most stressed demographic, out-worrying boomers and “matures”. The debate as to the cause has ping-ponged its way around popular and conservative media in Britain and the United States for months.
In the Telegraph, 25-year-old fashion writer Rachael Dove dubbed it the age of desperation, suggesting the rise of technology, over-protective parenting and “exam-factory” schooling might be fuelling the generational angst that afflicts her and many of her friends.
She understands her anxious thoughts are often irrational, but they are nonetheless overwhelming. “They include, but are not restricted to, a fear of failure, disappointment, not being good enough and not being liked. I worry that I don’t know who I am, that I look fat. I put off opening my post and checking my bank balance because it makes me feel so nervous. Towards the end of my degree, just going to lectures had me out in a rash.”
In June, Spectator columnist Mary Wakefield wrote that a third of the kids she met aged from 15 to 25 were suffering in some way from anxiety or depression. “I’ve heard kids listing their mental illnesses in the same bored, confident voice they use to order artisan coffee.”
At the same time, Vice UK writer Eleanor Morgan, described as “one of the sharpest young voices in today’s media”, released the book Anxiety for Beginners about her own crippling angst, calling it, in the inimitable manner of millennials, “a total fucker”.
“At times, the way my mind has short-circuited has made me feel hopeless, heartbroken and so frustrated – as though I’ve been cauterised from joy, while thinking myself inside out.”
The debate was further fuelled by a book released in May by libertarian writer Claire Fox, I Find That Offensive, in which she bit back at Generation Snowflake – “a new breed of hyper-sensitive censorious youth”. She posits that the main culprits in draining resilience from youngsters are “a new class of educational and social-policy experts. It is their therapeutic ideology that is doing the young a tragic disservice, leaving them ill-equipped to deal with uncomfortable ideas on campus, never mind the challenges of real life.
“We – adult society – protect children from criticism and suspend our critical judgment in order to massage their self-esteem. We scare them rigid by ‘catastrophising’ an endless list of fears. We make them hypervigilant about potential abuse from adults and their peers. We encourage them to equate abusive words with physical violence. We have, in short, shaped our own over-anxious, easily offended, censoriously thin-skinned Frankenstein monster. We created Generation Snowflake.”
Underpinning the anecdote, hyperbole and theories, however, is evidence of the burden of anxiety disorders – the most commonly diagnosed mental illness – particularly among women and young adults. In a University of Cambridge review published in the journal Brain and Behaviour in June, researchers said though the overall proportion of people suffering anxiety – around four per cent – remained largely unchanged in studies between 1990 and 2010, under 35-year-olds and women are disproportionately affected, with rates for young adults in some studies of up to nine per cent.
On World Health Organisation estimates, New Zealanders are among the most anxious in the world, with a quarter of people diagnosed with anxiety during their lifetime. This puts us third, behind the United States and Colombia. The 2011-2012 New Zealand Health Survey found six per cent – more than 200,000 people – had been diagnosed with an anxiety disorder (including generalised anxiety, phobias, post-traumatic stress and obsessive-compulsive disorder). Like the Cambridge research, it found women (7.7 per cent) and those younger than 44 were worst affected.
So what is going on in the Gen Y brain? Is it the result of helicopter parenting, the pressures and expectations of social media, a more complicated world – or even house prices and Donald Trump?
For Auckland psychotherapist Kyle MacDonald, who says more than half his clients have anxiety in one form or another, blaming millennials for going soft is wrong and counter-productive. “It involves finger-pointing and I don’t think any generation has found the older generation pointing at them and telling them what they’re like particularly helpful, for lots of reasons.
“When we say, ‘Millennials are like this,’ we are locating the problem in that generation and saying it’s their problem and they need to change, as opposed to recognising there are some really different, significant challenges they face, that we didn’t.”
That includes the problems of “just being able to live where they grew up, going to uni for five years with no guarantee of a job, let alone secure employment, and navigating relationships in a context we didn’t grow up with”.
