By Mara Baer

“Anxiety” made her debut last month on the silver screen in the “Inside Out” sequel and I jumped at the chance to see it with my 12-year-old daughter.

"Inside Out 2" is an imaginative exploration of the human experience, centered around a girl named Riley, set primarily within her mind, where her emotions live in “Headquarters” and guide her through life's experiences. Both the original movie and sequel provide an insightful look at the inner workings of the mind with humor and heart. Although geared towards kids, they provide some great lessons for adults too.

As someone who experiences anxiety, I was interested to see how Disney and Pixar portrayed this character. Anxiety can be an alarming reaction to one’s environment, causing uncertainty, worry and fear.

People like myself who live with chronic pain have elevated anxiety symptoms. Because the region of the brain responsible for generating pain is also partially responsible for anxiety, these connections should not be surprising. I know when I am having anxiety, but it is often hard to understand.

Inside Out’s new character drew me to the story of Riley, a 13-year-old girl in the throes of puberty, who is learning how to manage new feelings. The first movie introduces us to the characters of Joy, Sadness, Fear, Anger and Disgust, with each character’s physicality depicting their primary emotion.

In the sequel, five new emotions show up, just as Riley’s pubescent hormones take hold. In addition to Anxiety, there are Envy, Embarrassment, Ennui, and Nostalgia:

We can all recall our teenage years, when anxiety, envy, embarrassment and ennui became frequent visitors and often defined our interactions. Nostalgia pops up on occasion, to be told by the others that it isn’t her time yet and that she should come back later. Next movie, perhaps?

Anxiety is an eye bulging, shaky, intense character aglow in shades of orange. Her wiry hair and floating eyebrows make clear that Anxiety is intense, alert, and always “on.” While Anxiety’s goal in the movie is to keep Riley safe and protected, she eventually becomes destructive, pushing Riley’s limits in a hockey game in the name of “winning” and at the cost of her true self.

As someone known as a planner (sometimes to a fault), I relate to Anxiety’s need to think ahead and prepare for every problematic scenario, sometimes at the expense of my underlying values. This is the tension with anxiety, always pushing us to the limits for a cause, even at the expense of the individual experiencing it.

Knowing this tension and the shared brain region informing both anxiety and chronic pain got me thinking. What other ways are these two connected? 

As I explained in my article in Chronic Pain Chats, when we experience pain for more than three months, neural pathways can be altered, creating pain signals that are very difficult to turn off. Anxiety can be similar, sending negative feelings and thoughts into a spiral that can feel uncontrollable.

In Inside Out 2 (spoiler alert), Anxiety continues to push Riley at hockey camp to help her achieve success and build new friendships. In doing so, she ignores old friends, begins to fight with her parents, and eventually injures a friend in a game meant to determine if she would make the high school team. She is laser-focused on winning and loses touch with who she fundamentally is.

Chronic pain can do this too, becoming the center of our journey, disrupting our life path, our relationships, and who we are. Both anxiety and pain have robbed me at times of feeling like my true self. Riley experiences the same with Anxiety.

The similarities do not end here. Both anxiety and chronic pain are associated with physical sensations, feeling overwhelmed, excessive worry or fear, negativity, sleep problems, and avoidance. Anxiety can also exacerbate pain levels and lower pain thresholds. 

When Anxiety goes into overdrive during that hockey game, Riley experiences a panic attack. The audience watches as Anxiety goes into a trance-like state, trying to protect Riley and “fix” what has gone wrong, eventually sending Riley to the penalty box in a very powerful scene.

I saw my own anxiety in Riley’s, and feelings of sadness overcame me as I watched how strong and influential my own anxiety can be. That scene in the movie stuck with me, so much that it prompted me to investigate the anxiety/pain relationship and write this article. While I understand a bit better now why anxiety must exist, it can be distracting at best and debilitating at worst. 

How I Manage Anxiety

The key to managing anxiety is how I interpret its function in my life, starting with how I define it.   

While the movie portrays Anxiety as an emotion, there is some debate in the literature about whether it is. Some experts define anxiety as a state of being with feelings at its root -- what’s been called a “visceral form of emotional resistance.”

In essence, when anxiety is happening, it is because our brain is trying to protect us from a fundamental emotion that feels scarier and more threatening than anxiety itself (i.e., fear). Chronic pain is similar, sending a signal to try protect us from physical harm, even if the threat of harm is no longer there.

Other experts see anxiety as a  secondary emotion, meant to replace a more difficult primary emotion. Dr. Lauren Gorog, a Clinical Health Psychologist in Colorado, defines anxiety as a conditioned response (think mental, emotional, behavioral response) to fear. She says anxiety is typically driven by deep beliefs of inadequacy and our human tendency to “awfulize” an unwanted outcome. That can lead to a physiological and psychological state of hyperarousal that produces a distressed emotional state, with a host of mental, physical, and behavioral symptoms that negatively impact virtually all parts of our lives.

While the debate over anxiety’s role will no doubt continue, I choose to NOT define my anxiety as a simple emotion, because it takes away my ability to do something about it. Like pain, not all anxiety is bad, and both have protective factors. But we can still choose how we respond to each. 

Irrespective of whether we call anxiety an emotion or not, it is grounded in one’s mindset and can change. In fact, the best way to counter anxiety is to “feel your feelings.” Many people with chronic pain do not do this, pushing away feelings that harbor themselves in the body, which leads to more pain for longer periods of time.

Interestingly, similar strategies can be used to address chronic pain, including somatic tracking and Pain Reprocessing Therapy, which focus on paying attention to pain without judgement or fear, which has been proven to lead to less pain. 

At the end of the Inside Out 2, Joy tells Anxiety: “You don’t get to choose who Riley is. You need to let her go.”

Anxiety doesn’t choose who I am. Neither does pain. I will make sure of it. 

Mara Baer lives with Thoracic Outlet Syndrome, a nerve entrapment condition that causes severe pain. Mara is the founder of AgoHealth, a health policy consulting firm. She also serves on the Science and Policy Advisory Council for the National Pain Advocacy Center and publishes Chronic Pain Chats, a free newsletter.