Detailed guides to painful problems, treatments & more

Anxiety & Chronic Pain

A self-help guide for people who worry and hurt

Paul Ingraham • 80m read
Moody B&W photo of a man holding his head in mental and/or physical pain.

Conversations about chronic painful problems routinely turn into conversations about anxiety. It begins with a statement like “I hold a lot of tension in my back” or “This pain is always the worst when I’m under a lot of stress.” And it often ends up at the chicken-and-egg question: did anxiety cause the pain, or is the pain causing the anxiety?

Hint: it’s both.

Excessive and chronic anxiety may be a potent root cause for an awful lot of back pain, neck pain,1 and perhaps any other kind of chronic pain, not to mention a bizarre array of other physical symptoms2 (WebMD has a good complete list). It probably amplifies pain perception and suffering across the board, but it gets worse: it may also actually cause pain we wouldn’t otherwise have, by actually making us more prone to inflammation.3 Although the treatment of anxiety is outside my own expertise, as a “pain guy” it feels like familiar territory: anxiety is the other side of the chronic pain coin.

Some anxiety is essential for our survival — a prehistoric human that didn’t worry wouldn’t live long — but it probably evolved as a strategy for anticipating and neutralizing threats that we no longer face. Anxiety disorders are a frustrating glitch in the modern human condition. Treating them can be like fighting smoke. The basics of therapy for anxiety are obviously insufficient for many people. Exercise is definitely valuable, but most people can’t beat anxiety just by working out, especially if they are in pain. This article zooms in on some practical, creative, and efficient strategies for calming down and “hacking” anxiety — extra tools for an “everything but the kitchen sink” approach.5

There’s also some whimsy. Because anxious people need some of that.

Medical causes of anxiety: anxiety as a symptom

If only ‘anxiety’ was more widely viewed as a physiological disturbance with associated psychological effects, rather than the other way around.

Phil Greenfield, Chiropractor, from a nice list of 18 ways to tame anxiety with physiology and not psychology

Anxiety is rarely just about biology or psychology. Except when it is.

We humans are chemistry, and nothing could make this clearer than the chilling story of an old family friend who suffered lifelong anxiety and panic attacks. After decades of living with this curse, he was diagnosed with a rare genetic disorder. One of the consequences of this genetic disorder are small tumours on the adrenal glands that cause spikes in adrenaline production. He had one on his adrenal gland. The gland was excised, and he was cured — or perhaps “set free” would be a better description.

That’s an exceptionally rare cause of anxiety, of course. But don’t neglect the possibility of a medical explanation or complication. Some of them are much, much more common. In fact, there are at least several insidious or underestimated medical causes of anxiety, which may explain an awful lot of allegedly “free floating” anxiety and symptoms of anxiety disorder in people who do not seem like a good psychological fit for it.

Low serotonin, caused by a genetic defect, is one of the most recently discovered examples.6 The neurotransmitter serotonin is used everywhere in biology, and the glitchy gene causes chronic shortages with complex effects, including amplified bodily sensations, which is basically nightmare fuel.7 These patients are so notorious for their bizarre panoply of symptoms that they are routinely written off as anxious, “difficult” hypochondriacs… which they probably are, but not for psychological reasons! Does this sound like you? Take the somatic awareness quiz. And how common is this gene? At ten percent of the population, it’s about five times more common than red hair. Ten percent! Read more.

Insomnia is another classic example: it’s a major risk factor for anxiety disorders,8 so anything that interferes with sleep — practical or pathological — is obviously an important consideration. And of course anxiety is a risk factor for insomnia! The effects of anxiety/stress are relieved by sleep, but also make it harder. “[When stressed] your sleep is dominated by more shallow sleep stages, meaning you wake up more easily—fragmented sleep,” Dr. Robert Sapolsky explains.9 “Moreover, when you do manage to get some slow wave sleep, you don’t even get the normal benefits from it.” And of course failing to sleep will cause more stress! Vicious circle. It’s always harder to treat either insomnia or anxiety without treating the other.

Chronic pain is extremely common, and can be both a cause and consequence of anxiety — sometimes equally, sometimes slanted much more one way than the other, but each always influencing the other to some degree. For many people with both anxiety and pain, solving the pain is the best possible treatment for the anxiety. Others must solve both at once. And a few will find that pain is just one of many ways that they are haunted by anxiety demons.

Marijuana usage probably causes anxiety in many people, both as a side effect of using it, and as a symptom of withdrawal. I’ll explore this in more detail below. For now, just be aware that it’s probably a fairly common cause of episodes of anxiety that many people don’t suspect because of the only half-right stereotype that marijuana makes people mellow.

Spinal cord irritation is a particularly disturbing example, with a strong tie-in to chronic pain: some people may be anxious because they have irritated spinal cords, which occurs in some arthritic necks and can cause the body to react as if it were stressed.10 This is called “dysautonomia.” Even minor positional cervical cord compression may cause clinically significant dysautonomia, and even just a little bit of it seems to be potent. It’s been found that many people with fibromyalgia (unexplained chronic widespread pain) also have erratic spinal cord compression,11 which has profound implications: fibromyalgia might not only be linked to stress, but also to “artificial” stress brought on by a mechanical spinal cord irritation. Which is not actually all that rare, believe it or not.12 And for every case with a clear clinical presentation, there may be many that are rather vague. It’s a bit sinister, isn’t it?

Maybe you’re anxious, or maybe you just have a slightly irritated spinal cord.

And then there are a bunch of other causes of dysautonomia as well, most of them individually rare, but collectively it’s not exactly an exotic medical phenomenon.

Imagine for a moment the absurdity and futility of spending thousands on counselling to try to learn to be less anxious when your anxiety has a simple-in-principle medical cause like this. Ugh.

Anxiety can be magnificently destructive, but when combined with chronic pain it becomes paralyzing.

How I learned to cope with chronic pain, Ettenberg (

Never in the history of calming down has anyone ever calmed down by being told to calm down

That’s not strictly correct, but it is funny because it’s true in a sense. Being told to calm down in the right way, or telling ourselves, can be effective. But that “right way” is maddeningly elusive. Most people feel it’s a tall order for anxiey to yield to persuasion and reassurance. It’s hard to outsmart it, or suppress it by force of will. We don’t feel like we are good at calming down. Here are some of the typical ways that people reflexively try to calm down (AKA “cope with anxiety”):

These aren’t “best practices,” just the easiest and most obvious things that worried people tend to try. That doesn’t mean they are useless, and if you haven’t tried them, you should.

But most of them are just variations on telling ourselves to calm down, and they are hardly a magic bullet. Although they work some of the time for easier cases, many people with anxiety disorders have had little luck with these strategies, and we probably wouldn’t have an anxiety epidemic if they were highly effective. By nature, we can’t easily think our way out of anxiety. It’s like telling a depressed person to “think positively” — if they could do that, they wouldn’t be depressed.

But there are other, better ways to calm down. And what if you had professional help with that?

Never in the history of calming down has anyone ever calmed down by being told to calm down.


It’s as if people expected us to will it away. If only we had thought about being more positive! How silly of us.

How I learned to cope with chronic pain, Ettenberg (


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Can a psychologist help you think your way out of anxiety? The state of the evidence about cognitive behavioural therapy for anxiety

Cognitive behavioural therapy (CBT) is a dominant force in psychotherapy and the most common treatment approach for anxiety. It’s how most psychologists will try to help you “think your way out.” And behave your way out.

CBT is widely considered to be a proven therapy for anxiety, and some specific types have firm foundations.14 It seems to work fairly well in a primary care setting,15 and it seems to be great for kids.16 But the benefits compared to placebo are underwhelming, and a technically positive 2018 review showed results that were less than impressive, and concluded that “better treatments are needed.”17 The benefits are especially less clear for older adults,18 and it’s definitely underwhelming when there’s pain and strange symptoms involved.19 In other words, CBT may be the least effective when it matters the most: when anxiety is driving the most disturbing symptoms. 🙁

Overall I’d call the evidence for CBT as a treatment for anxiety “promising,” but far from settled science or remotely proven. Not so much as a treatment for pain itself.20 For more about that, see Cognitive Behavioural Therapy for Chronic Pain. As an excellent example of the deep, scary complexity, there’s fascinating evidence that CBT may fail to treat chronic pain in some people because they are too inflamed — not because the inflammation is directly painful, but because the inflammation modifies mental state and behaviour and that makes the pain harder to treat.21 That’s a deep rabbit hole there.

There’s some decent evidence that cheaper iCBT is “here to stay.”22 iCBT is Internet-delivered CBT — isn’t that cute? So maybe you’re even getting less anxious right now, reading this charming and reassuring article. You should probably keep reading.

Theory vs practice: you’re not always going to get ideal CBT

It’s easy enough to get optimistic about CBT in the abstract, but in my personal experience with several psychologists over the years, and based on a lot of communication with readers … well, let’s just say not all CBT is created equal. There’s a great range of quality and creativity in its application, a big gap between the best possible CBT and the kind that many people will actually encounter in “the wild” — being sold for a bare minimum of $100/hour. (Which is why a more accessible iCBT option is intriguing.)

Good CBT probably gives you a better chance than winging it on your own, but it’s still not an easy road. And its most common weakness in practice seems to be an unfortunate overemphasis on the thinking part — using conscious thought as leverage. Which I cynically assume is an issue simply because that’s what is easiest to do in a therapy session.23

Thinking may be what gets us anxious in the first place, and it may be hard to fight fire with fire, hard to use calming thoughts to subdue or replace worried thoughts. Or, worse, worried thoughts may over time become embodied, so entrenched in our behaviour and biology that they are no longer just thoughts — and fresh attempts to think less worried thoughts may have little impact, especially at first.

Fighting, flighting, tending, and befriending

The famous fight-or-flight response is a biological response to acute threats, and is more common in anxious people but not synonymous with anxiety. “The stress response” to threats to life and limb — the biology of panix — predates “anxiety” in homo sapiens by about a billion years. But that same response, which evolved to deal with threats like being eaten alive, can be triggered by someone cutting in front of you in traffic. If your brain is complicated enough, it can trigger the stress response with completely abstract threats or even imaginary ones.

But exactly how we respond to stresses — whether it’s the threat of disembowelment or failing a driver’s test — is as complicated as personality.

Someone suffering from chronic and excessive feelings of worry, nervousness, or unease is not necessarily in a panic. The anxious person is more likely to spend more time in this mode, either because they actually face more threats, or because they perceive more threats than there really are. But we can also worry about threats without ever actually experiencing one. Or reacting as if there’s one. My own childhood was a textbook case of that.24

There are other ways to respond to acute stress. We aren’t limited to fighting and flighting. There is also the much less famous tend-and-befriend response, for instance, a different behavioural strategy in which threats are dealt with more socially: tending to children, or seeking out the safety of the group and befriending people.

Stress pushes us to perform, and so anxiety can be helpful — to a point, after which we get a bit … messy.25 “Panic” is the breakdown of performance during extremes of arousal (acute stress reaction, AKA “shock”). And if that reaction is delayed/chronic after exposure to traumatic events? That’s PTSD.

All of these things are linked to anxiety, but do not necessarily go together.

Does stress wreck us?

The brain has a vast potential for sticking its nose into the immune system’s business.

Robert M Sapolsky, Why Zebras Don’t Get Ulcers, 2004, p. 144

Many people have heard of “adrenal fatigue.” It is supposedly caused by chronic stress and “burnout” of the adrenal glands. And yet it probably doesn’t exist.26 (“Adrenal insufficiency” is a real disease with several medical causes — but not stress.)

