Mental Health, Anxiety, and the Nervous System: When the Brain That Drives You Also Wears You Out
There are certain things about yourself that you don’t necessarily recognize as unusual until you’re old enough to realize that not everyone else’s brain works the same way. For me, one of those things has always been perfectionism. I was the student who wanted the assignment done correctly, but “correctly” wasn’t really enough. I wanted it done right. I wanted to understand what the teacher was asking, anticipate what they might be looking for, make sure I hadn’t overlooked something, and probably spend considerably more time on it than the assignment actually warranted. That tendency wasn’t limited to school, either. I liked things organized. I liked knowing the plan. I liked being prepared. If something mattered to me, I didn’t particularly enjoy doing it halfway, and while some of that was simply personality and conscientiousness, I can recognize now that anxiety was woven through some of it too.
It still is.
That’s something I think is important to say out loud, particularly as we begin a month devoted to mental health. I’m a doctor. I spend my days helping people understand their bodies, looking for patterns in complicated cases, teaching patients about physiology, and talking about ways we can support the nervous system. I have also dealt with anxiety myself for much of my life, and I come from a family in which anxiety and other mental health struggles are not foreign concepts. Knowing the science doesn’t somehow exempt you from being human. I can understand exactly what a stress response is doing physiologically and still have moments when my own brain decides that we should probably examine a situation from fourteen different angles, just in case angles thirteen and fourteen contain some previously undiscovered catastrophe.
Over time, though, my relationship with anxiety has changed. I don’t necessarily view every trace of it as something that needs to be eradicated, because I’ve come to recognize that some of the qualities living very close to my anxiety are also qualities I genuinely value about myself. I’m driven. I’m conscientious. I care deeply about doing good work. If I tell someone I’m going to do something, I want to follow through, and when I’m responsible for another person’s health, my employees, my family, or my business, I take that responsibility seriously. Anxiety can make me remarkably good at anticipating what could go wrong, which is exhausting when I’m lying awake thinking about something I cannot possibly solve at 2:00 in the morning, but quite useful when I’m running a medical practice and trying to catch a problem before it becomes a bigger one.
That doesn’t make anxiety inherently good, and I want to draw that distinction carefully. Severe anxiety can be profoundly disabling. It can interfere with relationships, work, sleep, appetite, digestion, concentration, decision-making, and the ability to enjoy a life that looks perfectly fine from the outside. There are times when anxiety absolutely deserves treatment, including psychotherapy and medication when appropriate, and I would never want someone struggling with debilitating anxiety to hear “maybe this is your superpower” as another reason they should simply learn to tolerate suffering. But I also don’t think every anxious tendency is evidence that something has gone terribly wrong. Human beings evolved with a nervous system designed to anticipate danger, remember negative experiences, notice changes in our environment, and prepare us for what might happen next. A brain that never worried about anything probably wasn’t especially advantageous when something rustled in the bushes outside the cave.
Our modern problem is that the bushes have changed.
The Same Brain, a Very Different World
The human stress response is spectacularly good at doing what it was designed to do. If your brain perceives a threat, sympathetic nervous system activity increases, stress hormones and catecholamines help mobilize energy, cardiovascular activity shifts to support action, attention narrows, and resources are temporarily prioritized toward what matters most for immediate survival. You don’t need to consciously instruct your adrenal glands, heart, pupils, blood vessels, liver, or muscles to participate. The response happens automatically, often before the thinking portions of your brain have had much opportunity to weigh in.
That’s incredibly useful when the threat requires immediate action. It becomes more complicated when the “threat” is a difficult conversation with your spouse, an unexpected bill, a business problem, a sick child, a disturbing news story, an unanswered text message, an overflowing inbox, or the realization at 10:47 p.m. that you forgot something you meant to do that afternoon. Your physiology doesn’t have a separate pathway labeled LEGITIMATE PHYSICAL THREAT and another labeled ANNOYING EMAIL FROM KAREN. The magnitude of the response may differ, of course, but many of the same biological systems participate.
This is where I think our cultural conversation about stress sometimes becomes too simplistic. We talk about stress as though it is a toxin that should be removed from our lives, and then we become stressed about the fact that we’re stressed. But a functioning stress response is not pathology. You want your body to respond when circumstances demand more from you. Exercise is a stressor. Learning is a stressor. Pregnancy is a physiological stressor. Getting married, moving, starting a business, traveling somewhere unfamiliar, raising children, training for an athletic event, and taking on meaningful work can all create stress even when those experiences are wanted and positive. The goal of a healthy nervous system isn’t to remain perfectly calm while life happens around it. The goal is flexibility: activation when activation is appropriate, followed by the ability to come back down.
That second part is where many of us struggle.
I see this in my patients, and I see it in myself. When you’ve spent years being productive, responsible, responsive, and prepared, it can become surprisingly difficult to recognize when your nervous system is never quite getting the message that the workday is over. You can sit on the couch while your brain continues working. You can go on vacation while mentally checking your inbox. You can finish one task and immediately feel the gravitational pull of the next. Sometimes people finally get an afternoon with absolutely nothing they have to do and discover that instead of feeling peaceful, they feel vaguely uncomfortable, as though surely there is something productive they should be doing.
I am, regrettably, quite familiar with this phenomenon.
When Anxiety Looks Like Competence
One of the more interesting things about anxiety is that it doesn’t always look like someone visibly panicking. Sometimes it looks like competence. It looks like the person who remembers everyone’s schedule, arrives early, researches everything before making a decision, keeps immaculate notes, prepares for contingencies, rarely misses deadlines, and somehow manages to hold a tremendous number of details in their head at once. Those people are often praised for being organized, reliable, ambitious, or “on top of everything,” and they may genuinely be all of those things. What isn’t always visible is how much internal pressure is required to maintain it.
This is where the relationship between anxiety and achievement gets interesting, because there is some overlap between traits associated with high achievement and traits that can contribute to anxiety: conscientiousness, vigilance, sensitivity to mistakes, future-oriented thinking, high personal standards, and the ability to anticipate consequences. None of that means anxiety causes success, and it certainly doesn’t mean people without anxiety are somehow less ambitious or capable. It means that the same nervous system tendencies can produce very different outcomes depending on their intensity, context, and how well someone can regulate them.
Perfectionism is a good example. Wanting to do something well can produce extraordinary work. Believing that anything short of flawless is unacceptable can make it nearly impossible to finish that work. Preparation can create confidence; endless preparation can become avoidance. Self-reflection can help us grow; relentless self-analysis can keep us trapped in conversations that ended three days ago. Anticipating problems can make someone an excellent clinician, parent, leader, or business owner, while constantly scanning for everything that might go wrong can leave that same person physically exhausted.
There have absolutely been times when my anxiety has pushed me forward. It has made me prepare more thoroughly, work harder, double-check something important, or refuse to settle for work I knew could be better. There have also been times when it has done the opposite, when wanting to make the “right” decision made the decision harder, when perfectionism created procrastination because the task felt too important to do imperfectly, or when my brain spent an impressive amount of energy trying to solve a problem that didn’t actually exist yet. Anxiety can press the accelerator and the brake at the same time, which is not particularly fuel efficient.
Learning to distinguish between those versions of anxiety has probably been more valuable to me than trying to eliminate anxiety altogether. I can ask whether the concern I’m feeling is giving me useful information. Is there something I need to prepare for, change, address, or pay attention to? Or have I already gathered the available information and now my brain is simply demanding certainty that life cannot provide? The first deserves action. The second often requires something much harder for a perfectionist: letting go.
