No Worries: A Guide to Releasing Anxiety and Worry Using CBT
Author: Sarah Edelman
Date: 2019-07-01T18:49:24.505795+00:00
Keywords: Health & Fitness; General; Self-Help; Anxieties & Phobias; Psychology; Psychopathology; Mental Health
Description: From the bestselling author of Change Your Thinking comes No Worries - the clear, compassionate and practical guide to understanding and managing anxiety and worry. Anxiety and worry rob us of the ability to think clearly, enjoy life and function effectively at home, at work and in social situations. One in five Australians have an anxiety disorder at some point in their lives, and many more have periods of debilitating anxiety. Using proven strategies from a range of psychological approaches, including cognitive behavioural therapy (CBT), acceptance and commitment therapy (ACT), and metacogni
Publisher: HarperCollins Australia

Contents

Introduction

ONE   The Nature of Anxiety

TWO   Worry and Generalised Anxiety Disorder

THREE   Healthy, Balanced Thinking

FOUR   Safety Behaviours

FIVE   Facing Our Fears

SIX   Building Worry Awareness

SEVEN   Mindfulness

EIGHT   Metacognitive Beliefs

NINE   Worry Experiments

TEN   Learn to Relax

ELEVEN   Managing Panic Attacks

TWELVE   Medications

THIRTEEN   Sleep and Lifestyle Habits

Summary of Key Strategies for Releasing Worry

Appendix

Index

About the Author

Also by Sarah Edelman

Copyright

No regrets, just lessons.

No worries, just acceptance.

No expectations, just gratitude.

Life is too short.

UNKNOWN SOURCE

Introduction

Some people’s lives are easy. Not because they are particularly privileged or clever, but because they have been blessed with a calm, easygoing nature. Like everyone, they experience difficulties, demands and pressures in their lives, but they are able to face them without unnecessary anguish. When problems arise they look for solutions, and in circumstances where there is nothing they can do, they adapt. They are able to do this because they have a relaxed disposition and a flexible thinking style that enables them to adjust to stressful situations, without the additional burden of worry, rumination and overthinking. So, they rarely experience the distressing thoughts and intense bodily sensations that accompany high levels of anxiety.

To have such a disposition is a gift. In the card game of life, they have been dealt a good hand.

Many of us are not so fortunate. A combination of nature and nurture have conspired to make us prone to anxiety, making our world feel unsafe. We may be overly focused on a myriad bad things that could happen to us or our loved ones, or we may zero in on specific threats, such as failure, disapproval, humiliation or not fitting in. We may be particularly anxious about unwanted thoughts that pop into our minds, or unwanted body sensations that signal the possibility of panic. We may be excessively apprehensive about potential illness and death, or we may fear being in places from which escape would be difficult, such as tunnels, lifts and freeways.

While the objects of our angst vary, the underlying problem is the same. Our mind keeps directing us to be alert to danger, and our body is prepared for action. Anxiety affects the way we feel and behave, and deprives us of the ability to relax and enjoy life.

Anxiety disorders affect approximately 14 per cent of Australians each year, and over 20 per cent at some stage in their lives. That’s over three million people annually, and over five million people over the course of their lifetime. It is also not uncommon for people to have a combination of anxiety disorders, sometimes with occasional periods of depression. Anxiety disorders are the most common mental-health problem experienced by both males and females, though women are affected more frequently than men (18 per cent versus 11 per cent).

Some people are particularly prone to worry. Although our life circumstances may be quite agreeable, we feel unsafe. So, we might find ourselves planning solutions to non-existent problems, or overthinking situations that don’t warrant analysis. At work or at play, with friends or with children, on holidays or at home, worry prevents us from being ‘present’. It impairs our ability to engage with what is happening right now. It robs us of joy and occupies too much of our mental space. It wastes energy and distracts us. Yet it can be such a habitual part of our thinking that it feels perfectly normal, and we may even assume that everyone thinks this way.

Anxiety is a big subject, and its various manifestations have been described in detail in many books. In No Worries, we will explore habits of thinking and behaviour that are common to many anxiety disorders. Understanding the way that anxiety operates – how it affects our brains, minds, bodies and behaviour – provides insight, and a rationale for strategies that can help us to recover. Working through the exercises in this book will increase understanding of your own anxiety, including the things you unwittingly do that perpetuate it.

In addition to exploring anxiety more broadly, we will focus specifically on worry, and the anxiety disorder characterised by excessive worrying: generalised anxiety disorder (GAD). Some researchers have described GAD as the prototype anxiety disorder, as many of its features are observable in all anxiety disorders. These include unrealistic assessment of threat, hypervigilance, physical arousal, muscle tension and other physical symptoms, reasoning errors, use of avoidance and safety behaviours, insomnia, restlessness, concentration difficulties and fatigue. Worry and intolerance of uncertainty are common manifestations of most anxiety disorders. Interestingly, successful therapy for GAD often results in reduced symptoms in coexisting anxiety disorders, including social anxiety, illness anxiety, panic disorder and phobias. So responding to the processes that give rise to and perpetuate anxiety and worry is likely to be helpful not just for resolving GAD, but for managing anxiety more broadly.

Individuals who are prone to anxiety also have greater likelihood of experiencing panic attacks. In some cases, repeated panic attacks can lead to panic disorder, which is characterised and reinforced by fear of further panic attacks. Panic disorder sometimes co-occurs with GAD, as well as with other anxiety disorders, and can be the source of much distress. Fortunately, it is a disorder that lends itself well to psychoeducation and self-help strategies. Understanding the nature of panic, what perpetuates it and how it can be relieved can lead to a significant reduction in symptoms. For this reason, I have included a chapter on this topic towards the end of the book.

The strategies described in No Worries derive from various psychological approaches, most predominantly cognitive behaviour therapy (CBT). This is one of the most widely researched psychological approaches for the treatment of anxiety and its disorders, as well as other emotional and behavioural problems. The underlying assumption of CBT is that thoughts create feelings, and changing the way we think can change the way we feel. A variety of methods and tools can be used in treatment, depending on the specific condition. Behavioural experiments, exposure exercises, cognitive reframing and arousal control strategies, such as progressive muscle relaxation and breathing exercises, have been a mainstay of CBT treatments for decades, and are key strategies described in this book.

CBT is continually evolving, and third-wave CBT therapies, which represent both an extension of and deviation from traditional CBT, have emerged in recent years. These include metacognitive therapy (MCT), mindfulness-based cognitive therapy (MBCT), acceptance and commitment therapy (ACT) and dialectical behaviour therapy (DBT). Some of the strategies described in this book derive directly from these therapies.

An important development in clinical psychology over the last two decades has been the identification of metacognitive beliefs – unconscious beliefs about our own thought processes. These matter, because they affect our willingness to release unhelpful thinking habits, such as worry and rumination. The role that metacognitive beliefs play in maintaining anxiety and depression has been described extensively by British psychologist Dr Adrian Wells, who developed metacognitive therapy (MCT). Unconscious beliefs about the benefits of worry play a key role in maintaining the urge to worry, and recent research has demonstrated that addressing these beliefs results in a dramatic reduction of the urge. Indeed, challenging metacognitive beliefs about worry is central to breaking the worry habit, and methods for doing this are discussed in this book.

Other strategies described in this book derive from mindfulness-based cognitive therapy (MBCT) and acceptance and commitment therapy (ACT). Building skills in mindfulness, including the ability to observe the processes of our own minds, helps us to develop insight, as well as tolerance of unpleasant emotions. Paying attention to what is happening in our minds enhances our ability to recognise worry and threat-focused thoughts as they arise, and opens the opportunity to change the way we respond to those thoughts. We discover the difference between observing the presence of particular thoughts versus getting caught up in their content. This differentiation is a key principle of all of the third-wave CBT therapies.

Mindfully observing unpleasant thoughts and emotions also allows us to discover that emotions pass. Instead of desperately trying to resist unwanted feelings, we can give them space and allow them to fade away. By coming to know and understand the habits of our own minds, we can unlock the hold that anxiety has over our lives, and turn our focus to a more meaningful existence.

Finally, I add the usual caveat that while No Worries provides useful information for managing anxiety and releasing the worry habit, it is not a complete treatment. Self-help books can be a useful resource, but when we are debilitated by mental-health problems, we are likely to benefit from the additional guidance of a mental-health practitioner. If you are dealing with an anxiety disorder that is significantly interfering with your life, I urge you to also seek assistance from a qualified therapist. Psychologists, psychiatrists or other mental-health specialists can fill in the gaps, reinforce information and skills, and tailor treatment to your specific circumstances. There are also many good online self-help programs that focus on anxiety disorders, which are listed in the appendix.

CHAPTER 1

The Nature of Anxiety

‘My life has been full of terrible misfortunes, most of which have never happened.’

MICHEL DE MONTAIGNE

Stuart comes from a long line of anxious worriers. Several members of his family, including his mother, sister and grandmother, suffer from anxiety, sometimes accompanied by depression. His parents were anxious and overprotective, and Stuart has taken on many of their fears. Stuart’s anxiety is visible in his body language, including his facial expressions, fidgety hands and persistently bouncy knee.

Stephanie is a senior partner at a large law firm. She dresses elegantly, speaks confidently and always comes across as calm and professional. Her colleagues would never guess that Stephanie suffers from anxiety, and inside her body there is a mass of tension and arousal. Stephanie has been struggling with obsessive-compulsive disorder (OCD) and generalised anxiety disorder (GAD) for many years, but she has learned to hide it well.

Liam had a turbulent history as a child. His father was an alcoholic and prone to angry outbursts when intoxicated. His parents would often argue, and Liam can remember sitting in his bedroom with his hands over his ears, trying to escape it all. Liam recalls ‘walking on egg shells’ for much of his childhood, as he never knew what to expect. Now he suffers from GAD, social anxiety and panic attacks.

Carol is a single mother with two young children and a stressful job. Normally relaxed by nature, Carol has started to have episodes of anxiety as pressure at work and in her home life escalates. She feels like she is always ‘putting out fires’ and ‘trying to keep her head above water’. During these times, Carol gets heart palpitations, tension in her chest and finds it hard to sleep at night.

Roy is an extrovert. He is funny, intelligent and creative, and has a successful career in film production. Roy has bipolar disorder, which is characterised by periods of depression and occasional elevated mood. Like many people with this disorder, he also suffers from frequent anxiety, which at times feels overwhelming.

Anxiety manifests in different ways, and disposition to anxiety develops for different reasons. It can be the product of one’s genetic inheritance (as in the case of Stuart) or stressful circumstances in early life (Liam). It can be a symptom of almost any mental-health condition, including those that are not specifically classified as ‘anxiety disorders’ (such as bipolar disorder, post-traumatic stress disorder, obsessive-compulsive and related disorders, eating disorders, substance-related disorders, schizophrenia, post-natal depression, autism spectrum, etc.).

We experience anxiety ‘on the inside’, and while for some people it is visible in their body language (Stuart), for others it is hard to detect (Stephanie and Roy). Indeed, friends may be surprised to learn of our struggle and the effect that anxiety has had on our lives. While those who are predisposed to anxiety are more frequently affected, an accumulation of stressful events can create high anxiety for any person (Carol).

We all get anxious at times – anxiety is a normal part of human experience. Usually, it is a temporary state triggered by specific events, which peaks and then disappears, or wanes after a problem is resolved or forgotten. Situations like Carol’s, where there are lots of demands and insufficient time in which to respond, are the most common triggers. When we are in those situations, problem-solving is often the most useful strategy. Carol, for instance, might benefit by asking for help from family members, organising after-school care for her children, getting a cleaner and learning to say ‘no’ more often at work. She might even consider working part-time if she is able to afford that option.

Anxiety may last for a few minutes, a few days, several weeks or, sometimes, months or more. Running late for an appointment may trigger a short burst of anxiety, while procrastinating over that much-needed but potentially unpleasant conversation may last for days or weeks, depending on how long we put it off. Anxiety associated with a stressful job or your child’s illness may last for months or more. Usually, though, once the perceived threat has passed, we relax and the feeling dissipates.

Sometimes, however, anxiety manifests as an unwelcome presence throughout much of our lives. It may rob us of the ability to enjoy pleasant experiences and to function effectively in our roles at work, as a parent, in social situations and in managing our home. For people like Stuart, Liam, Stephanie and Roy, learning to understand and manage anxiety is important. This will involve more than just problem-solving.

Learning to manage anxiety will include recognising its origins, and therefore the reasons we pay excessive attention to danger. It will also include understanding the way that anxiety distorts perceptions, and the various mental and behavioural habits we resort to, which paradoxically reinforce a high-threat view of the world. We come to see that our real problem is not a dangerous world but our learned habit of focusing on danger. It will also involve learning strategies that enable us to change the way we think, feel and behave.

WHAT IS ANXIETY?

Anxiety is our response to the perception of threat. The perception may be conscious or unconscious (you may feel anxious and not know why), and the threat may be real or imagined. Our brain perceives danger, and signals parts of the body to prepare for action. We feel aroused and highly motivated to act, even when there is nothing we can do. Muscle tension and physical arousal are central elements of anxiety, and are the reason why it often feels so unpleasant. Our mind becomes focused on danger, and attention to other issues diminishes – more about this later.

TRAIT ANXIETY

Within the population, the predisposition to anxiety – or ‘trait anxiety’ – lies on a continuum from very low to very high. Individuals who are high on trait anxiety are more likely to be affected by anxiety and its disorders.

A personality style that is characterised by frequent anxiety is often observable in childhood. Genes account for roughly 50 per cent of the variance on this trait, while the other 50 per cent is shaped by early life experiences.

People high on trait anxiety are more vigilant and sensitive to possible threat. They are more likely to notice ambiguous information and interpret it in a negative way (‘She said hello to him but not to me – she must be upset with me’; ‘I didn’t say much at the staff meeting – what must they be thinking?’; ‘I have a twinge in my throat – what if that’s a sign of something more serious?’). They overestimate the likelihood and consequences of possible negative events (‘If I don’t enjoy that holiday, it will be a huge waste of money!’; ‘If my daughter doesn’t get into the right course, she’ll ruin her future’; ‘If I don’t shine at work, I’ll end up on the scrap heap’).

NEUROTICISM

A subset of people who are high on trait anxiety are also vulnerable to a range of other upsetting emotions, including irritability, anger, guilt, sadness, depression, jealousy or shame. The underlying trait is referred to as ‘neuroticism’.

Neuroticism is one of the ‘Big Five’ personality traits, which have been identified in personality tests across a range of cultures. (The others are extraversion, agreeability, conscientiousness and openness to experience.) Like most personality traits, neuroticism is influenced by both genes and childhood experiences.

People who score highly on this trait are overly sensitive to environmental stressors and frequently worry excessively. They are emotionally reactive – minor events readily trigger upsetting emotions. Consequently, this personality trait is associated with an increased likelihood of developing mental-health problems, including GAD and other anxiety disorders, as well as depression.

Not all aspects of neuroticism are disadvantageous. When combined with ‘conscientiousness’, people high on neuroticism are likely to channel their energy into positive lifestyle behaviours, such as regular exercise and healthy eating. Consequently, the combined traits may contribute to better physical health and reduced likelihood of chronic health conditions.

ATTACHMENT STYLE

Aside from inheriting robust genes, good parenting is our most precious resource. Our parents (or caregivers) influence our psychological development from birth through to adolescence – and this includes our propensity towards anxiety.

The nature of the relationships with our parents (or primary caregivers) during our first few years of life play a critical role in our emotional development. Interactions with parents, particularly during times when we are distressed, shape our attachment style. Adults who respond sensitively and appropriately to the child’s needs build positive attachment bonds. These affect our perceptions, emotional responses and expectations of others throughout our adult lives, and influence the types of relationships that we come to develop.

In the second year of life, children start to explore the world, while using parents as a safe base. Children whose parents are attuned and responsive to their emotional state, and who behave consistently, are likely to develop a secure attachment style. This provides the best possible foundation for healthy physical, emotional and social development of the child, and optimises the likelihood of emotional stability and secure relationships in adult life.

When parents are inconsistent towards their infants – sometimes nurturing; sometimes dismissive, angry or unresponsive – children grow up insecure, not knowing what type of treatment to expect. This parenting style gives rise to an ambivalent/anxious attachment style, which is associated with frequent anxiety and insecure relationships in adult life.

Children whose parents were emotionally unavailable and encouraged their independence from an early age are more likely to grow up with an avoidant attachment style. As adults they are self-contained and rarely show vulnerability or emotional dependence on others. They regard relationships and feelings as relatively unimportant, and are emotionally distant towards others.

In the most extreme cases, when parents are abusive and frightening towards their young children, the infant has no safe base to go to for protection. This gives rise to a disorganised attachment style, where the person has no coherent sense of self, and has great difficulty developing emotional closeness to others. People with this attachment style are likely to suffer from a range of mental-health problems, including anxiety disorders, and often have dysfunctional relationships throughout their lives. (To learn more about attachment, see the books in the recommended reading section in the appendix.)

CHILDHOOD EXPERIENCES

While the first few years of life are critically important, events that happen during other stages of childhood also affect our disposition towards anxiety. Experiences throughout childhood influence the development of neural networks in the brain, and in an unsafe environment we learn that threat is ever-present, and vigilance is constantly necessary. Having parents or caregivers who are critical, volatile or abusive increases our likelihood of developing the expectation that aversive events are unavoidable, unpredictable and uncontrollable. Much of the time, poor parenting is attributable to the parent’s own mental-health problems and/or traumatic history.

In some cases, loving but highly anxious parents convey a high-threat view of the world. While they want the best for their children, repeated messages of ever-present danger and the need for vigilance contribute to the development of an anxious personality style.

COMPLEX TRAUMA

Some people experience extreme adversity in childhood or adolescence. Traumatic experiences, such as emotional or physical neglect, a highly unstable and unpredictable family environment, domestic violence, parental substance abuse, physical or sexual abuse or loss of a parent can give rise to significant mental-health problems. The effects of trauma may be visible from childhood or adolescence, or may emerge in early adulthood. Complex trauma (also known as complex PTSD) is a condition characterised by disturbances in personality as a result of childhood trauma. Symptoms include episodes of disassociation (disconnection from current reality), insomnia, frequent or chronic anxiety and depression, difficulty regulating emotions, attention deficits and physical health problems. Many people with this condition are not aware why they feel bad much of the time. Survivors of complex trauma are strongly advised to seek psychological therapy with a trauma-informed therapist. There are also some informative self-help books on this subject (see appendix).

ADOLESCENCE

Although our personality traits are largely developed by the adolescent years, our brain is not yet fully developed. Brain maturation continues until the age of 25, so experiences during this life stage continue to shape our emotional development, and the beliefs we hold about ourselves and the world. Relationships with peers take on particularly high importance during adolescence. Being part of a close, cohesive social group enhances feelings of belonging and social safety. Conversely, experiences of bullying or marginalisation during adolescence can create a long-term perception that ‘others’ are not safe and that we do not belong. These experiences, sometimes coupled with distressing events at home, can have long-term negative effects on self-esteem and perceived social safety.

COMMON THREATS

Most of us feel anxious in response to challenging situations, such as public speaking, job interviews, difficult conversations with authority figures or in response to a diagnosis of a serious illness. However, there is also lots of variation in what we find scary. Our history and personal experiences shape our cognitions (thought processes and perceptions) and determine the things we react to. For instance, if you didn’t have safe, secure relationships in early life or you were bullied as a teenager, you may become readily anxious in social situations. If events in childhood caused you to believe that you are unlikeable or defective, you may be determined to try to prove your worth through achievements, and become anxious in response to the possibility of failure – at work, or in sport or other endeavours. Or you might focus on material success and therefore become particularly anxious when your investment decisions look uncertain or the value of your house falls. If you witnessed serious illness or death at an early age, you may feel particularly unsafe when you experience unexplained physical symptoms. And if you have a history of depression, anxiety or other mental-health problems, you may become anxious when you detect signs of anxiety or depression. Indeed, the possibility of further or ongoing anxiety is one of the most common reasons why people remain anxious.

While triggers for anxiety vary according to personal meanings, one of the most common antecedents is the possibility of being judged or rejected. Much anxiety focuses on social relationships. Our brain evolved to help us function as members of a tribe, and throughout human history we depended on belonging for our survival. Although modern society is very different to that of our Stone Age ancestors, and we no longer need acceptance in order to survive, the possibility of rejection or disapproval remains one of our most common fears. While our history and genes influence the intensity of this need, evolutionary processes have hardwired a need for approval and fear of rejection in all of us.

ANXIETY HAS BENEFITS

Although most people dislike the feeling, anxiety has benefits. Being alert to possible dangers makes us more likely to take action to prepare, protect ourselves and overcome obstacles. Anxiety may compel us to persevere with difficult tasks, seek out useful information, perform well in competitive situations and give up leisure time to practise for an important event or presentation. Feeling anxious before an exam, job interview or speech motivates us to prepare, and, as long as it is not too overwhelming, optimises performance on the day. Anxiety about an impending deadline for a project at work can focus our minds and mobilise energy, and so enable us to deliver on time. Feeling moderately anxious before and during competition, be it a tennis match, bridge competition or a 100-metre sprint, increases energy and focus, and improves chances of success.

Anxiety can motivate us to do things that help us to achieve our goals. However, it can also lead to procrastination and other unhelpful behaviours that take us further away from where we want to be. Intense anxiety drains energy, exhausts and demoralises, and can impair our performance and ability to function.

CONSCIOUS OR UNCONSCIOUS TRIGGERS

Anxiety may arise in response to conscious thoughts (e.g. ‘There might be something wrong with my heart’ or ‘I might arrive late and they will not be happy’). Or it may be triggered by unconscious perceptions. Indeed, sometimes we may feel anxious without knowing why.

Tina feels anxious when arriving home from a relaxing holiday, but she has no idea why. Just beyond her conscious awareness is the perception that she has had her break, and now the really hard work is about to start.

Andrew feels anxious while sitting in the waiting room of a psychologist he is about to see for the first time. Below his conscious awareness is anxiety about disclosing personal information to a stranger, the possibility of being judged and uncertainty about whether this person can help him.

Sometimes, it is fear of anxiety itself that generates and perpetuates anxiety.

Maria feels anxious whenever she walks through the front door after spending time with friends. Although she does not consciously think about it, her unconscious mind recognises this is the place where her anxiety usually spikes, so it may well happen again.

Anxiety can also be triggered by chemically induced arousal. Substances like coffee, alcohol, illicit drugs and some prescription medications can produce physical symptoms that are similar to anxiety. If we are already sensitive to anxiety, these physical sensations may be perceived as a threat, and contribute to further anxiety.

PHYSIOLOGY OF ANXIETY

While we may notice feelings of anxiety through a sense of dread and physical changes in our body, the whole process is produced and orchestrated by our brain. Let’s take a look at some of the specific brain structures responsible for perceiving threat, sounding the alarm and mobilising various parts of our body to prepare for action.

THE BRAIN

Information from the outside world enters via our sensory organs – our eyes, ears, tongue, nose and skin. The meaning of this information is translated by various parts of the brain, including those involved in the storage of memories. These determine how we make sense of current events. Depending on our history, a particular song on the radio, the smell of horse manure, the smile of a stranger or the sensations of a dog licking our face may elicit delight, irritation, disgust or fear.

The brain is an extremely complex organ, comprising an intricate network of cells and structures that communicate with each other, as well as with other parts of the body. Emotions such as anxiety and anger are controlled by the limbic system, which is a group of brain structures involved in emotional responses, motivation, long-term memory, learning and arousal. These structures are largely responsible for the meanings we give to the information that enters via our sensory organs, how we react to it and the parts of our body that are mobilised.

Some of the key structures within the limbic system include the:

Thalamus: this determines where to send information from our sensory organs. Among many other functions, it behaves like a relay station, passing sensory information to the prefrontal cortex and the amygdala.

Hippocampus: this stores and retrieves memories that help us determine whether a situation is safe or dangerous. This access to memories enables it to provide feedback to the amygdala regarding potential danger in various situations.

Amygdala: this quickly determines whether incoming input is relevant to our safety. If it detects danger, it sends a neural impulse to the hypothalamus to activate a rapid survival response. Some have referred to it as a ‘smoke detector’, which sounds the alarm when it senses danger.

Hypothalamus: like a command centre, the hypothalamus receives messages from the amygdala and communicates with the rest of the body via the autonomic nervous system. When the amygdala signals that there is immediate danger, the hypothalamus sends an electrical nerve impulse to the adrenal glands (at the top of the kidneys), activating the release of adrenaline. The hypothalamus also signals the pituitary gland, which sends a chemical messenger to the adrenal glands, stimulating the secretion of adrenaline and cortisol.

In addition, other parts of the brain and body have strong neural connections to limbic structures. These include the prefrontal cortex, the pituitary gland and the adrenal glands. While not components of the limbic system, these structures also play an important role in our physical response to anxiety.

Prefrontal cortex: located directly behind the forehead, this is responsible for ‘executive functioning’, including analysing, decision-making, planning and implementing goals and moderating social behaviour. It is interconnected with much of our brain, including parts that are involved with attention, cognition, action and emotion. Signals to the prefrontal cortex take longer to arrive than to the amygdala, which is why our body sometimes goes into fight-or-flight mode, even before we have consciously thought about or made sense of our situation.

Pituitary gland: located at the base of the brain, it is also called the ‘master gland’ because it produces and stores hormones that travel throughout the body and stimulates other glands to produce hormones. When signalled by the hypothalamus, the pituitary gland sends chemical messengers to the adrenal glands, which release stress hormones cortisol and adrenaline. Together, these two stress hormones play a key role in our response to threat. They produce an increase in heart rate, blood pressure and breathing rate, providing extra energy, which historically served to optimise our chances of survival.

Adrenal glands: located on top of the kidneys, these receive information via nerve impulses and chemical signals initiated by the hypothalamus. Nerve signals activate the immediate release of adrenaline, while chemical messengers from the pituitary gland travel through the bloodstream, initiating the release of cortisol and further adrenaline within a few minutes.

THE AUTONOMIC NERVOUS SYSTEM

The physical changes we experience in response to anxiety are regulated by the autonomic nervous system (ANS), under the direction of the hypothalamus. The ANS controls the body’s unconscious and involuntary actions, such as the activity of our heart, digestive organs, bronchioles (the passageways in our lungs through which air enters), pupils, sexual organs and salivary glands.

The ANS has two components: the sympathetic nervous system and the parasympathetic nervous system. The sympathetic nervous system creates arousal and initiates the fight-or-flight response (see below), which increases available energy. The parasympathetic nervous system is more slowly activated, and has a dampening effect on neural activity. It triggers the release of acetylcholine, a chemical messenger that puts a break on arousal, slows the heart, relaxes muscles and returns breathing to its normal rate. Together these two systems play a key role in managing the body’s energy, one preparing for its expenditure, the other for its conservation. Jointly, they determine how intensely our body becomes mobilised in response to a perceived threat, and how quickly we recover once the threat has passed.

FIGHT-OR-FLIGHT RESPONSE

When our amygdala detects danger, it signals the hypothalamus to activate the adrenal glands to release adrenaline and cortisol. The immediate release of adrenaline causes the heart to speed up and blood pressure to increase. Our breathing becomes more rapid, and our bronchioles expand, in order to allow a greater intake of oxygen. Under more pressure, freshly oxygenated blood moves to the muscles faster, where our body burns oxygen and glucose at a higher rate. During this time cortisol switches off body functions that are not immediately essential to survival, including reproductive processes, immunity, digestion and growth, while also stimulating the continued release of adrenaline.

Our attention is focused on the perceived threat, and our sight, hearing and other senses become sharper, as our muscles tense up in preparation for action. This process, known as the ‘fight-or-flight response’, is our body’s survival mechanism. For the hazardous world of our Stone Age ancestors, this physiological response did a remarkable job of maximising our chances of survival, by increasing alertness and mobilising energy to help combat or escape predators or rival gangs.

Over the millennia, our environment has changed dramatically. These days we are no longer pursued by predators or club-wielding cavemen, so our need for immediate mobilisation of energy is rare. It may arise occasionally in situations like fleeing a bushfire, running from a bull in a paddock or escaping a pub brawl. In situations like these, the surge in energy triggered by the fight-or-flight response would enable us to run further and faster than we otherwise could.

Generally speaking, though, most of the threats we are likely to encounter these days are to our emotional safety rather than to our physical survival. However, our brain still responds as though our survival is at stake. Tight deadlines, unpleasant phone calls, mounting debt, exam stress, demands at work or dealing with difficult people are common triggers for the fight-or-flight response. We may notice our heart racing and our muscles tensing when we engage in an angry exchange, receive an outrageously high electricity bill or discover that a friend has betrayed our confidence, but our body’s response is not helpful. There is nowhere to run and no one to fight. In addition, being aroused and ready for action can be distracting, and make it difficult to concentrate, view our situation objectively, speak calmly or problem-solve.

SOMETIMES WE FREEZE

While the fight-or-flight response involves an elevation of energy and urge to act, in situations involving terror, there is another possible response: freeze. The term ‘paralysed with fear’ describes a state where one is so fearful it becomes almost impossible to move. In evolutionary terms, when fighting or fleeing a predator or adversary were not feasible options, the only other possibly life-saving response was to freeze. Standing perfectly still can make us a smaller, less attractive target, and may therefore have been a way to optimise chances of survival.

For this reason, people who face extreme fear or trauma (or those who have experienced trauma in the past), sometimes become physically immobilised when fearful. While the freeze response is far less common than fight-or-flight, it can be very distressing when it occurs. Understanding what is happening can help us to make sense of our body’s reaction, and better manage the symptoms until they pass. (For more information on the freeze response, see references on trauma in the appendix.)

PROPENSITY FOR AUTONOMIC AROUSAL

Some of us are biologically more prone to experiencing faster and more intense arousal (rapid elevation in heart rate, muscle tension, blood pressure, etc.) than others. This rapid sympathetic nervous system activation means we feel the physical effects of challenges or threats quickly and strongly. So, for instance, an argument, a perceived criticism at work or even a scary movie may cause strong arousal, which most people find unpleasant. For this reason, we may hate confrontation, or even find it difficult to watch suspenseful movies.

When Keiko feels under pressure during bridge tournaments, her hands shake and there is nothing she can do to control them. Her amygdala responds as though she is facing immediate danger. It doesn’t help when empathic opponents reassure her that ‘it’s only a game’. She knows that. Her prefrontal cortex knows that too, but tell that to her amygdala, which is ‘banging on’ as though her life is at stake.

Ravi needs to talk to the neighbours about noise levels and other issues that concern him. He knows what he wants to say but keeps putting it off. Because he experiences high levels of autonomic arousal, Ravi worries that when he knocks on that door, his physical symptoms will distract him and he will struggle to articulate what he needs to say.

ANXIETY VERSUS FEAR

When we face a situation that suggests immediate danger, we experience fear. If you are stuck on a terrifying carnival ride, or you are about to address a highly critical audience, or you have walked into the path of a venomous snake, you are perceiving immediate threat. That’s fear.

In contrast, anxiety is associated with perceived future threat. Something bad could happen today or tomorrow, or next week or next month. This perception produces less intense but longer-lasting arousal. Our sympathetic nervous system maintains a vigilance response. Instead of squirts of adrenaline that characterise the fight-or-flight response, the adrenal glands release a slow stream of cortisol and adrenaline. Our amygdala remains activated, and the possibility of danger sits in the back of our mind. Whether we are talking to friends, commuting to work or eating dinner, we have a background sense that something could go wrong and we need to be ready. This makes it hard to fully engage with whatever is going on in our world at the time.

The anticipation of a difficult conversation, an approaching medical procedure or an impending work deadline are more likely to trigger anxiety rather than fear, because our perceived threat is in the future. In that vigilant state we may feel tense, aroused, restless, on edge and find it hard to relax. We may also experience high startle reflex (we ‘jump’ in response to a sudden noise or an unexpected presence) and be more readily irritated or moved to anger in response to minor stressors. We may also have difficulty sleeping at night.

While the fight-or-flight response usually lasts for short periods (typically just a few minutes), the vigilance response that accompanies anxiety can last for days, weeks, months or longer. Some people also experience anxiety plus intermittent fight-or-flight episodes, which may manifest as occasional panic attacks.

PANIC ATTACKS

Most people experience the fight-or-flight response at times. For some people, the pounding heart, tight chest and shortness of breath is accompanied by rapid, shallow breathing. Hyperventilation (or overbreathing) gives rise to other unpleasant sensations, such as dizziness, numbness or tingling, confusion and agitation. In this aroused, uncomfortable state, many people become fearful of the symptoms themselves, which escalates fear and maintains the symptoms.

During a panic attack people frequently believe that they are about to die, lose control, go crazy, run out of breath or never recover. These catastrophic thoughts maintain sympathetic nervous system activation, and the ongoing release of adrenaline prolongs the episode. Learning to interrupt this cycle is a key feature of managing panic attacks (see chapter 11).

SOMATIC SENSATIONS

Given the physical arousal triggered by the activation of the sympathetic nervous system, it is not surprising that people with frequent or ongoing anxiety experience lots of body sensations. Anxiety can produce a multitude of somatic sensations – physical sensations triggered by the brain. Some are intermittent, while others linger. The most obvious are the intense sensations that accompany the fight-or-flight response, such as heart palpitations, muscle tension and heat, but there are many more. Below is a list of common somatic sensations:

light-headedness
muscle stiffness
tremor
headaches/migraines
dizziness
tight throat / difficulty swallowing
numbness
nausea
fatigue
tightness or pain in the chest
tingling
vomiting
neck pain
difficulty breathing
twitching
loss of appetite
dry mouth
tight scalp

‘electrical’ sensations
digestive disturbances
heat surges
missed heartbeats or ‘flutters’

itchy or ‘crawly’ skin
insomnia
diarrhoea
wobbly legs
sweating
clenched or sore jaw

Somatic sensations may become a source of distress, not only because they feel unpleasant but because they create uncertainty. You might find yourself wondering, ‘Why is this happening?’, ‘How long will it last?’, and ‘Will it ever go away?’ The symptoms themselves become a source of threat. Some people can’t believe that their anxiety can produce such strong physical reactions, and may worry that there is something seriously wrong with their health.

Worrying about somatic symptoms keeps us vigilant to body sensations. Shining a mental spotlight on particular feelings serves to magnify their intensity, and so maintains anxiety. A self-perpetuating cycle may be established, where anxiety produces somatic symptoms, which are perceived as a threat, which keeps us vigilant to them. This maintains anxiety, and the related somatic symptoms. It is not uncommon for anxious individuals to repeatedly see doctors, or have numerous medical tests and occasional hospital stays, trying to discover a medical explanation for their symptoms.

