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Mindfulness and Anxiety Disorders: Developing a Wise Relationship with the Inner Experience of Fear

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Perhaps no condition better illustrates the intimate relationship between brain and behavior – mind and body – as the inner experience of fear. In this chapter, we present an integrative scientific view of anxiety and clinical anxiety disorders, with an emphasis on awareness and acceptance as a foundation for mind/body health. Whereas anxiety-related psychopathology is characterized by a desire to avoid the inner experience of fear, we postulate that practicing mindfulness can promote a wise and accepting relationship with one's internal cognitive, emotional, and physical experience, even during times of intense fear or worry.
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Clinical Handbook
of Mindfulness
Fabrizio Didonna
Editor
123
Editor
Dr. Fabrizio Didonna
Coord. Unit for Mood & Anxiety Disorders
Department of Psychiatry
Casa di Cura Villa Margherita
Arcugnano, Vicenza - Italy
fabdidon@libero.it
ISBN: 978-0-387-09592-9 e-ISBN: 978-0-387-09593-6
DOI 10.1007/978-0-387-09593-6
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10
Mindfulness and Anxiety Disorders:
Developing a Wise Relationship
with the Inner Experience of Fear
Jeffrey Greeson, Jeffrey Brantley
... the term mental disorder unfortunately implies a distinction
between “mental” disorders and “physical” disorders that is a reduc-
tionistic anachronism of mind/body dualism. A compelling literature
documents that there is much “physical” in mental disorders and
much “mental” in physical disorders.
– American Psychiatric Association (DSM-IV-TR, 2000)
Introduction
Perhaps no condition better illustrates the intimate relationship between
brain and behavior – mind and body – as the inner experience of fear. In
this chapter, we present an integrative scientific view of anxiety and clini-
cal anxiety disorders, with an emphasis on awareness and acceptance as a
foundation for mind/body health. Whereas anxiety-related psychopathology
is characterized by a desire to avoid the inner experience of fear, we postu-
late that practicing mindfulness can promote a wise and accepting relation-
ship with one’s internal cognitive, emotional, and physical experience, even
during times of intense fear or worry. Further, we suggest that the “wise rela-
tionship” that develops by turning toward fear, anxiety, and panic with stable
attention, present focused awareness, acceptance, and self-compassion can
promote psychological freedom from persistent anxiety and greater behav-
ioral flexibility.
Mindfulness is a word that refers to a basic human capacity for non-
conceptual, non-judging, and present-moment-centered awareness. This
awareness arises from intentionally paying attention, from noticing on pur-
pose what is occurring inside and outside of oneself, with an attitude of
friendliness and acceptance toward what is happening while it is happen-
ing. Mindfulness has been cultivated by human beings using “inner tech-
nologies” of meditation in various spiritual contexts for literally thousands of
years. In the past 25–30 years, Western medical science has turned increas-
ing attention to the psychological and physical correlates of meditation and
mindfulness practices (Walsh & Shapiro, 2006). Modern clinical investiga-
tors have joined meditation teachers in offering definitions of mindfulness
(see Table 10.1).
171
172 Jeffrey Greeson, Jeffrey Brantley
Table 10.1. Definitions of mindfulness.
Definition Reference
“the non-judgmental observation of the ongoing
stream of internal and external stimuli as they
arise.
Baer (2003)
“self-regulation of attention [and] adopting a
particular orientation toward one’s experience in
the present moment, an orientation that is
characterized by curiosity, openness, and
acceptance.
Bishop et al. (2004)
“friendly, nonjudging, present-moment awareness. Brantley (2003)
“awareness, of present experience, with acceptance. Germer (2005)
“the awareness that emerges through paying
attention on purpose, in the present moment, and
nonjudgmentally to the unfolding of experience
moment by moment.
Kabat-Zinn (2003)
“the state of being fully present, without habitual
reactions.Salzberg and Goldstein
(2001)
Our central thesis in this chapter is that practicing mindfulness offers a
healthier and more effective means for relating to one’s inner experience of
fear and anxiety, through self-regulation built on intentional, non-judging
awareness.
In the sections that follow, we present current theoretical, scientific, and
clinical evidence in support of our hypothesis that practicing mindfulness
enables a “wise relationship” to develop toward one’s own inner life, partic-
ularly the internal experience of anxiety and fear. By bringing inner processes
of thinking, feeling, and physical sensations into consciousness using mind-
fulness practice, identification with and perpetuation of unconscious pat-
terns in mind and body can be transformed into interactions that are “wise”,
that is, based in accurate perception and inclusive of all the domains of expe-
rience available to each human being in each moment. The healing benefits
of mindfulness practice to the conditions of anxiety and fear follow from this
more conscious, wise relationship.
Prevalence, Characteristics, and Current Treatment
of Anxiety Disorders
Human anxiety occurs along a continuum, from normal fear reactions that
help avert clear and present danger to uncontrollable panic and maladaptive
avoidance of people, places, and things in an effort to feel safe from harm.
The experience of acute fear and mild-to-moderate anxiety is ubiquitous in
the human condition. When it occurs in the appropriate context, some fear
and anxiety can increase attention to threatening circumstances or enhance
effective performance in the face of a challenge. Thus, some degree of anxi-
ety is good.