We Were Never Promised Certainty
Anxiety has an interesting relationship with certainty because anxious brains tend to love it, and life stubbornly refuses to provide very much of it. We can make thoughtful decisions and still have unexpected outcomes. We can take excellent care of our bodies and still become ill. We can be wonderful parents and still watch our children struggle. We can prepare carefully for a presentation and still forget what we were saying halfway through a sentence. We can build financial plans, contingency plans, evacuation plans, meal plans, birth plans, treatment plans, and approximately six different versions of the family calendar, and life will occasionally look at all of them and laugh.
For someone whose brain likes control, that can be deeply uncomfortable.
I think this is one reason anxiety can become more pronounced during periods of transition or increased responsibility. There is simply more that matters. Becoming responsible for a family, a business, a patient population, aging parents, finances, employees, or other people we love gives the brain more material to work with. Anxiety often attaches itself to the things we value most because those are the things we most fear losing or failing.
That realization softened something for me. Anxiety wasn’t necessarily evidence that I was incapable of handling my life. Sometimes it was evidence that I cared tremendously about it. The work, then, wasn’t to stop caring. It was learning that caring deeply and controlling every possible outcome are not the same thing.
That is still a work in progress, by the way.
I would love to tell you that after years of studying medicine, understanding physiology, and working on my own mental health, I have reached some enlightened state in which I effortlessly surrender control and float serenely through uncertainty. I have not. My nervous system remains very enthusiastic about contingency planning. But I recognize it more quickly now, and I can sometimes laugh when I notice myself doing it, which turns out to be considerably more useful than becoming anxious about being anxious.
Anxiety Is a Whole-Body Experience
One of the reasons I wanted to begin our October mental health series with anxiety is that it creates a natural bridge between the emotional and physiological sides of mental health. We often describe anxiety as though it exists entirely within our thoughts, but anyone who has experienced significant anxiety knows that the body is very much involved. Your heart may race. Your chest may tighten. Your breathing can become shallow. Your shoulders creep upward until they seem determined to become earrings. Your stomach churns, your appetite changes, your muscles tense, your hands sweat, and sleep becomes difficult because the moment your head hits the pillow your brain suddenly remembers every unfinished task you’ve had since approximately 2007.
These aren’t random accompaniments to anxiety. They’re part of the same physiological response.
The brain is constantly communicating with the rest of the body through the autonomic nervous system, endocrine signaling, immune pathways, and the gut-brain axis. When your brain interprets something as threatening, the body changes in preparation for action. Conversely, signals coming from the body continuously influence how the brain interprets the environment. Mental health therefore isn’t simply a top-down phenomenon in which thoughts control physiology. Communication travels in both directions.
This matters clinically because sometimes we focus so intensely on changing thoughts that we overlook the biological conditions in which those thoughts are occurring. Someone sleeping five fragmented hours a night, skipping breakfast, surviving on coffee until 2:00 p.m., experiencing significant blood sugar fluctuations, and living under relentless occupational stress is asking their nervous system to perform under very different circumstances than someone who is rested, nourished, moving regularly, and experiencing predictable periods of recovery.
That doesn’t mean breakfast cures anxiety. I hope we’ve known each other long enough for you to know I’m not going to make that leap.
It means context matters.
The Brain Is Part of the Body, Too
This was one of the central themes of our September brain-health series, and it’s worth carrying forward into October because it changes how we think about mental health. The brain is enormously metabolically active. It requires a continuous supply of energy, oxygen, amino acids, fatty acids, vitamins, minerals, and other substrates to maintain electrical signaling, synthesize neurotransmitters, regulate inflammatory responses, repair cellular structures, and perform the staggering amount of work required simply to be conscious.
When patients come to me with anxiety, mood changes, brain fog, irritability, or difficulty concentrating, I’m interested in their emotional experience, but I’m also interested in what is happening physiologically. How are they sleeping? Are they eating enough protein? Are there large swings in blood sugar? What does their thyroid function look like? Is iron adequate? What about B12, folate, vitamin D, magnesium, and other nutrients relevant to neurological function? Are hormones shifting? Is chronic inflammation present? Are there medications that could be contributing? What is happening in the gut? Has there been significant trauma, illness, infection, concussion, environmental exposure, or prolonged stress?
Not because one of those things secretly explains every case of anxiety, but because the nervous system doesn’t operate independently of them.
There is a tendency in healthcare to divide “mental” and “physical” symptoms into separate categories, as though the neck is some kind of international border. Above it, psychiatry. Below it, medicine. Passport required.
Human physiology did not receive that memo.
The immune system communicates with the brain. The gut communicates with the brain. Sex hormones influence the brain. Thyroid hormones influence the brain. Glucose regulation influences the brain. Sleep alters brain function dramatically, and chronic psychological stress creates measurable physiological changes throughout the body. Our thoughts can affect our bodies, and our bodies can affect the landscape in which those thoughts occur.
For me, this doesn’t make mental health less psychological. It makes it more human.
Genetics May Set the Stage, but They Don’t Write Every Scene
My own family history has also shaped the way I think about anxiety. Mental health concerns run through my family, including anxiety and other psychiatric conditions, so I have never had the luxury of pretending that biology plays no role. There are clearly inherited components to many mental health conditions, although the genetics are generally far more complex than a single “anxiety gene” being passed from parent to child.
Genes can influence temperament, stress reactivity, neurotransmitter pathways, inflammatory signaling, nutrient metabolism, circadian biology, and many other processes that may shape vulnerability. Then those genetic tendencies interact with early life experiences, relationships, trauma, nutrition, socioeconomic conditions, illness, sleep, movement, environmental exposures, and the thousands of ordinary experiences that accumulate over a lifetime.
Even within the same family, those combinations can produce remarkably different people.
I find that encouraging. A family history can tell us something about susceptibility without becoming a prophecy. Knowing that my brain may be naturally inclined toward vigilance doesn’t mean I’m destined to spend my life at the mercy of it. It gives me information. It helps me recognize patterns sooner, understand why certain seasons of life may be more challenging, and take my own mental health seriously instead of waiting until I am completely overwhelmed to do something about it.
It also gives me tremendous compassion for patients who say, “I don’t understand why I can’t just stop feeling this way.”
Sometimes there isn’t a simple reason.
And “just stop” has never been a particularly impressive medical intervention anyway.
Maybe the Goal Isn’t to Become a Different Person
I used to think managing anxiety meant getting rid of it. I understand now that my goal is different. I want enough awareness to recognize when anxiety is giving me useful information and enough regulation to recognize when it isn’t. I want the conscientious part of myself without allowing perfectionism to make every task heavier than it needs to be. I want to care deeply about my patients, my work, and my family without believing that caring requires me to predict and prevent every possible problem.
Most of all, I don’t want to spend my life fighting my own nervous system.
The nervous system is adaptive. It learns from repeated experiences, which means patterns can become deeply ingrained, but it also means those patterns are not necessarily fixed. We can build greater flexibility over time. We can become better at moving into activation when life demands it and returning toward rest when the demand has passed. We can learn what makes our individual nervous systems feel safer, what pushes them toward overload, and which physiological factors make regulation easier or harder.
That is where we’re headed next in this series.
Before we talk about “regulating the nervous system,” though, I want to be careful with that phrase because it has become so popular online that sometimes it sounds like your vagus nerve is a misbehaving toddler you need to discipline. Nervous system regulation isn’t about remaining calm all the time, and it isn’t accomplished by finding one magical breathing exercise on Instagram. It is the capacity to respond appropriately to changing circumstances and then recover, and that ability is influenced by far more than mindset alone.
