My Anxiety Treatment Toolbox

In addition to introducing The Five Steps, It is also important that I help my clients become skilled at deep relaxation. This enhances their ability to identify the thoughts that are worrying or scaring them while they are arising, and makes it much easier to let go of mounting levels of fear or anxiety at that moment.

For that reason, I like to teach my clients meditation, which can help them to both relax physically and mentally, and experience states of peace and calmness on a regular basis. This can help a great deal for people with generally high levels of anxiety or worry.

I also employ techniques that have become known as ‘energy psychology’. These techniques involve certain patterns of tapping on acupuncture meridian points (EFT – Emotional Freedom Technique) or bi-laterally stimulating the brain through particular eye movements (EMDR – Eye Movement Desensitization and Reprocessing), and can help reduce the influence of past experiences and memories on present coping, as well as helping to develop more powerful present moment coping abilities.

Finally, in some instances I will utilize hypnosis to help my clients to more readily reach deep levels of relaxation, and gain the additional benefit of the subconscious mind in helping make the move towards genuinely accepting your anxiety more rapid and automatic.

I have outlined the steps I consider to be essential to self-managing anxiety successfully. If you take these steps when you are experiencing anxiety, whether moderate or severe, you should see a real difference in how it progresses. Individuals’ ability to complete these steps on their own will vary.

A number of people find that anxiety management techniques are all they need to learn and they will be able to successfully implement the steps on their own. Others will require a brief period of support from a licensed psychotherapist, such as myself, who is very experienced in working with clients with anxiety disorders. This additional support will help fine tune the process and ensure that you implement the steps effectively.

It is highly likely that individuals suffering with Simple Phobia, OCD, & PTSD will require the support of a licensed psychotherapist. In the first instance, Simple Phobia, the anxiety is absent except in the presence of a particular feared real-life situation, for example, a snake, standing on a high platform, sitting on an airplane. While the general principles I’ve outlined above still hold, there are very focused and powerful techniques available to directly eliminate such phobias.

With OCD there will be the need to focus on both the anxiety that triggers the obsessive thinking & the compulsive behaviors, which is complicated enough to require additional therapeutic support.

In the case of PTSD an individual has typically had a real life experience in a very dangerous situation and experienced some of the highest possible levels of fear, often in the context where it was possible, or the individual believed it was possible that their life was at its end.

For many years there was little help available for individuals suffering from PTSD. However, in the last several years techniques have been developed that can be highly effective in permanently reducing the associated symptoms and memories. For this reason, the support of a licensed psychotherapist with the proper training is really essential.

Finally, in severe and persistent Panic Disorder, as well as OCD and PTSD, there may be potential additional benefit from taking certain medications at the same time that self-management strategies are being implemented. Many physicians will require their patient to be working with a licensed psychotherapist in order for them to prescribe these medications.

(photo credit: life serial)

The Five Steps to Managing Anxiety

Now, with the physical exam out of the way, we can focus on what I consider to be the general principles for coping with anxiety. I have coined these as The Five Steps, as they are always involved in working effectively with anxiety disorders. I, myself, employed them for overcoming my social anxiety, and they form the foundation of my work with clients:

• Be willing to feel your fear
• Relax your resistance to the experience of fear in your body
• Accept your discomfort as distressing but not dangerous
• Regulate your breath, preventing hyperventilation and move your body
• Begin to say ‘yes’ to what you have been avoiding all this time

Remember that what you resist persists. On the other hand, if you are willing to feel the very uncomfortable sensations of anxiety for a few minutes and not attempt to distract yourself, numb yourself, or run away from the experience, it will begin to level off and diminish within a few minutes. Remind yourself that the feelings are certainly distressing, but anxiety is not dangerous, so there is no risk in staying put, and there is no real need for alarm.

Now, quite often as anxiety and fear increase your breathing will start to become shallow and rapid. Lengthen your breath so that each inhalation and each exhalation takes 3-4 full seconds, and move your body to interfere with the tendency to move towards hyperventilation.

As you have some successes shortening the periods of anxiety that develop you must stop avoiding the previously avoided situations. Otherwise, each time you avoid or run from the feared situation, your fear and tendency to avoid the situation becomes a little stronger. Most people find it easiest to begin doing this in their imagination.

