Anxiety

//Anxiety
Anxiety2013-01-23T09:43:32+10:00

Everything You Wanted To Know About Anxiety (But Were Afraid To Ask)!

by Dr Wayne Scott (Psychologist)

  • Types of disorders and their features
  • Psychological interventions specific to the disorders
  • What psychological interventions best fits the disorder
  • Step by step guide for implementing psychological techniques

ANXIETY MANAGEMENT THROUGH PSYCH INTERVENTION

Psychological treatments (especially cognitive-behavioural therapies) can restore the mental health of anxious people and overcome the debilitating effects of excessive anxiety. The key symptoms vary widely across preceding disorders which influences the type of psychological intervention to be used.

However there are 4 D’s of psychological disorder common to all:

– Disproportion
– Disruption
– Distress
– Duration

Anxiety disorders are manageable, given a skilful practitioner and a hard-working client

Types of disorders and their features

1. Generalised Anxiety Disorder

Features

  • Excessive anxiety or worry, occurring on most days for more than 6 months
  • The worry is out of proportion to the event, pervasive & excessive, difficult to control
  • Accompanied by muscle tension, hyperarousal and symptoms of the “flight or fight” response

Psychological management

  • Education about nature of disorder
  • Progressive muscle relaxation
  • Structured problem solving
  • Graded exposure to difficult situations
  • Cognitive-behaviour therapy (CBT) e.g. stimulus control techniques
  • Support (guidance, advice, development of coping strategies)
  • Counselling
  • Stress management (relaxation, meditation, exercise regimens that improve stress
  • recovery)

2. Obsessive-Compulsive Disorder

Features

  • Obsessions are thoughts, images or impulses that occur repeatedly, are intrusive & distressing & can’t be suppressed or neutralised
  • Compulsions are repetitive behaviours used to control or neutralise the obsessions & prevent the harm & reduce the anxiety, but which are excessive & disabling

Psychological management

  • Education about the nature of the disorder
  • Cognitive-behavioural strategies e.g. response prevention / help to resist carrying out compulsions

3. Social Phobia

Features

  • Excessive & unreasonable fears of being the centre of attention in case of negative evaluation because of looking anxious or doing something embarrassing
  • Situations that could lead to scrutiny or evaluation (social functions, being in a crowd, speaking to others) are avoided or endured with intense anxiety

Psychological management

  • Education about nature of disorder
  • Cognitive-behavioural strategies
  • e.g. graded exposure therapy, social skills training

4. Post-Traumatic Stress Disorder

Features

  • Exposure to extreme trauma e.g. that threatens life
  • Recurring images of trauma
  • Distress triggered by similar events; persistent hyperarousal
  • Avoidance of cues/reminders of trauma

Psychological management

  • Education about the nature of disorder
  • Hyperventilation control
  • Graded in vitro & in vivo exposure to cues
  • Treatment of co-morbid disorders, especially depression & substance abuse
  • Cognitive-behavioural strategies e.g. thought stopping, cue-controlled & differential relaxation, role playing etc

5. Specific Phobia

Features

  • Excessive fear of a specific object or situation e.g. flying, heights, animals, sight of blood, medical procedures such as injections
  • Exposure to phobic stimulus almost invariably provokes an immediate anxiety response e.g. Panic Attack
  • Person realises the fear is excessive or unreasonable

Psychological management

  • Education about nature of disorder
  • Graded exposure to difficult situations
  • Progressive muscle relaxation (or ‘applied muscle tension’ in needle phobics to counter vasovagal/fainting responses)

6. Panic Disorder with Agoraphobia

Features

  • Sudden attacks of fear or anxiety in situations of little danger
  • Symptoms of the “flight or fight” response, complicated by hyperventilation and worsened by the fear of collapse or death
  • Avoidance, for fear of panic, of situations from which escape is not possible or help is not available, typically public transport, travelling alone, crowded or lonely places

Psychological management

  • Education about nature of disorder
  • Hyperventilation control
  • Graded exposure to feared situations

7. Organic differential diagnoses for Panic Disorder

  • More common: hyperthyroidism, drug withdrawal, drug intoxications, infection
  • Others: Cardiovascular, Endocrinal, Neurological, Pulmonary & other miscellaneous conditions e.g. chemical exposure

Psychological interventions specific to the disorders

Listed below are various psycho-educational exercises and skills for treating anxiety disorders. These techniques are explained in detail.

  • Education
  • Breathing (shallow, deep and retraining)
  • Graded exposure
  • Structured problem solving
  • Thought stopping
  • Challenging negative thoughts
  • Coping ‘I’ statements
  • Positive self-talk
  • Worry-time/worry place
  • Time-Out: Recognise, Retreat, Relax, Return
  • Meditation
  • Relaxation
  • Cognitive Behavioural Therapy (CBT)

1) Education

Education about the disorder is imperative prior to starting any techniques or skills. Patients

need to understand what their body and mind are ‘going through’ when they experience

anxiety.

