Cognitive Behavioural Therapy (Brilliant Business) 1st Ed.

8. Conquering anxiety

‘My gran always used to say to me: “You never know what’s round the next corner, Em,” and she’s right. You can think everything’s fine but fate can pull the rug from right out under you and your whole world can fall apart – just like that.’

‘Every morning when I wake up the first thing I do is go through my list: “Who have I let down? What have I forgotten…?”’

‘Until I started therapy I never realised how wound up I was the whole time. That sick feeling in your stomach, pacing around, constantly waiting for the next thing to go wrong… It just becomes normal after a while because you never know any different. Your brain never stops working. You’re never at peace. It’s hell and you don’t even realise you’re in it.’

What is anxiety?

People who suffer from anxiety share two things in common: they overestimate the danger inherent in situations and underestimate their ability to cope with it. Living under the shadow of the constant threat – real or imagined – has all sorts of consequences, both psychologically and physically.

One of the things that fear does to our bodies is prime them for action. Hormones released into your bloodstream put you instantly into a state of red alert. You start breathing more rapidly in order to oxygenate your blood which is swiftly diverted to the muscles by your rapidly beating heart. Body systems not likely to be needed to cope with the immediate threat, like digestion, are shut down while sugar supplies stored in the liver are broken down to provide a potentially life-saving burst of energy. Your senses are sharpened while mentally all your attention is focused on the perceived threat. In this state of arousal you are now ready either to fight off the threat or leg it to safety as fast as possible.

Of course when our ancestors’ daily survival depended on keeping off the menu of local predators the ability to shift into this state of heightened arousal at a moment’s notice was really useful. However, the fight–flight response is designed to be a short-term measure. Neither body nor mind fare well if the state of anxious arousal is sustained over long periods.

Physically, anxiety can put you at greater risk of heart disease, stomach disorders, obesity and respiratory problems. In time it also weakens your immune system. Prolonged exposure to cortisol, one of the anxiety hormones, can even produce shrinkage in a certain region of your brain. Psychologically prolonged anxiety can make it hard to concentrate and remember things. Stress hormones leave you feeling ‘on edge’, exhausted and make you snappy and irritable.

Checklist of common anxiety symptoms

□ Breathlessness

□ Palpitations and erratic heart beat

□ Trembling

□ Sweating

□ Choking sensations or finding it hard to swallow

□ Nausea

□ Feeling dizzy or unsteady

□ Hot flushes

□ Fears of going crazy or losing control

□ Fears of dying

□ Dissociation – feeling detached, out of touch or ‘unreal’

Anxiety can manifest itself in a number of different forms. Among the diagnosable anxiety disorders are:

·        Panic disorder People who suffer from this condition are vulnerable to acute anxiety attacks that feature several of the symptoms listed above. These intense attacks usually last for several minutes. In the CBT model of panic disorder, sufferers catastrophically misinterpret the physical and psychological effects of anxious arousal and convince themselves that something must be seriously wrong with them. This then makes their physical symptoms worse and keeps the whole cycle lurching forward.

·        Social phobia Socially phobic people become highly anxious about the negative judgements of other people. Their fears usually focus around the evaluation of their own social performance. They may worry about blushing, stumbling over their words, or being perceived as stupid or awkward in some way. Socially phobic people fear humiliation – but their attempts to safeguard themselves against this possibility often end up working against them.

·        Agoraphobia This is not just fear of open spaces. Agoraphobics feel at risk when they are away from the people or places that they associate with safety. They usually picture themselves getting into trouble in public places where there is no one familiar to help them or where panic symptoms could lead to public humiliation. As a result, going out becomes difficult and many agoraphobics restrict themselves by leading highly reclusive lives.

·        Obsessive Compulsive Disorder (OCD) This is a condition that involves irrational intrusive thoughts or frightening impulses. To manage their anxiety many OCD sufferers develop compulsive rituals or checking behaviours that they pursue in attempts to neutralise their anxiety. Unfortunately the more they give themselves over to their compulsions, the worse their symptoms become. They often become convinced that unless they perform their safety rituals (such as hand washing, or counting up to 10 before they go through a door) terrible consequences will ensue. This can make it very difficult for people with OCD to give up the compulsions on which they have come to rely but which actually end up controlling their lives.

