Anxiety is a widespread problem and is the most common issue that I see in therapy despite working in a specialist service. Given the recent uncertain and restricted COVID-19 times we have found ourselves in, it seemed like an appropriate place to start this column.
Anxiety is split into several broad disorders. The most common two being Generalised Anxiety Disorder (often shortened to GAD) and Social Anxiety Disorder. GAD is ‘what if…?’ worries, thinking about all the ways that things might go wrong. In Social Anxiety Disorder we tend to focus on and criticise how we think we are performing and are fearful that others are judging us harshly. In all anxieties our thoughts are linked with physical sensations and these are what we traditionally think of when we say we have anxiety. These commonly include breathing changes, racing heart, butterflies in the stomach, sweating, trembling, feeling dizzy, blushing, needing the toilet, facial tics and twitches and less commonly a sense of being outside of ourselves (depersonalisation) or watching a situation happening as though it were a movie (derealisation). If we experience frequent panic attacks as part of our anxiety, this can develop into Panic Disorder.
The other main types of anxiety are health anxiety, OCD, phobias, post-traumatic stress disorder (PTSD) and other less common anxieties, which I won’t be covering today. However, the principles for treating these are similar across all anxieties, although PTSD has some differences.
Anxiety has an evolutionary purpose of alerting us to possible dangers and drawing our attention to potential problems so we can avert or escape them. From an evolutionary point of view it was also important that we were part of a group to stay safe and survive. So while we still operate with some brain functions as though we were living in those prehistoric times, we now find ourselves in 21st century life with all its complexities. There is no such thing as an anxiety-free life, it serves an important purpose and it’s unsafe to be without it altogether. Sadly, there’s no such thing as a risk-free life either and trying to avoid anxiety or to seek to feel completely safe all the time will lead to a restricted, unfilled, but stressful life.
Russ Harris, one of my favourite authors, has summarised this nicely and it’s worth a watch. He is a GP and (Acceptance and Commitment Therapy) ACT psychotherapist and trainer based in Australia and has written several popular books including The Happiness Trap and The Reality Slap. He has a number of YouTube clips which summarise ACT principles and explain how the brain is affected by both long term trauma and also stress and fears.
We don’t have to have a diagnosis to be able to benefit from noticing our cycles of anxiety and using CBT intervention principles. These are the same for children and adults, just adapted to the specifics of the situation and the person’s understanding.
To identify your anxiety cycle, just think about that last time you felt anxious. What was the situation that seemed to trigger that? You are looking to identify the facts of the matter, without the additional layer of how you interpreted them. An example might be catching the bus, speaking in a meeting, joining a group of friends, going to the supermarket, etc. This is our trigger situation.
Next think about how that made you feel emotionally and physically – most likely nervous, frightened, worried or anxious and some of the physical feelings described above.
Then consider what thoughts went through your mind? These are probably the hardest thing to capture and also not all that necessary in behavioural therapy, so don’t worry if you can’t get to the bottom of it. If you are interested in exploring your thoughts it can be helpful to think about what you most worry will happen or what the worst thing about that would be? You can also ask yourself what it would mean to you or say about you if your worries or fears were correct?
Finally consider what you did to cope? What actions did you take or what things did you avoid doing? The most common ways of coping with anxiety are avoiding the things that make us anxious if we can and, if we can’t, to seek reassurance from those around us and to use safety behaviours. Safety behaviours is a term applied to the unnecessary precautions we undertake to feel safe or try to stop our anxiety and they can be quite subtle. Almost anything can become a safety behaviour for us if we are using it to avoid or cope with anxiety in trigger situations. It might sound very strange that I suggest this wouldn’t be a helpful strategy. However, experience and research consistently show that while some things seem to help us in the short term and make us feel better for a time, they reinforce the anxiety going forward. Even things that we tend to think of as only positive (such as breathing techniques or relaxation strategies) can become safety behaviours. We can tell they aren’t a really effective solution because our anxiety continues to be triggered and often becomes more frequent, in a wider range of situations.