Social media is a big part of that picture, with its relentless but impersonal connectedness. He says research suggests that in terms of psychological health, for people who are generally emotionally healthy and pretty happy, it accentuates that. For those who are isolated and miserable, it accentuates that, too.
“We all need satisfying emotional connections with other human beings but we can fool ourselves into thinking we have those if we are connected to people online. I think all the generations are figuring out how to navigate that effectively.
It’s possible to frame it as the Snowflake Generation, that everyone just needs to toughen up and stop pandering to all these precious young people – which I don’t agree with – or it’s possible to ask, are we actually getting more aware of the emotional impact of things, and the sorts of things that are damaging to people?”
At universities, anxiety has in the past couple of years overtaken depression as the most common presentation for students, but Kimberly Farmer of Auckland University’s Health & Counselling Service doesn’t think that’s because they’re becoming less resilient. “They live in the world differently and have different strengths and weaknesses,” she says.
Courses on mindfulness, depression and anxiety are available throughout term time, and are always fully subscribed. The university is investigating offering webinars next year to cope with the demand, and a wellbeing educator was appointed last year to boost intervention and health promotion resources online.
Spikes in numbers seeking help commonly occur at exam times, and students in high-pressure courses such as medicine, law and engineering are relatively over-represented, along with first years and foreign students who may be living away from home in flats or halls of residence for the first time. Some students came with existing perfectionist or anxious traits.
“I think students are really capable of going online and looking up resources,” says Farmer. “I think they reach out [for help] sooner and are resilient in different ways. Anxiety is a key issue for tertiary students to get on top of – to study successfully, they need to manage it.”
What’s changing, says Henry Plant, a doctor who has specialised in treating anxiety for the past 20 years, and works at Auckland’s Anxiety Trust, is the way we deal with stress. “We’re a lot less physically active now than we were in the past, when people were more likely to walk or bike to work or be in physical jobs. And we know probably the best thing for anxiety is not actually medication, it’s physical exercise.”
Yes, he says, there is a tendency to over-protect children, and it’s possible we’ve gone too far so they’re not developing healthy ways of handling stress to give them the resources to cope when many of the pressures of early adulthood hit. But while there has been a big increase in the numbers of people in all age groups seeking help for anxiety, that doesn’t mean it’s becoming more prevalent, he says, just that it’s better recognised and more likely to be diagnosed.
“In the 1980s and 90s, anxiety was given very little attention. It was regarded as being a bit of a sideshow that people didn’t take very seriously, or if you went to the GP you were diagnosed with something else. Even recently, a psychiatrist colleague of mine referred to anxiety patients as the worried well.”
It’s true, though, that those who seem to have the least to worry about are the most anxious, with people in the developing world – confronted with real issues of survival in grinding poverty – at lower risk of anxiety disorders.
In New Zealand, there was no better illustration of this than John Campbell’s remarkable interview on Radio New Zealand’s Checkpoint in June with 11-year-old “TA”, who had just shifted to Te Puea Marae in South Auckland, having slept in a van since February, with her parents and five siblings.
All TA wanted was a library – she’d missed a scholarship to a private school by just two marks, after being unable to study in the car at night because the light drained the batteries. Despite this, she seemed resilient and upbeat, commenting on how good the marae meals were, and that she was pretty sick of takeaways.
Plant is not surprised. “You’re presuming her life is very stressful because they’re living in a car… but what stresses kids is lack of nurturing, lack of love, lack of parenting and people being hostile to them. If you grow up in a loving, caring background, it doesn’t really matter what you have in the way of possessions.”But are we really so mentally mal-
adjusted that we can be more stressed by a full inbox than an empty stomach?
The causes of stress and anxiety aren’t as important as the person’s perception of them, says psychological therapist Jock Matthews, of Rojolie Clinic in Auckland, which specialises in treating anxiety and depression.
“It’s the experience of distress that’s important, rather than whether or not someone has food to eat versus the fact they didn’t have someone like their latest photograph on Instagram. It’s being ‘out-grouped’; the humiliation, the embarrassment, the icky feeling that you’re not included or you feel shamed or embarrassed.