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a) You need to

describe the features of the disorder in detail. For example for SPECIFIC

PHOBIA cite the main features so that the person can identify and understand what is

happening to them., That is, excessive fear of a specific object or situation (flying,

heights, animals, sight of blood, medical procedures such as injections, etc). Explain

that this exposure to the phobic stimulus almost invariably provokes an immediate

anxiety response (e.g. Panic Attack) and the person then realises that the fear is

excessive or unreasonable.

b) You need to explain to the person what is happening to them physiologically in simple

non-medical jargon. The physiologic response to

fight or flight stimuli is ideal as the

person can identify the bodily changes that occurs for them as well as identifying the

tangible trigger (rapid breathing, breathlessness, etc) for experiencing the panic attack.

Identifying bodily changes is important for any intervention.

c) Outline to the person

your intervention for positive change and reassure them that

their condition can improve. For example, for Generalised Anxiety Disorder you may

use progressive muscle relaxation, structured problem solving, relaxation training and

cognitive behavioural therapy (CBT) in conjunction with a regime of medication

prescribed by their GP.

Education about the condition is essential for a successful intervention.

2) Breathing Techniques

Breathing techniques can assist the patient to combat the

flight v fight response, slow down

their heart rate and breathing, provide the time to gather their thoughts and to allow the person

to attempt to take control of their situation.

a) Slow Breathing Technique 1

Using the second hand on watch or clock:

Hold your breath for six seconds

Breathe in & out on six-second cycle, saying word “relax” as you breathe out

After one minute, hold your breath again, then continue to breathe on sixsecond

cycle

Repeat sequence until anxiety has diminished

Slow, steady breathing (not deep breathing) is central to controlling panic

b) Slow Breathing Technique 2

Slowly take a deep strong breath through your nose and hold it for 2 seconds (count 2001,

2002 in your mind).

Slowly release it through your mouth until the last of your breath has exhaled.

Repeat this process twice more

This simple technique will slow your heart rate and allow you time to gather your thoughts.

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c) Deep Breathing Technique 3

By concentrating on our breathing, deep breathing allows the rest of our body to relax itself. Deep

breathing is a great way to relax the body and get everything into synchrony. Relaxation breathing

is an important part of yoga and martial arts for this reason.

1. Lie on your back.

2. Slowly relax your body. You can use the progressive relaxation technique we described

above.

3. Begin to inhale slowly through your nose if possible. Fill the lower part of your chest first,

then the middle and top part of your chest and lungs. Be sure to do this slowly, over 8 to

10 seconds.

4. Hold your breath for a second or two.

5. Then quietly and easily relax and let the air out.

6. Wait a few seconds and repeat this cycle.

7. If you find yourself getting dizzy, then you are overdoing it. Slow down.

8. You can also imagine yourself in a peaceful situation such as on a warm, gentle ocean.

Imagine that you rise on the gentle swells of the water as you inhale and sink down into

the waves as you exhale.

9. You can continue this breathing technique for as long as you like until you fall asleep.

d) Five minute Breathing Exercise Technique 4.

This exercise is intended to restore you to feeling calm and at ease when you don’t have time

to practice the deep – relaxation technique.

This routine can be practice sitting or lying down – if you are sitting, sit well back in your

chair, letting the back of the chair support your spine, with your legs uncrossed and both your

feet on the ground.

– First, breathe out; let your breath out in a slow sigh. Now breathe in slowly, feeling

your diaphragm (just above your waist) expand outwards. As you breathe out again,

say to yourself “Let go”, and feel yourself beginning to release the tensions in your

body.

– Now breathe in again, feeling your ribcage expand sideways, on either side of your

body, and then slowly exhale, letting your out – breath be a little longer and a little

slower than your in – breath.

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– Repeat by inhaling slowly. Experience your ribcage spreading sideways and your

diaphragm expanding in the front of your body. Never hold your breath once you

have inhaled, just let your breath out again in a slow sigh. Pause for a second before

you breathe in again, as above, feeling the expansion in the middle of your body.

– Continue this rhythm for about five minutes. Concentrate on making sure that you are

breathing into the middle of your body, feel that part of you expanding sideways and

let your out – breath be a little longer and a little slower than your in – breath.

– Practise at first by counting to three as you breathe in, and to four as you breathe out.

Do this by saying slowly to yourself as you inhale: ‘In, two, three. Then, as you

exhale, say: ‘Out, two, three, four’. Continue for about five minutes. This counting is

simply to give you the experience of breathing out a little longer than you breathe in;

but if it feels wrong forget the counting and just focus on slightly lengthening your out

– breath.