It’s helpful to write this cycle down so we can get some clarity about what’s happening and also to keep track of things once we start making changes. This means we can see where we are progressing, spot themes and patterns and notice areas where we are stuck. It is often written down in the format below and sometimes called the Hot Cross Bun because it looks vaguely like one! These types of forms are freely available online and might be a helpful tool. If you write it in other ways that’s fine to!
So it’s likely that what you did this time to cope is what you will do next time too, this makes sense because it feels like it works to reduce our anxiety, but means that we stay stuck in this anxiety cycle.
Now, it makes sense that if I worry about a catastrophe happening I will avoid a situation, but what if I overestimated that something will go wrong or that I won’t cope with it or that others around me will make things worse? I’ve no way of knowing because I’m not testing it out and so I remain with my thoughts about all the worst things that could occur. Hence CBT for anxiety is about trying out different approaches and facing our fears in a systematic, step by step way, from what we consider to be the least to the most difficult things.
Many of us notice that our anxieties are making things progressively worse for us, but are apprehensive about exposing ourselves to our fears. We might think that worry is helping us be prepared or that avoiding people is stopping us from social embarrassment. When I speak with clients they often think this way, but they also notice that if they don’t change this cycle it becomes more entrenched and they begin to feel increasingly anxious in a wider range of situations and their world becomes smaller and more complicated
The premise behind anxiety interventions is that all emotions will subside over time, we don’t have to take any particular actions for both our thoughts or feelings to just move on with time. Our anxiety will always subside, even if we feel like it’s going through the roof. No emotion lasts forever! We may find that thoughts and emotions do stick around for extended periods, this tends to happen if we focus on them excessively or try to avoid having the thoughts and feelings that we don’t want or like. We can start to try and let them be and they will go. You may have heard the term ‘riding the wave of the emotion’, and this is a great visual aid for thinking about just letting it be, neither trying to stop it or getting stuck in it.
A couple of really great places to start making changes are to build up our baseline and also to consider all those high- and low-key selfcare (by Tine Landy) we can do to build up our emotional resilience and sense of wellbeing. It maybe sounds a bit simplistic, but some basic things can really help us feel less stressed and more able to take the risk of facing our fears. Think about sleep especially but also diet, movement and connecting with others. When we feel near the edge of our ability to cope it can be really hard to face our fears, so building up our baseline can help us start to address our anxiety.
As an aside, it’s also important to make sure that there are no underlying physical problems that account for the sensations you are experiencing. Don’t discount a chat with your GP to talk through whether anything needs to be investigated. If you think it’s anxiety, it probably is, but don’t discount that there are other possible factors at play here. Additionally, your GP can also direct you to therapy via the NHS, although this is most easily accessible for adults rather than under 18s.
I would just say here that it’s also important to note that we might have anxiety in relation to a difficult life situation, being bullied for example. Sometimes avoiding or leaving the situation can actually be the solution and it’s worth giving some thought to whether it’s best for us to do that or best to face the situation and treat our anxiety. Sometimes leaving the situation solves it, but other times it just appears in the next place too. Discussing things with others to get clarity or just trying out one approach over another is useful. Don’t tie yourself up in knots trying to decide on the ‘right’ course of action, just having even a small plan to try out something different towards your options can be enough to get started. At least you will be able to see what happens and come to know whether this is a good enough approach or whether you need to try another. Ask yourself ‘what’s the worst that could happen here?’ Even if you are trying to decide whether to make big life changes in relation to your anxiety – such as moving schools, jobs, house or relationships – it’s unlikely that the decision cannot be altered in some way if it doesn’t go as hoped.
For the quickest results in treating anxiety a behavioural approach can give you good results for your efforts. It obviously feels daunting to face your fears, especially when we have a load of uncomfortable physical sensations. But always remind yourself that while emotions are uncomfortable, they aren’t dangerous and that they will always subside even if we worry they won’t. Additionally worrying or overthinking things won’t make us better prepared, it just makes us better worriers and certainly doesn’t see our anxieties dissipate.
Next time, I will go into more detail about how we might make and monitor changes and what type of approaches to use, such as changing what we do or how we think (or maybe a combination of both). For now, have a start at building your baseline and observing and writing down your anxiety cycle.
© Delwyn kay 2020
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