November 27, 2024 • Brooke Siem
The 10 Most Important Ideas from The Anatomy of Anxiety by Dr. Ellen Vora: Understanding and overcoming the body’s fear response.
In the year before and months after MAY CAUSE SIDE EFFECTS released, I didn’t read a single book. I’d just finished writing one, and reading other people’s work did nothing but invite comparison and insecurity. But something shifted when we flipped the page to 2023, and I’m back to devouring books at all hours of the day.
Among the stack I’ve recently finished is Dr. Ellen Vora’s The Anatomy of Anxiety: Understanding and Overcoming the Body’s Fear Response.
Ellen is a Yale and Columbia University educated, board-certified psychiatrist who speaks openly about antidepressant withdrawal and the overprescription epidemic. Though Ellen and I haven’t ever met, we’re in occasional contact since she’s one of the few working psychiatrists with the balls to speak out about the pill for every ill “strategy” that seems to be doing more harm than good. Also an acupuncturist and yoga teacher, she practices from a functional-medicine foundation, meaning she believes most (if not all) mental health issues are caused not by disease or a chemical imbalance but by everything from unresolved trauma to lifestyle choices to blood sugar crashes.
The perk of this approach is that unresolved trauma, lifestyle choices, and blood sugar crashes are all things we have the power to fix. What a concept!
The conventional theory of anxiety is that it exists in the head and causes downstream, emotional and physical effects. In The Anatomy of Anxiety, Ellen argues that anxiety begins in the body, and that it’s the physiological stress response that causes mental anguish. Said another way, our brain chemistry changes as a result of an imbalance in the body, not the other way around. This is good news, she says, because this anxiety is both preventable and responsive to basic adjustments to habits, diet, and lifestyle.
Just as I did with Johann Hari’s Stolen Focus, I’ve compiled what I think are the 10 most important and interesting ideas from Ellen’s book. One caveat: The Anatomy of Anxiety is an outstanding starting point for those beginning to explore the mind-body connection and the basic science of anxiety. For those of you who spend a lot of time in this space, you’ll likely recognize much of the content. I worry that my familiarity with the topic means I’ve skimmed over obvious lightbulb moments. Thus, if you’re someone who struggles with anxiety and you don’t spend your free time nerding out over the science like I do, I highly recommend you take my word for it and get a copy for yourself. Understanding how your body works and why it reacts the way it does is a key first step in managing and healing anxiety.
Onward to the good stuff! (Bold emphasis mine.)
1. On true anxiety vs. false anxiety
Ellen likes to differentiate from “true anxiety” and “false anxiety” in order to help her patients understand what is anxiety they can control (false), and what is anxiety that’s baked into human existence (true)
“False anxiety is the body communicating that there is a physiological imbalance, usually through a stress response, whereas true anxiety is the body communicating an essential message about our lives. In false anxiety, the stress response transmits signals up to our brain telling us, something is not right. And our brain, in turn, offers a narrative for why we feel uneasy…this type of anxiety is not here to tell you something meaningful about your deeper self; rather, it’s offering a more fundamental message about your body. When we recognize that we are experiencing anxiety precipitated by a physiological stress response, we can address the problem at the level of the body, by altering our diet or getting more sunshine or sleep. In other words, false anxiety is common, it causes immense suffering, and it’s mostly avoidable.”
True anxiety arises from having strayed from a vital sense of purpose and meaning. This anxiety is what it means to be human—to know the inherent vulnerability of walking this earth, that we can lose the people we love and that we too, will one day die…it is essentially a guide for how to make our lives as full as they can be.
2. On anxiety as a genetic disorder
Between 2019 and 2021, the Kaiser Family Foundation estimated that rates of anxiety and depression skyrocketed by 270 percent.
Genes simply don’t adapt that quickly, which punctures quite the hole in the theory of anxiety as a genetic disorder. (Never mind the fact that an “anxiety gene” has never been identified.”