THE EFFECTS OF ANXIETY

Now that we have seen how anxiety manifests physically in our brain and body, let’s take a look at how it affects other aspects of our lives.

ANXIETY ABOUT ANXIETY

Some people focus on specific somatic symptoms, while others become preoccupied with the presence of anxiety itself: ‘Is it still there?’, ‘Why am I still anxious?’, ‘Will it ever go away?’, ‘Will I ever feel normal again?’ It may be the first thing you check when you wake up in the morning. Body sensations such as tightness in the chest, butterflies in the tummy or rapid breathing remind us that our anxiety has not abated.

While our anxiety may have been triggered by a particular stressful event, over time anxiety develops a life of its own. The more we try to resist it, the more of a threat it becomes, and the more anxious we may feel. As we will see in chapter 7 (on ‘mindful acceptance’) and in chapter 11 (on ‘panic surfing’), one of the best ways of breaking the self-perpetuating cycle is to stop fighting unwanted sensations, including anxiety itself. Paradoxically, when we drop the resistance, we release its hold over our lives.

ANXIETY AFFECTS THOUGHTS

While a threat-focused thinking style predisposes us to frequent anxiety, the reverse is also true – anxiety exaggerates threat perceptions. When we are anxious, our thinking changes and our minds become vigilant to danger. We overestimate the likelihood that bad things will happen (‘I’ll be late’, ‘I’ll do a bad job’) as well as the negative consequences should they occur (‘They will think I’m hopeless’, ‘I’ll be retrenched’). We have false alarms (‘This dizziness could be a brain tumour’, ‘My daughter may have had an accident’). While we might be able to see things logically when our anxiety is low (for instance, when talking to a trusted friend or therapist), we may see them as catastrophic when our anxiety is high (when lying in bed in the middle of the night or during a stressful period). When we manage to reduce our anxiety levels, we notice that not only is our body more relaxed, but our thinking is more rational.

ANXIETY AFFECTS ATTENTION

Evolutionary processes have ensured that our brain gives preference to high-threat information. When our amygdala detects even small or subtle threats, part of our attention is diverted to that issue. This response provided a survival advantage to our Stone Age ancestors, where a rustle in the grass could be a sabre-toothed tiger ready to pounce, but it is rarely helpful today.

Paying attention to possible threat prevents us from being fully engaged with whatever is before us, so it limits our attention and concentration. We are easily distracted by our own thoughts and find it hard to remain focused on the present. For instance, you might struggle to engage in conversation at a party or respond appropriately to simple questions. You might also make more mistakes at work, misplace your keys, miss vital information during a meeting or forget birthdays and appointments. You might even worry that you are ‘losing your mind’ because you are making lots of errors. Being vigilant to possible threats is a demanding job, and limits attentional resources available for other things.

ANXIETY AFFECTS BEHAVIOURS

When we feel anxious, our body is ready for action, and we feel an overwhelming desire to escape danger. Doing nothing can be the hardest thing to do when we are feeling anxious. Our instinct is to protect ourselves, so we try to escape situations we believe are unsafe. We also take lots of precautions to try to avoid danger. Without realising it, our avoidance and safety behaviours serve to maintain anxiety over time. In chapters 4 and 5 we will look at how this works, and ways in which these behaviours can be addressed.

NEED FOR CONTROL

While most people like to feel in control over aspects of their lives, this need is particularly acute among those high on trait anxiety. Feeling in control reduces our sense of vulnerability. We may assume that if we can control many aspects of our lives, our world will be safe. So for instance, we may try too hard to manage social events, micromanage our kids and set rules for ourselves regarding work, diet, exercise, cleanliness or keeping order. We may be very hard on ourselves, assuming that we need to do this to stay in control.

Many anxious people have a strong need for order, and feel disturbed when things are not in their proper place. Thus having an untidy or messy environment, unresolved issues, poorly defined or incomplete tasks, or being generally disorganised is likely to increase anxiety and feelings of distress. Perhaps for this reason, some people feel the urge to clean or tidy things when they feel anxious or perceive that they are not in control over their lives.

ANXIETY AFFECTS RELATIONSHIPS

The vigilance and arousal that accompanies anxiety can put us on edge and make us irritable. Friends may perceive us as ‘oversensitive’ or ‘touchy’. For some people this type of behaviour only arises occasionally, during particularly stressful periods. For others, it manifests as frequent irritability, with even minor issues triggering annoyance. These reactions can make us hard to live with, and may impact on relationships with friends, family members or colleagues.

Being anxious may make us feel insecure in our relationships and therefore question the motives and behaviours of others. We may worry about minor things that others say or do, and get upset over small issues. During calm periods we may recognise that the problem lies in our own thinking, but in an aroused, emotional state, it feels like others are to blame. The effect on our relationships can be a significant motivator for wanting to address our anxiety.

ANXIETY DISORDERS

Sometimes anxiety can become intense, enduring and debilitating. When anxiety persists for six months or more, and interferes with routine activities (such as work, education, social activity, housekeeping or parenting), it may be labelled an anxiety disorder. The DSM-5 – the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychological Association – is the main reference used by mental-health practitioners in many Western countries, including Australia, Canada and the United States. It defines the characteristics of mental disorders, including anxiety disorders. The most common anxiety disorders described in the DSM-5 are listed in the table below:

Generalised anxiety disorder (GAD): excessive attention to perceived threat, characterised by frequent worrying and excessive attempts to control things.

Social anxiety disorder: fear of negative evaluation by others.

Illness anxiety disorder: excessive fear of physical illness and death.

Panic disorder: fear of bodily sensations associated with high levels of arousal.

Agoraphobia: fear of being trapped in places from which escape would be difficult.

Specific phobia: intense fear of certain objects and situations that are not objectively dangerous.

Separation anxiety disorder: fear of separation from a primary attachment figure, like a parent or partner.

Substance-induced anxiety disorder: anxiety produced by use of or withdrawal from particular substances, such as caffeine, alcohol, certain medications and illicit drugs, e.g. cocaine.

Anxiety disorder due to a medical condition: caused by a medical condition such as hypoglycaemia, congestive heart failure and arrhythmia.

The various anxiety disorders present in different ways, but they have much in common. Each is characterised by exaggerated perceptions of threat, use of avoidance and safety behaviours, and prolonged physical tension and arousal. The specific objects of fear vary between disorders, from the broad perceptions of danger (where anything can be a threat) to more specific fears. While this book deals predominantly with strategies for managing excessive worrying and GAD, many of the described strategies are also relevant for managing anxiety in its various manifestations and disorders.

IN SUMMARY

Anxiety is a normal response to threat, and can be helpful when it motivates us to problem-solve, perform well or act on something that needs our attention. Anxiety becomes problematic when it is frequent, intense, enduring and affects our ability to function.

Some people are predisposed to anxiety because of their genetic makeup, early life experiences or a combination of both.

The specific things we perceive as threats vary, depending on our personal history and, therefore, the meanings we give to various situations.

The limbic system within the brain contains structures associated with identifying and responding to threat. The most important of these is the amygdala, which acts like a smoke detector, spotting possible threats and mobilising the body to prepare for danger.

The fight-or-flight response is activated when our brain perceives immediate threat, and includes symptoms like increased heart rate, breathing, blood pressure and muscle tension. Anxiety involves perception of future threat, which produces less intense but more prolonged symptoms. The ongoing vigilance response produces a range of physical symptoms that makes it hard to relax.

The physical (somatic) symptoms that are generated by anxiety can themselves become a source of threat because they are unpleasant, or because they are mistaken for an undiagnosed medical condition.

Anxiety disorders are more debilitating than normal anxiety, and affect our ability to function.

CHAPTER 2

Worry and Generalised Anxiety Disorder

‘How much pain have cost us the evils which have never happened!’

THOMAS JEFFERSON

Angelo is talking to an acquaintance at his best friend’s engagement party, nodding his head and making all the right noises. But when there is a pause and he is asked for his opinion, it becomes obvious that he has not heard a word. Worry about the speech that he is about to give has totally hijacked his mind.

Nadya reflects that she was unable to enjoy some of the most important events in her life, including her infant daughter’s birthday party, the family holiday in Greece, the day of her graduation and even her own wedding. Each experience was spoiled by worry and anxiety, which robbed her of the ability to enjoy the moment. They could have been fun, if only she had known how to relax.

Juan was delighted when he got tickets for Leonard Cohen’s last Australian concert, but what a wasted opportunity! He spent the whole concert worrying about a work-related issue that felt critical at the time, and missed the chance to fully experience this special event.

There is a busy world of thoughts going on inside our minds, and most of the time we are not even aware that we are thinking. Depending on our mood and emotional state, our thoughts may be positive, negative or neutral. When our mood is low or we are feeling depressed, we are more likely to engage in rumination. This involves thinking about negative events in a repetitive and unproductive way. We may focus on bad things that have occurred in the past, or aspects of our current distress, its causes and its consequences.

Some people are more inclined to worry. While overthinking is a common feature of both rumination and excessive worry, the latter involves focusing on perceived future threats, and is frequently associated with anxiety.

WORRY VERSUS ANXIETY

People who worry excessively usually experience a lot of anxiety, and, conversely, anxiety increases the frequency of worry. While the two often co-occur, they are not the same thing. It is possible to feel anxious without worrying, and to worry without feeling anxious.

Anxiety is a physical response to perceived threat. As we saw in the previous chapter, it begins in the limbic system, when the amygdala detects danger and signals the hypothalamus to trigger secretions of adrenaline and cortisol from the adrenal glands. The body quickly becomes charged and ready for action – there is a strong urge to do something, even when there is nothing we can do.

Worry, on the other hand, is a thought process. It involves thinking about bad things that could happen, and their possible consequences. It also involves trying to protect ourselves by thinking about how we might be able to prevent them, or how we could respond if they do occur. Worry stimulates activity in the prefrontal cortex – the thinking part of the brain – which then interacts with parts of the limbic system – the emotional part of the brain. When we keep focusing on possible threats, the amygdala is triggered, and worry may lead to anxiety.

Rick feels anxious when he arrives at the medical clinic, where he is due to have a biopsy on a suspicious lump. He is not worrying about the procedure, but his limbic system is reacting to perceived threat, and his amygdala is ringing alarm bells.

Elena feels anxious in situations like running late for an appointment, entering a room full of strangers or when boarding a plane. However, she does not consciously worry about any of these situations.

Michael started to worry when his son had not returned from his bike ride an hour after the time of his expected return. However, he did not feel anxiety at this stage.

Rene worries about her elderly mother, who is becoming frail and is at risk of falling, but she does not feel anxious. Rene’s worrying prompts her to think about things she can do to help her.

As we also saw in the previous chapter, anxiety may arise in response to conscious or unconscious perceptions. For this reason, we may sometimes experience anxiety and not know why. Worry, on the other hand, is a conscious thought process, so we can usually identify what we are worrying about.

Ilana frequently worries about her children. She worries about their physical health, their academic performance, their ability to make friends and whether her family will have the funds to provide them with a good education. Ilana will tell you that she worries too much, and if you ask her what she is worrying about, like most people who worry, she can describe it in detail.

NORMAL VERSUS EXCESSIVE WORRY

Most people worry at times, and if it happens occasionally, for a limited period, and is related to a specific challenge, it may be perfectly reasonable. The process of worry can focus our mind and motivate us to look for solutions, whether you are dealing with a stressful situation at work, a child who is struggling at school or the diagnosis of a medical illness.

Worry becomes problematic when we do it excessively or for extended periods, or when it is frequently speculative (‘What if . . .?’) rather than a response to an existing problem. Excessive worry involves focusing on unlikely contingencies (‘I couldn’t attend her school fundraiser – does she hate me now?’, ‘That sore could get infected, and I could end up with septicaemia’, ‘What if my husband leaves me and takes the kids with him?’) or on minor issues (‘Will I get all the cleaning done in time?’, ‘Will the bus stop?’, ‘Did I bring a good enough bottle of wine?’).

Habitual worry results in wasted time and energy preparing for improbable eventualities or non-existent problems. We imagine worst-case scenarios and where they might lead, and then we start thinking about possible solutions if that should happen. We may then realise that those solutions are not failsafe, so we start to think about backup solutions. Overthinking and overanalysing leads us down various ‘rabbit holes’ that lead nowhere.

The worry habit can be debilitating, and keeps us in an anxious state. It tenses and tires our muscles, and causes agitation, nerviness, sleep disturbances and ongoing fatigue. It diverts our attention, and causes poor concentration and errors. It can prevent us from feeling joy and appreciating the good things happening now, because we are not present with our current experience.

There are many reasons why we feel compelled to worry, and these are explored in detail in chapter 8. In short, excessive worry is a safety behaviour, directed by our own mind – an attempt to overcome uncertainty and make our world feel secure. By anticipating possible threats and expecting the worst, we try to prepare for all the things that may come our way. But, as you have probably noticed, far from making you feel safe, worry reinforces our fears and maintains anxiety over time.

WORRY TRIGGERS

While worry might appear to come out of the blue, there is usually a trigger. Something happens, and we start to think about bad things that could follow. Most frequently, worry is activated by situations that are unpredictable, novel or ambiguous.

Roberto heard on the grapevine that his office may need to be relocated to another area, and now he worries that such a move could disadvantage him.

Gary’s neighbour mentioned that they will be having a party on Saturday night. Gary starts to worry that he will not be able to sleep and will feel terrible the next day.

Leila has not heard back from her daughter after leaving her two messages, and now she worries that something may have happened to her.

Anika is worried about whether she will feel comfortable at the Meetup event that she is planning to attend.

Judy noticed that the pilot entering the cockpit of the plane was somewhat overweight. She immediately started to worry that he could have a heart attack mid-flight.

While the trigger is usually an external event, sometimes it is internal – we notice things happening inside of ourselves.

Daryl experiences intermittent feelings of ‘fullness’ in the head. While he has been reassured by several doctors that it is caused by anxiety, he worries that it might reflect a more serious medical problem.

Ali notices the familiar tension in his chest as his anxiety kicks in. He then starts to worry that his anxiety is back, and might never go away.

GENERALISED ANXIETY DISORDER

For some people, the tendency to worry excessively is a symptom of generalised anxiety disorder (GAD). This disorder affects six per cent of the population at some stage – women twice as often as men. Among women over 40 years, approximately ten per cent have or have had GAD at some stage in their lives. The median (most common) age for the onset of GAD is 31, which is quite late compared to other anxiety disorders. Around ten per cent of people with GAD have early onset (before the age of 13), and ten per cent have late onset (after the age of 51).

People with GAD worry about the same issues as anyone else – family (particularly children), health, finances, school, work, relationships, housing and physical safety. In addition, they may even worry about the fact that they worry too much. Some studies have found that for people with GAD, a lot of worry is focused on their family and relationships. As our brain is designed to help us survive in a tribe, it is not surprising that we frequently worry about other people. This includes those we want to protect, those whose friendship and approval makes us feel connected and safe, and those we perceive as threats.

Many people with GAD are not aware they have a disorder, and assume that worry is just part of their personality, or that everybody thinks that way. Some are incredulous when they discover that most people don’t. When compared to other anxiety disorders (such as phobias, panic disorder, illness anxiety disorder, social anxiety), a much smaller percentage of people with GAD seek treatment, perhaps because they don’t realise that their thinking is abnormal or that change is possible. Interestingly, after successful treatment of GAD, symptoms of coexisting anxiety disorders also frequently diminish. It is not uncommon for phobias, such as a fear of flying or of driving through tunnels, to develop shortly after the onset of GAD, and to resolve following its successful treatment.

While some people with GAD say that they have worried for much of their lives, others can remember a specific onset period. For instance, there may have been a stressful event or trauma that triggered fear, panic or dread, and their worry habit started at that time. Typical triggers include things like divorce, the death of a loved one, the diagnosis of a serious illness, being the victim of bullying, a falling out with a family member, a serious accident, a distressing dismissal from work, or episodes of rotational vertigo (spinning) or loss of balance due to vestibular illness. Even having children can trigger the onset of GAD for those who are already anxious. Some people can recall how they felt prior to the onset of GAD, and may wistfully long for their old life back.

The DSM-5 describes the features that need to be present for a diagnosis of GAD. The key features are listed below:

GENERALISED ANXIETY DISORDER – DSM-5 CRITERIA

Excessive anxiety and worry (apprehensive expectation) occurring more days than not for at least six months, about a number of issues.

Worry feels difficult to control.

The anxiety and worry are associated with at least three of the following symptoms:

•   muscle tension

•   restlessness

•   fatigue

•   irritability

•   sleep disturbance

•   concentration difficulties

The symptoms cause significant distress, and impair functioning in social, occupational or other areas.

Unlike panic attacks, which are characterised by the fight-or-flight response, GAD is characterised by an ongoing vigilance response. Even when nothing is wrong, the possibility of threat is always there in the background, so we remain tense, aroused and ‘ready’. This vigilance can make us jumpy or irritable, so for some people minor events trigger annoyance, anger or irritation.

EXCESSIVE WORRYING IS NOT ALWAYS GAD

Our disposition towards worrying lies on a continuum from very low to very high. At the high end of the continuum are those who worry habitually. This includes those with GAD, as well as those who worry a lot but do not meet all criteria for GAD. For instance, they may not experience three of the symptoms that typically accompany GAD, or their symptoms may not significantly affect their level of functioning.

Whether or not we meet criteria for GAD, however, habitual worry impairs quality of life. The strategies described in this book are relevant to all people who worry too much, including those who do not meet the full criteria for GAD.

ASSOCIATION WITH DEPRESSION

People with GAD have an increased likelihood of experiencing episodes of depression. While 15–20 per cent of the population experience depression at some stage, among people with GAD, it is between 60–70 per cent. The increased likelihood may be because worrying creates a negative mindset, is physically exhausting and can lead to feelings of hopelessness. In addition, some researchers argue that among people with GAD, there is a higher prevalence of neurotic personality style, which is a risk factor for both anxiety disorders and depression.

For people who experience GAD as well as depression, the latter usually occurs as discrete episodes, which resolve over time. In contrast, GAD is often chronic. While some people experience remission in their GAD symptoms (e.g. when they go on a relaxing holiday), relapse is common. The good news is contemporary treatment for GAD can resolve the condition permanently, or substantially reduce its impact on our lives.

ATTENTIONAL BIAS TOWARDS THREAT

Like all anxiety disorders, GAD is accompanied by an attentional bias towards threat. Our mind is frequently scanning for danger, paying excessive attention to possible risks (‘Why hasn’t she returned my call?’, ‘Why is my heartbeat elevated?’, ‘Why is that car parked in my street?’, ‘Those kids are playing on the footpath, but they are close to the road’, ‘The doctor didn’t wear gloves when she examined me’). Ambiguous information is often interpreted in a high-threat way, and we frequently jump to negative conclusions.

Giselle became alarmed upon feeling popping sensations inside her head, and wondered if she was having a stroke. She promptly went to the emergency department of the local hospital, where brain scans were performed. No problem was detected. Upon recounting what had happened to her husband that evening, he recalled popping sensations when he ate some sweets that the children had left on the bench. Giselle’s popping also occurred when eating those sweets, but she had not made the connection. Unlike Giselle, her husband looked at the label when he noticed the popping. It said ‘Popping Candy’.

Being constantly on the lookout for danger creates false alarms, and limits our ability to make rational assessments. The worst-case scenario immediately comes to mind, and often feels like the most plausible explanation.

People with GAD have a ‘busy’ internal world. Some say things like ‘People tell me that I think too much’ or ‘I always like to analyse situations from various angles’. Many perceive these qualities as personal strengths, because they assume that extensive scrutiny enables them to prepare for every contingency.

Overthinking, overanalysing and monitoring possible threats are common aspects of the worry process. Far from being helpful, these cognitive habits maintain a negative, threat-focused view of the world. While in some specific situations it is useful to think through various options (for example, when making career decisions, buying a house or planning strategies for a new business), habitual overthinking has few advantages, and is rarely conducive to good mental health.

POOR CONCENTRATION

When we are preoccupied with worry, we have limited attentional space to process other information. As a result, our concentration suffers, and we are more likely to make errors. Many people with GAD complain that their memory is poor, and some worry that they may be getting dementia. In reality, the problem is more often one of attention rather than poor memory, because worry hijacks our mind, so we are not present with the things happening before us.

REFLECT

Next time that you are having a conversation, observe how much of your attention is in the conversation, and how much is elsewhere. If, for example, you notice that 50 per cent of your attention is focused on the content of the conversation, where is the other 50 per cent? Can you see why you might miss things?

FATIGUE

Being vigilant much of the time is physically exhausting. Your muscles are tight and your body is using lots of energy to keep you in that state of preparedness. Tiredness may also be compounded by insomnia (difficulty falling or staying asleep), which is another common symptom of GAD. During periods of high anxiety, our thoughts are threat focused, and in the middle of the night, things seem much worse than they actually are. (We’ll talk more about sleep in chapter 13.)

INTOLERANCE OF UNCERTAINTY

Research suggests that the tendency to overthink things is largely a response to an intolerance of uncertainty.

The possibility of negative events can never be ruled out, and most people accept this and get on with their lives. For people with GAD, uncertainty is difficult to accept, so they use worry as a strategy to try to make their world safe. The perpetual thinking – imagining the worst and preparing what to do if it should happen – is a way of trying to gain some control over what feels like an uncertain world. Indeed, some would say they prefer the certainty of negative events (‘I lost my job’, ‘I have cancer’, ‘My marriage has ended’) over living with the uncertainty that these things could happen.

Carla describes herself as a worrier, and feels like the weight of the world is always on her shoulders. Many of her worries are about social relationships and the possibility of rejection. She sometimes replays earlier conversations in her mind, and scans them for possible signs of disapproval.

Carla also describes herself as a perfectionist. Although she enjoys entertaining, she finds it stressful because she has to make everything perfect – the food, her dress, the house and the guest list. She usually cleans and prepares the house for several days before hosting a dinner, and often the stress is greater than the enjoyment.

Carla has frequent tummy problems, and is particularly worried about the possibility of stomach cancer because her grandmother died of it. She has had repeated medical tests, but no diagnosis has been made. When told that it is likely to be irritable bowel syndrome, Carla’s worrying increased, because ‘likely’ is not a definitive diagnosis.

Carla tries to keep herself healthy by following a very strict diet, and taking vitamins and homeopathic remedies. She sees her GP whenever she gets new symptoms. She avoids watching programs on medical issues, as these add to her anxiety, and she never listens to the news because ‘It’s all bad news’.

Carla worries about the impact of her frequent negative thoughts on her health, but she also believes that to not worry would invite disaster. ‘What happens if I ignore something that could have been prevented?’ She believes that worrying enables her to be more effective at work, and worrying about her children keeps them safe and means that she is a good mother. She admits: ‘I always need to have something to worry about. If I’m feeling relaxed, I feel unsafe.’

Like most people with GAD, Carla believes that the problem is all the bad things that could happen – physical illness, social disapproval, becoming overwhelmed by upsetting thoughts, and harm to her children and loved ones. She puts lots of her energy into trying to prevent these things, but this does not make her feel any safer.

While Carla assumes that the problem is danger, the real problem is Carla’s thinking, and all the things she does to try to make her world safe. Learning to release attempts to eliminate uncertainty will enable Carla to discover that she can relax into an uncertain world (more about this in chapters 4 and 5).

REFLECT

Can you identify five safety behaviours that Carla uses to try to keep herself safe? Why do you think she engages in these behaviours?

OVERESTIMATING NEGATIVE CONSEQUENCES

People with GAD overestimate the likelihood that bad things will happen, but also overestimate the consequences if they should occur. So they worry about all sorts of negative possibilities, as well as their consequences further down the line.

Jin worries that he might have forgotten to lock his car when he parked it this morning. He assumes that if this turns out to be true, his car will be stolen or looted.

Cory worries that he will not know anyone at the social function he plans to attend. He also overestimates the negative consequences should this occur. He thinks to himself, ‘I’ll be on my own . . . People will think that I have no friends . . . I’ll be humiliated . . .’

Aisha confided to a work colleague that she is currently depressed and very anxious. Now she worries that her colleague may tell others, and that everyone will find out. She assumes that if that were to happen, it will affect her reputation and future job prospects.

Sometimes worry can spiral into catastrophic chaining, where we foresee a sequence of negative events, each being triggered by the previous one.

Upon hearing that her eight-year-old daughter’s class size is larger than last year, Chloe thinks to herself: ‘She may not get enough attention in class . . . She won’t learn effectively . . . It could end up compromising her education . . . She may not get into university . . . She won’t be able to get a decent job . . . Her life could be ruined . . .’

FEAR OF DISTRESSING EMOTIONS

Most people with GAD fear unpleasant emotions, particularly anxiety and depression. They often worry that if they don’t control their emotions, they will escalate and overwhelm them. Common fears include having a ‘breakdown’, not being able to stop crying or feeling anxious, or getting into a ‘bad place’ and not being able to recover.

Consequently, we try very hard to avoid experiencing unpleasant emotions, or to stop them in their tracks. To do this, we might refuse to talk about or engage with unpleasant topics, understate our distress (‘No, I’m fine – all good!’), keep very busy to avoid being alone with our thoughts and feelings, or use devices to distract from unpleasant emotions (e.g. wearing headphones, playing computer games or engaging with social media). While any of these strategies may be appropriate for short periods during times of extreme distress, habitually trying to block unpleasant emotions perpetuates our fear of them. These avoidance behaviours prevent us from learning that we can learn to tolerate distress, and that upsetting emotions pass.

Research psychologist Tom Borkovec and his colleagues at Pennsylvania State University argue that worry is itself an avoidance strategy, aimed at reducing anxiety. Borkovec identified that worry is a verbal linguistic process that blocks visual imagery, which would otherwise generate intense emotions. (We feel emotions more strongly when we have visual images. So, for example, worrying about giving a speech is less anxiety-provoking than visualising yourself before a live audience.) Through blocking images, worry allows us to process emotional topics at a linguistic rather than an emotional level, which produces less arousal in the short term. When the worry system is active, the fear system is less active, so we feel nervy, tense and on edge instead of fearful and highly aroused.

On the downside, blocking imagery disrupts the normal processing of emotions, and prevents habituation (overcoming of fears). Facing and feeling our emotions may be unpleasant, but it allows them to be processed and resolved. This is a far healthier way to respond to unwanted emotions than trying to block them.

UNDERESTIMATING ABILITY TO COPE

When we worry about possible future negative events, we often assume that we would not be able to cope if they should happen. We may even imagine being overwhelmed by negative emotions and not being able to function.

Over the course of our lives, many things have gone and will continue to go wrong at times. Most are minor, but some are significant. Stuff happens to all of us. If you think back to the many upsetting events that have occurred, you may notice a pattern – you felt bad for a while, and then over time you recovered.

When bad things happen, it feels like we will suffer forever.

But over time, we recover.

Either the situation resolves itself,
or we get used to the new reality and adapt.

Upsetting emotions pass.

We cannot always escape emotional distress. Pain is an unavoidable part of life. Rather than trying to ensure that we never experience emotional pain, it is healthier and more reasonable to accept that pain will sometimes come our way, and to deal with it if and when it arises. Paradoxically, emotional distress passes more quickly when we don’t see it as the enemy (more about this in chapter 7 on mindful acceptance).

POOR PROBLEM-SOLVING

Some people with GAD have difficulty with problem-solving – and all the more so when perfectionism is part of the personality mix. It is not that they cannot suggest possible solutions when presented with challenging situations – they are as creative as anyone else. The difficulty is that a threat-focused thinking style leads one to doubt any solutions that come to mind. We rarely feel confident in the ideas we come up with, and every possible solution opens the door to further uncertainty.

Krysta is planning an engagement party for her daughter. She originally planned to hold the party at home, but after listing all the people she wanted to invite, she worried that there would not be enough room. After searching for alternatives, Krysta decided to hire a venue, but then she worried that a large hall might feel ‘empty’, and they would have to invite a bigger crowd. After more deliberation, Krysta decided on a sit-down meal at a restaurant, but soon this, too, brought up worries. ‘Sit-down meals can be very dull, especially if you end up stuck next to someone you don’t like . . . Hopefully people will move around and swap chairs after the meal . . . But will they? . . .’ When challenged by her husband to just make a decision, Krysta insists, ‘But I want to get this right!’ Although there are many possible solutions, Krysta’s tendency to see threats with every option makes problem-solving difficult.

Anton is a talented video maker. He runs his own business and has plenty of work; however, he is frequently anxious, particularly as demand for his services continues to grow. Anton recognises that he can’t go on running every aspect of his business, so he contemplates the possibility of employing an assistant. They could do the administrative work while Anton concentrates on the creative side. Initially, this seems like a great idea, but soon alarm bells start to ring. What if there is not enough work for them to do? He may need to pay them for idle time. What if the assistant ends up being the wrong person for the job? He might lose control of the business. Could an assistant do more harm than good? What if he needs to sack them, but doesn’t have the courage? The idea of not being able to get rid of someone who is not right for the business is a huge turnoff, so he continues to cogitate.

Seeing threats in every possible solution makes problem-solving difficult. It can keep us deliberating without being able to settle on a good enough solution. Problem-solving is an important component of healthy stress management, and poor problem-solving prevents us from taking control or moving forward.

STRESS IN RELATIONSHIPS

It can be frustrating to live with someone who worries much of the time. Friends and family members may describe the person as ‘negative’, because they always seem to focus on things that could go wrong. Planning a holiday can be a major drama, full of worry about minutiae, focusing on things that could go awry and obsessional overpreparing. While teenage children are seeking independence, people with GAD focus on danger, and may resist their children’s pleas for autonomy. Mooted changes in the workplace may generate endless speculation, and worst-case scenarios are repeatedly canvassed. Friends, colleagues and family members may get frustrated at times, because the person always sees problems, even in positive situations.

MAGICAL THINKING

People with GAD sometimes engage in ‘magical thinking’. This is the tendency to perceive a causal relationship between unrelated events. Often it involves ideas like, ‘If I think, or say, or do [a particular act], this will affect some (unrelated) other thing. For example, ‘If I relax, stop worrying or feel good, something bad will happen’ or ‘If something good happens, something bad will follow’. It also includes associations between particular events and harm to self or loved ones. For example, ‘If my daughter points to her breast while describing someone’s breast cancer, she could get breast cancer too’ or ‘If I watch that science documentary about heart disease, it could happen to me’.

This type of thinking is superstitious, and is most typical of people with obsessive-compulsive disorder (OCD); however, it is also not uncommon among people with GAD. (In OCD, the links between behaviour and outcomes are often more bizarre. For example, ‘If I don’t tap at least 75 times, my family will come to harm’.)

Magical thinking gives rise to unnecessary safety behaviours, such as trying to avoid particular thoughts, activities or topics of conversation. While we may logically recognise that our thinking is irrational, on a gut level it may feel true.

It is not just uninformed people who engage in magical thinking – even mental-health experts like psychologists and psychiatrists do it. British professor of clinical psychology Paul Salkovskis is renowned for putting his audience to the test during workshops by asking them to write down: ‘I hope that [insert the name of your nearest and dearest] is violently killed in an accident today’. The request is usually met with horror and indignation. Many refuse to do it, while others tear the paper into shreds after they have written it.

If you know that writing words on paper has no causal relationship to life events, why would you be so disturbed by this task? Perhaps on some level, many of us make irrational connections between unpleasant thoughts and negative events that could follow.

IN SUMMARY

Anxiety is the perception of threat, and includes the physical arousal that accompanies the perception. Worrying is a thinking process that involves considering negative events that could happen, and ways that we could respond to prevent or ameliorate those events. While we may not always know what the source of our anxiety is, worry is a conscious thought process, so we can usually identify what we’re worrying about.

Occasional worrying is normal and sometimes helpful; however, frequent or excessive worry has many downsides, and may indicate an anxiety disorder.

Generalised anxiety disorder (GAD) is characterised by excessive anxiety and worry that is difficult to control, plus other symptoms, including muscle tension, restlessness, fatigue, irritability, sleep disturbances and concentration difficulties. The symptoms interfere with our functioning.

Excessive worry in GAD is a response to an intolerance of uncertainty – we assume that worrying about things reduces uncertainty and gives us greater control.

While it feels like our problem is all the bad things that could happen, the real problem in GAD is an unrealistic, threat-focused thinking style. People with GAD overestimate the likelihood of negative events, and the negative consequences should those events occur.

People with GAD often fear unpleasant emotions, such as anxiety and depression, and underestimate their ability to cope if they should occur.

People with GAD may have difficulty with problem-solving because every possible solution is associated with other perceived threats.

CHAPTER 3

Healthy, Balanced Thinking

‘People are not disturbed by things but by the view that they take of them’

EPICTETUS

Jenny felt threatened when a colleague, who normally shares her values and opinions, disagreed with her during a staff meeting. The disagreement felt personal, and, in Jenny’s mind, her colleague went from being her ‘ally’ to her ‘adversary’. He is no longer to be trusted.

Rubin is in a highly anxious state after seeing a psychologist for the first time. Among other questions, the psychologist had asked whether Rubin has had any suicidal thoughts. Rubin started to wonder why she had asked him that – was he coming across as suicidal? He then started to worry that he might become suicidal in the future, and this makes him feel more anxious.

Ursula frequently worries about her parenting, including whether she is doing a good enough job. She also worries that other people might judge her parenting. During a casual chat with the GP, her four-year-old mentioned that they had had party pies for dinner last night. Ursula became alarmed: ‘She must think I’m a terrible mother!’

Scott became anxious when his team leader noticed that he was making personal phone calls at work. Scott started worrying about the potential consequences: ‘She must think badly of me for this. She might tell others, and it could affect the way I am regarded here.’

The way we think determines the way we feel. This is a basic principle of cognitive behaviour therapy (CBT) – a psychological approach widely used by mental-health practitioners all over the world. We go through life assuming that our thoughts are truth – that we perceive things just as they are, and that our feelings are inevitable, given the situations in which we find ourselves. Other people, challenging life circumstances or our own inadequacies feel like the source of our unhappiness.

In reality our perceptions are subjective, strongly influenced by our history and our current emotional state. Some of our thoughts are realistic, others are biased and unreasonable, and some contain a grain of truth but are not the whole story. Upsetting emotions, such as anxiety, anger, shame, guilt or sadness, are created by cognitions – the thoughts, beliefs and assumptions we make about ourselves and the world. Because cognitions vary between individuals, we sometimes experience very different emotions in the same situations.

