ANXIETY

AN INFORMATION BOOKLET WITH GUIDELINES FOR HOW

TO MANAGE ANXIETY

index

Introduction

Anxiety is a normal response to stress or fear; we all feel wound up, nervous, worried or tense at certain times. Through a series of changes in the body and in the way we think and behave, anxiety prepares us to deal with threat or stressful situations.

Although the anxiety response can help us in the short term, people often have to cope with stresses which last for a long time and do not involve physical danger. Anxiety can become a very distressing problem, particularly when there does not seem to be an obvious reason for it.

The first step to overcoming anxiety is to understand it. This booklet was written by psychologists to provide information about anxiety and suggest guidelines on how to overcome the problems. Read it carefully and then re-read it several times. You may want to mark the parts that you find helpful and add your own examples. Do talk it over with your psychologist who will discuss the parts that are most relevant to you and answer any questions you have.

What causes anxiety problems?

Many people go through a ‘bad patch’ in their lives when anxiety becomes a problem, while others have always tended to worry about health or how to cope with new situations. There are many causes of anxiety and these vary from person to person. Sometimes a number of minor issues build up over time so there is no obvious single cause. Possible causes include:

• Unpleasant or unhappy events or change in circumstances, either recently or in the past, for example death or illness in the family, the break up of a relationship, losing a job, starting a new job or moving to a new area.
• A lengthy period of strain, worry, physical illness or work pressure. (You may only become aware of the anxiety after the worst of the strain is over).
• Growing up in an environment where those around you tended to be anxious and worry a lot.
• Growing up in an environment where those around you tended to be critical, blaming or unpredictable.

Why it can be difficult to get rid of anxiety

Once you have become anxious for whatever reason (and there may well have been reason enough in the past), the anxiety tends to remain, even though there may seem to be no cause for it at the present time. This is because anxiety has become a habit. Once you get into the habit of worrying, expecting difficulties and avoiding those things you know will be difficult, your body gets into the habit of being tense and reacting in an anxious way.

The three main ways anxiety affects us:-

1. The body - the many physical signs of anxiety

2. Thinking - worries and thoughts

3. Behaviour - how we behave and what we feel able or unable to do

ANXIETY AND THE BODY

Most people describe many different feelings when they get anxious but some are more unpleasant and upsetting than others. In a panic attack, physical changes occur suddenly and the whole experience is usually very frightening. The symptoms are often thought, mistakenly, to mean that something is seriously wrong. They are distressing and unpleasant but not harmful.

Some of the common physical signs of anxiety are shown below. Some people experience all of these, some only a few.

Some of the physical feelings come on when you are extremely anxious and may last a short time, e.g. palpitations or breathlessness. Others persist even when you do not think you are anxious, e.g. headache, tension in the neck or tiredness.

Other common complaints and physical changes include:

• Mood disturbance - irritable, quick-tempered, easily upset
• Sleeping difficulties - insomnia, bad dreams, recurring dreams
• Difficulty concentrating, mind going blank, forgetfulness
• Loss of confidence, indecisiveness
• Tendency to check and go over things, nagging doubts and fears
• Clumsiness
• Sensitive to noise which you used to tolerate.

How Anxiety Causes these Physical Changes

• The "Fight or Flight" Response: When anxious, the whole body automatically becomes aroused. The natural changes that take place in response to threat are set off by an increased flow of adrenaline into the blood stream. This is called the "fight or flight" response. These changes prepare us for the physical exertion of either taking on a challenge or escaping from a dangerous situation by making us ready for action. We experience, for example, an increase in breathing and heart rate and increased muscle tension. If you had to take action, such as running for help in an emergency, these changes would help you. On the other hand, if you were anxious about being in a crowded shop but there was no need for action, the uncomfortable symptoms would result from unexpected energy.

