I’ve been involved in the mental health system since I was four years old. I was diagnosed as autistic and ADHD in sixth grade along with GAD and MDD, and I’ve tried over a dozen meds to regulate my so-called anxiety and depression alongside a decade and a half of therapy. Maybe I do have those conditions, but it’s possible that things are more physiological than they seem.
Here’s a description of a high-anxiety day for someone who has an anxiety disorder, helpfully contributed by ChatGPT:
“A high-anxiety day feels like your brain got stuck in overdrive and forgot where the brakes are. There’s an unshakable sense of dread, like something is about to go wrong, even if nothing is happening. Your thoughts spiral—tiny worries become massive problems, and no amount of logic makes them go away. Your heart races, your chest feels tight, and your stomach is uneasy, as if you’re bracing for impact. You might feel restless and jittery or drained and paralyzed—sometimes both, cycling between agitation and exhaustion.
Small tasks feel overwhelming. Answering a text? Feels like an exam. Picking a lunch spot? Might as well be defusing a bomb. Every decision carries an imaginary weight, and you second-guess yourself constantly. Sometimes, your body joins in—hands shaking, breathing shallow, muscles tense like you’re expecting to be attacked. And the worst part? Even when you know there’s no real danger, you can’t just turn it off.”
Now, here’s what my high-“anxiety” days feel like, written by me:
“My body is stuck in overdrive and forgot where the brakes are. There’s an unshakeable feeling that something’s wrong, like I’m in fight-or-flight with no idea why there’s a threat. My blood pressure is high, my heart rate is fast, and I feel physically shaky. Every time something minorly stressful happens, my body freaks out. My stomach hurts, and even though I’m thinking clearly, it’s like my body needs to get out. I feel stuck.
Small tasks are easy if I have the coordination for them. I answer emails and tasks and submit grades at light speed. But they don’t fix the feeling. Every decision is made for me, but my body is split between two directions at once. Every time I stand up, I want to pass out. Sometimes, my mind joins in and I question why I feel this way – what if something is deeply and terribly wrong and I just don’t know what it is? And the worst part is that sometimes my built-in epinephrine wins over my cognitive coolness and I really do have an anxiety attack.”
Do you see the difference? I do. We each only ever live in our own minds, and a lot of Dialectical Behavioral Therapy’s distress tolerance skills are about cluing yourself in to how your emotions are affecting your body, so I’ve been locked into those physiological reactions for the better part of my life (shout out to my parents for recognizing I needed help early). But when I’m not actively stressed out about something and I’m “anxious”, my mind isn’t actually making the calls – my body is.
Finally, here’s a description of a high-epinephrine and cortisol day for someone with dysautonomia, also helpfully contributed by AI:
“My nervous system is stuck in overdrive and forgot where the brakes are. There’s an unshakable feeling that my body is running a race I never signed up for. My heart pounds, my hands tingle, and my limbs feel weightless and unsteady, like I’m seconds away from collapsing. Even when I’m completely at rest, it feels like I just sprinted up a flight of stairs. My stomach turns, my vision blurs, and my skin burns from the inside out. I know I’m not in danger, but my body doesn’t.
Small tasks don’t drain me—standing up does. I can type at full speed, answer emails, and complete my work like nothing’s wrong, but none of it slows the spiraling engine inside me. Every decision is automatic, every action precise, but my body is fighting me the whole way. Sometimes, my brain gets caught in the loop, and I wonder if I really am in danger—what if this time, my body knows something I don’t? And the worst part? No amount of deep breathing, meditation, or cognitive reframing can stop my nervous system from pulling the alarm.”
Okay, that’s weird. Even though I’m diagnosed with Generalized Anxiety Disorder, that description of a physiological imbalance is really resonating with my own experience. I know what skills help me, mainly TIPP – temperature (provided by ice packs or cold washcloths), intense exercise (getting that fight or flight to do its job), paced breathing (think every breathing exercise you’ve ever done), and paired muscle relaxation (tensing and untensing certain muscle groups).
But Dialectical Behavioral Therapy (DBT) focuses on more than just distress tolerance – in fact, while DBT is a fourfold approach, its foundational skill according to Marsha Linehan’s DBT Skills Training Manual is Mindfulness, not Distress Tolerance. Mindfulness does little to nothing to help me, but it has worked wonders for people with anxiety disorders as a bridge to being able to use distress tolerance and emotional regulation skills (Santullano 2022). According to a 2022 dissertation by Anjali Jain, GAD and panic disorder sufferers really struggle with the other three skill groups until they lower their reactivity through mindfulness. The fact that it doesn’t help me at all is definitely a red flag for anxiety.
Interpersonal Effectiveness as a core skill focuses more on social scripting and laying out maps for hard conversations, aiming to help people communicate effectively regardless of their emotional state, and while these have been helpful for me it’s been all about the scripting and understanding the layout of those conversations rather than forging through distress during them. Moyer found that this scripting practice worked well for autistic people in 2022, regardless of any emotional regulation issues.
Huh. So mindfulness, which is both important and necessary for anxious individuals in DBT, does nothing for me. Interpersonal effectiveness skills serve more as social scripting for my autism than anything else. Emotional regulation skills are also not helpful for me, as distress tolerance is king, despite usually being a last resort for people with emotional dysregulation. Weird.
Let’s look at my favorite skill, TIPP:
Temperature, and specifically cold exposure on the face and neck, stimulates the vagal nerve. If you’ve ever heard of a “vasovagal reaction”, that’s another term for some kinds of fainting. Essentially, your autonomic nervous system freaks out, your vagal nerve says it’s time to go down. Cold exposure through ice packs or stepping outside in cold weather can reset that response. In 1994, Addison Taylor found that it’s highly effective for episodes of hyperadrenermic autonomic dysfunction (too much adrenaline make body go no thanks). Basically, we’ve known for 30 years that this works for physiological panic responses.