THE COGNITIVE BIAS

In chapter 1 we saw how destabilising experiences during childhood, sometimes combined with a pre-existing anxious temperament, give rise to high trait anxiety. This makes us predisposed to ‘false alarms’ and overreactions. Our minds are vigilant to threat, and we readily perceive danger, even in low-threat situations. This bias means that we frequently think about and pay attention to negative contingencies. We overestimate the likelihood that bad things will happen and the adverse consequences that could follow if they should occur.

The cognitive bias towards threat is most pronounced during periods of high anxiety. When we are anxious, catastrophic thoughts proliferate. During these times we are more likely to believe things like ‘I could lose my job’, ‘Others are criticising me’, ‘I might have a serious health problem’ or ‘My friendships are at risk’. In the intense anxiety that arises with a panic attack, people often feel certain that they are going crazy or are about to die. When our anxiety is high, and our amygdala ‘smoke alarm’ blares, those catastrophic thoughts feel 100 per cent true.

CHANGING OUR THINKING

The role that our thoughts play in creating emotions, and the way in which unreasonable thoughts and beliefs can be challenged, has been described in detail in my earlier book on cognitive behaviour therapy, Change Your Thinking (see appendix). ‘Cognitive reframing’ or ‘disputing’ involves recognising and challenging negative or irrational thoughts, and identifying a more reasonable, balanced perspective. This process includes learning to recognise reasoning errors, such as ‘predicting catastrophe’, ‘mind-reading’ or seeing things in ‘black and white’. Acknowledging reasoning errors reminds us that our thoughts are not ‘truth’, and encourages us to consider alternative viewpoints.

In addition, various prompts can be used to help us challenge the content of our thoughts (e.g. asking specific questions to evaluate the evidence for and against our thinking). This process can help us view our situation in a more reasonable, balanced way, and can protect us from a range of upsetting emotions, including anxiety.

CHALLENGING THE CONTENT OF WORRY THOUGHTS IN GAD

The question of whether people with GAD should be encouraged to challenge the worry thoughts that pop into their mind using cognitive reframing or disputing has been debated among mental-health practitioners, and opinions are divided. The emerging view is that everyone can benefit from recognising that many of our perceptions are biased, and that our thoughts are not reliable indicators of danger. Just because we think something doesn’t mean it’s true. For people with GAD, it can be helpful to recognise reasoning errors and obvious flaws in our thinking.

However, trying to logically challenge the content of the many worry thoughts that arise each day may not be helpful for people who are already in the habit of overanalysing. Disputing the content of worry thoughts promotes further engagement with those thoughts, and may reinforce overthinking – the very habit we are trying to break.

In addition, people with GAD often continue to have lingering doubts, even after examining the evidence and logically challenging irrational thoughts. While for those with normal anxiety, recognising that feared negative outcomes are highly unlikely is often reassuring, for individuals with GAD, it may open up further questions. Even when we know that the probability of a negative contingency is extremely low, intolerance of uncertainty makes it hard to let go. If the possibility of disaster can’t be definitively ruled out, many overthinkers will remain focused on that possibility. Without addressing the underlying process that maintains the urge to worry, the overthinking and overanalysing persists.

Contemporary treatments for GAD focus on observing thought processes. The emphasis is on disputing the beliefs that maintain the urge to worry rather than challenging the content of individual worry thoughts. The information provided in this book takes this approach. The focus is on building an understanding of how our minds work, identifying the beliefs that perpetuate the urge to worry and developing strategies that directly address that urge.

For readers who are dealing with other types of anxiety (including other anxiety disorders) and who do not habitually worry, overthink and overanalyse, the following summary on cognitive reframing is likely to be useful.

Let’s start by recognising some of the common reasoning errors that give rise to anxiety.

COMMON REASONING ERRORS

If you were to observe the types of thoughts that pop into your mind, you might notice repeated patterns of thinking that contribute to anxiety and other upsetting emotions. These are variously referred to as ‘reasoning errors’, ‘faulty thinking’ or ‘cognitive distortions’. Most of the time, we are not aware that we are engaging in these habits.

Learning to recognise and label reasoning errors reminds us that our thinking is biased or distorted, and creates some ‘distance’ from our thoughts. Simply labelling reasoning errors can weaken their influence over our thinking, as we acknowledge that our thoughts are not necessarily ‘truth’ or ‘reality’. In addition, actively challenging the content of our thoughts (see pages 59–63) gives us insight into other, more reasonable ways of perceiving our situation.

Following are descriptions of common reasoning errors that play a role in perpetuating anxiety. As you read through them, you may be able to think of situations where you have engaged in this style of thinking.

PREDICTING CATASTROPHE

Predicting catastrophe is when we expect negative future outcomes without considering other more likely or less negative possibilities. For example:

‘Why am I getting these headaches? I can’t believe it’s due to anxiety – I think there’s something else more serious going on.’

‘I can’t work out the right combination of people to invite. The dynamics will be terrible!’

‘I wish I didn’t agree to go out with my friends this evening. Now I won’t be up to date on all my outstanding tasks, and tomorrow will be chaos!’

‘I shouldn’t have said that to my daughter – it could damage her forever.’

Predicting catastrophe is one of the most common reasoning errors associated with anxiety. Focusing on the worst possible outcomes provides a negative, distorted picture of how the world works. Few events result in catastrophe.

Keep in mind: the vast majority of negative events that we anticipate don’t happen, and even when they do, we manage to get through them.

REFLECT

Can you think of a situation where you were predicting catastrophe and your negative expectations turned out to be unrealistic?

MAGNIFYING (‘AWFULISING’)

Magnifying or ‘awfulising’ is when we exaggerate the ‘badness’ or negative consequences of current or past situations. For example:

‘I’ve got a cold! Oh, that’s terrible!’

‘The plane flight was horrendous.’

‘I made a complete idiot of myself!’

Because we perceive events in an overly negative way, we are more likely to feel anxious and alarmed. We may magnify relatively trivial events (as in the above examples). However, even more inherently stressful events (such as an upcoming surgical procedure or a significant restructure at work) can create unnecessary distress when we magnify the negative consequences.

The problem with this style of thinking is that we end up with two issues: the negative event itself that we may need to deal with, and the anxiety and other upsetting emotions that result from thinking that way. Often our distressing emotions create more suffering than the unwanted circumstances we are facing.

Keep in mind: most situations do not have terrible consequences. In the end, we cope.

REFLECT

Can you think of a situation where you were magnifying the negative consequences of something that had happened?

‘SHOULDS’

‘Shoulds’ are rigid, inflexible beliefs about how we, others and the world should be. For example:

‘People should always like and approve of me.’

‘I should be competent and effective in everything I do.’

‘I should be able to connect well with people in every social situation.’

‘If someone asks me to do something, I should always do it.’

Rigid beliefs about things like our behaviour, performance, appearance, achievements or social approval create anxiety because we may not always live up to them. A psychologically healthy approach is to work towards the things that matter to us, but to maintain flexibility. This enables us to adapt in situations where things don’t go exactly as we would like.

Keep in mind: cognitive flexibility is the key to a psychologically healthy thinking style. Sticking to rigid rules, without adapting to current circumstances, creates emotional suffering.

REFLECT

Can you think of some beliefs that you hold as inflexible ‘shoulds’?

BLACK-AND-WHITE THINKING

Black-and-white thinking is the tendency to see things in ‘black and white’, good or bad, success or failure. We don’t recognise or value the middle ground. Like ‘shoulds’, black-and-white thinking reflects the absence of cognitive flexibility. For example:

‘I didn’t sleep well, so today is a total write-off.’

‘I took a Valium to help me get through that flight – I’ve failed.’

‘They can’t cure my cancer, so there is no point in trying to help myself.’

‘If I don’t get that job, it’s the end of the road for me.’

This style of thinking is unrealistic because it lacks nuance. In the real world, very few things are black and white. Life events combine positives and negatives, and ‘shades of grey’ can be found in most situations.

Keep in mind: people and situations are rarely black or white. Most have ‘shades of grey’.

REFLECT

Can you think of an example of where you were seeing a situation in black-and-white terms? What ‘shades of grey’ may you have been overlooking?

MIND-READING

Mind-reading is when we assume we know what other people are thinking – that they are making negative judgements about us. For example:

‘They can see how nervous I am. They must think there is something wrong with me.’

‘I wish I hadn’t talked so much – she must have been totally bored.’

‘I was on my own at that exhibition – they must have thought I don’t have any friends.’

‘I’m overdressed for this party – they must be wondering why I’ve come in this outfit.’

Mind-reading is particularly common for those who feel anxious in social situations. We assume that we are being negatively evaluated. Most often we are reflecting our own self-doubts rather than accurately reading what other people are thinking.

Keep in mind: unless someone tells you what they are thinking, don’t presume you know.

REFLECT

Can you think of a situation where you were mind-reading? In retrospect, could your assumptions about what the other person was thinking have been incorrect?

LABELLING

Labelling is when we make a global judgement about ourselves or others on the basis of specific characteristics or behaviours. For example:

‘I didn’t fit in with that group – I’m defective.’

‘I’ve been single for two years – I’m inferior.’

‘I missed the deadline – I’m incompetent.’

‘I said something dumb – I’m an idiot.’

Labelling is the ultimate overgeneralisation because we sum up a person’s worth with a one-dimensional, usually unreasonable characterisation. When we label ourselves ‘bad’, ‘defective’, ‘a loser’, ‘incompetent’, ‘a failure’ or ‘dumb’, we make oversimplified assessments of our own worth, and reinforce feelings of inadequacy. When we label someone else ‘a creep’, ‘a fool’ or ‘an enemy’, we do the same about them, and so create disdain and tension whenever we need to deal with that person.

Keep in mind: people are complex – we have many traits and behaviours, and no single trait defines who we are.

REFLECT

Can you think of a label that you have given yourself that does not fairly reflect the totality of who you are?

COMPARING

Comparing is when we use other people’s behaviour, appearance or achievements as a basis for assessing our own worth, ignoring the inherent differences between us. For example:

‘Sam (who was in my class at school) is now a successful lawyer. I’ve achieved so little by comparison.’

‘She has hundreds of followers on Instagram. I’ve got just a fraction of that.’

‘They understand how to use this software package. I can’t work it out. What’s wrong with me?’

‘Other people are involved in all these interesting, lucrative projects, and I’m just plodding along in my job.’

When we compare, we focus on others who appear to have more or do things better than us. We perceive their strengths or achievements as a threat, because it highlights our own shortcomings. Typically, it creates anxiety in relation to our connections, achievements, appearance, financial status, family or capabilities. Comparing ourselves to others provides unrealistic benchmarks, because we have different histories, physiology (even different brains) and natural capabilities. While it is reasonable to be inspired by others at times, if other people’s success makes you feel bad about yourself, it means you are engaging in unhealthy comparisons.

Keep in mind: it’s unfair to compare. We have all been dealt a different hand. It’s more helpful to focus on goals that are life-enhancing for us.

REFLECT

Can you think of a situation where you compared yourself to others in a way that made you feel bad about yourself?

PERSONALISING

Personalising is when we take things personally, when it’s not about us. For example:

‘That receptionist was very unpleasant. What have I done to her?’ (Hint: she is always like that. It’s her personality.)

‘That guy walked out in the middle of my presentation. He must have been very unimpressed’. (In fact, he had a prearranged appointment to get to.)

‘She didn’t come up to me to say hello at the party. She’s ignoring me.’ (Actually, she was just distracted talking to other people, and so was I. We just never got around to chatting.)

‘He didn’t respond to my text message – he must dislike me.’ (In reality, he was busy with another task, and then forgot to respond.)

When we personalise, we perceive other people’s behaviour as necessarily directed at us. We assume that others are sending us a negative message, even though it may have nothing to do with us. Even rude behaviour is not necessarily personal – some people have an abrasive personality, or may be dealing with their own unhappiness or mental-health issues, which manifests as rudeness.

Keep in mind: not everything is about us. We don’t need to take things personally.

REFLECT

Can you think of a situation where you personalised someone’s behaviour or attitude that in fact had nothing to do with you?

FILTERING

Filtering is when we pay undue attention to one negative detail, instead of seeing the whole picture. For example:

Konrad is upset by the two negative evaluations of his presentation to colleagues at work, but he ignores more than 40 others that were predominantly positive.

Dereck worries he is getting dementia. He is acutely aware that he sometimes can’t remember certain words, or where he put his keys. However, he ignores all the things that he does competently every day, including his high level of functioning in a challenging job.

Kira is upset about a recent social event where she felt awkward and disconnected, and now worries about her social competence. She ignores the fact that feeling awkward at social events happens to most people at times, and that in the majority of social situations she connects well.

When we feel anxious or insecure, we are much more likely to notice negative information, and interpret ambiguous information in a negative way. We are also more likely to ignore positive information. Many people also miss the context of particular negative experiences, such as, ‘I made a mistake, but I had a migraine. I usually do things well,’ or ‘I said something silly, but no one noticed or cared.’

Keep in mind: anxiety may cause you to selectively home in on negative information while ignoring the positive. That prevents you from getting a reasonable, balanced picture.

REFLECT

Can you think of a situation where you filtered out positive information and focused solely on the negative?

JUMPING TO NEGATIVE CONCLUSIONS

Jumping to negative conclusions is when we interpret events in a negative way, or assume the worst, in spite of insufficient evidence. For example:

‘The doctor didn’t say hello when she saw me in the waiting room – she must have bad news for me.’

‘Very few people “Liked” my photo on Instagram – my friends are not interested in me.’

‘A woman stood up for me on the bus – I must be looking old.’

A cognitive bias towards threat means that we are more likely to jump to negative conclusions in situations that are ambiguous, or when insufficient information is available. (This thinking style often contains elements of mind-reading, predicting catastrophe, comparing and personalising.)

Keep in mind: The negative perspective is not necessarily correct. Consider other explanations.

REFLECT

Can you think of a situation where you automatically jumped to the most negative conclusion?

EXERCISE

For the next week, keep an eye out for situations where you experience upsetting emotions (such as anxiety, guilt, frustration, sadness, etc.). See if you can identify any reasoning errors that underlie your thinking.

How might recognising reasoning errors as they arise be helpful for you?

CHALLENGING NEGATIVE THOUGHTS

As mentioned earlier, cognitive reframing or ‘disputing’ is about not only recognising negative or irrational thoughts, but also challenging them. There are various strategies that can help us with this process: reality testing, asking ourselves what is ‘worst, best and most likely’ and using a thought-monitoring form.

REALITY TESTING

Reality testing involves focusing on objective evidence by asking a series of questions:

What are the facts?

What are my subjective perceptions?

What evidence supports my perceptions?

What evidence contradicts my perceptions?

Am I making any reasoning errors?

How else can I perceive this situation?

In the examples at the start of this chapter, we saw that Jenny was feeling anxious in response to her work colleague disagreeing with her at a staff meeting. Her immediate thoughts were that her colleague is no longer onside, and that he is now an adversary.

Below is an example of how Jenny challenged her thoughts using this method.

REALITY TESTING

What are the facts?

Martin disagreed with me during our staff meeting.

What are my subjective perceptions?

He is no longer to be trusted. He should agree with me, or at least keep his disagreement to himself. I have lost an ally.

What evidence supports my perceptions?

He publicly disagreed with me at a staff meeting.

What evidence contradicts my perceptions?

He is frequently helpful and collegial at work. We have good conversations at times, and he is usually open and friendly towards me.

Am I making any reasoning errors?

Shoulds, black-and-white thinking and jumping to negative conclusions.

How else can I perceive this situation?

People can disagree without it being a personal attack or sign of disrespect. Even trusted colleagues or friends can have different points of view. Martin supports me in other ways. Disagreeing with me on this occasion does not mean that he is no longer an ally.

We also saw Rubin, who became very anxious when his new psychologist asked him whether he was experiencing any suicidal thoughts. Rubin could challenge his thoughts in the following way.

REALITY TESTING

What are the facts?

The psychologist asked whether I have had any suicidal thoughts.

What are my subjective perceptions?

She thinks there is something seriously wrong with me. Perhaps my condition is more serious than I realised? Could I become suicidal?

What evidence supports my perceptions?

She asked me that question.

What evidence contradicts my perceptions?

She asked me many other questions as well. She did not indicate that she thought I was suicidal, and when I said ‘no’, she moved on to the next question. Until she asked about it, I have never thought about suicide, and it has never been something I have contemplated.

Am I making any reasoning errors?

I am mindreading, jumping to negative conclusions and predicting catastrophe.

How else can I perceive this situation?

I am feeling very anxious at the moment, so I am overreacting to everything, including things that the psychologist has said. Asking about suicidal thoughts is probably a standard question. It does not predict my future behaviour.

WORST, BEST, MOST LIKELY

During times of anxiety, it can also be helpful to focus on the likelihood of an event, by asking ourselves what the worst, best and most likely outcomes are. Below are some examples of questions we could ask:

What’s the worst thing that could happen?

If that happened, could I live through it?

How likely is it?

What’s the best thing that could happen?

What is most likely to happen?

What would I tell a friend who is in this situation?

Think of someone I consider to be a sensible, positive person. How would this person respond if they were in my situation?

Will this matter in five years time?

What have I learned from this situation?

At the start of this chapter we saw Ursula, who became anxious when her four-year-old told the GP that they had eaten party pies for dinner. Ursula automatically assumed that her GP must think that she is a bad mother. Ursula could challenge her thoughts using some of the above questions.

WORST, BEST, MOST LIKELY

What’s the worst thing that could happen?

My GP will think I am a bad mother.

If that happened, could I live through it?

I could live through it, but the thought makes me very uncomfortable. I really like my GP and I want her to like me.

How likely is it?

Maybe 50 per cent? She does know that I am a caring mother.

What’s the best thing that could happen?

She gives this comment no thought at all, and doesn’t judge me.

What is most likely to happen?

Rationally, I know that she probably won’t think too much about it.

What would I tell a friend who is in this situation?

‘Your GP knows that you are a caring and concerned mum. Everyone feeds their families convenience foods at times, and no one thinks anything of it.’

Think of someone I consider to be a sensible, positive person. How would this person respond if they were in my situation?

Ted (my partner) would say, ‘The things you worry about! No one thinks or cares about minor comments like this. She knows you are a good mum.’

Will this matter in five years time?

It will be totally gone and forgotten, probably in the next week or two. No long-term consequences.

What have I learned from this situation?

Children talk. If I am going to feel ashamed, then don’t do it. If I know it is not a risk to my children, I don’t need to feel ashamed.

USING A THOUGHT-MONITORING FORM

We can also challenge our thinking using a thought-monitoring form. This involves recording the situation or trigger that gives rise to our anxiety (or other unwanted emotions), identifying the thoughts and beliefs that underpin our emotional response, and determining a more reasonable perspective.

At the start of this chapter we saw Scott, who became very anxious after his team leader, Gail, noticed that he was making personal phone calls at work. Below is a thought-monitoring form that Scott completed in relation to this issue.

Activating Event

Gail noticed that I was making personal phone calls at my desk.

Beliefs (cognitions) Thoughts

Gail must think I’m lazy and have a poor work ethic. Word might get out. It could affect the way I am regarded here.

Beliefs (Any ‘shoulds’?)

When I am at work I should always be 100 per cent focused on the job, and never deal with private matters.

If someone at work sees me dealing with a private matter, they will judge me harshly.

Even a minor lapse is likely to have permanent negative consequences.

Consequences

Feelings: anxiety, shame.

Behaviours: fretting, ruminating, poor attendance to work tasks.

Dispute

Reasoning errors:

Black-and-white thinking

Personalising

Predicting catastrophe

Filtering

Labelling

Shoulds

Jumping to negative conclusions

Mind-reading

Magnifying (‘awfulising’)

Comparing

Alternative, more balanced view?

Gail and I have a good relationship, and it is unlikely that her opinion of me has changed significantly over this.

What would I tell a friend who was in this situation?

People judge others by their habitual behaviours. Making occasional personal calls is unlikely to be considered a major misdemeanour. I don’t do it often.

Problem-solve

What’s the best action I can take?

I could briefly explain to Gail why I needed to make those calls (or perhaps I don’t need to do anything at this stage?).

We have explored a number of strategies that can be used to challenge biased or unreasonable thinking. While these techniques are not always appropriate for the overthinking that accompanies GAD, they are likely to be helpful for managing anxiety and other upsetting emotions, including anger, sadness, shame, guilt and frustration. Getting in the habit of challenging unreasonable or biased thinking enables us to develop cognitive flexibility, a great psychological advantage in daily life.

IN SUMMARY

Thoughts create feelings, and upsetting emotions, such as anxiety, guilt, sadness, anger and frustration, derive predominantly from the way we think.

People who are prone to anxiety have a cognitive bias towards threat. This means they overestimate the likelihood that bad things will happen.

Most people engage in reasoning errors (unrealistic and unhelpful thought habits) at times. Common reasoning errors associated with anxiety include: predicting catastrophe, magnifying, black-and-white thinking, mind-reading, labelling, personalising, comparing, filtering and jumping to negative conclusions.

Acknowledging reasoning errors reminds us that our thoughts are not reality and improves our ability to see alternative perspectives.

There are various ways in which negative or unreasonable thoughts can be challenged. These include evaluating the evidence for and against our thinking, reflecting on the worst, best and most likely outcomes of the situations we are worried about and using thought-monitoring forms to recognise our triggers, thoughts and responses, in order to identify a more reasonable, balanced perspective.

CHAPTER 4

Safety Behaviours

‘Our anxiety does not come from thinking about the future, but from wanting to control it.’

KAHLIL GIBRAN

Rosa is extremely protective of her children and frequently reminds them to ‘be careful’. She is very involved in every aspect of their lives, and is reluctant to let them make decisions for themselves. Rosa does not allow her children to have sleepovers or go on school camps because she can’t be sure of adequate supervision, and she often texts them during the day to check that they are OK.

Tony has had dizziness on and off for the last few years. His doctor has told him that it is a common symptom of anxiety, but Tony is not convinced. He goes online looking for other possible explanations, and often feels alarmed by what he finds. He consults his GP on a regular basis, and sees a naturopath frequently for ‘backup protection’.

Alessa complains that she is always chasing her tail. She schedules too many events in her diary, and then rushes from one appointment to another. She is also frequently checking her Facebook account, texting friends, meeting people for coffee and making social arrangements. While Alessa grumbles about never having enough time, the truth is that most of her commitments are her own choice. Making herself overbusy is Alessa’s way of avoiding the anxiety that comes with being alone with her thoughts. As long as she is busy, she does not have the space to notice her anxiety or to think about issues that distress her.

If you perceive the world to be full of danger, it is normal to do things you believe will keep you safe. That is part of our survival instinct. Individuals high on trait anxiety frequently try to minimise danger by engaging in safety behaviours. These attempts to protect ourselves from possible threats can become so habitual and automatic that we often don’t even realise we are doing them.

The types of safety behaviours that people use are many and varied. They include avoiding events and situations that we perceive as threats (see pages 41, 70), as well as things we specifically do to try to protect ourselves. These things include:

overplanning a holiday,

overworking simple tasks,

frequent phone check-ins with family members,

sitting next to the exit to allow for a quick escape,

taking vitamin pills and unproven therapies,

carrying water wherever you go,

taking a friend with you for reassurance,

going to the loo at every opportunity (just in case!),

repeatedly telling loved ones to ‘be careful’,

carrying everything but the kitchen sink in your handbag or suitcase,

checking text messages more frequently than you need to,

rereading and editing emails before you send them,

overusing hand sanitisers,

staying in touch with ‘friends’ you don’t like,

being overly intrusive in your children’s lives,

having an excessively restrictive diet and

trying too hard to be in control over every area of your life.

Safety behaviours also include reassurance-seeking behaviours like:

re-asking questions that have already been answered,

seeking further medical opinions for a condition that has been exhaustively assessed,

repeatedly checking your appearance in the mirror,

calling friends for reassurance that they are still onside,

questioning a partner to make sure they still love you and

frequently asking a therapist if you are going to get better.

Safety behaviours aim to reduce threat and decrease uncertainty, but, paradoxically, they make the world feel more uncertain. Developing a more psychologically healthy outlook will include recognising and releasing many of the unnecessary safety behaviours that we have acquired.

With anxiety and its disorders,
the things we do to make ourselves safe
become a key part of the problem.

REFLECT

Can you think of any safety behaviours that you use on a regular basis?

PERFECTIONISM

While aiming for excellence when doing important tasks is appropriate and sensible, applying consistently rigid, perfectionistic standards in specific areas of your life is usually unhelpful. Common areas for perfectionism include work and study tasks, weight management, dress and grooming, orderliness, parenting, sporting achievements, house maintenance and hygiene. Typically, perfectionism has many negative consequences, including anxiety, poor use of time, lack of work–life balance and limited personal satisfaction.

The causes of perfectionism vary, and in some cases it is a personality trait observable very early in life. Among anxious individuals, perfectionism is often a safety behaviour – an attempt to create order and control in what may feel like an unsafe, shambolic world. Striving to excel can also be our way of trying to earn acceptance, respect and admiration from others. We assume that being exceptional in some way will make people respect us. If we are liked, admired and valued by others, then our world may feel safer. Most people with perfectionist traits don’t realise the underlying drives that fuel their behaviour, and rarely reflect on the personal costs.

REFLECT

Can you think of any areas in your life where you maintain unnecessarily perfectionist standards?

COGNITIVE SAFETY BEHAVIOURS

While many safety behaviours involve actions, others are cognitive in nature – things we do within our minds to try to make ourselves feel safe. Typically, they involve things like overthinking, overanalysing, overplanning, mental reviewing, worrying or trying to block negative or unpleasant thoughts by staying busy or focusing on other things. While many people can recognise safety-behaviour actions (such as telling loved ones to ‘be careful’, overpreparing and taking vitamin pills), they are less likely to notice the cognitive safety behaviours that they frequently use.

Perhaps you find yourself analysing a recent conversation (‘What exactly did she mean by that comment? Was she being critical?’) or mentally monitoring your body for signs of illness. You may be thinking about possible future negative scenarios and planning solutions to non-existent problems. You might spend too much time trying to make a decision, and then worry that you have made the wrong one. Perhaps you assume that if you look at the situation from every angle, you will be able to see the whole picture, and therefore know where you stand or be in a position to make better future decisions.

Of course, not all safety behaviours are inappropriate. It is sensible to take steps to minimise common risks, and most people do this without much thought. It is wise to do regular exercise, back up your computer files, wear sunblock, take out car insurance, check the smoke alarm periodically, wear seat belts, tell your kids to call you if they are stuck and need a lift home, and see your doctor if you find a suspicious lump.

However, there is a substantial difference between reasonable safety behaviours and those that are predominantly driven by high anxiety. The latter can be identified by their frequency and excessiveness. Instead of taking reasonable precautions as appropriate to our situation, we habitually engage in trying to make ourselves safe, even when the risks are very low.

WHAT’S WRONG WITH SAFETY BEHAVIOURS?

As we have seen, avoidance and safety behaviours are an attempt to protect ourselves in what we believe to be an unsafe world. But if the problem is our thinking style rather than a dangerous environment, are these behaviours appropriate or helpful?

The biggest drawback of safety behaviours is that they prevent us from learning that our assumptions about danger are incorrect. They reinforce the perception that we are at risk, because we don’t get the chance to discover that our fears are unfounded. When nothing bad happens, we unconsciously attribute this to the precautions we have taken, rather than the fact that negative events were highly unlikely in the first place. And when bad things do occasionally happen, we often admonish ourselves for not being more careful.

We cannot learn that our world is safe
while we keep doing things to try to make our world safe.

Although safety behaviours are intended to reduce the risk of harm, they rarely provide the reassurance we are seeking. The more we use them, the less safe we feel.

Safety behaviours also take up time. Repeatedly checking text messages and social media, surfing the net for physical symptoms, reexamining our emails, changing three times to look our best, calling family members to make sure they are OK . . . all these things take time and energy. Overthinking also takes up mental space and distracts us from things we are doing in the present. Conversations with friends, meetings at work, a child’s birthday party or the simple enjoyment of a morning walk can be spoiled by all the stuff going on in our mind.

‘How many sunsets have I missed while staring right at them?’

Ruby Wax, Frazzled

Excessive safety behaviours can also give rise to a narrow, uninteresting existence. The desire to be safe makes us reluctant to take risks, look to broader horizons or extend ourselves in other ways. We miss out on the joy that comes with spontaneity and being open to experience.

AVOIDANCE

When we perceive something to be unsafe we naturally try to avoid it, so it is not surprising that avoidance is the most common safety behaviour. Anxious individuals frequently practise avoidance and escape. For instance, you might try to avoid crowds, unfamiliar social situations, watching the news or disturbing documentaries, trying new things or having those important, albeit potentially unpleasant, conversations with a friend, family member or colleague. When you need to do necessary but anxiety-provoking tasks, you procrastinate. If you find yourself in situations that make you apprehensive, you try to escape as quickly as possible. You may also find it difficult to make decisions because you never have complete certainty, and there is a chance that your decision may be the ‘wrong’ one.

Individuals have their own unique avoidance profile. Those who feel anxious in particular social situations are likely to avoid them, or to flee at the earliest opportunity. If you fear flying, you are likely to avoid taking flights. If you have health-related anxiety, you might put off having medical tests for fear that it could lead to the discovery of a health problem. If you have anxiety about the possibility of panic attacks, you might avoid places and situations from which escape might be difficult (such as shopping centres, buses, tunnels). If you are anxious about the way others perceive you, you might avoid expressing your honest opinion or communicating assertively. If you are excessively afraid of failure, you might avoid situations where failure is possible, such as job interviews, challenging work or higher education.

Avoidance enables us to dodge some of the discomfort that accompanies anxiety, and therefore makes us feel better in the short term. However, like other safety behaviours, it reinforces our fears because it maintains the belief that our world is unsafe. If we do not confront our fears, we never learn to overcome them.

REFLECT

Can you think of any situations or tasks that you frequently avoid?

When you find yourself in an anxiety-provoking situation, you might try to flee at the first opportunity. Heading off in the opposite direction when you see the managing director approaching, or escaping a crowded shopping centre or an awkward social situation, may reduce anxiety in the short term. Fleeing is a powerful psychological reinforcer because it provides immediate relief from anxiety. The problem is we are motivated to do it again the next time a similar anxiety-provoking situation arises. Short-term relief, at the cost of unresolved anxiety, may be a high price to pay.

REFLECT

Can you think of any situations that you have fled from in the past? Do you still flee from those situations now?

Another form of avoidance involves blocking or numbing the unpleasant physical sensations associated with anxiety through measures such as eating, drinking alcohol, gambling, smoking, taking benzodiazepines (tranquilisers) or using illicit drugs. Because these behaviours often do provide temporary relief, they are reinforcing in the short term, so we may feel drawn to use them repeatedly. Habitual use of these strategies creates unhealthy habits or addiction, which comes with its own set of problems. As we become increasingly dependent on these habits, we become more vulnerable and less in control over our lives. In addition, they teach us that we cannot tolerate anxiety, and prevent us from learning how to manage it in the longer term.

REFLECT

Can you think of any strategies that you use to block or numb the unpleasant physical sensations associated with anxiety?

COMMON SAFETY BEHAVIOURS

Behavioural:

Cognitive:

Avoidance

Excessive attempts to be in control – self or others

Overpreparing and overplanning

Reassurance-seeking behaviours

Excessive social-media check-ins

Perfectionism

Excessive information-seeking

Chronic busyness

Double-checking

Worrying

Checking or reviewing things in your mind

Self-monitoring

Overanalysing and overthinking

Planning solutions to possible future problems

Trying not to think about unpleasant topics

Hypervigilance (vigilant monitoring of perceived threat)

MONITORING OUR SAFETY BEHAVIOURS

Once we recognise the role that safety behaviours play in maintaining anxiety, our next step is to try to break the habit. In order to do that, we need to become aware of the safety behaviours we frequently use.

The following exercise involves monitoring your own behaviours, and logging those that are designed to keep you safe – try to catch yourself in the act! If you do this exercise diligently, you may be surprised how many safety behaviours you use in the course of an average week.

EXERCISE

Use your phone or a small pad (that you can carry with you wherever you go) to monitor your safety behaviours (including avoidance behaviours). Each time you notice an example of this behaviour, jot it down. Try to notice cognitive safety behaviours that you do within your mind, as well as the more obvious action behaviours. Read through the table titled ‘Common safety behaviours’ on page 72 to remind yourself of typical examples of the two types of safety behaviour. Keep logging examples for one or two weeks.

AVOIDANCE AND SAFETY-BEHAVIOUR LOG

Day

Safety behaviours

After you have completed this exercise, reflect on your findings:

REFLECT

Did you find that you engage in more avoidance and safety behaviours than you realised?

Did you become aware of cognitive safety behaviours that you frequently use?

Why do you think you use each of these behaviours?

What is the effect of these behaviours? Do they help you in any way?

On the next page is a section from Denise’s safety-behaviour log. Notice that some of her behaviours are actions, others are avoidance and still others are cognitive – things she does inside her mind (mainly worrying and overthinking) to try to minimise threat.

Day

Safety behaviours

Monday

Managed to get out of speaking to the team at work by getting Russell [work colleague] to do it.

Procrastinated on reading for new project. Daunting!

Avoided calling Matt [friend recently diagnosed with cancer]

Worried about the approaching restructure at work.

Had three glasses of wine when I got home from work.

Tuesday

Cleaned the front of the house when Sally said she was going to drop by after work.

Still procrastinating about calling Matt.

Worrying about coming meeting.

Wednesday

Asked Sam again whether he really didn’t mind coming over to fix my tap. Insisted that I pay him, even though he didn’t want any money. (Don’t want him to think I take him for granted).

Took ages to write those emails because wanted to get the wording just right.

Thursday

Tried to work out why Shirley [work colleague] didn’t stop to talk to me in the staffroom. Have I done something to upset her?

Friday

Called my daughter when she didn’t reply to my text, to check if she was OK.

Judith called [friend who talks a lot] and after 45 minutes I said I have to go. After I hung up, I started worrying about whether I might have offended her.

Saturday

Didn’t pick up the phone when it rang this evening because I didn’t have the energy to sound ‘perky’.

Still haven’t called Matt.

Had some drinks before going to Helen’s 40th – wanted to be relaxed when I got there.

Sunday

A colleague thanked my supervisor for helping out on a job that I also contributed to. Spent the morning trying to analyse why she didn’t also thank me.

