An anvil, tenuously held up by a rope, hangs over a man's head

Credit: Mark Smith

Anxiety fallout

Are we ready for the next public health crisis?

Some describe anxiety as a wave. Fast and inundating, a heart-racing moment of fear that can pass as quickly as it arrived. For others, shipwreck is a better analogy.

"I would wake up each day and just feel this huge worry," remembers Marissa Lightkep, 29. Lightkep's problems with anxiety began in graduate school, when she was studying to be a school counselor while trying to deal with a poorly understood physical illness that frequently left her with stomach pain and dizziness from nausea. As specialists failed to settle on a diagnosis, Lightkep withdrew into a swirl of daily panic, her mind racing with fears about her health, how she would cope, and what could happen next. "I was just constantly on edge," she says, remembering how she would lie in bed for days on end. Where before she had been the life of the party, now her friends wondered where she had gone. "I was crippled to my core," she says.

Illustration of a person with swirling thoughts of anxiety

Image credit: Mark Smith

If you are feeling anxious these days, you are not alone. Amid the fear, isolation, and uncertainty of the COVID-19 pandemic, mental health has been deteriorating across the country. According to the Household Pulse Survey, a Census Bureau and National Center for Health Statistics initiative designed to rapidly test mental health changes during the pandemic, rates of anxiety and depression symptoms have quadrupled in the U.S. since this time last year. In July, nearly one in three American adults reported in surveys significant anxiety symptoms, including often feeling nervous, on edge, and unable to stop worrying—up from one in 12 this time last year. One in four reported symptoms of trauma and stress-related disorder, like PTSD. In a survey conducted this summer by the Kaiser Family Foundation, half the respondents said that "worry and stress" related to the pandemic had harmed their mental health.

Anxiety is normal. It's a natural physiological and psychological response to a stressor, which is anything that challenges us, say, a venomous snake in the middle of a trail or a disastrous flat tire on the way to a meeting. Its purpose is to maximize our capacity to respond to the challenge in the short term, to gain rewards and avoid catastrophe, largely by initiating our biological fight or flight response and laser-focusing our attention on the problem at hand.

For the most part, the anxiety response works as designed. We feel alert and "on edge" as a work deadline looms and then feel the downshift of relief as we successfully turn in the assignment. Given a large enough stressor though, or, as is the case today, continuous hard-to-anticipate stressors, anxiety can take on a life of its own, becoming disproportionate to the precipitating event, or spiral downward detached from any actual problems that need solving. There are many flavors of "anxiety disorder," but all are variations on fear of a trigger. If social interactions send your heart racing, you may have social anxiety disorder. If you really don't like heights, you may have acrophobia. If you are constantly on edge, with numerous alarms and triggers, you may have what's called generalized anxiety.

Johns Hopkins psychiatrist Karen Swartz, who leads the School of Medicine Psychiatry Department's mental health support plan for COVID-19 first responders, described our current problem bluntly at the start of the pandemic. "I think that 100% of people are dealing with stress and anxiety right now," she said. For those with preexisting mental health issues who have gained emotional stability, the pandemic is causing a reemergence of symptoms, Swartz says, be they generalized or specific. For those without a history of problems, new issues are forming, particularly around irritability, lack of sleep, and intrusive worry about health, employment, and what the future will bring. "Some amount of worry is probably reasonable right now," Swartz acknowledges. But a level of worry that starts interfering with your ability to function, "that's a problem."

"Some amount of worry is probably reasonable right now," says psychiatrist Karen Swartz. But a level of worry that starts interfering with your ability to function, "that's a problem."

In many ways the coronavirus pandemic was only our first public health crisis. The question now isn't whether we will see a mental health crisis but rather when it will peak and how large it will be. Already, rates of substance abuse are up, as are rates of suicidal thoughts, both of which lag depression and anxiety symptoms as responses to emotional distress. In a nationwide survey conducted in late June by the Centers for Disease Control's COVID-19 Response Team, one in four young adults admitted to having "seriously considered suicide" over the past month (up from one in nine the previous year). That same number applies to people who admitted starting or increasing substance use "to cope with pandemic-related stress or emotions."

The statistics are grim, but the good news is that we understand how anxiety and stress can take over the brain and body, and we have treatments that work for these and related disorders. The looming crisis of millions of anxious Americans represents a profound challenge, but also an opportunity: Can we use this moment to refine diagnosis? To deploy new treatments? To find ways to reach the millions for whom necessary mental health care is too expensive or simply unavailable? Johns Hopkins researchers and clinicians are at the forefront of an innovative effort to address this pressing need.