– Practise this exercise every day, a number of times a day, so that when you actually

need it, you will be skilled at calming your breathing and bringing it down to your

diaphragm, where breathing is designed to take place for ordinary, everyday activities.

Use this technique to re-establish equilibrium after, or during any stressful event, or after a

difficult encounter with another person.

When you have mastered your breathing try to imagine that you are breathing out any

negative emotions you are feeling. Visualise them floating away, and then breathe in positive

emotions, to calm your inner state. For example, breathe in calmness and tranquillity. Also

breathe out attitudes that are no longer relevant or useful to you; breathe in an attitude that

would be more helpful. For example, breathe in an attitude of tolerance, patience, stability or

centeredness.

Remember an ancient Yoga saying:

When you can control your breath, you will control your life”.

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2) Graded Exposure

Graded exposure is a form of desensitization to something unpleasant. By starting to

experience controlled ‘exposure’ to the adverse stimuli at a minimal level of fear the person is

able to slowly increase their confidence in dealing with the adverse stimuli. It is essential that

the person has a rating scale (Likert Scale showing 10 points of the anxiety or panic levels

experienced from

none to extremely severe, Fear meter as depicted below or GSR) which they

can self-assess their fear levels as they progress through the different levels of graded

exposure. This is a self-assessment for improvement and fear reduction.

Identify specific goals & break them into smaller, manageable steps

Learn to master situations that cause mild anxiety (lower on subjective scales like

child’s fearmometer)

Progressively master situations that are associated with greater anxiety

Confront fears regularly & frequently

Emphasise habituation to anxiety in each exposure session

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Examples of graded exposure hierarchies

Goal:

To travel alone by bus to the city & back

1. Travelling one stop, quiet time of day (anxiety level 4/10)

2. Travelling two stops, quiet time of day

3. Travelling two stops, rush hour (anxiety level 6/10)

4. Travelling five stops, quiet time of day

5. Travelling five stops, rush hour (anxiety level 8/10)

6. Travelling all the way, quiet time of day

7. Travelling all the way, rush hour (anxiety level 10/10)

Graded exposure for pain-related anxiety

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4) Structured Problem Solving

Step 1: What is the problem/goal?

Think about the problem/goal carefully, ask yourself questions. Then write down exactly what

the problem/goal is.

_________________________________________________________________

Step 2: List all possible solutions

Put down all ideas, even bad ones. List the solutions

without evaluation at this stage.

1. ______________________________________

2. _______________________________________

3. _______________________________________

4. _______________________________________

5. _______________________________________

6. _______________________________________

Step 3: Assess each possible solution

Quickly go down the list of possible solutions and assess the

main advantages and

disadvantages of each one.

Step 4: Choose the “best” or most practical solution

Choose the solution that can be carried out most easily to solve (or to begin to solve) the

problem.

Step 5: Plan how to carry out the best solution

List the resources needed and the major pitfalls to overcome. Practise difficult steps, make

notes of information needed.

Step 1. ___________________________________

Step 2. ___________________________________

Step 3. ___________________________________

Step 4. ___________________________________

Step 6: Review progress and be pleased with any progress

Focus on achievement first.

Identify what has been achieved, then what still needs to be

achieved. Go through steps 1 to 6 again in the light of what has been achieved or learned

What has been achieved? __________________________________________________

What still needs to be done? __________________________________________________

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5) ‘Thought Stopping’

You know what it is like when a particular thought keeps running around in your head. It

might be the words to a song, a tune, or a worry, but whatever it is, it usually goes away again

after a day or two.

But sometimes we have trouble getting rid of these thoughts, especially when they are about

something negative or unhappy. Sometimes these thoughts are so constant and persistent, that

you might start to believe they are true. This can make us feel stressed and anxious, and stop

us thinking good things about ourselves.

So how can you get some relief from these unhelpful thoughts?

Thought-stopping is a brief

technique which has helped many people.

1. Arm yourself with a rubber-band, one which will fit loosely around your wrist.

2. Spend a few moments thinking up an alternative thought. It should be a

pleasant and

calming

one – perhaps a memory of a relaxing holiday you once enjoyed, or of a walk

you once took in the country. In any case you should be able to picture it quite clearly

when needed.

3. To practice thought-stopping, sit yourself in a room where you will not be interrupted.

Start by thinking up your unwanted or unhappy thought until it is clearly in your mind.

4. Suddenly shout

“Stop” and at the same time flick yourself with the rubber-band. This

will shock both your mind (through the shouting) and your body (by the rubber-band),

and for a moment the unwanted thought will vanish.

5. Straightaway, start counting backwards from 10 to 1

out loud. When you have

reached 1, begin thinking about your alternative, pleasant thought. Go on thinking it

for about 30 seconds. Repeat Steps 1-5 two or three times for practice.

6. Now do it again several more times, each time making the

“stop” and the counting a

little quieter. However, you should go on shouting and counting

inside your head.

