Practical Buddhism:

Strategies for Managing Anxiety

Nalaka Gooneratne, MD, MSc

Helen Rosen, PhD

Disclosures

• Nalaka Gooneratne: No equity, intellectual property, consulting or other financial support from outside companies in the past year related to this topic.
• Dr. Gooneratne conducts research supported by the NIH and the University of Pennsylvania; this research is overseen by independent regulatory agencies.
• This presentation should not be viewed as a substitute for professional diagnosis, treatment or other advice.
• We encourage you to always obtain the professional advice of your physician or other qualified provider for specific psychologic/psychiatric/medical conditions.

What are the types of Anxiety Disorders?

Overview

• Review of psychiatric/psychologic categories
• Major disorders
• Personality Disorders
• “Normal” anxiety: focus of our session

DSM-IV Framework

• Axis 1: Mental health disorders
• Clinical disorder that can cause profound disruptions and may require hospitalization
• Ex: PTSD, Depression, Schizophrenia
• Axis 2: Personality disorders
• Personality traits that may contribute to Axis 1 disorders or become severe enough to turn into Axis 1 disorders
• Ex: Narcissistic, Paranoid
• DSM-V has dropped the multi-axis model

Widiger and Shea, J Abn Psychol 1991

Ekselius, Ups J Med Sci, 2018

Anxiety Disorders

• Anxiety/worry is a survival tool
• Problematic Anxiety: Definition
• Be out of proportion to the situation or age inappropriate
• Hinder your ability to function normally

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American Psychiatric Association https://www.psychiatry.org/patients-families/anxiety-disorders/what-are-anxiety-disorders

Anxiety Diagnoses

• Generalized Anxiety Disorder
• Chronic/persistent levels of anxiety
• Phobias
• Usually specific to a certain event/condition
• Panic Disorder
• Strong physiologic reaction
• Social Anxiety
• Separation Anxiety

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OCD/PTSD Disorder

• Are also characterized by significant levels of anxiety/fear
• Are in different chapters than Anxiety Disorders in DSM-V
• Characterized by obsessive thoughts and repetitive behaviors
• Repetitive behaviors intended to reduce anxiety
• Thoughts are excessive or unreasonable

Personality Disorders

• Three clusters in DSM-V
• Cluster A: Odd/Abnormal behavior (paranoid, schizoid)
• Cluster B: Dramatic behavior (histrionic, narcissistic)
• Cluster C: Anxiety
• Obsessive-Compulsive Personality Disorder (less severe than Axis 1 OCD)
• Avoidant (aka Anxious Personality Disorder): Avoids new situations, etc.
• Dependent: Need excessive reassurance from others)

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“Normal” Anxiety**

• Anxiety/worry/stress necessary as a survival tool
• Physiologic basis: Fight or flight mechanism
• Can still cause momentary distress or disproportionate/counterproductive response
• Can be a tool to motivate our practice
• “there is the case where a monk considers, ‘O when will I enter & remain in the dimension that those who are noble now enter & remain in?’ And as he thus nurses this yearning for the unexcelled liberations, there arises within him sorrow based on that yearning.”—-MN 44
• Focus of our session on Buddhist perspectives will address management of normal anxiety
• Management of clinically significant Anxiety Disorders, OCD/PTSD is best handled by a mental health professional

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Anxiety is counterproductive in Buddhism

“Meditating in this way, they don’t grasp at anything in the world. Not grasping, they’re not anxious. Not being anxious, they personally* become extinguished. They understand: ‘Rebirth is ended, the spiritual journey has been completed, what had to be done has been done, there is nothing further for this place.’ That’s how I briefly define a mendicant who is freed through the ending of craving, who has reached the ultimate end, the ultimate sanctuary from the yoke, the ultimate spiritual life, the ultimate goal, and is best among gods and humans.””

MN37 Cūḷataṇhāsaṅkhayasutta “The Shorter Discourse on the End of Craving”https://suttacentral.net/mn37/en/sujato

*Refers to dissolving the sense of self/ego that arises from the five aggregates of self which is necessary to transcend samsara and enter nirvana.

Uttara Sutta

“Life is swept along,

next-to-nothing its span.

For one swept to old age,

no shelters exist.

Perceiving this danger in death,

one should drop the world's bait and look for peace.”

SN 2.19

Uttara Sutta: Uttara the Deva's Son

translated from the Pali by

Thanissaro Bhikkhu

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Role of Self

• A key factor contributing to normal anxiety: desire to preserve/protect “self”
• “…regards body as the self…Change occurs to this man's body, and it becomes different. Because of this change and alteration in his body, his consciousness is preoccupied with bodily change. Due to this preoccupation with bodily change, worried thoughts arise and persist, laying a firm hold on his mind…”
• SN 22.7 Upaadaaparitassanaa Sutta: Grasping and Worry, translated by Maurice Walshe

Self and the Five Aggregates**

• Self in Buddhism is deconstructed into the five aggregates
• Form
• Perception
• Feeling
• Mental Volition
• Consciousness
• Anxiety can arise from any of these aggregates

Role of Change**

• Change in our lives is a constant source of anxiety
• Five aggregates of self arise from changing conditions

Strategies: Disclaimer

• Approaches we will be discussing are relevant for normal, day-to-day anxiety
• Consult with a healthcare provider if:
• Thoughts of self-harm or harm to others
• Impairment in ability to function

Strategies: Principles

•De-personalizing situations (non-self or anatta)

•Recognizing clinging/grasping

•Accepting change (anicca)

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Strategies: Implementing**

•Awareness of our internal state: gradual rise of anxiety

•Simplified Affective Labelling (MN19)

•Disengagement strategies (MN20)

•Calming: Mindfulness of Breathing (MN118)

•Compassion: Metta meditation (SN1.8 Karaniya Metta)

•Reflecting on positive qualities (AN 11.11: With Mahānāma)

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Conceptual Approach to Anxiety

This framework is displayed in more detail on the next slide

Other Suttas: MN146

“Sisters, by developing and cultivating these seven awakening factors, a mendicant realizes the undefiled freedom of heart and freedom by wisdom in this very life. And they live having realized it with their own insight due to the ending of defilements.

What seven?

It’s when a mendicant develops the awakening factors of mindfulness, investigation of principles, energy, rapture, tranquility, immersion, and equanimity, which rely on seclusion, fading away, and cessation, and ripen as letting go.” (emphasis mine)

-MN146, Advice from Nandaka, translated by Bhikkhu Sujato

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Acknowledgements

The members of SuttaCentral: Discuss and Discover who provided feedback/input on this topic

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