Checked layout of seating on the plane, and decided not to book this time because I couldn’t get a seat next to the exit.

Although Denise recorded only a small fraction of the many safety behaviours that she engaged in that week, it was enough for her to recognise that safety behaviours are an automatic and frequent response in all sorts of situations. She also noticed that she tends to avoid situations that make her feel uncomfortable, and many of these are about dealing with people. Upon reflection, she acknowledged that most of the safety behaviours are not helpful, and often hold her back from achieving things that she wants.

Once you have identified the safety behaviours that you frequently engage in, the next step is to test what will happen when you stop using them. In the following chapter, we will look at how to use behavioural experiments to challenge, and ultimately release, some of these habits.

SAFETY BEHAVIOURS AND UNCERTAINTY

We saw in chapter 2 that excessive worry is frequently associated with intolerance of uncertainty. Safety behaviours are a means of trying to compensate for uncertainty by attempting to make our world safe and predictable.

In truth, we can never be sure that negative events will not occur when we relinquish safety behaviours. But we never have certainty anyway, even when we are preoccupied with trying to make ourselves safe 100 per cent of the time. We have no certainty about our friends, family, job, health, finances or physical safety. If you drive a car, drink alcohol, eat in restaurants, go for a swim, do regular walking or jogging, take medication, do home repairs, go on holidays, deal with sensitive people, belong to a club, go out in the sun, use stairs, go to work or play football, there are always risks. We accept uncertainty in many areas of our lives because we know that trying to protect ourselves from all danger would make it impossible to lead a normal, healthy life. Indeed, if we tried to eliminate uncertainty, our lives would be so limited, dull and constrained that we would lose all spontaneity and enjoyment. (Sadly, this actually happens to some people who are preoccupied with danger.)

Remember, too, that excessive safety behaviours are not harmless – they have a cost. They take up our time, use our energy, distract our attention and contribute to errors. They make us tired, complicate our lives and provide an unhelpful model for our children. They create stress within our relationships and problems in the workplace. In addition, safety behaviours reinforce our fears, and maintain a high-threat view of the world.

Releasing anxiety and worry involves accepting that we cannot control every aspect of our lives. We can learn to tolerate uncertainty, take risks and embrace challenges. We relinquish the perpetual search for safety, the scanning for threats, the overthinking and all the other safety behaviours that we have come to habitually use. Instead, we turn our attention to things that make our lives richer and more meaningful. That may include nurturing friendships, developing interests, stimulating our minds, doing things that build a sense of community, engaging in leisure activities and taking on new challenges.

You don’t always need a plan.

Sometimes you just need to breathe, trust, let go,
and see what happens.

Mandy Hale

In the next chapter we will look at ways in which we can start relinquishing some of our safety behaviours by doing behavioural experiments. Through dropping some of our safety behaviours we can discover that most of our feared situations don’t eventuate, and even when they occasionally do, we can cope with whatever comes our way.

IN SUMMARY

People who are prone to anxiety frequently use safety behaviours to try to protect themselves.

Safety behaviours include specific actions that we take, as well as avoidance behaviours. These include situational avoidance (not going to certain places or doing certain things), fleeing and numbing feelings of anxiety through substances that provide temporary relief.

Safety behaviours can also be cognitive – things we do within our own mind to make ourselves safe, such as worrying, overanalysing and overthinking.

Monitoring our safety behaviours can increase awareness of our own habits, and highlight behaviours that we can address.

Safety behaviours are a way of trying to eliminate uncertainty; however, we can never achieve this, and there are many associated costs in trying to do so.

CHAPTER 5

Facing our Fears

‘There is no living thing that is not afraid when it faces danger. The true courage is in facing danger when you are afraid’

L FRANK BAUM, THE WONDERFUL WIZARD OF OZ

As a teenager Colin was always shy and self-conscious. He used to struggle with making phone calls, going to parties or talking to people he didn’t know. Now those situations don’t bother him at all. Colin’s job in hospitality requires him to make frequent phone calls, attend social events and talk to people from various walks of life. By repeatedly facing the situations he once feared, Colin’s social anxiety resolved. He discovered that most of the time people are friendly or neutral towards him. Even on rare occasions where people were not pleasant, he realised that he was able to cope without feeling overwhelmed.

Lucia has feared injections for as long as she can remember, and has gone to great lengths to try to avoid them. She refused to have flu shots and vaccinations all of her life, and avoided the dentist for almost 20 years. Finally, in her 40s, Lucia’s worst fear was realised – she needed to have surgery. Lucia ended up having more than 20 injections over a period of three weeks. One positive consequence was that repeated exposure to injections enabled Lucia to overcome a fear that had plagued her since childhood. Through having to face her fear, Lucia discovered that injections are not as terrible as she had assumed, and that she was able to cope. She now says, ‘I used to have a fear of injections, but I overcame it.’

Rod developed a driving phobia following a serious car accident, and initially did not drive for many months. Eventually, Rod started driving short distances, mainly to local places. He gradually increased the distance travelled and ventured out into busier traffic. Over time, his anxiety subsided, and within a few months he returned to his previous level of confidence on the road.

We overcome our fears by confronting them directly. This sometimes happens because we are compelled to do so through life circumstances. Or we may recognise that our lives are seriously compromised through frequent avoidance – for instance, it may be preventing us from being able to work, drive, socialise, have surgery or go to the supermarket – and consciously decide to face our fears. But even moderate avoidance can have negative consequences, and it prevents us from overcoming our fears over time.

Repeatedly confronting anxiety-provoking situations provides the opportunity to discover that the negative consequences we had expected do not arise, or if there are some negative consequences, we can cope. While challenges like expressing an unpopular opinion, addressing an audience or trying online dating might trigger your amygdala ‘smoke alarm’ on the first few occasions, with repeated exposure, threat perceptions diminish and amygdala activation subsides.

You may have noticed how this happens naturally. Country people are less fearful of snakes than are city people; entomophobia (fear of crawly insects) is less common in hot climates, where people frequently encounter bugs; nurses are less disturbed at seeing dead bodies than are office workers; and people who have done lots of public speaking are less fearful talking to a group compared to those with no such experience.

Avoidance and other safety behaviours are typical responses to perceptions of danger, but if what we are experiencing is just the byproduct of an anxious mind, are the measures we use to make ourselves safe really helpful? Could they be preventing us from discovering what we need to know? By resorting to ‘protections’ we miss the opportunity to learn that we are already safe, and that those measures are unnecessary.

The best way to overcome our fears is to deliberately confront them. This involves relinquishing the strategies we habitually use to try to keep ourselves safe. Behavioural exercises are a more powerful way of reducing anxiety than logic alone because of experiential learning. We come to feel that the situation is not dangerous, beyond just knowing that to be the case.

‘It’s easier to act your way into a new way of thinking
than to think your way into a new way of acting.’

Jerry Sternin, The Power of Positive Deviance

EXERCISE

Make a list of all the safety behaviours (including avoidance) that you frequently use to keep yourself safe. Write down as many examples you can think of. You can include some of those you listed in your record of safety behaviours in the previous chapter.

My safety behaviours

Below is a sample of Carla’s (see page 38) list of safety behaviours:

My safety behaviours

Make excuses to avoid social functions where I may not feel comfortable.

Say ‘yes’ to requests for help from others, when I’d prefer to say ‘no’.

Make doctor’s appointment as soon as I get any unexplained symptoms.

Get my daughter to drive me to unfamiliar places, rather than driving myself.

Check my phone dozens of times a day, just in case something has happened.

Overprepare when having friends over for lunch or dinner.

Don’t speak up when I disagree with colleagues at staff meetings.

Screen calls in advance, and don’t answer unless I recognise the number.

Use stairs rather than lifts, because don’t want to get stuck in the lift.

Remind my children to drive carefully.

BEHAVIOURAL EXPERIMENTS

Now we’re ready to face some of our fears head on. Behavioural experiments involve relinquishing our safety behaviours, and observing whether the outcomes support our feared predictions.

Some compelling research in this area is that of Professor Michelle Craske and her colleagues at the University of California, Los Angeles. They found that people are more likely to overcome their fears when there is ‘expectancy violation’ – that is, when what they experienced was not what they had expected. By recording our expectations prior to the experiment, and subsequently recording what happened, we can clearly see any discrepancies between our expectations and outcomes. Writing down our observations and conclusions helps us to consolidate new learning. The form below (a slightly modified version of that developed by Craske and her colleagues) provides a useful guide for this process.

EXPERIMENT:

What are you most worried will happen?

What specific things would you expect to see if that is correct?

On a scale of 0–100, how likely does it seem? ____ per cent

AFTER COMPLETING THE EXPERIMENT:

Did what you most worried about actually occur? Yes or No

How do you know?

What did you learn?

So let’s take a look at each of the sections of the form:

EXPERIMENT

The experiment will involve relinquishing a safety behaviour that you normally use or confronting a situation that you normally avoid. This might be, for example, dropping admonitions for your children to be careful, expressing your honest opinion when others might disagree or making a potentially unpleasant phone call that you have been putting off.

WHAT SPECIFIC THINGS WOULD YOU EXPECT TO SEE IF THAT IS CORRECT?

Describe what you will be able to observe if your feared assumption is correct. Note that the outcomes need to be objective rather than presumed. In other words, what evidence would support this assumption? For instance, saying ‘People will think I’m strange’ is not appropriate here, because you don’t know what other people are thinking. A more well-defined prediction would be, for example, ‘People will laugh at me, roll their eyes, whisper to each other and look around at me . . .’.

Also, it is not sufficient to say ‘I will feel anxious’. Behavioural experiments are often anxiety-provoking, but they are a means of overcoming anxiety in the longer term. So if anxiety is the thing you fear most, you need to state why that would be a problem. What negative consequences could arise? For example, ‘I will be so anxious that I will become paralysed and unable to talk’ or ‘People will see my hands shaking and will laugh at me’ or ‘I will be so anxious I will try to jump out of the plane’.

After you have filled in these first four items, you are ready to conduct your experiment. After completing the experiment, record your findings in the next section.

DID WHAT YOU MOST WORRIED ABOUT ACTUALLY OCCUR?

State ‘Yes’ or ‘No’.

HOW DO YOU KNOW?

Write down the objective evidence that you observed. For example, ‘After expressing my honest opinion, two people agreed with me. No one laughed, rolled their eyes or criticised me.’

WHAT DID YOU LEARN?

Describe the conclusion that can be drawn from this experience. For example, ‘Expressing my honest opinion does not necessarily lead to criticism from others.’

CARLA’S BEHAVIOURAL EXPERIMENTS

After identifying many of her safety behaviours, Carla has conducted some behavioural experiments. These involved relinquishing some of her safety behaviours and observing the outcomes. Below are some of the forms that she completed.

EXPERIMENT:

Resist the urge to immediately make a doctor’s appointment to look at the red swelling under my eye. Wait one week.

What are you most worried will happen?

It will end up becoming a serious medical problem.

What specific things would you expect to see if that is correct?

The swelling will increase and become painful. It will not resolve.

On a scale of 0–100, how likely does it seem? 60 per cent.

AFTER COMPLETING THE EXPERIMENT

Did what you most worried about actually occur? No.

How do you know? The swelling remained for a few days, and then it disappeared.

What did you learn? Not acting immediately when I notice a new physical symptom does not necessarily result in a serious medical problem.

EXPERIMENT:

Drive to an appointment in an unfamiliar area, rather than getting someone drive me.

What are you most worried will happen?

I will get lost and miss the appointment.

What specific things would you expect to see if that is correct?

I will get to some area where I don’t know which way to go. I will drive around without knowing where I am, and will eventually arrive too late for my appointment.

On a scale of 0–100, how likely does it seem? 70 per cent.

AFTER COMPLETING THE EXPERIMENT

Did what you most worried about actually occur? No.

How do you know? I found it OK. It wasn’t difficult.

What did you learn? I can drive to some unfamiliar places by myself, without getting lost.

EXPERIMENT:

Decline my friend’s invitation to her son’s ‘destination wedding’ in Bali.

What are you most worried will happen?

She will be hurt and disappointed, and I will lose the friendship.

What specific things would you expect to see if that is correct?

She will be cold and reserved when I tell her. Conversation will be difficult. She will stop initiating contact with me, and will not return my calls. We will stop connecting socially.

On a scale of 0–100, how likely does it seem? 90 per cent.

AFTER COMPLETING THE EXPERIMENT

Did what you most worried about actually occur? No.

How do you know? She said, ‘That’s a shame’, but then we talked about other things. She has been texting and messaging me on Facebook as usual, and there is no observable change in her behaviour.

What did you learn? I can be honest/assertive to my friend without losing the friendship.

EXPERIMENT:

When having people for dinner, don’t prepare an elaborate meal and spend hours cleaning the house beforehand.

What are you most worried will happen?

The dinner will be a flop, and guests will not enjoy themselves.

What specific things would you expect to see if that is correct?

Guests will look disappointed. They will have little to say, pick at their food and perhaps joke about it. They will leave food on their plate.

On a scale of 0–100, how likely does it seem? 60 per cent.

AFTER COMPLETING THE EXPERIMENT

Did what you most worried about actually occur? No.

How do you know? The conversation was lively, there was lots of laughter and the guests had a good time. I got lots of positive feedback about the food and there was very little left on people’s plates.

What did you learn? I can have people for dinner without preparing an elaborate meal or spending hours cleaning the house beforehand, and people can still enjoy themselves.

EXPERIMENT:

Speak up at staff meetings.

What are you most worried will happen?

People will be irritated by my comments.

What specific things would you expect to see if that is correct? People will sigh, roll their eyes, laugh or criticise what I say.

On a scale of 0–100, how likely does it seem? 60 per cent.

AFTER COMPLETING THE EXPERIMENT

Did what you most worried about actually occur? No.

How do you know? People briefly talked about the issue I raised, and then the conversation moved to another topic. No one was scornful or critical.

What did you learn? I can speak up at staff meetings without being criticised.

EXERCISE: PRACTISE BEHAVIOURAL EXPERIMENTS

Now it’s your turn. Look back on your own list of safety behaviours, and select at least three times to target. Using the behavioural experiment form as your template (page 80), fill in the first four items on the form for each experiment.

Your next step is to confront those fears directly by doing the experiment and observing the outcomes. Log your findings on the form. Do as many behavioural experiments as you can – the more the better. (If the idea of facing some of your fears is too daunting, start with some of the easier tasks, and then move on to those that are more challenging.)

When conducting behavioural experiments, your goal is not necessarily to reduce anxiety during the experiment, even though this may sometimes happen. Rather, it is to identify any discrepancy between what you expected and what you observed. It is these ‘expectancy violations’ that are the most important elements for overcoming anxiety over time.

REFLECT

Once you have completed your behavioural experiments, think about the following questions:

Looking back at the various experiments that you conducted, what percentage of the time were the negative consequences that you predicted actually correct?

What have you learned so far through doing these exercises?

Is it possible that most of your threat assumptions are similarly exaggerated or incorrect?

BUT WHAT IF MY NEGATIVE PREDICTION IS TRUE?

‘Hold on!’ you may be thinking to yourself. ‘What if the thing I am most worried about does happen when I drop my safety behaviours? What if I go to a social function and, just as I predicted, no one talks to me? Or I drive to an unfamiliar location and I do get lost and miss the appointment? Or I speak up at a meeting and get criticised?’

It is true that negative events can and sometimes do happen when we conduct behavioural experiments. That is the nature of experiments – the results are never guaranteed. However, by repeatedly testing our expectations, we learn that most of the things we fear don’t happen, and even when they sometimes do, we are able to tolerate the consequences. Discovering that we can cope with disappointment is an important part of developing resilience. Instead of trying to avoid every negative contingency, we can discover that most of the time our feared outcomes don’t occur – but also that we can cope even if they occasionally do.

In situations where negative consequences do arise, it is often helpful to repeat the experiment several times. Doing so may yield different results, or at the very least provide evidence that we can cope with disappointing outcomes.

Norman found the courage to apply for a job promotion, but got nervous and tongue-tied during the interview. Although he was initially upset by his poor performance, Norman subsequently realised that it was a useful experience, and not the end of the world. This meant he was willing to try again when other opportunities arose.

Tracey had been dreading a particular party for weeks, and assumed that she would have a terrible time. Although her prediction was partly correct – she did not enjoy the evening – she discovered that it was not awful or disastrous. It was a boring night, but that’s all.

After much trepidation, Stan’s worst fears were confirmed when some of his colleagues made derogatory comments after he came out as gay. Nevertheless, the act freed him of anxiety and shame, and facilitated self-acceptance in the longer term.

Dylan decided to be less controlling of her teenage daughter, and then discovered that she had been smoking marijuana in her bedroom. While Dylan believed that the experiment was a disaster, he later saw it as a learning experience. The conversations that followed between himself and his daughter proved beneficial to their relationship, and with time he was willing to trust her again.

EXPERIENTIAL LEARNING

When reading this chapter, you might feel tempted to do just a couple of experiments and skip the rest, as, rationally, you already know that nothing bad is likely to happen.

Don’t.

There is a huge difference between logically ‘knowing’ that a situation is safe, and experiencing that to be the case. To change threat assumptions, we need repeated expectancy violations. Behavioural experiments are the key to modifying your view of the world as an unsafe place. Aim to do several experiments each week, and record your findings in a workbook. A dataset based on your own experiences will provide powerful evidence to challenge high-threat assumptions.

ONGOING EXPOSURE

Once we have experimented with dropping some of our safety behaviours and discovered that nothing terrible happens (or that we can cope regardless of what happens), our next step is to embrace exposure more consistently. In addition to planned experiments, look out for spontaneous opportunities to drop safety behaviours. Always reflect on what you have learned, even with unplanned experiments. You will know that you are making progress when previously feared events or situations no longer feel scary.

IN SUMMARY

Safety behaviours maintain anxiety because we do not get the chance to discover that our exaggerated threat perceptions are incorrect.

Behavioural experiments involve dropping our safety behaviours and observing whether our predicted negative outcomes arise.

The strongest learning occurs in response to ‘expectancy violations’, where the negative consequences we had expected do not eventuate. This produces experiential learning that our high-threat perceptions are incorrect.

Planning, monitoring and drawing conclusions in written format, using an exposure form, helps to consolidate learning from behavioural experiments.

Behavioural experiments also provide the opportunity to learn that we can tolerate negative events if they occasionally do occur.

CHAPTER 6

Building Worry Awareness

‘If you don’t pay appropriate attention to what has your attention, it will take more of your attention than it deserves.’

DAVID ALLEN, GETTING THINGS DONE

If you are prone to worry, negative thoughts and ‘what-ifs’ pop into your mind frequently, and much of the time you are not even aware that it’s happening. Your thinking style is ingrained, and your thoughts feel like ‘reality’. At times you might acknowledge that you worry too much, but when you are in the process of worrying, it feels like the most natural thing to do.

Perhaps you have occasionally wondered if there is an alternative – would it be possible to have a better life, without the persistent presence of negative thoughts that rob you of the ability to relax and enjoy the moment? If you have decided that this is a habit you would like to break, where do you start?

There are three key steps in the process of releasing the worry habit:

1.     Worry awareness: noticing the thoughts as they pop into your mind, and recognising that you are engaged in worry as it occurs.

2.     Understanding the way your mind works, including the beliefs that maintain the urge to worry. (More about this in chapters 6 and 7.)

3.     Experimenting with new ways of using your mind. Learning through experience that it is safe to release worry. (More about this in chapter 8.)

A key aspect of changing any habit is insight. This involves observing the habit as it manifests, and gaining some understanding of the process. In this chapter we will focus on building awareness of our worry thoughts as they arise. The technical name for noticing what is happening within our minds is ‘meta-awareness’. This includes awareness of our own thought processes as they operate within our mind. Meta-awareness is helpful, not just for releasing the urge to worry, but also for resolving many psychological problems. The exercises in this chapter and the next (chapter 7 on mindfulness) will help to build meta-awareness.

Let’s start with the ‘worries log’. This exercise will increase your awareness of the worry process. By noticing and categorising each worry thought as it arises, you will gain greater insight into what your mind is doing, and whether it has value.

EXERCISE: THE WORRIES LOG

Get yourself a little pad that you can take with you wherever you go, and keep it in your pocket or bag (or use the notepad in your mobile phone). Start to notice the worry thoughts that pop into your mind. (If you find this difficult, practising mindful attention to thoughts can help you to do this – see chapter 7.) Each time you notice a worry thought enter your mind, briefly jot down the subject – just a few words – so that you can keep a record of those thoughts.

Label each thought as either ‘CP’ (‘current problem’) or ‘WI’ (‘what-if’). CP thoughts relate to real problems that have arisen, that it might be useful to address. ‘WI’ worries are speculative – the problem has not occurred, but you are worrying that it might.

In addition, label each thought to indicate whether you were engaging in problem-solving – ‘PS’ – or just futile speculation – ‘FS’.

Be sure not to confuse worry with problem-solving. Sometimes we assume we are problem-solving because the issue we are focused on may be amenable to solutions. However, when we look closely at our specific thoughts, we may realise that we are just worrying after all. If you label something as ‘problem-solving’, it means that while you are thinking about it, you are seeking solutions.

In your own diary or workbook, set up a form similar to the one opposite:

Worries log

WORRY THOUGHT

CURRENT PROBLEM (CP) OR WHAT-IF (WI)

PROBLEM-SOLVING (PS) OR FUTILE SPECULATION (FS)

After recording worry thoughts for at least a week, reflect on the questions below.

REFLECT

1.      What did you notice about the frequency of your worry thoughts? Do they arise just occasionally, or are they a persistent presence in your mind?

2.      Looking back at the content of your worry thoughts, what proportion focus on real, existing problems, and what proportion are speculative what-ifs?

3.      When you find yourself worrying, what proportion of time are you engaged in practical problem-solving versus futile speculation?

4.      Looking back at all of your worry thoughts, how important do they seem now?

Below is an example page from Carla’s worries log.

WORRIES LOG

WORRY THOUGHT

CURRENT PROBLEM (CP) OR WHAT-IF (WI)

PROBLEM-SOLVING (PS) OR FUTILE SPECULATION (FS)

Is Steph going to be OK when the new baby arrives? Will she cope?

WI

FS

Maybe I shouldn’t have cancelled that doctor’s appointment? What if I really do have a tumour?

WI

FS

I wonder if Stella and Evelyn will talk about me when they see each other.

WI

FS

Will I get a parking spot?

WI

FS

Restructure at work – will it affect me? Will I be happy with the new system?

WI

FS

Did I make a fool of myself at that dinner? I wish I hadn’t talked so much.

WI

FS

Why am I still getting this nausea? Will it ever go away completely? Could it be something serious?

CP + WI

FS

Financially, things are looking pretty bad overseas. The stock market could crash, and our superannuation funds could become worthless.

WI

FS

We’ve paid for this holiday, but can we really afford it? Maybe we are living beyond our means?

WI

FS

CARLA’S REFLECTIONS

1.      What did you notice about the frequency of your worry thoughts? Do they arise just occasionally, or are they a persistent presence in your mind?

I seem to worry all the time – more often than I realised.

2.      Looking back at the content of your worry thoughts, what proportion focus on real, existing problems, and what proportion are speculative what-ifs?

The majority of my worries are what-ifs. Very few were concerns about existing problems.

3.      When you find yourself worrying, what proportion of time are you engaged in practical problem-solving versus futile speculation?

Very little is problem-solving. Most of my worrying is futile speculation.

4.      Looking back at all of your worry thoughts, how important do they seem now?

Looking back on the things I worried about this week, almost none are important now. They seemed important at the time, but not anymore.

Many people who complete this exercise are surprised to discover how frequently they engage in worrying. They also often learn, as Carla did, that much of their worries are speculative what-ifs – things that could happen – as opposed to problems that have arisen (or are clearly about to arise). Separating current problems from what-ifs can help us to distinguish issues that could possibly benefit from problem-solving, from those that are hypothetical.

Is it a good idea to spend your time searching for solutions to non-existent problems?

Although you may already know all of this in theory, doing this exercise provides experiential learning. This enables us to see things more clearly, and to understand on a deeper level that most of our worrying is futile.

When reviewing their worries log at the end of the day, many people find that their perception of the majority of their worries has changed as the anxiety that was connected to those thoughts subsided. While our worries seemed important at the time, many of those concerns may now seem trivial or implausible.

IS PROBLEM-SOLVING APPROPRIATE?

While most of the issues you identified as current problems may no longer seem important, there may be some that still matter. So at the end of the week when reviewing your worry items, if you recognise some that are still important, ask yourself, ‘Are there issues that are amenable to problem-solving, and if so, what should I do?’ It is possible that some of those problems can be resolved – either partially or completely – by taking appropriate action?

While exploring solutions may help to solve some problems, many problems are beyond your control. Worrying about these will not make any difference to their outcome. You might as well worry about the possibility of a comet hitting planet Earth, or tomorrow’s storm. Whether or not it happens, you can’t control it!

Below are examples of issues that Carla categorised as amenable to problem-solving, versus those that are not. (Note that some issues could fall under either heading, so it is best to categorise them in the way that feels most true for you.)

WORRIES: AMENABLE TO PROBLEM-SOLVING?

AMENABLE TO PROBLEM-SOLVING

NOT AMENABLE TO PROBLEM-SOLVING

Did I say the wrong thing to my friend? Perhaps I have offended her.

I have to give a presentation at work on Friday – will I do a good job?

I haven’t been to the gym in weeks. Will I be able to regain my fitness?

I have so many things to get through today – where do I start?

Terrorist attacks – what if it happened here?

Will my daughter be safe while she is travelling overseas?

Will I like the culture at my new workplace?

If my husband dies before me, I will have to cope without him. How will I ever manage?

When dealing with life’s challenges, distinguish between things that you can control and those you can’t. Make it your life philosophy to not waste your time worrying about things that are beyond your control.

REFLECT

Do you sometimes worry about things that are beyond your control? Which ones? Is there any benefit?

EXPLORING SOLUTIONS

When we are faced with problems that are within our control, it may be appropriate to explore solutions. This might involve brainstorming ideas and implementing those we believe are most likely to be effective. Sometimes the solutions are obvious, and we just need to get on with it and do what needs to be done (e.g. a spat with a family member, increased blood pressure, an important approaching exam). At other times talking to people, doing some research or even seeking professional help may enable us to work out the best course of action.

While problem-solving can be helpful at times, be sure that the things you turn your attention to really matter and warrant the time, effort and energy that you put into them. Remember, too, that many problems resolve themselves over time, and some are really not that important in the first place. Sometimes our best strategy is to allow time to pass, and revisit the issue a few weeks later. If it still matters, do something about it then.

If you were to recall all the times you have worried in the past, chances are, the vast majority of those issues did not come to anything, or they resolved themselves. Many things don’t require intervention. Just give them time.

REFLECT

Can you think of any issues that you worried about in the past, which became unimportant over time?

OUTCOME OF FEARED EVENTS

While most habitual worriers acknowledge that the things they worry about rarely come to pass, this awareness is theoretical in nature. At a deeper level, the threat feels real, and negative outcomes feel plausible. For this reason, keeping a record of the things you worry about as they arise, and then recording how they are resolved over time, can provide useful insights.

EXERCISE

Create an ‘Outcome of feared events’ form (similar to the one below) on paper, in your diary or in your phone. Over the next two weeks, record worry thoughts that pop into your mind in the left-hand column. Be sure to only record worries for which an outcome will be known within two weeks – otherwise you will have no way of knowing whether or not your worries were realised. Once you know the outcome, record it in the right-hand column.

Outcome of feared events

BEFORE THE EVENT:

Describe what you worry might happen

AFTER THE EVENT:

Describe what actually happened

After completing this exercise, reflect on the questions below:

REFLECT

1.      What proportion of the things you worried about actually happened?

2.      What proportion of the things you worried about didn’t happen?

3.      Of the things you worried about that did occur, how many had significant negative consequences?

4.      What did you learn from doing this exercise?

Below is the form that Carla completed for this exercise.

OUTCOME OF MY FEARED EVENTS

BEFORE THE EVENT:

Describe what you worry might happen

AFTER THE EVENT:

Describe what actually happened

Will Steph be able to find the surgery? [not in an area she usually travels to]

She found it no problem.

Will the traffic will be heavy? [driving on a Friday night]

It was heavy – but we coped.

Will Phillip be annoyed when I tell him I cancelled the appointment?

He was annoyed, but not for long.

Will the plane crash on the way to Noosa?

It didn’t crash.

Will the kids get on in the holiday house?

They got on fine.

Sarah will be angry with me because I didn’t do all my homework.

She wasn’t angry.

(I still have to do the homework.)

Will I get all of my work done before the deadline?

I got it done on time.

It wasn’t perfect but it was OK.

What if I can’t sleep tonight?

I need to be alert for tomorrow’s meeting.

Took me half an hour to fall asleep.

The meeting was fine.

Will my neighbour abuse me when I talk to him about where he parks his car?

I talked to him about it, and he was totally reasonable – not rude or abusive.

CARLA’S REFLECTIONS

1.      What proportion of the things you worried about actually happened?

Only two things happened (Phillip was annoyed; traffic was heavy).

2.      What proportion of the things you worried about never occurred?

The vast majority of the things I worried about did not happen.

3.      Of the things you worried about that did occur, how many had serious negative consequences?

The two things I worried about that did happen were not important. They did not have serious consequences.

4.      What did you learn from doing this exercise?

Most of the things I worry about don’t happen. Even on occasions when they do, they don‘t have major consequences.

If you are a habitual worrier, you are likely to discover that the vast majority of things you worry about never come to pass. And even on those occasions when they do, they are rarely as bad as you anticipated. In the end, you will cope with them if and when you need to.

While our feared events occur infrequently and are rarely significant, the worrying process itself extracts a significant toll. It generates physical tension and nervous energy, disturbs our sleep, impairs our concentration, perpetuates emotional distress, disconnects us from present-moment experience and prevents us from living normal, healthy lives.

Ironically, worry creates much more suffering
than the things we worry about.

Note to those who prefer to use an app: the feared events exercise can also be undertaken using the Worry Watch app, which can be purchased online.

FROM CONTENT TO PROCESS

Habitual worriers get caught up in the content of their thoughts – we think that what we are thinking about is the most important thing:

‘I said the wrong thing – they might disapprove.’

‘That class size is too large – will my child will be disadvantaged?’

‘I made a mistake – what if I lose my job?’

‘Why am I feeling this tingling?’

The thoughts create distress, so we assume we need to keep thinking about the issue. Thus we analyse, prepare for negative contingencies, imagine the worst, perform retrospective analysis of things that were said and done, and consider all possibilities. The more we think, the more uncertainty we create (the possibilities are endless) and the more uneasy we feel.

Trying to respond to and resolve each worry as it arises is not the answer. Even if we were able to resolve every issue, others would soon take their place. There is a bottomless pit where those worries came from!

If the problem is overthinking
getting more absorbed in the content of our thoughts
is not the solution.

A more helpful approach is to step back and observe the thought process we are engaged in. Observe worry and overthinking as it occurs – build meta-awareness. Watching thoughts like an observer of our own mind, rather than getting caught up in the content of each thought, enables us to recognise repetitive, unhelpful patterns. Once we notice the presence of worry thoughts, we can start to experiment with other ways of responding to them.

METAPHORS FOR DETACHING FROM WORRY THOUGHTS

Metaphors have long been used for enriching our understanding of theoretical concepts. By creating associations with images, metaphors engage parts of our emotional brain and create stronger connections with the ideas we wish to describe. Below are some metaphors that can be used in relation to worry thoughts that pop into our mind.

THE HOOK

British psychologist Dr Adrian Wells has referred to the process of engaging with a new worry like ‘swallowing a hook’. Imagine a hook, floating in the water where you swim. If you ‘swallow the hook’, you become caught up in the content of the worry (analysing, thinking, preparing). By recognising that the initial thought is just another ‘hook’, you can choose to not to ‘swallow’ it, or to ‘release the hook’ if you are already engaged with worry.

Note that you are not fighting against the thought or trying to dispute its validity. You are simply noting the presence of another worry thought, and acknowledging that it has no importance and requires no further attention. You can choose to ‘swim’ right past it.

THE WORRY TRAIN

Your mind is a very busy place – like a city-centre train station. Worry trains appear on a regular basis, but is it a good idea to ‘climb aboard’ every train that comes by? You may end up going to places you don’t want to go. Instead of climbing aboard every train (that is, engaging with every worry thought that enters our mind), you can choose to ‘watch the trains go by’ (that is, notice a worry enter your mind but choose not to engage with it). And even if you do inadvertently ‘board this train’, you can make a decision to get off. (‘I’m engaged in another worry thought – I can let it go now.’)

SIRENS ON THE ROCKS

In Greek mythology, the Sirens on an island would lure passing sailors with their enchanting singing. Unable to resist, the sailors would navigate towards them and meet their fate on the rocks of the island’s coast. Worry thoughts are like the Sirens, trying to entice you towards them. Their song feels compelling, and you may be tempted to sail towards it, but you know that doing so does not end well. Instead, you can recognise the song (‘Ah, that’s another worry thought’), understand where it’s coming from (‘That’s just my anxious mind’) and choose not engage with it further.

As we develop greater awareness of our worry thoughts, we can begin to change the way we respond to them. In the next few chapters we will look at other ways in which we can break the habit of engaging with worry thoughts. This will include mindfully switching our attention back to objects in the present moment, experimenting with worry delay and challenging some of the underlying beliefs that maintain the urge to worry.

IN SUMMARY

Building meta-awareness – awareness of our own thought processes – provides insight and helps us to change unhelpful habits of thinking.

Keeping a worries log enables us to learn experientially that much of our worrying is speculative and futile. It helps us to recognise the difference between worrying and problem-solving.

By monitoring the outcomes of our fears, we can learn experientially that the vast majority of things we worry about never happen, and, even if they do, the consequences are rarely catastrophic.

While we assume that our problem is all the things we worry about, the real problem is processes within our minds that maintain the urge to worry. These will be explored in chapters 8 and 9.

Metaphors such as ‘swallowing the hook’, ‘Sirens on the rocks’ or ‘the worry train’ can reinforce useful ways of responding to worry thoughts that enter our mind.

CHAPTER 7

Mindfulness

‘Many people live habitually as if the present moment were an obstacle that they need to overcome in order to get to the next moment. Imagine living your whole life like that. Always, this moment is not quite good enough because you need to get to the next one.’