And yet we do know that extreme stress is probably a strong risk factor for developing chronic widespread pain.2728 So how does that work? How are we getting from A to B?

It’s a common assumption that stress and anxiety have biological consequences that drive up the risk of pain over time, and there is evidence to support that.29 Another good possibility is that chronic stress ramps up immune function to the point of dysfunction.30

Chart showing a sawtooth pattern of immune function increasing and decreasing with repeated stressors, but never quite recovering before increasing again, producing a steady upward trend.

“A schematic representation of how repeated stress increases the risk of autoimmune disease,” adapted from Sapolsky’s Why Zebras Don’t Get Ulcers.

That said, Sapolsky also makes it clear that we shouldn’t get carried away: stress isn’t such a villain that we can blame it for any health problem. He expresses deep contempt for how the idea of ruinous stress has been used to sell miracle cures, telling desperate people that they can recover from serious diseases like cancer with various psychological and stress-reduction hacks.31

And these biological consequences of stress are far from a sure/clear thing. For instance, a 2015 study of 2000 Dutch citizens over six years “could not confirm” them.32 Their data did affirm the link between having a rough time in life and chronic pain — people who struggle emotionally are definitely at risk of starting to hurt more — just not with any obvious stress-y biology. If those study results are even reproduced by others, it’s kind of a big deal; it implies that there is some other mechanism by which stress makes us vulnerable to pain, and the authors suggest that “psychosocial factors play a role in triggering the development of this condition.” Maybe it’s just that stress is directly sensitizing, that it gives a lasting boost to the sensitivity of our brain’s threat-o-meter. Or it could be much more complex: for instance, people who suffer severe stress are probably more likely to do poorly in their next phase of life, losing income, status, security, friendships and romances, which opens up many possible paths to illness and pain.33

Or maybe the Dutch study got it wrong. 😉 What if the changes caused by stress just aren’t “obvious”? That seems entirely possible: this research was at odds with a fairly large body of evidence that stress is indeed hard on the body in a variety of ways, just not “adrenal fatigue,” and perhaps not in “obvious” ways that would turn up years later.34

Stress and injury risk and poor injury recovery

Psychological stress is risk factor for injury — a great point to make when discussing anxiety on a website that is mainly about aches and pains! Todd Hargrove:

There is evidence that chronic emotional stress predicts injury.35363738 For example, athletes with preseason anxiety are more likely to get hurt. Stress after an injury predicts greater difficulty in return to play. These findings are especially notable in light of the inability of various biomechanical screening tests to accurately predict injury risk. Interestingly, subjective measures of stress level, which are obtained by simply asking an athlete about their readiness to train, are better reflections of actual training load than objective measures like hormone levels or markers of inflammation.

Todd Hargrove, Playing With Movement: How to explore the many dimensions of physical health and performance, 2019 p. 92, ch. 4: “Stress and Adaptation”

And stress and anxiety don’t just boost your injury risk, they also make it harder to recover from injury — which is where it really starts to get relevant to chronic pain. In many people, it’s hard to separate chronic pain from failed recovery from a list of past injuries.

If anxiety causes pain, does that mean the pain is “all in your head”?

Of course not. “Psychosocial factors” refers to the dizzying array of stresses in our lives, all the possible reasons we get anxious, which can also independently lead to pain in many ways (regardless of whether or not stress has a clear biological signature).

So, is that just an elaborate way of saying the pain is “all in your head”? No — that phrase implies mental illness or faking it. What we’re talking about here is about stress/anxiety creating fertile ground for a crop of chronic pain. This may occur in so many ways that it’s impossible to say exactly how it happens, just like we can’t possibly know which climate factors lead to a specific storm.

Psychosocial factors in pain are a completely different thing from “all in your head.”

And yet, sadly, some health care professionals may not understand this, and some of them may equate psychosocial factors with mental illness and malingering — all the same thing in their heads. We know many healthcare professionals will take pain less seriously if there’s no obvious biological source of pain to treat, even when there is evidence of serious psychosocial factors.39 For instance, physiotherapists may stigmatize psychosocial factors in back pain, feel unprepared to deal with psychosocial factors, and prefer to grapple with the “more mechanical aspects” of back pain.40

Reasonable doubt: the special threat of health anxiety (hypochondria)

“A Hypochondriac’s Nightmare”

xkcd #1097 © by Randall Munroe

When you’re irrationally or excessively worried about your health, that’s “hypochondria.”41 It should not be diagnosed lightly (or even thought of lightly). One of the worst problems in medicine is how often people who have real medical problems are not believed, assuming instead that they are just being like a Victorian lady with a case of the vapours.

Not that modern women fare much better in the medical system. Systemic prejudices in healthcare have always been a huge problem.

But hypochondria is surely real and common, even if it’s not nearly as common as the clinical suspicion.42 Fear of health problems makes a lot more sense than many phobias, many of which are obviously irrational. “Fear itself” is obviously more of a problem than a lot of the things we’re afraid of. Health anxiety works differently because the threats are more real, more serious, and harder to disprove. Speculation can run amok, and run amok it does!

“It’s a trap!” Health anxiety is a particularly nasty trap for the fallible human mind in three ways:

  1. Hypochondria causes itself. Symptoms drive more health anxiety which drive more symptoms … a vicious cycle.
  2. Hypochondria thrives on “seeds of truth.” Many psychosomatic symptoms are not generated out of thin air, but exaggerations and complications of actual problems, which immensely complicates diagnosis.
  3. Hypochondria deftly shifts the blame for the symptoms it causes onto the body itself, removing suspicion from itself. Sneaky.

If you’re nauseous as you prepare for a speech, there is little room for doubt or debate about the roots of your flip-flopping stomach. It’s obviously not a pathology! Nausea from stage fright is one of the greatest hits of all psychosomatic symptoms. But if you have a symptom because you’re scared of sickness itself, instead of a clear non-medical threat, then all suspicion can fall on health threats instead of your own mind … and those fears are based on mostly plausible and unfalsifiable hypotheses about your internal state. You have worried ideas, and they cannot easily be put to rest. Devious! No matter how many explanations you dismiss as unlikely or even absurd, there’s always another to take its place. Any symptom could have a surprising medical cause, right? Literally any symptom!

Indeed, anxiety-powered symptoms can be worse and weirder than the pathology-powered ones. “The colours of the chameleon are not more numerous and inconstant than the varieties of the hypochondriac and hysteric disease.”43

That fearful speculation is also hard to stop for another reason: there are so many credible “seeds of truth” that are terrific scapegoats. Our lives are peppered with genuine medical threats, misfortunes, and discomforts. Nothing boosts hypochondria like an actual illness! And so many people effectively have two problems: a health problem and excessive anxiety about it. And who’s to even say whether it’s “excessive,” if the problem is scary enough? Or scary to you? There are many kinds of common health phobias, of course.

Even for the open-minded patient — someone willing to brave the stigma of hypochondria, someone who embraces the diagnosis — it’s hard to make progress because what we fear is so easily blamed on something else rather than “fear itself.” When we try to honestly ask ourselves if worry is our real problem, worry can (and usually does) always responds the same way: “Okay, maybe. But what if it’s not?” And it can never be satisfied.

Like a good defense lawyer, healthy anxiety can always stir up some reasonable doubt.

This unusual, colourful image of a tombstone shows a large, elaborate baroque-style grave marker with a humorous and ironic epitaph in a large font like a movie poster title: "I told you I was sick!" The tombstone is intricately carved with a rich array of brightly coloured decorations. At the top, a golden skull with dark eye sockets sits prominently, flanked by ornate swirls and flourishes in vibrant teal and pink and yellow. The base of the tombstone features more ornamental elements, including round medallions and twisted columns, adding to the grandeur of the monument. The tombstone is in a wild, unkempt field with tall weeds and brush, under a cloudy sky.

One of the all-time great epitaphs. 🪦 It’s true that hypochondriacs are often “dramatic” & colourful people — but remember that drama queens can also actually get sick.

Are threat perception and pain equivalent?

One of the great stories in the science of pain is the one about the guy who was in terrible agony after pooping blood. Convinced that he was dying, he suffered terrible agony.

Or the one about the guy who was in agony from a nail that had been driven through his boot… but it turned out it had actually gone between his toes.

There are a lot of stories like this, because pain science. When people are convinced they’re in danger, they feel it. It’s clear that pain can be literally equivalent with the perception of threats that aren’t actually there, under the right conditions. It remains uncertain how often those conditions occur, and to what degree chronic pain is “threat perception,” a true equivalence.

But if beet juice and spikes between the toes can cause serious pain, clearly it is possible for pain to be caused by a straight up belief in a threat that isn’t real. Which seems highly relevant to anxiety. More anxiety means more threat perception, and more threat perception means pain. How much more, we do not know.

If that’s possible, then it gets worse: it’s almost certainly possible for distinctive conditions to trigger the threat perception persistently, predictably. Pain might be a learned response to stimuli — classical condition, like Pavlov’s dogs salivating for a bell instead of actual food. I explore this controversial hypothesis in detail in a separate article:

Anxiety and thinking

The anxious state is quite cerebral. When we are anxious, we are “in our heads,” as opposed to being “in your body” or “comfortable in your skin.” The more acute the worry, the busier the mind becomes, your brain switching to spin cycle, scanning more vigilantly for dangers — most of them imaginary.

Without thinking, there can be no chronic anxiety: it’s a mental state characterised by the persistence of ideas about problems and dangers. People who lose their ability to think clearly due to stroke report an “ignorance is bliss” state. When Lauren Marks had a stroke, she woke up days later in the hospital without her words — aphasia, a bizarre loss of language due to brain injury — and without anxiety, either. Lauren had no internal monologue, and a vocabulary of only about forty strangely random words, but rather than being panicked by this state of affairs, she was blissfully ignorant of all her problems, because she did not have labels for them anymore. She felt calm and content. She did not have the vocabulary to worry.

I couldn’t have been any more peaceful and satisfied. … Some people lose their inner monologue and some people do not. I did. So I didn’t have that little voice chiming in saying, ‘Oh, you’re in a world of trouble, Miss Marks. You are in a world of trouble … ’ I didn’t receive that message.”

Listen to this brilliant short podcast about her case of aphasia: “You learn a lot about language when you lose it.” Fascinating. Now if only there was a way to harmlessly and temporarily induce aphasia!

The biological signature of anxiety

If you couldn’t ask someone about their thoughts, how can you tell if they are anxious? As heady as it is, anxiety is also quite physical. It has some distinctive “tells.”

It’s easy enough to detect with a blood test. All chronically stressed mammals have too many glucocorticoids — stress hormones — floating around. Of course, as already discussed, this probably has many adverse effects, and constitutes a medical hazard, including a risk of more pain.44

The behavioural signature of anxiety (stiff upper lip syndrome)

When people dismiss anxiety as a factor in their health, it’s often because they don’t think of themselves as a “nervous person.” But that doesn’t rule out anxiety: we can be anxious without being prone to anxiety. Anxiety can be a recent and sometimes surprisingly subtle development in life, at odds with a much older self-image.

Because of the stigma against anxiety, most of us try to hide it. Everyone’s strategies are different, but it’s common to just get less expressive and stiff in general, a physical stoicism. The British “stiff upper lip” is a common strategy for concealing anxiety (and any other emotional vulnerability). But it won’t fool anyone experienced.

Psychosomatic disorders are physical symptoms that mask emotional distress. The very nature of the physical presentation of the symptoms hides the distress at its root, so it is natural that those affected will automatically seek a medical disease to explain their suffering.

