When Anxiety Is Overwhelming

Public speaking is often anxiety-inducing for many people—just the thought of having to do it brings nervous butterflies to the stomach. 

Xandra Kredlow remembers when she was young being uncomfortable speaking up in class. “I would force myself every class to say one thing, then two things, and then say a slightly longer thing,” says Kredlow, Dean of Arts and Sciences Assistant Professor in Psychology. “Initially that was really anxiety provoking for me, but eventually I became much more comfortable with it. I realized that the thing I was thinking was going to happen, like someone laughing or saying that my comment was stupid, didn’t happen.”

Now Kredlow studies a similar approach—exposure therapy—in much greater detail in her Translational Emotion and Memory Laboratory, a part of her research into fear and anxiety and what can be done to alleviate them. “We study these basic learning processes in a controlled setting to understand how fear memories are formed and how we can reduce their impact or salience, so we can eventually develop better treatments,” she says.

Fear, of course, has evolved in us for a reason. If there’s something dangerous, be it walking on a cliff edge or being chased by a bear, being afraid is a smart thing—it helps us deal with danger. “If we didn’t have any fear, we would not be prepared to handle real threats in our environment,” says Kredlow, who teaches the popular class The Psychology of Fear. “Physiological symptoms we experience, like our heart racing, are there to biologically prepare us and to help us in that situation.”

The same is true with anxiety. It usually arises when there’s not necessarily an immediate threat, but a looming threat or challenge—it might help us prepare for, say, an interview or a test. “We wouldn’t want to try to get rid of anxiety completely,” Kredlow says. “It’s more to figure out how to manage that anxiety and have it be more helpful and productive and less distressing and interfering.”

Kredlow mostly studies cognitive behavioral strategies, which involve intentionally changing how one is thinking about or acting in fear or anxiety provoking situations.

Exposure Therapy for Fear and Anxiety

Exposure therapy, a cognitive behavioral strategy, involves a gradual repetition of confronting the thing that is bringing up the fear, so that it starts to become less fear-provoking or anxiety-provoking. “You’re getting used to it, you’re learning that nothing catastrophic is going to happen, that you can handle some of the anxiety, and that it will decrease with time, the more experience and exposure you get to the situation,” says Kredlow.

Exposure therapy is very effective for improving anxiety symptoms. However, for some people, the gains may not last to the same extent for years after therapy. 

A key aspect of exposure therapy is called extinction learning, and like acquiring any new skill, there are pitfalls. Sometimes people don’t get a full course of exposure therapy—they will start it, and when things start to improve, stop the treatment. “It’s like if we’re taking an antibiotic and we don’t complete the entire course of treatment,” she says.

There are many factors that contribute to whether a person responds to the treatment, she says, such as the individual’s background, the kind of treatment and how it was delivered, and the match between patient and the type of treatment. “Other factors might predispose us to having anxiety that’s more resistant to treatment, and maybe exposure therapy is not enough given a certain profile.”

Consolidating Therapy Gains

One aid to improving response and combat relapse that has been extensively researched is taking the drug d-cycloserine during the exposure therapy process. “It’s thought to enhance that process so when confronting the stimulus later, people are better able to remember that extinction learning,” she says.

Kredlow is looking for other ways to consolidate gains in exposure therapy that don’t involve medication. To do that, she studies the basic processes that are involved in the therapy, trying to isolate ways to enhance it. She and her graduate students and undergraduate research assistants work mostly with individuals who do not have current mental health conditions, gathering preclinical evidence before doing further studies with patients with anxiety disorders.

One approach explores how to use the circumstances immediately before and after extinction learning to consolidate learning. “If something really novel and unusual happens that we’ve never encountered before, we’re more likely to remember that thing—as well as what we were doing right before and right after, compared to our day-to-day life experiences,” she says. Her lab is now testing the theory, using virtual reality headsets to provide novel experiences just before and after efforts to extinguish fears.

Reframing Negative Experiences

Another tool that cognitive behavioral therapy uses to alleviate fear and anxiety is cognitive restructuring—focusing on identifying and helping people reframe negative or unhelpful anxiety-provoking thoughts they are having about themselves or events.

“In our work, we look to apply cognitive restructuring to memories of past negative social experiences,” she says. “These are things that might’ve happened years ago, but were really salient negative experiences—like someone with social anxiety who had a traumatic public presentation or breakup. The goal is to have them restructure thoughts about those socially difficult experiences.”

If someone felt deeply embarrassed about a talk they once gave, for example, Kredlow would first ask them to identify their thoughts that happened during the presentation. 

“The thought might be, ‘Oh gosh, everybody thinks I’m stupid.’ Then we would ask them to really take a step back and try to realistically evaluate the evidence for and against that, and have them focus on the facts of the situation. How many people were there? How many people were laughing? Were you sure they were laughing about you? What are other possible things they might’ve been laughing about?”

“We would then encourage the patient to come up with other interpretations for the situation. For example, instead of thinking, ‘Oh wow, that was awful and people thought I was stupid,’ they might come up with, ‘That wasn’t the best presentation of my life, but it motivated me to do better the next time,’ or ‘Maybe it wasn’t as bad as I thought it was.’”

In a recent study, Kredlow and her team found that teaching people the cognitive restructuring strategy was most effective for those who are not already apt to do that kind of self-analysis and self-reframing in their day-to-day lives. For that study, they gave a questionnaire that assessed how likely people were to think about things from different perspectives, to reframe the way they think about things to change the way they feel about them.

“The people who don’t generally do that benefited the most from training on how to do it, which makes sense,” she says. “We also found some evidence that activating the memory before you do the cognitive reframing is better than just doing the cognitive reframing in a vacuum.”

Kredlow’s lab and collaborators at Harvard are now doing a study related to cognitive restructuring, to see if a specific technique—vividly recalling the event just before the cognitive restructuring effort—helps reinforce the learning. 

To do that, they are scanning people’s brains using fMRI as they recall the memories before and after the restructuring session “to see if that process in the brain changes and the representation of the memory changes more when you pair this kind of recalling of the memory with this cognitive reframing of the memory,” she says. 

This story describes Xandra Kredlow’s research and is not meant to provide mental health advice. If you are looking for mental health advice and are an undergraduate at Tufts, please consider contacting the university’s Counseling and Mental Health Services. Other online resources include those from the Anxiety and Depression Association of America.