Anxiety is ubiquitous. It is a mental phenomenon with a clear survival-protecting function; as such, in and of itself, it could not be pathological. However, persistent, recurring, or exaggerated anxiety is a mental health disorder. Anxiety disorders are common, and their consequences range from trivial to completely disabling.
The sensation of anxiety is functionally a pain: a signal designed to redirect attention from where it is to where it is needed. As is the case with all forms of pain, anxiety can be acute or chronic. Chronic pain disorders, including chronic anxiety, increase the risk of chronic irritability, anger, and despair. Additionally, anxiety can have an extrinsic cause — triggered by the external environment — or it can be intrinsic, generated internally by the nervous system itself, in which case it can be considered a phantom pain (as discussed in the Pain, Suffering, and Misery chapter).
Anxiety is inseparable from the experience of suffering, as is true of all pain. The suffering associated with anxiety is usually referred to as ‘stress.’
Anxiety is different from all other forms of pain in that, at a low level, it is an integral part of normal nervous system operations, playing a role in sustaining wakefulness and purposeful alertness. The link between anxiety and wakefulness is illustrated by the fact that higher levels of anxiety make it increasingly difficult to initiate or sustain sleep. Conversely, substances that rapidly, directly reduce anxiety are sedating — for example, alcohol and anti-anxiety medications such as Valium and Xanax. At a high enough dose, these substances induce sleep (i.e., narcotize).
The link between anxiety and purposeful alertness manifests in daily activities: driving, operating machinery, and even crossing a street become hazardous under the influence of anti-anxiety substances because they reduce the level of alertness required to perform these tasks safely.
As the intensity of anxiety increases, its benefits decrease: the initial wakefulness and alertness associated with low levels give way to hyper-arousal, hypervigilance, and insomnia. High anxiety causes difficulty concentrating, a sensation of tension (both mental and physical), and ultimately impairs functioning. At an extreme level, anxiety can become overwhelming (for example, in a panic attack) and even temporarily paralyzing.
Medical research continues to produce valuable insights into the biochemical, cellular, and anatomical underpinnings of anxiety, giving rise to numerous pharmacologic and non-pharmacologic treatment options. However, the medical aspect of anxiety and its management is outside the scope of this work.
Anxiety is a central topic in our discussion because it directly undermines the pursuit of happiness. This impact stems from the fact that anxiety is inversely related to inner peace: the more anxiety a mind experiences, the less inner peace it has. Moreover, anxiety is often experienced as a mental trap — difficult to shake off, to move away from — which makes it a threat to one’s freedom, thus further undermining one’s inner peace.
Given that inner peace is one of the three prerequisites for an effective pursuit of happiness (as discussed in the Happiness chapter), anxiety — a direct threat to it — deserves careful examination.
The following two complementary models of anxiety provide insight into its dynamics, which can help in managing it. They also provide the theoretical foundation for the practice methods discussed in the Anxiety Management chapter (Practice section).
The First Model: Anxiety as a Response to the Perception of a Potential Threat
Anxiety is similar but not identical to fear. Fear is a response to the perception of an actual threat, i.e., one that is objectively measurable, present, and immediate. For example, the appearance of a predator in immediate proximity or the detection of a tumor on a brain MRI. Anxiety, in comparison, is a response to the perception of a potential threat. For example, a noise from behind the bushes that might be caused by a hiding predator, or a headache that could be a symptom of an as-yet-undiagnosed brain tumor.
Anxiety is a more complex mental function than fear, because it is designed to handle potential, rather than present, threat. A system managing potential threats must be able to recognize ominous meanings in innocuous cues — recognizing a neutral-appearing signal as harboring a threat before the threat materializes. This is the system’s sensitivity. Additionally, the system must estimate the likelihood that a perceived potential threat will materialize and accordingly either trigger a reaction or refrain from doing so. This is the system’s reactivity. In an ideal state, such a system’s sensitivity would be calibrated to perfectly discriminate innocuous signals from those that appear innocuous but are genuinely ominous. Similarly, an ideal system’s reactivity would be calibrated to perfectly discriminate between low-likelihood threats that do not require a response and high-likelihood (or imminent) threats that necessitate a response.
