Clinical Anxiety: When Pre-Performance Jitters Become Chronic

Junior high is brutal for many people. And Alyssa Marciniak, a newbie at a Catholic middle school outside Orlando, Florida, was no exception.

The kids were mean, and the teachers turned the other cheek, Marciniak recalls. Her classmates would say things like, “Your face is ugly,” or “Why are you looking at me?” “I kind of tried to be invisible,” she says.

By the time Marciniak reached high school, she was afraid to look anyone in the eye. The first time she had to do a class presentation in the ninth grade, she broke out in tears. By that time, she had transferred to a public school, and her new teachers were concerned. Marciniak’s mother sent her to a therapist, who said Marciniak had social anxiety.

Things slightly improved throughout Marciniak’s school years. “Kids weren’t mean to me. I just had the reputation as the really quiet girl,” she says. Therapy took the edge off her anxiety — especially group therapy, where “it was nice to know I wasn’t alone,” she says.

Now, as a 27-year-old market research analyst for an applied research firm in the District of Columbia, Marciniak looks back at her 14-year-old self and realizes she’s come a long way. At the same time, overcoming anxiety doesn’t have a quick fix, but rather is a “long process,” she says, akin to “chipping away at fear.”

How Chronic Anxiety Works

Chronic anxiety is a real condition for many people. In fact, anxiety disorders are the most common psychological condition in the U.S., and they include generalized anxiety, obsessive-compulsive disorder, social anxiety, panic disorder and post-traumatic stress disorder.

What makes chronic anxiety different from run-of-the-mill pre-performance jitters is what Maggie Perry, a psychology associate at the Anxiety and Stress Disorder Institute of Maryland in Baltimore, calls the “second fear.”

“The second fear is the fear of the fear [that anxiety invokes],” Perry says. “It creates all kinds of resistances and avoidances that end up ruining your life.” This level of impairment distinguishes chronic anxiety from episodic anxiety, which is what many of us experience before we have to give a speech or do something daunting. “The sweaty palms and ‘what ifs?’ are all part of the fight or flight response triggered when we are doing something challenging,” Perry says. “No matter how intense it gets, it will never be an anxiety disorder.”

And for most people, those anxious moments pass when the trigger is over. Those for whom anxiety persists seek professional help, usually because they’re afraid of something outside themselves, Perry says. This may include a fear of dogs, getting cancer or driving. “They assume the problem is outside themselves, but the triggers are actually internal: a sensation, a thought or memory, and the anxiety disorder basically develops in response to these,” Perry adds.

So people with a panic disorder, for example, may feel panicked while in a crowded space or just before an exam. They take it to the next level by letting that panic consume them to the extent that they fear the panic attack itself, even imagining it could kill them, Perry says. As a result, people will just avoid a potentially traumatic situation.

“The more you avoid it, the scarier and scarier that thought becomes,” Perry says. “No matter what the original trigger was, at this point it’s self-maintaining because [people] are responding as if it’s a threat.”

A ‘Mindful’ Approach to Treating Anxiety

For that reason, a treatment called mindfulness-based behavioral cognitive therapy initially focuses on educating patients about what’s going on in their minds, Perry says. That way, they can anticipate their own anxiety and recognize it for what it is, which helps alleviate at least part of the anxiety. “Our research shows that seeing thoughts for what they are is the best way out,” she says.

However, that doesn’t necessarily mean ruminating about the origin of the trigger — say, a painful past event or a particular family dynamic, Perry continues. “Focusing on ‘why’ doesn’t bring relief. From the beginning, I like to tell people to take out the ‘why’ and stay with the ‘how [it makes you feel].'”

That said, it can be important to be aware of anxiety that runs in families, since anxiety disorders have both biological and environmental causes, Perry says. And certain disorders, like panic disorder, run more strongly in families than other disorders, adds Richard Maddock, a psychiatry professor at the University of California — Davis.

Maddock’s research looks at underlying biological changes that occur during panic attacks, like the accumulation of lactic acid, a chemical compound produced in muscles during exercise. “It would be nice if we could find treatments to mitigate this underlying biology,” Maddock says, adding that exercise alone can probably help many people. “When people do it regularly, their bodies get more efficient at metabolizing lactate.”

Other Self-Help Methods

Exercise also helps people with PTSD, and antidepressants can generally be helpful for those with all types of anxiety disorders, he adds.

Breaking out of therapy and medications altogether has helped some people. Marciniak, for example, recently tried improvisational theater classes for the first time in her life; she decided to give it a try after freezing up at a work presentation last summer. Acting was her hidden passion growing up, but her anxiety prevented her from doing it.

The result was great — much more effective and fun, she says, than all those years of therapy. The magic of improv for her, she suspects, has been realizing that it’s OK to be or look silly — in part because everyone else is, but also because when it happens, the world doesn’t actually end.

It’s also empowering, she adds. Unlike therapy, where a measure for overcoming anxiety might have been going to the grocery store, doing improv is something many people without anxiety find daunting. So the feat feels real. “Not everyone can do that, so it’s a legitimate thing,” she says.

Kristine Crane is a Patient Advice reporter at U.S. News. You can follow her on Twitter, connect with her on LinkedIn or email her at