A watermelon-size ball is hurtling toward your head. You've got a few options: Duck? Dodge? Block it with raised fists? Think fast because here come some cubes. It's an unusual treatment protocol for an anxiety disorder, says Joseph McGuire, an assistant professor of child and adolescent psychiatry at the Johns Hopkins School of Medicine. The cubes are sharp and yellow, breadbox-size; the bright red spheres resemble kickballs. There are a lot of cubes and spheres, actually, moving very quickly.

"The idea is to elicit the same fear and uncomfortableness you would have if you were faced with a threat in the real world," McGuire says.

McGuire is pioneering the use of virtual reality to treat anxiety disorders in kids and young adults. The spheres and cubes are virtual, dramatic props in a VR dodgeball game designed to aid the therapeutic process. "The goal is to make therapy and therapeutic learning more fun and more effective," he says. He has many other simulations at his disposal, from classroom public speaking scenes to dramatic nighttime storms, allowing him to tailor the VR treatments to his patients' particular problems. But his goal is always to make them anxious, just a little.

Anxiety can come from many sources, but problems tend to emerge when we consistently avoid the things that make us anxious, like painful thoughts or scary situations. The front-line treatment for many anxiety disorders, from specific phobias to fear of social interactions, is to gradually expose yourself to what you are afraid of so that you (and your brain) can learn that smoke does not always mean fire.

"We know that exposure therapy works really well," McGuire explains. "But it can be hard to expose patients in a therapy setting to the things that make them afraid." For kids, storms and spiders are a big source of unwarranted anxiety. For adults, it can be heights and public speaking. You can ask patients to go find spiders themselves, or wait for a storm, but compliance can be tricky. Anxiety is maintained by avoidance. "So, we've started testing out these immersive, interactive virtual reality exposures," says McGuire, "where I can control every part of the process." Kids and adults alike will often balk at doing their therapy homework. But, so far, "no one has said no to a VR exposure."

Virtual reality exposure therapy has been around since the 1990s, when veterans with post-traumatic stress disorder were first treated using simulated combat environments, typically jungle scenes for Vietnam veterans, complete with the sounds of crickets and gunfire, simulated landmine explosions, and visuals of helicopters passing overhead. "That was clunky, clunky VR," McGuire says, but it proved to be effective.

Before we go further, let's go inside the brain for a moment. When faced with a stressor, your almond-shaped amygdala, a cluster of neurons at the front of your temporal lobes, analyzes the potential threat and asks your hypothalamus to trigger the pituitary and adrenal glands to release hormones like adrenaline and, eventually, cortisol into your bloodstream. You have definitely experienced this chain reaction, which happens so quickly we often feel the results before we are aware of the stressing event. Heart rate increases dramatically. Alterations in the constriction of blood vessels shunt extra blood to the muscles and drop flow to the stomach and reproductive organs. The lungs' smallest airways expand wider. Your pupils dilate. Your brain gets a surge of oxygen. Muscle tone increases. Sugar and fat stores are mobilized. Salivation ceases.

In the short term, this response causes no problems. When the threat has passed, a separate set of glands and hormones replaces, or balances out, the first, slowing the heart rate, realigning blood vessels, and reactivating your host of "rest and digest" functions. But over time, constant activation of the threat system can put excess wear and tear on the body, weakening blood vessels, raising baseline blood pressure, and increasing weight gain and risk of cardiovascular disease, poor immune function, and even dementia. It can also change the circuitry of the brain to keep us constantly looking for threats, or anxiously avoiding things that we have learned to associate with threats—like the last cupboard where we encountered a spider. Taken to the extreme, these brain and behavioral changes can themselves lead to other debilitating disorders in vulnerable individuals, including depression and psychosis.

Over the past decades, psychologists have learned that, in addition to facing our fears, we can combat chronic stress and disproportionate anxiety using relaxation techniques that help engage the rest and digest system, including mindfulness meditation; deep, slow breathing; or simply imagining you are somewhere peaceful.

These techniques can be easy to learn but require concerted practice to become effective. To foster skill learning quickly, McGuire has his patients play the fast-paced virtual dodgeball game. While patients play, McGuire monitors their heart rate—an excellent measure of anxious arousal, or fight or flight activity—and asks them to use relaxation strategies to calm down, even while ducking and dodging. If their heart rate gets too high, the edges of the VR field will darken, and the game becomes more difficult. If their heart rate gets too low, the room grows fuzzy. "In this way we also help people learn how to be the most effective in using the skill to reach a preset target state of arousal," McGuire says.