We’ll get into that physiology next.
For now, perhaps the more useful place to begin is simply noticing your own relationship with anxiety without immediately labeling every part of it as good or bad. Maybe some of it has protected you. Maybe some of it has propelled you. Maybe some of it has exhausted you. Maybe the exact same tendency has done all of those things at different points in your life.
Mine certainly has.
I still rewrite things more times than necessary. I still occasionally struggle to decide when something is “done.” I can still overthink decisions, and there are moments when I have to deliberately push through anxiety instead of waiting until I feel perfectly comfortable, because if I waited for complete certainty before doing difficult things, I suspect I’d accomplish considerably less. The difference is that I understand that part of myself better now. I can appreciate what it has contributed without giving it unrestricted access to the control panel.
And some days, that feels like progress enough.
What Is Actually Happening in the Body When We Feel Anxious?
One of the strange things about anxiety is that you can know intellectually that you are safe while your body remains thoroughly unconvinced. You can be sitting in your own house, wearing comfortable clothes, drinking tea, with no tiger in sight and nothing particularly dramatic happening, and yet your heart is beating faster, your shoulders are tense, your stomach feels unsettled, and your brain has begun producing increasingly creative explanations for why something might be wrong. This disconnect can be frustrating because we tend to assume that if anxiety originates in the mind, we should be able to reason our way out of it. Sometimes we can. Other times the rational part of the brain is essentially standing in the corner holding a clipboard while the rest of the nervous system has already pulled the fire alarm.
That isn’t a failure of willpower. It’s physiology.
The brain is constantly gathering information about what is happening both outside and inside the body and making predictions about what those signals mean. Some of that information reaches our conscious awareness, but an enormous amount of it doesn’t. Your nervous system is monitoring blood pressure, breathing, glucose availability, inflammation, temperature, hormones, digestive activity, sensory information, previous experiences, facial expressions, tone of voice, and countless other signals without asking you to participate. Its primary objective isn’t to make you happy. Its primary objective is to keep you alive, and from an evolutionary standpoint, being occasionally overcautious was a relatively reasonable tradeoff. The ancestor who heard rustling in the grass and unnecessarily prepared to run wasted a little energy. The ancestor who repeatedly assumed it was probably nothing may eventually have become lunch.
The problem is that this protective system doesn’t operate in a vacuum. Its threshold can change depending on what has been happening in the body and in our lives. When we are rested, nourished, connected, and generally doing well, we may tolerate a frustrating email or a difficult conversation without much difficulty. Give the same person several nights of poor sleep, an illness, three skipped meals, a looming deadline, a toddler who has recently discovered the word “no,” and six months of unresolved stress, and suddenly that email lands very differently. The external event hasn’t necessarily changed. The physiological context in which the nervous system receives it has.
That context is one of the reasons I think understanding anxiety biologically can be so empowering. It doesn’t reduce our emotional lives to chemistry, and it certainly doesn’t mean that every difficult feeling needs a laboratory explanation. It simply reminds us that the brain experiencing an emotion is attached to a body, and that body has a history.
Your Nervous System Is Supposed to Change Gears
When people talk about nervous system regulation, they are often referring primarily to the autonomic nervous system, the network that helps control processes we don’t have to consciously manage, including heart rate, blood vessel tone, digestion, breathing patterns, pupil dilation, sweating, and many other functions. Most people are familiar with its two major branches: the sympathetic nervous system, commonly associated with “fight or flight,” and the parasympathetic nervous system, commonly associated with “rest and digest.”
Those descriptions are useful, but they can also create the impression that sympathetic activity is bad and parasympathetic activity is good. Biology is rarely that tidy. You need sympathetic activation to stand up without fainting, exercise, concentrate intensely, respond to an emergency, compete athletically, give an important presentation, and do many of the things that make a full human life possible. Likewise, parasympathetic activity is involved in recovery, digestion, restoration, and conservation of energy, but a healthy nervous system isn’t trying to remain permanently parked there either.
The important concept is flexibility.
Your nervous system should be able to change gears according to circumstances. If you nearly get hit by another car, I would very much like your sympathetic nervous system to respond. Your heart rate should increase. Your attention should sharpen. Your muscles should receive more available energy. You should be prepared to react quickly without first conducting a committee meeting about whether this particular threat warrants physiological activation.
Then the danger passes.
This part matters just as much.
Your heart rate begins settling. Breathing normalizes. Muscular tension decreases. Digestion resumes its usual priorities. The brain updates its assessment of the environment and gradually receives the message that the immediate threat has ended. You don’t need to become completely serene within thirty seconds, but the system should be capable of moving toward recovery.
Chronic stress changes that rhythm. Instead of distinct periods of activation followed by recovery, we can begin living in a state of low-grade vigilance where the nervous system rarely receives a convincing signal that everything is finished. There is always another notification, another deadline, another patient, another bill, another piece of news, another responsibility, another thing we should probably be doing. Nothing is necessarily chasing us, but nothing is ever quite done either.
For perfectionists, this is particularly dangerous territory because there is technically always something that could be improved. If your nervous system is waiting for the moment when every item on the list has been completed before allowing you to rest, I have unfortunate news about adulthood.
The list regenerates.
Stress Is Bigger Than Cortisol
Cortisol has somehow become the celebrity hormone of the wellness world. Depending on what corner of the internet you’re visiting, cortisol is apparently responsible for your belly fat, your insomnia, your anxiety, your fatigue, your afternoon snack cravings, and possibly your Wi-Fi going out.
Cortisol is important. It just deserves a more accurate biography.
Cortisol is one component of the body’s broader stress-response system, particularly the hypothalamic-pituitary-adrenal axis, or HPA axis. When the brain perceives a challenge, the hypothalamus communicates with the pituitary gland, which then signals the adrenal glands to produce cortisol. At the same time, other pathways, including the sympathetic nervous system and adrenal medulla, can rapidly increase catecholamines such as epinephrine and norepinephrine. Together, these systems help mobilize energy, influence cardiovascular function, alter immune activity, sharpen certain aspects of attention, and prepare the body to respond.
Cortisol itself is not a toxin. You need it.
Under normal circumstances, cortisol follows a circadian rhythm. Levels typically rise toward morning, helping us wake and mobilize energy for the day, and gradually decline toward evening as the body prepares for sleep. Cortisol also increases appropriately in response to physical and psychological stressors. Exercise raises cortisol. Illness can raise cortisol. Public speaking can raise cortisol. So can fasting, sleep deprivation, infection, pain, and a long list of other perfectly understandable circumstances.
Problems arise when stress-response systems become repeatedly activated without adequate recovery or when their normal rhythms become dysregulated. Importantly, chronic stress doesn’t always mean cortisol simply becomes “high” and stays there. Human stress physiology is more complicated than that. Depending on the person, duration of stress, time of day, health status, medications, sleep, and other factors, patterns can become altered in different ways. This is one reason I hesitate whenever I hear someone attribute a complicated collection of symptoms to “high cortisol” without actually considering the larger clinical picture.
The body isn’t a bathtub where stress turns on the cortisol faucet until eventually it overflows.
It is a dynamic regulatory system constantly attempting to adapt.
That adaptation has a cost, however, particularly when demands remain high for long periods of time.