·        Specific phobias These are irrational fears of particular things that may operate as a focus for other underlying anxieties. Arachnophobia (fear of spiders) is a common specific phobia. Some psychologists argue that we are more easily conditioned to become fearful of aspects of the environment that might be associated with health risks. However, it is hard to understand some of the more exotic phobias, such as sesquippedaliophobia (the rather cruelly entitled fear of long words) within the context of such an explanation. The truth is we can develop a phobia about almost anything. Sometimes we learn our phobic responses from other people. People who suffer from atypical phobias often struggle because it is hard for non-sufferers to take their anxieties seriously, but depending on the nature of the phobia concerned the condition can be extremely limiting.

·        Post Traumatic Stress Disorder (PTSD) People who have experienced life-threatening or violent events can suffer intrusive recollections of the event, often in the form of flashbacks. PTSD sufferers try to avoid anything associated with the original trauma and experience a range of other anxiety symptoms including low mood, emotional numbing, irritability and concentration problems.

·        Generalised Anxiety Disorder (GAD) This is a state of persistent worry and arousal that lasts over a period of at least six months. There are no panic attacks, obsessions or phobias involved but the sufferer usually worries about many different things – so much so that the levels of anxiety interfere with his or her ability to conduct life as normal. People with GAD are particularly prone to anticipating danger and negative outcomes to an unrealistic degree.

One in 10 of us will suffer from an anxiety disorder at some point during our lives. Severe stress can damage relationships, ruin careers and wreck lives. It is worth getting on top of, and CBT offers a number of strategies for doing just that.

Why do people suffer from anxiety?

We often refer to people as ‘born worriers’ and it certainly does appear to be the case that some of us have a genetic predisposition towards anxiety. We know that if one identical twin has an anxiety problem the chances of the other twin also suffering from anxiety may be as high as 88% although some studies have found much lower rates and you cannot rule out the influence of the environment that both twins have shared. The character trait labelled neuroticism is associated with worry and the area of the primitive emotional forebrain designed to react quickly to potential danger appears to be particularly responsive in people who score high on the neuroticism scales. The neurologist Klaus Peter Lesch likens such individuals to fire detectors pre-set to go off at the merest suggestion of smoke.

Environmental factors also seem to play a part. There seems to be strong evidence that certain messages given in childhood can predispose people towards anxiety by forging unhelpful core beliefs and dysfunctional assumptions.

Children of parents who are critical, rejecting or who have conveyed the message that the world is a treacherous and dangerous place are more likely to experience anxiety symptoms in adult life. If you haven’t been brought up in a family that welcomes the expression of emotion and you have been taught to repress difficult feelings, then you are also more likely to be vulnerable.

Triggers

If background anxiety levels are high, one stressful life event may be all it takes to precipitate an anxiety syndrome. Just as in the cognitive model of depression, these events can activate buried beliefs about not being able to cope. Be aware that if any of the following top 10 most stressful events are taking place in your life you may need to take extra care of yourself, even though your circumstances will make it hard for you to motivate yourself to do so.

Top ten life stressors

·                  Death of a partner

·                  Divorce and separation

·                  Time in prison

·                  Death of close family member

·                  Injury and illness

·                  Getting married

·                  Getting fired

·                  Domestic conflict

·                  Retirement

·                  Pregnancy

What you will notice from this list is that some of the most stressful things that can happen to us are usually considered happy events such as marriage and pregnancy! Change is intrinsically stressful, because new situations demand more of us. We can no longer rely on automatic pilot. We are in uncharted waters and have to keep our wits about us. It is not difficult to understand how this kind of uncertainty, combined with high demands on our processing abilities, can trigger the same kind of arousal as a threat to our wellbeing.

Physiological changes that mimic the effects of anxiety can also set the anxiety response in motion. Stimulants like caffeine or drugs like amphetamines can make anxiety symptoms worse. Some physical health conditions such as hyperthyroidism or low blood sugar levels can also exaggerate latent anxiety responses which is why it is important to consult a doctor before assuming that your ‘anxiety’ is necessarily psychologically driven.

Maintaining factors in anxiety conditions

c08fig002

As the diagram above illustrates, the anxiety cycle is kept going by the mutual interaction of three main factors, and cognitive behavioural interventions work by addressing each of the three links in the chain.

Getting physical

‘An anxious mind cannot exist in a relaxed body.’