That might be a First-World problem for many people, but it’s also an experience where people fear being judged badly, and that’s hard.”
He notes an increase in the numbers of patients aged 18 to 35 seeking help, but says he’s been struck by how hard they are working to understand and deal with their anxiety. A turning point in therapy is often when they realise “their brain is tricking them”, he says. “When they realise their distress is driven by a false belief about something.”
He recalls one patient with an obsessive compulsive disorder who believed they couldn’t stand on a crack or someone in the family would die. “Well, we went out to the veranda the other day and stood all over the cracks and I had a text this morning that no one in the family had died over the weekend.”
However, even if they know deep down their anxiety isn’t rooted in logic, that alone isn’t enough to change their thinking. As MacDonald explains it, “We can’t just tell our brain there is no threat. We have to put our brain in situations where we down-regulate that anxiety and train our brain to be calm again.”
It’s why mindfulness is always on his list of to-dos for anxious patients. “Without question, the most useful starting point for people is to just stop. It’s entirely possible, with the busy life we lead, to wake up, immediately pick up the phone, have breakfast watching TV, drive to work while listening to the radio or talking on the phone, work all day, eat lunch at the desk, come home and rinse, repeat...”
It’s incredibly important, he says, to schedule gaps into our days. “Just being able to go and sit on the park bench at lunchtime for 20 minutes and leave the phone in the office. Go for a walk for 15 minutes without headphones, or the phone. Drive to work with the windows in the car down and the stereo off. What we tend to do is drive ourselves to distraction and that can often be a factor in anxiety – there is no space to just stop and have that cup of tea.”
A criticism of cognitive behavioural therapy, which is commonly used to treat anxiety, is that for some, it can feel like being told to “just get over it, and think something different.
“The thing about the brain is that once it is wired into an anxiety state, it can take some time to shift that. The usefulness of mindfulness, often in tandem with CBT, is that it gives us a way to behave our way out of anxiety, to give the brain an opportunity to rewire itself and get used to the absence of threat.
“But you can only do that through experience.”
The Confidence Gap
How acceptance and commitment therapy “saved a life”.
When Ministry of Justice stenographer Matt Hamilton had his first panic attack at the age of 26, his fiancée called 111 for an ambulance.
“I woke myself up. It was just unbridled fear… of nothing. I was just intensely afraid. I felt super-lightheaded. I was so weak that I couldn’t stand. The adrenalin was just dropping out of my body. Heart pumping, sweating, everything.”
His anxiety disorder has affected his life since he was about 13, although he became fully aware of it only in his 20s. “I used to be quite outspoken and not shy – extroverted even – and I just remember slowly closing up. I became very reserved, extremely shy. I put myself down as an introvert and thought I would never change, but a lot of it was just anxiety.”
Eventually, he would do everything in his power to stay in “my little bubble”, shutting himself off from friends and family. He rarely went out and, when he did, was the first to leave.
That panic attack led to a deep depression and the first of several breakdowns. He believes it may have been partly triggered by the responsibilities of his first job – until then he’d been working from home because “I couldn’t function in the real world. I was cripplingly shy. I taught myself up to that point to just avoid everything that made me feel that way.”
In the weeks that followed the attack, “everything basically shut down. I didn’t understand what was going on and I thought something was seriously wrong with me, even though the hospital said I was fine. I wasn’t eating, I wasn’t sleeping. I was afraid to sleep because that’s when it happened. Every waking hour, I was crying. I was convinced I had either an aneurysm or a brain tumour – the anxiety is just so illogical it jumps to the worst-case scenario possible.”
His first efforts to get help weren’t too successful, with a GP essentially telling him, “Here, take these pills, you’ve got a good life; don’t dwell on the bad stuff.”
Eventually diagnosed with a generalised anxiety disorder and referred to public mental health services, he found the counselling under-resourced, with time limited and the sessions of cognitive behavioural therapy not particularly useful. “I didn’t really gel with CBT; I had a hard time challenging my thoughts.”