There is a process I employ with clients called ‘covert rehearsal’ in which you repeatedly imagine yourself in the feared situation, beginning to feel the anxiety mounting, and successfully employing the five steps. You then progress to putting yourself in the actual situation, a little bit at a time, while employing the five steps.

Next post in this series: “My Anxiety Treatment Toolbox“

(photo credit: TuTuWoN)

The ‘How To’ of Anxiety Self-Management

Of course, what you really care about is the ‘how to’ of getting your anxiety under control, and not the academic typology and research on anxiety. To sum up the majority of research studies on treating anxiety disorders, what works best in most cases is: learning to be aware of and modifying the anxious thoughts that are telling your brain that danger is at hand; learn to increasingly tolerate the uncomfortable sensations that arise; gradually exposing yourself to the feared situation. That is the simple, but not easy, path that is usually the most effective approach to diminishing the grip anxiety has on your life.

Before moving on to my particular treatment approach for helping clients with anxiety problems I want to say that all anxiety treatment should begin with a good physical exam with your primary care doctor. This is because, while rare, there are a handful of medical problems & medication side effects that can cause high levels of anxiety or panic.

For instance, hyperthyroidism and hypoglycemia can cause panic attacks, as can deficiencies of certain minerals, and certain kinds of allergies. You don’t want to embark on a self-management strategy when an appropriate medical intervention might remove the cause of the anxiety or panic altogether.

Along similar lines, there is some pretty good indication that consumption of stimulating substances such as caffeine and sugar may contribute to higher levels of anxiety in certain individuals. You may want to cut back on these substances and notice the effects it has on you if you reintroduce them.

This would be a great topic to discuss with your physician, who may also recommend other lifestyle changes and nutritional suggestions. Please don’t skip this step!

Next post in this series: “The Five Steps To Managing Anxiety“

The ‘Anxiety Disorders’

For the record, there are officially seven main types of anxiety disorder, and as you’ll see, we have so far addressed elements that are common to all of them, and the general dynamics of the first four: Panic Disorder, Generalized Anxiety Disorder, Social Phobia, and Agoraphobia.

All of these are considered anxiety ‘disorders’ because there is no current life-threatening situation present when we experience the fear/anxiety. Nonetheless, it feels very much like there is, and therefore we engage in efforts to escape or avoid the feared situation, often disrupting the flow of our lives in a significant way.

Can you find yourself in these descriptions somewhere? Here is the official list:

• Panic Disorder: characterized by sudden episodes of acute apprehension or intense fear that occurs ‘out of the blue’ without any apparent cause. Symptoms may include: shortness of breath or a feeling of being smothered; heart palpitations; dizziness, unsteadiness, or faintness; trembling or shaking; choking; sweating; nausea or abdominal distress; feeling of unreality; numbness or tingling in hands ad feet’; hot and cold flashes; chest pain or discomfort; fears of going crazy or losing control.
• Generalized Anxiety Disorder: this is pretty much constant anxiety that is unaccompanied by panic, phobias or obsessions. Fears may relate to losing control, failure, rejection or abandonment, death and disease, going crazy.
• Social Phobia: this involves fear or embarrassment or humiliation in situations where you are exposed to the scrutiny of others or must perform in some way. The fear is so strong that individuals typically avoid the situation altogether.
• Agoraphobia: the word itself means fear of open spaces, but it pretty much boils down to fear of having a panic attack in situations where escape might be difficult, such as in a store. Fear of embarrassment plays a role, as in what other people will think of you if you are seen having a panic
• Simple Phobia: this involves a strong fear and avoidance of a particular situation or object. It doesn’t involve fear of panic attacks or fear of being embarrassed or humiliated. Some such fears include fear of particular animals, heights, enclosed places like elevators or airplanes, fear of dentist or doctors’ offices, fear of thunder or lightning, fear of injury or illness.
• Obsessive Compulsive Disorder: obsessions involve recurring ideas, thoughts, images or impulses that seem nonsensical but intrude in your mind on a pretty continuous basis. Compulsions are behaviors or rituals performed in an attempt to rid you of the anxiety brought up by the obsessions.
• Post-Traumatic Stress Disorder: this is brought on after exposure to severe trauma that produces intense fear, terror, and feelings of helplessness, such as experienced in a car crash or in wartime. These symptoms can persist for years, and are typically, triggered by memories of the past situation arising in waking consciousness or in dreams.