However, when anxiety is unwarranted, excessive, and persistent, and/or
it interferes with everyday functioning, it can be categorized as a psychi-
atric disorder (American Psychiatric Association, 2000). The Diagnostic and
Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-
TR) includes six primary anxiety disorders (see Table 10.2). Each anxiety
disorder shares characteristic symptoms of intrusive and disturbing thoughts,
Chapter 10 Mindfulness and Anxiety Disorders 173
Table 10.2. Primary anxiety disorders, clinical descriptions, and lifetime
prevalence.
Diagnostic category Clinical description Lifetime prevalence
Generalized anxiety
disorder
Persistent, pervasive worry that
is difficult to control
5%
Obsessive-compulsive
Disorder
Obsessive thinking about
possible threats to safety and
compulsive ritualistic
behaviors to allay fear
2.5%
Panic disorder Sudden, overwhelming, intense
fear of something going
wrong
1.0–3.5%
Post-traumatic stress
disorder
Intrusive thoughts,
hyperarousal, and
reexperience of past trauma
8%
Social anxiety
disorder
Fear of negative social evaluation Up to 13%
Specific phobia Fear of a specific object or
situation
7–11%
Obtained from DSM-IV-TR, American Psychiatric Association (2000).
heightened psychophysiological arousal, and intensely unpleasant appraisals
of one’s internal emotional experience (Brantley, 2003). Taken together, anx-
iety disorders are the most prevalent category of mental health diagnoses,
affecting an estimated 25–30 million Americans during their lifetime (Lepine,
2002; Narrow, Rae, Robins, & Regier, 2002).
Anxiety disorders are often conceptualized as a fear of fear that results in
high levels of subjective distress, somatic symptom manifestation, and disrup-
tion of daily living (Barlow, 2002). Worry has been described as the persistent
activation of one’s cognitive representation of anxiety, including disturbing
thoughts,stories,orimagesaboutapossibledangerorthreat(Borkovec,Ray,
& Stober, 1998). Despite its useful function in helping one to cope, feel safe,
and prepare for what may come, persistent worry and its associated affec-
tive distress and physiological arousal can produce defensive, self-protective,
and avoidant behavior out of context, typical of psychiatric disorder (Barlow,
2002; Borkovec et al., 1998).
The Psychobiological Nature of Fear and Anxiety
The psychological experience of fear occurs concomitantly with a pattern of
stress-related physiological activation designed to promote survival by avoid-
ing danger through fight-flight-or-freeze behavior (Barlow, 2002). A startle
response initiated by sensory detection of a potentially threatening stimulus,
such as a sudden loud noise, a looming shadow, or an unexpected touch,
immediately signals the subcortical structures in the brain (i.e., the limbic
system) that perceive threat and mediate an alarm reaction. This alarm reac-
tion descends from the limbic system through the brainstem, spinal cord, and
peripheral nervous system, ultimately activating a broad-spectrum physio-
logical response throughout the body. Integrated psychophysiological activa-
tion in response to a perceived threat enables one to cope through vigorous
defensive action, such as fighting or fleeing (Schneiderman & McCabe, 1989).
These adaptive responses are generated by activation of multiple body sys-
tems, including the central and peripheral nervous systems, cardiovascular
174 Jeffrey Greeson, Jeffrey Brantley
system, endocrine system, metabolic system, neuromuscular system, and
immune system (Selye, 1976). Conversely, select biological systems unessen-
tial for survival in the face of an immediate threat, including the digestive
system and the reproductive system, are deactivated under conditions of fear
or stress (Selye, 1976).
Psychophysiological activation and accompanying energy mobilization is
certainly useful in supporting escape behavior when actual escape is possi-
ble. When a threat outweighs one’s perceived ability to escape or otherwise
cope, however, behavioral freezing and cognitive hypervigilance may occur
in an attempt to passively avoid harm (Schneiderman & McCabe, 1989).
Under conditions of passive avoidance rather than active coping or escape,
the physiological effort and energy generated can go unused. While acute,
time-limited onset and recovery of stress-related mental and physical acti-
vation clearly provides an adaptive advantage in the face of a true threat
(i.e., when actual fighting, fleeing or freezing is needed to promote survival),
chronic or unwarranted activation of fear-related psychophysiology can be
detrimental to health. Indeed, a growing body of animal and human research
indicates that repeated, exaggerated, or prolonged activation of stress physi-
ology, as well as delayed recovery of biological responses to stress, can con-
tribute to premature breakdown of organ systems that may increase suscep-
tibility to disease (McEwen, 1998).
Mind/Body Connections and Processes Underlying Clinical Anxiety
Anxiety disorders can be characterized by a set of dysregulated cognitive,
affective, physiological, and behavioral processes that manifest as maladap-
tive ways of responding to one’s inner experience of fear. Dysregulated cog-
nitive processes in anxiety disorders typically include the following:
a narrow focus of attention on some disturbing aspect of internal experi-
ence, such as a distressing thought or physical sensation,
misappraisal of threat in the absence of real danger, and
distortion of the magnitude of a true threat or challenge through magnify-
ing, catastrophizing, or fortune telling (Barlow, 2002).