• The Role of Overbreathing: For physical activity, our muscles need oxygen, so when we are anxious we feel we need to breathe harder with quick deep breaths through the chest. This is fine during exercise but if we are not physically active, we take in more oxygen than the body needs. This is called overbreathing or hyperventilation. This is not dangerous but results in some very uncomfortable physical changes, including:

- shortness of breath

- tightness or pain in the chest because the muscles get too tense

- dizziness, light-headedness or strange unreal feelings

- tingling in the fingers

• Tiredness: the physical changes are also very tiring, as they use up a lot of energy. People are often left feeling exhausted and lose motivation to do things.

ANXIETY AND THINKING

When we get anxious, our minds can be full of all sorts of worrying thoughts and feelings. It is often hard to concentrate or think straight. Sometimes the thoughts may be about various problems but they are often about the anxiety itself, particularly the unpleasant physical sensations.

Common thoughts are: "What if I can’t cope?"

"I’ll make a fool of myself and others will notice"

"I’ll faint in front of them"

"What if I’m having a heart attack?"

"I’m going to lose control".

Of course, all these thoughts are very alarming and make the person’s anxiety worse. The physical signs of anxiety then seem to confirm their worst fears. A vicious circle can soon develop and a panic attack may occur:-

A panic attack is a combination of physical symptoms and frightening thoughts. People usually have the urge to try to escape from the situation where it has occurred and may then continue to avoid this situation, believing that the situation caused the panic. In fact, it is nearly always fear of the physical feelings which is the problem, rather than the situation in which they occurred.

Panic attacks start suddenly; sometimes there is an obvious trigger but they can seem to happen completely out of the blue. Once you have experienced one panic attack, you may well become very sensitive to any slight physical change for fear that this signifies the start of another panic attack. This can then act as the trigger which starts the vicious circle off.

Anxious thinking can bring on the physical symptoms without any other obvious trigger.

Anxious thinking is usually biased; the anxious person overestimates the danger and underestimates his or her ability to cope. He or she may exaggerate the risk of things going wrong, ignore the positive and jump to the worst possible conclusions. Catastrophising is also common. This is when a person anticipates disaster as the only possible outcome, for example, one mistake means failure, a chest pain means heart attack or a scowl from a colleague means hatred.

This kind of negative thinking can become a habit which is hard to break. Eventually anxious thoughts come to mind automatically and the person begins to accept these thoughts without question, as facts.

HOW ANXIETY AFFECTS BEHAVIOUR

AVOIDANCE

Avoiding situations which make you feel anxious is natural. When you are anxious you feel uneasy and you probably have uncomfortable physical sensations. Your first reaction is to escape and avoid getting into a similar situation again.

By escaping and avoiding, you are not getting the chance to learn:

1. How to cope with difficult situations.

2. That anxious feelings do not increase to the point when you lose control or where something dreadful happens.

Like thinking negatively, avoiding things can become a habit. You may feel frustrated or guilty for not being able to do some things and you may miss out on things you would have enjoyed. After a time you lose confidence in yourself, which only adds to your anxiety and feelings of failure.

Avoidance is also part of the vicious circle

Anxiety provoking

situation

More fear of Physical

anxiety-provoking reaction

situation

Avoidance

CONCLUSIONS: HOW ANXIETY BECOMES A PROBLEM

Changes in your body, thinking and behaviour all contribute to the vicious circle of anxiety in a number of ways:

1. By increased sensitivity to the physical signs of anxiety. After suffering unpleasant and panicky feelings, you become more aware of the physical signs of anxiety. You become very sensitive to the slightest change in your breathing or heart-rate and because these feelings have troubled you in the past, you over-react and become alarmed by them. This in turn makes them worse. You have become afraid of the symptoms themselves.

2. By Association: If you have felt very anxious in one setting, for example, in a crowded shop or when away from home, you will tend to react in a similar way to other similar settings, such as in all shops or every time you leave the house.

3. By Anticipation: If you have experienced anxiety in some situations, you begin to feel anxious before going into that kind of situation again. You begin to expect to feel anxious before more and more situations, until it affects very many areas of your life.