While McGuire is in the pilot phase of his studies, he plans to seek funding for randomized controlled trials and, eventually, to widely disseminate VR tools for kids and teens so that therapy becomes more accessible and effective.

"Ultimately, I want to deploy this to your living room," he says.

While virtual reality presents one futuristic path to improving treatment for anxiety disorders, making therapy potentially more enjoyable and effective, the largest obstacle yet to be overcome is far more pedestrian: How can we get more people in front of a mental health care provider in the first place?

Paul Nestadt, an assistant professor of psychiatry and behavioral sciences in the School of Medicine, with a joint appointment in the Bloomberg School of Public Health's Department of Mental Health, runs the Jack and Mary McGlasson Anxiety Disorders Clinic. In his experience, a number of barriers keep people from getting treatment that could help. "People will suffer for a long time before getting care," he says.

"It takes a long time to recognize when anxiety becomes a problem. A little bit of it is actually very good. It helps us perform at our best. But people also don't recognize when they have been miserable for a long time."
Paul Nestadt
Johns Hopkins School of Medicine

First, "it takes a long time to recognize when anxiety becomes a problem. A little bit of it is actually very good. It helps us perform at our best," he says. "But people also don't recognize when they have been miserable for a long time. They may view anxiety as something that has helped them be successful. Often it takes a loved one or a boss or a co-worker to tell them, 'You need to see somebody.'" Constant irritability, noticeable to others, Nestadt says, tends to bring people in for treatment more than anything else. "Otherwise people just get to a point on their own where they say, 'I am miserable, I need help.'"

Second, Nestadt concedes, finding the right help can be a hurdle. "I'll admit that it is hard to get help. It is hard to find providers who are covered by insurance and who do good cognitive behavioral therapy," which is the front-line treatment for most anxiety disorders and other psychiatric illnesses, like depression and insomnia, whose prevalence is exploding during the pandemic. While the Affordable Care Act mandated "parity" for reimbursement of mental and physical health care, most insurers still reimburse psychological services well below market rate, and well below what is needed to recruit, train, and retain professionals. As a result, there are not enough therapists trained in cognitive behavioral therapy, and many will not accept insurance. Once they do find the right help, most patients will linger on waitlists for months.

That's one reason the growth of telehealth, or virtual visits, during the pandemic has been a beacon in the dark. Now it is easier for patients to see trained professionals who practice, potentially, hundreds of miles away. Nestadt, like many in his profession, was wary of telehealth in the past, viewing it as cumbersome and unlikely to allow for the nuance in observation and communication that effective psychological treatment requires. "But now I have recognized that it is doable and very much better than nothing," he says. "It is saving lives." Regulations restricting telehealth have been relaxed during the pandemic, but they need to be modernized and expanded to meet the coming need. "As we become more facile with telehealth programs, this kind of care can be even more helpful going forward."

Regardless of how patients are seen, the goal for the next few years will be widespread screening, according to Swartz, associate professor of psychiatry and behavioral sciences in the School of Medicine and head of Clinical Programs at the Johns Hopkins Mood Disorders Center. "There is a risk of seeing a person's mood and anxiety symptoms simply as a response to the extraordinary circumstances of the pandemic and therefore missing more serious conditions," she says. All of us are stressed and anxious, but we need to be on the lookout for people—like the friend who has stopped returning phone calls or the loved one who can't quit ruminating on conflicts at work—who have been tipped over the edge, into a place where their daily function is impaired.

At Johns Hopkins, the Anxiety Disorders Clinic focuses the brunt of its work on this kind of comprehensive assessment, and it tends to take referrals of cases that others have been unable to crack. In comparison to the 50 minutes that most clinicians can typically spend with their clients for an initial "intake" visit, medical residents rotating into the anxiety clinic have a comfortable four hours with their patients. During that time they can home in on the likely source of complex anxiety and develop highly targeted recommendations for care. "We are able to really go into detail with patients that they haven't had a chance to do before," Nestadt says. The residents gain world-class training, "and we treat people who wouldn't be able to benefit in other settings."

As a result, says Joe Bienvenu, an associate professor of psychiatry and co-director of the clinic, patients will travel to Baltimore from all over the world to be assessed in the clinic. Last year, a quarter of their patients came from abroad, primarily the Middle East.

Nestadt and Bienvenu now worry about new, "therapy naive" patients who may wait too long to receive help. Although suicide is mostly associated with depression, anxiety can also be a trigger. Nestadt has research now under peer-review that reports a recent surge in suicide deaths among Black Maryland residents, a demographic who have been hit hard by the pandemic. It is not yet clear what is causing the rise, but stress and anxiety are likely contributing.