Your aim is to be able to do this entirely within your own head, so you can do it

anywhere you start to feel anxious or have a negative or unhelpful thought. As you get

well-practised, you should also be able to give up the rubber-band.

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6) Challenging Negative Thoughts

When we start to feel anxious or stressed, we sometimes start to think negative or unhelpful

thoughts, which stop us feeling happy and getting on with our lives. One way to get rid of

these unhelpful thoughts is to ask ourselves questions to challenge these thoughts. Every time

a negative or unhelpful thought pops into your head, use this list of

20 questions to help

change your thinking:

1.

What evidence or support do I have for believing this?

2.

Am I jumping to conclusions that are not completely supported by the evidence?

3.

Are there any small things that challenge my thoughts that might be important?

4.

Have I had any experiences that show that this thought is not completely true all the

time?

5.

What’s an alternative explanation for what I’m feeling?

6.

Is what I believe the only or best way to explain what is going on or are there other

explanations?

7.

Would everyone in a similar situation think this way?

8.

What would I tell a friend who was in the same situation?

9.

In what ways might I be twisting reality?

10.

What is the worst thing that could happen?

11.

How likely is it that the worst will happen?

12.

What is most likely to happen?

13.

If the worst thing happened, how bad would it really be?

14.

Would it still be bad in a week/month/year?

15.

Five years from now if I look back at this situation, will I look at it any differently?

16.

What is fact in this situation and what are my own feelings?

17.

What have I learned from past experiences that could help me now?

18.

Are there any strengths or positives in me or the situation that I’m ignoring?

19.

Are things really as bad as I’m making out?

20.

What’s positive about this situation?

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7) Coping statements

“I” Statements

The words we use have a great impact on the quality of our life. Certain words can be

damaging and unhelpful, while others make us feel stronger and better about ourselves.

Using

“I” statements is an important part of becoming responsible for ourselves and

“owning” what we do, what we think, and what we feel.

“She really made me mad”, “You hurt my feelings” “Roller coasters scare me” are all

examples of how we use words to convince ourselves that we do not have control over our

feelings. When we think in terms of “you make me feel” we give up our personal power and

give others control over how we feel.

By changing the words we use, we can become in control of how we feel. Statements like, “I

really felt angry with her”, “I’m afraid of roller coasters” or “I feel hurt” show that you are in

control of how you feel and that you are taking responsibility for feeling the way you do,

rather than pretending it’s someone else’s fault.

When we realise that we are in control of our feelings, we give ourselves the freedom to feel

the way we do or choose to feel differently.

Think of the following statements:

“I can’t” implies I have no control over my life

“I won’t” puts this statement in the area of my choice.

When we constantly tell ourselves “I can’t” we start to believe this about ourselves. By

changing “Out-of-Control” words to “My-Choice” alternatives, we start to change how we

think and feel about ourselves and can take responsibility for where our lives are going.

Out-of-Control Words My-Choice Alternatives

I can’t I won’t/I choose not to

I should I will/I choose to

I must I will/I choose to

I have to I choose to

If only Next time/When I

It’s not my fault I’m responsible for

It’s a problem Its a challenge/an opportunity

It’s terrible It’s a learning experience

I’ll try I will/I can

Never Rarely

Always Most of the time

Right Appropriate/Acceptable

Wrong Inappropriate/Unacceptable

Every time you hear yourself using an ‘Out-of-Control’ word, say the statement again, this

time using a ‘My-Choice’ word and see how this changes the way you feel.

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8) Positive Self-Talk

We talk to ourselves all the time. We give ourselves more feedback than anyone else ever

could. Self-talk can be negative or positive, and it can affect all parts of life, such as health,

finances, and relationships. Self-talk is very powerful. After a while, you start to believe your

own self-talk. When you say to yourself “I am no good at meeting new people. I always

freeze up and look stupid…” your heart beats faster, you breathe more shallowly, your

stomach tightens, and adrenalin clouds your thinking. This negative self-talk creates stress in

your body and your mind.

Negative self-talk is discouraging. Some examples of negative self-talk:

“I’m dumb.”

“I can’t do it.”

“I’m no good at this.”

I did it before and I failed, so what is the point of failing again

There is too much pain for me to have a go.

Positive self-talk is encouraging. This kind of self-talk helps us achieve our goals. Some

examples of positive self-talk:

“I can do it.”

“I’m good enough.”

“If I want to, I can.”

“I wasn’t no good the last time I did it but I have learned from my mistakes and this time I

can do it.”

“It doesn’t matter if I make a mistake.”

“I can make it happen”.

“If I try hard, I’ll get there”.

“No pain, no gain – I will do it”.