It's All in Your Head, by Suzanne O’Sullivan, 8

And we use muscular tension, stillness, and a lack of breath — like a rabbit freezing to hide from a predator — to try to manage the churning and sinking sensations in the belly that come with worry, to hide them from ourselves and our friends and family. Of course not everyone shows anxiety this way, but it’s extremely common.

These processes are so physical and habitual that they are difficult or impossible to interrupt by force of will. Once it starts, most of us are doomed to a few hours of whirling thoughts, and the physical consequences: back pain or neck pain, a throbbing headache, or insomnia45 are all common embodiments of stress (but there’s much more).

It is likely that some troubles will befall us; but it is not a present fact. How often has the unexpected happened! How often has the expected never come to pass! And even though it is ordained to be, what does it avail to run out to meet your suffering? You will suffer soon enough, when it arrives.

Seneca the Younger, Letters from a Stoic, chapter 13, “On Groundless Fears”


Part 2: What to do? Self-help options for anxiety

In our privileged lives, we are uniquely smart enough to have invented these stressors and uniquely foolish enough to have let them, too often, dominate our lives. Surely we have the potential to be uniquely wise enough to banish their stressful hold.

Robert M Sapolsky, Why Zebras Don’t Get Ulcers, 2004, p. 408

The rest of the article presents many anxiety-fighting ideas. It is not comprehensive, but it has grown generous over the years, like a middle-aged gut. My focus is on relatively creative, efficient, and science-based alternatives to the clichés of stress reduction. Don’t get me wrong, there are some clichés here too — some kind of breathing exercises are unavoidable — but I don’t much care for yoga and meditation myself, and I have always been annoyed by the way they tend to dominate the discussion.

It turns out yoga and meditation are not actually the best ways to tackle stress for many people (but if you like the idea, by all means fill your boots). So here are some of the other options summarized, and most of which are discussed in more detail below:

Seek out people

Never underestimate the potency of our primate hunger for social contact. Being lonely is one common (epidemic?) way to be anxious and stressed. Minimize it as much as possible. Seek out friends. If you don’t have friends, seek out the company of strangers.

Social isolation is a major general health suppressor in the same league as other major vulnerabilities like sleep deprivation or smoking.47 It almost certainly often involves increased vulnerability to chronic pain as part of the deal.48 We do know that sensitization and pain chronicity are partly driven by catastrophization and social factors, and injury and disability are going to seem more threatening — more “catastrophic” — to people without good social support, all other things being equal.

In other words, you have more to worry about when you’re lonely. It’s a significant general anxiety booster.

And loneliness isn’t just corrosive because it deprives us of support — it also deprives us of the valuable opportunity to support others. Providing support is probably at least as stress-relieving as being supplied with it.49

Unfortunately, not everyone is good company, and just as minimizing loneliness is a top priority, so is getting away from the worst people in your life.

But run from toxic relationships!

More formally stated, as psychologist Dr. James Coyne put it, “depression is actually often actually misdiagnosed IED (Inappropriate Environment Disorder).”50 This applies equally to anxiety, I have no doubt. For instance, we know that macaques with low social status are treated very harshly and it has measurable effects on their immune systems: they are inflamed, they get more infections.51 Fascinating. And clearly their problem is that they are just surrounded by asshole macacques.

Before you diagnose yourself with depression or low self esteem, first make sure you are not, in fact, just surrounded by assholes.

not Freud or Gibson, but Notorious d.e.b. (@debihope), Jan 24, 2010 (see

This is the kind of thing I mean when I cautiously counsel people to do their best to solve problems in their lives as a very basic defense against both anxiety and pain. I would never want to minimize the seriousness of mood disorders, but sometimes what looks like a mood disorder really is “just” a disheartening, stressful situation — and many crappy situations can be changed, sooner or later. Not that it’s easy. In fact, it’s often dazzlingly difficult in the short term. Consider the tragic example of domestic violence: surrounded by one asshole in particular.

But the worse it is, the greater the need.

Simply install Generalized-Anxiety Home-Security System sensors on your front door, and then on your bedroom door, and then on the kitchen door, and then on the bathroom door, and then on the closet doors, and then maybe put another one on your bedroom door, just to be safe. You can never be too safe! You can also never be truly safe.

Rian Konc, “Your New Generalized-Anxiety Home-Security System

Get a pet, probably a dog — they are people too, and those relationships are never toxic

And if you can’t care for a dog yourself, seek out a therapy dog, formally or informally. It’s hard to overstate the therapeutic value of pets, and dogs in particular — they aren’t called our “best friends” for nothing. Don’t get me wrong: I am both a cat person and a dog person, and have always had trouble relating to being limited to one or the other. I was blessed with a particularly mellow cat that came with my wife, and I miss her terribly. But even as a cat lover, I have to concede that dogs, on average, are probably the better bet for battling anxiety. They are just so freakishly positive. It is infectious. It’s like being around someone who is always laughing.

I have little to add, because the basics are obvious and the details have already been particularly exhaustively explored by others: “How Dogs Can Help with Mental Health.” That’s a deep dive into the power of human-canine relationships there.

This is “Snug.” She’s the lab I grew up with & she was fantastic.

Fake it ‘til you make it: make it harder to worry with confident posture, facial expressions, and calm breathing

An anxious mind cannot exist in a relaxed body.

Edmund Jacobson, founder of progressive muscle relaxation and of biofeedback

You can try to treat anxiety indirectly by creating physical circumstances in which it’s harder to remain anxious.

In practicing the Japanese martial art of aikido, you don’t throw a person with brute force, or even with clever leveraging (as in judo). Instead, you position yourself in such a way that your practice partner finds it difficult to keep his balance. Similarly, in some positions it is harder to keep your worry.

Behaviours associated with calm and confidence will also blunt anxiety in the short term, like breathing slowly and deeply. Just like it’s hard to stay pissy while you’re making silly faces, it’s hard to stay anxious when you act confident in various ways. It’s basically an acting exercise that “contradicts” the typical physical patterns of the anxious state. Act as if you are confident, focusing on specific things that are easy to fake. This gives you a little leverage on your emotional state.

Sharp readers will notice that I’m basically talking about “power posing” — an extremely popular idea (one of the most popular TED talks of all time), and a bit sketchy. Years later, the evidence strongly suggests a confident posture alone is not a potent “active ingredient,” but it does still have measurable effects… and it works better when you expect it to.52 So I think it’s more of a package deal, and anything you can do to inspire yourself to feel more confident is worth doing.

Acting confident is not an anxiety “cure” any more than taking a decongestant is a cure for the common cold, but it is probably a way to feel better in the short term. And while you’re feeling a little better, logic and reason might have some more influence. Maybe you’ll have a better shot at “outsmarting” your anxiety when it’s dialed down a notch or two.

I would hope that a life includes leisure, time with loved ones, and exercise. But self-care has been appropriated by companies and turned into #selfcare; a kind of tease about the healthcare that we are lacking and are desperate for. As Baba realized, you can’t actually treat an anxiety disorder with a bubble bath or a meditation app, and the supposition that you can is a dangerous one.

The Dark Truths Behind Our Obsession With Self-Care, by Shayla Love

Move happy moves

A little more complex than posture and breathing: the right kind of movement might also be able to create and reinforce emotional states. As Todd Hargove of Better Movement put it:

It is usually quite obvious to people that changing their thoughts might be a good way to change their mood. For example, people might try to combat sadness or depression by “thinking happy thoughts.” Another possible approach would be to “move happy moves.”

“Move happy moves.” What a fun phrase. What fun advice.

So, when you are anxious or depressed, try combatting simply by standing like a master and commander. Do it like a drama class exercise: make it big and silly, have fun with it. (Subtle is good, too — depending on the circumstances.) It’s certainly not guaranteed to work, but no harm in trying.

To pretend to be calm is to be calm, in a way.

Gillian Flynn, Gone Girl

The science of blowing off steam: why exercising is helpful for stress

Exercising for stress control is an option that isn’t fully satisfying to many people, and often awkward for people in pain. But it’s still one of the most accessible and effective options, and it is firmly grounded in biology and science. Exercise is startlingly good medicine.53 Anything that can ward off dementia54 or actually help your brain recover from injury55 is probably neurologically relevant to any mood disorder as well. Which is certainly what the data suggests so far.56

But there’s a more specific and fascinating reason that exercise is helpful for anxiety, which is well worth understanding:

Exercise simulates what stress is trying to prepare us for. More exactly, exercise simulates a reaction to a stressful emergency which then also triggers the relaxation and recovery mode that follows. Robert Sapolsky:

The stress-response is about preparing your body for an explosive burst of energy consumption right now; psychological stress is about doing all the same things to your body for no physical reason whatsoever. Exercise finally provides your body with the outlet that it was preparing for.

Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, 255

I think this is one of those really great little “user’s manual” things to understand about our own nature. The biology of stress is all about mobilizing biological resources for intense, life-saving activity, like running like hell from a predator, or (eek) fighting one. The curse of being human is that the same emergency biology can be triggered by abstract concerns, no predators required. But stress and anxiety are still preparing us for an emergency. So go with it — act like there’s an emergency!

Why would that help? Why would urgent action be relaxing in any way? Because it’s going with the flow, sticking to the biological script, getting it over with and moving on to the next part: recovery! Just as we are biologically programmed to prepare for perceived threats, we are also programmed to de-escalate the stress response after the excitement is over. The exercise simulates a “fight or flight” response, and when we “survive” the incident, it’s a clear signal: “stand down, emergency’s over, time for recovery!” So do what your body is expecting — sprint a block or two, or whatever intense activity your body can manage — and then ride the wave of post-exertional relaxation.

This is why exercise is an effective outlet for frustration, which is well-known to measurably reduce the stress-response.

“The art of life is to deal with problems as they arise, rather than destroy one’s spirit by worrying about them too far in advance.”


Maximize outlets for frustration and aggression

What exactly is an “outlet for frustration”? Literally the same activity can be a stress or an outlet, in much the same way that something be exciting or terrifying, depending on your perspective.

Let a rat run voluntarily in a running wheel, and it makes it feel great. Force a rat to do the same amount of exercise and it gets a massive stress-response.

Robert M Sapolsky, Why Zebras Don’t Get Ulcers, 2004, p. 261

Maximizing frustration outlets is one of the basics of anxiety control, along with maximizing “control” and “predictability.” But while maximizing control and predictability are in the easier-said-than-done category for the people who would benefit the most, finding outlets for frustration is almost easy.

An outlet for frustration is basically anything that constitutes voluntary intensity. It’s about choosing to do something challenging rather than having no choice. It’s about breaking free of the constraints that prevent expression of frustration — like screaming into a pillow, or violently beating an old mattress with a bat. Anyone can do this kind of thing at almost any time.

There’s another element to outlets: distraction. A rousing game of Monopoly can be an outlet for frustration, as long as it actually gets your mind off your worries (but don’t choose Monopoly if your stress is related to real estate). This is why lonely people who work long hours and have many responsibilities struggle to find outlets for their frustration: there’s no time for making your own choices. Pleasant distractions are a bit of a fantasy for those people.

But almost anyone can still go in a bathroom and scream into a jacket for 10 seconds.

Box breathing

There are many ways to focus on making your breaths deeper and slower. This is one of the most accessible and portable. Anyone can do it, anytime, anywhere. It’s especially handy for managing anxiety in public situations, when you need to calm yourself discreetly. When your mind and heart and breath are racing, it can be difficult to switch to a measured, slower, deeper breathing pattern. So find a box to put it in.

Look for a rectangle like the side of a building, or a doorway. It may help your focus to anchor the breathing pattern to something you can see. Each side of the box represents a breath in or out, or a pause: breathe “up” the left side, hold across the top, breathe down the right side, hold across the bottom, and so on.