"The bottom line is, if you feel like you can't handle it on your own, then reach out," he says. "Seeking professional assistance can be appropriate and lifesaving." And keep an eye on others. "If you are watching someone suffer, and it doesn't occur to them to seek out help," he says, "please remind them that they can."

On a Monday afternoon last September, Neda Gould, an assistant professor of clinical psychology and head clinician at the Johns Hopkins Bayview Medical Center's Anxiety Disorders Clinic, demonstrated another path to improving our mental health in these trying times. Gould directs the Johns Hopkins Mindfulness Program, and since the start of the pandemic she has been leading daily mindfulness sessions for the wider Hopkins community. So far, over 3,000 people have attended.

Exactly at noon, Gould appears in a Zoom window, a serene presence in contrasting black and white athletic clothes that mirror her dark hair and eyeglasses.

"It's great to see you all again," she says to the dozens of gathered participants, who include young and old faces, folks dressed in hospital scrubs and pajamas, students and retirees, all joining remotely, some from offices, others from less-than-tidy kitchens.

"Let's begin with some gentle stretching," Gould says, raising her arms above her head. "This is particularly important if you are sitting at a computer all day long and typing." As Gould moves through stretches, people dip into and out of frame, sometimes replaced by wobbling arms or legs. Soon they are asked to notice their breath and, after that, to dwell on "the places in the body that come into contact with the chair or the floor," Gould says, "grounding you into this one moment." Time and again, Gould returns to the theme of anchoring, asking her audience to notice what is happening "just now" in their body, thoughts, or emotions. Eventually, a bell rings out and the session comes to a close.

"Thank you all so much for taking time out of your day to cultivate awareness," Gould says. Gratitude pours in for Gould herself, as people unmute and begin to chatter while she smiles back warmly. "I love seeing everyone; please come back."

Mindfulness practices seek to train the brain, and the person attached to it, to be present in the moment, to accept what comes with that, nonjudgmentally, and to find meaning in simply being alive.

"The idea is that so much of our distress comes from our thinking about the future and our thinking about the past," Gould explains. Being in the present allows us a different perspective. "It's not that the present moment is a perfect moment," she says, but we can take in the pleasant and positive experiences to a greater degree. On the negative front, if we can be with the unpleasant experiences as well, we can develop a resilience to them. The approach is reminiscent of Joseph McGuire's virtual reality efforts to help people face their fears. "We spend so much of our time pushing away negative experiences," Gould says, "And that really doesn't work as a long-term strategy."

If followed intensively, the mindful approach can be life changing.

"I was on edge all the time," Cindy Bentz remembers. Bentz, who suffers from a connective tissue disease, was encouraged by her internist to participate in one of Gould's Mindfulness-Based Stress Reduction courses, which are extensive multiweek training seminars that she has led for faculty, staff, and patients at Johns Hopkins since 2017. In her pre-mindful days, family conflict would regularly leave Bentz in tears, and she would ruminate about blowups endlessly. "I couldn't let things go," she says. Some days, "my heart would race so bad that I could feel it in my throat." Through mindfulness, Bentz learned to let go of what she couldn't control. Her mantra now is "not to dwell on the past because that makes you sad and not to dwell on the future because that makes you anxious." It takes work, she says, but after following Gould's course, she now has peace and contentment. "I was thrown a lifesaver."

Mindfulness is ultimately what turned things around for Marissa Lightkep. She also took one of Gould's courses, which run for approximately 10 weeks of three-hour weekly sessions. She had been seeing Gould for one-on-one therapy and found it helpful, and she decided that a more intense dose couldn't hurt. "On the outside I was living a normal life, but on the inside I was suffering so badly. I was not functional at all."

"Anxiety is the constant worry and fear about what is going to happen or maybe has already happened. And stress is … just dealing with the cards that you are dealt."
Marissa Lightkep

The first sessions generated anxiety of their own. She thought, "What the heck is this?" But by the time Lightkep finished the course she felt such psychological relief that she dropped one of the many prescription drugs that she took for anxiety.

"I didn't know that feeling that much better while still being sick was an option," she says, referring to her physical illness, which was eventually identified as gastroparesis, a problem of dysregulated stomach emptying. "I learned that your mind has so much more power than you think it does. You can build resilience." With new clarity, Lightkep was able to weather setbacks in her physical symptoms and rebuild her life. Eventually she took Gould's course a second time, and was able to remove a second medication from her list.