Additional resources on anxiety & panic disorder:

http://www.adaa.org/AboutADAA/PressRoom/Stats&Facts.asp

Next post in this series: “The How To Of Anxiety Self-Management“

(photo credit: LunaDiRimmel)

‘What we resist persists!’

As a clinician with 30 years of experience I have worked with a great many people struggling with uncomfortable levels of anxiety and even panic. I have great empathy for their plight, given my own personal encounter with a fear of public speaking, a form of social anxiety that plagued me all the way into my late 20’s.

The very thought of getting up in front of any size group of people (even six!) terrified me, and I almost always found a way to avoid such situations. If I had to give a talk, my heart would be pounding in my chest; I would be feeling a significant level of fear, palms sweaty, approaching panic, wishing I was anywhere else in the world at that time. I dreaded the possibility of embarrassing myself in front of others, or even being humiliated (both concerns of social anxiety).

As I’m sure you can imagine, I said ‘NO!’ to any requests of me to give a presentation, which reinforced my fear & feeling of being powerless in the face of it. However, when I accepted my first professional job, which I was very excited to begin, I was told that I would be giving public talks as part of my new job. The jig was up. I had to figure out how to overcome my public speaking anxiety.

Fortunately for me, I had studied the nature of anxiety disorders and their treatment and the related research in Clinical Psychology graduate school. I intellectually understood the facts that I am sharing with you in this article. Now I had to ‘walk my talk’.

I understood that I had to be willing to feel fear and feel like fleeing the event while at the same time beginning my presentation, and that by doing so the anxiety would begin to diminish. I knew that I could ‘take the edge off’ of the anxiety by regulating my breath and moving my body while speaking.

Most powerfully of all, I put my faith in the knowledge that accepting my discomfort and fear as distressing but NOT dangerous, and relaxing my resistance to feeling that way would stop the anxiety from escalating further, and would allow it to level off and begin to fade away. I began to say ‘yes’ to invitations to speak in public, knowing full well that I would have to endure several minutes of feeling afraid, but that I would then quickly grow comfortable.

Ultimately, I discovered a part of me I call my ‘inner ham’, a part that actually enjoys being up in front of a group of people. I went on to present at numerous medical conferences at highly prestigious institutions, each time being among the most highly rated presenters by the participants. Confronting my fear of being embarrassed or humiliated in front of the public led to my involvement in a weekly live radio show, and co-authoring a weekly health & wellness column in the Ann Arbor News.

Enough about me! I just wanted you to know that I can truly relate to what you are experiencing, and that I have personally put into practice in moments of intense anxiety the information and techniques I am writing about in this article.

So far in this article I have addressed the range of anxiety from helpful levels of worry, all the way to escalating anxiety and panic. You learned that anxiety is a normal part of our ‘fight or flight’ response (the ‘flight’ part), and that it is not dangerous. Nature meant for fear to be uncomfortable and to drive us into life saving activity.

You have also learned that if a high level of anxiety is experienced in the absence of an obvious clear and present danger, you can quickly escalate the level of anxiety, even to the point of panic or a trip to the emergency room thinking we are having a heart attack.

Next post in this series: “The Anxiety Disorders“

Panic: When Anxiety Itself Is the Threat

Depending on just how threatened a person feels about a situation, the level of anxiety triggered can be anywhere from ‘nagging’ or ‘annoying’ to outright panic. If your survival substances are released but you are not aware of any real danger at the time this can cause you to feel even more alarmed, thus releasing even more of the same. It’s as if the brain says, ‘with all of this fear there must be a real life-threatening danger at hand!”

Some people will fear that this feeling will continue escalating without end, and that they might pass out, or go crazy. Others focus on the physical sensations triggered, such as pounding heart, shallow, rapid breathing, tightness in the chest, feeling dizzy, etc.

Many people head for the emergency room when these sensations are present, fearing a heart attack or stroke is in process. In fact, some experts believe the symptoms of up to 50% of individuals visiting an emergency room concerned that they are having a heart attack are really caused by stress or anxiety and not any serious physical problem.

Everyone has a threshold of anxiety beyond which they get motivated to do something about it. The bottom line is this: If you believe your anxiety will keep escalating until you pass out, have a heart attack or go crazy, you inadvertently trigger a panic attack. Who wouldn’t be alarmed if they believed one of those outcomes was really about to happen?