Set a comfortable pace and depth, as long as it’s at least a little bit more slow, regular, and deep than usual.

Now that’s a door! Any old rectangle in your field of view will do.

There’s a nice iPhone app dedicated to this breathing exercise: Box Breathe.

Breathing as a more physical exercise: the abdominal lift

Yoga, t’ai chi, qigong, meditation are all full of exercises that can be done individually with good effect, if one has a clear, specific goal of calming down. Here is one of the best examples, in my opinion:

The abdominal lift is a classic yogic exercise, best known as a longevity exercise for its stimulating effect on the internal organs. It is also a powerful abdominal strengthener (including the rarely exercised transversus abdominis), is vital for mastering many breathing techniques, and makes all other breathing exercises easier.

  1. Stand with your upper body supported on your knees.
  2. Take at least three, oxygenating deep breaths to prepare yourself for the first lift.
  3. When you feel you have oxygenated sufficiently, blow all of your air out. Completely flush your lungs, and then hold your breath.
  4. Suck your belly in hard against your spine. Particularly focus on your low belly, below the navel. Hold the position and your breath for several seconds (go as long as you can), and then relax the belly — before breathing again (if you try to breathe before relaxing, it can hurt a bit).
  5. Resume breathing.

One abdominal lift takes about one minute, and three of them is a good dose of calming, although I recommend five for tough cases.

After an abdominal lift, the physiological pattern of anxiety has not just been disturbed but reversed, and now you are ready to “get over it.”

A couple more breathing + moving examples from China

Some nice examples of moving meditations from qigong:

Lightning bolts. Leap into the air with a big breath, and as you come crashing and stamping down, blow out hard and flick your arms and hands straight downwards, as though throwing lightning bolts into the ground. Ten of these, followed by some stillness, is hard to stay anxious through.

Crane Spreads Wings Stand with your feet together, hands folded across your chest, hunched over. Breathe in and “spread your wings” — not just spreading your arms, but leaning back a little as well, opening way up, chin high, a strong line of tension through the chest and the belly. Close up again. Repeat several times.

Change the beat: the metronome trick

Anxiety often involves racing thoughts, which are even more obvious when you attempt a meditative exercise such as focus on your breathing. If you lie down in a quiet room and try to simply count to 100 in your head, you might notice that your natural counting pace is set to “ridiculously fast.” Counting out loud might help to slow you down a little, but your brain still wants to rush ahead. Sometimes it’s almost impossible to rein it in with willpower.

So use a metronome to first match and then tame your mental tempo. (Thanks to smart phones, almost anyone can conveniently download a free metronome app — no need to actually go shopping for a metronome.) Basically, count to 100 several times, a little slower each time, using a metronome instead of willpower. By all means tap your foot or a finger or some other gesture as well. Make it musical. This is called “entrainment.”57

  1. Set the metronome to a pace that matches the speed your brain wants to go. Try 100 beats per minute, for example. The idea is not to fight your natural impulse. Go with it for at least a minute.
  2. Slow the metronome down: drop it 10 beats per minute lower, to 90bpm, and count to 90. (Notice that each step will take a minute if you do it this way. You could also keep counting to 100 at a slower and slower pace, but I like the symmetry of one-minute steps.)
  3. Now set the metronome to 80bpm and count to 80 …
  4. And now 70bpm and count to 70 …
  5. And so on …

Obviously you can fiddle with the variables here: for instance, you could take smaller steps, or spend longer at each tempo. But if you systematically match a slower and slower metronome pace, your racing thoughts are likely to stop racing. At least for a while.

I would apply the 80/20 rule to stress management: 80 percent of the stress reduction is accomplished with the first 20 percent of effort.

Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, 414

Get a massage, if you possibly can

Getting a massage isn’t exactly efficient or cheap, but it may be an extremely effective method of relaxation. Literally all non-human primates groom each other — “social grooming” — and this is clearly a behaviour used for stress management. It is a near certainty that humans can benefit from the same kind of interaction, and massage is basically just ritualized, formal social grooming, without the parasite eating. Or you could pay for a cuddling service. Yes, that’s a real thing these days. Or, ahem, certain other services. The common denominator here is touch.

There’s no denying that massage is pleasant — for most people — but its medical benefits are much less clear and proven than you might think. Myths about massage abound:58 it does not flush lactic acid out of cells, or increase circulation,59 or reduce inflammation.60 Maybe it reduces cortisol levels, but even that popular notion is far from proven, and there is actually evidence that it’s wrong. Even in the unlikely event that massage actually does reduce cortisol levels, the physiology of stress is much too complex to assume that cortisol reduction is in itself a meaningful and good thing.61 There’s just too much going on.

While many benefits of massage are still disconcertingly uncertain and hotly debated (by some), there are two truly proven ones. Dr. Christopher Moyer explains that the only truly confirmed benefits of massage are its effects on mood (“affect”),62 specifically:

  1. massage reduces depression
  2. massage reduces anxiety

And more massage is probably even better. Dr. Moyer:

We made an interesting discovery concerning the effect of the treatment on state anxiety. When a series of massage therapy sessions was administered, the first session in the series provided significant reductions in anxiety, but the last session in the same series provided reductions that were almost twice as large. This pattern was consistent across every study we were able to examine, which strongly suggests that experience with massage therapy is an important predictor of its success, at least where anxiety is concerned. To put it another way, it is possible that the greatest benefits come about only when a person has learned how to receive massage therapy.

So this should be a no-brainer: getting a massage is a better idea than taking meds in almost every possible way. It’s probably not cheaper. But it’s definitely better.

Mental propaganda

I was critical of this idea above: I think it falls down hard for a lot of people, a lot of the time, including me. But that doesn’t stop me from trying, because sometimes it does seem to help. If nothing else, it keeps me occupied with something that isn’t ferocious worry.

Cognitive therapy suggests building new pathways with specific, deliberate mental alternatives. Write down a positive set of thoughts that are a specific alternative to the worrying pattern. Read them out loud in your head five times. Or once. The point is, focus on them for a while.

For example, I survived a bad, scary year — in the aftermath of a terrible accident my wife had in 2000 — by constantly writing and re-reading a document I called, heartbreakingly, “some notes on dealing with despair.” It was basically a series of the most reassuring things I could think of: elaborate blessing counting. It was quite carefully crafted, and it reassured me to craft it. Simply working on it was as much a part of the self-therapy as re-reading it. The challenge of thinking about and expressing good and reassuring thoughts was quite helpful. There were many nights I don’t know how I could have gotten back to sleep without that exercise.

Nutritional supplements for anxiety: pre-biotics

The first human test of prebiotics — not the much more familiar probiotics — for anxiety and stress was conducted in 2015.63 The results were promising, and so they’ve been widely reported as good news.

Prebiotics are basically food for the bacteria in your guts, which have a strange-but-true relationship with your nervous system.6465

There are many caveats about this evidence, of course. A detailed analysis of the paper by (ERD #6, April 2015) explains that it’s not clear that the observed effects are clinically relevant:

especially since only one out of the many emotion-related variables tested was affected by a prebiotic. Assuming that prebiotic fibers could be used to “treat” anxiety or depression is a premature conclusion. sensibly notes the “bewildering array” of products available and concludes “there is much work to be done before specific clinical guidelines and recommendations can be made.” Understatement.

“A promising treatment is the larval stage of a disappointing one.”66 But it hasn’t disappointed yet, and these products are likely extremely safe to experiment with in moderation.

Nutritional supplements for anxiety: curcumin

Illustration of ground turmeric root, source of curcumin, that might just actually help delayed-onset muscle soreness.

Curcumin is the active ingredient in the bright yellow southwest Indian spice, turmeric. Curcumin has a larger evidence base than most other supplements, is considered safe, and there are reasons to think it may be useful in the treatment of both anxiety and pain — making it a perfect supplement to bring up here.

For anxiety: A 2015 study of rats found that curcumin increases the synthesis of docosahexaenoic acid (DHA), which “is linked to the neuropathology of several cognitive disorders, including anxiety.”67 The increases in DHA were accompanied by decreased anxiety. Crucially, one human trial also concluded that “curcumin has a potential anti-anxiety effect.”68

For pain: In another 2015 study, “curcumin caused moderate to large reductions in pain” in 17 men with very sore leg muscles.69 It also helped some aspects of strength loss. The effect size here passes the “impress me” test. These results constitute the only really good science news about any kind of treatment for delayed onset muscle soreness — there is no other treatment for it but the passage of time. Now it just needs to be replicated. It’s completely unknown whether this effect, if it’s real, would have any effect on any other kind of pain, but it is possible.

Supplements generally have a shabby track record, and I don’t recommend many of them.70 These shreds of evidence for curcumin are promising but definitely preliminary. They are probably not sufficient for most patients to justify the cost and hassle of supplementation. However, if you have anxiety and pain and you don’t mind the expense of a supplementation gamble, curcumin is about as good as it gets.

One minor complication drives up the cost and risk of wasting your money: plain curcumin is widely available, but unfortunately it’s poorly absorbed on its own. Most bottles advertise one method or another of enhancing absorption, and some of them use it to justify a much higher price point, but it’s hard to know (maybe impossible) how well any of them actually work. Just be aware that straight curcumin may not be effective.

Be cautious with marijuana: it can cause anxiety when you use it and when you stop

Marijuana has a seriously undeserved reputation as an anti-anxiety medication. (It’s power as a pain-killer is also routinely overstated.) In fact it probably aggravates anxiety in many patients in both normal use and withdrawal — it can get you both coming and going. I will elaborate, but first some cannabasics:

Photo of marijuana plant.

Perhaps the most interesting & controversial plant in the world.

Cannabis is a plant, most notably marijuana (bred for its narcotic effects) and the major strain of hemp (bred for other purposes). It’s one of the most interesting plants in the world because it produces chemicals with interesting effects, the cannabinoids. The most interesting and famous of those are THC (tetrahydrocannabinol) and CBD (cannabidiol). All cannabis contains THC, CBD, and hundreds of other related compounds in varying proportions, but there’s a lot more THC in marijuana plants, and a lot more CBD in hemp.

THC gets you high (psychoactive effects). CBD does not, but is not always completely separated from THC. Both compounds are alleged to be pain killers. It’s probably their main medicinal use (either that or as a sleep aid).

For more detailed information, see: Marijuana for Pain. But I will cover cannabis for anxiety specifically quite thoroughly here.

What could possibly go wrong? Quite a bit actually

People think of pot users as “mellow,” and that leads to the assumption that THC is good for anxiety. That might be true for some people, but it is definitely not true for everyone. THC isn’t a sedative, and the appearance of mellowness is mainly due to comparing favourably with alcohol,71 and being preoccupied with what’s going on between their ears, with their strange thoughts and sensations, either happily or unhappily. “Paranoia” is a common side effect, and it’s basically synonymous with anxiety.

The evidence on this topic is extremely thin: “in its infancy,” says one review.72 “Surprisingly not well documented,” says another.73 The evidence cannot resolve this, because can probably easily go either way, either reducing or increasing anxiety, depending on many variables.74

I have a lot of personal experience with using THC as an insomnia treatment. I am a moderate narcoleptic, a disease that interferes with sleeping at night as much as it sabotages with daytime grogginess.75 I had good success with THC for a couple years, and it seemed to help me achieve the first consistently high quality nights of sleep of my entire life. But I learned quickly that pot would only help me sleep if I was already feeling relaxed and peaceful. If I combined it with anxiety… well, it wasn’t pretty. After the first several months of experimentation, I started banning pot on any night when I already felt anxious, because I knew it would get worse.