Lightkep, a stubborn public school counselor with a full smile, now devotes herself to helping children overcome adversity using the skills she learned to help herself. She is finding that, right now, nearly all her students, who are low-income and from disadvantaged neighborhoods, need more help than they are getting. "First and foremost, we focused on food, water, do they have their utilities turned on?" Now she is worrying about their emotional needs.

There's another worry that Lightkep has, related to the virus itself. Lightkep is a member of a Facebook group for individuals with POTS (postural orthostatic tachycardia syndrome), one of her health problems, which involves disturbance of blood flow when standing. A woman who was new to the group asked her for advice about exercise routines. "She said, I never had any health issues before, but I had COVID-19 in March and now I have POTS." It terrifies Lightkep to think that the virus could worsen her own symptoms or cause them in others. "I don't think people really grasp what the long-term consequences of COVID could be."

Life under COVID-19 has not been easy for Lightkep, who is at elevated risk for severe complications. (Doctors trace her decade of physical illness to a viral infection earlier in life, the flu, or maybe a bout of mono that she had in high school.) But she is able to use the skills she has learned to keep stress and anxiety separate.

"When I was with Dr. Gould, my anxiety was a 10 out of 10. And I would say that right now my stress level is high, but I only feel an appropriate amount of anxiety, a regular amount. Two out of 10. It took me awhile to determine the difference between anxiety and stress," she says. "Anxiety is the constant worry and fear about what is going to happen or maybe has already happened. And stress is … just dealing with the cards that you are dealt."

Her motto, stay positive.

"I have been telling myself throughout this process that I have a lot of grief and I have a lot of gratitude. I can get up and take a walk today. I have a healthy body. I have a house," she says. "I have hope and I feel lucky to have hope."

Don't Panic: Ways to Cope With Anxiety

When in a crisis:

Slow breaths. Your body's high-alert setting tends to lead to shallow breathing, sometimes hyperventilation. Override that response and take long, deep breaths into your belly, not chest. Five minutes of deep breathing has been found to significantly lower anxious arousal. The more you practice, says Joseph McGuire, an assistant professor of child and adolescent psychiatry at the Johns Hopkins School of Medicine, the more effective this technique becomes.

Cold water. The mammalian diving response is a physiological phenomenon seen in all vertebrate animals. When your body thinks it's in cold water, it calms the nervous system to conserve oxygen. This response can be leveraged when you are in an anxious crisis. Fill a large bowl with ice water and hold your face in it for 30 seconds. This will reliably take the edge off intense distress.

When stress and anxiety are low-grade, constant companions:

Try a cognitive behavioral therapy course. CBT from a trained professional significantly reduces anxiety for most people with a diagnosed disorder, whether it is social anxiety, post-traumatic stress, panic, or generalized anxiety. A word of caution: It takes about eight to 12 weekly sessions to see results. Reach out to local clinics when you feel anxiety is impairing your quality of life at home or work. You'll know you are getting the real deal if you are assigned homework between sessions.

Develop a daily mindfulness meditation practice. There are many ways to practice mindfulness meditation these days, including short courses, podcasts (Mindfulness for Beginners), and helpful apps like Mindful Moments (provided free by the Cleveland Clinic) and Calm or Headspace (which both require subscriptions). Meta-analysis of mindfulness meditation by Johns Hopkins researchers has found that this technique of being "present in the moment" can significantly reduce anxiety. "We cannot control the world around us," says Madhav Goyal, an assistant professor of medicine at Johns Hopkins and lead author of the analysis. "But we can control our reaction to the world, and this is what mindfulness can do for us."

Stop ruminating. "When you find yourself talking about the same problem over and over again, without finding you've made any progress on it, that's when you can tell it's rumination," says Alison Papadakis, director of clinical psychological studies in the Department of Psychological and Brain Sciences, who studies rumination among college students. Too often we get stuck in defining problems when we need to move on to problem-solving. She recommends sharing your concerns with others, and asking them to gently point out when you've been chewing the cud for too long. "Just being aware of this can help jolt us out of the unhelpful pattern."

Look out for your physical health. We know from decades of research that sleep and exercise can influence your mental health. In the short term, a rigorous workout and a decent night's sleep can do wonders, says Karen Swartz, an associate professor of psychiatry and behavioral sciences in the School of Medicine. Doing both consistently helps lower stress hormones like cortisol and maintains your homeostasis at lower levels of anxious arousal. But don't force sleep to come when it doesn't want to. If you are anxious and awake in bed, get up and do an activity. You want to avoid training your brain that the bed is a place for worry. Worry less about total hours of sleep and more about getting high-quality hours in.

Freelance science writer Aaron Reuben is a PhD candidate in clinical psychology at Duke University.