Some Anxiety Needs Reflection and Some Needs Regulation.
Anxiety has become one of the defining words of modern life. We often see it as a problem to fix, a symptom to quiet and regulate. This is often appropriate, and despite its prevalence, clinical anxiety remains one of the most misunderstood and debilitating psychological conditions I see.
However, sometimes anxiety is not only a dysregulation of the nervous system. Sometimes it appears when the life we are living no longer feels entirely our own and its foundations begin to feel uncertain.
Changes to our situation and circumstance can bring this about. In today’s world of political instability, ideological polarisation, cost of living crises and AI’s uncertain impact on work and the labour market, paying attention to what existential anxiety asks of us is becoming increasingly important.
Here I offer a brief outline of how existential and clinical anxiety differ. They can coexist, and they both ask for your attention — existential anxiety requiring reflection, clinical anxiety asking for regulation.
Existential Anxiety
Sometimes anxiety is a signal that the life you are leading is no longer your own.
Existential anxiety is usually less familiar and more obscure than the clinical anxiety described below. Clinical and existential anxiety can overlap — a person can experience clinical anxiety from one source while also feeling the unease of existential anxiety. As with many existential phenomena, existential anxiety is complex to distil, but here follows my best effort.
The foundation of our sensemaking is context. Take my nephew who is a great public speaker. At this point in reading you know nothing about that. Is my nephew a 10 yr old boy reading at a school event or a 30 yr old politician delivering a great parliamentary speech? How great is he? He is 9, and at his school some of the parents commented that ‘He spoke better than the senior kids 4 years older than him’. That feels more descriptive than simply saying he is a good public speaker. Without the context it makes little sense. (In actual fact he is a better speaker than his 51 yr old uncle!)
The context that many of us use to make sense of our own lives is a backgrounded ‘They’. One of the most common questions my clients ask me is “Is my behaviour normal?” or “Why can’t I be like other people?”. When I ask what normal looks like, or who other people are, the usual response is “you know… like most people…’. If only I could actually show each of these clients how so many others ask the same question.
But the point is that we all have our own sense of what ‘They’ expect of us, and this can provide the ground of how we make sense of our lives. We should be strong. Be successful. Be good looking. Get good grades, go to university, get a job, pay the mortgage, retire with a good pension.
We all have our own version of the ‘They’.
In my case, ‘They’ expected me to go into finance in pursuit of monetary wealth. I wasn’t sure what I wanted. I played with becoming a psychologist, but it was so alien to my internal ‘Them’, that I spent years working in an unfulfilling job in financial services before becoming depressed enough to question my choices.
The question was never “Are ‘They’ right or wrong?”. The ‘They’ is simply the context. The question was really “Am I living a life that I have taken on as my own?”. For me I was not living my own life. But for various reasons I had been neither aware nor brave enough to question my direction and live my own life until I had no choice — and then I had to endure the existential anxiety of grappling with that.
Existential anxiety is the unsettling process in which we begin to see that while relationship and context is inescapable, the ‘They’ is not our ultimate ground. The process of questioning and loosening our attachment to the ‘They’ can be profoundly disquieting. It forces us to question both ‘Them’ and ourselves. It exposes our motivations for questioning. It confronts us with our own decision making. It calls us to reflect on how we spend our time and attention. It invites us to contend with freedom to make choices and take risks. It faces us with our own responsibility.
But existential anxiety doesn’t only loosen our attachment to social and cultural scripts, it also confronts us with our finitude — the fact that our time has an end. Whatever our beliefs about the afterlife, it asks us to contend with the inevitability of our death, so that we do not find ourselves at our life’s end looking back and realising we lived in unquestioning obedience to our version of the ‘They’. In doing this we are confronted with the question of how we want to live a fulfilling and meaningful life. Existential anxiety essentially asks you whether the life you are living is one that you have taken on as your own — or one you are still borrowing.
Clinical Anxiety
This is one of the most common complaints that people come to psychotherapy to address. Severe agoraphobia, PTSD and panic attacks are some of the more acute examples of anxiety, while chronic insomnia, phobias, health and social anxiety can also have big impacts on life and well-being. Sometimes anxiety is trauma-related, but not always. It often becomes entrenched when an individual minimises, dismisses or ignores it over time — often through shame or embarrassment.
When we speak of anxiety, we are most often speaking about a state of nervous system activation, which is a mobilisation of the body in response to perceived threat. It has a clear structure: something feels dangerous, so the body prepares to act.
We are all familiar with fear. We recognise it as a physical experience — raised heart rate, rapid and/or shallow breathing, sweating, trembling hands. This is a function of the autonomic nervous system, which regulates the body’s unconscious responses to our environment. When calm, the parasympathetic nervous system allows us to rest, reflect and engage socially. In the face of threat, the sympathetic nervous system mobilises us for fight or flight.
A key factor here is that the nervous system responds to what you perceive as a threat. What I call clinical anxiety involves sustained sympathetic dominance (i.e. the fight or flight system is chronically and/or acutely activated) and a struggle to regulate the sympathetic system — even when the threat is understood as more perceived than real. This might be situational such as phobias, social anxiety, health anxiety or performance anxiety. However, when sympathetic activation becomes persistent across environments and circumstances, it is often described as General Anxiety Disorder (GAD).
Cognitive behavioural therapy (CBT) often uses exposure therapy to address clinical anxiety. This approach helps the nervous system to recalibrate its threat response. Typically, it involves gradually introducing a person to the threat — spiders, public speaking, social situations, etc — and seeing that they survive. The nervous system acclimatises, and the threat perception diminishes. CBT also often explores the underlying assumptions and beliefs that unconsciously underpin the threat perception in the moment it arises and challenge these on a cognitive level.
By contrast, depth psychotherapy explores the origins of the threat perception and helps the individual understand why this perception emerged and the role it continues to play in the person’s unconscious efforts to feel safe. This often uncovers unconscious defence mechanisms and processes, as well as making sense of how life history and self-narrative is incorporated into the psychological structure.
In my view a combination of these approaches is most useful in addressing clinical anxiety. The cognitive and nervous system approach addresses the immediacy of the anxiety, which is important — if left unaddressed the nervous system doesn’t learn. The depth work gives greater insight and self-understanding. It helps the individual to make sense of their experience more broadly, to explore and accept parts of themselves and see how anxiety might interact with other aspects of their psyche.
Not all anxiety asks to be eliminated. Clinical anxiety asks to be regulated, understood and calmed. Existential anxiety asks to be listened to and acted upon.
A big part of the work may be discerning which is which.
Sometimes the nervous system needs reassurance. Sometimes the life we are living needs reconsideration. And sometimes both are true at once.