The Cost of Constant Adaptation
Researchers sometimes use the term allostatic load to describe the cumulative physiological burden associated with repeatedly adapting to stress. I like this concept because it gets us away from the idea that stress itself is inherently harmful and instead asks a more useful question: how much demand is the system carrying, and how often does it get the opportunity to recover?
Two people can experience the same external stressor very differently because their overall loads are different. Someone may be managing a demanding job reasonably well until a parent becomes ill. Another person may be coping with a new baby until financial strain appears. Someone else has handled years of work stress, but then menopause changes sleep and temperature regulation, and suddenly the strategies that used to work aren’t enough. Sometimes patients tell me, “I don’t understand why I’m struggling now. I’ve dealt with more stressful things than this before.”
I believe them.
The nervous system doesn’t reset to factory settings every morning. What we experience today occurs on top of what happened yesterday, last month, and sometimes years ago. Sleep debt matters. Chronic pain matters. Grief matters. Nutrient status matters. Caregiving matters. Trauma matters. Social isolation matters. Infection and inflammation matter. Whether we feel supported matters. Even the degree of control we perceive ourselves to have over a stressful situation can influence how that situation is experienced.
Eventually the issue may not be that one particular stressor is enormous. It may simply be the thing that arrived when the backpack was already full.
This is also why resilience shouldn’t be confused with tolerating an unlimited amount of stress without consequences. I sometimes see high-functioning people wear their ability to push through as evidence that everything is fine. They continue working, parenting, caregiving, exercising, volunteering, managing households, and meeting deadlines, so surely they must be handling it. Meanwhile they’re sleeping poorly, clenching their jaw, experiencing digestive changes, losing patience more easily, relying increasingly on caffeine, forgetting things, and wondering why their heart sometimes seems to be auditioning for a drum solo.
Functioning and thriving are not synonyms.
Why Anxiety Can Feel So Physical
The physical sensations associated with anxiety can be unsettling precisely because they are real. When sympathetic nervous system activity increases, heart rate and cardiac output may rise, breathing patterns can change, muscles tense, sweating increases, and digestion may temporarily shift because the body is reallocating priorities. These changes can produce sensations such as palpitations, chest tightness, trembling, dizziness, nausea, diarrhea, dry mouth, tingling, or the feeling that you cannot take a satisfying breath.
Then something particularly interesting can happen: the brain notices those sensations.
Our brains don’t simply receive information from the outside world. They are also continuously receiving information from inside the body, a process often described as interoception. The brain monitors heartbeat, breathing, gut sensations, temperature, muscular tension, and other internal signals, then attempts to interpret what they mean. For someone prone to anxiety, a completely benign change in heart rate may be noticed quickly and interpreted as evidence that something is wrong. That interpretation creates more anxiety, which increases sympathetic activation, which makes the heart beat faster, which provides the brain with even more evidence that perhaps we should be concerned.
A feedback loop has begun.
This is one reason panic attacks can feel so frightening even when a person understands what is happening. The physical sensations aren’t imaginary. The interpretation and amplification of those sensations are part of the experience, but the pounding heart, altered breathing, sweating, trembling, and gastrointestinal changes are genuine physiological events.
It also explains why simply telling someone to “calm down” is rarely useful. Their nervous system is already responding to signals it believes are important. Regulation often requires helping the system gather new information, sometimes through cognition and sometimes through the body itself.
We’ll spend much more time on that next week.
The Brain’s Alarm System Is More Than One Structure
You may have heard the amygdala described as the brain’s “fear center.” That’s convenient shorthand, but neuroscience is considerably more complicated. The amygdala participates in detecting emotionally significant information and learning associations related to threat, but anxiety emerges from interactions among multiple brain regions and networks involved in attention, memory, prediction, emotional processing, and executive function.
One especially useful relationship to understand is the ongoing communication between more reactive threat-processing networks and areas of the prefrontal cortex involved in planning, judgment, inhibition, and contextualizing information. Under manageable circumstances, these systems work together. You notice something potentially concerning, assess it, compare it with previous experiences, decide whether action is necessary, and move on.
Under intense or prolonged stress, that balance can shift. Attention may become increasingly biased toward potential threats while higher-order cognitive functions become less efficient. Anyone who has tried to make a complicated decision while severely sleep deprived or panicked has experienced some version of this. You don’t suddenly lose intelligence. Your brain is simply operating under different priorities.
Stress can also influence memory. Emotionally charged experiences are often remembered particularly well, which makes evolutionary sense, because remembering what nearly killed you is useful information. Unfortunately, the brain can sometimes become very good at associating relatively ordinary cues with previous distress. A smell, location, bodily sensation, tone of voice, or particular circumstance may later trigger a response before we consciously understand why.
This is especially relevant in trauma, where nervous system responses can persist long after the original danger has passed. Trauma deserves far more nuance than I can give it in a few paragraphs, and I don’t believe every uncomfortable nervous system response should be labeled trauma, another trend I sometimes see online. But past experiences absolutely shape how the brain predicts future safety and threat. Our nervous systems learn.
Fortunately, learning isn’t a one-way street.
Neuroplasticity means the brain continues changing in response to experience. Patterns reinforced for years may require time and intentional work to shift, but they are not necessarily permanent. This is one of the biological reasons therapies that help people develop new interpretations, behaviors, associations, and responses can be so powerful. The goal isn’t simply to “think positively.” It is to repeatedly provide the brain with experiences that allow it to update its predictions.
Sometimes Anxiety Begins Below the Neck
Because anxiety is classified as a mental health symptom, we naturally focus on the brain. Clinically, though, I also want to know what the rest of the body is doing. This is where naturopathic and functional approaches can add useful context, as long as we resist the temptation to turn every biological finding into the explanation.
Blood sugar is one example. If glucose drops rapidly or the body perceives inadequate fuel availability, counter-regulatory hormones such as epinephrine and cortisol can increase. The resulting sensations, including shakiness, sweating, palpitations, irritability, weakness, and difficulty concentrating, can feel remarkably similar to anxiety. Some patients eventually realize that the mysterious wave of anxiety that hits them at 3:30 every afternoon is considerably less mysterious when lunch consisted of coffee and half a granola bar.
Thyroid function matters too. Excess thyroid hormone can produce symptoms including palpitations, tremor, heat intolerance, sleep disturbance, and anxiety. Iron deficiency, B-vitamin deficiencies, medication effects, stimulant use, hormonal transitions, and other physiological factors may also influence how someone feels. None of this means we should order every laboratory test imaginable whenever someone feels anxious, but it does mean persistent or changing anxiety deserves thoughtful clinical evaluation rather than an automatic assumption that the cause is purely psychological.
Hormonal transitions are particularly worth mentioning because many women notice significant changes in anxiety during puberty, the menstrual cycle, pregnancy, postpartum, and perimenopause. Estrogen and progesterone interact with neurotransmitter systems and brain function, and fluctuations can influence sleep, temperature regulation, mood, and stress sensitivity. Someone who has never considered herself particularly anxious may suddenly experience significant symptoms during one of these transitions and wonder why her personality appears to have changed overnight.
Her personality may not have changed.
The biological environment in which her brain is functioning has.
The Gut and Brain Are Constantly Talking
After spending August talking about gut health and September exploring the brain and gut-brain connection, I would be remiss if I suddenly pretended the digestive system had left the conversation.
It has not. The gut is persistent like that.
