Have you ever said to yourself, “I am dreading this event, and I am nervous about what will happen?” What you were likely experiencing was anticipatory anxiety. As outlined by the American Psychological Association, anticipatory anxiety is defined as the development of fear or dread in the face of an anticipated event or situation. More simply, it is a growing worry that something we may experience in the future will be scary, stressful, or result in a distressing outcome. Anticipatory anxiety can impact anyone, and if it is not addressed in real time, can progress to clinical anxiety.
How Is Anticipatory Anxiety Different From Clinical Anxiety?
According to the DSM-5, clinical anxiety is qualified by three or more of the following symptoms persistent for at least six months:
- Feeling restless or on edge
- Becoming easily fatigued
- Having difficulty concentrating or experiencing a blank mind
- Feeling irritable
- Experiencing muscle tension
- Having trouble sleeping, such as difficulty falling or staying asleep, or waking feeling unrested
The symptoms of anticipatory anxiety are more subtle and understated. They can look like lower-grade symptoms of worry, feelings of fear, avoidance, or catastrophic thoughts. The Anxiety and Depression Association of America describes anticipatory anxiety as the “third layer of fear,” and provides an accessible framework to think about how anticipatory anxiety shows up in daily life. According to the ADAA, the first layer of fear is the baseline knowledge that we are afraid of something – “I am afraid of sharks.” The second layer is being afraid of how we will express the fear of that something – “If I ever encounter a shark in the ocean, I will be so panicked and scared that I will just freeze and be eaten alive.” And the third layer is described to be the fear of the event that will cause the fear response to the thing one is afraid of – “I am dreading going on this beach vacation because I may see a shark in the ocean and then be so consumed with panic that I won’t know how to swim to safety.”
If unrecognized or unaddressed, this third layer of fear can be a breeding ground for catastrophic thoughts, social avoidance, and ultimately a risk factor for progressing to full-blown anxiety.
Anticipatory Anxiety Can Affect All Ages
In my experience as a therapist who works with both kids and adults, I have seen how anticipatory anxiety can impact all ages. For young children and teens, some examples of anticipatory anxiety can be related to an upcoming school year, a major test, or a sports competition. For adults, this may be tied to returning to a toxic work environment after a vacation, an upcoming medical appointment, or the outcome of a political election. As clinicians, the traditional diagnostic tools and behavior definitions we use to diagnose clinical anxiety are not geared to provide focus on early signs of anticipatory anxiety. That is why it is important we help our clients verbalize feelings of worry or dread as soon as they start.
Strategies to Identify and Address Anticipatory Anxiety
I once worked with an adult client who expressed anticipatory anxiety to me about going in for her first-ever mammogram after recently learning that a close friend had been diagnosed with late-stage breast cancer. She was having catastrophic thoughts about the exam and the potential that she might screen positive for cancer herself. We employed a few strategies to help her acknowledge and address her dread and equip her with ways to recognize signs of it in the future.
- Shift Your Focus to Your Body and Your Senses
Both anticipatory and clinical anxiety trigger a response in the part of our brain called the hypothalamus. It sets off an alarm system that works to address a perceived threat, whether it be small, in the future, or acutely in the present. Hormonally, we respond to perceived threats with two hormones: adrenaline and cortisol. Adrenaline increases our heart rate, speeds up blood flow, and gives us bursts of energy to confront the perceived threat. Cortisol slows down any essential functions that inhibit fighting the threat, like digestion, reproductive systems, and mood control. When someone is experiencing anticipatory anxiety, this can result in avoidance, irritability, and worry. It can also result in sleep dysfunction, increased heart rate and changes in appetite.
I try to help my clients who experience anticipatory anxiety to find ways to do things that regulate their nervous system, engage their senses, and re-calibrate their mind and hormonal function. Leading up to the stressful event, I suggest things like belly breathing, hydration, nutritious food, getting sunlight, or taking a hot shower.
In the case of my client and her upcoming mammogram, she expressed that she was having poor appetite and struggling with low energy. She was an avid runner, but her worry was preventing her from feeling motivated to go running. To soothe her adrenal and cortisol response, I suggested she take a walk outside in the sunlight to slow her heart rate down, while also allowing her body to move and build up a bigger appetite. This helped her to manage her stress response leading up to the appointment and make it easier to manage her catastrophic thinking.
- Focus On What You Know and What You Can Control
One of the biggest reasons anticipatory anxiety progresses to clinical anxiety is because one does not take time to acknowledge all the information available to anticipate outcomes of the event and prepare effectively. A strategy I employ with clients is to ask and answer a series of “who,” “what,” “where,” “when,” and “how,” questions to assess what information you already know about the anticipated event, what information you need to be more informed about it, and what information is out of your control due to it being in the future and unknown. For my client, those questions played out like this:
- Who is going to be at my appointment? I encouraged her to look up the physicians and hospital administering the exam, learn about their background, and come up with any questions she might bring to the appointment to feel grounded in their expertise. I also encouraged her to think about having a friend or partner accompany her to her appointment for social support.
- What will they do at the appointment, and what will the potential results be? I suggested my client research exactly what the mammogram would entail, what to expect, and what all the potential outcomes could be. We also used our therapy sessions to talk through scenario planning to equip her nervous system with tools to leverage in the event any of them occurred.
- Where will the mammogram take place, and where will I be before and after the appointment? This particularly helped my client structure her day to be soothing toward her nervous system and hormonal stress response, incorporating scheduled activities that prioritized relaxation and stress reduction before and after the appointment. For her, it meant she walked or ran the morning before the appointment and made plans with her friends afterwards to decompress.
- When will I get my results? It was important for my client to have an awareness of how long she should expect to wait before she received the results of her exam. She researched this information and called the office ahead of time to inquire about what to expect. This helped her plan and schedule nervous system soothing activities during the waiting period, and alert loved ones that she may need extra support while she waited for her results.
- How can I be sure I’m doing all I can to prevent cancer already? My client was already quite healthy with her lifestyle habits. It was an exercise in strengths-based and positive psychology to remind her that she was an athlete, a healthy eater, had a balanced work-life schedule, and was already doing a lot of what most doctors recommend to prevent illnesses, like cancer. I also encouraged her to probe her family about their medical history. This helped her ground herself in what she could control and prioritize before, during, and after the exam.
These strategies helped my client prevent her anticipatory anxiety from becoming clinical by empowering her to quell her worry, center her nervous system, and ground herself in what she could control. Whether you are engaged in therapy or not, if you are experiencing anticipatory anxiety, these strategies can help you to mitigate symptoms and manage your well-being ahead of a difficult event. Lastly, anticipatory anxiety is normal, and it happens to everyone at some point in their lives. Remind yourself of all the things you have already overcome and lived in life. The power of your mind will rarely fail you, if you trust it.
Madhuri Jha, LCSW, MPH, is a nationally recognized and award-winning psychotherapist, researcher, professor, and clinical advisor. She currently serves as the Clinical Advisor for Psych Hub and the Founder and Principal of Thriving For All. For more information, she can be reached at madhuri@thrivingforall.com.