Edmund Jacobson, doctor and creator of the progressive relaxation method

The processes that catapult us into a state of red alert are largely automatic, and they happen so instantaneously that they can be hard to control. We have already referred to the research that suggests anxious people have a hair trigger response when it comes to anxious arousal. However, the body does have its own mechanisms for bringing itself down from the fight–flight state and returning things to normal. This is the parasympathetic nervous system, and the good news is that it is possible to harness this system to bring levels of arousal down using relaxation strategies.

One thing you can learn to do is consciously reverse some of the typical physical changes that take place in the anxious arousal state. You will have noticed that when you are anxious you tend to breathe rapidly and shallowly from the upper chest. This is because this is the most efficient way to oxygenate your muscles. However, when we are in a relaxed state we tend to breathe slowly and deeply from the diaphragm in a regular, effortless rhythm. Practising diaphragmatic breathing when you are anxious sends a powerful signal to the parasympathetic nervous system.

tip

Harness the power of breathing

Next time you feel stress levels escalating, simply take five controlled breaths through your nose as slowly as possible, drawing the air deep into your lungs and taking time to exhale until you can expel no more air. It is the sustained out-breath that is actually more critical than the inhalation phase.

This is often sufficient to kick start a cycle of diaphragmatic breathing that, over the course of five minutes or so, should help bring your anxiety level down. Combine it with mentally picturing yourself in a beautiful, relaxing place and the effects will be even more pronounced. I know this sounds too simple to be true, but if you practise the technique it does work.

Check that you are breathing from the diaphragm by placing a hand on your stomach just below your rib cage. You should feel your stomach gently push out as you breathe in. Some people find it helpful to imagine they are sitting in front of a lit candle and that their task is to keep the flame moving slightly using their breath without putting it out.

The other physical manifestation of anxiety that it is relatively easy to undo is the muscle tension that accompanies it. Anxious people hold themselves taut and deliberately relaxing your muscles again sends the signal to both body and mind that the danger is past. There are several ways you can achieve this including progressive muscle relaxation and autogenic training.

Progressive muscle relaxation

Paradoxically you can trigger a relaxation response by racking up the tension in various muscle groups until your natural instinct is to release them. Work your way round your body scrunching up the major muscles groups in turn really tightly for a few seconds before letting go. When you do release them try to let them go completely floppy and limp. Be aware that tension often gathers in the neck and shoulders so make sure you hunch your shoulders up as far as they will go before releasing them. When you do release your muscles, mentally picture tension draining from your body as you do so. Again this takes practice, but in trials subjects who practised regularly experienced a number of beneficial effects including decrease in their anxiety levels, reduction in the frequency and intensity of panic attacks and improved concentration. You can find the full protocol for progressive relaxation at http://socialanxietydisorder.about.com/od/copingwithsad/qt/pmr.htm.

Autogenic training

In the 1930s psychiatrist Johannes Schultz found that some of his patients were able to put themselves into a light trance state simply by thinking about sensations of warmth and heaviness radiating through their bodies. Practised daily, autogenic training can produce a deep relaxation response that, once established, can be cued on demand. Autogenic training instructions and a link to a free MP3 download can be found at: http://socialanxietydisorder.about.com/od/copingwithsad.qt.autogenic.htm.

Facing your fears

‘One ought never to turn one’s back on a threatened danger and try to run away from it. If you do that, you will double the danger. But if you meet it promptly and without flinching, you will reduce the danger by half.’

Winston Churchill

One of the main problems for anxious people is that we have a perfectly natural tendency to avoid the source of our fears. This may seem like a good idea but, as with all safety behaviours, there is a catch. Every time you avoid a perceived threat you unwittingly reinforce the notion that there is some very good reason for keeping out of its way. This belief then confirms in your mind that the threat is genuine with the result that next time you encounter a similar situation you are even more likely to get worked up.

Furthermore, if you run from the threat – either physically or mentally – you never get the opportunity to allow your state of anxious arousal to subside in its presence and allow your body to unlearn its fear response. The fact is that if you can just stick around for long enough in the presence of your fear your anxiety symptoms will subside.