In addition, from a cognitive standpoint, anxiety disorders can be char-
acterized by a focus of attention on future-oriented concerns about possi-
ble misfortune (Barlow, 2002). The narrow focus of attention on disturbing
thoughts or physical sensations, coupled with a future-oriented tendency to
worry about potential threatsofharm,canpredisposeanindividualtoalack
of awareness of what is actually happening in the present moment (Brantley,
2003).
When one is unaware of what is actually happening in the present
moment, one’s attentional focus is more susceptible to being hijacked by
a train of cognitive interpretations about one’s experience that may be inac-
curate and distress provoking. For instance, in the case of depression, the
“downward spiral” of automatic, negatively biased information processing,
or “depressogenic thinking,” can transform momentary emotional distress
into longer-lasting mood disturbance, which in turn, can increase suscepti-
bility to depressive relapse (Segal, Williams, & Teasdale, 2002). Similarly, in
the case of anxiety, a cognitive style marked by a narrow focus of attention,
Chapter 10 Mindfulness and Anxiety Disorders 175
orientation to future events as opposed to present moment experience, and
a propensity to catastrophically appraise or misinterpret mental or physical
phenomena can result in the arousal of anxiety and other emotional distur-
bances such as anger, sadness, and loneliness.
While the perception of fear and anxiety occurs in the brain, the response
can be most noticeable in the body. The induction of fear and other forms
of negative affect stimulates widespread sympathetic activation, which orig-
inates from pathways in the cerebral cortex and subcortical limbic struc-
tures (e.g., amygdala, hippocampus, hypothalamus), and descends through
the brainstem, spinal cord, and peripheral sympathetic nerves to organ sys-
tems throughout the body (Thayer & Brosschot, 2005). Consequently, fearful
cognitive interpretations and associated emotional and physiological arousal
can manifest in an array of somatic symptoms, including painful muscle ten-
sion, racing pulse, elevated blood pressure, cardiac arrhythmia, labored respi-
ration, and gastrointestinal disturbance. Moreover, given one’s anxiety-prone
cognitive style, somatic symptoms can be interpreted as evidence of harm,
which may result in even narrower attention to the symptoms, catastrophic
thinking, acute panic, emotional distress, and even a sense of impending
doom. Because these internal experiences are unpleasant and aversive, they
are typically avoided by actively attempting to distract attention away from
the inner experience when it is present and attempting to prevent recurrent
anxiety in the future by avoiding associated people, places, or things. Taken
together, it has been noted that “reactions (both cognitive and emotional) to
one’s own internal experiences (thoughts, feelings, bodily sensations) may
underlie the development and/or maintenance of anxiety disorders,” which
categorically manifest as psychological and behavioral inflexibility (Orsillo,
Roemer, & Holowka, 2005).
Overview of Current Treatments for Anxiety
Given the integrated mind/body nature of fear and experiential anxiety, it is
logical that effective treatment strategies for anxiety disorders address both
mental and physical functioning. Standard treatment approaches for clinical
anxiety include psychotherapy and medication, both of which are intended
to modulate cognitive, affective, physiological, and/or behavioral reactions to
perceived threat (American Psychiatric Association, 2005). Several different
psychotherapies and medications are equally efficacious in the short-term
amelioration of anxiety-related symptoms (American Psychiatric Associa-
tion, 2005). Effective psychotherapies include behavior therapy in which
an individual is systematically exposed to a feared condition without being
permitted to engage in an automatic, avoidant behavioral response, and
cognitive-behavioral therapy (CBT), in which distorted beliefs, misappraisals,
contextually inappropriate emotional reactions, and inflexible behavior pat-
terns are identified and corrected using self-monitoring, cognitive restructur-
ing, and relaxation training (for detailed reviews see Barlow, 2002). CBT for
anxiety has demonstrated to be superior to medication for long-term symp-
tom reduction (Otto, Smits, & Reese, 2005). There are many “active ingredi-
ents” in psychotherapeutic approaches to anxiety disorders, and it remains
unclear to what extent specific cognitive, affective, behavioral, or psy-
choeducational components account for therapeutic change, as opposed to
176 Jeffrey Greeson, Jeffrey Brantley
non-specific factors such as therapist attention, empathy and positive regard,
or perceived social support (Barlow, 2002). Effective medications for the
treatment of clinical anxiety include benzodiazepines, tricyclic antidepres-
sants, monoamine oxidase inhibitors, and selective serotonin reuptake
inhibitors (Sheehan & Harnett Sheehan, 2007). In chronic and/or treatment
refractory cases, psychotherapy may be effectively combined with pharma-
cotherapy (Sheehan & Harnett Sheehan, 2007).
In recent years, mindfulness- and acceptance-based approaches have
been combined with traditional change-based approaches such as CBT in
an attempt to enhance effective treatment of psychopathology, including
anxiety and depressive disorders (for reviews see Feldman, 2007; Hayes,
2005; Lau & McMain, 2005; Orsillo & Roemer, 2005; Segal et al., 2002).