Ellen says: “These rates would not have risen so precipitously if these disorders had a predominantly genetic basis—which was our presiding understanding over the last several decades. Our genes cannot adapt so quickly as to account for our recent catapult into anxiety. It stands to reason that we are increasingly anxious because of the new pressures and exposures of modern life—such as chronic stress, inflammation, and social isolation. So, odd as it may sound, this recent acceleration is actually good news because it means there are straightforward changes we can make.”
3. On the body’s stress response, or why modern life is a mild threat to survival
Though we have the same stress response as we did thousands of years ago—when stress meant running from a saber-tooth tiger or finding consistent food supply—modern life gives us a very different set of circumstances to cope with. Rarely are we in life or death situations and instead experience regular, low-grade stressors like a bloated email inbox or road rage.
Still, “with our modern diets and habits—which frequently trigger stress responses in our bodies—many of us live in a near constant state of feeling under siege. Your blood sugar is crashing after eating something sweet? The body interprets this as a mild threat to survival. You stay dup too late doom scrolling on your phone? The body feels surrounded by danger. Sleep deprivation, chronic inflammation from eating foods you don’t tolerate, and the comment section on Twitter—these are all, from your body’s perspective, indications that your environment is not safe. So, the body releases stress hormones into your bloodstream, and this invisible chemical cascade manifests as the feelings and sensations of false anxiety.”
4. On taking a false anxiety inventory.
Because false anxiety is often caused by outside stressors, it’s also manageable if you know what to look for. The book goes into the science behind each of these bullet points, but as a starting point, here are Ellen’s recommendations for “pausing in the midst of turmoil” in order to understand the particular false anxiety that’s occurring as well as how to address it:
“I’m anxious, and I’m not sure why. Am I…
- Hungry? (eat something)
- Sugar-crashing or having a chemical comedown? (Did I just eat something sweet, processed, or laden with food coloring or preservatives? Have a snack and focus on making different choices next time.
- Overcaffeinated? (Perhaps this jittery anxiety is really caffeine sensitivity; tomorrow, drink less caffeine.)
- Undercaffeinated? (I drank less caffeine today than usual; dose up and aim for consistent daily caffeine consumption going forward)
- Tired? (Take a nap; prioritize an earlier bedtime tonight.)
- Dehydrated? (Drink some water.)
- Feeling sluggish? (Take a quick walk outside; dance.)
- Dysregulated? (Did I just engage in an internet rabbit hole or social media binge? Dance or go outside to rest the nervous system.)
- Drunk or hungover? (File this away to help inform future choices around alcohol.)
- Due for a dose of psychiatric medication? (Right before the next dose, I’m at the pharmacological nadir—or the point where the level of medication in my bloodstream is at its lowest, and this can affect mood. Time to take meds.)
(A note from Brooke in bold: I’d argue that the last bullet point could also include, “Time to take meds or if coming off meds, recognize this as a sign of psychiatric drug withdrawal and be kind to yourself.” )
5. On true anxiety as a superpower.
True anxiety serves a purpose in society, as demonstrated by this fascinating 1980s study of primates:
“Studies of primates show that some members of the tribe are more anxious than others—these are the ones that tend to hang back, gathering the peripheries of the main group. In the 1980s, the late zoologist Dian Fossey decided to remove these more sensitive members of one group of chimpanzees to see how it would affect the rest of the community. Six months later, all the chimps were dead. ‘It was suggested that the anxious chimps were pivotal for survival,’ Sarah Wilson writes compellingly of this experiment in her book First, We Make the Beast Beautiful. ‘Outsiders, they were the ones who were sleeping in the trees on the edge, on the border, on the boundary of the community. Hyper-sensitive and vigilant, the smallest noise freaked them out and disturbed them, so they were awake much of the night anyway. We label such symptoms anxiety, but back when we were in trees, they were the early warning system for the troop. They were the first to scream, “Look out! Look out!”’”
(Side note, I’ve never used that many quotation marks before. My 10th grade English teacher Mrs. Utter would be proud.)
