"Wait to worry" and other ways to cope with anticipatory anxiety

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During the COVID-19 pandemic itself and now in the new normal environment, I have seen a significant number of veterinary professionals and students struggling with anxiety disorders and related symptoms pertaining to their health, social situations, returning to work, finances, school performance, and overall concerns related to current uncertainties in our world.

One of the most common and challenging anxiety symptoms is anticipatory anxiety. The purpose of this article is to discuss anticipatory anxiety within the context of veterinary medicine, describe the common symptoms, and offer strategies for coping.

Understanding anticipatory anxiety

Anxiety is a normal human process and a reaction to stress. Anxiety only becomes a problem when it involves excessive fear or worry that affects an individual’s well-being and functioning.¹

Although not considered a diagnosable mental health disorder, anticipatory anxiety is challenging but manageable.² Anticipatory anxiety involves an excessive or debilitating level of worry about a future event or situation, and it tends to focus on negative outcomes.³

Of course, some level of worry, concern, or even stress about future occurrences is typical and understandable. For example, if you are performing anesthesia on a healthy pet for a routine procedure and you notice that its heart rate suddenly drops into the 30s, becoming worried or anxious is totally normal/healthy. However, anticipatory anxiety occurs when the worries become extreme and negatively affect our personal and professional lives because of the potential emotional and even physiological consequences that can result.

Anticipatory anxiety is the type of anxiety individuals experience when they anticipate exposure to triggers that are frightening to them. For example, someone who is claustrophobic may worry about feeling confined on an airplane. Or if someone is afraid of turbulence, they may worry that their flight next week will be rough.⁴

Anticipatory anxiety fuels one’s need to avoid contact with causes/sources of anxiety. It drives individuals to avoid their irrational fears (phobias) and uncertainties. Anticipatory anxiety can be exceptionally strong and challenging to eliminate. As seen in the above example, it can maintain and intensify a fear of flying.⁴

Ironically, as with all aspects of anxiety, anticipatory anxiety is completely paradoxical. One’s efforts to avoid it only result in it becoming more intensified. The anticipatory anxiety precipitates more anxiety.⁴

Here are some important aspects of anticipatory anxiety⁴:

• It is not an actual predictor of the level of anxiety an individual will feel during the situation itself; 95% of the time, anticipatory anxiety is much greater than the anxiety experienced when contact is made with what causes the fear.
• It is real anxiety but differs from the anxiety experienced during the situation that triggers a reaction. This is supported by research demonstrating that anticipatory anxiety and phobic avoidance (eg, avoiding flying) are produced in separate areas of our brains.
• Anticipatory anxiety can appear rapidly but is slow to disappear. Its persistent nature makes it challenging to overcome.
• A formula for maximizing anticipatory anxiety relates to an internal “Should I or shouldn’t I” debate about experiencing short-term relief (eg, canceling a flight). This essentially reinforces an individual’s fear or phobia, rendering them less capable of managing their anxiety. The decision to conquer the phobia or fear will reduce anticipatory anxiety but not eliminate the fear.

Anticipatory anxiety in veterinary medicine

Individuals with anticipatory anxiety may feel anxious for hours, days, weeks, or months before an event.¹ In their professional domain, individuals may experience anticipatory anxiety before work meetings or presentations, interviews, musical or athletic performances, or social events. Individuals also may have anticipatory anxiety about potential future occurrences such as natural disasters, the death of a loved one, or a relationship breakdown.³

Other examples include a well-trained newly graduated veterinarian who isn’t comfortable with emergencies and fears that a critical care case may come in on their next day at work. Or a veterinarian who doesn’t enjoy surgery and fears that there may be a large breed dog that needs a deep-chested gastropexy on their next surgery day.

Let’s examine how anticipatory anxiety might manifest in the routine gastropexy mentioned above. You might start worrying that something could go wrong the day before the procedure to the point that you don’t sleep well. The day of the procedure, you are short with your team members and aren’t fully present for your other duties of the day. Unnecessary worry and fear surrounding something that isn’t likely to happen is anticipatory anxiety.

These represent common anxiety-provoking situations for veterinary professionals. They can generate anxiety-related feelings and reactions regarding potential worst-case scenarios pertaining to potential outcomes, which may never happen. Two elements are clearly discernible: Each scenario encompasses future-based thinking about an event that has not yet occurred, and the feared negative outcome specific to each event may never occur at all.

Anticipatory anxiety symptoms

Anticipatory anxiety causes individuals to automatically assume the worst-case scenario when faced with a perceived challenge or difficulty. They also may experience stress about situations that have yet to happen or find themselves anticipating disaster around every corner.³

Additionally, the prospect of making a decision typically leaves individuals feeling overwhelmed and paralyzed. From subtle avoidance behaviors to the most nightmarish terrors, anticipatory anxiety is the engine that drives it all. Understanding how this hidden enemy tricks you, and, most importantly, how to overcome it will liberate you to live a more flexible and joyful life.⁴

Notably, those who experience anticipatory anxiety will typically have other anxiety symptoms, which may differ from one individual to another. Each anxiety disorder has its own symptoms, which can vary in intensity and duration.⁵

Some common symptoms of anticipatory anxiety (and anxiety in general) include the following⁵:

• feeling apprehensive or having a feeling of dread
• feeling tense or jumpy
• being restless or irritable
• anticipating the worst
• watching for signs of danger
• feeling short of breath or having a pounding or racing heart
• experiencing headaches, fatigue, and insomnia
• sweating, trembling, or twitching
• having an upset stomach, frequent urination, or diarrhea

Suggestions and strategies for coping

Good self-care begins with taking care of your basic needs.⁵ Tips to help with anticipatory anxiety and reduce fear and uncertainty about the future include the following:

• Reduce sources of stress where possible.
• Eat a balanced diet and limit caffeine and sugar, which can make anxiety worse.
• Exercise regularly, as research indicates it can reduce anxiety.
• Get enough sleep. Go to bed at the same time each night and get up at the same time each morning. Anticipatory anxiety may cause sleep disturbance and insomnia, and sleep deprivation worsens anxiety. Breathing exercises or meditation may help you fall asleep more easily. If you’re struggling with chronic sleep disturbance, see a doctor if mindfulness activities do not help.

Practice relaxation and grounding

Techniques to help relaxation can reduce anxiety over time and enhance sleep quality. Therapists can share useful methods such as deep breathing, progressive muscle relaxation, guided imagery, and grounding techniques. Also, there are numerous online videos and apps that detail each process.⁵

These techniques are not a cure for anxiety. If used incorrectly, they can serve as avoidant coping.³ Ideally, these exercises should be practiced at scheduled times, rather than when you are feeling anxious. A health care professional can help you mindfully incorporate relaxation techniques into various types of therapy.⁵

Journal

Journaling may help reduce anxiety by exploring your fears and triggers. Do this with the guidance of a trained mental health professional to avoid rumination (dwelling on negative thoughts) or developing a compulsion that functions as avoidant coping.⁵

Address negative thoughts

Changing your thinking can help change your mood. Do this by considering the source of the anxiety and the negative thoughts that are generated. Then explore how realistic these thoughts are. Instead of imagining a worst-case scenario, challenge negative thoughts when they arise, and these thoughts should become less frequent over time.

Practice self-compassion

Self-compassion—treating oneself with kindness and care in negative situations—may reduce anticipatory anxiety. For example, practice self-compassion by exploring how you might treat a friend who was having anticipatory anxiety. Often we are kinder to others than we are to ourselves.

Working through anxiety

• Take charge of the situation. For example, if you are anxious about a job interview, it may be helpful to practice answering interview questions with a friend or family member.
• Stop worrying about what might happen. Start facing your fears, rein in your self-defeating imagination, and live fully in the moment.
• Label your anticipatory anxiety for what it is—anticipatory anxiety.
• Know that anticipatory anxiety does not accurately indicate your actual level of anxiety when encountering your anxiety trigger. Remember that 95% of the time your anticipatory anxiety will be greater than the anxiety experienced when in that situation.
• Make a commitment to follow through with the triggering event. A “Should I or shouldn’t I” debate will only intensify anticipatory anxiety. The commitment to follow through and face your fear will prevent it from increasing.
• Remember that dealing with anticipatory anxiety can be a learning experience about how powerful an effect your brain can have on your feelings. Anticipatory anxiety is a real anxiety but it is 100% generated by your mind’s images—there are no physical or behavioral triggers for this anxiety.⁴

Professional therapy and medication

Treatment options for anxiety may require the assistance of mental health or medical providers or other licensed professionals. There are prescription medications to help manage anticipatory anxiety and other anxiety symptoms. Although primary care physicians can diagnose and manage anxiety, they may recommend that you consult a psychiatrist for severe anxiety, concurrent disorders, or treatment-resistant anxiety disorders.⁵

Wait to worry

Many of us are worrying more and more about things that may never happen, and we waste a lot of mental energy and time doing so. I encourage patients to remember and incorporate a 3-word mantra to enable them to identify and then help them manage their anticipatory anxiety: “Wait to worry.” This approach helps many of them realize what is supported by anxiety research and gives them a simple strategy. More importantly, this phrase reinforces that what they fear, in all probability, will never happen. Incorporating this strategy has proven helpful for many.

Conclusion

Although some anxiety before events and situations is common, excessive levels of anticipatory anxiety can suggest an anxiety disorder.¹ If you have overwhelming fears or worry about the future, contact your physician or a mental health professional. Overall, living with an anxiety disorder can be challenging, but such conditions are highly manageable with therapy, medications, or both.

Barry N. Feldman, PhD, is the behavioral health consultant for Get MotiVETed. He is a nationally recognized educator, trainer, and investigator in suicide intervention and prevention and has worked with many veterinary-related institutions.

References

1. Vassilopoulos SP, Moberly NJ, Tsoumanis P. Social anxiety, anticipatory processing and negative expectancies for an interpersonal task in middle childhood. J Exp Psychopathol. 2014:151-167. doi:10.5127/jep.032412
2. Anxiety. American Psychological Association. Accessed May 20, 2022. https://www.apa.org/topics/anxiety
3. What to know about anticipatory anxiety. Medical News Today. Accessed May 21, 2022. https://www.medicalnewstoday.com/articles/anticipatory-anxiety#what-it-is 
4. Winston SM, Seif MN. Overcoming Anticipatory Anxiety: A CBT Guide for Moving Past Chronic Indecisiveness, Avoidance, and Catastrophic Thinking. New Harbinger Publications; 2022.
5. Anxiety. Psychology Tools. Accessed May 21, 2022. https://www.psychologytools.com/self-help/anxiety/