Communication between the gut and brain occurs through multiple pathways, including the vagus nerve, immune signaling, microbial metabolites, endocrine signaling, and compounds produced or modified by intestinal microbes. Research continues to explore how the composition and function of the gut microbiome may influence stress responsiveness, mood, cognition, and behavior. This is a fascinating area of science, but it’s also one that lends itself to spectacular overstatement online.
Your gut microbiome influences brain health.
That does not mean every case of anxiety is caused by “bad gut bacteria,” nor does it mean a probiotic is an antidepressant in a capsule.
What it means is that the gut-brain axis is one part of a larger biological network. Chronic gastrointestinal symptoms can themselves create stress. Inflammation originating in the gut may influence systemic immune signaling. Microbial metabolites can interact with neurological and metabolic pathways. The vagus nerve carries substantial information from the body toward the brain, making the conversation very much bidirectional.
This is another place where the artificial division between physical and mental health begins falling apart. Someone with chronic digestive symptoms may become anxious because they’re constantly worried about where the nearest bathroom is, while physiological changes occurring in the gut may simultaneously influence inflammatory and neurological signaling. Which came first?
Sometimes that’s the wrong question.
Systems can reinforce each other.
Inflammation Can Change How the Brain Feels
The immune system is also deeply connected to the nervous system. During infection, inflammatory signaling can produce what researchers call sickness behavior: fatigue, reduced motivation, changes in appetite, altered sleep, social withdrawal, and cognitive slowing. If you’ve ever had influenza and found yourself uninterested in doing much beyond lying under a blanket and staring vaguely at the television, you’ve experienced the brain responding appropriately to immune activity.
That response is adaptive during an acute illness. The body is encouraging rest and conserving resources.
Chronic inflammation is a different situation. Researchers are increasingly studying relationships between inflammatory signaling and conditions including depression and anxiety, although the relationship is complex and certainly not universal. Not every person with anxiety has elevated inflammatory markers, and inflammation isn’t a singular cause of mental illness. Still, immune mediators can influence neurotransmitter pathways, neural signaling, stress physiology, and brain function, which means inflammation belongs in the broader conversation about mental health.
This is particularly important when someone experiences a significant change in mood or cognition alongside other systemic symptoms. Rather than assuming every symptom represents a separate problem, sometimes we need to ask whether several systems are being affected by the same underlying physiology.
That question is one of the reasons I love medicine.
The body rarely organizes itself according to the chapter headings in our textbooks.
And Then There Are Neurotransmitters
Serotonin. Dopamine. GABA. Glutamate. Norepinephrine.
These molecules receive enormous attention in conversations about mental health, sometimes to the point that we talk about emotions as though they are simply the result of having the correct quantities of five chemicals floating around the brain.
Neurotransmitters absolutely matter. They allow neurons to communicate and participate in networks governing mood, motivation, attention, arousal, learning, reward, sleep, and countless other functions. But there is no simple equation in which low serotonin equals depression, low GABA equals anxiety, and low dopamine equals lack of motivation. Neurotransmitter activity depends on where signaling occurs, receptor sensitivity and density, synthesis and breakdown, neuronal circuitry, interactions with other signaling molecules, and the physiological environment surrounding all of it.
This complexity becomes especially important when we talk about neurotransmitter testing, which we’ll explore more closely later this month and through our upcoming Group Lab Review. Measuring neurotransmitter metabolites or neurotransmitters outside the central nervous system is not the same thing as directly measuring synaptic neurotransmitter activity inside a living human brain. There is legitimate scientific debate about how these tests should be interpreted, and I think patients deserve to know that rather than being handed a colorful laboratory report and told it reveals exactly how much serotonin is in their brain.
At the same time, I don’t believe the existence of controversy means we stop asking questions. It means we interpret information in context, understand what a test can and cannot tell us, combine it with symptoms and history, and remain willing to change our conclusions as the science evolves. That’s medicine. Or at least, that’s what medicine should be.
Our November Group Lab Review will give us an opportunity to dig into this much more deeply. Registration will be open during October, and because we need enough time for kits to be completed, processed, and returned before the group review, participants will need to register by October 23. We’ll talk more about exactly what we’re testing and what we hope to learn as we get closer.
For now, the important point is that neurotransmitters are one piece of a much larger puzzle.
Anxiety Rarely Has Just One Doorway
This is probably the most important clinical idea I want to leave you with before we move into what we can actually do with all of this physiology: two people can experience nearly identical anxiety symptoms for very different reasons, and the same person can experience anxiety for different reasons at different points in life.
One person’s nervous system may be responding primarily to unresolved trauma. Another may be navigating postpartum hormonal changes on four hours of fragmented sleep. Someone else may have developed panic symptoms after months of occupational stress, while another is taking a medication that increases sympathetic activation. A college student may be genetically prone to anxiety, consuming 400 milligrams of caffeine a day, sleeping five hours a night, skipping meals, and wondering why breathing exercises aren’t fixing the problem. An executive may appear extraordinarily high functioning while living in a state of near-constant physiological activation that has gradually become normal to them.
Often there isn’t even one dominant cause. There are layers.
That is why I resist simplistic explanations for mental health. “It’s your cortisol” isn’t enough. “It’s your gut” isn’t enough. “It’s your neurotransmitters” isn’t enough. “It’s your trauma” may not be enough either. Sometimes those are meaningful parts of the story, but human beings are not single-variable experiments.
The more useful question is: what is asking this particular nervous system to work so hard?
Once we begin there, the conversation changes. Instead of trying to suppress every uncomfortable sensation, we can look for the places where the system needs support. Sometimes that support is psychotherapy. Sometimes medication. Sometimes better sleep, more consistent nourishment, treating an underlying medical condition, changing an impossible workload, moving the body, spending more time with people who make us feel safe, or learning how to tolerate uncertainty without immediately trying to solve it.
Usually, it’s some combination.
And this is where anxiety becomes less of an enemy to defeat and more of a signal worth understanding. We don’t have to obey everything it tells us, but we can become curious about why it is speaking so loudly.
In the final part of this article, we’ll turn toward that question: what actually helps an anxious nervous system become more flexible, what “nervous system regulation” really means outside of social-media wellness language, when testing may be useful, and perhaps most importantly, how we support mental health without accidentally turning being mentally healthy into one more thing we have to perform perfectly.
Learning to Work With an Anxious Nervous System
After spending this much time explaining everything that can influence anxiety, it would be tempting to arrive at the final section with a beautifully organized protocol. Sleep eight hours. Eat enough protein. Exercise regularly. Meditate. Take magnesium. Reduce caffeine. Practice deep breathing. Go outside. Maybe buy a houseplant for good measure.
None of those suggestions is inherently unreasonable, although I remain unconvinced that the correct number of houseplants has ever been established in a randomized controlled trial. The larger problem is that mental health doesn’t work particularly well as a checklist. If it did, most anxious perfectionists would have conquered anxiety years ago because, believe me, we are excellent at checklists.
What I’ve learned instead, both through medicine and through my own experience, is that supporting an anxious nervous system is less about discovering the one thing that switches anxiety off and more about understanding the conditions under which your particular brain and body function well. Some of those conditions are remarkably ordinary. Sleep matters. Food matters. Movement matters. Relationships matter. Feeling safe matters. Having meaningful work matters. Rest matters. Addressing underlying medical problems matters. Therapy can matter tremendously. Medication can matter tremendously. So can learning that an uncomfortable feeling does not always require an immediate response.
That last one has probably taken me the longest.