He says a psychologist he consulted privately who used acceptance and commitment therapy – accepting instead of challenging the anxious thoughts and realising “they hadn’t killed me yet” – saved his life.
“It wasn’t easy by any means, but eventually it became easy. My mind decided that because I’m safe in it and nothing is happening, it can’t be that bad. I basically just faced it.”
At 34, Hamilton says his fiancée is now his wife and he is still working for the Ministry of Justice in Auckland, where his bosses have always been understanding, allowing him to take time off to manage his mental health issues. He remains on anti-depressants but is coming off his anti-anxiety medication.
He says his employers’ attitude is more often mirrored in the community now, when a decade ago, it was not. “All I’d say is, ask for help. Ask everyone because you’d be surprised at how many people are empathetic.”
SNAPPING OUT OF IT
Seven Steps to controlling anxiety
We all know the feeling – did I lock the house, did I turn the stove off, did I leave the iron on? Our anxiety builds as we imagine burglars ransacking the place, or flames licking up the wall because of our carelessness. Should we dash home to check – or leave it to chance? We all know, too, of the heart-pounding adrenalin rush of a near-crash on the road.
These worry pathways illustrate the two different areas of the brain that are activated in an anxiety response. The first involves our cortex, the perceiving and thinking part of the brain, which attaches meaning and memories to the perceptions. Here, anxiety is aroused by conscious thoughts – what’s the risk from leaving the stove on all day, what’s the worst that could happen? – and exacerbated when we become preoccupied with them, imagine the house burning down or can’t think of a solution.
Then there’s the amygdala, the brain’s alarm system and danger-detector that is wired to save our lives in an emergency by provoking the physical response that enables us to hit the brakes before we even consciously decide to do it.
In the book Rewire Your Anxious Brain: How to Use the Neuroscience of Fear to End Anxiety, Panic and Worry, published last year, American clinical psychologist Catherine Pittman says understanding the two pathways is critical to understanding and controlling anxiety.
“We humans aren’t consciously aware of the way the amygdala attaches anxiety to situations or objects, just as we aren’t consciously aware of the liver aiding digestion. However, the amygdala’s emotional processing has profound effects on our behaviour.
“It’s frustrating to realise that, at times, your insightful cortex can be entirely overtaken by your amygdala. But once you have this knowledge, you can use it. The key is to realise that many cortex-based coping strategies, such as telling yourself to stop being afraid or that there’s no logical reason to be anxious, won’t stop the activation of the stress response once it’s initiated. At these times, strategies that target the amygdala are called for, instead.
Panic attacks are a common result of an over-active stress response, but there are different ways to help your amygdala get past them, compared to the techniques used to support your cortex. Deep breathing, muscle relaxation and exercise are amygdala-based coping strategies, while for the cortex, distraction could help, along with remembering it’s only a feeling (albeit an intense one).
The book offers a seven-step path to controlling anxiety:
- Use relaxation, sleep and exercise to reduce sympathetic nervous system activation.
- Monitor your thinking for anxiety-igniting thoughts.
- Replace anxiety-igniting thoughts with coping thoughts.
- Determine your life goals and what interferes with them.
- Identify triggers of fear and anxiety that interfere with your goals.
- Design exposure exercises that can modify your amygdala’s response to these triggers.
- Practice exposure exercises until you notice a decrease in your anxiety and fear.
Donna Chisholm goes under the wire for science
I am wired, not for sound, but for a signal far more subtle – a brain wave from the right frontal cortex that has possibly been triggered deep in my hippocampus. It will appear as a slight oscillation on my EEG tracing; an unconscious response so slight that if I blink my eyes rapidly or grind my teeth, it will be lost in a cacophony of electrical noise.
For internationally noted University of Otago anxiety researcher Professor Neil McNaughton, who is monitoring this test at his Dunedin lab, the signal is the culmination of 50 years’ work. This brain wave – his brain wave – will, he believes, become the world’s first biomarker of anxiety.