The body cannot sustain its state of acute arousal for more than a few minutes. Panic burns itself out because it gears the body for a short, intensive burst of activity. It becomes acute over the course of a few minutes and then will hit a biological ceiling before automatically subsiding. Because anxiety symptoms are so unpleasant it seems completely counterintuitive to stay put in a situation that is causing them to escalate, but actually it is one of the most effective things you can do. Exposure is a cornerstone of CBT treatment for many anxiety disorders including phobias, panic, PTSD and OCD.

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Work your way up the ladder of fear

By definition, this means exposing yourself to the thing you fear is going to be difficult, even if rationally you know you are perfectly safe. To make things easier psychologists often encourage people to embark on a programme of graded exposure. This means rather than throwing yourself in the deep end you break down confronting your fear into a series of more manageable steps.

Start by thinking of the two extremes of the scale: a situation likely to produce the most unbearable level of anxiety you can imagine (say letting a large spider crawl on your hand - fear factor rating 10+) and a situation or activity still related to your anxiety but that you are fairly confident you can manage with only minimal discomfort (maybe saying the word ‘spider’ out loud five times or looking at a stylised picture of one in a children’s book – fear factor rating 2). Then you need to work out a series of intermediate stages ranked in order of their stress-inducing potential. By the time you have done this you will have 10 or so progressive stages that take you up towards your ultimate objective.

Don’t worry if at this point you cannot begin to imagine yourself doing some of the tasks on the higher rungs of the ladder. The beauty of graded exposure is that you take it a step at a time, and you don’t proceed to the next rung until you are entirely comfortable with the stage before. I cannot stress this enough. Some people find it tempting to rush through their hierarchy to ‘get it over with’ like gulping down a foul-tasting medicine. This is just another form of avoidance and it won’t help you. The whole point of graded exposure is that you have to sit with the anxiety long enough for it to subside. If you can hang in there it will happen. As you become confident and comfortable with each level, it will make the next step possible.

It is important to bear in mind that avoidance can take many forms. It is not just a question of physically keeping yourself away from situations associated with danger. We may also avoid the things we fear by mentally blocking them out or distracting ourselves when unwanted thoughts about them intrude into consciousness. This is not a helpful strategy because attempting to suppress thoughts usually only makes them stronger.

In fact the opposite approach can be useful for some people. Deliberately inviting the feared scenario into your mind and accepting the feelings that it generates rather than fighting them is a valid form of exposure that can help desensitise you to the fear. Imaginal exposure is a good starting point for people who are struggling with the prospect of physically exposing themselves to the source of their anxieties. The technique is as follows:

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Imaginal exposure

·        Prepare by writing down a paragraph describing your feared scenario or the next step in your hierarchy of fear. It may be helpful to record what you have written onto CD or other recording device. Try to create a detailed and vivid description: a vague or abstract description will simply allow you to carry on avoiding.

·        Get yourself into a state of physical relaxation using breathing, visualisation or another technique that works for you.

·        Spend 15 minutes reading the paragraph over to yourself, vividly picturing the feared scenario in your mind.

·        Accept the physical symptoms of anxiety that will start to develop but notice also how your anxiety levels tend to drop back down as you persist with the process.

·        Repeat until exposure to the feared situation no longer evokes a significant anxiety response.

Anxious thinking

Situation

Emotions (%)

Automatic thoughts

Late for meeting

Fearful 70%

Tense 40%

Vulnerable 30%

I’ll probably be sacked.

I’ll never make partner now.

Everyone will see how hot and flustered I am: I will be a laughing stock.

Notice a scratch on new kitchen floor

Stressed 90%

Angry 10%

Frustrated 70%

It’s totally ruined – why can nothing ever just go right? The flooring people saw me coming… they knew they could get away with it.

See a police car parked in the street

On edge/nervous 60%

Feeling of foreboding 80%

Something terrible has happened. What if someone has broken into my house?

Picture policemen on own doorstep breaking the news that partner has been involved in a fatal accident.

These thought record sheets kept by Alex, a 27-year-old website designer, illustrate several of the classic thinking errors of anxious people.

The hallmark of the anxious thinking style is catastrophising. Anxious people keep themselves in a state of anxious arousal by continually overestimating the danger they are in, and underestimating their capacity to deal with it. Much anxious thinking is consequently oriented towards the future in which the anxious person is at liberty to populate it with terrifying scenarios.