ECKHART TOLLE (SUNDAY PROFILE, ABC)

Mindfulness practice has been part of the Buddhist tradition for thousands of years, but it is only in the last two decades that it has been embraced by Western mental-health practitioners. As scientific studies around the world began to identify benefits, psychological therapies utilising components of the practice emerged. Mindfulness is a key feature of several psychological therapies, including acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT) and mindfulness-based cognitive therapy (MBCT), and it is frequently included in treatments for various conditions, including anxiety disorders.

The term ‘being mindful’ has become part of the common vernacular, meaning to be conscious of what is happening in this moment. During mindfulness practice we notice whatever is present in our current experience, be it thoughts, emotions, physical sensations, sounds or mood. We observe without judging, with an open and accepting mind.

Mindfulness can be practised as a formal meditation or as a state of awareness in daily-life situations. Both involve paying attention to current experience.

Mindfulness meditation is usually practised in a seated position, with eyes closed (or, if preferred, open with a diffuse or soft gaze). Typically, we direct our attention to a single object within our current sensory experience, such as our breath, body sensations or sounds, repeatedly returning our focus to that object when we notice the mind has wandered. While it shares many features with other types of meditation (e.g. Qi Gong, Transcendental Meditation and zazen), mindfulness meditation encompasses focused attention on any component of consciousness, including thoughts, emotions and body sensations. The increased insight that comes from these observations makes mindfulness a particularly suitable adjunct to psychological therapy.

In addition to enhanced self-awareness, a growing body of evidence suggests that regular meditation helps to modulate upsetting emotions, decrease the likelihood of relapse into depression, improve concentration, assist in the management of pain and achieve better sleep.

Mindfulness in daily life involves focusing attention on objects in our current experience as we go about our daily lives. Because we can apply mindful attention to any object or situation, this format provides lots of opportunities for practice.

Two key principles are associated with the practice of mindfulness: paying attention to aspects of our present experience and not judging any part of the experience. Let’s take a closer look at these.

PAYING ATTENTION TO PRESENT-MOMENT EXPERIENCE

‘Being in the present moment’ is perhaps the most widely cited definition of mindfulness. During mindfulness meditation we choose to pay attention to a single object or stimulus. It may be physical sensations, such as the movement of our lungs, or the sensations of air moving through our nose or down the back of our throat as we breathe, or the sensations within our bodies as we sit or walk. We might focus on body sensations sequentially, as in a ‘body scan’; observe specific parts of the body; or observe the body as a whole, noting any salient sensations. Or we may focus on auditory stimuli – the sounds coming from within the room or outside the room, or even from within our own bodies. We can also focus on other aspects of sensory experience, such as tastes, smells and things within our visual field.

The object of our focus becomes our ‘anchor’, to which we repeatedly return when the mind has wandered. With regular practice, intrusive, scattered or racing thoughts diminish, and our capacity to pay attention strengthens. Although our minds will always wander, most people discover that the process becomes easier over time.

We also use focused attention when paying mindful attention to objects encountered in daily-life situations. Because we are not limited to being still or closing our eyes, this type of meditation can be practised anywhere. Any aspect of our sensory experience can be an object of focus, including:

Body sensations experienced while exercising, showering, walking or drinking a cup of tea.

Sounds that we can hear while washing dishes, travelling on a bus, watering the garden or sitting at our desks.

Objects in our visual field: we could focus on things like the equipment we are using as we work out in the gym, a point on the horizon during our daily walk, our hands over a keyboard as we type or a sign on the train.

Smells: You can notice the smells in the room you are in or when you are at a cafe, in your car or sitting in the garden. Take note of smells that are pleasant and unpleasant, familiar and foreign. You may even notice how particular smells evoke certain emotions.

Tastes: Mindful attention to the process of eating or drinking is a particularly fascinating experience. While you discover tastes, textures, smells and other pleasurable sensations that you had never noticed before, you also have a very salient anchor to focus your attention.

COMMENCING MINDFULNESS MEDITATION PRACTICE

Focusing attention on the breath, sounds or body sensations helps to train the mind to be present, and is a foundational skill of all meditation practice. If you find this challenging, you are not alone! It is easy to describe, but for most, not easy to do. Beginners are recommended to start practising for short periods, and gradually increase the time spent. (For more information on establishing a daily practice, Tara Brach’s book How to Meditate can be downloaded from her website.)

Below are instructions for a simple two-minute meditation. Before commencing, set a timer. Remind yourself that this is your own special time, and giving two minutes to this practice will not detract from other things you plan to do today. Indeed, by building attentional skills through regular practice, you will be able to use time more effectively.

TWO-MINUTE MEDITATION

Sit upright in a chair, close your eyes and focus your attention on your breath. Feel your breath through the sensations in your body – feel your lungs expand and contract, or the air going through your nose or passing the back of your throat. Try to stay focused on the physical sensations of your breath. Make your breath your ‘anchor’, to which your attention repeatedly returns when you notice that your mind has wandered.

Whenever you discover the presence of a thought, briefly acknowledge the thought, noting its content, and then bring your attention back to your breath. Repeat this with any thoughts that enter your mind.

At the end of two minutes, open your eyes, and reflect on what you noticed.

This exercise involves practising focused attention, and also helps to build meta-awareness. By noticing thoughts that pop into our mind, we become aware of thoughts as entities or objects that enter our minds, seemingly at their own volition. We learn that they are not reality. With practice we may notice anxious thoughts, planning or ‘to-do’ thoughts, recurrent thoughts, racing or scattered thoughts, both during meditation and in our daily life.

We will notice some thoughts moments after they enter our mind, and others only after long periods of thinking. We may also notice that when we feel emotionally charged (e.g. anxious, angry or frustrated) our thoughts are more intrusive and ‘racy’, while when we are calm, it is easier to focus our mind.

As you continue to practise meditation, try to extend the period of your practice. Be sure to set a timer before you start so that you can free yourself from keeping an eye on the time or wondering how long to continue. For beginners, guided meditations are often very helpful. (Recommended guided meditations are listed in the appendix.) Enrolling in a course can also facilitate learning and regular practice.

THE ‘MONKEY MIND’

Traditional Buddhist texts have likened our minds to that of a monkey, jumping from branch to branch, chattering, screeching and moving about endlessly. Most people who have tried meditation can relate to the idea of the ‘monkey mind’ that refuses to be still. The uninvited thoughts are a frequent source of frustration, and a reason why some people abandon the practice.

It is important to recognise that intrusive thoughts are a normal part of meditation. While their prevalence diminishes with practice, they invariably return, even for meditators with many years of experience. In mindfulness practice we aim not to judge their presence, but to acknowledge the thought and return attention to our anchor. Thoughts are not the problem, but an attitude of judgement and frustration in response to them can be, and may derail the practice. (More on releasing judgement later.)

German philosopher and researcher in the fields of neurobiology and consciousness Professor Thomas Metzinger has written about spontaneous, unrelated thoughts that pop into our minds every day. According to Metzinger, our minds wander several hundred times a day, and for up to 50 per cent of our waking lives. We become particularly aware of thoughts during meditation, because we are trying to focus our mind, but they are also constantly intruding as we go about our daily lives.

Metzinger likens the thoughts that arise during meditation to a line of children with outstretched arms, each calling out, ‘Think me! Think me!’ Instead of engaging with each child when they call out to us, he suggests we ‘give them a hug’ and release them. That is, acknowledge the thought, and then return our attention to our anchor.

METAPHORS FOR RELEASING THOUGHTS

In the previous chapter we saw how metaphors can be powerful tools for conceptualising ideas, because they combine image with theoretical concepts. The idea of our thoughts being like children clamouring for attention is a good example of a metaphor on how we can respond to intrusive thoughts. Other examples include seeing our thoughts as clouds drifting across the sky (the landscape of our mind) or leaves floating along a stream. We may initially get caught up in their content because they feel significant, but once we recognise the presence of a thought, we elicit the image of just one more cloud drifting across the sky, or just another leaf floating along a stream. The thought has no special significance, so we let it ‘float away’ and return our attention to our anchor. Or we may see the thought as just another bubble in a pond. Once you notice the thought, see the bubble float up to the surface of the pond and burst at the top.

‘TO-DO’ THOUGHTS

When we observe our intrusive thoughts, we may notice that many of them fall into the category of ‘to-dos’: appointments that need to be made, people who need to be contacted, meals that need to be prepared, jobs that need to be completed. These may sit in the back of our minds and enter consciousness at various times during the day. To-do thoughts are a common source of anxiety, particularly for those of us with a strong need for control (a common trait of anxious individuals). Unconsciously, we may assume that if we don’t keep bringing them to mind, we will lose control or forget to do them.

For some, to-do thoughts are pervasive throughout the day. Fuelled by the desire to maintain control and spend our time productively, they may become more frequent during meditation. Sitting passively observing our breath may feel like a waste of time, especially when we get caught up in thoughts. And there is so much to do!

‘Everything you’ve told yourself you ought to do,
your mind thinks you should do right now.’

David Allen, Getting Things Done

One way of managing to-do thoughts is to move them from the back of your mind to the front, by recording them in a diary, phone or ‘Things to do’ list that you keep in a prominent place. Keeping an up-to-date list and referring to it frequently makes it safe for your mind to let go of those thoughts for now. Knowing that they are recorded reassures us that they will not be forgotten.

RELEASING JUDGEMENT

A key tenet of mindfulness practice is to observe what is happening in the present moment without judgement. It is this aspect that makes the practice particularly powerful when we are faced with unwanted situations, emotional distress or physical pain. Not judging means acknowledging and not resisting unpleasant aspects of our current experience, including distressing emotions like anxiety, sadness, guilt, shame or loneliness; or body sensations like muscle tension, pain or other forms of physical discomfort. It includes not judging the unpleasant tension and arousal we may feel when we crave a substance or feel an urge to act. Whatever is there, we observe it with an open and accepting mind.

Buddhist philosophy describes an attitude of ‘equanimity’ – the quality of being poised, composed and accepting. Whatever we notice, be it physical pain or emotional distress, we witness the experience with curiosity. Instead of trying to escape those feelings, we allow ourselves to inhabit them more fully. We remain present and open to whatever we notice, and we do not strive to change it. We do not try to be relaxed or escape those feelings, although these things may sometimes happen when we release judgement. We simply surrender to whatever is present, releasing any resistance in our minds and in our bodies.

So why is this a good idea? Why shouldn’t we judge our experience? If something is unpleasant or bad, why shouldn’t we reject it, rail against it or at least try to block it?

The answer is that fighting something we cannot control only magnifies its presence and increases our suffering. Agreeing to ‘go with’ whatever is happening does not mean we like it, or that we should abandon future efforts to change our situation if problem-solving is feasible. However, it frees us from the unnecessary distress that comes with struggling against something that we cannot change right now.

‘When we resist change, it’s called suffering. But when we can completely let go and not struggle against it, when we can embrace the groundlessness of our situation and relax into its dynamic quality, that’s called enlightenment . . . Another word for that is freedom.’

Pema Chödrön, Living Beautifully with Uncertainty and Change

ACCEPTANCE

According to Buddhist teachings, we live our lives grasping for the pleasant and struggling against the unpleasant, and these are habits that underpin our suffering. This idea is explored by professor of clinical psychology Mark Williams and his colleagues in the book The Mindful Way through Depression. The authors assert that a major contributor to human suffering is the disparity between where we are and where we want to be. They refer to an unconscious ‘discrepancy monitor’ within our mind that is alert to the gap between how we feel and how we would like to feel. Our mind is constantly monitoring for and identifying discrepancies: ‘I am anxious, but I want to be calm’, ‘I am depressed, but I want to be happy’, ‘I am lonely, but I want to be connected’, ‘I am stuck, but I want to be free’. The greater the discrepancy, the greater our distress. In an attempt to escape our pain, we engage in rumination – repetitive thoughts about our perceived problems, and their possible causes and consequences. We ruminate about past and current events, and worry about the future. Analysing, analysing, thinking, thinking . . .

Sometimes anxiety itself becomes the object of our struggle. It feels unpleasant and we want to be free of it, so we become determined to eliminate it. The more we focus on it, the more anxious we become.

Whenever we judge and struggle against unpleasant emotions or experiences, we end up with two problems: the primary problem (which may be anxiety, shame, depression, physical pain, illness, etc.) and the secondary problem, which is the distressing emotions that arise from judging the primary experience. So we may have, for example, anxiety about our anxiety, shame and despair about our loneliness, depression about our depression, anguish about a personal failure or frustration at our insomnia. Suffering multiplies through the negative emotions that accompany judging the experience.

Buddhist philosophy teaches that pain is an unavoidable part of life, but suffering is not. Pain will be present at various times in our lives in the form of unpleasant emotions, urges and body sensations. Suffering comes from judging and resisting those experiences.

Being present and nonjudgemental of our current experiences and circumstances allows us to perceive them in a different way. When we stop ‘grasping for’ and ‘struggling against’, we close the gap between where we are and where we want to be. We are fully present and open to every aspect of our current experience, including our emotions and body sensations, so there is no struggle. We may feel anxiety, regret, sadness, anger, frustration, shame or despair, but we do not compound our suffering by fighting against those feelings or insisting that we must not feel this way. Paradoxically, through releasing resistance, we create the conditions under which suffering can diminish.

‘Accepting means you allow yourself to feel
whatever it is you are feeling at that moment . . .

You can’t argue with what is.

Well, you can, but if you do, you suffer.’

Eckhart Tolle, A New Earth

Some people balk at the idea of releasing judgement because they believe that doing so would mean that things will never change. We feel the urge to resist because unconsciously we assume that judgement will lead to a solution. But does it? Judging our situation or circumstances very often keeps us stuck in emotional turmoil, and reduces the likelihood of effective problem-solving. While the lost job, the health problem or the messed-up relationship may be realities we cannot undo, our internal railing against them perpetuates suffering.

Note that accepting our current experience does not mean we should abandon future efforts to change our circumstances if they are within our control. While we surrender to what is present right now, we can subsequently reflect on our situation and explore problem-solving, if it is feasible (see page 117). Doing so enables us to respond thoughtfully rather than impulsively, and therefore helps us to make wise decisions.

‘Acceptance does not mean that you have to like everything or that you have to take a passive attitude towards everything and abandon your principles and values. It does not mean that you are satisfied with things as they are, or that you are resigned to tolerating things as they ‘have to be’. It does not mean that you should stop trying to break free of your own self-destructive habits, or to give up on your desire to change and grow. . . . Acceptance simply means that you have come around to a willingness to see things as they are.’

Jon Kabat-Zinn, Full Catastrophe Living

REFLECT

Think of an unwanted situation in your life that is beyond your control. If you were able to fully accept the situation, what would be different? Is there any part of you that resists the idea of acceptance? Why?

MINDFULNESS FOR ANXIETY AND WORRY

Emerging evidence suggests that mindfulness practice can be helpful for managing anxiety and worry, however, the underlying processes are not clearly understood. Possible mechanisms include the direct calming effects of concentration meditation, increased meta-awareness that arises from observing one’s own mind and greater tolerance of anxiety and other unwanted sensations. Let’s take a closer look at each of these.

DIRECT CALMING EFFECTS

During meditation we observe what is present, without striving towards any particular outcome or state. Nevertheless, many people report that focusing on the breath (or some other anchor) has a direct calming effect.

One possible explanation is that focused attention on a single object disconnects us from the thoughts and/or cognitive processes that are driving anxiety, including ‘back-of-the-mind’ vigilance. When our attention detaches from perceptions of danger, our muscles relax and arousal diminishes. The state of relaxation feeds back to the brain via the vagus nerve, which tells our brain, ‘Muscles are relaxed, it is safe now!’ (More about the vagus nerve in chapter 10.) Perhaps for this reason, meditation is often associated with a drop in anxiety and arousal. Indeed, many people are motivated to practise largely because of this direct calming effect.

INCREASED META-AWARENESS

Most of us go through life caught up in dramas directed by our own minds, lost in our thoughts, without even realising we are thinking. We rarely stop to observe what is going on inside our minds. Without insight, we assume our thoughts are truth, reality for us.

Mindfulness practice builds meta-awareness – awareness of our own internal thought processes. We come to see that we are the perceiver of our thoughts, and that our thoughts are transitory occurrences that come and go. They are not us, and they are not reality. We start to notice worry thoughts as they arise, and see them as objects within our minds rather than self-evident truths.

Meta-awareness creates a space between our thoughts and our reactions to them. As we observe what the mind is doing, it becomes easier to not over-identify or automatically engage with the content of our thoughts. We start to recognise: ‘That’s another worry thought’, ‘My mind keeps searching for threat’, ‘Here I go again’. Observing worry in action helps us to see it as part of a familiar pattern.

‘Meditation creates greater mental clarity . . . It’s a place – a vantage point – from which we can witness our own thoughts and feelings as they arise. It takes us off the hair-trigger that compels us to react to things as soon as they happen.’

Mark Williams and Danny Penman, Mindfulness: Finding peace in a frantic world

Developing the ability to notice worry thoughts as they arise opens up options regarding how to respond. We may observe our urge to engage with the thought as part of our ongoing practice of safety behaviours. We may use a metaphor, like choosing ‘not to swallow this hook’ or ‘to disembark this worry train’ (see ‘Metaphors’, chapter 7). Or we may choose to ‘park the thought for now’ by logging it in the ReachOut WorryTime app or the phone’s note pad, to be returned to at the end of the day (more about this in chapter 9). The very awareness that we are engaged in another worry thought enables us to respond in a more considered, non-reflexive way.

GREATER TOLERANCE OF UNPLEASANT EMOTIONS

When we react with aversion to our inner experience, we magnify its impact. This applies to all unpleasant emotions, including anxiety. The more we resist, the more of a threat it becomes. Struggling against anxiety makes us vigilant to its presence. This keeps us aroused and anxious, paradoxically feeding the very feeling that we wish to be free of. Anxiety maintains itself via a self-perpetuating cycle.

Mindful acceptance of our current experience, including that which is unpleasant and unwelcome, builds tolerance of the experience. Sitting with, rather than reacting against, unwanted emotions helps us to understand their nature without becoming overwhelmed by them. Anxiety, anger, loneliness, despair – the feelings are unpleasant, but if we let go of judgement, and experience them with openness and acceptance, we provide the space for them to fade. We also come to recognise that anxiety, like other unwanted emotions, body sensations and life situations, is transient, and it, too, will pass.

BUILDING AWARENESS OF OUR INTERNAL STATE

When practising mindfulness, whether in meditation or in daily-life situations, we can explore our current experience by focusing on various aspects of our internal state. For instance:

Thoughts: Notice the transient nature of the thoughts that enter your mind, and their habitual patterns. You might label the thought, for instance, ‘worry thought’, ‘pleasant thought’, ‘to-do thought’, ‘recurrent thought’, ‘negative thought’, etc.

‘Back of the mind’: These are not thoughts, but issues or threats that reside in the ‘background’ of our mind. If we are perceiving some threat that is not immediate, it may not elicit conscious thought, but we may keep the issue ‘on hold’. This may include a mistake we have made, an approaching medical procedure, possible criticism by a colleague or things we need to do in limited time. We are not consciously thinking about it right now, but our amygdala tells us to remain ‘on alert’, so there is tension in our body, and it does not feel safe to relax.

Mood: Notice the general tenor of how you feel right now: elevated, low or neutral.

Emotions: Notice if you are experiencing any emotions right now (e.g. anxiety, anger, sadness, frustration, guilt) and the body sensations that connect with them.

Urges: Notice the physical and emotional discomfort that accompanies a strong desire to act. For instance, you may feel an urge to stop a meditation session and get on with other things, or it may be an urge to drink, eat, take drugs, make a phone call, leave, check social media or distract yourself from boredom.

Body sensations: Notice the physical sensations within your body (e.g. tension, jitteriness, heat, butterflies, arousal) and the thoughts and emotions that connect with them. For instance, ‘That knot in my stomach is anxiety, which is connected to my thought that I have done the wrong thing’, ‘That feeling of lethargy and the heaviness in my chest is connected to my sadness’ or ‘That feeling of arousal connects with my anger towards my colleague’. You may even start to notice the levels of energy in your body, and become aware of times when it is high versus other times when it is low.

While meditation develops our ability to be more present and focused in our daily lives, mindful attention to our thoughts, emotions, body sensations and urges makes us more attuned to our internal state. This enables us to respond to our current needs more appropriately.

RESPOND TO CURRENT NEEDS

Becoming more aware of the various components of our internal state gives us greater insight, and enables us to modify aspects of our experience. It also allows us to respond to our current needs in a more helpful way.

EXERCISE

Take a few minutes to sit with your eyes closed and connect with your current experience. Ask yourself, ‘What’s going on for me right now?’

Observe any issues or concerns that are in the back of your mind, as well as your mood (low, elevated or neutral), any emotions (e.g. anxiety, guilt, sadness, frustration, excitement), body sensations (e.g. tension, arousal, heaviness, fatigue, pain) and thoughts that are popping into your mind.

After completing this exercise, reflect on your observations, and consider whether there is any helpful action you can take in response to what you observed. For instance, would it be helpful to:

relax your body (e.g. do some progressive muscle relaxation or breathing exercises – see chapter 10),

spend some time focusing on your anchor (e.g. sounds or the breath) to slow those racing thoughts,

lie down and rest or

change your physical state by having a shower, doing an active house task or going for a walk?

Or perhaps you would benefit from addressing some unresolved issue or task that is keeping you anxious or vigilant?

Kate is feeling anxious and agitated, but she doesn’t know why. She takes a few minutes to sit quietly and observe what is going on for her right now. The first thing she notices is physical tension in her tummy and chest. She also notices some to-do thoughts that are in the back of her mind. Kate now sees that she is anxious because she has several jobs that need doing, but they are poorly defined. She has a general sense of ‘So much to do, but I’m not sure what, or where, to start’. Her mind is going from one task to another, trying to keep them all in play.

Kate acknowledges what she is experiencing right now, and gives it a label: ‘I am anxious over too many poorly defined to-dos’. After completing this practice, Kate writes a list of all the things that she plans to do today. She may not get them all done, but now that they are listed Kate feels organised, and her anxiety diminishes. By recognising the issues that underpin her anxiety, Kate can now address them directly.

PROBLEM-SOLVE IF APPROPRIATE

Allowing ourselves to mindfully observe our thoughts, emotions and body sensations without judging enables us to avoid escalating emotional distress and reacting impulsively to unwanted situations. Free from the distraction of disturbing emotions, we have the mental clarity to enable us to make considered decisions. If our situation is one that lends itself to problem-solving, and is unlikely to resolve without intervention, it may be helpful to think about solutions.

Problem-solving is very different to worrying, although we sometimes mistake the two (see chapter 4). The best way to ensure that we are focused on solutions is to define the problem in writing, and brainstorm possible solutions with pen and paper (or keyboard) in hand. (For complex problems, consider doing brainstorming in collaboration with another person.) The discipline of writing our ideas keeps us solution-focused, and keeps a check on our urge to switch to unhelpful worry and overthinking.

‘Mindfulness does not negate the brain’s natural desire to solve problems. It simply gives it the time and space to choose the best ways of solving them.’

Mark Williams and Danny Penman, Mindfulness: Finding peace in a frantic world

SPEND MORE TIME IN THE PRESENT

The present moment is not a bad place to be most of the time. Although we may feel anxious, worried, sad or angry, the things happening right now are rarely the cause of our distress. As our mind turns to problems, threats, perceived criticisms, resentments, frustrations, ‘shoulds’, regrets, fears, injustices and other negative issues, we disconnect from the present, and create suffering.

Of course, it is not realistic or appropriate to always focus on the present. Reflecting on past events – both happy and unhappy – enables us to learn and improve aspects of our lives. Similarly, contemplating the future is healthy and beneficial at times. Thinking about what we want in life, setting realistic goals, making plans and working towards them can help us create a rich and meaningful existence, and improve our wellbeing in the longer term.

However, there is a big difference between constructively reflecting on the past and planning for the future on the one hand, and engaging in pointless rumination about past events or speculation about negative future scenarios on the other.

It is a beautiful day today
but they predicted rain for tomorrow.

What should I focus on?

Do I enjoy today’s sunshine
or should I start thinking about tomorrow’s grey skies?

REFLECT

If you are currently experiencing distress, are your feelings caused by things that are happening now, or by your thoughts about things that have happened or may happen?

The following is an email exchange between myself and my friend who we’ll call SD. Her holiday apartment is on the market, and the real-estate agent has been contacting her, wanting to bring through potential buyers.

SD: Starting to feel frazzled here after all. Having to keep cleaning up the flat for inspections and packing away our stuff is a pain. Every time we think it’s over, the agent calls and wants to come through again. Well, would you believe it, the agent just rang, and he wants to bring someone else through this afternoon. What a total pain!

SE: Oh, that’s a bummer! But here’s the thing: the agent showing people around is taking up less than five per cent of your time, but it is on your mind and keeping your frazzled nearly 100 per cent of the time. So thoughts are making this worse than it needs to be. Mindfulness, SD. The stuff happening in the present moment is rarely the problem.

IN SUMMARY

Mindfulness can be practised as a meditation, or as focused attention to our current experience in daily-life situations.

Mindful attention to our thoughts enables us to recognise worry and other forms of overthinking as they arise. Seeing thoughts as objects of the mind, rather than ‘truth’ or ‘reality’, enables us to view them more objectively, without automatically getting caught up in their content.

A key principle of mindfulness is releasing judgement. A nonjudgemental attitude towards our current experience enables us to better tolerate unwanted situations, physical pain, anxiety, depression and other unpleasant emotions.

Mindfulness practice may reduce anxiety via a direct calming effect, and by enabling us to see worry thoughts as simply objects of our mind, rather than ‘reality’. It may also help us build tolerance to unwanted emotions, including anxiety.

Mindful awareness of our current thoughts, emotions, body sensations and back-of-the-mind issues can provide greater insight into our current state, and therefore enable us to respond to our needs more appropriately.

Mindful acceptance of our current state does not preclude problem-solving, if solutions are appropriate. Mindfulness practice can help us to make more considered and wise decisions.

CHAPTER 8

Metacognitive Beliefs

‘Worry pretends to be necessary but serves no useful purpose.’

ECKHART TOLLE

Noah admits that he worries too much, and the habit makes it hard for him to relax and enjoy life. However, he also believes that worry is protective because it enables him to be ready for anything that comes his way. Although the things he worries about rarely happen, Noah assumes that if they should happen, at least he will be psychologically prepared. Perhaps worrying beforehand will help him to cope? If, on the other hand, his worries turn out to be unfounded, he will be able to breathe a sigh of relief.

Miriam worries about her children and grandchildren. She worries about their physical safety, future financial security, health and happiness. Although Miriam knows that worrying does not protect them in any way, she believes that it would be wrong not to worry about them. On a gut level, it feels like worrying protects her family, and that she would be a bad mother and grandmother if she were to stop worrying about them.

Calvin worries about his health, and frequently catches himself going through a mental check of various parts of his body. Whenever he gets a new pain or symptom, Calvin immediately presumes the worst, and starts to think about how serious it could be. Calvin’s worry feels helpful, because he believes it enables him to catch any potentially serious health problems early. He assumes that if he did not worry, he would miss signs of illness, and by the time it is discovered, it would be too late.

Samantha has been a worrier all her life. She is learning skills to relinquish the habit, but, at some level, she is uncomfortable with it. The idea of giving up worry altogether sounds far too radical. Worry is so much a part of her personality, she believes that without it she would be lost. What will she think about and who will she be if she is no longer worrying?

Most habitual worriers recognise the many downsides of frequent worrying, including concentration difficulties, nervousness, somatic symptoms, irritability, sleep disturbances and a diminished ability to enjoy life. On the one hand, they would dearly love to be free of the habit, but, at a deeper level, they often feel a resistance to letting it go. The idea of not worrying may feel uncomfortable, careless, wrong or irresponsible. It may seem like not worrying would be exposing ourselves to danger, and that we won’t be prepared for bad things that could come our way. Giving up worry may involve a whole new way of thinking that does not sit well with who we are.

While the rational part of our mind insists that we would love to stop worrying, when we try, we might notice some resistance. The paradox of habitual worry is that it feels exhausting but necessary. Does this ambivalence sound familiar to you?

In this chapter we will explore some of the common beliefs that maintain the urge to worry. The following exercise may help you identify some of your own beliefs about the benefits of worry.

EXERCISE

Using a pen and paper, describe a scene where you are pottering around at home, doing the things you normally do (e.g. sitting in an armchair, reading, cooking, washing up, on your computer, etc.). But there is something unusual in this scene – you are entirely free of worry. You are completely relaxed . . . The worry habit has gone for good.

In your description, write about where you are, what you are doing, how you feel and what you are thinking about. Try to engage with the scene as you describe it. What are you feeling in your body? Are you able to relax, now that worrying has disappeared? Is there any part of you that resists relaxing?

After exploring the scene in detail, read through what you have written, and then close your eyes and visualise the scene once again. (For most people, writing with a pen provides more emotional connection to the subject matter than using a keyboard, so a pen is preferable but not essential.)

REFLECT

How comfortable did you feel describing and imagining this scene?

Did your picture – being completely relaxed and free of worry – feel like something that is possible for you? Or did it feel unrealistic?

Did you notice any ambivalence or resistance to the idea of relinquishing worry altogether? Do you feel that something bad could happen if you were to let go of anxiety and worry? (Try to respond from an emotional or ‘gut’ level rather than a purely rational level.)

When performing this exercise, many habitual worriers will notice resistance to the thought of being totally worry-free. Some reactions include:

‘I feel exposed, vulnerable.’

‘I feel aimless . . . like I am not trying, not caring and not motivated. I am going to fail.’

‘I don’t know what I am doing wrong.’

‘I don’t realise that I have problems that need my attention.’

‘I don’t know what to focus on.’

‘I have lost sight of the fact that I need to worry.’

‘A big surge of anxiety will come and I won’t be ready.’

Not everyone who does this exercise notices resistance, although often it is there at some level. If you do notice resistance, the concerns that come up for you will provide insight into reasons why you feel drawn to worry.

RATIONAL VERSUS EMOTIONAL MIND

When people think about it rationally, the idea of being totally free of worry and all of its encumbrances seems desirable. The rational part of your mind tells you that worry is a hindrance that limits your life. However, on an emotional level, there is often ambivalence about the idea. The emotional part of your mind (the ‘gut’ level) tells you that worry helps you to prepare for and prevent negative outcomes, motivates you to act, psychologically prepares you for the worst or protects you in other ways. You feel like relinquishing the habit may leave you vulnerable and exposed.

Although we can rationally see the benefits of abandoning the worry habit, on a gut level, we may feel uneasy about doing this.

METACOGNITIVE BELIEFS

All of us have beliefs about ourselves, others and our world. For instance, we might believe that the world should be fair; that people should behave decently; that we should be liked and approved of by others; that we should be reliable, successful, productive and achieve the things we set out to do, etc. (More details about these types of beliefs are described in my earlier book, Change Your Thinking.)

In addition to beliefs about ourselves, others and the world, we also have beliefs about our own thought processes and emotions – how we should be thinking and feeling. These beliefs, called metacognitive beliefs, are held at an unconscious level, although they can be brought to awareness through self-reflection. Metacognitive beliefs play an important role in maintaining many of the unpleasant emotions we experience, and they explain why some people are particularly resistant to releasing established habits.

The following are examples of metacognitive beliefs that perpetuate distressing emotions and unhelpful thoughts:

‘If I have made a mistake, I need to suffer. I shouldn’t let myself off the hook too easily, or else I will do it again.’ (This perpetuates guilt and self-criticism.)

‘Just because this depression is starting to lift, I shouldn’t focus on the positive. Better to stay pessimistic, so that I can avoid possible future disappointment.’ (This perpetuates a depressed mood.)

‘I need to stay angry. If I release my anger, I am giving a victory to the culprit – it means they win and I lose.’ (This perpetuates anger.)

‘I need to maintain unrelenting perfectionist standards. If I don’t, I will become lazy and achieve nothing. If I don’t give myself a hard time, I won’t succeed.’ (This perpetuates perfectionist thinking and self-criticism.)

‘I need to be hypervigilant to my body sensations all the time. If I stop focusing on my body, I might miss something and end up having a panic attack.’ (This perpetuates hypervigilance and anxiety.)

Notice that these are beliefs about how we should be thinking and feeling, rather than beliefs about our external world.

COMMON METACOGNITIVE BELIEFS ABOUT THE BENEFITS OF WORRY

Most habitual worriers are not aware of their metacognitive beliefs about the benefits of worrying, but these play a very important role in perpetuating the urge to worry. Metacognitive beliefs are the ‘engine room’ of GAD. As long as we believe that worry is protective, we remain motivated to keep it going.

These beliefs vary between individuals. Below are some common examples:

‘Worry helps me to identify problems.’

‘Worry prepares me for the worst.’

‘Worry motivates me to get things done.’

‘Worry gives me control.’

‘Worry means I care.’

‘Worry can prevent bad things from happening.’

‘To not worry would make me careless and irresponsible.’

Addressing metacognitive beliefs that maintain the urge to worry is a key to breaking the worry habit. The first step is to identify our own metacognitive beliefs about worry. The second step is to put those beliefs under scrutiny, and question their unrealistic suppositions. By doing this, we will discover that our assumptions about the benefits of worry do not add up. Worrying does not provide the protections we assume.

EXERCISE: IDENTIFY YOUR METACOGNITIVE BELIEFS ABOUT WORRYING

For each of the beliefs listed in the table below, circle a number between 0 and 2 to indicate how true it feels to you. Be sure to respond with what feels true on an emotional (‘gut’) level, rather than what you logically know to be true. (It is our ‘gut’ response that underpins the urge to worry.)

The aim of this exercise is to identify beliefs that influence your own urge to worry. These are the beliefs for which you circled either a 1 or a 2. Take another look at these beliefs now, and think about how true they feel for you. Can you think of any other ways in which you might assume that worry is protecting you? If so, add them to the list.

EXAMINING AND CHALLENGING OUR METACOGNITIVE BELIEFS

Challenging metacognitive beliefs is critical to releasing the worry habit. Once you have identified your own metacognitive beliefs and held them up to scrutiny, you may be surprised to discover how irrational your assumptions are. This can enable you to release those beliefs, even when they have been part of your thinking for decades. Let’s take a closer look at some examples.

‘WORRY MOTIVATES ME TO PROBLEM-SOLVE’

We saw in chapter 2 that occasional worry can focus our minds on a particular problem and motivate us to look for solutions. However, most people can problem-solve without the presence of worry. In fact, worry can provide too much motivation, to the point that it becomes unhelpful.