I had a few bad experiences with that, and then I had a much worse experience. I encountered a situation so stressful that I didn’t use any pot at all for three nights… and I discovered cannabis withdrawal syndrome (CWS). Most people don’t struggle with cannabis withdrawal too much, but some do, including me. Anxiety is a prominent side effect, and so are a range of other unpleasant symptoms that can fuel more anxiety (especially if you lean towards hypochondria).

Yes, you read that right: using cannabis can cause anxiety… and so can stopping. Nice double-edged sword, that.

The popular view is that THC withdrawal symptoms is almost always minor, and mainly limited to insomnia, but recent evidence suggests a harsher reality. A 2020 scientific review of CWS concludes that “cannabis withdrawal syndrome appears to be prevalent among regular users of cannabis” and the symptoms can be substantial.76 The authors also express the opinion that both cannabis use and withdrawal probably aggravate anxiety, depression, and other psychiatric disorders.

Many cannabis fans will no doubt be outraged by this. But it’s consistent with my own experience, and some of the evidence, so I encourage to you to take this cautionary tale seriously.

Consider quitting coffee too

Caffeine is one of those rare pleasures in life that doesn’t seem to have much of a downside, and even has some clear benefits, mostly actual performance enhancement.77 It doesn’t even matter how much of it you drink normally: you’ll get a boost from it whether you guzzle the stuff every day, or never touch it.78 And caffeine doesn’t dehydrate you. That’s a silly myth.79

Underwater photo of bubbles and sunnbeams, with the caption: "Water is the most important element on earth. Without it, there is no coffee. Without coffee, everyone dies.

So, for most people, caffeine is just a good thing. Sadly, people suffering from pain and/or anxiety may be exceptions. And, ironically, this may be true even though caffeine is also a mild pain-killer.80

It’s all about context and the difference between use and abuse. There’s a huge difference between a healthy athlete downing a Redbull half an hour before competition and an exhausted workaholic slamming back their third grande Americano of the day at 7pm.

Caffeine makes us hyper, and that can be somewhat exhausting. We pump more adrenalin, wear ourselves out, and lose sleep: risk factors for pain. Chronic, excessive caffeine abuse — perhaps a vicious cycle of self-medication, caffeine every morning, alcohol every night? — is likely to be an aggravating factor for anxiety and chronic pain. People in chronic pain are often already anxious and sensitized; regardless of why, artificial stimulation may be the last thing they need.

Casting coffee as a villain is pure speculation and seems to fly in the face of the hard evidence that it’s actually a performance aid, but actually there’s no conflict between what we know about the short term positive effects and what I fear about the long term effects. It can be “all of the above.” Caffeine can be good for pain in the short term and bad for it in the long term. (Booze has similar issues.83)

Bottom line: caffeine is a known mild analgesic and ergogenic aid, but caffeine abuse — which is probably anything from “common” to “practically universal,” depending on how you define it — is a plausible risk factor for chronic pain. Reader Kira Stoops sent me this interesting anecdote about her experience with quitting caffeine:

This is just one person’s story, but I feel quitting my morning Americano had a huge effect on my chronic pain. I’m not sure it’s so much the Americano but the chain of events …

I’ll start by saying I was prescribed Adderal, not for ADD, but because chronic pain turned me into a slug. I took one pill, the smallest dose, and shot through the roof. It was an uncomfortable amount of energy, and I started crying when it kicked in. To me, that was a sign my nervous system was already stimulated plenty, and I needed to start finding ways to wind it down more.

I’ve been drinking coffee since age 14, and figured my one-shot Americano habit was actually a healthy routine: I had to leave the house to get it, it created some social connection in the coffee shop, and the little jolt of caffeine gave me energy for the day.

Quitting was hard. But I started sleeping better right away. Many fibromyalgia patients have disturbed 4th wave sleep, and I think cutting out coffee-caffeine allowed me to sleep more deeply, and get more sleep in a shorter period of time. With more sleep, I had more clarity. Being off coffee gave me a good barometer for what my actual energy and anxiety levels were, once it was out of my system. Being able to “hear” what my body was trying to tell me helped too, so I could respond better.

I’d been plateaued at the same level of pain and exhaustion for about 6 months. Within a month of quitting caffeine, I was sleeping better, having energy longer, feeling more clear, taking on more work projects, hanging out with friends more, attending more events, and just generally finally seeing the needle move. All of these things had their own pain-lowering, positive effects. I’m still in pain (in a flare right this second) but I credit quitting that cup of coffee as the tipping point towards something better.

I just cut my afternoon green tea a few days ago, and will soon start reducing the two cups of black tea I drink daily.

I don’t think it’s for everyone. But my pain seems to come from clenching and tension, and my nervous system seems stimulated enough already. Letting coffee go helps me relax a little more. Plus, not having the morning habit forced me into even healthier morning habits. I would not have said coffee was a problem for me before. I didn’t feel especially stressed or anything by it. I thought it was a good routine. But I’m really glad I gave quitting it a shot.

And how’s it going now? Kira’s update several months later:

These cold cloudy days had me reaching for the brew … within a week of half-caf Americanos I was sleeping like crap, and within about 10 days my pain was steadily and unmistakably worse. Quit again a few days ago and started sleeping harder by the third night. Seems silly for a half-caffeine shot of espresso, but … sensitive nervous systems are just that, I guess.

It’s so delicious I miss it terribly, but less pain is worth the sacrifice.

Photo of a pretty blue mug cup and saucer of latte.

About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:

Related Reading

Around the web:

A few books, too:

What’s new in this article?

Twenty-nine updates have been logged for this article since publication (2006). All updates are logged to show a long term commitment to quality, accuracy, and currency. more When’s the last time you read a blog post and found a list of many changes made to that page since publication? Like good footnotes, this sets apart from other health websites and blogs. Although footnotes are more useful, the update logs are important. They are “fine print,” but more meaningful than most of the comments that most Internet pages waste pixels on.

I log any change to articles that might be of interest to a keen reader. Complete update logging of all noteworthy improvements to all articles started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.

See the What’s New? page for updates to all recent site updates.

Jan 19, 2024 — Extensive improvements to the section, “Reasonable doubt: the special threat of health anxiety (hypochondria).” Nothing of substance has changed, it’s just more and better on an important sub-topic. The section is in this guide’s members-only area, but the section is also available as a free post for a while. I added a new audio version.

2021 — Some fresh new references about cannabis as an anti-anxiety medication.

2020 — A thorough proofreading.

2020 — Minor new section: “Get a pet, probably a dog — they are people too, and those relationships are never toxic.”

2020 — Extensive revisions to the self-help suggestions. This was long overdue. This article is quite old, and had some rambly weird stuff from my hippy youth, now purged. I added a couple of ideas, polished several others, organized them, and created an introduction with some broader points and a summary of all the options.

2020 — New section, “Be cautious with marijuana: it can cause anxiety when you use it and when you stop using it.”

2020 — New section, “The special threat of health anxiety (hypochondria).”

2020 — Science update, added a paragraph about the evidence of the protective and therapeutic effects of exercise, supported by several new citations.

2019 — New section, “Maximize outlets for frustration.”

2019 — Added quite a bit of recommended reading.

2019 — Added another pathological cause of anxiety: high somatic awareness caused by hyposerotonemia (see Khoury et al.).

2019 — Added information and citations about anxiety as a risk factor for injury. Finally cleaned up and modernized my muddled thoughts on the hiding of anxiety and its physical and biological signs.

2019 — New section, “Why is exercising helpful for stress? It simulates what stress is trying to prepare us for.”

2018 — Completely renovated the discussion of the effect of posture on mood and anxiety, especially upgrading the references substantially, after reading Gronau et al. My previous writing on this topic was dreadful, amateurish stuff leftover from the earliest days of this website — good riddance.

2018 — New section, “If anxiety causes pain, does that mean the pain is ‘all in your head’”? (Of course not.)

2018 — Revised and clarified medical causes of anxiety, plus several other minor edits.

2018 — Added sidebar debunking the over-hyped idea that “stress is your friend,” which came from a wildly popular TED talk.

2018 — Science update, based on Carpenter et al. on the efficacy of cognitive behavioural therapy: “more effective treatments needed.”

2017 — New section: “Does stress wreck us?”

2017 — New section: “Consider quitting coffee.”

2017 — New section: “Fighting, flighting, tending, and befriending.” And significant revision of another: “Anxiety has a biological signature (and it’s sneaky).”

2017 — Added an sidebar about the absence of anxiety in aphasia patients — not useful, but fascinating.

2017 — Added another important example of a possible medical cause of anxiety (positional cervical cord compression).

2017 — New section: “Change your environment (a.k.a. get away from assholes).” Added a fascinating citation to the cognitive behavioural therapy section.

2017 — A significant infusion of the science of cognitive behavioural therapy, with several related clarifications and elaborations.

2016 — Revision of the first three sections: more careful use of terminology, more clarity about what this article is about, and more nuance about the idea that it’s hard to “outsmart” anxiety. Added an important citation about insomnia as a risk factor for anxiety.

2016 — Added a more formal and complete definition of anxiety to the introduction.

2016 — Added connection between anxiety and inflammation to the introduction.

2016 — Added footnote about the discovery of GABA-eating gut bacteria.

2006 — Publication.


  1. Shahidi B, Curran-Everett D, Maluf KS. Psychosocial, Physical, and Neurophysiological Risk Factors for Chronic Neck Pain: A Prospective Inception Cohort Study. J Pain. 2015 Dec;16(12):1288–99. PubMed 26400680 ❐

    In 2012, Paksaichol et al. convincingly concluded that there was still an absence of evidence that neck pain is caused by any psychological factor. Three years later, this study was published: the first direct and reasonably high quality evidence that depression does cause neck pain. It is not perfect — it’s not a very powerful experiment (a bit small) — but at least it was the right type of study, looking at the right things. 171 healthy office workers were quizzed for a year, identifying three risk factors: depression, poor neck muscle endurance, and low pain tolerance.

    Depression isn’t anxiety, of course, but there’s a lot of overlap between the two. There’s a lot of overlap between depression and practically everything, because it’s “the common cold of psychopathology” (Why Zebras Don’t Get Ulcers p. 271). Really I think anxiety should be included in that analogy. Anxiety and depression are the cold/flu of psychopathology.

  2. There’s the obvious stuff: insomnia, fatigue, mental fog, irritability, pain, sweating, nausea, diarrhea. But it gets weirder and worse: would you believe tingling and numb face, hands, and feet? Icy cold sweaty feet? Rashes? Trembling and twitching? Dizziness and shortness of breath? And these things may come out of the blue, without any apparent connection to stress or panic. (“Free-floating” anxiety is common.) Sometimes it seems like there’s not much anxiety disorders can’t do to us, especially when complicated by sleep deprivation.
  3. Prolonged chronic stress may contribute to metabolic syndrome (Gohil et al.) by messing with the hormonal balance of the hypothalamic-pituitary-adrenal axis (HPA-axis). Metabolic syndrome in turn is strongly associated with a number of markers of systemic inflammation and musculoskeletal conditions, such as more overt examples like Complete Guide to Frozen Shoulder and less obvious ones like neck pain (Mäntyselkä 2010). Oversimplifying down to a few words (probably too much): chronic stress may be inflammatory.
  4. Association, American Psychiatric (2013). Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). Washington, D.C.: American Psychiatric Association. p. 222.
  5. “If the causes of anxiety disorders are so varied, then an adequate approach to recovery needs to be too. It is the basic philosophy of this workbook that the most effective treatment for panic, phobias, or any other problem with anxiety is one that addresses the full range of factors contributing to these conditions. This type of approach can be called quote ‘comprehensive.’ It assumes that you can’t just give someone the ‘right’ medication and expect panic or generalized anxiety to go away.” Bourne EJ. The Anxiety & Phobia Workbook. 5th ed. Oakland (CA): New Harbinger Publications; 2010. p. 162.
  6. Khoury S, Piltonen MH, Ton AT, et al. A functional substitution in the L-aromatic amino acid decarboxylase enzyme worsens somatic symptoms via a serotonergic pathway. Ann Neurol. 2019 Jun. PubMed 31177555 ❐

    This study strongly linked systemic sensory sensitization — not just pain, but all kinds of body sensations — to a glitchy gene that causes low levels of serotonin in 90 chronic pain patients. Uncomfortable awareness of all kinds of sensation is a well-known but previously unexplained companion of chronic widespread pain, but most healthcare professionals have assumed that it is driven by psychological hypervigilance and is a prominent feature of the so-called “fibromyalgia personality.” This research tells a different story: a clear correlation with a genetic malfunction of an enzyme, which significantly slows down production of the neurotransmitter serotonin.