The health benefits of positive self-talk may include:

– a sense of well-being and being able to deal with things

– breathing easier if you have chronic obstructive lung disease, such as emphysema

– less chance of catching a cold

– less stress

– living longer

– reduced risk of coronary artery disease

How do I make my self-talk positive?

We can talk ourselves into or out of many things. You may not be aware of the things you say

to yourself. The first step is to notice the things that you say to yourself.

To change your self-talk from negative to positive:

Carefully choose the words you use. Generally it is best to say things in the present, even if

you don’t completely believe it yet. For example, instead of saying “I will be a better parent”,

say “I am a terrific parent.” Talk about things the way you want them to be.

Accept occasional setbacks and mistakes as normal and natural. Tell yourself that you can rise

above them and carry on.

Focus on the solution rather than the problem. Rather than complaining about what you can’t

do, tell yourself “What I CAN do is…”

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Watch out for words like “always” and “never”. Very often we make things sound worse than

they are. Instead of saying “I never stick to a diet,” say “I can lose one pound, and that’s a

start.”

Replace criticism with praise. Learn to be your own best fan.

Once you become aware of how your self-talk sounds, imagine what a kind, supportive voice

would say. Picture a person being encouraging to you. This could be a grandparent, a sibling,

a favourite teacher or friend.

Here’s what an encouraging person might say:

“Go ahead. Give it a try. You do have the skills required to do the job. You deserve this

promotion!”

“You’re good!”

“Good for you! You did very well!”

What would you think?…

How would you feel?…

What would you do?…

Use Positive Self-Talk in the following situations.

Right when you wake up

While you are brushing your teeth

While you take your shower

When you eat breakfast

While you drive to work or go to school

When you are at school/work throughout the day

Whenever you feel down

Whenever you feel uplifted

On your way home

While eating dinner

While spending time with friends/family

While getting ready for bed

While laying down in bed

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Examples of Positive Self-Talk

Positive Self Talk for Confidence

I am as capable as anyone else out there

I know with time and effort I can accomplish

anything

I am comfortable in front of people and say

the right things

I know who I am and I am special

Anyone who meets me will remember how

fascinating I am

I can accomplish any task set out before me

I find things out when no clear answer is

defined

I am worthwhile, successful, and happy

Positive Self Talk for Being Stress Free

I am always cool, calm, and understanding

I always observe before reacting

Being busy means I am important

I am organized and know what I need to do

I know where I am going in life

I accept the choices of other people

I am learning and growing

I love to meditate and reflect on life

Positive Self Talk for a Healthy Life Style

I eat food that has a lasting benefit for me

I love to eat healthy food!

Occasionally I indulge myself in tasty food

Vegetables and fruits strengthen me and I

love to eat them

I love going for a walk and seeing the

outdoors

Exercise is a time for me to get stronger and

reflect on life

Running makes me feel good

I only eat what I need to sustain myself

Positive Self Talk for Financial Freedom

I only spend money on what is essential

I constantly seek other ways to make money

I am generous with my money and give back

to others

I am confident in my career and I am worth a

lot

I am successful in anything I try

I always keep plenty of money on hand

I am able to make money because I am smart

and talented

Money helps me do great and wonderful

things

Positive Self Talk for Overcoming Fear/Doubt

I don’t worry about anything

I accept the things I cannot control

I always give my best effort and that is good enough

I am smart, confident, and capable

I seek the best in other people and accept their weaknesses

I love challenges and the gain from overcoming them

I can solve any problem

Anything is possible with a little faith

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Positive Self-Talk – ‘Making it happen’

A little voice in our head gives us messages. Sometimes the messages say that we are clever

and doing well. At other times they say that we are ‘stupid’ or that we can’t do anything.

Write down how you feel when the messages are negative as well as how you feel when they

are positive. The first has been done as an example. You can also add some other situations to

the list. Note the feelings you have in your examples. Frightened versus excited – how you

feel in a situation can reduce anxiety.

Situation Negative self-talk Positive self-talk

Example:

Speaking to someone new

I’m dull. They won’t want to

talk to me.

I’m interesting. Maybe I’ll make a

new friend.

Feelings

Frightened Excited

1. Trying a new problem

I’ll make a mistake. The more I try the better I’ll get.

Feelings

2. Giving a talk to a group

They’ll laugh and tease me. I can do it.

Feelings

3. Asking if you can join a

group of people

They don’t like me. This will be fun.

Feelings

4. Asking to borrow something

special

They’ll say no. They’ll say yes.

Feelings

5. Giving an opinion

They’ll all laugh. They’ll think I’m smart.

Feelings

6. Making a speech

I’ll make a fool of myself. I’ll do a pretty good job.

Feelings

7.

Feelings

8.

Feelings

9.

Feelings

10.