Anxiety loves action because action creates the sensation that we are regaining control. If I’m worried about something, perhaps I should research it. If I’m uncertain about a decision, perhaps I need more information. If something feels unfinished, perhaps I should work on it a little longer. If I’m worried that I’ve made the wrong choice, perhaps I should revisit all of the alternatives one more time. Sometimes those impulses are useful, but eventually there comes a point when another hour of research doesn’t create more clarity. It simply feeds the idea that certainty is available if we look hard enough.
For me, learning to live with some unanswered questions has been every bit as important as learning about neurotransmitters, cortisol, nutrition, or the vagus nerve. I can support the biology that makes my nervous system more resilient, but I also have to practice allowing life to remain occasionally unresolved.
That is a different kind of regulation.
Regulation Is Not the Same Thing as Calm
“Nervous system regulation” has become one of those phrases that seems to be everywhere right now, and I’m generally pleased that people are becoming more interested in how the autonomic nervous system works. I become less enthusiastic when regulation is presented as a state in which a healthy person is perpetually calm, peaceful, grounded, sleeping beautifully, digesting perfectly, and responding to every inconvenience with the serene expression of someone sitting beside a mountain lake in a pharmaceutical commercial.
That’s not regulation.
That’s marketing.
A regulated nervous system can get angry. It can become anxious before an important event. It can respond intensely when something frightening happens. It can grieve, become overwhelmed, feel excitement, experience disappointment, and occasionally have a day when everything seems like too much. Emotional health isn’t the absence of emotional range.
Regulation is better understood as flexibility: the ability to mobilize when something requires action, experience the response, and eventually return toward baseline rather than becoming stuck in a prolonged state of activation or shutdown. It also includes the capacity to experience an emotion without automatically interpreting the emotion itself as dangerous.
This distinction matters enormously for people with anxiety because sometimes the attempt to eliminate anxiety becomes another source of anxiety. We notice our heart beating faster and immediately think, Oh no, I’m anxious. Then we worry that the anxiety means we’re becoming dysregulated, so we try to force ourselves to calm down, notice that it isn’t working quickly enough, and become concerned that perhaps our cortisol is too high or our vagus nerve isn’t “toned” properly.
We have now managed to become stressed about our stress response.
The human brain is nothing if not creative.
Sometimes the healthier response is simply recognizing, My nervous system is activated right now. That makes sense. It will change.
Not every wave needs to be stopped. Sometimes we need to learn that we can ride it.
Start With the Unsexy Things
I realize that telling people to prioritize sleep, nutrition, movement, and relationships is considerably less exciting than discovering a secret neurological hack. It also happens to be where I would begin for most people.
Sleep is particularly important because inadequate sleep changes the way the brain processes emotional information. When we’re sleep deprived, emotional reactivity tends to increase while higher-order regulation becomes less efficient. Anyone who has ever become disproportionately upset about something trivial after several terrible nights of sleep doesn’t need a neuroscience paper to understand this phenomenon. The problem isn’t that you’ve suddenly become an irrational person. You’re trying to perform complex emotional regulation with a brain that has not had adequate opportunity to recover.
This is also why I don’t love the cultural tendency to treat sleep as optional time that ambitious people borrow from when they need to accomplish more. I understand the temptation. I have participated in it. There are only twenty-four hours in the day, and sleep can look suspiciously like eight hours during which we could otherwise be getting things done. Unfortunately, the brain uses those hours for a rather impressive amount of housekeeping, including memory processing, metabolic regulation, immune function, emotional processing, and cellular maintenance.
Borrowing indefinitely from sleep is a little like financing your productivity on a very high-interest credit card. Eventually the bill arrives.
Food can influence the nervous system in similarly mundane but meaningful ways. The brain requires a steady supply of energy and raw materials, and dramatic fluctuations in glucose can produce symptoms that overlap considerably with anxiety. I don’t believe everyone needs to eat according to one rigid schedule, and I’m certainly not interested in creating food anxiety while trying to treat anxiety, but I do pay attention when someone routinely goes most of the day without eating and then develops shakiness, irritability, palpitations, or anxious feelings in the afternoon.
Protein matters because amino acids provide substrates used in numerous neurological processes, including neurotransmitter synthesis. Micronutrients such as iron, B vitamins, magnesium, zinc, and others participate in biochemical pathways throughout the nervous system. Essential fatty acids contribute to neuronal membranes and signaling. Again, none of this means anxiety disappears if you eat salmon and take magnesium. It means brains require nutrients because brains are organs, and supporting the basic physiology of an organ is rarely a bad place to begin.
Movement belongs in this conversation as well, not because everyone needs an intense exercise program, but because physical activity affects mood, sleep, metabolic health, cardiovascular function, neuroplasticity, and stress regulation. Sometimes anxiety creates an enormous amount of physiological activation without giving that activation anywhere to go. Walking, lifting weights, running, dancing, martial arts, yoga, swimming, gardening, or whatever form of movement someone genuinely enjoys can give the body an opportunity to do something with that energy.
I strongly prefer that framing to “you need to exercise because you’re anxious.”
The goal isn’t punishment.
It’s participation in your own physiology.
Breathing Is Simple. That Doesn’t Make It Silly.
I used to find some nervous system advice almost annoyingly basic. When your brain is capable of generating an extremely sophisticated problem involving twelve variables and three hypothetical future outcomes, being told to breathe slowly can feel a little insulting.
And yet breathing is one of the unusual physiological functions that operates automatically while also remaining partly under voluntary control, which gives us a direct way to influence autonomic activity. Slower breathing, particularly when the exhalation is not rushed, can influence heart rate variability and parasympathetic signaling. The goal isn’t to inhale enormous quantities of air; in fact, excessive deep breathing can sometimes worsen lightheadedness or tingling by altering carbon dioxide levels. Gentle, comfortable, slower breathing is generally the point.
The same principle applies to other body-based approaches. Walking outside, stretching, humming, singing, spending time with people we trust, physical affection, yoga, meditation, prayer, progressive muscle relaxation, and certain forms of mindfulness can all provide sensory information that influences the nervous system. Not because any one of them contains magical vagus-nerve powers, but because the brain is constantly updating its interpretation of the body and environment.
The key is finding what actually works for the person in front of me.
Meditation is wonderful for some people and deeply frustrating for others. Someone with significant anxiety may initially find sitting quietly with their thoughts more activating, not less. A vigorous walk might be much more regulating. Another person might respond beautifully to slow breathing or restorative yoga. Someone else needs to call a friend, play with their dog, work in the garden, or put on music and clean the kitchen with entirely unnecessary enthusiasm.
There is no prize for choosing the most Instagrammable nervous system practice.
Safety Is Also Relational
One of the pieces that gets lost when mental health becomes heavily focused on individual wellness practices is that humans are social mammals. Our nervous systems developed in relationship with other people, and relationships continue influencing physiology throughout life.
Being around someone we trust can change how a stressful situation feels. A difficult medical diagnosis received alone may be experienced differently than the same diagnosis received while holding the hand of someone who makes us feel safe. A challenging season at work becomes more tolerable when we feel supported by colleagues. Parenting becomes easier when there are other people available to share the load. Grief doesn’t disappear when someone sits beside us, but it changes when we aren’t carrying it alone.
This is sometimes described as co-regulation, and although the terminology can sound technical, the experience is deeply familiar. A baby settles against a caregiver’s chest. A frightened child reaches for a parent’s hand. An adult calls a friend after receiving bad news. We borrow steadiness from each other.
That doesn’t stop when we become adults.