In principle, the value of anxiety as a threat-management system is clear: Responding to the potential of a threat amounts to an early response. The earlier the response, the higher the likelihood of faring well. However, the actual value of a threat-management system depends entirely on the system’s calibration. An under-sensitive system overlooks genuine threats, which can have catastrophic consequences; an over-sensitive system triggers responses to irrelevant signals, which, at best, is wasteful. Similarly, an under-reactive system responds too slowly to high-likelihood threats; an over-reactive system wastes resources responding to threats unlikely to materialize.
Under normal conditions, signals with low harm-potential or low-probability threats trigger only low levels of anxiety, compatible with normal functioning. As the perceived potential for harm or the likelihood that a threat will materialize increases, the corresponding level of anxiety rises. This produces a gradual shift of mental and physical resources toward threat-management, leaving fewer for routine operations. Above a certain threshold, so much resource capacity is committed to threat-management that routine operations stop and the individual enters survival mode. Operating in survival mode is incompatible with the effective pursuit of happiness.
Anxiety disorders result from miscalibrations of a system’s sensitivity and reactivity settings. An overly sensitive system misinterprets benign signals as ominous. An overly reactive system overestimates the likelihood that a threat will materialize. These miscalibrations manifest in exaggerated responses to trivial or unlikely threats and, ultimately, in unnecessarily triggering survival mode.
Survival mode increases the chances of surviving existential threats, but, not surprisingly, at a cost. Sustained survival mode states negatively impact both physical and mental well-being (Osborne et al., 2024; Glaus et al., 2014). This is consistent with the observed association between anxiety disorders and increased risk of physical problems (e.g., immune system disorders, cardiovascular disease) and mental problems, most commonly despair (typically misdiagnosed as major depression, as discussed in the Depression chapter).
From an evolutionary perspective, it makes sense to design a threat management system that errs on the side of overestimating threats. Overestimating a threat results in unnecessary resource expenditure — inefficient, but affordable compared to the cost of erroneously underestimating it (i.e., possible death, an unaffordable outcome). This understandable design bias toward overestimation explains the near-universal occurrence of problems with high anxiety and the high prevalence of anxiety disorders.
Using this model, the approach to anxiety management focuses on creating an alternative to the system’s automatic response to perceived threats. It requires developing the ability to examine perceived threats rationally before permitting the reflexive response to run its course — suppressing the automatic response until the completion of an objective assessment of the threat’s nature and magnitude, as well as the spectrum of possible outcomes and one’s degree of vulnerability. This is not easy, primarily because the mind resists letting go of its reflexes and habits, especially when potential survival threats are involved. Nonetheless, it can be done — with sufficient practice. The ability to override the system’s built-in settings amounts to reclaiming mental territory hijacked by anxiety, thereby regaining freedom and inner peace. Given the value of freedom and inner peace in the pursuit of happiness, the effort is worthwhile.
‘Perspective’ is a psychological function that plays a key role in evaluating threats (e.g., their magnitude and immediacy). Anxiety and perspective are inversely related: as anxiety rises, perspective narrows. Survival mode narrows perspective, and a narrowed perspective reinforces survival mode (by excluding data that might interfere with threat assessment). At low levels of anxiety, this narrowing is mild and largely inconsequential, as rational thinking remains unimpeded. As anxiety intensifies, the narrowing accelerates. At the extreme — during a panic attack, for example — the object causing the anxiety fills the entire screen of consciousness, leaving no room for anything else. Functioning stops not because the threat is necessarily severe, but because perspective has collapsed to the point where severity cannot be assessed at all.
The practical implication here deserves recognition: broadening perspective is not merely a byproduct of reduced anxiety — it is a direct route to it.
A useful way to think about this is to imagine a camera that has moved too close to its subject. At that close distance, the object fills the frame so completely that its edges are no longer visible. At that point, it is impossible to assess the object’s actual size. The only corrective move is to step back.