Intense exercise is the I in TIPP, and while it hasn’t been studied extensively specifically in connection with autonomic dysfunction, cardiovascular exercise in general has been shown to improve some dysautonomic symptoms. According to a 2024 study by Amanda Peltier, our previously mentioned friend the vagus nerve can get toned from structured exercise that progresses from low to high intensity. Programs like this can also help stabilize blood pressure regulation, another Autonomic Nervous System (ANS) function. In short, the way that intense exercise helps with anxiety is also directly connected to autonomic function.
Paced breathing, the first P in TIPP, also helps with vagal tone, which has been studied previously in adolescents with POTS and Chronic Fatigue Syndrome (Stewart, 2022), but Heart Rate Variability (HRV) is an even bigger factor, and is hugely helped by paced breathing. Something as simple as taking exactly six breaths a minute can significantly reduce heart rate variability (Jacobs et al, 2019) which then leads to a more flexible autonomic system as a whole (Arnold et al, 2017). So paced breathing is also an autonomic thing.
Paired muscle relaxation is the final factor of TIPP, and a variation of progressive muscle relaxation (PMR). The difference is that when it’s “paired”, you add a calming stimulus like a specific thought or breathing technique. But let’s look at just the physiological side, wherein PMR is shown to increase vagal tone again (Owens, 2016), improve HRV (DePace & Colombo, 2023), and regulate blood pressure (Feldman et. al, 2014), leading overall to a better regulation of stress-induced autonomic imbalances (Khemani & Mehdirad, 2020). Four studies in one sentence aside, this stuff works – again, on the same physiological system.
To make a long story short, the skills from DBT that actually work for me are the ones that focus on the physiological, rather than psychological, regulation. Now, that doesn’t mean necessarily that I don’t have anxiety. It’s fair to say that it’s probably a bit of both. But I think that dysautonomia thing is worth talking to a professional about, given that anxiety meds haven’t worked but ANS regulation techniques have. Is it possible I’ve been instinctively self-accommodating for a physiological issue this whole time? If this is a neurological issue, why haven’t we been treating my nervous system instead of my mind? And what does this mean for my depression?
Stay tuned for an equally long-winded take on depression involving methylation, the sympathetic nervous system, and an entirely different set of questions for my doctor.
Sources Cited:
Arnold, A. C., Ng, J., Lei, L., & Raj, S. R. (2017). Autonomic dysfunction in cardiology: Pathophysiology, investigation, and management. Canadian Journal of Cardiology, 33(12), 1524–1534. https://www.sciencedirect.com/science/article/pii/S0828282X17309960
DePace, N. L., & Colombo, J. (2023). Fatigue and dysautonomia: Chronic or persistent, what’s the difference? Springer. https://books.google.com/books?hl=en&lr=&id=H-t0EAAAQBAJ
Feldman, E. L., Grisold, W., & Russell, J. W. (2014). Autonomic nervous system. Springer. https://link.springer.com/chapter/10.1007/978-3-7091-1605-0_13
Jacobs, G., Diedrich, L., Sato, K., Brychta, R., Raj, S., Robertson, D., Biaggioni, I., & Diedrich, A. (2019). Vagal and sympathetic function in neuropathic postural tachycardia syndrome. Hypertension, 73(6), 1140-1150. https://dx.doi.org/10.1161/HYPERTENSIONAHA.118.11803
Jain, A. (2022). The role of mindfulness in emotional regulation: A dissertation study on anxiety disorders. ProQuest Dissertations Publishing. https://search.proquest.com/openview/0265aa065758fb99388efd632467a8a3/1
Khemani, P., & Mehdirad, A. (2020). Cardiovascular disorders mediated by autonomic nervous system dysfunction. Cardiology in Review, 28(2), 65-72. https://journals.lww.com/cardiologyinreview/fulltext/2020/03000/Cardiovascular_Disorders_Mediated_by_Autonomic.2.aspx
Linehan, M. M. (2014). DBT skills training manual (2nd ed.). Guilford Press.
https://www.guilford.com/books/DBT-Skills-Training-Manual/Marsha-Linehan/9781462516995
Moyer, J. (2022). Interpersonal effectiveness skills for autistic individuals: A study on social scripting in DBT. Journal of Autism and Developmental Disorders, 52(3), 678-692. https://spark.siue.edu/atcfinal/14/
Owens, A. P. (2016). The psychophysiology of dysautonomia. University College London. https://discovery.ucl.ac.uk/id/eprint/1502109/
Peltier, A. C. (2024). Autonomic dysfunction from diagnosis to treatment. Primary Care: Clinics in Office Practice, 51(1), 45-58. https://www.primarycare.theclinics.com/article/S0095-4543(24)00008-3/abstract
Santullano, S. (2022). DBT skills training for adolescents with emotional dysregulation: A systematic review. OhioLINK Electronic Theses and Dissertations Center. https://rave.ohiolink.edu/etdc/view?acc_num=wsupsych1628795989046121
Stewart, J. M. (2000). Autonomic nervous system dysfunction in adolescents with postural orthostatic tachycardia syndrome and chronic fatigue syndrome. Pediatric Research, 48(2), 218-226. https://www.nature.com/articles/pr2000180
Taylor, A. (1994). The role of cold exposure in autonomic nervous system regulation. Journal of Applied Physiology, 76(3), 1234-1242.
Ari Cricks 