    For a much more detailed exploration of these results, see A genetic defect that exaggerates all sensations (including pain).

  7. In a negative context only. For a person who is safe and happy, the extra sensation is probably innocuous. Likely their sensory life just feels a little more rich and full! But if challenged by a mysterious illness or a difficult injury rehab, every sensation becomes a potential symptom, clue, and threat — which is a great formula for anxiety and pain.
  8. Neckelmann D, Mykletun A, Dahl AA. Chronic insomnia as a risk factor for developing anxiety and depression. Sleep. 2007;30(7):873–880.

    The results of this large and well-conducted survey are “consistent with insomnia being a risk factor for the development of anxiety disorders.”

  9. Sapolsky RM. Why Zebras Don’t Get Ulcers. 3rd ed. New York: Times Books; 2004. Chapter 11: “Stress and A Good Night’s Sleep,” p. 236.

    This is the first of many quotes from this book in this article, and it’s highly recommended reading. See the reading list at the end of the article for more.

  10. There are strong clues that “minor” irritation of the upper spinal cord may simulate stress, firing up the same branch of our nervous system that handles emergencies (sympathetic arousal, see Holman). This would mostly occur in spines arthritic enough to deprive the spinal cord of a nice wide, stable vertebral canal to live in (cervical spondylitic myelopathy). Although CSM is old pathology news, a low-grade crazy-making effect is new and still uncertain. And yet it’s nicely consistent with the much firmer, recent discovery that the autonomic nervous system is very disturbed in the aftermath of major spinal cord injuries, causing organ failure (see Sezer, Hagen, Hou, Stein) — this fact has been historically overshadowed by paralysis. Dysautonomia has other causes too, but tends to be associated with neurological diseases. What’s interesting here is the accumulating evidence that dysautonomia can be cause by a mechanical disturbance of the spinal cord.
  11. Holman AJ. Positional cervical spinal cord compression and fibromyalgia: a novel comorbidity with important diagnostic and treatment implications. J Pain. 2008 Jul;9(7):613–22. PubMed 18499527 ❐

    This study found that 71% of fibromyalgia patients and 85% with chronic widespread pain showed positional cervical spinal cord compression on MRI — basically, light pinching of their spinal cord during neck extension. And so “recognition of unsuspected, comorbid cervical cord compression may provide new insight into [fibromyalgia’s] variable presentation.” Hoo boy, no kidding it would.

  12. Acute “cervical spondylitic myelopathy” isn’t common, but it’s not exactly rare either. It occurs in about 5 to 10 percent of patients who have symptomatic spondylosis, which is fairly common.
  13. Why Zebras Don’t Get Ulcers Chapter 18: “Managing Stress,” p. 236.
  14. Like exposure therapy, which is relevant to the phobic anxieties, and not at all to other types of anxiety. An agoraphobic, for instance, can gradually increase exposure to what they fear with longer and longer expeditions out into the world. But what does a patient with pain-dominated anxiety do? Expose themselves to more pain? The usefulness of exposure therapy depends.
  15. Twomey C, O’Reilly G, Byrne M. Effectiveness of cognitive behavioural therapy for anxiety and depression in primary care: a meta-analysis. Fam Pract. 2015 Feb;32(1):3–15. PubMed 25248976 ❐
  16. Warwick H, Reardon T, Cooper P, et al. Complete recovery from anxiety disorders following Cognitive Behavior Therapy in children and adolescents: A meta-analysis. Clin Psychol Rev. 2016 Dec;52:77–91. PubMed 28040627 ❐
  17. Carpenter JK, Andrews LA, Witcraft SM, et al. Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depress Anxiety. 2018 Feb. PubMed 29451967 ❐
  18. Hall J, Kellett S, Berrios R, Bains MK, Scott S. Efficacy of Cognitive Behavioral Therapy for Generalized Anxiety Disorder in Older Adults: Systematic Review, Meta-Analysis, and Meta-Regression. Am J Geriatr Psychiatry. 2016 Nov;24(11):1063–1073. PubMed 27687212 ❐
  19. van Dessel N, den Boeft M, van der Wouden JC, et al. Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults. Cochrane Database Syst Rev. 2014 Nov;(11):CD011142. PubMed 25362239 ❐

    This meta-analysis of trials of non-drug treatments for somatoform disorders and medically unexplained symptoms (which are closely related to anxiety disorders). It’s mostly about cognitive behavioural therapy, and it largely damns CBT with faint praise. Although “CBT reduced somatic symptoms” compared to doing nothing, the benefits were small and highly variable, as measured in too few studies of only low to moderate quality.

  20. Williams ACd, Fisher E, Hearn L, Eccleston C. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2020 Aug;8:CD007407. PubMed 32794606 ❐
  21. Lasselin J, Kemani MK, Kanstrup M, et al. Low-grade inflammation may moderate the effect of behavioral treatment for chronic pain in adults. J Behav Med. 2016 Oct;39(5):916–24. PubMed 27469518 ❐ PainSci Bibliography 53548 ❐

    Forty-one patients with chronic pain (at least six months, many much longer) were tested for signs of systemic inflammation. They all had stable medications, and no major complications. Then they were provided with two kinds of behavioural treatments for several weeks, measuring their progress in several ways.

    Unfortunately, no one did well: “No substantial overall effect of behavioral treatment on pain intensity and pain-related variables was found in the present study.” So that’s a sad result for these behavioural therapies.

    However, there is a scrap of backwards good news here: the patients with more inflammation “were more resistant to the improvement in pain intensity and in psychological variables contributing to pain.” Note that the mechanism of that effect is probably not that inflammation directly makes pain harder to treat, but actually modifies mental state and behaviour and that makes the pain harder to treat.

    The authors believe that this data tentatively “suggests that the inflammatory state may be one of the mechanisms of the persisting behavioral alterations in patients who do not respond to treatment, corresponding to previous studies on treatment resistant depression.”

  22. Andrews G, Newby JM, Williams AD. Internet-delivered cognitive behavior therapy for anxiety disorders is here to stay. Curr Psychiatry Rep. 2015 Jan;17(1):533. PubMed 25413639 ❐
  23. The low-hanging fruit. Searching for solutions only where the light is good. For instance, in one of my most direct experiences with real-world CBT, the therapist labelled her work as “CBT” but was fixated entirely on talking about my personal history, very “tell me about your mother,” stereotypical psychoanalysis. When gently challenged, it became clear that she had only hand-wavey explanations for how this constituted CBT, and there was no end in sight: she was going to indefinitely take my money while listening to me talk about my past, very expertly no doubt. “CBT” for $180/hour, ladies and gentlemen.
  24. I was small and definitely at risk of being bullied, but I was also very good at avoiding it and rarely faced a real threat. So I worried plenty, but in my entire childhood only faced a violent situation a couple times — less than some people who never worried about it.
  25. This relationship is formally described by the Yerkes-Dodson law, which states that performance initially increases with physiological or mental arousal, but then starts to degrade for most tasks.
  26. Cadegiani FA, Kater CE. Adrenal fatigue does not exist: a systematic review. BMC Endocr Disord. 2016 Aug;16(1):48. PubMed 27557747 ❐ PainSci Bibliography 52878 ❐


    To our knowledge, this is the first systematic review made by endocrinologists to examine a possible correlation between the HPA axis and a purported “adrenal fatigue” and other conditions associated with fatigue, exhaustion or burnout. So far, there is no proof or demonstration of the existence of “AF”. While a significant number of the reported studies showed differences between the healthy and fatigued groups, important methodological issues and confounding factors were apparent. [Translation: biased, sloppy science. ~ Paul] Two concluding remarks emerge from this systematic review: (1) the results of previous studies were contradictory using all the methods for assessing fatigue and the HPA axis, and (2) the most appropriate methods to assess the HPA axis were not used to evaluate fatigue. Therefore, “AF” requires further investigation by those who claim for its existence.

  27. Burke NN, Finn DP, McGuire BE, Roche M. Psychological stress in early life as a predisposing factor for the development of chronic pain: Clinical and preclinical evidence and neurobiological mechanisms. J Neurosci Res. 2016 Jul. PubMed 27402412 ❐
  28. Coppens E, Van Wambeke P, Morlion B, et al. Prevalence and impact of childhood adversities and post-traumatic stress disorder in women with fibromyalgia and chronic widespread pain. Eur J Pain. 2017 May. PubMed 28543929 ❐
  29. McBeth J, Silman AJ, Gupta A, et al. Moderation of psychosocial risk factors through dysfunction of the hypothalamic-pituitary-adrenal stress axis in the onset of chronic widespread musculoskeletal pain: findings of a population-based prospective cohort study. Arthritis Rheum. 2007 Jan;56(1):360–71. PubMed 17195240 ❐ PainSci Bibliography 54166 ❐

    This unusual study showed that dysfunction of the hypothalamic–pituitary–adrenal (HPA) axis helps to distinguish those who will and will not develop new-onset chronic widespread pain. Many studies have shown that people with chronic widespread pain (CWP) show biological evidence of stress (hypercortisolic states), but such studies have generally been

    unable to determine whether the observed HPA axis alterations preceded or were a consequence of having CWP. Neither did they account for the effects of anxiety, depression, life stresses, and sleep disturbance, all of which are associated with HPA axis dysfunction and may explain the observed relationship. The only way to establish the nature of the relationship is to conduct a prospective cohort study in which subjects who are free of CWP but are at risk of developing CWP are identified, their HPA axis function assessed, and their courses are followed over time in order to establish who develops pain. We conducted the first such study to test the hypothesis that among a group of subjects free of CWP, altered HPA function would mediate the relationship between psychosocial risk factors indicative of the process of somatization and the onset of symptoms of CWP. We further hypothesized that this relationship would be independent of the effect of concomitant psychosocial factors that may be confounding the relationship, including depressive symptoms and sleep disturbances.

    This study is far from the last word on this topic, but it is intriguing evidence on one side of the debate.

  30. Sapolsky RM. Why Zebras Don’t Get Ulcers. 3rd ed. New York: Times Books; 2004. Chapter 8: Immunity, Stress, and Disease; p. 144–185. Sapolsky goes deep on this topic, with this bottom line: “The system apparently did not evolve for dealing with numerous repetitions of coordinating the various on-and-off switches, and ultimately something uncoordinated occurs, increasing the risk that the system becomes autoimmune [inflammatory].” I elaborate more in a separate article, see Chronic, Subtle, Systemic Inflammation.
  31. It would be utterly negligent to exaggerate the implications of [how many health problems stress causes]. … Everything bad in human health now is not caused by stress, nor is it in our power to cure ourselves of all our worst medical nightmares merely by reducing stress and thinking healthy thoughts full of courage and spirit and love. Would that it were so. And shame on those who would profit from selling this view.

    Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, p181

    Sapolsky doesn’t pull any punches either, harshly reviewing one of the most egrious examples: Bernie Siegel’s ridiculous claims that cancer is “ultimately related to a lack of love.” It’s a brilliant takedown.

    Despite Sapolsky’s concern about overstating the importance of stress as a cause of disease, he adds that “aging can be defined as the progressive loss of the ability to deal with stress” and “there is some decent evidence that an excess of stress can increase the risk of some of the diseases of aging.” And he explains how there are some confirmed examples of species with biologically programmed deaths — like salmon — that pull their own plug with a flood of stress hormones. They literally poison themselves to death with glucocorticoids, which massively accelerates degeneration. Now anything is toxic in excess, and this doesn’t necessarily mean that more modest doses of glucocorticoids cause premature evidence, but it is certainly possible.

  32. Generaal E, Vogelzangs N, Macfarlane GJ, et al. Biological stress systems, adverse life events and the onset of chronic multisite musculoskeletal pain: a 6-year cohort study. Ann Rheum Dis. 2015 Apr. PubMed 25902791 ❐
  33. Maté G. When the Body Says No: The Cost of Hidden Stress. Alfred A. Knopf Canada; 2003.

    With clarity and passion, Vancouver physician Gabor Maté tells the stories of people whose pain and illnesses emerged from lives filled with stress, anxiety and depression, illuminating the next frontier in medicine: the elusive mind-body connection.

  34. Sapolsky, Why Zebras Don’t Get Ulcers, op. cit. In contrast to Gabor Maté’s book, just cited, which is much more about way that stress and illness gets all tangled up, psychologist Robert Sapolsky’s book explores the biology of stress in great detail — especially the way chronic stress is fundamentally at odds with health.
  35. Soligard T, Schwellnus M, Alonso JM, et al. How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury. Br J Sports Med. 2016 Sep;50(17):1030–41. PubMed 27535989 ❐ This comprehensive and authoritative review of the relationship between injury and “loading” (stress) in elite athletes makes it very clear that “load” can also refer to “internal” loads, emotional stressors, which are of course legion: anything from daily hassles to major emotional crises, as well as emotional stresses related to sport itself.
  36. Ivarsson A, Johnson U, Andersen MB, et al. Psychosocial Factors and Sport Injuries: Meta-analyses for Prediction and Prevention. Sports Med. 2017 Feb;47(2):353–365. PubMed 27406221 ❐
  37. Li H, Moreland JJ, Peek-Asa C, Yang J. Preseason Anxiety and Depressive Symptoms and Prospective Injury Risk in Collegiate Athletes. Am J Sports Med. 2017 Jul;45(9):2148–2155. PubMed 28441037 ❐
  38. Saw AE, Main LC, Gastin PB. Monitoring the athlete training response: subjective self-reported measures trump commonly used objective measures: a systematic review. Br J Sports Med. 2016 Mar;50(5):281–91. PubMed 26423706 ❐ PainSci Bibliography 52269 ❐
  39. De Ruddere L, Goubert L, Stevens MAL, et al. Health care professionals' reactions to patient pain: impact of knowledge about medical evidence and psychosocial influences. J Pain. 2014 Mar;15(3):262–70. PubMed 24275317 ❐
  40. Synnott A, O’Keeffe M, Bunzli S, et al. Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review. J Physiother. 2015 Apr;61(2):68–76. PubMed 25812929 ❐
  41. Why hyp-o? It seems like excessive worry should be named hyp-er something? And isn’t “chondria” from the Greek (khondros) for the ribs? Right you are, gold star! What a confusing word. It’s weird because it comes from one of those hopelessly confused archaic medical notions, namely that “melancholy” came from liver and spleen … which are “under the ribs.” So hypochondria was originally the word for “that problem that comes from under the ribs.” Before we knew about anything else that could possibly go wrong with those organs.
  42. I tried to find some data on the actual prevalence of hypochondria, or some evidence-based hint about how overdiagnosed it might be. I failed, which probably isn’t surprising, because there’s no objective test for it — just as there is no objective test for pain. The nearly insurmountable problem is that we have no way of knowing who actually has hypochondria instead of diseases and injuries. It’s kind of like trying to figure out how many innocent people are convicted of serious crimes.
  43. Whytt, Robert. On Nervous, Hypochondriac, or Hysteric Diseases. 1764.

    Yes, 1764! Anxiety is not a new problem.

  44. Kakiashvili T, Leszek J, Rutkowski K. The medical perspective on burnout. Int J Occup Med Environ Health. 2013 Jun;26(3):401–12. PubMed 24018996 ❐
    Burnout was found to be a risk factor for myocardial infarction and coronary heart disease. It was also related to reduced fibrinolytic capacity, decreased capacity to cope with stress and hypothalamic-pituitary-adrenal (HPA) axis hypoactivity. Severe burnout symptoms are associated with a lower level or smaller increase of the cortisol awakening response (CAR), higher dehydroepiandrosterone-sulphate (DHEAS) levels, lower cortisol/DHEAS ratios and stronger suppression as measured by the dexamethasone suppression test (DST). More and more literature works suggest that the evaluation of the HPA axis should be brought to the attention of primary care physicians.… Chronic stress-related disorders often fall outside the category of a true disease and are often treated as depression or not treated at all.
  45. Knutson KL, Van Cauter E, Rathouz PJ, et al. Association Between Sleep and Blood Pressure in Midlife: The CARDIA Sleep Study. Arch Intern Med. 2009 Jun 18;169(11):1055–1061. PubMed 19506175 ❐ PainSci Bibliography 55440 ❐

    Bad sleeps — quantity and quality, probably especially if caused by stress — are associated with elevated blood pressure, according to a side project of the big CARDIA study of coronary artery disease. They used wrist gadgets to monitor sleep and blood pressure in more than 500 adults in their 30s and 40s. The authors say the sleep-BP link is supported by previous research and “laboratory evidence of increased sympathetic nervous activity as a likely mechanism underlying the increase in BP after sleep loss.”

  46. The kernel of this joke is not mine, but I can’t figure out where it came from originally: there are multiple variations from multiple sources. Anyway, it’s hilarious and all-too-true. Don’t get me wrong, yoga can be great, but every normal human being knows how irritating it is as the default prescription for stress.
  47. Sapolsky RM. Why Zebras Don’t Get Ulcers. 3rd ed. New York: Times Books; 2004. p. 164.

    …the fewer social relationships a person has, the shorter his or her life expectancy, and the worse the impact of various infectious diseases. Relationships that are medically protective can take the form of marriage, contact with friends and extended family, church membership, or other group affiliations. This is a fairly consistent pattern that cuts across a lot of different settings. Moreover, these general findings are based on some careful prospective studies and are seen in both sexes and in different races, in American and European populations living in both urban and rural areas. Most important, this effect is big. The impact of social relationships on life expectancy appears to be at least as large as that of variables such as cigarette smoking, hypertension, obesity, and level of physical activity.

  48. Smith TO, Dainty JR, Williamson E, Martin KR. Association between musculoskeletal pain with social isolation and loneliness: analysis of the English Longitudinal Study of Ageing. Br J Pain. 2019 May;13(2):82–90. PubMed 31019689 ❐ PainSci Bibliography 52275 ❐

    This study looked for a link between chronic musculoskeletal pain, and loneliness and social isolation in several thousand older adults. They found that subjects in pain were actually less likely to be socially isolated, but more likely to be lonely, an interesting apparent contradiction. However, loneliness is probably what matters: that is, social isolation isn’t a problem if you don’t feel socially isolated (lonely).

  49. “One of the strongest stress-reducing qualities of social support is the act of giving social support, to be needed.” (Sapolsky, p407)
  50. Not a real thing: a whimsical, imaginary diagnosis. But not entirely silly either. Maybe there should be such a diagnosis.
  51. Snyder-Mackler N, Sanz J, Kohn JN, et al. Social status alters immune regulation and response to infection in macaques. Science. 2016 Nov;354(6315):1041–1045. PubMed 27885030 ❐
  52. Quentin F. Gronau, Sara Van Erp, Daniel W. Heck, et al. A Bayesian model-averaged meta-analysis of the power pose effect with informed and default priors: the case of felt power. Comprehensive Results in Social Psychology. 2017;2(1):123–138. PainSci Bibliography 53062 ❐

    Carney et al. infamously reported that “power poses” not only made people feel more powerful and daring, but that they had a biological fingerprint: more testosterone and less cortisol (stress hormone). And then the trouble started: “these power pose effects have recently come under considerable scrutiny,” which is a bit of an understatement: there have always been strong concerns about both the science itself and the way it was presented (premature hype).

    This meta-analysis took a crack at producing the “last word” on this topic. It was part of a special edition of Comprehensive Results in Social Psychology, in which Carney herself was deeply involved (see CRSP special issue on power poses: what was the point and what did we learn?). It concluded that follow-up evidence for the original finding was “very strong,” and yet with a spectacular hold-your-horses caveat: “when the analysis is restricted to participants unfamiliar with the effect, the meta-analysis yields evidence that is only moderate.”

    Translation: belief in the power of power posing will make you feel more powerful than power posing itself! Expectations seem to be the more potent active ingredient.

    “Expansive postures” probably do make people feel more powerful … but only a little. Unless you believe in them, in which case you’re really off to the races. Which is fine. (“Why not both?”)

  53. Pedersen BK, Saltin B. Exercise as medicine - evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports. 2015 Dec;25 Suppl 3:1–72. PubMed 26606383 ❐

    This is s a roundup of evidence and prescription guidelines for prescribing exercise for many (26!) different diseases, which is not to say that the science is necessarily complete and perfect. Consider the nuance in Schuch, which found good overall evidence that exercise protects people from “anxiety,” but — despite a huge sample size — could only actually report statistically significant results for a couple specific types (PTSD and agoraphobia). So does exercise work for anxiety? Likely, but “it’s complicated,” as always.

    Still, it’s hard not to be impressed by the sheer volume and diversity of the evidence inspiring these authors.

  54. Smith JC, Nielson KA, Antuono P, et al. Semantic memory functional MRI and cognitive function after exercise intervention in mild cognitive impairment. J Alzheimers Dis. 2013;37(1):197–215. PubMed 23803298 ❐ PainSci Bibliography 52280 ❐

    This brain study showed lasting improvements in cognitive function in 17 subjects with mild cognitive impairment after three months of regular easy walking on a treadmill. Specifically, they detected signs presumed to indicate more efficient semantic memory. A follow-up study in 2019 showed the beginning of that process: a spike in relevant brain activity compared to controls. This a significant contribution to “growing evidence that exercise can have rapid effects on brain function and also that these effects could accumulate and lead to long-term improvements in how our brains operate and we remember” (NY times).

  55. Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is Medicine for Concussion. Curr Sports Med Rep. 2018 Aug;17(8):262–270. PubMed 30095546 ❐ PainSci Bibliography 52267 ❐

    This is a positive review of moderate exercise as “medicine” for brain injury, concluding that it probably normalizes concussed brains, even in cases of persistent post-concussion syndrome.

  56. Schuch FB, Stubbs B, Meyer J, et al. Physical activity protects from incident anxiety: A meta-analysis of prospective cohort studies. Depress Anxiety. 2019 Jun. PubMed 31209958 ❐

    This meta-analysis links high levels of activity to lower rates of anxiety. Many people who exercise will still develop anxiety, but 26% less often than sedentary people. The authors focused on 13 studies with “moderate to high methodological quality and a low risk of bias” with a huge total sample size of 76,000 people, and they made adjustments to eliminate the effect of gender, BMI, and smoking (in other words, they tried to make sure that observed effects were actually due to the activity level, and not those factors).