We feel compelled to worry because it feels productive – you might assume, ‘At least I’m doing something about it.’ To not worry feels like we are ignoring a threat or problem. We confuse worry with problem-solving; however, the two are not the same. Problem-solving is a concrete, solution-focused process that often leads to helpful actions. In contrast, habitual worry is speculative, repetitive and pointless. (If you wish to problem-solve, brainstorm possible solutions with pen and paper in hand to clearly separate the process from worry.)

People with GAD experience far more ‘problems’ than others, because the cognitive bias towards threat creates frequent false alarms. We are motivated to problem-solve, so we spend a lot of time and energy contemplating solutions to non-existent problems.

‘WORRY IMPROVES THE OUTCOMES OF PROBLEM-SOLVING’

Habitual worriers often assume that worry helps them to problem-solve. They might assume, ‘The more I worry, the better my solution will be.’ In reality, excessive worry impairs rather than assists with problem-solving, because we go down too many ‘rabbit holes’, and get distracted from the things that matter.

Recognising problems and planning solutions can be a helpful way to respond to life’s challenges, but adding worry to the mix does not lead to better outcomes. When we are dealing with genuine problems or challenges, we can problem-solve more effectively without worrying.

If worry and overthinking were a useful component of problem-solving, we would expect individuals who worry a lot to be more effective problem-solvers, and therefore achieve better outcomes than those who don’t. In fact, the opposite is true. (As we saw in chapter 2, people with GAD are generally poor problem-solvers, because they perceive threat in most of the possible solutions they consider.)

REFLECT

How do people who are not habitual worriers manage to problem-solve? Is worrying really helpful for problem-solving?

‘WORRY PREPARES ME FOR THE WORST’

You may feel compelled to worry because you believe that it will psychologically prepare you for possible future distress. As one person put it, ‘If I expect disaster and it doesn’t happen, I will feel relieved. If it does happen, then at least I will have prepared myself, so I won’t feel as upset. Either way, I win.’

Really?

This is flawed logic for two reasons. First, the process of worry creates suffering, regardless of whether or not the negative event occurs. Second, because the vast majority of the things we worry about never eventuate, we deprive ourselves of the opportunity to feel good and function normally much of the time, for no tangible benefit. Our worrying ends up creating much more real and immediate suffering than the situations we worry about.

You don’t need to walk around with your umbrella open
when it’s not raining.

British psychologist Professor Paul Salkovskis likens habitual worrying to taking out an insurance policy where the premium is greater than the payout. Imagine buying insurance that requires you to pay a $1-million premium each year, and if you need to make a claim, you will receive a maximum of $100. Would that be good value? The price you pay to try to achieve what you believe to be protection is a thousandfold greater than any possible benefit that might come your way from preparing for the worst.

In addition, on the rare occasions where our feared situation does eventuate, having worried about it for weeks, months or years beforehand does not protect you. On the contrary, the anxiety you experienced throughout the period of worry may make psychological adjustment more difficult.

The reality is that, if our feared situations do eventuate, we will need to face and deal with them when they arise, whether or not we worried about them beforehand. All the worry that preceded the event will not make it easier. We simply suffer much more than we need to.

Claude hates going to the dentist, and is dreading his coming appointment, which is scheduled for three weeks time. Claude hasn’t been for many years, and worries that he will need extensive dental work. He frequently thinks about how unpleasant it will be – poking, prodding, needles, drills and who knows what else! As he imagines what he might encounter, he feels a sense of dread. His appointment is in three weeks time, but Claude has already started suffering.

REFLECT

If Claude does need extensive dental work, will the unpleasantness of his experience be diminished because he worried about it for the previous three weeks?

When should Claude start suffering? (Hint: his mouth will be open.)

Is Claude’s ‘insurance premium’ greater than his ‘payout’? That is, does his worrying cause him to suffer unnecessarily, with little or no benefit?

Leonie’s husband has recently been diagnosed with prostate cancer. Although his prognosis is good, both know that there are no guarantees. Leonie worries for months after his surgery. She often imagines how lonely and difficult her life would be if the disease were to return and claim his life. She continues to worry, even though she knows that there is nothing she can do.

While it is normal to worry when loved ones face serious illness, the intensity and persistence of Leonie’s worry (in the face of her husband’s good prognosis) creates additional distress. Upon reflection, Leonie realises that she is focusing on the most negative scenario because she is trying to prepare herself psychologically, in case the worst should happen. By focusing on her feared outcome, Leonie assumes that she will be better able to cope if his illness returns.

But rather than protecting her, these thoughts plant themselves permanently in the back of her mind, and diminish her ability to enjoy life with her husband, even though he is currently well. Once again, the insurance premium is much greater than the payout.

For every person who is part of a loving couple, either they or their partner will one day face the devastation of losing their soulmate (except in those rare instances of simultaneous death in a plane crash or car accident, and most of us don’t relish that either!).

Is it a good idea to start worrying now about how terrible it will be if we should be the one who is left behind? Will focusing on the prospect protect us in any way? When should we start to suffer?

It is certainly helpful to plan for the future. Developing interests, nurturing social relationships, staying active and maintaining a healthy and balanced lifestyle improves our current quality of life, and can make things easier if we should end up widowed. However, beyond that, worrying about the possibility of future loneliness or other contingencies that are not within our control provides no benefits – now or in the future.

Isn’t it better to enjoy the relationship we have, accept uncertainty as a part of life and resolve to deal with whatever comes our way if and when we need to?

‘IF I COVER ALL MY BASES, IT WILL KEEP ME SAFE’

Many habitual worriers assume that if they can identify and mentally prepare for every harm that could come their way, they will have ‘covered all their bases’. The aim is to be protected and ready for anything bad that could happen. You might assume, ‘The more dangers I can anticipate, the safer I will be.’

Of course, this cannot work. First, it’s impossible to cover every base. The possibilities for negative events are endless, and, even with our best efforts, we could identify and prepare for only a small fraction. The majority of bad things that arise happen without warning, and we would not have been able to predict them. (If you’re not convinced, think about specific negative events you experienced in the past – would worrying more beforehand have helped you to foresee them? How would you know you were worrying about the right thing?)

Remember, too, that there is a cost associated with excessive worry – you pay less attention to things happening now. Are you listening? Are you fully present while working on this job, coming down those stairs, putting out the rubbish, transferring that money, having this conversation or parking the car? Are you focused on what you need to do? Overthinking and preoccupation with imaginary threats can make you less safe, because you get caught up in minutiae and miss important information.

‘WORRY MOTIVATES ME TO GET THINGS DONE’

While it may seem like worrying provides energy and drive, it is an inefficient motivator. Worry takes up mental space, interferes with planning, creates stress and fatigue, and reduces productivity. Imagine how much more you could achieve in a day without the burden of the busy mind! Most people manage to get things done in the absence of worry. By defining goals, planning steps towards those goals and thinking about the rewards, we can motivate ourselves without the drawbacks of worrying.

‘WORRY PREVENTS BAD THINGS FROM HAPPENING’

This belief is an example of ‘magical thinking’, which, as we discussed in chapter 2, is the tendency to perceive a causal relationship between unrelated events. But this belief makes no sense. Worry cannot influence the course of events, but it may feel like it does.

For many habitual worriers, the association between worry and positive outcomes is reinforced by decades of paired association. If you have worried hundreds of thousands of times in the past, you have experienced countless pairings of worry with positive outcomes – the things you worried about didn’t happen. With thousands of recurrent pairings, you may unconsciously associate worry with positive outcomes. We make the classic error of mistaking correlation (two things happen sequentially) with causation (one must have caused the other).

Of course, the vast majority of things we worry about never come to pass. This is not because we worried about them but because they were highly unlikely in the first place!

‘WORRY MEANS THAT I’M A CARING PERSON’

Many people feel compelled to worry because they regard it as a positive human attribute: ‘It means that I am a good, caring person.’ Some people fear that if they stop worrying, they will not care enough – perhaps they will stop caring about their children, family and friends. It almost feels callous to not worry about the people we love.

But if that were true, how is it that most of the population don’t worry excessively, and yet they still manage to be decent people? The majority of psychologically healthy individuals are not habitual worriers, yet they are loving to their children, caring to their friends and supportive to their work colleagues. How can this be?

REFLECT

Can you think of anyone you know who is a caring parent and friend, but who does not worry excessively?

Is it possible to be a loving and caring person without habitual worrying?

Further, excessive worry may be detrimental to the very people we love. By frequently focusing on danger, habitual worry creates stress for our children and loved ones. Having a parent who is frequently focused on bad things that could happen provides an unhelpful role model, and our children are more likely to grow up fearful and hypervigilant. Is that the view of the world you want to convey? It is not uncommon for family members to express frustration at a loved one’s preoccupation with danger and exhort them to ‘be careful’.

Excessive worry is frequently reinforced by overly protective behaviour, which limits children’s ability to explore their environment, take risks and develop social and physical confidence. While it is appropriate to set boundaries and ensure that children are safe, excessive protections do not create an ideal environment for children to flourish.

REFLECT

Identify an issue that you have no control over, which you sometimes worry about. How comfortable do you feel with the idea of no longer worrying about this? Do you feel compelled to worry about this issue, even though you know there is nothing you can do?

Suggest some metacognitive beliefs that might underlie your urge to keep worrying about this issue.

CHALLENGING METACOGNITIVE BELIEFS

The table below contains some common metacognitive beliefs about the benefits of worry, and statements that directly challenge their validity. Read through the table, and if there are any beliefs that feel particularly relevant to you, read through the challenging statement a few times. It may also be helpful to write down the rational perspective in your diary or on a piece of paper placed in a prominent place.

METACOGNITIVE BELIEF

RATIONAL PERSPECTIVE

Worrying enables me to be prepared for negative events.

Unless I am problem-solving, just thinking about bad things that could happen does not ‘prepare’ me in any way. It just makes me feel nervous, and prevents me from enjoying life.

Worrying means I will be less upset if something bad happens.

Worrying creates unnecessary suffering for days, weeks, months or years. If something bad should happen, I can deal with it when it happens. Worrying beforehand will not make it easier. I can cope and adapt to the situation if and when I need to.

Worrying gives me control.

Unless I am problem-solving or taking some positive action, worrying makes no difference to outcomes. (I can problem-solve if necessary, should the need for problem-solving become evident.)

Worrying helps me to plan for negative events.

It is impossible to plan for every negative contingency. Being too focused on possible threats causes me to waste time and energy planning for events that are unlikely to occur. By distracting my attention, it increases the likelihood of errors.

Worrying enables me to take measures to prevent negative events.

Most bad things that happen occur unexpectedly. There are countless things that can go wrong – how do I know that I am worrying about the right thing?

Worrying motivates me to do things.

I can achieve the things I need by setting goals and following through with action. Worry does not help me to get things done. I can achieve more without worrying.

Worrying means that I am a prudent, sensible person.

Habitual worrying is not a healthy or adaptive trait, or a marker of sensible thinking. I can be appropriately prudent and sensible without resorting to excessive worry.

Worrying makes me more effective in the things I do.

The opposite is true. Worrying impairs my concentration. I can be more effective when I can focus my attention on the present, rather than engage in pointless speculation and distractions.

Worrying can in itself prevent bad things from happening.

This is ‘magical thinking’. Worrying has no impact on life events.

Worrying means that I care.

People who are not worriers care just as much about their loved ones as those who worry, but they don’t waste energy on pointless overthinking. I can care just as much when I am not worrying.

Worrying helps me to solve problems.

Problems can be solved without worrying. People who do not worry are just as effective (or better) at solving problems.

My worrying will help me to cope if things go wrong.

If things go wrong, I will deal with it then. Worrying beforehand does not help me to cope – it just robs me of living well now.

If I did not worry I would be careless and irresponsible.

I am so used to worrying that the idea of not worrying feels scary. I can be appropriately responsible without habitual worry.

Worrying helps me to protect my health.

I can look after my health by maintaining a healthy lifestyle. Worrying does not provide additional protection.

Worrying keeps my children safe.

I can be a good parent and care for my children without constantly worrying. Modelling psychologically healthy behaviour will benefit my children more than habitually worrying about them.

EXERCISE

Write down your own metacognitive beliefs about the benefits of worry, and then, in your own words, write a more reasonable perspective that challenges that belief. Use the examples in the previous table as a guide.

Consider talking about this issue with friends and family members. Do they also believe that worry protects them? How do other people look after their children without constantly worrying about them?

If worry was really helpful or protective, we would expect habitual worriers to have advantages over the rest of the population. For instance, they would be more effective problem-solvers and higher achievers. They would have more successful careers, better health, more enjoyment, and more functional relationships than those who don’t worry.

In reality, the opposite is true. Frequent worrying and overanalysing are not adaptive human traits, as they waste energy and put us at a disadvantage. Habitual worriers tend to have greater difficulties and poorer functioning compared to non-worriers.

So is all that worrying really helpful?

In spite of our beliefs about the benefits and protections of worry, the evidence suggests the opposite is true.

So far, we have looked at challenging metacognitive beliefs about the benefits of worrying by putting them under scrutiny, and recognising their lack of logic. In the next chapter, we will learn how to challenge these beliefs using behavioural experiments. As you may recall, these types of experiments provide more compelling evidence, because they enable us to learn through experience.

NEGATIVE BELIEFS ABOUT WORRY

While metacognitive beliefs about the benefits of worry play an important role in maintaining the urge to worry, many people also hold metacognitive beliefs about harm caused by worry. For example:

‘Worry can make me go crazy.’

‘Worry will cause me to have a nervous breakdown.’

‘Worry can harm my health.’

Worrying about the harm that might be done by frequent worrying can also contribute to ongoing worry. Dr Adrian Wells, originator of metacognitive therapy, argues that negative beliefs about worrying create a self-perpetuating cycle for people with GAD, because worry about the harmful effects of worrying generates further worrying.

Strangely, it is not uncommon for individuals to hold both positive and negative metacognitive beliefs about worry. They believe that their worrying protects them, but they also believe that their worrying is harmful. So they may worry about the harm done by their worrying, but don’t feel motivated to relinquish the habit because it also feels protective.

Negative metacognitive beliefs about the harmful effects of worrying are most effectively challenged experientially, through worry-exposure exercises. These involve deliberately and intensely engaging in worry for periods of time, and learning experientially that the feared consequences do not arise.

WORRY EXPOSURE

If you believe that worry will do you harm, why not put that belief to the test via a behavioural experiment? See if you can make yourself go crazy, have a nervous breakdown or damage your health by worrying as intensively as you can? This process is called ‘worry exposure’, and has been found to be a powerful technique for reducing fear of distressing thoughts and feelings, including the fear of the process of worrying itself.

The best way to do worry exposure is to write down worry thoughts, without censoring or creating happy endings. Elaborate the details of your worry story, describing the most negative possible outcomes in the present tense, as though they are happening right now. Describe what it feels like when those negative events occur, and how it affects you and your loved ones. Visualise the negative consequences in as much detail as possible. Allow yourself to experience any anxiety, sadness, shame or other emotions that arise from this process, without trying to block them. Spend at least ten or 15 minutes on this process. Repeat this exercise every day for a week, adding more negative content if you can think of any further details. Read it out loud as well as visualising it in your mind. The more you engage with the thoughts, the more powerful the learning. (You will know when to stop, as the story will no longer evoke any emotion, and will simply become boring. When this happens, create another worry story and repeat the process.)

When introduced to this technique, many habitual worriers say that they already worry all the time, so they are constantly exposed to their worry thoughts. But worry exposure is not the same thing. Worrying involves imagining the worst and preparing for negative contingencies, all the while hoping that it won’t happen. It involves thinking about possible negative events, imagining possible solutions or actions they could take, thinking about other things that could happen, going to other possibilities, thinking about the worst-case scenario and then thinking about other things they could do to prevent them.

On the other hand, worry exposure involves describing worst-possible scenarios without considering other options. We elaborate the details of negative outcomes and allow ourselves to experience the thoughts, images, emotions and body sensations that they evoke. There is no searching for solutions – just sitting with the imagined events, visualising what that would be like.

Mandy has always been anxious by nature, and describes herself as a worrier. She works as a junior architect at a large architectural firm, and notices that she is always tense during the day. At night, she thinks about her work, and tries to reassure herself by mentally reviewing some of the decisions she has made. Although her designs are always precise, Mandy worries about the accuracy of her calculations, as even a small error could lead to significant costs to the company. Mandy realises that she worries far too much, but finds it hard to stop. She also worries that all her worrying is not healthy, and could lead to a breakdown. Mandy decides to do a behavioural experiment to put this belief to the test, using worry exposure exercises. The following is an extract from her exposure diary:

For weeks I have had a nagging feeling that my calculations on the Johnsons’ new kitchen are incorrect, and now I get a phone call from my supervisor. He tells me that my drafting is rubbish, and it will all need to be done again. My errors have set the project back by months, and have added thousands of dollars to the cost. The owners are furious and blame me. They ring me up and give me a serve. Two days later I am called to the CEO’s office, and he tells me that I am hopeless and that they are terminating my employment right now. I feel devastated and ashamed, and can’t think of anything to defend myself. I have to break the news to my husband, and I know he will be very disappointed in me.

When I tell my husband, he is very quiet, and I know that he’s thinking that I am useless. He is wondering why he ever married me. For the next year I try to get another job, but everyone has heard about how hopeless I am, and no one wants to employ me. I have become unemployable. My children are ashamed of me. I end up getting a job in a supermarket, stacking shelves, but then someone tells them about my previous job, and they immediately sack me. I have nothing to do, and my family is suffering financially. My husband tells me that it would be better for everyone if I left, but I have nowhere to go. I end up homeless, sleeping rough . . .

Writing and reading through worry exposure stories can generate upsetting emotions, so why would we put ourselves through this process?

There are actually many benefits. Among individuals with GAD, fear of upsetting emotions normally leads to cognitive avoidance. We try not to think about things that are distressing, because it feels like the resulting emotions would be overwhelming. We try to suppress anxiety-provoking thoughts because we want to avoid feeling anxious. We may even believe that we could have a breakdown if our distress level becomes too great.

Doing worry exposure exercises enables us to learn that facing our fears, including feared thoughts, does not lead to terrible consequences. While our worry story may be anxiety-provoking or depressing, it is just a story, and allowing ourselves to sit with upsetting thoughts and emotions builds tolerance to them. We discover that worry and other unpleasant thoughts do not harm us, and that we do not need to be afraid of them.

We also learn that sitting with negative, distressing thoughts does not leave us stuck in overwhelming anxiety forever. On the contrary, repeated imaginal exposure to disturbing thoughts reduces anxiety, and other upsetting emotions that arise, through a process of habituation. The more you expose yourself to something unpleasant, the less distressing it becomes.

In the same way that deliberate exposure to feared situations reduces our fear of them over time (see chapter 5), repeated exposure to distressing worry thoughts also reduces our fear of worrying. We learn experientially that even extreme, very unpleasant thoughts do not make us go crazy, have a breakdown or damage our health.

IN SUMMARY

Metacognitive beliefs are beliefs that we hold about our own thought processes and emotions. They play a key role in maintaining resistance to releasing unhelpful thinking habits, including worry and overthinking.

Common metacognitive beliefs about the benefits of worry maintain the urge to worry. These include beliefs that worry ‘assists with problem-solving’, ‘psychologically prepares me for the worst’ and ‘helps me to stay safe’.

Identifying, challenging and releasing unhelpful metacognitive beliefs about worry is critical to releasing the ongoing urge to worry.

Metacognitive beliefs can be challenged logically, using more reasonable perspectives.

Metacognitive beliefs about the harmful effects of worry can maintain recurrent worry, as we may worry about the fact that we are worrying. These beliefs can be challenged through worry-exposure exercises.

Worry exposure also provides experiential learning that when we face our feared thoughts, we can cope with the resulting unpleasant emotions, and they diminish with time.

CHAPTER 9

Worry Experiments

‘Life isn’t about waiting for the storm to pass. It’s about learning to dance in the rain.’

VIVIAN GREENE

In chapter 5 we saw how behavioural experiments can help us to change our perceptions of an unsafe world. By relinquishing habits driven by fear, we can discover that our world is not full of danger, and excessive safety behaviours are not necessary or helpful. Examples of behavioural experiments include things like taking social risks; dropping extreme perfectionistic behaviours; travelling to places outside of our comfort zone; relinquishing monitoring of body processes (e.g. blood pressure, heart rate or twinges); confronting unpleasant tasks that we have been avoiding; and withholding admonitions for loved ones to ‘be careful’.

While we can usually recognise safety behaviours through the actions we take, we might easily miss the things we do within our own minds to try to make ourselves safe. These cognitive safety behaviours include worrying, overthinking and overanalysing (all part of the worry process). Typically, this might involve thinking about bad things that could happen, planning responses in case they do and mentally preparing for various possible contingencies. Like the actions we take to keep ourselves safe, cognitive safety behaviours aim to prevent bad things from happening. Worrying is also our way of trying to eliminate uncertainty in what feels like an unsafe world.

Just as we can experiment with relinquishing ‘active’ safety behaviours, we can also experiment with letting go of cognitive safety behaviours. Releasing the worry habit for a period of time can enable us to establish whether not worrying compromises our safety. If you were to stop worrying, and nothing changed (other than you felt more relaxed), would this be a useful discovery? Perhaps you would learn experientially that you really don’t need to worry after all.

People often assume that experimenting with worry is impossible, because, unlike other safety behaviours, worry thoughts pop into our mind seemingly at their own volition. But if we could stop worrying for periods of time, we could conduct behavioural experiments to test whether the habit really is protective.

Enter the worry-delay pad.

USING WORRY DELAY

The worry-delay pad is a tool that enables us to switch off worrying for periods of time, and so allows us to conduct lots of interesting experiments. Let’s take a look at how it works.

EXERCISE

Get yourself a small pad that you can carry with you wherever you go. Over the next two weeks, be on the lookout for any worry thoughts that pop into your mind. Each time you notice that you are worrying about something, record the topic in your pad (just a few words), so that you can come back to it later.

An alternative to a pad is the WorryTime app that can be downloaded onto your phone or tablet (available for free from the ReachOut website). The app is used in the same way as the pad, with the added convenience that if you normally carry your digital device with you, it will be on hand more often. (The app has a few extra features, including notifying you when it is time to worry, and allowing you to graphically ‘screw up and throw away’ worry thoughts when they are no longer relevant.)

Once you have logged the worry, make a commitment to postpone any further engagement with that issue until 8 pm, or some other designated time that evening. You will be able to worry about it as much as you like at that time, but, for the time being, ‘park it’ in your pad. By recording the topic, there is no risk that you will forget this issue. Tell yourself: ‘I’ll focus on this tonight’ and then return your attention to whatever is happening in your current environment.

If the same worry thought re-enters your mind, you can mark it with a ‘tick’ in your worry-delay pad, or simply remind yourself that it is already in the pad and you will come back to it at the designated time. Whenever a new worry thought enters your mind, log it in your pad, and remind yourself that you will come back to it during worry time.

Note that you cannot prevent worry thoughts from entering your mind. Threat-focused thoughts will pop into your mind at various times during the day or night. But you do have some control over what you do with the thought once you notice its presence. You can choose not to engage with the thought right now – that is, not get caught up in its content (analysing, thinking, preparing, etc.). By reminding yourself that you will come back to it later, you will discover that it is not too difficult to park the worry for now.

While we have no control over thoughts that enter our mind,
once we are aware of a thought
we do have some control over whether or not we engage with it.

Carla used her worry-delay pad for two weeks, and noticed that her worry thoughts reduced substantially over this period. Below is the list of worries she logged in her pad on the first day.

Tuesday:

I could be late.

Get my report finished on time?

Is Carol taking care of the kids?

Will I sleep tonight?

Will we find a place to live?

Canberra.

Have I prepared enough?

Ate too much.

The traffic.

Will the washing be dry in time?

Flight back could be turbulent.

Do I look okay?

Worry delay is one of the most helpful exercises for releasing the worry habit. Most people discover that after just two or three weeks, the frequency of their worrying diminishes, and the longer they practise, the more powerful the results.

WHAT DOES WORRY DELAY TEACH US?

Many interesting things can be discovered through doing this exercise. First, you may be surprised to find that it is not so difficult to let go of worry thoughts, as long as you know that they will not be ‘lost’ – that is, you will come back to them later. (The same thing applies when people write down the thoughts that are keeping them awake in the middle of the night. Recording the issue ensures that it will not be forgotten, and you can return to it on the following day, if it is still relevant.)

The only exception to using worry delay is during periods of high anxiety. When the amygdala ‘smoke alarm’ is blaring, the prefrontal cortex is subdued and threat perceptions flood the mind. Delaying worry is therefore difficult during this time. The most helpful response during periods of intense anxiety is to mindfully observe our internal reactions, including the thoughts that are popping into our minds. It can be helpful to label the thoughts you notice (e.g. ‘This is a worry thought’, ‘That’s another catastrophic thought’), and do some physical exercise if possible. The anxiety, as well as the thoughts that accompany it, will diminish with time, so patience and curious observation are our best options during high-anxiety periods.

REVIEWING YOUR WORRIES AT THE END OF THE DAY

Most people who practise worry delay discover that when they come back to their recorded worries at the end of the day, most no longer seem as important as they did when they first arose. The majority of things we had worried about earlier now seem unlikely or trivial, and don’t require further attention.

Practising worry delay for a few weeks enables us to discover that whether or not we worry makes no difference to outcomes. Just like behavioural experiments that target our safety behaviours, worry experiments provide experiential learning. The more often you use worry delay, the more this learning is reinforced. (While you may already know this on a rational level, on an emotional level you may not believe it completely.) We learn through experience what it feels like to be free of worry – that there is another way of using our minds. We discover that letting go of worry does not expose us to danger or make us careless. We can take sensible precautions, without the added burden of worry and all those other safety behaviours. We learn experientially that it is safe to relax.

Some people who do this exercise report that they don’t bother to review their worry thoughts at the end of the day, because they no longer seem important. Others say that if they are worry-free, they don’t want to trigger more worry by looking back at all the things they worried about earlier. While you may be tempted to skip the review at the end of the day, be aware that there are benefits to this process. Not only do you see that the majority of things you worried about were inconsequential, but you also realise that just because something felt important at the time doesn’t mean that it really was. What a difference a few hours can make!

In addition, reviewing your worry-delay pad may highlight some worries that are unresolved problems in your life. They might not be trivial in nature (e.g. a sick child, financial difficulties, impending loss of job), and may be a source of ongoing concern. If these are on your list of worries, it can be helpful to reflect on them during the review period. Consider whether there is any problem-solving you could do to address these issues.

SUMMARY: DON’T WORRY, BE HAPPY!

Whenever you catch yourself worrying:

Log it in your worry-delay pad (or WorryTime app), and park it until review time.

During review time, ask yourself, ‘Does it still matter?’

If ‘No’ drop it. (Most things no longer matter.)

If ‘Yes’ ask yourself, ‘Is it within my control?’

If ‘No’ practise mindful acceptance.

If ‘Yes’ ‘Can I park it for a week, and see what happens?’ (Most things resolve without intervention.)

If ‘No’ ‘Is it a current problem that requires intervention? Should I problem-solve?’

If ‘Yes’ do problem-solving in writing. Plan a strategy.

BEHAVIOURAL EXPERIMENTS TO TEST METACOGNITIVE BELIEFS ABOUT WORRY

In chapter 8 we looked at various metacognitive beliefs that maintain our urge to worry. These beliefs include things like, ‘Worry motivates me to solve problems’, ‘Worry prepares me for the worst’, ‘Worry prevents bad things from happening’ and ‘Worry means that I’m a caring person’. We saw that these beliefs can be challenged logically, and we came up with various statements to provide us with a more rational perspective. These included things like, ‘I can be a caring person without worrying’, ‘Worrying does not prevent bad things happening’ and ‘Worrying does not add value to problem-solving’ (see pages 134–5). Reviewing these statements can provide a useful reminder that worry does not provide the protections we presume.

In chapter 5 we saw that behavioural experiments are a particularly powerful way of testing our beliefs because they provide experiential learning. Now that we have a tool that enables us to switch off worrying for periods of time, we can use behavioural experiments to test our metacognitive beliefs about the protections of worrying.

Below is a list of common metacognitive beliefs, as well as examples of experiments that can be done to test those beliefs.

METACOGNITIVE BELIEF

BEHAVIOURAL EXPERIMENT

My worrying is uncontrollable.

Use the worry-delay pad to switch off worrying for a week.

Did you have some control over your worrying?

Not worrying increases the likelihood of negative events.

Use the worry-delay pad to help you switch off worrying every alternate week for a few weeks. Keep a list of negative events that arise during the weeks you worry, as well as during the weeks you don’t, and compare the number of negative events in each.

Did you experience more negative events during the weeks you did not worry?

Worrying motivates me to get things done.

Use the worry-delay pad to help you switch off worrying on every second day or week for two or three weeks, and keep a record of the things you get done on the days or weeks that you worried, as well as on the days or weeks that you did not.

Did you achieve more on the days or weeks when you worried?

Worrying helps me to solve problems.

Use the worry-delay pad to help you switch off worrying on alternate days or weeks, and keep a record of the problems that you solved each day during this period.

Did your problem-solving ability improve on the days or weeks when you worried?

To not worry would make me a careless, irresponsible person.

Use the worry-delay pad to switch off worrying on alternate days or weeks for two weeks, and keep a log of any instances of carelessness or irresponsibility that arise each day (e.g. neglecting important tasks, forgetting things, making careless mistakes). Compare the number of issues that arose on the days you worried with those on the days you did not.

Were there more instances of careless, irresponsible behaviour on the days when you did not worry?

My worrying keeps my children safe.

Use the worry-delay pad to help you switch off worrying every alternating week for four weeks. Keep a record of your children’s safety threats during that time (e.g. whether they fell over, got hurt, got into trouble or anything bad happened to them). Compare the number of negative events that occurred on the days you worried with the days you did not worry.

Did your children experience more negative events on the days you did not worry?

My worrying enables me to feel less upset when something bad happens.

Use the worry-delay pad to practise not worrying for several weeks, and then observe the way you feel when any negative events arise.

Ask yourself whether you would you have felt better about this event if you had worried about it for those few weeks beforehand. (Most people discover that worrying provides no emotional protection, and sometimes adds to the distress when negative events arise.)

My worrying can cause me to have a nervous breakdown.

Try to intensify your process of worrying by doing repeated worry exposure (see chapter 8, page 137). Visualise the things that you worry about and try to experience your worries more intensively.

Did intensive worry cause you to have a nervous breakdown?

In chapter 5 we saw how behavioural experiments can be recorded using a prepared form. We can use a very similar form for conducting behavioural experiments to test whether our metacognitive beliefs about worry are correct. Planning the experiments and documenting their results in written format helps to consolidate learning and reinforces changes in our thinking.

The behavioural experiment form is on the next page.

BEHAVIOURAL EXPERIMENT

Belief:

Experiment:

What are you most worried will happen?

What specific things would you expect to see if that is correct?

On a scale of 0–100, how likely does it seem? ____ per cent

AFTER YOUR EXPOSURE SESSION:

Did what you worried about actually occur? Yes or No

How do you know?

What did you learn?

Each section is completed in the same way as in chapter 5, except that now we will be relinquishing worry for periods of time to test whether our beliefs about worry are correct.

BELIEF

The form contains this additional section to record the metacognitive belief about worrying that you wish to test, e.g. ‘My worrying enables me to prevent bad things from happening’ or ‘Worry helps me to make decisions’.

EXPERIMENT

When testing metacognitive beliefs, we need to switch off worry for a period of time, to observe whether our feared outcomes arise. The worry-delay pad (or Worry Time app) can enable us to do this. Our experiment may be, for example, ‘Use my worry-delay pad to switch off worrying every second day, and observe whether more things go wrong on the days I do not worry’ or ‘Use my worry-delay pad to switch off worrying every second day, and observe whether it is harder for me to make decisions on the days I do not worry’.

WHAT SPECIFIC THINGS WOULD YOU EXPECT TO SEE IF THAT IS CORRECT?

Provide specific examples of what you would expect to observe on the days you don’t worry. For example, for the belief ‘My worry prevents things from going wrong’, you might predict ‘On the days that I don’t worry, I will experience more negative events such as missing appointments, getting a parking fine, getting a cold sore, losing money, hurting my back, etc.’ For the belief that ‘My worry helps me to make decisions’, you might predict that ‘On the days that I don’t worry, I will find it harder to decide things such as what to wear, what to have for lunch, what tasks to focus on when I arrive at work, what to buy at the supermarket, what to make for dinner, etc.’

After you have conducted the experiment, record what happened.

DID WHAT YOU WORRIED ABOUT ACTUALLY OCCUR?

State ‘Yes’ or ‘No’.

HOW DO YOU KNOW?

Provide evidence, for example, ‘On the days I didn’t worry, there were no more negative incidents than on the days when I did’ or ‘On the days when I didn’t worry, I was just as able to make decisions as on the days when I did.’

WHAT DID YOU LEARN?

Record the conclusions that can be drawn from this exercise. For example, ‘Releasing worry does not cause more things to go wrong’ or ‘I can make decisions just as effectively without worrying’.

Let’s now take a look at how conducting behavioural experiments with worry helped Carla discover that her metacognitive beliefs about the protections of worry are incorrect.

EXAMPLE: CARLA

Carla believes that her worrying enables her to be more effective at work, and that if she did not worry, she would not be a good mother. She decides to test these beliefs by conducting behavioural experiments. Below are the two of the forms that she completed.

BEHAVIOURAL EXPERIMENT

Belief: My worrying is part of being a good mother. If I did not worry, I would not be a good mother.

Experiment: Use worry delay to switch off worrying about my children for two weeks.

What are you most worried will happen? I will be a bad mother.

What specific things would you expect to see if that is correct? On the days that I don’t worry, I will be less caring and more neglectful of my children. For example, I might not pack their lunches, wash and iron their uniforms, ask them about their day, spend time talking to them, show them affection, drive them to sports on Saturdays, pick them up when they have spent time with friends, etc.

On a scale of 0–100, how likely does it seem? 60 per cent.

AFTER YOUR EXPOSURE SESSION:

Did what you worried about actually occur? No.

How do you know? I looked after them as usual.

What did you learn? Not worrying about my children does not make me a bad mother. I can be a loving, caring mother without worrying all the time.

BEHAVIOURAL EXPERIMENT

Belief: Worrying makes me more effective at work.