Part 2 - Ways of Coping with Anxiety

THINGS WHICH DO NOT HELP ANXIETY IN THE LONG TERM

1. Repeatedly asking for reassurance that you are not ill.

Someone with the frightening thoughts that go with anxiety often seek such reassurance. It may help initially but after a while it stops working. The person gets sneaking doubts about the reassurance. For example:-

"They’re just trying to be kind to me"

OR "How do they know. They don’t know how if feel"

OR "I need a doctor..... I need a special test"

So more and more reassurance is asked for with less and less effect. Reassurance is really a type of avoidance - avoiding facing the fear of illness and personal danger.

2. Safety routines.

Sometimes people do not avoid situations altogether but try to find ways to prevent the anxiety or bring it down to a manageable level once it starts. Some people have "safety routines" or things they do to ward off anxiety or panic before or just after it strikes, for example:-

• taking pills or alcohol before doing something
• taking a friend, relative or even a child with them
• only tackling things on good days
• staying close to walls or near doors
• lying down

checking for exits and always parking close-by

Like avoidance, safety routines are only short term solutions. In the long run they do not solve the problem because they prevent you from learning how to cope with panic and anxiety and they can make the problem worse.

3. Diet and sleep

Certain conditions and substances can affect your physical state and make you more prone to anxiety feelings. These include a lot of coffee, tea, cola or alcohol. Even a slight hangover can make you feel on edge. Going too long without eating should be avoided and poor sleeping habits (such as naps during the day and an irregular sleep pattern) are also unhelpful .

HELPFUL WAYS TO COPE WITH ANXIETY

1. Acceptance - Learning not to fear the fear

Acceptance means letting the symptoms happen without fighting them or getting frustrated, angry or guilty. The feelings of panic will pass quite quickly, although it may seem like a very long time.

The golden rule is never to leave a situation until the fear or panic has started to go down.

It should help to read through the following rules very carefully so that they are clear in your mind. When you feel panicky run through these rules in your mind, or if you prefer, make a copy of them to carry with you to read at the time. You could also write down a personalised plan for coping with panic.

Rules for Coping with Panic

1. Wait and give the fear time to pass without fighting it or running away from it. Just accept it, let it happen and let it pass.

2. Remember that the feelings are nothing more than an exaggeration of quite normal bodily reactions to stress.

3. The feelings are not harmful or dangerous - just very unpleasant. Nothing worse will happen.

4. Notice what is actually happening in your body when you are panicking, not what you fear might happen.

5. See each panic attack as an opportunity to learn how to cope with these feelings - with practise you will learn how to cope better.

6. When the panic begins to fade, congratulate yourself for having stayed in the situation and put up with it.

2. Keeping Records or Diaries

This can serve several purposes.

a) Helping you become more objective about your problems, worries or fears.

b) Making the problems clearer and therefore easier to tackle.

c) Informing you about what progress you are making

It is easy to form mistaken ideas about your difficulties and the tendency is to assume they are much greater than they really are. It is also very easy to ignore the good points and successes along the way.

The more you know exactly what the problems are, the better able you will be to deal with them. Keeping a diary for one or two weeks will help you to answer the questions:

• What things or situations trigger my distress?
• What are my bodily feelings and my thoughts when I am distressed?
• What differing levels of distress do different situations case?
• What do I tend to do when I am distressed?
• What helps me best to cope with my distress?

There are many different forms of diary keeping: you may need help from your psychologist in deciding what to record.

It can be useful to start by recording the severity of your anxiety and symptoms and when or where the anxiety occurs. Use a scale of 0 up to 10, with 0 = no symptoms or anxiety and

10 = severe anxiety or panic (the higher the number you give, the worse you are feeling).

A typical diary could look like this:

3. Stop Rushing: Reducing Overactivity

Rushing causes anxiety and tiredness. If you are overactive, ask yourself these questions:-

• Do you have to be doing something every minute of the day?
• Who or what is forcing you to keep on the go all the time?
• What do you expect will happen if you don’t get everything done?