In the context of anxiety, ‘stepping back’ means deliberately expanding the frame of consciousness to include data beyond the immediate threat — other people’s circumstances, a wider time frame than the present moment, the spectrum of possible outcomes, and one’s track record of having survived difficulty before. Each of these is a form of perspective-broadening, and each directly reduces the pressure anxiety exerts. (Specific practices for cultivating a broad perspective are presented in detail in the First Order of Business chapter in the Practice section.)
The Second Model: Anxiety as a Result of the Wish to Control
According to this model, anxiety is produced by the collision of two opposing forces: the wish to control something on one hand and the knowledge that controlling it is not an option on the other.
To illustrate this, imagine a crash-testing operation in which safety is tested by driving cars into a brick wall. Think of the control-wish as the car being tested and the wall it rams into as the knowledge that control is not an option. Anxiety is the noise produced in the collision. Anxiety management amounts to reducing that noise.
Imagine living next door to such a crash-test facility. In all likelihood, you would find the noise generated by repeated crashes bothersome; it would make it difficult to concentrate, relax, socialize, and sleep. It would be natural to get jumpy and irritable if the noise was persistent. If moving away or stopping the noise-producing activity were not options, you would seek methods to reduce the noise level.
One solution you might consider is to use earplugs, which are likely to help but dampen all sounds indiscriminately, onerous as well as desirable. Additionally, they must always be within reach; the thought of misplacing or losing them can paradoxically become a source of anxiety.
In this analogy, earplugs correspond to anxiolytic (i.e., anxiety-reducing) substances such as alcohol and anti-anxiety medications.
Alcohol is an effective anxiolytic, but with repeated use, it causes severe and potentially irreversible damage — like earplugs that damage your ears. Additionally, it can become very difficult to stop using alcohol, making it an unattractive option.
Anti-anxiety medications are also effective but, like all medications, have side effects. Common side effects include sedation and a nonspecific dulling that interferes with experiencing life normally — like earplugs that prevent you from hearing sounds you want to hear (e.g., the phone ringing or music). Additionally, regular use of anti-anxiety medications can lead to dependency, with consequences ranging from a minor annoyance to a serious problem.
[Sidebar: Both the positive and negative effects of medications vary greatly among individuals. Some people are very sensitive to medications’ effects (positive and negative), and others may hardly notice them. Therefore, choosing whether or not to use a medication in the treatment of anxiety is a personal choice that should be made on the basis of a pros-and-cons analysis specific to the person and the situation.]
Another way to lower the noise is to reduce the speed at which the cars hit the wall. Simply backing off the gas pedal reduces the engine’s energy output and slows the car. Given the physics of collision, a small reduction in the car’s speed results in a significant reduction in the noise produced.
In our analogy, this means reducing the energy behind the control-wish — a key component of the psychological approach to anxiety management. In practice, this hinges on the ability to replace the wish to control something with a willingness to influence it. Developing this ability usually takes considerable practice, but the effort is worthwhile given how likely this strategy is to significantly lower anxiety.
Before we examine how to reduce the energy behind the control-wish, we should define what control actually is. Control is one of those universally recognized but poorly defined concepts — we know what it feels like, yet struggle to articulate what it means. This ambiguity makes the illusion so persistent. Understanding what control actually means goes a long way toward letting go of it.
Control refers to a relationship between a consciousness and some process. To have control, the consciousness must have two things: first, full and complete awareness of every variable that can potentially impact the process, and second, access to each and every one of these variables such that each can be manipulated with infinite precision according to the consciousness’s wishes.
In reality, since neither of the preconditions for control can be met, control is imaginable but unattainable. The appearance of control (one’s own or observed in another) is inevitably an illusion.
Control is a binary concept. If we aim for precision in our use of terminology (and we should), a process is either under control or it is not. ‘Partial control’ is as meaningless as ‘more than complete control’ — which is to say, partial control is no control at all. The notion that one can have more control (or less control) is simply mistaken. To be accurate, one can have more (or less) influence. Control is 100% influence; any less is no control (and any more is not rational).