Because individuals who experience clinically relevant anxiety typically have
a strongly conditioned desire to avoid distressing internal experiences –
despite the tendency of experiential avoidance to prolong or even exac-
erbate distressing sensations – mindfulness practice offers a fundamentally
different orientation in which anxiety is deliberately noticed, allowed, and
responded to with openness, curiosity, and acceptance. Therefore, practic-
ing mindfulness may increase distress tolerance, interrupt habitual avoid-
ance, and ultimately promote adaptive self-regulation and healthy mind/body
functioning.
How Mindfulness May Target the Shared Roots
of Anxiety-Related Suffering
Modern-day responses to psychological stress, fear, and uncertainty are often
marked by rumination, worry, anticipatory anxiety, and stagnant delibera-
tion. These habits of thinking continue to stimulate fear reactions in the body,
which in turn, feed back to fuel worried thoughts, causing a cycle of unpleas-
ant experience (Brosschot, Gerin, & Thayer, 2006; Feldman, Hayes, Kumar,
Greeson, & Laurenceau, 2007). Consequently, one might say that human
beings today are more likely to fight the unpleasantness of their own inner
experience of threat rather than fight off the threat itself. In the short term,
strategies for avoiding one’s inner experience of anxiety, such as distraction,
thought suppression, or the use of emotion-regulating substances including
cigarettes, alcohol, illicit drugs or food, may be effective in reducing dis-
tress temporarily. This behavioral approach can certainly be reinforcing, and
thus can become quite habitual, automatic, and rigid. However, attempts to
avoid the inner experience of fear, anxiety, and panic not only fail to ame-
liorate the root cause of emotional upset, but also paradoxically exacerbate
the inner experience of suffering by reinforcing maladaptive (i.e., avoidant)
coping behaviors that permit an emotionally upsetting experience to recur
indefinitely outside of an appropriate context.
Knowing Without Identifying or Reacting
From the perspective of mindfulness, thoughts, emotions, physical sensa-
tions, and impulses that arise in association with one’s internal experience
of fear, anxiety or panic are merely events in the broad field of one’s present-
moment awareness (Brantley, 2003). Mindfulness practice is believed to
Chapter 10 Mindfulness and Anxiety Disorders 177
improve effective self-regulation of anxiety-related cognition, emotion, sen-
sation and behavior, although the precise mechanisms are not yet clear
(Baer, 2003; Bishop, 2002; Garland, 2007; Kabat-Zinn, 1990; Shapiro, Carl-
son, Astin, & Freedman, 2006; Shapiro, & Schwartz, 2000).
Central to the self-regulatory capacity of mindfulness is a fundamental shift
in one’s relationship with one’s inner life and the outer world. In essence,
mindfulness enables conscious awareness of inner life and physical sensa-
tions. This shift in awareness brought about by mindfulness has variably been
termed “reperceiving,” “decentering,” “detachment,” “metacognitive aware-
ness,” “bare attention,” and “clear seeing” (Salzberg & Goldstein, 2001; Segal
et al., 2002; Shapiro et al., 2006; Teasdale et al., 2002). Shapiro et al. (2006),
for instance, have described reperceiving as “rather than being immersed in
the drama of our personal narrative or life story, we are able to stand back
and simply witness it.
The capacity for mindfulness – and its resultant perspective shift on the
inner life – is traditionally cultivated by regular meditation practice (Hahn,
1976; Kabat-Zinn, 1990; Salzberg & Goldstein, 2001; Brantley, 2003). Medi-
tation can be understood as an intentional training of attention, embedded
with acceptance, and the resulting awareness and understanding that emerge
(Brantley, 2003). As observed by Goleman (1980), “The first realization in
‘meditation’ is that the phenomena contemplated are distinct from the mind
contemplating them.
Walsh and Shapiro (2006) have emphasized that meditation training typ-
ically differs from other self-regulatory strategies such as self-hypnosis,
visualization, and psychotherapy in that meditation primarily aims to train
attention and awareness, whereas other approaches primarily intend to
change mental contents (i.e., thoughts, images, beliefs, emotions) and mod-
ify behavior. Although mindfulness has been described as the “heart of Bud-
dhist meditation,” being mindful is considered an innate human capacity that
is universal, secular, and compatible with nearly every major world religion
(Kabat-Zinn, 2005). Indeed, mindfulness and the ability to reperceive are con-
ceptualized as part of a developmental process (Shapiro et al., 2006).
From a meditation teacher’s perspective, practicing mindfulness may help
in the following way. As one pays attention on purpose to one’s actual direct
experience of anxiety, as opposed to being identified with what one thinks
about anxiety, one gains significantly greater understanding and insight about
the experience of anxiety and about oneself in relation to one’s world
(Goldstein, 1976). Such understanding and insight can provide a foundation
for more skillful responses in the face of fear, anxiety and panic, including
equanimity rather than reactivity and wise self-regulation rather than aver-
sion. By virtue of the psychological and behavioral flexibility mindfulness
can afford in the present moment, one might be better able to consciously
choose actions that are effective in meeting one’s needs for safety, a sense of
security, and calm.