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Positive Self-Talk – ‘

Nothing ventured, nothing gained’

Some people don’t try new things because they’re scared. Complete the following

activities:

1. What would be the worst thing that could happen if you didn’t do as well as

you would like at:

Learning pottery? _______________________________________________

Reading aloud? _________________________________________________

Surfing? _______________________________________________________

Trying a new hairstyle? ___________________________________________

Introducing yourself to someone new? _______________________________

A job interview? ______________________________________________

2. List some additional activities you could try and give the worst and best

things that could happen.

I should try The worst that could happen The best that could happen

3. The messages we give ourselves are called ‘self-talk’. Give some examples of

negative self-talk that could make you feel frightened of trying something new.

a _____________________________________________________________

____________________________________________________________

b _____________________________________________________________

____________________________________________________________

c _____________________________________________________________

____________________________________________________________

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4. Now give the positive self-talk that should replace these negative messages.

a _____________________________________________________________

____________________________________________________________

b _____________________________________________________________

____________________________________________________________

c _____________________________________________________________

9) Worry-time/worry place

Devote some time during the day to do your thinking and worrying. Your bed is not a

good place to think and worry because it interferes with sleep. So, it’s a good idea to

devote some time in your day to do your worrying and any thinking that needs to be

done (you may choose to put between 5-60 mins aside). Your ‘thinking/worrying’

time should end at least a couple of hours before you go to bed. Then, when you go to

bed and thoughts come into your head, say gently to yourself (and over again if need

be):

‘Stop. I have already thought about that today and I’ll review the situation again

tomorrow. Now, I’m going to bed

For this self-talk to be effective, it’s important that you do actually put time aside in

your day to do your thinking. Choose a location which is sterile and make it your

‘worry place’ – where you can sit quietly and ponder over your worries, fears and

concerns. It is a good idea to jot down your worries or to talk them out aloud. This

provides you with visual and auditory record that you have already spent time on the

issues at hand.

If you don’t, you won’t be convinced when you tell yourself that you have already

dealt with the problem that day.

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10) Time-Out: Recognise, Retreat, Relax, Return

Time-out is a choice you make to leave or prepare for a situation before your anxiety

takes control of you. Taking a time-out is how you demonstrate to yourself that you

are in control.

Examples.

– approaching a shopping complex and you start feeling anxious.

– attending an exam which you have been worrying about.

– giving a presentation

– making a phone call

– starting a new job

– flying for the first time.

How do you take a time–out?

Here’s a simple memory aid that can help you take a good time–out:

R

ecognise, Retreat, Relax, Return.

RECOGNISE

In order to know when to take a time-out you must become very aware of the early

signals your body sends to you that you are quickly getting to the point where you

may become anxious. Think of the kinds of physical reaction(s) that you’ve noticed

which seem to be associated with increases in your anxiety(eg. palpitations, feeling

flushed in the face, butterflies in your stomach, shaky, and so on). On the lines

provided below please write some of the bodily reactions that you believe might be

good indicators that you should stop what you are doing and take a time-out.

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

RETREAT

Once you’ve recognised your body’s warning signs (as above) the next step is to

make a strategic retreat. Remove yourself from the potentially explosive situation.

There is enough anxiety in your life, you don’t need to hang around and experience

some more. Go for a walk, sit out on the back steps, go out to your shed, go to your

worry place or just spend a bit of time alone. Remember that you’re not giving to

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anxiety, your choosing now not to suffer the negative consequences of anxiety.

You’re choosing to stay in control.

Consider using one of the following phrases to facilitate taking a time-out: “Look, I’m

getting very anxious. I’ve just got to go. I’ll be back soon”; “I’m getting pissed-off.

I’m taking a time-out. I need to address the matter again later”; or “I will talk about

this when I am feeling a bit calmer”.

On the lines provided below, write down some strategies you can do in the interim but

you intend to return and more calmly face the anxious issue.

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

RELAX

While away in your ‘worry’ area your goal is to calm down; both physically and

mentally. Use relaxation methods to reduce your level of physiological arousal. It is

a good idea if we can use a combination of these techniques during a time-out period

to help us achieve a calmer, rational, problem-solving perspective on the problem or

issue at hand. We tend to think more clearly when we are not upset. Thus, we are far

more likely to come up with a logical solution or, at least, have a more constructive

perspective if we are thinking with a calm, focused mind.

Please write down three things you can do during a time-out that will help you relax.

_____________________________________________________

_____________________________________________________

_____________________________________________________

RETURN

This might be considered the most difficult part of the time-out because you are

deliberately facing a very contentious fear that you were previously very anxious

about. It is important that you develop a logical strategy for tackling your fears and

worries.

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11) Meditation

Meditation is a holistic discipline by which the person attempts to get beyond the

reflexive, “thinking” mind into a deeper state of relaxation or awareness. Meditation is

a component of many religions, and has been practiced since antiquity. It is also

practiced outside religious traditions. Different meditative disciplines encompass a

wide range of spiritual goals—from achievement of a higher state of consciousness,

compassion and loving kindness, to greater focus, creativity or self-awareness, or

simply a more relaxed and peaceful frame of mind.

