Anticipatory Anxiety: Bleeding Before You Are Cut

By Sally Winston, PsyD, and Martin Seif, PhD, coauthors of Overcoming Anticipatory Anxiety

In Overcoming Anticipatory Anxiety, we explore the issue of anxiety that arises prior to tackling a difficult decision, action, or situation. Phobias, social anxiety, panic attacks, obsessive fears, and unwanted intrusive thoughts all have a component of anticipatory anxiety. It can be present in the form of physical symptoms or simply as an ongoing parade of worries.

Doubts about performance, safety, or well-being are common forms of anticipatory anxiety. So is apprehension about bad things that are possible or failures that could happen. Anticipatory anxiety is how we feel when we buy into our own creative worry stories. It is the expectation of distress accompanied by a push to avoid. Anticipatory anxiety seems to predict danger; it feels like a warning not to proceed.

We think of anticipatory anxiety as a third layer of fear. Let us explain:

First, we can be afraid of something. For example: “I am scared of a bee.”

Second, we can be afraid of being afraid. This is sometimes called the fear of fear, often leading to panic: “If I see a bee, I might get so frightened that I have a panic attack and then lose control or have a heart attack.”

Finally, we get to the third level of fear—being afraid of being afraid of being afraid. This is not as complicated as it sounds: “I am miserable even thinking about camping next week because I might see a bee and have a panic attack, lose control, and do something crazy. Maybe I should cancel the camping trip.”

This third layer of fear is the avoidance layer. Anticipatory anxiety is a powerful motivator of avoidance because it specifically focuses your attention on the negative things that could possibly happen.

Catastrophic predictions—like having a panic attack, making a complete fool of yourself, or damaging a relationship—can lead to incapacitating anxiety that stops you from proceeding. Anticipatory anxiety can make it seem like avoidance is your only choice.

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

The anxious experience therefore has two separate components: the anxiety disorder itself (phobia, social anxiety, panic, obsessive-compulsive disorder [OCD], worry,) and, separately, the anticipatory anxiety.

If you are worried that you might have a panic attack in a situation you expect to enter, anticipatory anxiety may start hours, days, or even weeks before it. If you are trying to decide if it is safe to meet a new person or use a public bathroom or ignore a brief sensation or thought, anticipatory anxiety is the dread you feel when you “try on” that activity or decision and scare yourself with imagining all the ways things could go badly.

Anticipatory anxiety varies widely in the way it appears and looks different in different settings. It can present as phobic avoidance, fear of being alone, performance anxiety, or insomnia. It can look like the elaborate planning that someone with OCD must do to avoid possibly encountering contamination, or the agony that a person with illness anxiety goes through waiting for test results. It can be the haunting fear of the return of an unwanted intrusive thought.

Anticipatory anxiety drives the compulsions that define OCD and related conditions. It is anticipatory anxiety (“I won’t be able to stand it if…”) that pushes people to perform the mental rituals and behavioral compulsions to reduce the immediate discomfort caused by the obsession.

Anticipatory anxiety might be expressed as a fear of going to parties or restaurants or travel, lest you encounter something there you believe you can’t handle. A desire to avoid being alone at night might stem from anticipatory anxiety about suddenly becoming ill or having scary thoughts. Anticipatory anxiety about imagined relationships might be why you avoid dating. Anticipatory anxiety about getting fired might make you “sick” every morning before you leave for work.

At times, anticipatory anxiety has been inaccurately called free-floating anxiety because there may be muscle tension, headaches, and other signs of anxiety without a conscious focus of worry. It is anticipatory anxiety that plays a large role in chronic hyperventilation, which is a setup for panic attacks. Chronic gastrointestinal problems such as diarrhea, nausea, or vomiting might be directly traced to anticipatory anxiety.

Anticipatory anxiety is the primary driver of generalized anxiety disorder (GAD), a tendency toward unproductive and excessive worrying. Simply put, the anxious imagining and distressing “what if” of GAD is anticipatory anxiety. Anticipatory anxiety can develop out of an overactive imagination or from conditioned responses to memories. It can be driven by a trait called anxiety sensitivity—the fear of the mind and body manifestations of anxious arousal. It can also emerge from a depressed and withdrawn mood state, or it can find its origins in beliefs about one’s own inability to cope with novelty or challenge.

Overcoming Anticipatory Anxiety is a seamless integration of metacognitive, behavioral, and acceptance-based approaches, focusing on the factors which maintain and exacerbate anticipatory anxiety. Successful therapy aims for a shift toward sensory input, a modification of attitudinal factors, and a change in one’s relationship with inner experience.

These include gently redirecting the attention to the present moment reality rather than the imagined future, while allowing for and not struggling against the experience of doubt or worry. As always, too much thinking is not solved by more thinking. False beliefs that anticipatory anxiety signals danger or provides prediction need to be addressed. And escape planning, ruminative entanglement with content, and other forms of avoidance such as empty reassurance and unhelpful self-talk must be discouraged.

Sally M. Winston, PsyD, is founder and executive director of the Anxiety and Stress Disorders Institute in Baltimore, MD. She is a founding clinical fellow of the Anxiety and Depression Association of America (ADAA), winner of the inaugural ADAA Jerilyn Ross Award, and was previously awarded the Association for Behavioral and Cognitive Therapies (ABCT) book award. She has over forty years of clinical practice and training specializing in anxiety disorders and obsessive-compulsive disorder (OCD). She is coauthor, with Martin Seif, of What Every Therapist Needs to Know About Anxiety Disorders, Overcoming Unwanted Intrusive Thoughts, and Needing to Know for Sure.

Martin N. Seif, PhD, is cofounder of the ADAA, and was a member of its board of directors for fourteen years. Seif was associate director of The Anxiety and Phobia Treatment Center at White Plains Hospital, a faculty member of New York-Presbyterian Hospital, and is board certified in cognitive behavioral therapy (CBT) from the American Board of Professional Psychology. He was previously awarded the ABCT book award, and maintains a private practice in Greenwich, CT. He is coauthor, with Sally Winston, of What Every Therapist Needs to Know About Anxiety Disorders, Overcoming Unwanted Intrusive Thoughts, and Needing to Know for Sure.