“How Are You Treating Anxiety?” Establishing Wise Relationship
Put simply, distress seems to increase as we stray further from the present
moment. As Mark Twain, a famous worrywart, once said, “There has
beenmuchtragedyinmylife;atleasthalfofitactuallyhappened.”The
178 Jeffrey Greeson, Jeffrey Brantley
consequences for psychological suffering are clear when we live in the
future. Moreover, reflexively and rigidly attempting to avoid one’s inner expe-
rience of fear, anxiety, and panic not only fails to address the problem, but
actually functions to exacerbate it and prolong suffering. But, what happens
when one deliberately takes a different relationship to one’s inner life experi-
ence? A more conscious and allowing relationship? Can such an act of inten-
tion, attention, and acceptance increase one’s awareness of the mind/body
connection, including implications for self-regulation, wise action, and opti-
mal health?
When one changes their relationship to their internal experience from that
of automatic judgment, rigid thinking, and disconnection to one of accep-
tance, openness, and intentional connection, an immediate impact occurs
in the circuits and feedback loops of mind and body. Because mindfulness
represents a completely different perspective than the prevailing Western
cultural norm of narrowly focused attention, avoidance of unpleasantness,
and behavioral reactivity contingent on environmental circumstances, it has
been described as an “orthogonal rotation” in consciousness (Kabat-Zinn,
2005).
Many mindfulness teachers emphasize that practicing mindfulness is an
invitation to relate to life differently. In more practical terms, mindfulness
may be described as an intentional willingness to fully and completely engage
with one’s direct experience of living, on a moment-to-moment basis, with
whatever pleasant, unpleasant, or neutral events that arise. The central goal
of living mindfully is to open to the fullness and richness of each moment,
and not to add, subtract, or modify any part of one’s psychological or phys-
ical experience. At its core, mindfulness is intended to help one live a life
of deep meaning, value, direction, and purpose even when emotional or
physical pain is present (Kabat-Zinn, 2003). By awakening to the possibilities
available in the present moment, one often becomes empowered to choose
a wise response in the face of an upsetting internal experience or external
event, as opposed to having an upsetting experience or event dictate how
one responds.
Scientific Evidence to Support Mindfulness as a Model Self-
Regulatory Mechanism
Mindfulness enables one to establish a radically different relationship to one’s
experience of internal sensations and outer events by cultivating present-
moment awareness based on an attitude of allowance and a behavioral orien-
tation based on wise responsivity rather than automatic reactivity. As shown
in Figure 10.1, mindfulness offers an alternative response to the reactive ele-
ments of fear and anxiety in the mind and body. By purposefully engaging
higher order mental functions, including attention, awareness, and attitudes
of kindness, curiosity and compassion, mindfulness may effectively activate
control over emotional reactions via cortical inhibition of the limbic system.
Mindfulness practice, therefore, not only offers a new way of seeing, a new
way of being, in relationship to one’s interior life and external world, but
also provides a possible means for effective self-regulation of the mind/body
connection (Kabat-Zinn, 2005, 1994, 1990).
Chapter 10 Mindfulness and Anxiety Disorders 179
Prefrontal Cortex (attention, intention)
Limbic System (emotional processing)
Brain Stem/Spinal Cord (vital functions)
Sympathetic Nervous System (SNS)
Organs (heart, gut, glands, immune)
Somatic symptoms ( HR, BP, tension)
F
e
a
r
f
u
l
r
e
a
c
t
i
o
n
M
i
n
d
f
u
l
r
e
s
p
o
n
s
e
Behavior (fight-or-flight; freeze; poise)
Figure. 10.1. An automatic reaction versus a mindful response to the inner expe-
rience of fear. In the case of a fearful reaction, higher-order thinking centers in the
prefrontal cortex are taken “offline” (dashed line on left) so that one’s mind/body
experience is dictated by activation of the subcortical limbic system. Unencumbered
by conscious thought, activation of fear circuitry in the limbic system stimulates sym-
pathetic nerves that originate in the brain stem, descend through the spinal cord,
and innervate internal organs to prepare the body for vigorous defensive behavior
(e.g., “fight-or-flight”; solid lines on left). In the case of anxiety disorders, one’s per-
ception of threat may be greatly magnified or completely imagined. In this context,
mindfulness, including paying attention on purpose to one’s internal experience in
the present moment, may activate prefrontal cortex areas to come “online” (solid line
on right), which in turn, can inhibit reactive emotional circuitry, fear-related physio-
logical arousal, and automatic behavior (dashed lines on right).
Considerable data support the rationale for a model of conscious, accept-
ing attention to unfolding mind/body experiences as a skillful self-regulatory
process. A brief review of several psychological and biological pathways
through which mindful attention, awareness, and attitudes may influence
brain and body functioning follows.