Though this study was on monkeys, the same can be said about more sensitive and anxious folks in the world. They alert everyone else to potential problems and dangers. (I.E., climate activists.)
6. On middle of the night blood sugar crashes that lead to poor sleep
The most positive (and counterintuitive) change I ever made to my sleep hygiene was when I started eating a hefty portion of starchy carbs at dinner.
Prior to this directive—which came from a high performance nutritionist and professor of muscle science at Cal Fullerton—I’d often skimp on starchy carbs at dinner in order to rationalize dessert, or go low-carb all together in a misguided attempt to cut calories and stay lean. My shitty sleep, I assumed, was unrelated.
As it turned out, this strategy was causing blood sugar spikes and crashes (with dessert) or causing overall low blood sugar (low-carb) that disturbed my sleep. When I added about a cup of cooked white rice or potatoes to the meal, my sleep issues evaporated. What happened?
Ellen explains: “If you typically get ‘hangry’—angry and irritable when you’re hungry—at 3pm, the overnight equivalent is waking up at 3am with racing thoughts, unable to fall back asleep. This typically happens when your blood sugar crashes overnight and your body counters with a stress response…a stress response can make your sleep more superficial, shunting you out of the deeper stages of sleep and making it more likely you’ll be jolted awake.”
The solution is to stabilize blood sugar throughout the night. I do this with a big, starchy carb heavy (but low sugar) meal. Ellen likes to eat a spoonful of almond butter before bed, and eats another spoonful if she wakes up jittery and anxious.
7. On the connection between processed food and anxiety.
“Our bodies are increasingly bombarded with unrecognizable chemicals and food—ranging from pesticides to phthalates to Pop-Tarts (essentially, foreign agents our bodies didn’t evolve to deal with)—that provoke the immune system in much the same way a genuine infection would. A daily ingestion of Doritos, for instance, leaves the immune system belligerent and confused. It keeps fighting, thinking it stands a chance at killing off the ‘infection’ of Doritos, but our immune system isn’t build to defeat chips—not to mention that we get ‘reinfected’ with every snack. Over time, a consistently inflammatory diet can result in a dysregulated, hyper-vigilant immune system, an inflamed body, and sustained feelings of depression or anxiety.”
8. On our assumption that calm should be the default state.
“The body is hardwired for survival,” Ellen says, “not for feeling calm.”
She’s says this in the chapter about psychiatric drug withdrawal, specifically in relation to benzodiazepines. But what I find most interesting about the statement is that we’re all walking around under the assumption that calm should be the norm and anxiety a pathogen to eradicate.
In reality, a part of our body is always looking out for dangers. It’s why we startle when we hear an unfamiliar thunk. Debilitating anxiety needs to be dealt with, of course, but bouts of it is just the body doing its job of trying to stay alive.
9. On allowing children to feel big feelings—including anxiety
“We’re taught from a young age that when something is difficult, it is necessary to distract ourselves. When a child has a tantrum, we think, How can I make the crying stop? We know that if we hand the kid some sugar or a screen, they’ll probably be satisfied. Problem solved, right? Well, actually, now we’ve taught the kid: I can’t handle your big emotions, you can’t handle your big emotions, and should ever feel big emotions in your future life, quickly find something that will distract you, offer you a hit of dopamine, or numb you out. It’s no wonder even we adults turn to our phones or emotional eating when in fact we just need to feel our feelings and let our tantrums run their course.”
10. On the illusion of safety.
This is where true anxiety comes into play. Safety is an illusion. All our effort put into keeping our kids “safe,” building equity, or eating clean could be undone in a matter of moments. We do these things to bring a sense of order into our lives, but trying to white-knuckle our way to control often creates the exact anxiety we’re trying to prevent.
“We are anxious and exhausted because wee are fighting with reality, beliving things are supposed to go a certain way. Instead of showing us where we need more control, anxiety actually alerts us to where we need to let go; when we need to take a breath and patiently, courageously see where our particular path will take us.”
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