Anxiety
Introduction
Anxiety can be a crippling disease and some can suffer from its various forms for years. In this blog, I first identify six main forms of anxiety: generalised anxiety disorder, social anxiety, panic attacks, phobias, obsessive compulsive disorder (OCD) and post-traumatic stress (PTS) disorder. I then outline some of the scientific knowledge of the source of anxiety in the amygdala of our brain. Typical thoughts and behaviours associated with anxious conditions are then considered. I finish with some advice about how to treat anxiety.
Forms of Anxiety
Most of humanity suffer the adverse effects of anxiety at one time or another in various degrees from those who suffer from the anxiety caused by the common stresses of every day to those who have generalised anxiety disorder. Those with generalised anxiety disorder find themselves always worrying, in a constant state of dread as to what might happen next. They may feel tired all the time, as a result.
Countless people suffer from social anxiety. Are you one of those dreading the next social occasion where you will have to expose yourself to the perceived scrutiny of others? Are you dreading the feelings of anxiety and embarrassment that this occasion will bring? Are you terrified to be asked to speak in public situations?
Hundreds of thousands of people in Ireland suffer from panic attacks often as a result of the stresses and strains of their lives overwhelming them. Then waves of physical sensations sweep over them and their body feels totally out of control. Many find panic attacks take over their lives and some may have lived in this shadowy world for up to 20 years.
Others suffer from phobias. They may find themselves terrified of getting on a plane, driving on the motorway, visiting shopping centres and churches, open areas, entering lifts, being exposed to blood or simply of spiders.
Obsessive Compulsive Disorder (OCD) is an anxiety disorder dominated by obsessions (intrusive thoughts, images) and compulsions (rituals, urges and behavioural responses to the thoughts). A lot of people with OCD feel very responsible for preventing a terrible thing from happening (e.g. I must keep bacteria away from my family otherwise they might become ill or die and it will be my fault"). Others do not have these catastrophic thoughts, but might feel very uncomfortable and become increasingly anxious and distressed if they don't do what their head is telling them to do. Compulsions can be 'overt' or obvious behaviours such as cleaning, touching or checking, or 'covert' hidden mental rituals such as counting, repeating things, questioning or mental checking. A few people only experience obsessions, and a small minority only compulsions.
People who suffer from post-traumatic stress disorder find themselves living in a state of hyper-vigilance, always seeking out danger. Some live in the world of general anxiety. They may find themselves worrying, in a constant state of dread as to what might happen next. They may feel tired all the time, as a result.
Amygdala
In moderation, like so many other things in life, anxiety is actually good. It is the body's activation system when we are in danger or facing a major test. Scientists believe it was vital for us to survive as a species amongst many dangerous animals in Africa where our ancestors are meant to be originally from. It wakes us up and stirs us into action activating adrenaline to boast our concentration during an exam or stir us to better performances at sports, musical or artistic endeavours. Crucially it can save our lives in dangerous situations.
The amygdala is the area in the brain where this alarm system is located. When we are a little anxious before an exam or actually in a dangerous situation, the amygdala releases adrenaline into our bloodstream to enable us to either run away from the danger, fight the danger or engage more fully and freely in the moment. However, the amygdala is also the gunslinger of the stress system. It shoots from the hip often without thinking and does not really worry about the consequences. The gunslinger is not particularly smart, has a long memory, does not respond to talk therapies and regularly disregards instructions from our logical brain. Sometimes the gunslinger keeps shooting when it's not needed particularly when we imagine danger in our heads rather there being danger in reality. We think we're in danger, so that's enough to trigger the gunslinger to shot!
Anxious Thoughts and Behaviours
Cognitive Behavioural Therapy (CBT) is a very common therapy used to treat anxiety. Studies have shown that CBT can reduce and sometimes eventually eliminate the harmful effects of the over activation of our alarm system by identifying the thoughts, behaviours and physical symptoms associated with the feelings of anxiety activated by the amygdala. This resets the amygdala, the anxious gunslinger settles down only to come into action when he is actually needed. I will now outline some thoughts and behaviours that CBT will help anxiety sufferers to identify in themselves.
Thoughts that often occur relate to our overestimating or exaggerating of the actual threat and underestimating or minimising our ability to cope:
• I'm in danger right now
• The worst possible scenario is going to happen
• I won't be able to cope with it
Behaviours might include:
• Avoiding people or places
• Not going out
• Going to certain places at certain times, e.g. shopping at smaller shops, at less busy times
• Only going with someone else
• Escape, leave early
• Safety Behaviours: Go to the feared situation, but use coping behaviours to get you through; examples include self-talk, holding a drink, smoking more, fiddling with clothes or handbag, avoiding eye contact with others, having an escape plan, medication.