A tell-tale sign of such thinking is the presence of NATs that begin ‘What if…?’ However, one of the problems with anxious individuals is that they don’t actually pursue their anxiety scenarios through to their logical conclusion. They get frozen by the prospect of how things might go wrong. They seldom take stock and appreciate that even if the worst happened (which is probably unlikely) they are not completely helpless and would have to deal with the situation as best they could. If you suffer from anxiety try to replace ‘what if?’ thinking with ‘what then?’ However uncomfortable it makes you, try to follow your anxious scenario through.

If your partner did die you probably would be devastated initially. Your grief might incapacitate you for several months and you might carry on missing your partner intensely for years. But your friends would support you, and those insurance policies would mean that you and the children would be financially secure. Eventually you would pick up the threads of your life again, drawing on the same coping skills that you have used in other contexts. Unthinkable though it might be, you might even meet someone else.

The point is that life would go on. Terrible and tragic events do happen to people from time to time, but dealing with the reality of them is often easier than dealing with the fantasy.

·        Rather than trying to block out the feared scenario ask yourself: ‘What is the very worst that could happen in this situation?’

·        Think practically about how you would have to manage in this eventuality. What resources do you have? Who would support you?

·        Relate the situation to other difficulties that you have survived and dealt with in your life. Are there any transferable skills that would help you deal with the new crisis?

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What are the odds?

For anxious people their associated level of fear makes the possibility of a bad thing happening feel like a certainty to them. This emotional reasoning results in them miscalculating the odds of impending disaster.

One technique that helps people to deal with this distortion is to break the situation down and think about the likelihood of all the separate elements that have to be in place for the unwanted outcome to occur.

If you suffer from health anxiety you might feed your fear by constantly picturing yourself in the terminal stages of cancer. But in order for this image to become true what would have to be in place or what would have to be true? These are the necessary conditions of your belief:

1.    I would have to contract cancer in the first place.

2.    The strain of cancer I contract would have to be a potentially fatal kind.

3.    It would have to prove untreatable or resistant to treatment.

Using the appropriate research you could reliably establish the separate risk of each of these conditions. The probability of the only pathway that takes you to your imagined deathbed scene is the likelihood of each of the separate elements multiplied together. If you express the probabilities as fractions then the more you multiply together the smaller the end fraction (and hence percentage) becomes.

Fear of fear

For many, anxiety is maintained through a process of constant, anxious self-talk, but psychologists have also discovered recently that dysfunctional beliefs about the nature of a person’s reactions to anxiety can be a significant maintaining factor in itself.

For example, if I tell myself continually how awful it would be to re-experience my anxiety I am even less likely to confront the immediate source of my fear. Sufferers often elaborate such dysfunctional assumptions by developing exaggerated beliefs that they will not be able to cope with symptoms or that their anxiety will drive them mad.

These beliefs about one’s own thought processes are called metacognitive beliefs and if you suffer from anxiety you need to be aware of them. They could be holding you back.

Develop a stress-busting lifestyle

‘Stress is what happens to us when we perceive our available resources to be insufficient to meet the demands of our circumstances.’

Richard Lazarus, academic and psychologist

Stress is cumulative, and if it is building at a rate faster than your body and mind can deal with it then eventually you will reach a point of meltdown and start to experience anxiety symptoms. Repeated low-level stressors such as squabbling children or too much noise and stimulation can have as much long-term impact as a more immediately stressful event like a road accident or losing your job. Keep an eye on the niggling stressors in your life as well as trying to protect yourself from major traumas.

Managing anxiety successfully cannot be done without attending to the bigger picture. Adequate rest, a healthy diet and keeping oneself in good physical shape are all protective factors against anxiety disorders. Rushing around trying to cope with multiple demands on our time and attention is a recipe for poor mental health. Unfortunately, the pace of modern life is such that it is hard to avoid being overloaded by a barrage of excessive stimuli. Learning to meditate, developing a yoga or t’ai chi practice, or simply making sure you carve out time to do some of the things that you enjoy will strengthen your resilience and improve your quality of life. Anxious people often feel far too flustered and out of control to prioritise such activities, but of course the reality is that they are precisely the ones who would most benefit from taking more care of themselves.

The advice is simple and I am sure not new to you, but reading the advice and putting it into practice are very different things. When you have finished this chapter why not sit down and contract with yourself to make one practical change to your lifestyle that you have been putting off until now?



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