Meditation techniques have also been used by Western theories of counseling and

psychotherapy. Relaxation training works toward achieving mental and muscle

relaxation to reduce daily stresses. Jacobson is credited with developing the initial

progressive relaxation procedure. These techniques are used in conjunction with other

behavioral techniques. Originally used with systematic desensitization, relaxation

techniques are now used with other clinical problems. Meditation, hypnosis and

biofeedback-induced relaxation are a few of the techniques used with relaxation

training. One of the eight essential phases of EMDR (developed by Shapiro), bringing

adequate closure to the end of each session, also entails the use of relaxation

techniques, including meditation. Multimodal therapy, a technically eclectic approach

to behavioral therapy, also employs the use of meditation as a technique used in

individual therapy.

From the point of view of psychology and physiology, meditation can induce an

altered state of consciousness, and its goals in that context have been stated to

achieving spiritual enlightenment, to the transformation of attitudes, and to better

cardiovascular health.

12) Methods of Relaxation

This section will provide you with proven and effective strategies for relaxing when

you are in an adverse emotional state (anxiety, anger, etc). You can make a recording

from the ‘scripts’ provided for yourself on a CD which you can use: prior to an

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anxious activity, prior to having to do something unpleasant, or in bed prior to

sleeping.

Progressive Relaxation

This technique is often most useful when you tape the instructions beforehand. You

can tape these instructions, reading them slowly and leaving a short pause after each

one.

Lie on your back, close your eyes.

Feel your feet. Sense their weight. Consciously relax them and sink into the bed. Start

with your toes and progress to your ankles.

Feel your knees. Sense their weight. Consciously relax them and feel them sink into

the bed.

Feel you upper legs and thighs. Feel their weight. Consciously relax them and feel

them sink into the bed.

Feel your abdomen and chest. Sense your breathing. Consciously will them to relax.

Deepen your breathing slightly and feel your abdomen and chest sink into the bed.

Feel your buttocks. Sense their weight. Consciously relax them and feel them sink

into the bed.

Feel your hands. Sense their weight. Consciously relax them and feel them sink into

the bed.

Feel your upper arms. Sense their weight. Consciously relax them and feel them sink

into the bed.

Feel your shoulders. Sense their weight. Consciously relax them and feel them sink

into the bed.

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Feel your neck. Sense its weight. Consciously relax it and feel it sink into the bed.

Feel your head and skull. Sense its weight. Consciously relax it and feel it sink into

the bed.

Feel your mouth and jaw. Consciously relax them. Pay particular attention to your jaw

muscles and unclench them if you need to. Feel your mouth and jaw relax and sink

into the bed.

Feel your eyes. Sense if there is tension in your eyes. Sense if you are forcibly closing

your eyelids. Consciously relax your eyelids and feel the tension slide off the eyes.

Feel your face and cheeks. Consciously relax them and feel the tension slide off into

the bed.

Mentally scan your body. If you find any place that is still tense, then consciously

relax that place and let it sink into the bed.

Toe Tensing

This one may seem like a bit of a contradiction to the previous one, but by alternately

tensing and relaxing your toes, you actually draw tension from the rest of the body.

Try it!

Lie on your back, close your eyes.

Sense your toes.

Now pull all 10 toes back toward your face. Count to 10 slowly.

Now relax your toes.

Count to 10 slowly.

Now repeat the above cycle 10 times.

Guided Imagery

In this technique, the goal is to visualize yourself in a peaceful setting.

Lie on your back with your eyes closed.

Imagine yourself in a favourite, peaceful place. The place may be on a sunny beach

with the ocean breezes caressing you, swinging in a hammock in the mountains or in

your own backyard. Any place that you find peaceful and relaxing is OK.

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Imagine you are there. See and feel your surroundings, hear the peaceful sounds,

smell the flowers or the barbecue, fell the warmth of the sun and any other sensations

that you find. Relax and enjoy it.

You can return to this place any night you need to. As you use this place more and

more you will find it easier to fall asleep as this imagery becomes a sleep conditioner.

Some patients find it useful to visualize something boring. This may be a particularly

boring teacher or lecturer, co-worker or friend.

Muscle Relaxation Routine

You should try to practice this routine for half an hour every day. It will refresh and

restore your body and calm your mind and emotions.

Lie down on a firm surface, a bed or sofa, or on the floor. Place a small cushion

under your head and a large cushion under your thighs to take the strain off your

abdomen and ease the small of your back. Make sure that you are warm, as you

cannot relax if you are cold. It is a good idea to cover yourself with a rug or blanket,

as your body temperature falls as you relax deeply, because your heart rates slows a

little and your blood pressure drops. This is why regular practice of deep relaxation is

especially good for anyone who suffers from high blood pressure. Become aware of

your shoulders and pull then down towards your hips (the opposite of shrugging),

hold them stretched down for a few seconds and then let them go. Now feel as if your

shoulders are tipping backwards towards the support you are laying on, the bed, sofa

or floor.