Safety behaviours can also help to keep your anxiety going. Whilst you depend on them to help you cope, you don't get to find out that without them, the anxiety would reduce and go away on its own. Whilst avoiding people or situations might help you feel better at that time, it doesn't make your anxiety any better over a longer period. If you're frightened that your anxiety will make you pass out or vomit in the supermarket aisle, you won't find out that won't actually happen, because you don't go. So the belief that it will happen remains, along with the anxiety.
Treating Anxiety
First things first. I’ll start by suggesting very useful things to try anytime you find yourself anxious. As part of this, I will suggest questions which will counteract the harmful effects of anxious thoughts. Exposure therapy is then introduced. This is a CBT intervention for treating some anxious behaviours. Then I will consider the importance of identifying both the triggers of your anxiety and also how it shows up in your body.
When Anxiety Strikes
• STOP! Pause; take a few breaths deep into the stomach; close your mouth and breathe only through your nose; count to 5 on the inhale, pause and count to 7 on the exhale.
• Orientation: Bring yourself into the here and now by doing a brief orientation of your surroundings. Look around you and note the main features of the room. Listen to the sounds around you. Touch some objects in the room. Ground your feet against the floor and your back against the chair.
• Question yourself: What am I reacting to? What is it that I think is going to happen here?
What's the worst (and best) that could happen? What's most likely to happen? Am I getting things out of proportion? Am I overestimating the danger? Am I underestimating my ability to cope? Am I putting more pressure on myself? Is there another way of looking at this? Is this fact or opinion?
How important is this really? How important will it be in 6 month’s time?
Am I mind-reading what others might be thinking? Am I believing I can predict the future?
What advice would I give someone else in this situation?
What would be the consequences of responding the way I usually do? Is there another way of dealing with this? What would be the most helpful and effective action to take? (for me, for the situation, for others) What do I want or need from this person or situation? What do they want or need from me? Is there a compromise?
• Visualise yourself coping in the situation you feel anxious about. See the situation to a successful completion.
Exposure Therapy
In Exposure therapy, counsellors create a safe environment in which individuals ‘expose’ themselves to the things they fear and avoid. Over time, if clients continue to expose themselves to the feared objects, activities or situations, in a way that is safe for them, their fear gradually reduces and their avoidance gradually decreases to the point where the problem eventually disappears.
There are several variations of exposure therapy. These include:
In vivo exposure: Directly facing a feared object, situation or activity in real life. For example, someone with a fear of snakes might be instructed to handle a snake, or someone with social anxiety might be instructed to give a speech in front of an audience.
Imaginal exposure: Vividly imagining the feared object, situation or activity. For example, someone with Posttraumatic Stress Disorder (PSD) might be asked to recall and describe his or her traumatic experience in order to reduce feelings of fear.
Virtual reality exposure: In some cases, virtual reality technology can be used when in vivo exposure is not practical. For example, someone with a fear of flying might take a virtual flight in the psychologist's office, using equipment that provides the sights, sounds and smells of an airplane.
Interoceptive exposure: Deliberately bringing on physical sensations that are harmless, yet feared. For example, someone with Panic Disorder might be instructed to run in place in order to make his or her heart speed up, and therefore learn that this sensation is not dangerous.
Exposure therapy can also be paced in different ways. These include:
Graded exposure: The psychologist helps the client construct an exposure fear hierarchy, in which feared objects, activities or situations are ranked according to difficulty. They begin with mildly or moderately difficult exposures, then progress to harder ones.
Flooding: Using the exposure fear hierarchy to begin exposure with the most difficult tasks.
Systematic desensitization: In some cases, exposure can be combined with relaxation exercises to make them feel more manageable and to associate the feared objects, activities or situations with relaxation.
Triggers
What or when are the times when you are more likely to get anxious? If you can see the patterns, then maybe you can do something about those situations, and do something different. Certain places? Certain people? Anytime, anyplace? See certain things? Hear certain things? Think ahead to certain situation?
Physical Sensations of Anxiety
The body keeps the score. The ups and downs of our lives are imprinted in our bodies. The effects of our anxiety too are imprinted in some or various parts of the body. Learning to identify where we store these physical sensations is a great help to reducing the symptoms of anxiety. Anxious clients talk of ‘butterflies in their stomach’, ‘a weight on their shoulder’, tension in their forehead, over heating of their body. The mere conscious awareness of these tensions and reactions helps to start taking the edge off the anxiety. We can develop this bodily awareness by practicing mindfulness for some period every day As we learn to tune into the ‘felt sense’ of our body, we become more grounded, more relaxed in our own skin and gain more control over the anxiety. Learning to be mindful of our body and learning from the messages of these bodily felt senses is a great way to bring healing to mind and body.
Lastly, a great way to counteract some of the adverse effects of the body’s anxious adrenaline response is by using it up healthily in physical exercise. Go for a walk, run or cycle, or do some gardening or housework.