The result will have nothing to do with how stressed I feel or my ability to “succeed” at the computer test McNaughton has designed. “We can do this with lizards if necessary.” This is good news. Lizards are apparently less intelligent than dolphins, orangutans, bears, parrots, donkeys, cats, raccoons and even naked mole rats.
The beauty of McNaughton’s right-click, left-click, stop-go test is that it is providing new insights into the anxious brain – without the owner of the brain knowing any anxiety-related circuitry is firing up at all.
Anxiety, he says, is not fear, but rather the adaptive reactions that help us to approach danger rather than flee from it. Think of a hungry rat that wants food but must weigh up the risk of the cat sitting next to it. The brain rhythm McNaughton has found – first in rats and now in tests on people – controls goal-conflict responses and is reduced by anti-anxiety drugs even if they don’t work for depression, phobia, panic or obsession.
Critically, says McNaughton, the biomarker will allow us to define a biological type of anxiety. At present, he says, guidelines for the diagnosis of mental disorders lump together symptoms to define them. “Nobody has ever got a biological definition of any mental disorder – we may have the first one of these.
The key problem at the moment is the way these are diagnosed. You have a group of things that we currently call high temperature spotty disorder. We should be able to end up effectively with a test which allows you to say, okay, this thing here is German measles.”
In EEG recordings from human volunteers, McNaughton has been able to accurately identify groups who have been given small doses of anti-anxiety drugs, based only on the levels of this right-frontal brain wave, which reflects the goal-conflict aspect of anxiety.
“My main claim to fame is to have attempted to nail down the idea that the hippocampus, which most people talk about as being to do with controlling memory, is actually a key area controlling anxiety. What I think we are dealing with is a mechanism that essentially can keep defensive, fearful, anxious memories going.
“This adds a parallel anxiety system (moving towards danger/risk assessment) to the established fear systems (moving away from danger). It sees anxiety and fear as almost opposites of each other, rather than being two words for the same fundamental thing.
“The hippocampus is not only strongly connected to the amygdala but also to lower (hypothalamus) and higher (prefrontal cortex) areas involved in fear and anxiety.”
So, to the test. It is, as McNaughton promises, so simple as to be almost tedious. Left click on the mouse when a left-facing arrow appears on screen, right click when the right-facing arrow appears. But when a beep sounds, do not click. The speed of the beep is adjusted so that sometimes it will be easy to stop, sometimes almost impossible, or evenly balanced 50-50. It’s those 50-50 calls which generate the anxiety-related response. Tellingly, the signal is unaffected by the annoyance of failure. Which is just as well: expletives punctuate my test.
“You are trying to stop reliably every time there is a stop signal, and a lot of the time you can’t and that’s irritating, but a real advantage of the test is that we aren’t exposing people to a major threat. This task, in terms of its nature and surroundings, is very unthreatening. Then we arrange conflict, which is the key part of my theory.”
My EEG suggests I am not particularly, or overtly, anxious. I am, unremarkably, boringly average, having a similar-sized signal “bump” to McNaughton’s “middle of the road” group. “We expect clinical cases to have a much larger positive bump, with a spread to the lower frequencies.”
But what does all this mean for patients? Surely it isn’t viable for every patient to go through a brain scan to be diagnosed with anxiety? While that may be true of the present test, there is the prospect of cheap, clip-on EEG headsets. “By the time we are down this track, there may well be EEG systems that you could hand to your patient and use for neuro-feedback training.”
His research is also being used to better define and target the patients who score most highly on the anxiety brain signals, to then see if he can devise a questionnaire that identifies them as being anxious compared to having other types of mental disorder.
“The problem is different people are being given different drugs and some of the drugs work for different people some of the time, so the clinicians have to keep swapping round. The question is whether they can be given the right ones first off.”
