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 the egg question: did anxiety cause the pain, or is the pain causing the anxiety? (Hint: it’s both.)
Excessive and chornic anxiety is a potent root cause for an awful lot of back pain, as well as virtually any other kind of chronic pain,1 and even a bizarre array of other physical symptoms2 (WebMD has a good complete list). It almost certainly 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 to me: 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 like fighting smoke. The basics of therapy for anxiety are obviously insufficient for most people. Exercise is 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.
Anxiety is never exclusively 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. Some patients will find that pain is only one of many ways that they are haunted by their anxiety demons. He suffered lifelong anxiety and panic attacks — episodes of dizzying, heart-pounding anxiety. Much later in life, 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 adrenalin 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 quite a rare cause of anxiety, of course. But do not neglect the possibility of a medical explanation or complication. Some of them are much, much more common. For instance, we know that insomnia is a major risk factor for anxiety disorders,6 so anything that interferes with sleep — practical or pathological — is obviously an important consideration.
Or pain: pain is extremely common, and can be both the 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.
This is not strictly true, but it is funny, and there is an important truth in it. Being told to calm down in the right way can be very effective. But it is hard to outsmart anxiety, or suppress it by force of will. We aren’t very good at calming down. For instance…
These are all low-hanging fruit coping strategies, the easiest and most obvious things to try. Most of them are variations on telling ourselves to calm down. Although some of them work some of the time, 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 what if you had professional help?
Never in the history of calming down has anyone ever calmed down by being told to calm down.
Professionals also hope that changing your thinking will lead to changes in mood and behaviour, and that’s what cognitive behavioural therapy (CBT) is all about. It’s the most common psychotherapeutic approach to the problem. It’s how most psychologists will try to help you “think your way out.”
Recent evidence suggests that its benefit for depression has been overestimated in the past,7 and may be minimal. It may be better for anxiety, where CBT can include some strategies that may be more effective.8
Not all CBT is created equal. There’s a great range of quality and creativity in its application, with a great many things that can get in the way. CBT probably gives you a much better chance than winging it on your own, but it’s still a hard road. And its weakness tends to be an excessive emphasis on the thinking part — using conscious thought as leverage — which I cynically think is simply because that’s what is easiest to do in a therapy session.
Thinking is often what gets us anxious in the first place, and it may be very difficult to fight fire with fire. Why are anxiety and worry so difficult to “get over”? Because they get entrenched in our behaviour and biology in ways that thought has little power over.
Many anxious people do not think of themselves as anxious. Anxiety can be “sneaky.” It’s a common human pattern to contain, control, hide and cope with our symptoms of anxiety — to hide them from others and from ourselves by minimizing and embodying their expression.
It’s actually unusual for an anxious person to be obviously anxious. When people dismiss anxiety as a factor in their health, it’s because they don’t think of themselves as a “nervous person.” And you might not be. But you may well still suffer from anxiety.
Obvious or not, anxiety involves a distinctive set of changes in your mind and body. Adrenalin and cortisol — the stress hormones — flow too freely and for too long. Of course, this has many adverse effects, and constitutes a genuine medical hazard.9
In this state, your sense of self and your vitality and attention typically shift upwards and away from the body in general and into the head. When you are stressed out and worrying hard, you are probably “in your head,” as opposed to being “in your body” or “comfortable in your skin.” The mind becomes busy, as your brain switches to spin cycle and the eyes and ears scan more vigilantly for dangers — most of them imaginary.
We use muscular tension, stillness, and a lack of breath — like a rabbit freezing to avoid predator detection — to try to manage the churning and sinking sensations in the belly that come with worry.
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 insomnia10 are all common embodiments of stress. (And yet those are just the tip of the iceberg.)
So what can you do?
“An anxious mind cannot exist in relaxed body.”
Edmund Jacobson, founder of progressive muscle relaxation and of biofeedback
You can treat anxiety by making it harder to remain anxious.
In practicing the martial art of aikido, you don’t throw a person with brute force, or even with clever leveraging (as in Judo) — you simply position yourself in such a way that your practice partner finds it difficult to keep his balance.
Similarly, in some postures it is difficult to keep your worry. For instance, it is almost impossible to worry intensely if you adopt a confident posture, draw your attention downward into your trunk, and restore vitality and movement and breath to the belly. If you “contradict” the physical patterns of anxious state.
This can be called “grounding.” A lack of grounding is the mind-body pattern at the heart of anxiety. You probably can’t “get over” anxiety without some kind of grounding.
Once you are grounded, you won’t necessarily stop worrying! However, it will be harder to worry, and logic and reason might start to have some influence again. Many other responses to anxiety become easier. Once you are grounded, maybe then you have a shot at outsmarting your anxiety.
But grounding comes first.
Some well-chosen, specific grounding exercises can be done in two minutes in the office washroom, right after that incredibly irritating meeting with your boss.
They can be done quickly in the middle of the night when you have insomnia and don’t have the will to do anything challenging. You don’t have to get up for an hour and do yoga, or run up and down the apartment building stairs.
Unfortunately, most people don’t know that grounding exercises can be this quick and relevant to a crisis — assuming they know what grounding is in the first place!