First, mindfulness practice may increase one’s ability to maintain a stable
focus of attention that is intentional and chosen, as opposed to automati-
cally driven or hijacked by emotional reactivity (Jha, Krompinger, & Baime,
2007). Consequently, one may be more likely to avoid maladaptive, uncon-
scious patterns of anxiety-producing thinking, including perseveration on
upset, unpleasantness, or discomfort. Many forms of perseverative cogni-
tion, including worry, anticipatory anxiety, and rumination are associated
with increased sympathetic arousal and dysregulated (persistently activated)
cardiovascular, neuroendocrine, metabolic, neuromuscular, and immune pro-
cesses (Brosschot et al., 2006; Brosschot, Pieper, & Thayer, 2005; Thayer
& Brosschot, 2005). Notably, trait mindfulness has been associated with
lower levels of worry, rumination, thought suppression, experiential avoid-
ance, and stagnant deliberation (Baer, Smith, Hopkins, Krietemeyer, & Toney,
2006a; Feldman et al., 2007). In addition, formal training in mindfulness
meditation has produced significant reductions in the tendency to ruminate
and to problem-solve using an inflexible cognitive style (Feldman, Hayes,
180 Jeffrey Greeson, Jeffrey Brantley
& Greeson, 2006; Jain et al., 2007; Ramel, Goldin, Carmona, & McQuaid,
2004). Based on these shifts in attention, awareness, and cognitive process-
ing, one might also expect mindfulness to correlate with decreased physio-
logical arousal and somatic symptom manifestation.
A second line of scientific inquiry for the self-regulatory capacity of mind-
fulness practice involves the investigation of autonomic nervous system reg-
ulation. Preliminary evidence for such regulation was recently demonstrated
by a study in which mindful body scan meditation produced greater parasym-
pathetic activation than progressive-muscle relaxation (Ditto, Eclache, &
Goldman, 2006). In a different study, practice of a mindful body scan medita-
tion immediately prior to a standardized psychosocial stress task was asso-
ciated with normal stress-related activation of the hypothalamic-pituitary-
adrenal (HPA) axis among medical students trained in mindfulness-based
stress reduction (Greeson, Rosenzweig, Vogel, & Brainard, 2001). In addi-
tion to possible attenuating effects on stress-related physiological activation,
mindfulness and meditation may also induce a relaxation response, charac-
terized by relaxed alertness, passive disregard for internal stimuli or external
events, and low-level physiological arousal (Benson & Klipper, 1975).
A third line of scientific inquiry into the self-regulatory effects of mind-
fulness practice is the rapidly growing field of contemplative neuroscience.
This burgeoning area of investigation is beginning to reveal some of the
ways in which paying attention on purpose, cultivating inner attitudes of
acceptance and non-judgment, and setting meaningful intentions such as
to direct lovingkindness toward oneself or others can actually modify brain
activity, including perception, higher order cognition, and emotion regula-
tion (Cahn & Polich, 2006; Siegel, 2007; Wallace, 2006). One recent analysis
based on a comprehensive review of the current scientific literature spanning
neuroscience and meditation concluded that neural plasticity may indeed
enable humans, including adults, to gradually transform mindful states into
traits based on repeated exposure to experiential shifts in perspective, emo-
tional processing, and behavioral responses (Begley, 2007). A landmark clini-
cal intervention study by Davidson, Kabat-Zinn et al. (2003) demonstrated
for the first time that systematic mindfulness training in a real-world set-
ting can produce observable changes in the brain, namely greater left pre-
frontal activation, which has previously been associated with positive emo-
tion. Of particular interest, the study by Davidson, Kabat-Zinn et al. (2003)
further revealed a connection between change in the brain, and change in
the body, as greater intervention-related shifts toward left prefrontal activa-
tion corresponded with more vigorous antibody responses to influenza vac-
cination. The connection between changes in central nervous system activ-
ity and peripheral immune function is well established (Ader, 2007). Two
very recent examples of the power of the mind to change the brain include
modification of attentional subsystems following eight weeks of group-based
mindfulness meditation training (Jha et al., 2007), as well as enhanced pre-
frontal cortex regulation of affect through labeling negative emotions, a core
mindfulness skill (Creswell, Way, Eisenberger, & Lieberman, 2007).
Finally, behavioral scientific evidence suggests that mindfulness prac-
tice can positively impact health-related behaviors through its effects on
cognitive, affective, and physiological self-regulation. Specifically, mindful-
ness practice appears to increase behavioral flexibility in conditions previ-
ously associated with maladaptive rigidity, such as fear-related avoidance of
Chapter 10 Mindfulness and Anxiety Disorders 181
normal everyday activities. A “third wave” of behavioral psychotherapies has
recently emerged in which mindfulness- and acceptance-based approaches
have been combined with traditional cognitive-behavioral treatment of anx-
iety and other emotionally dysregulated conditions, including depression,
chronic pain, eating disorders, and borderline personality disorder (Baer, Fis-
cher, & Huss, 2006b; Hayes, 2005; Lau & McMain, 2005). These new inte-
grated psychotherapies include mindfulness-based cognitive therapy (MBCT)
for active depression and anxiety as well as the prevention of depressive
relapse (Finucane & Mercer, 2006; Segal et al., 2002); acceptance and com-
mitment therapy (ACT) for anxiety disorders and chronic pain (Eifert &
Forsyth, 2005; Dahl, Wilson, Luciano, & Hayes, 2005); dialectical behav-
ior therapy (DBT) for borderline personality disorder (Linehan, 1993); and
mindfulness-based eating awareness training (MB-EAT) for binge eating dis-
order (Kristeller, Baer, & Quillian-Wolever, 2006). The primary objective of
integrating mindfulness meditation with traditional CBT is to increase treat-
ment efficacy by exploring the relationship between acceptance of one’s
present moment experience as a catalyst of desired behavior change, includ-
ing modification of self-destructive ways of thinking, feeling, and acting (Lau
& McMain, 2005).
