The Anxiety That Gets Rewarded

By Julie Brownley, MD, PhD

Psychiatrist, Founder of Psychiatry for Women

During residency, we had a patient who wasn’t getting better. This was despite real effort, real thought, and a lot of care.

We were sitting with an older attending (what I like to call a dinosaur), trying to come up with next steps. The options on the table felt… limited. Not wrong, but not reassuring either.

I remember saying, “There are a lot of ways this could go sideways.”

He paused and looked at me. “Are you depressed?”

To him, anticipating negative outcomes meant something was wrong. But that wasn’t what was happening.

I wasn’t hopeless. I wasn’t disengaged. I was preparing.

The Kind of Anxiety We Don’t Talk About

Some people move toward uncertainty with optimism. Others move toward it by thinking through what could go wrong. The second group often gets labeled as anxious. Or negative. Or overly cautious.

But in many cases, what they’re actually doing is something more nuanced. There’s a term for this: defensive pessimism.

It’s a way of managing uncertainty by anticipating possible problems ahead of time. Not because you believe things will go badly, but because thinking it through helps you feel more prepared, more steady, and more in control.

And importantly, it often works.

What This Looks Like in Real Life

I saw several versions of this just last week. I like to call these, "the theme of the week".

One woman I’m working with is pregnant with a very wanted baby. She and her partner both carry a genetic condition, and there’s a 1 in 4 chance their child could be affected.

She’s excited, but also holding back.

She uses the word “it” instead of the baby’s name.She hasn’t started preparing the nursery.She’s waiting for amniocentesis results before letting herself fully attach.

Her partner is celebrating. He’s glass-half-full.

She described herself as glass-half-empty.

And honestly?

Both of them made sense to me.

She’s not detached in a pathological way. She’s pacing her emotional investment in the face of real uncertainty.

That’s not dysfunction.

That’s adaptation.

Why This Type of Anxiety Gets Rewarded

Defensive pessimism often flies under the radar because it looks like competence.

These are the women who:

• anticipate problems before they happen

• think things through carefully

• stay organized and prepared

• rarely get caught off guard

They’re often high-functioning, reliable, and “have it together.”

And because of that, this form of anxiety is often reinforced both internally and externally.

It gets results.

Where It Actually Helps

This way of thinking can be adaptive when it:

• reflects realistic risks

• helps you prepare in a meaningful way

• allows you to stay grounded in uncertain situations

• doesn’t interfere with your ability to function

In these moments, it’s not pathology.

It’s a strategy.

Where It Starts to Cost You

But there’s a point where this shifts.

Where thinking ahead turns into being unable to stop thinking. Where preparation becomes tension. Where the “what ifs” stop being useful and start being exhausting.

You might notice:

• difficulty relaxing even when things are okay

• trouble sleeping because your mind won’t turn off

• feeling constantly “on” or braced

• increased irritability or emotional fatigue

At that point, it’s no longer helping.

It’s taking something.

The Part My Attending Was (Sort of) Right About

Looking back, I understand what my attending was reacting to. He was trained in a model where negative thinking signaled depression or pathology.

And sometimes, that’s true.

But not always.

Anticipating what could go wrong is not the same thing as believing nothing will go right.

There’s a difference between:

• preparation and rumination

• realism and hopelessness

• caution and paralysis

And clinically, that difference matters.

A More Useful Way to Think About It

The goal is not to eliminate this way of thinking. It’s not to turn every glass-half-empty person into a glass-half-full one. The goal is flexibility.

To be able to think ahead when it’s helpful, and to let go when it’s not.

To prepare without becoming consumed.

To stay engaged without needing to control every possible outcome.

Final Thought

Some forms of anxiety don’t look like struggle.

They look like competence.

They get rewarded. They get praised. They get reinforced.

But that doesn’t mean they’re free.

If This Feels Familiar

If you recognize yourself in this. Constantly thinking ahead, staying one step in front, and feeling like you can’t fully relax, then you’re not alone.

At Psychiatry for Women, this is something we work with often. Helping women understand their patterns, keep what’s working, and reduce the cost where it’s not.

Because you don’t have to give up your strengths to feel better.

Learn more about our work at Psychiatry for Women.

Psychiatryforwomen.org

About the Author

Julie Brownley, MD, PhD is a psychiatrist specializing in women’s mental health and the founder of Psychiatry for Women. She is an educator at Johns Hopkins School of Medicine, teaching residents the ropes. Her clinical work focuses on perinatal mental health, hormonal transitions, and helping women make thoughtful, individualized decisions about their care.