McNaughton, who co-authored a seminal work in the field, The Neuropsychology of Anxiety, with renowned Oxford University psychologist Jeffrey Gray (who died in 2004), is recruiting people who identify themselves as being anxious but are not on drugs to treat it, and healthy controls, to take part in the EEG trials, which have the backing of a $1 million Health Research Council grant, in Auckland and Dunedin. Anyone who’s interested can find out more by emailing firstname.lastname@example.org.
The brain response typically associated with anxiety is known as “fight or flight”. This reaction starts in the amygdala – the centre for emotional processing – which sends an SOS to the hypothalamus, the command centre.
One of the troops the hypothalamus dispatches in response to stress and anxiety is the corticotropin-releasing hormone known as CRH. Ultimately, the hormonal cascade through the adrenal and pituitary glands shows up in our blood with increased levels of cortisol. We need these physiological changes to help us cope with the danger, but when the change becomes chronic, or occurs inappropriately, the stage is set for anxiety and stress disorders.
A few streets away from McNaughton’s lab, at the University of Otago’s Centre for Neuroendocrinology, Associate Professor Greg Anderson and Dr Karl Iremonger have come to regard CRH neurons as the equivalent of the Prime Minister, and the many and varied processes that act on them as the PM’s specialist advisers and Cabinet. Anderson has also identified a key member of the Cabinet with a previously unrecognised but important role – to continue the analogy, a kind of biochemical Minister for Anxiety, known in scientific circles as RFRP neurons.
Anderson stumbled on the idea that RFRP might be affecting stress about five years ago, when he was researching (in rat models) their role in suppressing fertility.
“We were looking at situations where people are known to be infertile – before puberty, post-menopause, generally when lactating, and perhaps when stressed – to see whether this chemical might be ramped up. Some situations didn’t fit our hypothesis. There were times we were expecting to find high levels of this chemical and they were really low. But a much better explanation for the levels we were seeing was that they seemed to reflect whether the animals were anxious or not,” he says.
The RFRP neurons seemed to be “really ramped up” when the animals were stressed. “If the RFRP neurons are chronically elevated, it means the CRH neurons are chronically elevated.”
About five years ago, Anderson’s group developed a chemical, known as GJ14, which stops RFRP acting on its receptor on the CRH neuron. In 2015, they published their research showing how the drug completely reversed the anxiety-promoting effects of RFRP, and changed the behaviour of the mice treated with it. The behavioural tests are relatively simple – mice prefer dark enclosed spaces rather than being exposed in lighted areas and the activities are monitored in a light-dark box. Mice treated with GJ14 spent significantly more time in the open than mice infused with RFRP.
The discovery has changed Anderson’s research focus, from fertility to anxiety, and his team is now working to find out if the drug can successfully cross the blood-brain barrier (at the moment it’s injected into the brain), which would be essential if it’s to be clinically effective.
Adding to the excitement of the find is that the drug appears to be “wonderfully without adverse side effects” and isn’t on the research radar of any other scientists in the field, internationally.
Another advantage is that it’s highly specific in its target. Earlier in the research, Anderson says they tested another drug that blocked RFRP but also blocked other related receptors, causing unwanted side effects such as potential fertility complications.
“Only one in 1000 research drugs will make it into clinical use; we are realistic about that. We will have to line our drug up against the SSRIs [antidepressants] and benzodiazepines [anti-anxiety drugs] and show ours is better in order to get a drug company excited about developing it further.”
Iremonger says a key goal of the research is to understand how stress neurons function. We already know about the cyclic nature of the reactions in the brain – that stress activates the CRH neurons, which activate the stress hormone levels, which feed back to the brain and regulate how the brain functions. “The problem seems to be that it’s not just a single stress that’s the problem. Most people can cope with those quite well – it’s chronic elevations in the cortisol which change brain activity in a detrimental way.”
He’s also looking at how neural structures within brain cells change after long-term exposure to cortisol. “Other labs around the world have shown quite convincingly that in the emotional circuits, you get quite dramatic changes in structure after long-term exposure to cortisol and to stress.”
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