Control belongs to the same category of concepts as Certainty, Guarantee, Happiness, Heaven, and Nirvana — all are imaginable and desirable. They can be conceived, aspired to, pursued, and approximated, but they cannot be fully attained.
Accepting the fact that, as a law of nature, control is simply and non-negotiably not an option is a key step toward liberation from the fear of losing it. Firmly incorporating this fact of life, that control cannot be had, into one’s worldview is not only realistic (and therefore an upgrade), it negates the fear of losing control — because one cannot lose something one never had. Otherwise, the fear of losing control can be burdensome and have a negative mental impact, even if it is not recognized consciously.
Letting go of the illusion of control is not easy because the mind desperately wants to believe in it. It requires a leap of faith. The motivation for such a leap can be discovered in the recognition that clinging to the illusion of control perpetuates anxiety and therefore undermines the pursuit of happiness.
The principle of exposure is a centerpiece of anxiety treatment used by several therapeutic modalities. The idea, which is well recognized to have therapeutic benefits (Carpenter et al., 2018), is to override the reflexive avoidance of the source of anxiety and replace it with the opposite — exposure. Avoidance offers immediate relief but perpetuates the fear in the long run. Exposure — facing one’s fears — produces short-term discomfort which, therapeutically, must be tolerated. It is well worth the effort because, over a usually fairly short time, it leads to a reduction of both the acute discomfort and the associated broader anxiety.
The same dynamic applies to accepting that control is not an option. At first, acknowledging that one does not have control over something important — for example, the well-being of a loved one — is anxiety-provoking. However, with practice, as this fact becomes integrated into one’s worldview, the anxiety it initially triggers gives way to a sense of liberation and inner peace.
Embracing the illusion of control not only supports the persistent wish for having it but also spawns a host of related illusions: the illusion of losing control, the illusion of certainty, and the illusion of a guaranteed outcome. These illusions perpetuate anxiety and cloud one’s ability to assess situations accurately.
The realistic alternative to the wish to control is a willingness to influence. Exerting deliberate influence over a process is a realistic option. It requires an understanding of the process one wishes to affect and access to at least one of the variables involved in it. With such understanding and access, one can attempt to nudge the process in a desired direction. Unlike control, influence does not guarantee an outcome — it only increases the likelihood of a desired outcome. Not nearly as sweet, but because it is not illusory, it works much better.
Influence is compatible with and sufficient for the effective pursuit of happiness. It allows one to participate meaningfully in shaping outcomes without the anxiety-generating burden of needing to control them. This shift — from seeking control to exercising influence — is both liberating and practical.
Attachment to the illusion of control is negotiable. With practice, it becomes progressively easier to maintain awareness that control is imaginable but unattainable, which supports moving toward letting go of it.
The Control-Wish in Specific Anxiety Disorders
Psychiatry recognizes a number of specific anxiety disorders, including generalized anxiety disorder, panic disorder, and social anxiety disorder. Obsessive-compulsive disorder and post-traumatic stress disorder were classified as anxiety disorders until recently (when they were reclassified, for questionable reasons, in my unconsulted opinion, under Obsessive Compulsive and Related Disorders and Trauma and Stressor-Related Disorders, respectively). Since exaggerated anxiety is their common denominator, they can all be understood through the wish to control the uncontrollable. They differ in the focus of that control-wish:
Generalized anxiety disorder patients suffer from persistent, excessive worry about real-life matters. Their pathologically intense control-wish focuses on facets of real life, such as financial status, career, health, and family members’ well-being. The persistent mental collision between the high-energy control-wish and the immovable realization that control is unobtainable produces ongoing, disruptive mental noise experienced as generalized anxiety. Consequently, patients experience insomnia, irritability, difficulty concentrating, feeling physically and mentally keyed-up, and, secondarily, feeling fatigued.