There is a burgeoning literature to support the integration of mindfulness-
and acceptance-based strategies with traditional change-based strategies in
the treatment of anxiety disorders in particular. This area of clinical inves-
tigation has recently been reviewed in special journal issues, professional
handbooks, and practitioner’s treatment guides (for detailed reviews see
Borkovec, 2002; Craske & Hazlett-Stevens, 2002; Eifert & Forsyth, 2005; Ger-
mer, 2005; Orsillo & Roemer, 2005; Roemer, Salters-Pedneault, & Orsillo,
2006; Roemer & Orsillo, 2002; Wells, 2002). In addition, several literature
reviews have concluded that mindfulness-based stress reduction programs in
both controlled research and real-world community settings have produced
clinically significant reductions in anxiety, mood disturbance, and stress-
related physical symptoms (Baer, 2003; Brantley, 2005; Grossman, Niemann,
Schmidt, & Walach, 2004; Lazar, 2005; Shigaki, Glass, & Schopp, 2006; Smith,
Richardson, Hoffman, & Pilkington, 2005).
Whereas a number of different mindfulness-based clinical interventions
have demonstrated effectiveness in ameliorating maladaptive cognition, neg-
ative affect, and somatic symptoms, one should note that the core intention
of mindfulness practice centers around personal growth, transformation, and
the pursuit of what is possible, meaningful, and truly valued in life despite
any particular diagnosis, limitation, or pathology (Shapiro, Schwartz, & San-
terre, 2002). By virtue of progressively awakening to one’s senses, core val-
ues, intended life direction, and even spiritual purpose, mindfulness practice
may be effectively coupled with other positively oriented behavior-change
interventions like hypnosis to further increase contact with what is affirm-
ing, comforting, and fulfilling (Lynn, Das, Hallquist, & Williams, 2006).
Illustrative Case Report
Background: “John” is 25-year-old, single, Caucasian male graduate student
with an 18-month history of treatment refractory hypertension, non-cardiac
chest pain, and irregular heartbeat. He was referred for psychotherapeutic
182 Jeffrey Greeson, Jeffrey Brantley
management of anxiety and recurrent panic attacks. Extensive biomedical
workup prior to psychotherapy revealed no known medical cause for his
physical or psychological symptoms, which were consistent with a diagno-
sis of panic disorder. Hypertension was reportedly non-responsive to com-
bination treatment with a beta-blocker (Toprol XL) and diuretic (hydrox-
ychlorothiazide; average blood pressure reading before and after medica-
tion =145/95). The client reported that healing touch, breathwork with
heartrate variability (HRV) biofeedback, and yoga instruction had been
“somewhat beneficial” in reducing physical symptoms and anxiety, but
not blood pressure. Several months of individual counseling for the treat-
ment of anxiety and panic was reportedly “not helpful.” Current self-care
activities included yoga 5 days per week, running 1 day per week, avoid-
ing foods with processed sugar and added sodium, eating more fruits and
vegetables, and nightly deep breathing with sound therapy. The client
denied illicit substance use and reported minimal alcohol use (1 drink per
month). Family psychiatric history was significant for anxiety in mother and
father.
Intervention: Nine individual therapy sessions, which included a combi-
nation of formal mindfulness training, anxiety-specific cognitive-behavioral
skills training, and supportive psychotherapy to aid the client in clarifying
his vision of optimal health, wholeness, and life direction. Treatment goals
included the following: (1) ability to tolerate distressing physical symptoms
without panic, (2) reduction in muscle tension, including chest pain, and (3)
reduction in blood pressure. Each session emphasized formal mindfulness
meditation practice (i.e., awareness of breath; body scan; mindfulness of
thoughts, feelings, physical sensations, and sounds), cognitive-behavioral
strategies to reduce anxiety and related physiological symptoms (e.g., cog-
nitive restructuring, exposure therapy with response prevention), and self-
help readings to reinforce learning and to provide structured mindfulness-
based exercises (e.g., the book Calming Your Anxious Mind). In-session
meditation practices were recorded for home use. During the course of treat-
ment, “John” stated that he experienced a shift in his relationship to worri-
some thoughts, noting that “[his] feelings are temporary.” In addition, “John”
stated that he was “not focusing on what could happen, but focusing on
what is happening.” The client further described a shift in his relationship to
“strange pains” and other unpleasant physical sensations, noting that “[his]
experience of chest tightness dissipated with allowance.” Notably, “John”
did not experience a panic attack during his 9 weeks of therapy, which he
attributed to the shifts in perspective he experienced. Midway through ther-
apy, he described feeling “a bit nervous, but okay” in situations that he typi-
cally feared and avoided, such as flying and being outdoors in remote areas.