Experiment: Use worry delay to switch off worrying on alternating weeks over four weeks.

What are you most worried will happen? I will be less effective at work on the days I don’t worry.

What specific things would you expect to see if that is correct? On the days I don’t worry, I will get through less work, make more mistakes, need to stay back late, receive more negative feedback and get confused with tasks.

On a scale of 0–100, how likely does it seem? 80 per cent.

AFTER YOUR EXPOSURE SESSION:

Did what you worried about actually occur? No.

How do you know? There was no change in my productivity, feedback and performance.

What did you learn? I can be just as effective at work when I don’t worry.

EXERCISE

Now it’s your turn! Select one of the metacognitive beliefs that influences your own urge to worry. (See the beliefs that you identified in chapter 8.) Create a behavioural experiment form based on the form on page 148, and use it to plan and record a behavioural experiment that tests your belief. Reflect on your findings in the results and conclusion section. Does this experiment provide evidence to challenge your beliefs about the protections of worrying?

Behavioural experiments are among the most powerful tools for releasing threat-focused thinking, and are well worth the time and energy involved in planning and executing them, and reflecting on findings. Most of the time, our negative expectations are proven to be incorrect. The findings can be reinforced by repeating the experiments or creating new ones. Very occasionally, there may be a coincidence of timing, where we begin an experiment and some negative events do occur. For example, you stop worrying and you lose your credit card, have an argument with a friend or your child develops a high fever. Negative events can happen whether or not we worry, so it is unrealistic to automatically attribute such events to worry delay. On the rare occasions where negative events occur during a period of worry delay, repeating the experiment several times can enable us to discover the true effects of releasing worry.

IN SUMMARY

Just as we can use behavioural experiments to learn that it is safe to relinquish our ‘active’ safety behaviours, we can also use them to learn that it is safe to relinquish our cognitive safety behaviours. This enables us to discover that our perceptions of danger are exaggerated or incorrect.

The worry-delay pad or WorryTime app allows us to release worry for periods of time. This enables us to conduct behavioural experiments to test our metacognitive beliefs about the benefits (or costs) of worrying.

Worry delay can provide experiential learning that our metacognitive beliefs are incorrect, and that it is safe to release worry.

Using a behavioural experiment form for planning and recording the experiment consolidates learning.

CHAPTER 10

Learn to Relax

‘Most people are more aware of the weather, the time of day or their bank balance than they are aware of the tension in their bodies. Body awareness is the first step in recognising and reducing stress.’

MARTHA DAVIS, ELIZABETH ROBBINS ESHELMAN, MATTHEW MCKAY, THE RELAXATION AND STRESS REDUCTION WORKBOOK

When asked what they dislike most about anxiety, many people nominate things going on in their minds (e.g. perceiving threats, thinking about bad things that could happen). If we are not tuned in to our own bodies, we might miss a key feature of anxiety that makes it particularly unpleasant – the physical sensations that it generates. These include things like tightness in the chest, shallow breathing, muscle tension, tremor, feelings of arousal, ‘nervyness’ and ‘butterflies’ in the stomach. At times we may also experience sensations like dizziness, nausea, headache, knotted tummy, neck pain, tight jaw, numbness, tingling, heat surges and lightheadedness.

If you were able to eliminate all the physical sensations that accompany anxiety, what would be left? Not only would the unpleasant sensations of anxiety disappear, but so would anxiety itself. In fact, it is impossible to feel anxious when your body is relaxed. While you might find it very difficult to relax during periods of high anxiety, if you were able to do so, your anxiety would disappear for that time.

The mind and body are part of the same system, and are constantly interacting. Just as our minds influence what happens in our body, the reverse is also true – body processes provide feedback to our minds and brains. Information from our muscles is transmitted to the brain via the vagus nerve (also known as the ‘tenth cranial nerve’). This longest and most complex of the 12 pairs of cranial nerves transmits information between the brain and various tissues, muscles and organs, including the heart, diaphragm, gut and bladder.

The flow of information from the body to the brain is called ‘interoceptive feedback’, and it plays a key role in perpetuating anxiety. When we are anxious, the associated physical arousal and muscle tension is communicated to the brain via the vagus nerve. The amygdala perceives these signs as threat, and signals the hypothalamus to maintain sympathetic nervous system activation (see chapter 1). The message is, ‘It’s not safe, stay vigilant’.

Relaxing the body produces the opposite effect. Relaxed muscles signal ‘It’s safe now’. Neural activity in the amygdala diminishes, and ‘high-alert’ signals are switched off. Relaxed body, calm mind.

Helga arrived to our session in a highly anxious state. She was visibly aroused, breathing quickly and feeling dizzy and unbalanced. She also had a sharp pain in her chest. In response to questioning, Helga stated that she was 100 per cent certain that her dizziness and chest pain indicated that she had a serious medical problem, and was going to die.

Rather than try to logically convince her that the unpleasant body sensations are typical somatic symptoms that accompany high levels of anxiety, I focused on trying to reduce her arousal level. We started by getting her to tense up her whole body, hold the tension for a few seconds and then relax. After doing this several times, she focused on different parts of her body, tensing and relaxing, and then allowing them to become heavy and relaxed. Finally, Helga focused attention on her breath, and noticed times when her mind wandered. Each time she became aware of thoughts, she returned her attention to her breath.

The entire exercise took about 15 minutes. I noticed that Helga’s breathing had become slow, and she looked more relaxed. I then put to Helga two possibilities: ‘So either you have a serious medical illness, or you are experiencing anxiety, and some catastrophic thoughts that go with it. Which do you think it is?’

The answer was obvious to her now: ‘It’s anxiety – I can see that.’

It is fascinating to observe how relaxing our muscles changes the content of our thoughts. Because Helga was initially very anxious and aroused, logical argument would have been unpersuasive. By reducing her physical arousal, Helga’s brain got the message that ‘It is safe’. Her anxiety decreased, and the associated catastrophic thinking diminished. This made it possible for her to see things realistically.

A deep state of relaxation engages the parasympathetic nervous system – the part of our autonomic nervous system that slows the heart and relaxes the muscles. It involves more than the normal relaxation we experience when we put our feet up at the end of the day, have a glass of wine and listen to our favourite music. Relaxation that produces measurable changes in physiology is a deeper state, and inducing it requires conscious effort.

Deep relaxation techniques have been incorporated into treatments for anxiety and its disorders since the 1960s, and its benefits were first described decades before. Over the years, many different methods for inducing a state of deep relaxation have been developed. Two of the most common methods are progressive muscle relaxation and meditation.

PROGRESSIVE MUSCLE RELAXATION (PMR)

This method was first described by American physician Edmund Jacobson almost a century ago. In 1929, Jacobson published the book Progressive Relaxation, which detailed a technique called ‘progressive relaxation therapy’. It involved tensing and then relaxing muscle groups, starting from either the feet or head, and working sequentially throughout the rest of the body. Jacobson’s method has been found to be very effective in decreasing arousal and inducing a state of calm, and it is still widely prescribed as a simple technique for reducing anxiety. Variations of this technique have also been developed, including progressive relaxation of muscles without tensing, or commencing training with tensing and relaxing, and then switching to progressive relaxation without tensing.

PRACTISING PMR

Find a quiet place that is free of distractions and loosen any clothing that is tight or uncomfortable. Sit upright, with your feet flat on the floor. (Note that sitting rather than lying down is recommended in order to reduce the likelihood of falling asleep.) Place your hands wherever they feel most comfortable. Close your eyes and take a little time to get in touch with the sensations within your body. Feel free to adjust your body at any time.

Breathe in and tighten the muscles of your feet. Hold your breath and maintain tension in your feet for a few seconds, and then breathe out and relax your feet. Observe the sensations within your feet as they relax. Let go a little more. Take at least 15 seconds before moving on to other muscles.

Repeat this procedure for all the major muscle groups, in the following order: calves, thighs, buttocks, stomach, chest, arms, shoulders, neck and face.

Now observe your whole body. Notice any part that is still tense, and consciously relax the muscles in that area. If you find any persistent tightness, repeat tensing and relaxing of muscles in that area a few more times. Then sit quietly for a few minutes and enjoy the sensations of relaxation.

To achieve a deep state of relaxation, this exercise usually takes 15–20 minutes. Once we have learned the skill, we may be able to achieve deep relaxation within a shorter period, although it is beneficial to remain in that state for at least ten minutes. Benefits are more likely to be observable when relaxation is practised daily, and twice daily during stressful periods.

While PMR can be practised without guidance, for many people, having the direction of a guiding voice can improve pacing, and lead to deeper relaxation. There are many apps, CDs and online audio that provide guidance for PMR (including audio produced by the author – see appendix).

‘THE RELAXATION RESPONSE’

The effects of inducing a state of deep relaxation were first scientifically measured by Harvard physician Dr Herbert Benson in the 1970s. In his 1975 book The Relaxation Response, Benson described research with subjects who practised Transcendental Meditation (TM). This form of meditation involves repeating a mantra (a word or short phrase) in one’s mind and using it as an ‘anchor’ for focusing attention. (It is a concentration meditation approach similar to focusing on the breath, sounds or body sensations that are commonly used in mindfulness meditation.)

Benson reported that during the practice there was a reduction in subjects’ heart rates, breathing rates, oxygen consumption and blood pressure. There was also a reduction in blood lactate levels (high levels are associated with anxiety, and low levels with calm). In addition, during meditation, subjects’ brainwaves showed an increase in frequency of alpha waves (associated with relaxation), and a decrease in beta waves (which are associated with normal waking activity).

The research found that TM produced measurable changes in physiology. Benson named these changes ‘the relaxation response’, a term that is still used to describe a state that is biologically the opposite of the fight-or-flight response. You may recall from chapter 1 that the fight-or-flight response is initiated by the activation of the sympathetic nervous system – part of the autonomic nervous system which mobilises us for action. The relaxation response is initiated by the parasympathetic nervous system, inducing a state of calm (see page 19, chapter 1).

Although the mantra used in TM is provided as a secret by a meditation teacher, Benson and many others have argued that any neutral word or phrase can be used to the same effect. Benson suggested the word ‘one’ could be suitably used as a mantra, and recommended the following technique.

MANTRA MEDITATION

Sit quietly in a comfortable position. Close your eyes.

Relax all your muscles, beginning at your feet and progressing up to your face.

Breathe through your nose. Become aware of your breathing. As you breathe out, say the word ‘one’ silently to yourself. That is, breathe in and out, and then say ‘one’, in and out, and repeat ‘one’ . . .

Continue for 10 to 20 minutes. When you finish, sit quietly for several minutes, at first with your eyes closed and later with your eyes open.

Meditation has long been known to induce feelings of calm and deep relaxation, and TM is one of several types of meditation that can produce this effect. In chapter 7 we reviewed mindfulness meditation, which has become the dominant meditation model promoted by Western practitioners. Although the philosophy underpinning mindfulness makes it particularly suitable as an adjunct for psychological therapy, it is very likely that all forms of concentration meditation can reduce anxiety and produce a relaxation response.

INTERNAL RESISTANCE TO RELAXATION

For our Stone Age ancestors, letting down their guard during times of perceived danger could mean becoming someone’s dinner. Those instincts still guide us today, even when our perceived threat is imagined or insignificant.

This is why some people can feel themselves resisting relaxation, as though relaxing would make them vulnerable. During periods of intense anxiety, when your amygdala is yelling ‘danger’, you may find it almost impossible to relax. While you might realise on a rational level (using your prefrontal cortex) that it is safe to let your guard down, your amygdala stays activated. Your limbic system is telling you that you are not safe, so your muscles remain tense.

In these situations, trying to relax may actually increase anxiety for some. Instead, vigorous physical exercise is usually the best way to bring down anxiety levels. Exercise also burns up the extra glucose and fatty acids that have been released into the blood stream as an extra energy source during stressful periods.

Deep relaxation may also be difficult because paying attention to possible threat creates the illusion of control, and relaxation feels like surrender. If we have spent much of our lives trying to protect ourselves from danger, letting go can feel unsafe. Our instinct may be to keep trying. Paradoxically, it is through releasing our attempts at control that we actually gain control over the way we feel.

Practising deep relaxation on a daily basis helps to lower physical arousal, and sends feedback to the brain that we are safe. Neural activity within our amygdala diminishes, and our body starts to relax.

NOTICE BODY SENSATIONS

Look to the body – it is constantly sending us feedback regarding what is going on in our minds. Body sensations are integral components of all emotions. Whether you feel anxious, sad, angry, frustrated or guilty, body sensations are part of what you are experiencing. Many of us are disconnected from the messages that our bodies are sending. We may notice tension in the shoulders or stiffness in the neck at the end of a stressful day, but we rarely notice our muscles tightening in response to things happening in our environment or the thoughts that are popping into our mind.

Regular practice of deep relaxation makes us more attuned to our bodies. We are more likely to notice tension developing, and this gives us the option of intervening. We can stop what we are doing and relax our muscles, do a short mindfulness exercise, or slow down our breathing. Responding to growing tension as it arises enables us to prevent it from escalating.

OTHER METHODS FOR INDUCING DEEP RELAXATION

Although meditation and progressive muscle relaxation are the two most widely known methods for producing a state of deep relaxation, other techniques are also effective. These are described below.

RELAXATION USING THE BREATH

Breathing is one of the few systems in the body that is both involuntary (controlled by the autonomic nervous system) and voluntary (we can choose to speed up, slow down, deepen or hold our breath). When we are not aware of our breathing, it is automatic and determined by physical factors, including our current level of arousal. When we are calm and relaxed, our breath becomes slower and more rhythmic. When we are anxious, angry or irritated, our breath is more rapid and shallow.

Having some voluntary control over our breathing enables us to use it to regulate our level of arousal. By consciously slowing down our breathing, we can engage the parasympathetic nervous system. During a panic attack we can eliminate many of the unpleasant sensations associated with hyperventilation by slowing our breathing (see chapter 11). Focusing on our breath calms the mind, distracts from catastrophic thoughts, and can prevent anxiety from escalating. Below are some simple breathing exercises that can be used to reduce arousal.

DIAPHRAGMATIC BREATHING

This involves directing the breath down into the lower part of our lungs. To do this, we use our diaphragm (the muscle separating our lung cavity from the abdominal cavity) to direct air downwards. You can monitor the movement of your breath by placing your hands on your chest at the bottom of your rib cage, just above the navel, so that the tips of your middle fingers just touch. As you direct your breath slowly into your lower lungs, you will feel your fingertips being forced apart slightly by the expansion of your abdomen. As you breathe out, you will feel your fingertips touching again.

SLOW RHYTHMIC BREATHING

Take in one diaphragmatic breath, and hold it to the count of six. Breathe out slowly, mentally saying the word ‘relax’ as you do so. Then breathe in to the count of three and out to the count of three, mentally saying the word ‘relax’ at the end of each out-breath. This process will slow your breathing rate to ten breaths per minute. After every ten breaths, take another diaphragmatic breath and count to six, and return to slow breathing again. Keep repeating this process for a few minutes, until your anxiety drops.

CUE-CONTROLLED RELAXATION

This method involves linking particular ‘cue words’ to your breath, in order to form an association between breathing and deep relaxation. Start by doing a progressive muscle relaxation exercise. Then focus on the natural rhythm of your breath, and in your mind say ‘breathe in’ with each in-breath, and ‘and relax’ with each out-breath. The words are both meditative (they give you an anchor to focus on) and reinforcing of relaxation.

Once you have used this technique on a few occasions, your mind will start to link your cue words with relaxation. This enables you to use those words to evoke a state of deep relaxation within just a few minutes – simply close your eyes, relax your body and within your mind start to say ‘breathe in’ with each in-breath and ‘and relax’ with each out-breath.

VISUAL IMAGERY

It has long been recognised that images can evoke powerful emotional states. Calming visual imagery can produce a state of calm, and therefore deepen your level of relaxation. Imagery can be an adjunct to PMR, or a standalone practice. The technique involves immersing ourselves in an image that we associate with peace, tranquillity and positive memories. The most widely used images are nature scenes (e.g. rainforests, beaches, countrysides, waterfalls, beautiful gardens), dream-like imagery (e.g. imagining you’re floating on a cloud or on a magic carpet) or a personal protector, such as a guardian angel or inner guide. Adding sensory information such as sounds, colours, shapes, textures, smells, temperature and physical sensations makes the experience more vivid. For instance: hear the crackling of leaves under your feet and the sound of the birds as you make your way through the forest. Smell the damp sweet odour of the undergrowth, see the brightly coloured wild flowers that grow near the track, feel the rough textures of the ancient trees . . .

Alternatively, visualising a place and time from your past that evokes positive memories and associations can also evoke feelings of calm.

APPLIED RELAXATION

During the 1970s, a relaxation strategy called ‘applied relaxation’ was described by Swedish professor in clinical psychology Lars-Göran Öst. This sequential group of relaxation techniques was taught to individuals with high levels of anxiety. In the 1980s and 1990s, this method was frequently used as a control group condition when measuring the effects of other types of therapy for GAD. It was often assumed that the other therapies (including CBT) would do better; however, applied relaxation was found to be a reasonably effective treatment in its own right. Until more powerful therapies for GAD were developed after 2000, applied relaxation was as effective as other recognised treatments of the day.

Applied relaxation consists of six stages:

1.     Progressive muscle relaxation: using tensing and relaxing to maximise levels of relaxation. Practise twice daily for 15 minutes, over one to two weeks.

2.     Release-only muscle relaxation: progressively scan major muscle groups and consciously relax each group. Practise twice daily for five to seven minutes, over one to two weeks.

3.     Cue-controlled relaxation: create a state of deep relaxation using the PMR technique, and then start to focus on the breath. Internally say the words ‘breathe in’ with each in-breath, and ‘and relax’ with each out-breath. Use the words ‘breathe in’ and ‘and relax’ as cues to induce deep relaxation in future sessions.

4.     Differential relaxation: create a deeply relaxed state using one of the above techniques, and, while in this state, remain relaxed while moving various parts of the body. Move your arms, head, legs, and even walk around while consciously maintaining deep relaxation throughout your body.

5.     Rapid relaxation: tune in to body sensations 15–20 times per day (mobile phone reminders could be good for this) and consciously relax the body if it is not already relaxed.

6.     Application training: practise remaining physically relaxed while exposing yourself to situations that evoke anxiety, either in real life or through imagined scenarios.

Applied relaxation is a group of relaxation exercises, and its effectiveness may come from consistently and intensively practising various relaxation techniques over many weeks. While the potential benefits of contemporary psychological treatments for GAD (described in this book) are greater and more likely to be sustained than those of applied relaxation, the practice is nevertheless a good option for people who find psychological strategies difficult to navigate.

YOGA, MARTIAL ARTS AND MASSAGE

There are also other techniques that can be used to achieve deep relaxation. Yoga, for example, has been found to be effective in reducing symptoms of both anxiety and depression. The practice involves a combination of slow stretching movements done in conjunction with coordinated breathing. Yoga exercises result in relaxation of the muscles, and feelings of calm. Many yoga classes finish with meditation or PMR, which also help to reduce anxiety.

Eastern martial arts such as Tai Chi, Qi Gong and Taekwondo are also widely reported to be effective for managing mood and emotions. These techniques involve flowing and sometimes challenging physical movements, combined with intense concentration on those movements. They are a form of meditation in action. While some experts focus on the precision of the movements, others argue that it is the intense focus on movement to the exclusion of other things that is most beneficial. The movements serve as an ‘anchor’, in the same way that the breath, body sensations or sounds provide an anchor in mindfulness meditation.

Massage is another a method for inducing deep relaxation, and some people swear by its calming effects. While massage can be a relaxing treat, its benefits are often regarded as less enduring than those of the other deep relaxation techniques because it is administered externally, by another person. Learning to induce a state of relaxation from within is likely to be more effective in the longer term. Developing deep relaxation skills using PMR, cue-controlled relaxation or breathing techniques means that we can practise at any time, without needing another person to help us to relax.

MEDITATION VERSUS DEEP RELAXATION

Meditation and deep relaxation have a lot in common – both involve sitting quietly and focusing attention inwards. However, they are not the same thing.

While practising meditation often produces feelings of calm and relaxation, this is not its primary aim. In the case of mindfulness meditation, our intention is to observe aspects of our current experience as they present themselves, whatever they may be, without judging or resisting them. It is a process performed within our mind. Using our object of focus as an anchor, we may notice thoughts, emotions, body sensations and urges that arise for us. Meditation opens the door for greater insight into our mind and emotions. We become more aware of our thought processes, including unhelpful habits like overthinking, worrying and ruminating, as they occur. This awareness of what is happening within our mind (‘meta-awareness’) helps us to recognise and observe recurrent worry, as well as the urges that maintain it.

Deep relaxation has one key purpose – to produce a state of relaxation. Regular practice can reduce anxiety, both now and in the longer term. By focusing our attention on various body sensations, it also helps us to be more aware of what is happening in our bodies. This enables us to consciously relax our muscles when tension arises. Deep relaxation is less likely to produce insight; however, it can reduce catastrophic thoughts by lowering anxiety levels. Regular practice can reduce hypervigilance and arousal over time.

Deep relaxation also has the advantage of being relatively easy to learn (most people find it easier to practise than meditation), and it does not require a high degree of mental discipline. It can therefore be a useful technique for individuals who find psychological strategies difficult to apply.

‘BUT RELAXATION WILL NOT SOLVE MY PROBLEMS’

You may be thinking to yourself, ‘But relaxing my body will not solve my problems. I still have a stressful job, a demanding partner, conflict with my friend or a serious health problem.’

It is true that learning to relax our bodies will not change the stressful situations we are dealing with. These need to be addressed directly through problem-solving if solutions are available. However, deep relaxation can reduce the unpleasant body sensations and catastrophic thinking that accompany anxiety and other upsetting emotions. This will make the stressful situations you are facing easier to deal with. Staying relaxed in the face of stressful circumstances will allow you to feel calmer, think more clearly, and make better decisions when problem-solving.

IN SUMMARY

Anxiety produces strong physical sensations, including muscle tension, physical arousal and elevated heart rate.

Relaxation techniques that release the tension and other physical changes associated with anxiety have been used for managing anxiety for many decades.

Various methods can be used to create a state of deep relaxation. Progressive muscle relaxation (PMR) is the most widely known and practised technique. Other methods include meditation, breathing exercises, cue-controlled relaxation and calming visual imagery.

When we are very anxious and our amygdala is highly activated, we may experience internal resistance to relaxation because it feels unsafe to relax. In these situations, doing some physical exercise may reduce arousal, and make it easier to subsequently relax.

While meditation involves techniques that change the way we use our mind, deep relaxation involves techniques that directly relax our body.

Although deep relaxation does not alter the stressful situations in our lives, by reducing anxiety, it makes those situations easier to manage.

CHAPTER 11

Managing Panic Attacks

‘The mind is its own place, and in itself can make a heaven of hell, a hell of heaven.’

JOHN MILTON, PARADISE LOST

Virginia started to have panic attacks a few weeks after commencing her new job. When her anxiety was high, she became shaky, sweaty and dizzy, and thought she was going to pass out. At these times she would worry that she was having a heart attack, or that her throat would close up and she would be unable to breathe.

On the way to work each morning Virginia worried that she wouldn’t be able to get off the bus. She counted the stops, urging herself to ‘hang in there’. When she came out of the station, the city felt impersonal, noisy and unsafe. She felt alone, surrounded by strangers, and everyone seemed to be in a hurry.

At work, Virginia’s productivity was low. Her concentration was poor, and even simple tasks took a long time to complete. She was finding it hard to make decisions, and worried that other people would notice there was something wrong with her.

Virginia’s home became her safe haven. She stopped going out with friends, doing the shopping, going to the movies or working out at the gym. If she had to go out, she always took someone with her. Virginia turned down opportunities to travel and cancelled a planned holiday because she feared having a panic attack on the plane.

To help her cope, Virginia took lots of vitamin pills and complementary therapies, including ‘Rescue Remedy’ and a tonic recommended by her homeopath. She used her phone for distraction, trawling through social media to try to escape from the thoughts, body sensations and fear that she was experiencing.

Virginia dreaded going to bed each night, as she would often wake up at 2 am, unable to get back to sleep. She felt tired and sleep-deprived during the day, and frequently worried about whether she would be able to sleep that night. At times she felt completely hopeless, and noticed feelings of depression creeping in.

People who have gone through periods of repeated panic episodes may be able to relate to some of Virginia’s experiences. Panic attacks can be distressing and disabling, so understanding their causes, what perpetuates them and how they can be dealt with can build confidence in managing them. So let’s have a look at what panic is all about.

PANIC ATTACKS

A panic attack is a sudden experience of intense fear that reaches a peak within minutes. A surge of adrenaline triggers the fight-or-flight response with its associated symptoms, including pounding heart, tightness in the chest, shortness of breath, elevated blood pressure, sweating and tremor (shakiness). We may also experience other sensations, such as dizziness, nausea, numbness, tingling, heat surges or chills, chest pain and feelings of unreality.

Because the fear that accompanies a panic attack is intense, and the physical symptoms are unpleasant, people often have catastrophic thoughts about what is going on. Fear of dying, fainting, having a heart attack, losing control or going crazy are common concerns during a panic attack.

Between 30 and 50 per cent of the population will experience a panic attack at some stage in their lives. The first occurrence is frequently during the late teens or early 20s, and females are twice as likely to experience panic as males.

For the majority, panic attacks are an isolated or occasional experience, which do not interfere significantly with one’s life. For some, they may precede the development of panic disorder, which affects about six per cent of Australians at some stage of their lives.

INITIAL TRIGGER

The first panic attack often arises during a period of high stress. The surge in adrenaline may be triggered by events such as conflict, workplace demands, rejection or criticism by others, a financial crisis, a relationship breakdown or pressure to perform. Sometimes it is the accumulation of several stressors that start to feel overwhelming.

The initial trigger can also be physical. Coffee, illicit drugs, a bout of flu or other illness, high-energy drinks, nicotine, an episode of rotational vertigo, medication side effects or dehydration may trigger panic symptoms. Some medical conditions, such as hyperthyroidism, hypoglycaemia and tachycardia, can also trigger panic-like symptoms, and catastrophic thoughts about the sensations may give rise to a panic attack.

Because panic is unpleasant, we may become vigilant to our own body sensations, looking out for the possibility of further episodes. This vigilance increases the likelihood of further panic attacks.

HYPERVENTILATION

We saw in chapter 1 that when our brain perceives threat, our body prepares for action by mustering internal resources to optimise our chances of survival. During the fight-or-flight response, we breathe faster, and the additional oxygen is sent to our muscles, where it is combined with glucose and burned at a faster rate. This gives us greater energy with which to fight or run away. At the same time, our chest muscles tighten, putting extra pressure on the chest and reducing lung capacity. To compensate, we breathe faster.

Breathing too quickly increases oxygen intake and displaces some of the carbon dioxide circulating in the blood, causing it to fall below normal levels. This increases blood alkalinity, which in turn produces unpleasant sensations, such as dizziness, confusion, lightheadedness, numbness or tingling sensations in the hands and feet, and feelings of unreality. These sensations, in addition to heart palpitations, tightness in the chest and other symptoms of the fight-or-flight response, contribute to the dreaded cluster that most panic sufferers want so desperately to avoid.

DIZZINESS

People who are frequently anxious are more likely to experience dizziness at various times, and dizziness is particularly common among those who have panic attacks. One of the causes is hyperventilation – we breathe too quickly, and therefore take in too much oxygen. (If you have any doubts, try deliberately breathing very quickly for 10–20 seconds and see how dizzy you get.) Even without panic attacks, anxious individuals often overbreathe, and consequently experience frequent or episodic dizziness. During panic, our body directs more blood to flow to our muscles, and reduces blood flow to our brain. This causes the lightheadedness and dizziness that we may experience during panic attacks.

COULD THIS BE A HEART ATTACK?

Some of the symptoms of panic (such as shortness of breath and chest pain) are similar to those associated with cardiovascular disease. People who experience panic often worry that they are having a heart attack, and therefore believe they cannot ignore the symptoms. Many end up in emergency departments in hospitals, worrying that there is something seriously wrong with their heart. While in the majority of cases it is just panic, if there is any doubt about your heart health, see your doctor and get checked out. Once you get the all clear, it is easier to feel reassured.

FROM PANIC ATTACK TO PANIC DISORDER

Many people have had the occasional panic attack, but only a small proportion go on to develop panic disorder. This is a condition that involves ongoing vigilance and anxiety in anticipation of possible future panic attacks.

Panic disorder is different to most other anxiety disorders, where the perceived threats are things happening in our external world (such as social situations, work, relationships, finances and new challenges). With panic disorder, the perceived threat is inside our own bodies, so we monitor our body sensations, looking out for signs that could indicate the onset of another panic attack. It is our ongoing dread and apprehension of further panic attacks that maintains the disorder. Although not physically dangerous, most people hate the sensations, and may feel desperate to find ways to avoid further panic.

Quite often the stressor that triggered the initial panic attack (e.g. relationship problems or work stress) has resolved or is no longer significant, but now our anxiety focuses on the panic itself. We start to worry about the possibility of further panic attacks, and how we might be able to avoid them. The greater the threat that panic represents, the greater our focus on the possibility of further panic, and the more catastrophic are our thoughts. We become hypervigilant (excessively focused) to our own body sensations, unconsciously hoping that we can pre-empt further episodes.

Tuning our attention to body sensations makes us overly sensitive to even small physical changes, including normal fluctuations that we would not have previously noticed e.g. gastrointestinal sensations, muscle twinges or tightness, slight dizziness, heart rate variations, premenstrual symptoms, elevated arousal, etc. Any change in body sensations may be perceived as a threat, which increases anxiety, as well as the associated physical symptoms and worry. In the end, we may become locked into a cycle where anxiety coupled with hypervigilance triggers further physical symptoms, which perpetuates worry and catastrophic thoughts about panic. This self-perpetuating cycle maintains panic disorder.

EXERCISE

If you experience panic attacks, list your symptoms and your worry thoughts about the possibility of panic in the diagram below.

‘OUT OF THE BLUE’

While some panic attacks are triggered by predictable situations or events (e.g. being in a busy shopping centre, boarding a flight or following a cup of coffee), others appear to come out of the blue. Sudden, seemingly unprovoked panic attacks feel particularly scary and cause much consternation, as without any obvious trigger we may feel totally devoid of control. Being roused from sleep by a panic attack (called ‘nocturnal panic’) can be particularly distressing because of the intrusiveness and unpredictability. Following such experiences, we may get caught up in worry and attempts to analyse why it occurred: ‘Why did this happen?’, ‘Why am I feeling this way?’, ‘How can I stop it?’ and perhaps ‘Could this be a medical illness?’ We reason that if we can understand why it happened, we may be able to prevent future episodes.

Unfortunately, overanalysing reinforces preoccupation with panic, and rarely moves us closer to where we want to be. As with GAD and other anxiety disorders, the more we focus on perceived threats, the greater their presence in our mind.

AGORAPHOBIA

Some people become so fearful of further panic attacks that they develop extreme apprehension and/or avoidance of situations where they believe a panic attack could happen. They may fear being trapped, helpless or embarrassed in front of others, and worry that there will be no easy way to escape or get help should their anxiety escalate. Busy public places are most often avoided. These include shopping centres, movie theatres, restaurants, auditoriums, sports stadiums, carparks, planes and public transport. People may also shy from open spaces (such as public ovals, parking lots and marketplaces), standing in line or driving on bridges, freeways or in tunnels. For some people, travelling alone anywhere outside of home is scary, and may ultimately lead them to become housebound, or totally dependent on others to accompany them.

The extreme fear, with or without avoidance of those situations, is called ‘agoraphobia’, which often (but not always) accompanies panic disorder. Agoraphobia is associated with fear or avoidance of situations from which escape would be difficult or help may not be available. Some people with agoraphobia also avoid substances or activities that produce bodily arousal (which our brain associates with a panic attack). So, for instance, we might avoid caffeine, alcohol or stimulant medication, because these generate sensations that we associate with panic. For the same reason, we might avoid physical exercise, sexual activity or being in hot, stuffy environments. Even normally enjoyable activity, like playing computer games, watching or playing competitive sport or watching suspenseful movies, might be feared and avoided because the excitement they generate feels similar to panic sensations.

In addition to avoidance behaviours, we may use other types of safety behaviours to try to prevent panic. For example, we might make reassurance-seeking phone calls to a friend or family member when outside the home, or only go out of the house when a ‘safe person’ accompanies us. We might also do things like carry water wherever we go, use unproven therapies like vitamins or Rescue Remedy, chew gum, suck on a mint, distract ourselves using social media, listen to podcasts or loud music, sit near the door or exit when in public places, check our pulse, open windows and keep the room temperature cool (hot, stuffy rooms are associated with difficulty breathing and running out of air).

REFLECT

Thinking back to Virginia, what safety behaviours did she use in order to try to avoid panic attacks?

Can you identify any safety behaviours that you use in order to protect yourself from panic attacks?

REDUCING PERCEPTIONS OF THREAT

During a panic attack, catastrophic thoughts prevail. High levels of sympathetic nervous system activity generate grossly exaggerated perceptions of danger. In this state, you may believe that you are going to faint, go crazy, have a heart attack, draw attention to yourself or die. The catastrophic thoughts and desperate attempts to stop the sensations perpetuate fear, and make us vulnerable to further panic. It is therefore important to correct some of the misperceptions we may hold about the dangers of panic attacks.

While the body sensations and thoughts that accompany panic attacks are very unpleasant, the process itself is harmless. The dreaded physical symptoms are caused by the fight-or-flight response, a natural mechanism that provided a survival advantage for our primitive ancestors for thousands of years. The following table contains some common catastrophic thoughts that may arise in response to body sensations during, as well as after, a panic attack, and some corrective information.

CORRECTING CATASTROPHIC THOUGHTS ABOUT PANIC SENSATIONS

PHYSICAL SENSATIONS

CATASTROPHIC THOUGHTS

CORRECTIVE INFORMATION

Rapid heart rate or palpitations

Tightness in the chest

‘I’m having a heart attack.’

A rapid heart rate is part of the fight-or-flight response, and not a sign that you are having a heart attack. (If an electrocardiogram – ECG – is taken during a panic attack, it will show no abnormalities.) The tightness in your chest is caused by muscle tension, and is not related to your heart.

Difficulty breathing

‘I’m going to run out of air and suffocate.’

During panic, chest muscles tighten and reduce respiratory capacity; however, this cannot lead you to run out of air. No one has ever stopped breathing from panic. Your brain has a reflex mechanism that will force you to breathe if you are not getting enough air.