Social isolation, conflict, loneliness, caregiving strain, unsafe relationships, and lack of community can all influence mental health, and no amount of magnesium glycinate can substitute for addressing those realities. Sometimes the most biologically appropriate intervention for a nervous system is not another supplement. It’s having someone safe to talk to.
This is also where psychotherapy can be extraordinarily valuable. Different therapeutic approaches may help people identify patterns, process trauma, change behaviors, tolerate uncertainty, challenge distorted interpretations, or develop new responses to difficult emotions. Cognitive behavioral therapy has substantial evidence for anxiety disorders, and other approaches may be useful depending on the individual and their history.
I see therapy and physiology as complementary rather than competing approaches. We don’t have to decide whether anxiety is “psychological” or “biological” before treating it.
It is occurring in a human being.
That is enough.
Sometimes Medication Is the Right Tool
Because I practice naturopathic medicine, people sometimes assume my goal is always to keep someone off medication.
It isn’t.
My goal is to help someone get better.
There are people for whom appropriate psychiatric medication is life-changing, and there are situations in which medication may create enough stability for someone to sleep, participate in therapy, return to work, reconnect socially, or simply experience what life feels like without constant overwhelming anxiety. Some people may use medication temporarily while others benefit from longer-term treatment. Those decisions deserve individualized discussion with a qualified healthcare professional, particularly because medications differ in their effects, risks, discontinuation considerations, and interactions.
Where I think naturopathic medicine can add something valuable is not by positioning itself against conventional treatment, but by asking what else might help this particular person function better. If someone takes an SSRI and it works beautifully, I’m not interested in proving they secretly don’t need it. I’m interested in whether they’re sleeping well, whether nutritional deficiencies have been addressed, whether thyroid function is appropriate, whether they’re moving their body, whether their relationships are supportive, whether chronic gastrointestinal symptoms need attention, and whether there are other modifiable contributors to their health.
Medication and foundational care can coexist.
Therapy and laboratory testing can coexist.
Breathing exercises and evidence-based psychiatric treatment can coexist.
We do not receive bonus points for making healthcare unnecessarily ideological.
Where Testing Fits, and Where It Doesn’t
This is also a good place to return to laboratory testing because when people hear that anxiety can be influenced by physiology, there is an understandable temptation to test everything. I love data. I run a practice in which laboratory testing plays an important role. I can also tell you that more data isn’t automatically more clarity.
Testing is most useful when we have a reason to ask the question and some idea of what we’ll do with the answer.
For someone experiencing new or worsening anxiety, that may include evaluating thyroid function, blood counts, iron status, B vitamins, vitamin D, glucose regulation, hormones when clinically appropriate, or other markers suggested by their history. Someone with substantial gastrointestinal symptoms may warrant a different evaluation. Someone with a history suggesting environmental illness, infection, or inflammatory disease may take us down another path entirely.
This is where individualized medicine becomes important because there isn’t an “anxiety panel” that tells us why every anxious person is anxious.
Neurotransmitter testing occupies an especially interesting place in this conversation. As we discussed earlier, peripheral or urinary neurotransmitter measurements should not be interpreted as direct measurements of neurotransmitter concentrations inside the brain. The blood-brain barrier, peripheral production, metabolism, renal handling, diet, medications, supplements, and other factors complicate interpretation. That doesn’t necessarily mean these measurements contain no useful information, but it means we have to be thoughtful about what conclusions we draw from them.
This is precisely why our upcoming November Group Lab Review isn’t simply about handing participants a report with red and green numbers and telling them which neurotransmitter they need to “fix.” I want people to understand the pathways, the limitations, the relationships between markers, and how results fit alongside symptoms, history, nutrition, stress physiology, sleep, gut health, and other clinical information.
Enrollment will close October 23 so there is adequate time for everyone to receive and complete their testing and for results to return before the November review. If you’re someone who enjoys understanding the biology behind how you feel, this is exactly the kind of conversation I love having.
Not because a laboratory report can explain a human being.
Because sometimes it can give us another useful piece of the story.
When Anxiety Needs More Than Self-Care
I also want to be careful not to end an article about anxiety by suggesting that everyone should simply eat breakfast, go for a walk, breathe slowly, and become more comfortable with uncertainty. There is a meaningful difference between ordinary anxiety, chronic stress, and an anxiety disorder that significantly interferes with someone’s life.
If anxiety is persistent, escalating, causing panic attacks, interfering with sleep or work, affecting relationships, leading you to avoid important parts of your life, or simply making it difficult to function, it deserves professional support. You don’t need to wait until you’re completely incapacitated before asking for help. Mental healthcare isn’t reserved for people who have reached some imaginary threshold of being “sick enough.”
There is also no virtue in suffering longer than necessary simply because you believe you should be able to handle something yourself.
I say that as someone who is very good at trying to handle things herself.
Part of emotional resilience is knowing when our own resources are insufficient for the circumstances we’re facing. Sometimes strength looks like pushing through discomfort because something matters. Sometimes it looks like recognizing that pushing harder is exactly what got us into trouble.
Learning the difference is part of the work.
Anxiety Doesn’t Have to Disappear for Life to Get Bigger
Perhaps the most important change in my own relationship with anxiety has been realizing that I don’t need to wait until I feel completely unafraid before doing something.
That sounds obvious until you’re the one standing at the edge of a decision your brain has analyzed to death.
Anxiety often whispers that once we have enough information, enough preparation, enough reassurance, or enough confidence, then we’ll be ready. But sometimes readiness arrives after action rather than before it. We give the presentation while nervous. We have the difficult conversation even though our heart is pounding. We submit the work even though another revision is technically possible. We make the best decision we can with the information available and accept that we cannot know exactly how it will turn out.
That has been an important lesson for a lifelong perfectionist.
Some of the things I’m most proud of doing weren’t things I felt completely comfortable doing. They required me to move forward while anxiety was still sitting in the passenger seat offering unsolicited navigation advice.
I’ve become better at letting it ride without handing it the keys.
There are still moments when anxiety is crippling, when I have to deliberately push through something my brain would prefer to avoid, and there are other moments when that same tendency toward vigilance and preparation genuinely serves me. I don’t think I need to pretend one side doesn’t exist in order to acknowledge the other. Anxiety has sometimes made my life harder. It has also contributed to the way I prepare, the way I anticipate problems, the way I care about doing things well, and perhaps even some of the persistence that allowed me to build the life and career I have.
I wouldn’t prescribe anxiety as a success strategy. There are considerably more pleasant options.
But I also don’t spend as much energy wishing I had a completely different brain.
The goal, for me, has become learning how to use the parts of it that serve me while recognizing when those same tendencies have crossed the line from motivation into fear, from preparation into rumination, or from conscientiousness into perfectionism. That line isn’t always obvious, and I don’t always catch it immediately. Sometimes I still realize that I’ve spent an absurd amount of time trying to make something “just right” when it was perfectly good forty-five minutes ago.
Old habits have excellent endurance.
What has changed is that I’m more likely to notice.
Working With the Brain You Have
World Mental Health Day gives us a reason to talk openly about mental health, but I hope the larger message extends far beyond one day in October. Mental health is not separate from physical health, and it isn’t something we should only pay attention to when it becomes unbearable. Our emotional lives are shaped by experiences, relationships, genetics, culture, sleep, nutrition, hormones, immune function, nervous system activity, and the accumulated history of living inside one particular body.
That complexity can make mental health frustrating because there isn’t always one answer.
I think it also makes it hopeful.