Become aware of your arms. Move your arms a little away from the sides of your

body, and bend your elbows slightly outwards. Let your hands rest on your lower

abdomen or at the side of your body. Now push your arms down into the support,

hold for a moment and then stop pushing. Feel your arms get heavier. Tell yourself

to let go more and more through the muscles in your arms. Feel them being

completely held by the support. Let go a little more.

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Now be aware of your hands. With your hands still supported, either beside you or

resting on your lower abdomen stretch out your fingers and thumbs. Hold the stretch

for a few seconds and then let your fingers flop. Let them go limp, not holding onto

anything, not clasped to together and feel your hands completely still and relaxed.

There is nothing for them to do right now, just rest. Feel how calming it is to have

completely relaxed hands.

Now be aware of your legs. Push your legs down into the support – hold for a few

seconds, then let go. Now point your toes down, stretching your feet away from you,

to stretch the muscles in your lower leg. Hold for a second or two (not too long, as

this can cause cramp) and then stop and let your feet flop outwards. Feel your legs

sinking down into the support. Let go a little more. Feel your legs becoming heavier

and completely relaxed.

Now be aware of your abdomen muscles below your waist. As you breathe out, let

these muscles feel loose, limp and easy – no holding on. Now feel your buttocks

muscles letting go. Feel the whole of your lower body being held more fully and

relaxing more completely.

Now be aware of your diaphragm – just above your waist. Feel as if this part of you

is expanding slightly. Just let go all around your middle, and feel your easy breathing

in this area. Feel your ribcage stretching outwards as you breathe in, and feel your

diaphragm expanding. As you breathe out slowly, feel yourself relaxing – feel your

body letting go more thoroughly as the out – breath relaxes you.

Now be aware of your back being supported. Press down a little more heavily into

the support, hold for a few seconds, then stop pushing and let go. Feel your whole

body being held a little more completely than before. Now let go even more deeply.

Now be aware of your mouth and jaw. Make sure your top and bottom teeth are

slightly apart, not clenched together. Let your tongue rest on the bottom your mouth.

Let your lips touch lightly. Become aware of how it feels to have a relaxed mouth

and jaw.

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Now imagine you are about to smile, beginning in your mouth and spreading out into

your cheeks – feel as if your cheeks are widening, stretching out a little.

Now be aware of your eyes. Close your eyelids, slightly. Let your eye muscles relax

– there is nothing to focus on or stare at. Let your eye muscles rest, and enjoy the

peace that comes from shutting out all visual stimuli for a while.

Now be aware of your forehead. Imagine gentle fingers smoothing your forehead

outwards from the centre to the temples at either side. Feel as if your forehead is

widening. Feel as if your forehead is getting higher. Feel as if you have a high, wide

brow that is calm and smooth.

Now imagine gentle hands are massaging over your scalp: up over the top of your

head and down the back of your head. Feel as if your whole head area is expanding a

little. Let go through all the muscles in your scalp. Relax your scalp and head.

Now just enjoy the felling of being relaxed. Enjoy the feeling of ease. Rest in the

feeling of calm that comes from letting go.

Stay with this relaxed feeling, and rest your mind by picturing a beautiful, peaceful

place – somewhere you would like to be right now. Rest in this beautiful place in

your imagination for a few minutes. Enjoy being there and taking time away from the

outside world. Be aware that this is a very healthy thing to do.

You are not wasting time– you are using time very creatively to restore your energy

and vitality.

Hold the awareness that all the repair processes of the body are enhanced and the

immune system is boosted, when you are in this state of deep relaxation.

Half an hour is an ideal time span for this deep, restorative relaxation. When you wish

to come back into normal alertness, do so gently and slowly. First, gently wiggle your

fingers and toes; then, have a gentle stretch – stretch out your arms, fingers, legs, feet

and toes. Push your heels away from you to stretch out your spine and body. Roll

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onto your side and sit up slowly, as all the systems in the body have slowed down and

you do not want to shock or strain them. Just sit still for a few moments, then stand

up slowly, so as not to feel dizzy; and try to move and speak a little more slowly than

you usually do for as long as you can. Just keep that feeling of calm with you as long

as possible.

13) Cognitive behavioural therapy (CBT).

This is a form of structured problem-solving that aims to change the way a person thinks, so

they come to see that the feared situation isn’t as fearful as he or she thinks. It requires special

training, is usually done by a psychologist or psychiatrist, and typically requires ten to 12

sessions to be effective.

Resources