Next post in this series: “What We Resist, Persists“

(photo credit: JAMALadi)

The “Work” of Worrying

There was a very interesting research study conducted several years ago on children who required surgery. The researchers studied children who were scheduled for surgery and their pre-surgical and post-surgical style of coping.

They identified three types of coping style: the ‘macho’ child was characterized by the attitude, ‘I’m not afraid of anything, let me at it.’ The ‘terrified’ child was overwhelmed with anxiety, clinging to mom’s skirt and sometimes pleading for the surgery to be canceled. The ‘appropriately worried’ child wasn’t crazy about the idea of surgery, but was characterized by the attitude, ‘I’d rather not have to do this…do I really have to? OK, then let’s get it over with.’

The researchers studied which of the three types of children coped better with the surgical procedure and had a speedier and less complicated recovery. Guess which type of child did the best? Nope, not the ‘Macho’ child, contrary to common sense, they actually did the worst! Next best was the ‘terrified’ child. That’s right; the ‘terrified child’ coped better than the ‘Macho’ child! Best of all was the ‘appropriately worried’ child.

The researchers theorized that there is a level of anxiety that is required to engage one’s coping resources, and that too little anxiety/worry fails to engage effective coping, yet overwhelming anxiety/worry interferes with optimal coping. So there you have it…worry, though uncomfortable, may well be necessary for effective coping, but overwhelming anxiety or panic clearly interferes with it.

Next post in this series: “Panic: When Anxiety Itself Is the Threat“

The Good News about Anxiety

You are supposed to feel afraid. Honest! Under certain circumstances your level of fear is supposed to increase to uncomfortable levels. Every human being is ‘wired’ that way, and thank goodness.

Imagine how life would be if we had no internal warning system telling us when danger was at hand. That would be like not having a reflex that causes us to instantly pull our hand back from a hot stovetop.

Nature in its infinite wisdom has given us all a self-protective device alternately called the ‘fight or flight’ or ‘emergency’ response. This device dumps the equivalent of rocket fuel into our bloodstream and is meant to cause us to fiercely attack something dangerous or run away like a ‘bat out of hell’, in both cases saving our precious life.

These substances entering our system are not supposed to feel comfortable, or even tolerable. They are supposed to propel us, way faster than we can possibly think, into a short burst of life-saving activity. This has worked really well since the days of dinosaurs and saber tooth tigers. Feeling fear in the face of real danger is no accident.

The ‘fight or flight’ response is triggered by our brain when it perceives that a dangerous, life-threatening situation is at hand. That’s a very good thing, I’m sure you would agree. If you hear footsteps coming up behind you on a dark alley you want to be on alert. If you are approaching the edge of a cliff, it could be really handy to be forewarned.

The same is true if someone or something is threatening a loved one, including a coyote slyly approaching your sweet little dog at the park. Very helpful! The ‘old (instinctual) brain’ is quite good at picking up these actual life-threatening situations.

Lesser amounts of fear, for the purpose of this article, we shall consider anxiety. This anxiety can also be quite helpful to you. The thinking, planning, imagining, worrying part of our brain can perceive all sorts of social, financial, & emotional situations as threats to your well-being, even if not life threatening.

The perception of this type of danger can cause the body to release anything from mild or moderate anxiety, up to out and out panic, depending on the individual and the situation. This reaction can sometimes be even more upsetting than when an obvious real life threat is at hand, if you can’t determine why you are feeling so apprehensive or afraid.

There is a very helpful role mild to moderate levels of anxiety in the form of worrying plays in effective coping. Think about how you feel if the threat of unemployment enters your life, or mortgage rates soar, or you watch your 401k become a 201k. Something subtler, like that look of disapproval on your partner’s face as you left for work this morning can also feel dangerous, or having a child struggling socially or academically in school.

In these examples worry arises because there is a real world problem that has real impact on your quality of life, and perhaps your social and economic survival. Problem solving is in order.

However in such situations having a severe or overwhelming level of anxiety actually interferes with effective coping, because high levels of fear are meant for immediate action, not problem-solving or brainstorming.

Next post in this series: “The Work Of Worrying”

(photo credit: TuTuWoN)