Grounding is associated with all those flaky eastern spiritual disciplines and calisthenics: yoga, taijiquan, qigong, meditation and so on. Most people treat these things as slow and preventative medicine for stress, instead of a source of efficient and curative responses to episodes of anxiety.
People who are devoted practitioners in the preventative spirit may get paralyzed when anxiety strikes, forgetting everything they ever learned about yoga. It’s easy enough to do calming and grounding exercises when you are already calm. The challenge is doing them when you are not!
To beat anxiety, you need to do efficient grounding exercises as a direct response to anxiety. An hour of yoga is not efficient. Neither is a run on the sea wall, or a game of squash, or sitting meditation.
Posture and movement might be able to create and reinforce emotional states.11 And, if posture can change emotions, it’s no surprise that it might also change pain sensitivity — and there is science that suggests it can.12 So, here’s an easy science-y anxiety and pain relief tip: Stand tall! Bold posture. Or, as a mentor of mine liked to put it, “Tits up!” Or 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
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 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.”13
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.
Here’s another way of “changing the beat,” a minor tip but a good one, which is 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: breath "up" the left side, hold across the top, breath 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.
Getting a massage isn’t exactly efficient or cheap, but it may be an extremely effective method of grounding and 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.Massage is basically just ritualized, formal primate social grooming, without the parasite eating.
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. For instance, massage does not flush lactic acid out of cells, or meaningfully increase circulation, or reduce inflammation. Maybe it reduces cortisol levels, but even that popular notion is far from proven, and there is actually evidence that it’s wrong.14 Even in the unlikely event that massage actually does reduce cortisol levels, the phsyiology of stress is much too complex to assume cortisol reduction is in itself a meaningful, good thing.15 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”),16 specifically:
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.
Yoga, taiqi, qigong, meditation are all full of exercises that can be done individually with great effect, if one has a clear, specific goal such as “efficient grounding when freaked out.” Here is the single best example, in my opinion, effective for most people, most of the time:
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.
One abdominal lift takes about one minute, and three of them is a good dose of grounding, 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.”
Other great examples of efficient grounding exercises from qigong include:
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 wonderfully grounding.
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.
And it’s not just the eastern spiritual disciplines that can be mined for useful grounding exercises. The anxiety pattern can also be broken by exercises drawn from many western traditions, such as Reichian body work or cognitive therapy. Here are two more examples:
Mental Propaganda. Worrying is a mental rut. 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. (Why is this a grounding exercise? Because your mind and body are one system. It doesn’t matter whether you change the anxiety pattern in the head or the body first, just so long as you change it.)
For example, I survived a bad, scary year — in the aftermath of a terrible accident my wife had — 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.
Round Breathing. Twenty-five fast, deep clear breaths, without pausing at the top or the bottom, can ground you more completely — bring you back into your body — than most people will feel after any amount of meditation. This is hyperventilation, yes, and you may feel dizzy and that’s fine. For much more information, see The Art of Bioenergetic Breathing.
The examples I’ve offered you here are the tip of the iceberg, but you now possess the essential principles: anything you can come up with that disrupts the mental and physical patterns of anxiety will make it difficult to stay there.
The first human test of prebiotics — not the much more familiar probiotics — for anxiety and stress was conducted in 2015.17 The results were promising, and so they’ve been widely reported as good news.
There are many caveats about this evidence, of course. A detailed analysis of the paper by Examine.com (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.
Patient.co.uk 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!
But we still have “promising,” and these products are likely extremely safe to experiment with in moderation.
Curcumin is the active ingredient in the bright yellow southwest Indian spice, turmeric. It has a larger evidence base than most other supplements, is considered very safe, and there is some evidence that 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.”20 The increases in DHA were accompanied by decreased anxiety. Crucially, one human trial also concluded that “curcumin has a potential anti-anxiety effect.”21
For pain: In another 2015 study, “curcumin caused moderate to large reductions in pain” in 17 men with very sore leg muscles.22 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.23 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.
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.
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— 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.
— Added a more formal and complete definition of anxiety to the introduction.
— Added connection between anxiety and inflammation to the introduction.
— Added footnote about the discovery of GABA-eating gut bacteria.
The results of this large and well-conducted survey are “consistent with insomnia being a risk factor for the development of anxiety disorders.”BACK TO TEXT
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.BACK TO TEXT
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.”BACK TO TEXT
This experiment supposedly shows that adopting a “powerful” (confident) pose changes people’s hormonal levels and increases their willingness to take risks as if they actually had more power. “A person can, by assuming two simple 1-min poses, embody power and instantly become more powerful.” This is plausible and interesting, but melodramatically stated, and probably over-stated. There’s a very popular TED talk about this paper, and so (unsurprisingly) the authors have been accused of reaching beyond what their data can support:
So, take this idea with a grain of salt.
See also Bohns, which presents evidence that power postures can also reduce pain sensitivity.BACK TO TEXT
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 problem.” He proposes that “the time is right to name a new subfield for massage therapy research and practice: affective massage therapy.”BACK TO TEXT