If anxiety were simply a fixed flaw in someone’s personality, there wouldn’t be much room to work. But nervous systems learn. Brains change. Sleep can improve. Nutritional deficiencies can be corrected. Medical contributors can be identified. Relationships can become healthier. Therapy can change deeply established patterns. Medication can help when it’s needed. We can practice tolerating uncertainty, build greater awareness of our bodies, create more opportunities for recovery, and gradually become better at recognizing when the alarm system is responding to an actual fire versus burnt toast.
And perhaps most importantly, we can stop treating every uncomfortable emotion as evidence that we’re doing mental health incorrectly.
Anxiety is part of the human experience. For some of us, it’s a louder part than we’d prefer. The goal isn’t necessarily to silence it forever. Sometimes the work is learning what it’s trying to tell us, deciding whether that information is useful, supporting the biology underneath it, and then choosing what we want to do next.
For a perfectionist like me, that occasionally means doing something truly radical.
Deciding that something is good enough.
Closing the laptop.
And walking away before I edit it one more time.
I’m still working on that last part.
References
- McEwen, B. S. (1998). Protective and damaging effects of stress mediators. The New England Journal of Medicine, 338(3), 171–179.
Use for: allostasis, allostatic load, adaptive acute stress versus chronic physiological burden. The later McEwen review also nicely explains that allostatic load can arise from repeated stressors, failure to habituate, or failure to shut down the stress response appropriately. - McEwen, B. S. (2008). Central effects of stress hormones in health and disease: Understanding the protective and damaging effects of stress and stress mediators. European Journal of Pharmacology, 583(2–3), 174–185.
Use for: HPA-axis physiology, stress hormones, cortisol, catecholamines, and the distinction between adaptive and chronic stress responses. - Goldstein, D. S. (2010). Adrenal responses to stress. Cellular and Molecular Neurobiology, 30, 1433–1440.
Use for: sympathetic nervous system activation, adrenal catecholamines, and the broader stress response rather than reducing stress physiology to cortisol alone. - Paulus, M. P., & Stein, M. B. (2010). Interoception in anxiety and depression. Brain Structure and Function, 214, 451–463.
Use for: the section explaining why anxiety feels so physical, awareness of heartbeat/breathing/body sensations, and feedback between bodily sensations and anxiety. This is an especially good reference for the interoception section. - Walker, M. P., & van der Helm, E. (2009). Overnight therapy? The role of sleep in emotional brain processing. Psychological Bulletin, 135(5), 731–748.
Use for: sleep and emotional processing. - Goldstein, A. N., & Walker, M. P. (2014). The role of sleep in emotional brain function. Annual Review of Clinical Psychology, 10, 679–708.
Use for: the stronger claims about sleep deprivation, emotional reactivity, the amygdala, and prefrontal regulation. Experimental work reviewed here found substantially greater amygdala responses to negative stimuli after sleep deprivation alongside reduced functional connectivity with medial prefrontal regulatory regions. - Cryan, J. F., O’Riordan, K. J., Cowan, C. S. M., Sandhu, K. V., Bastiaanssen, T. F. S., Boehme, M., et al. (2019). The microbiota-gut-brain axis. Physiological Reviews, 99(4), 1877–2013.
Use for: the gut-brain axis, vagus nerve, immune communication, microbial metabolites, tryptophan metabolism, and bidirectional gut-brain signaling. This is a particularly strong comprehensive review and supports the cautious wording we used rather than claiming that dysbiosis “causes” anxiety. - Costello, H., Gould, R. L., Abrol, E., & Howard, R. (2019). Systematic review and meta-analysis of the association between peripheral inflammatory cytokines and generalised anxiety disorder. BMJ Open, 9(7), e027925.
Use for: inflammation and anxiety. Importantly, I would retain our cautious language here because an association between inflammatory signaling and anxiety does not establish inflammation as a universal cause of anxiety. - Zaccaro, A., Piarulli, A., Laurino, M., Garbella, E., Menicucci, D., Neri, B., & Gemignani, A. (2018). How breath-control can change your life: A systematic review on psycho-physiological correlates of slow breathing. Frontiers in Human Neuroscience, 12, 353.
Use for: slow breathing, HRV, autonomic effects, parasympathetic activity, and the relationship between breathing and emotional state. - Russo, M. A., Santarelli, D. M., & O’Rourke, D. (2017). The physiological effects of slow breathing in the healthy human. Breathe, 13(4), 298–309.
Use for: the more detailed physiology of breathing, respiratory sinus arrhythmia, HRV, cardiorespiratory coupling, and autonomic balance. - Carpenter, J. K., Andrews, L. A., Witcraft, S. M., Powers, M. B., Smits, J. A. J., & Hofmann, S. G. (2018). Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depression and Anxiety, 35(6), 502–514.
Use for: the psychotherapy/CBT discussion. This meta-analysis included 41 randomized placebo-controlled studies and found a moderate effect of CBT on target anxiety-related symptoms. - Aylett, E., Small, N., & Bower, P. (2018). Exercise in the treatment of clinical anxiety in general practice: A systematic review and meta-analysis. BMC Health Services Research, 18, 559.
Use for: exercise and anxiety. The meta-analysis found improvement in elevated anxiety with aerobic exercise, although the evidence base had important limitations. - Stonerock, G. L., Gupta, R. P., & Blumenthal, J. A. (2024). Is exercise a viable therapy for anxiety? Systematic review of recent literature and critical analysis. Progress in Cardiovascular Diseases, 82, 29–39.
Use alongside #12, because this newer critical review is more skeptical and points out substantial methodological limitations in the exercise literature. I actually like including this because it keeps your article scientifically balanced: physical activity has broad health benefits and may help anxiety, but we shouldn’t present exercise as an established replacement for evidence-based anxiety treatment. - Hettema, J. M., Neale, M. C., & Kendler, K. S. (2001). A review and meta-analysis of the genetic epidemiology of anxiety disorders. American Journal of Psychiatry, 158(10), 1568–1578.
Use for: the family-history/genetic susceptibility discussion and the concept that anxiety disorders reflect both inherited vulnerability and environmental influences. - Schiele, M. A., & Domschke, K. (2018). Epigenetics at the crossroads between genes, environment and resilience in anxiety disorders. Genes, Brain and Behavior, 17(3), e12423.
Use for: the more nuanced discussion of genetics interacting with environment rather than genetic determinism. - Albert, P. R. (2015). Why is depression more prevalent in women? Journal of Psychiatry & Neuroscience, 40(4), 219–221.
Use sparingly for: sex hormones and mood vulnerability. For the blog’s discussion of puberty, pregnancy/postpartum, menstrual cycling, and perimenopause, I would actually prefer a more targeted review if we’re going to cite those transitions individually rather than treating them as one broad hormonal claim. - Bandelow, B., Reitt, M., Röver, C., Michaelis, S., Görlich, Y., & Wedekind, D. (2015). Efficacy of treatments for anxiety disorders: A meta-analysis. International Clinical Psychopharmacology, 30(4), 183–192.
Use for: evidence-based treatment of anxiety disorders, including pharmacologic and psychotherapeutic approaches. - Baldwin, D. S., Anderson, I. M., Nutt, D. J., Allgulander, C., Bandelow, B., den Boer, J. A., et al. (2014). Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: A revision of the 2005 guidelines from the British Association for Psychopharmacology. Journal of Psychopharmacology, 28(5), 403–439.
Use for: the discussion acknowledging an appropriate role for psychiatric medication and individualized treatment.