Think about what other people do. Normal working days, whether at home or in a job, are not filled with activity every second of the day. There are regular breaks - for lunch, coffee or just because there’s nothing to do for a time. Typical days for most people have boring or downright unpleasant periods. Most people also have off-days and no-one is perfect at their work all the time.

What to do:

1. Be reasonable about what can be done. Do not expect yourself to be the perfect housewife, worker or whatever - there is no such thing. You do not have to be active all the time.

2. Work out a reasonable daily routine. You cannot do everything today, so leave things till tomorrow, next week or even next year.

3. Include proper breaks in your day, e.g. an hour for lunch, ten minutes for a coffee break or times just to sit down and do nothing.

4. Learn relaxation techniques and controlled breathing.

5. Take time to do things just for yourself, e.g. have a leisurely bath, visit a friend or have coffee with a neighbour. Do something restful in the evening, if you do anything at all.

6. Be pleased with the work you do get through rather than thinking of the things you feel you still have to do - they can wait.

4. Managing Problems One at a Time: Tackling Underactivity.

Take a moment to ask yourself these questions:

• Do you have to tackle everything today?
• Would it be better to do something rather than nothing?

 

If you usual routine has been disrupted, then it is difficult to make a start on what seems like a mountain of tasks. Part of this difficulty is thinking things like "I’ll never be able to get back to my usual routine" and "I’ll never get on top of all these tasks". It can become quite depressing. You know you would feel better if you could just make a start.

What to do:

1. Think of some small things to do first, e.g. wash the dishes or make a phone call. Leave everything else in the meantime.

2. Make a list of things to be done. Mark those things which can wait until next week or even next year.

3. Pick out those things which could be done quickly. Do one or two of these; then leave the rest. Check things off your list as you do them.

4. Divide the day into a few short working periods, e.g. half an hour at first. Do what you can in that time and leave the rest.

5. Do one unpleasant or boring thing. Then do something you would enjoy more, as a reward.

6. Do not expect too much of yourself at first. It will take time to get back into your routine.

7. Sometimes if may even be more profitable to leave everything in the meantime and do something completely different e.g. visit a friend, see a film, take a walk or go for a

drive.

 

5. Overcoming Avoidance and Gaining Confidence

Facing your fear can be a very effective way of dealing with it in the long run. It means that you face up to those situations which made you anxious and which you may have been avoiding, perhaps for a very long time.

The aim is to learn that you can cope with these difficult situations, whether it is going into a crowded shop, or surviving having a panic attack.

 

There are some important things to remember with this strategy:

1. Be specific about what you are going to do.

e.g. a) plan to spend one hour in Marks & Spencer (rather than "spend some time in the shops).

or b) Plan to sit still for an hour.

2. Expect to feel anxious - no one is expecting you to do this without feeling anxious.

3. The point is for your to learn that you can cope with these anxious feelings and with the situation you are in.

4. Do not leave the situation when the anxiety mounts - put up with those feelings, they will not harm you, and you will begin to feel better if you stay.

5. Doing this once is not enough, repeat the exercise several times and keep practising.

6. You can either face the feared situation in one go or in graded stages. You might discuss

with your psychologist which of these two approaches would be best for you.

a) Total Exposure: think of the most difficult situation for you and go into it, remembering the Roles for Coping with Panic from Page 9. The best way to overcome a fear of panic is to experience a full blown attack in order to learn that you are able to cope with it and you do not lose control.

Or

b) Graded Practise: - make a list of situations which you find difficult, ranging from extremely difficult to "a little difficult", and arrange them in order from most to least difficult. Try to be as specific as you can about different situations. Then start at the least difficult end and go into that situation, more than once, until you feel that you can cope with it and the anxiety which you experience. Then work your way up the list. This approach is most helpful for specific fears, e.g. spiders, heights etc.