Panic disorder patients suffer from episodic bursts of high anxiety, typically associated with an intense focus on their heart (panic disorder is the most common reason for emergency room visits for chest pain of non-cardiac cause (Fleet et al., 1996)), lungs, and, at times, other internal organs. The wish to control the functions of these organs is often experienced as fear of dying. Alternatively, the control-wish in panic disorder can focus on one’s own behavior, often expressed as “fear of going crazy,” or on the ability to escape a physical environment, often expressed as “fear of getting trapped.” The mental noise produced by these high-energy collisions can be so disruptive that, during panic attacks, patients are unable to function at all.
Patients suffering from social anxiety disorder focus their control wish on how they are perceived in the minds of others. Social situations (impending or actual) trigger anxiety that results from the mental collision between the wish to control others’ perception and the recognition of its futility. Complete avoidance of socializing is an understandable, albeit dysfunctional, strategy to circumvent the discomfort. Avoidance of social situations, which can be extreme and disabling, is a core symptom of the disorder. Another very common strategy employed to dampen the collision/anxiety noise is using alcohol as the ‘earplugs.’ This is at least a partial explanation for the extremely high prevalence of alcohol use disorders seen in patients with social anxiety disorder — about 20% (Randall et al., 2001), compared to about 6% in the general population (Schneier et al., 2010).
Obsessive-compulsive disorder (OCD) can be understood as a manifestation of the wish to control one’s own mind: to control anything (illusory as that is), one must first have control over one’s own brain — one’s own thoughts and mental processes. If one’s brain is ‘out of control’ (which it is, like everything else), then nothing can be under control (and nothing is). Obsessions are thoughts, images, or impulses that register in the patient’s mind as repeating reminders that their brain can produce material not only arbitrary but often in stark conflict with their own preferences and values. Compulsions, by definition, are responses to obsessions — futile attempts to distract one’s attention from the noise produced by the collision between the wish to control one’s own brain and the admission that even this rudimentary level of control is unobtainable, thus reducing or neutralizing its negative impact.
Post-traumatic stress disorder (PTSD) can be understood as a control wish focused on past events. Patients with PTSD have a wish (which may be conscious or subconscious) to go back in time and exercise control over events that have taken place, thus preventing their traumatizing experience. The focus on the past — on controlling traumatizing events that have already occurred — distinguishes PTSD from the other anxiety disorders. As such, replacing the wish to control with a willingness to influence is an irrelevant approach — the past can neither be controlled nor influenced. The willingness to influence becomes relevant when its focus is shifted to the relationship the patient has with their past: The past cannot be changed, but it can be forgiven. Indeed, in my clinical experience, cultivating forgiveness is the key to recovery from PTSD (as discussed in the Forgiveness chapter).
The Anxious Brain as a Statistical Instrument
The human brain is a statistical instrument: As part of routine functioning, the brain automatically rounds high probabilities to 100% (inviting the seductive illusion of control) and low probabilities to zero (permitting the distasteful illusion of complete loss of control and helplessness). Rounding off a high or low probability to certainty (100% or 0%, respectively) is acceptable for practical purposes — it helps the flow of planning and decision-making. For example, when deciding to meet a friend for dinner at 7 pm, one ignores the fact that the future is uncertain in order to get something on the books; it works better than emphasizing that the likelihood of actualizing the plan is well below 100% and acknowledging the fact that there is always a chance of a mishap preventing it from happening.
Practicality, however, does not justify ignorance. Ignoring the rounding off of a high (or low) probability to a certainty amounts to manufacturing fiction and subsequently considering it a discovery. The manufactured, fictitious certainty goes hand in hand with the illusion of a guaranteed outcome, which, in turn, supports the seductive illusion of control.
A mind attached to the illusion of control is vulnerable to anxiety (as well as to pessimism, the setup of unchecked expectations, and even fanaticism). The brain’s tendency to round probabilities to certainty is a key mechanism behind the illusion of control (as discussed in detail in the Hope chapter). Denial of the fact that control is unattainable and that, in reality, the best one can do is influence, is incompatible with an effective pursuit of happiness.
(Practices designed to clarify and anchor these concepts are presented in the Anxiety Management chapter in the Practice section.)
This section was kindly edited by S.G. Raphaely, M.D., for which I am ever so grateful.
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