By the end of treatment, “John” had experienced a significant reduction in
self-reported levels of anxiety and muscle tension, as well as a decrease in
blood pressure readings following his regular yoga, breathwork, and mind-
fulness exercises. He insightfully reported discovering how to “be in control
by letting go.” Moreover, “John” was no longer avoiding formerly feared social
situations. He reported actively engaging with co-workers, community mem-
bers, and spiritual guides. And at the final session he enthusiastically shared
that he had become engaged to his long-time girlfriend, because “[he] was
no longer afraid.” Taken together, the multimodal intervention approach with
Chapter 10 Mindfulness and Anxiety Disorders 183
mindfulness as a core self-regulatory skill resulted in marked improvements
the client’s quality of life, including mental, physical, and social functioning.
Illustrative Mindfulness Practice: “Awareness of Breath”
Paying attention on purpose to your breath sensations is an effective way
to reconnect with your inner experience as it is unfolding moment to
moment.
(1) Notice and follow the full duration of an in breath...an out breath...and
the spaces between them....
(2) Noticing the physical sensations of the breath with a sense of curios-
ity and kind attention...allowing the sensations to unfold moment to
moment...breath by breath...observing as best you can....
(3) Noticing whether your attention is on the breath in this moment...and
if it is not, where did the mind go...perhaps it began thinking, telling
some sort of story about your experience, or analyzing...just noticing
these thoughts or judgments as mere events in the field of your own
spacious awareness....
(4) Noticing the transient nature of these mental events as you continue
to surf the rising and falling waves of the in breath and the out
breath...consciously choosing to acknowledge and let go of thoughts,
feelings, body sensations, or impulses with the next exhale....
(5) Gently escorting your attention back to your focus on the present
moment...using the sensations of the breath as your anchor for
mindfulness...dropping back into your direct experience of what is here
in the present moment whenever you choose....
(6) And whenever you are ready, reorienting to the room...noticing
where your body makes contact with the furniture...perhaps stretching
gently...and gradually opening your eyes.
Future Directions
A growing body of scientific literature demonstrates that mindfulness- and
acceptance-based treatment approaches to anxiety work, in part by creat-
ing a fundamental shift in perspective toward one’s inner life. Much work,
however, remains to be done across conceptual, definitional, and research
fronts applied to mindfulness-based interventions for fear and anxiety. In
addition, there is theoretical and empirical support for the concept that pay-
ing attention on purpose to the inner experience of fear and anxiety with
a sense of openness, curiosity, and acceptance can actually change one’s
experience by directly modifying habitual circuits and mind/body feedback
loops in the brain. Additional research is needed to examine more deeply
the aspects of consciousness, including awareness, attention and intention,
which may be used to effectively self-regulate mind-brain-body-behavior sys-
tems implicated in anxiety and anxiety disorders. Questions that await fur-
ther inquiry include: Who benefits most (and least) from mindfulness training
in the context of clinical anxiety? How can mindfulness training be integrated
most effectively with existing evidence-based treatment approaches, includ-
ing CBT and/or medication? And finally, what is the role that institutions and
184 Jeffrey Greeson, Jeffrey Brantley
communities may play in facilitating the development of greater mindfulness,
individually, and collectively?
Conclusion
Human beings have the capacity for accurate, present-moment awareness
of the flow of their inner life. Mindfulness is a name for this accepting and
accurate awareness. Mindfulness arises from paying attention on purpose.
Practicing mindfulness appears to complement and enhance established
psychotherapeutic approaches to the treatment of anxiety and underlying
mind/body dysregulation. Taken together, mindfulness practice appears to
offer a healthy and effective means of relating to one’s inner experience of
fear and anxiety, in part through cultivating the ability to pay attention on
purpose with an open, curious, and accepting attitude toward oneself and
one’s outer world. This “wise relationship” offered by mindfulness practice
may help ease the suffering of excessive fear, anxiety or panic by encour-
aging an individual to “reperceive” the transient conditions of internal dis-
comfort by maintaining equanimity as one’s experience unfolds, moment by
moment. Using the higher-order skill of “metacognitive awareness,” one may
more easily perceive unpleasant internal stimuli or external events simply
as they are, without creating a story about one’s present-moment experi-
ence that can fuel perseverative thinking, upsetting feelings, disconcerting
physiological arousal, and reactive behavior in an attempt to avoid distress.
With practice, as automatic reactions are deliberately acknowledged and let
go and consciously chosen behavioral responses are selected, one begins to
realize increasing wisdom, psychological freedom, and behavioral flexibility.
These characteristics afforded by mindfulness practice define healthy, adap-
tive mental functioning, which includes acknowledging fear and anxiety, but
does not allow fear to control or distort one’s life.
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... Our findings support the hypothesis about negative associations between mindfulness and anxiety disorders, including PD (Kim et al., 2016;Kim et al., 2010) and GAD (Hoge et al., 2013;Mankus et al., 2013); as well as about the negative association of mindfulness with dysfunctional metacognitions (Martínez Ruiz, 2018;Mörck, 2009;Sanger & Dorjee, 2016). Greeson and Brantley (2009) proposed that mindfulness practice is a profoundly atypical way of coping with anxiety where it is "deliberately noticed, allowed, and responded to with openness, curiosity, acceptance, and self-compassion." Consequently, this intervention may "interrupt habitual avoidance, increase distress tolerance, and promote greater behavioral flexibility in response to anxiety," resulting in lower anxiety levels. ...
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