6. Challenging Your Worrying Thoughts and Images

When you are feeling calm, it is not always easy to recall the thoughts and images which triggered your anxiety. Thinking in a negative way can become such a habit, you hardly notice it. Keeping a diary of what goes through your mind near the time of the anxious episode can be the best way of discovering the words, images or phrases which case your tension.

As you become more familiar with the way you think, you will also become familiar with any negative biases in your thinking. You can then begin to find alternatives to anxiety promoting thinking. Rational thinking will make you feel less anxious and better able to cope with difficulties.

 

There are five questions which you should ask yourself in order to find a more confident way of thinking.

• Are there any reasons for my having this worrying thought? Looking for evidence which does support the worrying thought will hell you to understand why you have the worry and make it less likely that you feel silly or embarrassed about it.
• Are there reasons against me holding this thought? Now you are beginning to look for evidence which does not support worry. You might use a friend or partner to help you find statements to challenge your worry.
• What is the worst thing that could happen? How likely is it to happen?
• How could I cope with this? Now work out a plan for cooping in the worst situation. If you can cope with the worst thing that could happen, you can feel confident that you can manage your anxiety. Think about your strengths and skills and when you have coped successfully in the past. Think about how you might change the problem situation or change how you feel about it. Also consider how others can help: what advice or support are available from family, friends or professionals? Again, you might find it helpful to get some else’s views on this.
• What is a more constructive way of viewing the situation? Look back over the notes you have made and try a new rational statement in response to your initial worry.

Challenging negative thoughts is a demanding technique. When you first start to do this you might find it takes some time and you may need some help from your psychologist.

7. Dealing with any underlying cause of anxiety

Sometimes other stresses and problems make anxiety worse. The anxiety response prepares us if we have to respond physically to threat or danger, however, these days stressful situations rarely need much physical exertion to be solved. They are often problems at home, in a relationship, financial worries, work pressures, etc.. All these worries cause anxiety but don’t need anxiety to be solved. We also worry about things or people we can’t do anything about.

If problems can be sorted out anxiety improves. It may help to talk and share the problem with somebody else, for example with your partner, a relative, a trusted friend or with your doctor or psychologist.

If the problem cannot be solved you may have to concentrate on learning to live with and accept the difficulty.

CONCLUSIONS

Many people expect that their symptoms will disappear immediately and feel fed up when they don’t. Although you will probably see improvement if you follow the exercises in the booklet, you will probably still be left with some anxiety. Remember that it is normal to feel anxious some of the time. The aim is to stop worrying about feeling anxious.

Being anxious about being anxious is part of the problem!

During recovery, most people experience "set backs". This is normal and does not mean you are back to square one.

Re-read this booklet several times. Try to work out what helps you to cope with anxiety and work out your own personalised plan for coping. Remember that anxious habits which you have had for a long time take time to be unlearned, but it will be well worth making the effort to learn new ways of coping.

Breathing Exercises

Many people who experience panic or generalised anxiety tend to overbreathe. Be aware of your breathing pattern as you go about your daily routine, and whether you overbreathe.

Use your lungs fully and avoid breathing from your upper chest alone. Breathing should be smooth. When you first practise, it can be easier to do this lying down, so that you can feel the difference between shallow and deep breathing. As you become more practised, you can try the exercise sitting or standing.

• Place one hand on your stomach and as you breathe in through your nose, allow your stomach to swell. This means you are using your lungs fully. Try to keep the movement in your upper chest to a minimum and keep the movement gentle.
• Slowly and evenly, breathe out through your nose.
• Repeat this trying to get a rhythm going. You are aiming to take eight to twelve breaths per minute (breathing in and breathing out again counts as one breath). This might be difficult to gauge at first, so practise saying "one thousand" as you breathe in and "two thousand" as you breathe out.

All psychoeducational handouts are provided courtesy of the Clinical and Counselling Psychology Department, Royal Cornhill Hospital.