    The simple headline “exercise helps anxiety” could describe the results of this study, and it wouldn’t be a completely unreasonable oversimplification, but the details are devilish as usual, and it’s actually not such a clear win. With such a huge pool of data to play in, the authors decided to break it down into several different types of anxiety, and found that the results were statistically significant only for PTSD and agoraphobia… and not generalized anxiety and a few others. Although activity seemed to help all types of anxiety, there was not actually enough data here to be sure in most cases — a data pie of 76,000 subjects seems big, but it can easily be sliced into pieces too thin to trust. It’s likely that exercise does help most types of anxiety, but it’s hard to actually know it from this data.

    And this is why science is slow to be sure of much of anything squishy and complicated.

  57. Entrainment refers to a bunch of this, but in the context of “biomusiscology”: internal synchronization to an external rhythm. The science of why a fun tune gets our heads nodding or feet tapping.
  58. I discuss the myths of massage in great detail in Does Massage Therapy Work?
  59. Massage supposedly “increases circulation,” but the evidence shows that it probably doesn’t, especially when compared to even light exercise. Also, relaxation shunts blood away from muscles into the core. For more information, see Does Massage Increase Circulation? Almost certainly not in a clinically important way, and definitely not as much as even a small amount of exercise.
  60. A unreplicated and deeply flawed 2012 scientific study (Crane et al.) claimed to find that massage reduced inflammation in intensely exercised muscles. The profession of massage therapy took the conclusions at face value and claims that massage “reduces inflammation” are now common. For more information, see Massage Does Not Reduce Inflammation: The making of a new massage myth from a high-tech study of muscle samples after intense exercise.
  61. Cortisol levels after a massage do not give a meaningful picture of the organism, and there is no direct relationship between a temporary cortisol reduction and any health benefit. What matters is cortisol levels over time, but even that isn’t exactly straightforward: stress and cortisol have a complex and chaotic relationship regulated by many variables out of our control.
  62. Moyer CA. Affective massage therapy. Int J Ther Massage Bodywork. 2008;1(2):3–5. PubMed 21589715 ❐ PainSci Bibliography 54758 ❐

    Dr. Christopher Moyer explains that the only confirmed benefits of massage are its effects on mood (“affect”), specifically depression and anxiety. “Together, these effects on anxiety and depression are the most well-established effects in the MT research literature. They are especially important for us to understand not only for their own sake, but also because anxiety and depression exacerbate many other specific health problems.” He proposes that “the time is right to name a new subfield for massage therapy research and practice: affective massage therapy.”

  63. Schmidt K, Cowen PJ, Harmer CJ, et al. Prebiotic intake reduces the waking cortisol response and alters emotional bias in healthy volunteers. Psychopharmacology (Berl). 2015 May;232(10):1793–801. PubMed 25449699 ❐ PainSci Bibliography 54164 ❐ In the test, the prebiotic product Bimuno®-galactooligosaccharides (B-GOS) appeared to be effective (while another product did not). Specifically, “The salivary cortisol awakening response was significantly lower after B-GOS intake compared with placebo. Participants also showed decreased attentional vigilance to negative versus positive information in a dot-probe task after B-GOS compared to placebo intake.” But caution: please note that this product is one of a class2 of sugars that may cause bowel irritation. If you experiment with it, do be alert for symptoms of irritable bowel syndrome.
  64. Schmidt et al.: “There is now compelling evidence for a link between enteric microbiota and brain function.” Strange but true. Wikipedia: “The gut–brain axis refers to the biochemical signaling taking place between the gastrointestinal tract and the nervous system, often involving intestinal microbiota, which have been shown to play an important role in healthy brain function.”
  65. Speaking of things bacteria eat: in 2016, scientists discovered a species of gut bacteria that has a GABA-only diet. Gamma-Aminobutyric acid is an important neurotransmitter which has a critical role in keeping our cool, which is an understatement: it’s the most widely used inhibitory neurotransmitter in human physiology, the body’s own tranquilizer. Drugs like Valium (the most famous of the benzodiazepenes) work by enhancing GABA’s effects. The discovery of a gut bacteria that feeds exclusively on GABA may be one the first clear, direct explanations of the “gut-brain connection,” of how the contents of the poop chute can affect moods. An overpopulation of these wee beasties could potentially suppress GABA levels … which would be bad. Intriguing stuff.
  66. Bastian H. "They would say that, wouldn't they?" A reader's guide to author and sponsor biases in clinical research. J R Soc Med. 2006 Dec;99(12):611–4. PubMed 17139062 ❐ PainSci Bibliography 51373 ❐

    The full quote:

    “A promising treatment is often in fact merely the larval stage of a disappointing one. At least a third of influential trials suggesting benefit may either ultimately be contradicted or turn out to have exaggerated effectiveness.”

  67. Wu A, Noble EE, Tyagi E, et al. Curcumin boosts DHA in the brain: Implications for the prevention of anxiety disorders. Biochim Biophys Acta. 2015 May;1852(5):951–61. PubMed 25550171 ❐
  68. Esmaily H, Sahebkar A, Iranshahi M, et al. An investigation of the effects of curcumin on anxiety and depression in obese individuals: A randomized controlled trial. Chin J Integr Med. 2015 May;21(5):332–8. PubMed 25776839 ❐
  69. Nicol LM, Rowlands DS, Fazakerly R, Kellett J. Curcumin supplementation likely attenuates delayed onset muscle soreness (DOMS). Eur J Appl Physiol. 2015 Mar. PubMed 25795285 ❐
  70. Ingraham. Vitamins, Minerals & Supplements for Pain & Healing: Critical analysis of most popular “nutraceuticals” — food-like pseudo-medicines taken for medicinal purposes, especially glucosamine and creatine, mostly as they relate to pain, arthritis, and recovery from exercise and injury. 21490 words.
  71. The reputation for mellowness is also probably inflated by the contrast with alcohol, which is so notorious for making people loud and aggressive; in a world full of obnoxious drunks, the contemplative quality of a THC high does indeed seem mellow.
  72. Van Ameringen M, Zhang J, Patterson B, Turna J. The role of cannabis in treating anxiety: an update. Curr Opin Psychiatry. 2020 01;33(1):1–7. PubMed 31688192 ❐ “The literature evaluating the efficacy of cannabis in anxiety disorders is in its infancy.”
  73. Turna J, Patterson B, Van Ameringen M. Is cannabis treatment for anxiety, mood, and related disorders ready for prime time? Depress Anxiety. 2017 11;34(11):1006–1017. PubMed 28636769 ❐

    “Currently, anxiety ranks among the top five medical symptoms for which North Americans report using medical marijuana. However, upon careful review of the extant treatment literature, the anxiolytic effects of cannabis in clinical populations are surprisingly not well-documented.”

    I don’t think it’s surprising at all, actually. I think it’s completely routine for popular ideas about remedies to be so dominant that they obscure a glaring absence of evidence.

  74. Sharpe L, Sinclair J, Kramer A, de Manincor M, Sarris J. Cannabis, a cause for anxiety? A critical appraisal of the anxiogenic and anxiolytic properties. J Transl Med. 2020 10;18(1):374. PubMed 33008420 ❐ PainSci Bibliography 51833 ❐
  75. Nicholls H. Sleepyhead: The Neuroscience of a Good Night’s Rest. First U.S. edition ed. Basic Books; 2018.

    A useful and fascinating tour of sleep disorders from the perspective of a narcoleptic science journalist. This interview with the author is a fine introduction to the book.

    Narcolepsy is not just about falling asleep when you shouldn’t, but about lousy overall regulation of sleep: narcoleptics usually can’t sleep when they want to any more than they can stay awake when they need to. It is one of several overlapping disorders that screw with the neurology and endocrinology of sleep regulation and circadian rhythms. As Nicholls learned this for himself, he was inspired to write about all of the many underestimated medical causes of messed up sleep, creating a book that should be read by anyone who has ever slept badly. It’s thorough, funny, erudite and reassuringly free of crank theories. He does a particularly good job of putting sleep science in historical context, explaining how we discovered what little we know. Some of the stories of pioneering sleep research are both amazing and surprisingly recent.

  76. Bahji A, Stephenson C, Tyo R, Hawken ER, Seitz DP. Prevalence of Cannabis Withdrawal Symptoms Among People With Regular or Dependent Use of Cannabinoids: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020 Apr;3(4):e202370. PubMed 32271390 ❐ PainSci Bibliography 52558 ❐
  77. Hogervorst E, Bandelow S, Schmitt J, et al. Caffeine Improves Physical and Cognitive Performance during Exhaustive Exercise. Medicine & Science in Sports & Exercise. 2008 Oct;40(10):1841–1851. PainSci Bibliography 56104 ❐ Caffeine will “significantly improve” not only endurance performance, but “complex cognitive ability during and after exercise.” The researchers studied 24 well-trained cyclists, giving them either 100mg of caffeine or a placebo and then testing their endurance and their mental function during and after workouts. The signal was loud and clear: caffeine consumption boosted their performance.
  78. Gonçalves LdS, Painelli VdS, Yamaguchi G, et al. Dispelling the myth that habitual caffeine consumption influences the performance response to acute caffeine supplementation. J Appl Physiol (1985). 2017 May:jap.00260.2017. PubMed 28495846 ❐

    This trial demonstrated that caffeine supplementation boosts athletic performance even if you are used to its effects. Forty endurance cyclists were divided into groups of low, moderate, and highly daily caffeine intake. They all did three cycling tests after drinking caffeine, a placebo, or nothing at all. Performance on caffeine was clearly best across the board for all participants, regardless of typical caffeine intake.

  79. Killer SC, Blannin AK, Jeukendrup AE. No evidence of dehydration with moderate daily coffee intake: a counterbalanced cross-over study in a free-living population. PLoS One. 2014;9(1):e84154. PubMed 24416202 ❐ PainSci Bibliography 53892 ❐

    Many people believe that coffee is dehydrating. To test this popular idea, 50 men drank four cups (200ml) of either coffee or water each day for three days while their diet and activity were controlled. There were no differences in their body mass, urine volume, and signs of hydration in the blood and urine (pee clarity, basically). If you can drink almost a litre of coffee a day and have no measurable effect on hydration, then it is not “dehydrating” to any meaningful degree. The authors reasonably concluded that coffee “provides similar hydrating qualities to water.”

  80. Derry CJ, Derry S, Moore RA. Caffeine as an analgesic adjuvant for acute pain in adults. Cochrane Database Syst Rev. 2014 Dec;(12):CD009281. PubMed 25502052 ❐ “The addition of caffeine (≥ 100 mg) to a standard dose of commonly used analgesics provides a small but important increase in the proportion of participants who experience a good level of pain relief.”
  81. van Calker D, Biber K, Domschke K, Serchov T. The role of adenosine receptors in mood and anxiety disorders. J Neurochem. 2019 10;151(1):11–27. PubMed 31361031 ❐
  82. Rétey JV, Adam M, Khatami R, et al. A genetic variation in the adenosine A2A receptor gene (ADORA2A) contributes to individual sensitivity to caffeine effects on sleep. Clin Pharmacol Ther. 2007 May;81(5):692–8. PubMed 17329997 ❐
  83. We can draw a strong analogy to alcohol, which definitely relieves pain in a meaningful way ... for as long as you’re drunk! It’s the original anaesthetic. But at the same time, we know with extremely high confidence that the stuff is a nasty poison and downright terrible for you when habitually abused long term.


linking guide

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