Dizziness

‘I’m going to faint.’

During the fight-or-flight response, blood moves to the arms and legs and there is a slight drop in blood flow to the brain, which may cause dizziness. However, you are highly unlikely to faint. Although it is technically possible, if it has not happened to you yet, it almost certainly never will.

Confusion; disorientation; feelings of unreality

‘I’m going mad.’

Confusion and disorientation are common during panic attacks, and not a sign of madness. People don’t ‘go crazy’ in a sudden, spontaneous way. Serious mental disorders do not arise from panic attacks.

Confusion, disorientation, feelings of unreality

‘I might behave strangely and draw attention to myself. I might run around screaming or do something dangerous, like run onto a busy road or try to jump out of the plane.’

‘People will think I’m strange.’

A panic attack cannot cause you to behave in a ‘crazy’ way. It cannot cause you to harm yourself or others, or to do anything dangerous. You may feel very bad inside, but you remain highly motivated to stay safe.

Symptoms of a panic attack are rarely perceptible by others. Unless you tell someone, people are unlikely to notice.

Arousal sensations

‘It will never stop.’

A panic attack typically lasts for about ten minutes or less. While there may be residual anxiety after a panic attack, the very unpleasant symptoms don’t last very long.

There are two key steps in learning to manage panic disorder. The first involves learning how to manage a panic attack that is in progress. The second involves using strategies that diminish our ongoing fear of further panic attacks. Let’s take a look at each of these.

LEARNING TO MANAGE PANIC: RESPONDING TO A PANIC ATTACK IN PROGRESS

The most widely used approaches to managing a panic attack in progress are panic surfing and hyperventilation control. Panic surfing involves learning to ‘go with’ the symptoms of a panic attack without trying to stop them. Hyperventilation control involves using the breath to reduce autonomic arousal, and therefore reduce the unpleasant sensations created by hyperventilation.

PANIC SURFING

Panic attacks become more intense as we panic in response to the sensations themselves. Because they are unpleasant, we may feel desperate to stop them. (‘Oh no! Here it comes again! I can’t stand this!’)

Panic attacks are initiated by the amygdala raising the alarm, followed by an immediate ‘shot’ of adrenaline. It would last just a few minutes if we were able to give it ‘space’ – that is, let it be. Panic attacks usually last longer because of the self-perpetuating cycle of panic about the panic. The fight-or-flight response is triggered, and we perceive the sensations as dangerous or intolerable. (Interestingly, the same sensations arise in response to aerobic exercise, but in that context we give it a low-threat meaning.) Catastrophic thoughts about the symptoms elevate threat perceptions, which cause further sympathetic nervous system activation. This maintains the fight-or-flight response, with all of the associated symptoms, which perpetuates the panic cycle.

DURING A PANIC ATTACK

Panic surfing involves letting go of resistance – dropping any attempts to control the symptoms. Instead of panicking about the panic, we let the panic do what it needs to do. We don’t intervene.

Interestingly, when we relinquish attempts to control panic sensations, we short-circuit the self-perpetuating response. Some people are uncomfortable with this idea because it feels like releasing attempts to control our panic would mean it will escalate or never stop. In fact, the opposite is true.

This approach for responding to panic was first described by Australian GP and author Dr Claire Weekes, in her 1972 book Peace from Nervous Suffering. The term ‘panic surfing’ was coined many years later by Australian psychologists Ron Rapee and Andrew Baillie as a metaphor for this process. Trying to stop a panic attack is like trying to swim against the waves. You waste a lot of energy crashing against them, and rarely get very far. Instead of resisting, turn around and let the waves carry you. Let your body do what it needs to do.

A variation of this metaphor is to imagine yourself on a boat drifting along a river. Allow the boat to carry you, without trying to control it or change its course. Trust the boat, and it will always take you to safety.

Panic surfing is often experienced as a wave of panic – it peaks, and then passes through you, and then subsides. When we give up the fight, the elevated adrenaline that maintains the fight-or-flight response recedes, often within a few minutes, and the associated physical symptoms dissipate soon after.

PANIC SURFING

1.      Drop resistance to the panic.

2.      Relinquish control.

3.      Let your body do what it needs to do.

4.      Allow the panic to peak and pass.

Panic surfing is a powerful technique, and worth persevering with. Practising this method, either alone or with a therapist, may help you discover that it is safe and effective. An alternative technique is one that directly addresses the unpleasant symptoms created by hyperventilation.

HYPERVENTILATION CONTROL

The breath is a useful barometer of our level of arousal. When we are relaxed, our breath is slow and rhythmic. When we are anxious, our breath is rapid and shallow, and high levels of anxiety may cause hyperventilation (taking in too much oxygen).

While the breath reflects our level of arousal, it can also be used as a tool to modify our arousal. By slowing down our breathing, we send a signal from our diaphragm to our brain that our arousal has reduced.

In addition, slowing the breath reduces the ratio of oxygen to carbon dioxide in the blood, and therefore diminishes the unpleasant effects (lightheadedness, confusion, jitters, dizziness, numbness and tingling) caused by hyperventilation. Once those unpleasant sensations diminish, our anxiety drops and we start to feel better.

Various techniques can be used to achieve hyperventilation control. Our aim is to slow down our breathing rate by pacing it into a slower rhythm. This can be done by counting in- and out-breaths, or by using an app to pace our breathing.

Below is a commonly used method of slowing the breath by counting. This method results in a breathing rate of ten breaths per minute. Keep in mind that the aim is slow breathing, not deep breathing, as the latter will increase the level of oxygen circulating in the blood, which is the opposite of what we want to achieve.

SLOWING THE BREATH BY COUNTING

1.      Breathe in (using a normal breath, not a deep breath), hold your breath to the count of six, then breathe out.

2.      Breathe in slowly while counting to three (inside your mind), pause for a moment, and then breathe out slowly while counting to three. Repeat this sequence ten times.

3.      Repeat step 1 (that is, breathe in, hold your breath to the count of six, then breathe out).

Keep doing this exercise until you experience a reduction in arousal – aim for three to six minutes.

There are also several free apps (such as Breathe2Relax and ReachOut Breathe) that can be downloaded onto phones or tablets. The external guidance provided by an app can make the process easier.

PANIC SURFING VERSUS SLOW BREATHING

Both panic surfing and slow breathing help to reduce the symptoms of a panic attack that is in progress. Panic surfing is consistent with the principles of mindfulness – we allow unpleasant experiences to be there, without judgement or resistance. By facing the feared sensations without trying to stop them, we learn to be less afraid of them. We also discover that the catastrophic events we imagined do not come to pass. This reduces fear of panic attacks in the longer term.

On the other hand, hyperventilation control provides reassurance that we can decrease some of the unpleasant symptoms of a panic attack reasonably quickly, which reduces anxiety and increases feelings of control.

Fear of further panic attacks is a key aspect of the self-perpetuating cycle that maintains panic disorder. Learning to respond to a panic attack in progress using either panic surfing or slow breathing can reduce that fear and, for some, disrupt the self-perpetuating cycle. For others, fear of future panic continues, in which case we need to look at other strategies to manage the fear.

LEARNING TO MANAGE PANIC: DEALING WITH FEAR OF PHYSICAL SENSATIONS

We saw in chapter 5 that exposure to feared situations, in the absence of the expected negative consequences, results in decreased anxiety over time. If our expected negative outcomes do not eventuate following repeated exposure, we learn that we are safe. This principle applies not only in relation to feared situations, but also to feared body sensations. What do you think would happen if, instead of trying to avoid panic, you deliberately induced some of those panic sensations?

INTEROCEPTIVE EXPOSURE

‘Interoception’ is the perception of sensations within our own body, such as our heart beating, face flushing, temperature rising and muscles tensing. ‘Interoceptive exposure’ involves deliberately inducing some of our feared body sensations, in order to learn not to be afraid of them.

The method was first described and evaluated by American psychology professors David Barlow and Michelle Craske during the late 1980s and early 1990s. It has since been repeatedly evaluated, and variations of the original technique have been developed and assessed. Interoceptive exposure is now recognised as a powerful component of CBT treatment for panic disorder.

The underlying rationale is that through deliberate and repeated exposure to the physical sensations that we associate with panic, we become less responsive to them. ‘Anxiety sensitivity’ – our tendency to notice and feel distressed by the physical sensations of anxiety – diminishes. This method provides experiential learning, which is more persuasive than just logically telling ourselves that nothing terrible is going to happen. When our amygdala no longer perceives those sensations as a massive threat, its activation subsides and anxiety reduces. Consequently, catastrophic thoughts about panic diminish, and the self-perpetuating panic cycle starts to dissolve.

Anyone who has had panic attacks knows how distressing the experience can be, and is likely to feel horrified at the idea of deliberately producing sensations they have been working so hard to avoid. This is understandable, but remember that as long as we fear something, it remains a threat within our minds. This is particularly true when the object of our fear is unpredictable and uncontrollable, and resides within us.

When it was first conceptualised, interoceptive exposure comprised two stages. The first involved doing various tasks that aimed to identify ways to produce sensations most similar to those experienced during a panic attack. These included things like shaking your head from side to side, repeatedly lowering your head between your legs and then lifting it, spinning on a swivel chair, breathing through a straw, running on the spot and breathing rapidly. The second stage involved practising repeated exposure to the tasks identified as producing symptoms most similar to one’s panic attacks.

More recent research has found that hyperventilation (deliberate, rapid breathing) alone can be effectively used for exposure, as it produces panic-like symptoms for nearly everyone. Typically, the person is encouraged to hyperventilate at least three times during the therapy session. Other research has found that more prolonged and intensive delivery of exposure – eight or more hyperventilations per session – produces greater reductions in fear of body sensations. For those who hate the idea of deliberate hyperventilation, an alternative is aerobic exercise, such as brisk walking or jogging. While still aiming to bring on feared body sensations, you might perceive exercise as a more ‘natural’ and therefore more agreeable option.

If just reading about this makes you weak at the knees, you are not alone – the idea of deliberately bringing on panic-like sensations is counterintuitive and scary. In practice, most people find that interoceptive exposure is not as terrifying as sounds, and it can produce rapid and substantial reductions in fear. If it is something you are open to trying, it may be helpful to discuss it with a CBT therapist who has experience in treating panic disorder. They can answer questions, supervise your initial exposure sessions and set exercises for you to practice at home.

NATURALISTIC INTEROCEPTIVE EXPOSURE

In addition to planned interoceptive exposure, it may be helpful to take advantage of opportunities to practise in daily-life situations. Here are some examples:

Run up several flights of stairs when going into an apartment or office building.

Watch suspenseful, exciting movies on TV.

Go along to watch your favourite sports team play.

Resume sexual activity.

Join a gym, jog, cycle, swim or do some type of aerobic exercise every day.

Sit in a hot, stuffy room, with the door and windows closed.

Walk outside on hot days, on the sunny side of the street.

Accept all offers to attend social events, and initiate some yourself.

Stand up quickly when getting up from a seated position.

Periodically turn your head from side to side quickly.

LEARNING TO MANAGE PANIC: EXPOSURE TO AVOIDED SITUATIONS

When we experience panic attacks, we quickly learn which situations are likely to trigger further episodes and, unsurprisingly, try to avoid them. This creates two problems. First, as we saw earlier, the more we avoid things, the scarier they become. Avoidance strengthens our fears. Second, avoidance impairs our functioning. It limits our ability to perform at work, enjoy friendships, engage in exercise, enjoy leisure activity and live a normal, healthy life. The more we avoid, the more our lives shrink.

We have already seen that fear of panic sensations can be reduced by deliberately and repeatedly exposing ourselves to them. The same is true when it comes to fear of situations we associate with panic. These may include things like shopping centres, theatres, lifts, carparks, bridges, tunnels, public transport, social gatherings, driving, sports stadiums, supermarkets and venturing far from home.

Once again, exposure is the key.

REFLECT

Write a list of all the situations and activities that you have been avoiding for fear of panic attacks.

How do you feel about starting to face those situations?

CREATE AN EXPOSURE SCHEDULE

Exposure can be done in a graded or non-graded way. Graded exposure involves creating a hierarchy, starting with low-threat exposure and gradually moving to more challenging exercises. We begin by working on the easier tasks, and as we develop confidence in those situations, we challenge ourselves with more anxiety-provoking tasks. This is the method that most people prefer, because it is more gentle, and easier to tolerate. For this reason, it also increases our likelihood of completing the exposure exercises.

The alternative is to face the situations we fear randomly, in no particular order, or even to throw ourselves into our most feared situations from the outset (called ‘flooding’). For someone with panic disorder, this might involve going into a busy shopping centre or crowded theatre and staying there for several hours, on at least a few days per week. Although this type of exposure is more confronting than graded exposure, and likely to generate higher anxiety in the short term, research suggests that this type of exposure may produce faster and more sustained recovery from panic.

Planning our exposure tasks and recording the outcomes on an exposure schedule helps with motivation and monitoring our progress. The exposure schedule form below can be used for this purpose. In the left-hand column, list the exposure tasks that you plan to do. As you complete each task, record the date on which it took place, the length of time that you spent on the task and the level of anxiety you felt during the exposure.

EXPOSURE SCHEDULE

For each exposure record: date, length of exposure, anxiety level (0–10).

When doing exposure exercises you can focus on one activity at a time, or you can work on several exposure tasks each day. With graded exposure you can manage the intensity of anxiety you are likely to experience by including some safety behaviours during the initial steps.

The example opposite demonstrates graded exposure for one feared activity – travelling on the train. The degree of difficulty is initially modified via safety behaviours such as taking a friend or using distraction through things like music, podcasts, puzzles, computer games and social media. The time of day (off-peak versus peak periods) and the length of each exposure session can also be adjusted from low threat to high threat. If safety behaviours are used, it is usually only in the beginning, as our aim is to ultimately face our feared situations without them.

If you decide to try a session of flooding instead, in the example below you might choose to sit on a train unaccompanied during peak hour for one hour, on four occasions in one week. If you use this type of exposure, you are likely to experience higher levels of anxiety in the short-term, although it may also lead to a faster and greater reduction of fear. (If you should experience panic during any of the exposure exercises, it is a good opportunity to practise panic surfing or slow breathing.)

The following graded exposure schedule was completed by Virginia to overcome her fear of travelling on trains:

EXPOSURE SCHEDULE: TRAVELLING ON TRAINS

For each exposure record: date, length of exposure, anxiety level (0–10).

Note that with repeated exposure, anxiety tends to trend downwards over time; however, it is never a smooth ride. On some days, anxiety may rebound for no apparent reason. Setbacks are a normal part of the process, so don’t be discouraged when this happens. The key indicator of progress is what happens over several weeks, not from one day to the next.

In order for exposure exercises to be effective, keep these principles in mind:

Frequency: Do some exposure exercises as often as you can – every day if possible.

Repetition: Repeat each exposure exercise until it no longer elicits anxiety.

Challenge: Exposure exercises need to be anxiety-provoking to be effective, so keep pushing the boundaries. If it’s too easy, increase the level of challenge.

Duration: Don’t just ‘dip your toe into the water and run away’. Try to do some longer exposure sessions whenever possible.

Spontaneous: Add unplanned exposure tasks to your scheduled tasks whenever opportunities to practise arise.

The information in this chapter provides key components of CBT treatment of panic disorder. Understanding the nature of panic, and knowing that it is not dangerous, can in itself be reassuring. For further information about managing panic, see the recommended reading and self-help websites listed in the appendix.

IN SUMMARY

A panic attack is an episode of intense fear and physical arousal caused by the fight-or-flight response. Many people experience panic attacks at some stage, and a small percentage go on to develop panic disorder.

Panic disorder is underpinned by ongoing vigilance in anticipation of further panic, creating a self-perpetuating anxiety cycle.

Hyperventilation (overbreathing) contributes to some of the unpleasant sensations experienced during a panic attack.

Practising ‘panic surfing’ or slow breathing can reduce unpleasant physical sensations during a panic attack, and enable the episode to resolve more quickly.

To recover from panic disorder, it is helpful to overcome our fear of panic attacks. This can be done by correcting erroneous beliefs about the dangers of panic sensations.

Interoceptive exposure – deliberately and repeatedly inducing some of the feared physical sensations that we associate with panic – can be a powerful technique for overcoming fear of panic sensations. If the idea feels very confronting, it may be helpful to consult a CBT therapist about this.

Avoidance of feared situations and activities that are associated with panic – prevents recovery from panic disorder. Repeated exposure to the situations and activities we have been avoiding helps to reduce fear of panic attacks. This can be done using an exposure schedule, and by taking advantage of spontaneous opportunities that arise.

CHAPTER 12

Medications

‘Stay committed to your decisions, but stay flexible in your approach.’

TONY ROBBINS

Anxiety begins in the mind, and most treatments for anxiety and worry focus on changing the way we think. Some treatments (such as slow breathing and progressive muscle relaxtion) affect our minds indirectly by reversing the physiological changes that anxiety generates. In this chapter, we will look at anxiety treatments that directly alter the chemistry of our brains.

Medications have been part of the mainstay treatment of anxiety and its disorders for decades, and new drugs and biological treatments continue to be developed. Those that reduce anxiety also usually reduce the frequency and intensity of worrying.

CONSIDERING MEDICATION

If you have been dealing with anxiety for months or years, the option of taking medication is likely to have come up in discussion. It may have been recommended by a GP or mental-health professional, or suggested by a friend or family member. You may have started thinking about it seriously, particularly if nothing else seems to be helping.

People who experience extensive worry, anxiety or depression are often reluctant to take medication. Some fear unpleasant side effects that may arise, while others worry about becoming addicted. Many people just don’t like the idea of swallowing pills for a psychological condition. Some see medication as appropriate for medical problems like heart disease or diabetes, but not relevant for mental-health issues. Some believe that they should be able to control anxiety (or depression) by themselves, and taking medication feels like failure.

Response to medication varies. For some people, it is the circuit breaker they have been looking for, diminishing not only the unpleasant symptoms of anxiety, but also the catastrophic thoughts and preoccupation with threat that comes with it. For others, it produces little or no observable benefit, and may have some unpleasant side effects to boot.

Medication can be helpful by decreasing the physical symptoms of anxiety (e.g. heart palpitations, sweating, shaking, nervousness), and reducing the worry and negative thoughts that accompany it. As anxiety diminishes, worry also reduces. For individuals who are experiencing both depression and anxiety, antidepressant medications can improve or resolve both conditions at the same time.

While medication can be helpful, most experts agree that it should not be a first line of treatment (without trying other methods first), or used as the sole treatment. It is likely to be most effective when part of a broader treatment approach, which combines it with psychological therapy and self-help strategies. Medication as a sole source of treatment may provide relief in the current episode. However, without learning what causes and maintains our anxiety, and without developing appropriate strategies to manage it, there is no protection once we stop taking it. For this reason, it is always advisable to begin with psychological therapy. This can be accessed via self-help (online and reading), or by seeing a mental-health practitioner.

START WITH PSYCHOLOGICAL THERAPY

Self-help tools such as e-therapy (online self-help programs), bibliotherapy (self-help books), apps and podcasts are a good place to start (see appendix for some useful resources). Disciplined adherence to a self-help program can make a significant difference to symptoms, providing substantial relief and, in some cases, complete recovery.

For ongoing or more severe anxiety, seeing a skilled professional is likely to produce greater benefits. A mental-health professional, such as a psychologist, psychiatrist or other qualified practitioner, can provide a more personalised, tailored approach. They can fill in the gaps that remain following self-help, and provide reassurance and hope for the future.

Good psychological therapy will include a review of your history, an exploration of what is causing and perpetuating your anxiety, and information about how anxiety works and how it maintains itself. Evidence-based therapy for managing GAD includes the strategies described in this book: becoming informed about anxiety and worry; building mindful awareness and learning to recognise and label worry as it arises; identifying and releasing safety behaviours; using worry delay to break the worry habit; and challenging metacognitive beliefs that maintain the urge to worry.

While each person’s history and biology varies, and each plays a role in the process of recovery, effective psychological therapy often results in a substantial decrease or elimination of symptoms. This includes a reduction in biased or catastrophic thinking, less physical arousal and a reduction in behaviours that perpetuate anxiety. In addition to resolving current anxiety, it can also reduce the likelihood of future relapse.

IS MEDICATION RIGHT FOR YOU?

If you have already sought the help of a mental-health practitioner and have used self-help strategies, and are still suffering from high levels of anxiety, it may be appropriate to consider medication. Following are some questions that may help you to decide whether it is appropriate.

HOW LONG HAVE YOU BEEN SUFFERING FROM THIS EPISODE OF ANXIETY?

If it has been several months, and there is little improvement in spite of using strategies that are known to be helpful, it may be time to think about medication.

HOW INTENSE AND DISABLING IS YOUR ANXIETY?

If the anxiety is unpleasant but manageable, it may be worth persevering with psychological therapy and self-help strategies. If the anxiety feels overwhelming and is having an impact on your ability to function (in areas like work, social relationships, parenting, etc.), it may be worth trying medication.

IS YOUR ANXIETY ASSOCIATED WITH DEPRESSION?

If you are suffering from depression as well as anxiety, your symptoms are likely to be more disabling. Antidepressant medication can reduce symptoms of both conditions, so may be worth considering.

ARE YOU FEELING HOPELESS?

Some people find themselves at their wits’ end. They feel totally overwhelmed by anxiety, and find it hard to believe they will ever recover. Feelings of hopelessness and/or depression, in addition to anxiety, suggest that medication may be worth considering.

DO YOU HAVE A BIOLOGICAL DISPOSITION TO ANXIETY?

If you have a family history of severe anxiety and/or depression, the disposition to anxiety may be biologically, as well as psychologically, driven. When anxiety has a strong biological underpinning, medication can be a good adjunct to psychological therapy.

DO MEDICATIONS WORK?

For those thinking about taking medication, a common question is will it help? The answer is often, but not always. Evidence from clinical trials suggests that antidepressant medication can reduce worry and distressing symptoms in GAD, as well as other anxiety disorders. Clinical experience of most mental-health practitioners is that many people do feel considerably better with medication, and, for some, the symptoms largely resolve. However, the potential benefits need to be balanced with possible side effects, which may be minor or substantial.

If you are considering medication, this is an issue that you should discuss with your GP or a psychiatrist. They will provide relevant information and, if you both agree that you should give it a go, write a prescription.

TYPES OF MEDICATIONS

There are various types of medication that can be used to treat anxiety, and their benefits and side effects vary between individuals, so they are hard to predict beforehand.

Here is a description of the main categories of medication and some key facts about each.

BENZODIAZEPINES

This category of drugs are known as ‘minor tranquilisers’, and include diazepam (Valium), oxazepam (Serepax), lorazepam (Ativan), clonazepam (Rivotril) and alprazolam (Xanax). There are also sleep-inducing versions, such as nitrazepam (Mogadon) and temazepam (Normison, Temaze), which are prescribed for insomnia.

Benzodiazepines act on the brain and central nervous system by enhancing the action of the neurotransmitter GABA (gammaaminobutyric acid). Neurotransmitters are chemical messengers that enable brain cells (neurons) to transmit impulses from one to another. Once released, neurotransmitters signal inhibition or excitation of neighbouring brain cells. GABA is the major inhibitory neurotransmitter. The function of GABA is to slow or calm things down. Benzodiazepines increase the efficiency of GABA, thus creating a calming effect.

For most people, benzodiazepines produce a rapid reduction in anxiety, and in the late 1970s, they were the most frequently prescribed medications in the world. This situation changed in the 1980s when it was discovered that these drugs are tolerance-forming (that is, they lose their effect with repeated use) and addictive over time.

While there is debate about the suitability of prescribing benzodiazepines for anxiety disorders, many clinicians believe that judicious use can be a helpful adjunct to treatment. Current prescription guidelines recommend no more than two to four weeks of continuous use. Beyond that, tolerance and risk of addiction outweigh any potential benefit. (As benzodiazepines are commonly misused, or taken in combination with drugs of abuse, many doctors are reluctant to prescribe them.)

While not a long-term solution, benzodiazepines can be useful for short-term, acute anxiety in specific high-threat situations. For instance, for individuals with a fear of flying, a drug like Valium or Ativan taken before the flight (at a dose recommended by your GP) can eliminate much of the fear. For some, the mere knowledge of a ‘pill in my pocket’ can provide reassurance and freedom from anxiety. Benzodiazepines are also helpful for people dealing with intense performance anxiety, such as having to give a speech, perform at a music recital, give evidence in court or attend an important job interview. A low dose of benzodiazepine can reduce anxiety and apprehension, and so improve performance on the day.

Benzodiazepines are generally well tolerated and usually take effect within 20 to 30 minutes. The most common side effect is drowsiness, particularly at higher doses. Other, less common side effects include lightheadedness, confusion, unsteadiness and headache.

While benzodiazepines may be helpful for managing occasional high-threat situations, they are not a solution for fears that need to be faced frequently (e.g. regular meetings at work, trips to the supermarket or daily commuting). For these situations, other strategies (including exposure, mindfulness and panic surfing) are more appropriate.

ANTIDEPRESSANT MEDICATIONS

Medications that are prescribed for the treatment of depression are also frequently used for the treatment of anxiety disorders. The term ‘antidepressant medication’ is misleading because it suggests they are specifically for depression. Many people with high levels of anxiety and worry are not depressed, and may therefore assume that the medication is not suitable for them.

Even though anxiety and depression are different conditions with distinctly different symptoms, two key neurotransmitters, serotonin and norepinephrine, play an important role in both. Therefore, medications that affect the availability of these neurotransmitters in the synaptic cleft – the space between neurons (brain cells) – are used for treatment of both conditions. ‘Antidepressant medications’ could just as easily be called ‘anti-anxiety medications’.

This category of drugs need to be taken on a daily basis, usually for at least a few weeks, before benefits are felt (although some people notice benefits more quickly). While some medications are likely to produce greater side effects than others, most people experience some side effects, at least for the first week or two.

Side effects may include dryness in the mouth, gastrointestinal symptoms, sexual dysfunction, jitteriness or tremor, constipation, headaches, sleep disturbances and fatigue. (Note that reading about and anticipating side effects increases the likelihood of experiencing them. People who are apprehensive about taking medication are more likely to perceive side effects, even when taking placebo pills, so doing too much research on possible adverse effects may influence your experience.) Some people experience no side effects, or minor side effects that resolve within a week or two, while others have unpleasant side effects that lead them to discontinuing.

Antidepressant medications can interact with other drugs, so before commencing, you should remind your prescribing doctor of other medications you are taking. While this category of drugs is not considered to be addictive (in the way that benzodiazepines are), ceasing antidepressant medication after long-term use can result in ‘discontinuation syndrome’, which is characterised by unpleasant symptoms such as increased anxiety, depressed mood, headaches and agitation. The symptoms can usually be avoided by gradually tapering the dose over a period of weeks or months.

There are different categories of antidepressant medications that have been found to be helpful in the management of anxiety disorders, so let’s take a brief look at these.

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)

Common types (and brand names) of SSRIs include: escitalopram (Lexapro), fluoxetine (Prozac, Lovan), sertraline (Zoloft), paroxetine (Aropax), fluvoxamine (Luvox) and citalopram (Cipramil).

While antidepressant medications have been around since the 1950s, the emergence of SSRIs in the 1980s resulted in a substantial increase in their prescribing. SSRIs are now the most widely prescribed drugs for anxiety and depression, because they have fewer side effects than the older types and, unlike benzodiazepines, are not considered addictive.

SSRIs work by increasing the availability of the neurotransmitter serotonin in the synaptic clefts (the spaces between adjoining neurons) within the brain, by preventing its natural reuptake (via a reuptake pump in the neighbouring neuron). The resulting greater availability of serotonin in the synapses may increase feelings of wellbeing and reduce symptoms of anxiety and depression.

While SSRIs are frequently effective, for some people, there is an increase in anxiety and insomnia. This usually lasts for just a week or two, but may be ongoing. For this reason, medical practitioners sometimes prescribe benzodiazepines to be taken concurrently with SSRIs for the first two weeks.

SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)

Common types (and brand names) of SNRIs include: venlafaxine (Effexor), desvenlafaxine (Pristiq) and duloxetine (Cymbalta). These drugs emerged in the 1990s, as pharmaceutical researchers sought to develop drugs with broader mechanisms of action.

SNRIs influence the levels of serotonin and norepinephrine in the synaptic clefts by inhibiting the reuptake of both neurotransmitters. This may result in feelings of greater wellbeing, and a reduction in anxiety and depression.

People who do not respond to treatment with SSRIs are sometimes directed to this category of medication. Because they are broader-acting (affecting both serotonin and norepinephrine), SNRIs are considered potentially more effective, but also possibly producing more side effects. There is some debate about both of these contentions, and the evidence is inconsistent. It is clear that individuals respond differently to the various medication, and psychiatrists often juggle medications at various doses, trying to find the most effective dose or combination for each individual.

TRICYCLIC ANTIDEPRESSANTS (TCAs)

Common types and brand names of TCAs include: amitriptyline (Tryptanol, Endep), clomipramine (Anafranil), dothiepin (Dothep, Prothiaden), doxepin (Sinequan), imipramine (Tofranil), nortriptyline (Allegron) and trimipramine (Surmontil).

TCAs have been around since the 1950s and are among the oldest types of antidepressant medication. They are named after their three-ringed chemical structure, and, like SNRIs, they also work by inhibiting reuptake of serotonin and norepinephrine.

Common side effects of TCAs may include sleepiness, weight gain and postural hypotension (drop in blood pressure when changing body position, which can cause dizziness). These days, SNRIs and SSRIs are more frequently prescribed than TCAs because they are believed to produce fewer side effects and have a better safety profile. However, for some people, TCAs are more effective in reducing anxiety and/or depression, and also often have a sleep-inducing effect, which may help with insomnia when taken at night. Because they are not considered addictive (unlike most sleeping pills), a low dose of TCAs is sometimes prescribed for the management of insomnia.

MONOAMINE OXIDASE INHIBITORS (MAOIs)

Common types and brand names of MAOIs include: isocarboxazid (Marplan), phenelzine (Nardil) and tranylcypromine (Parnate). These drugs work by inhibiting the action of the enzyme monoamine oxidase from destroying neurotransmitters serotonin, epinephrine and norepinephrine in the synaptic space. When these neurotransmitters remain in the synaptic space for longer periods, they may reduce anxiety and depression.

MAOIs can be an effective treatment for individuals who have not responded to other types of antidepressant medication; however, they are less frequently prescribed because of the potential toxic effects when combined with tyramine, which is present in many foods. People taking MAOIs need to adhere to dietary restrictions, avoiding foods such as matured cheeses, condiments, fermented foods, certain alcoholic beverages, processed meats, nuts, chocolate, and many other products. MAOIs are also more likely to interact with other types of medication, and are considered less safe than the newer generations of antidepressants.

A more recent variation is moclobemide (Aurorix), which is categorised as a ‘reversible MAOI’. This is more frequently prescribed these days, as it does not require many dietary restrictions.

ATYPICAL ANTIDEPRESSANT MEDICATION

This category includes mirtazapine (Avanza), nefazodone (Serzone), trazodone (Desyrel), bupropion (Zyban), vortioxetine (Brintellix) and agomelatine (Valdoxan). These newer types of antidepressant medication do not fit into any of the common categories and work through different processes. Their benefits and common side effects vary.

ANTIPSYCHOTIC MEDICATIONS

The first generation of antipsychotic medications include haloperidol (Haldol), loxapine (Loxitane), thioridazine (Mellaril), molindone (Moban). The second generation includes olanzapine (Zyprexa), quetiapine (Seroquel) and risperidone (Risperdal).

This category of medication is predominantly used for treating disordered thinking that accompanies schizophrenia and psychotic episodes in bipolar disorder. It is also sometimes prescribed for treatment-resistant depression, to reduce agitation, and for anxiety conditions that do not respond to other treatment. They work by blocking specific dopamine and serotonin receptors (allowing for more of these neurotransmitters to remain in the synaptic cleft), as well as some other receptors (which vary between medications).

The first generation of antipsychotics was developed in the 1950s. Due to concern about extensive side effects, a second generation of antipsychotics were developed and released in the 1990s and early 2000s. These days, it is mainly the second-generation drugs that are prescribed. While these newer medications were initially considered to produce fewer side effects, their side effects are still extensive, and possibly as severe as those of the first generation.

At low doses, antipsychotic medications may be well tolerated, but at higher doses, substantial unpleasant side effects often arise. These may include weight gain, drowsiness, increased risk of diabetes, cardiac disease, blood clots, and a movement disorder called ‘tardive dyskinesia’.

BETA BLOCKERS

This is a class of drugs commonly prescribed for treatment of high blood pressure, arrhythmias and angina. By blocking adrenaline receptors in the heart and muscles, beta blockers prevent the heart palpitations, high blood pressure, sweating and shaking that normally accompany the fight-or-flight response and the release of adrenaline.

Like benzodiazepines, beta blockers can be useful in specific situations where we anticipate high levels of anxiety. By suppressing the fight-or-flight response, these drugs can alleviate the distressing symptoms that accompany performance anxiety. They may therefore reduce arousal during situations like public speaking, job interviews, exams and musical recitals. Unlike benzodiazepines, this category of medication does not create drowsiness and is not addictive. The most frequently studied beta blocker for performance anxiety is propranolol (Inderal), which is normally taken about half an hour prior to the feared event.

For people with social anxiety who worry about the visible signs, like shaking, blushing and sweating, beta blockers can alleviate those symptoms. The reassurance that comes with being able to avoid overt signs of anxiety can reduce fear of social situations, and encourage exposure to previously feared social events.

Unlike benzodiazepines, beta blockers have no direct effect on anxiety other than controlling physical arousal (for instance, they do not prevent worrying or modify catastrophic thoughts). Nevertheless, for some people, the reassurance of being able to avoid feared symptoms can indirectly reduce anxiety and create feelings of control.

While beta blockers can sometimes be a useful aid for confronting feared situations and building the confidence to practise exposure, their potential benefits are limited. Not all feared situations can be anticipated and planned for, especially for situations that arise frequently. In addition, reliance on beta blockers may prevent learning that we can face and tolerate our feared situations without medication, which may impede recovery in the longer term.

SUPPLEMENTS, AND HERBAL AND NON-PRESCRIPTION MEDICINES

In addition to conventional medicines, many herbal remedies have been promoted for reducing anxiety, including passionflower, lavender, valerian, lemon balm and chamomile. These are sometimes combined with other herbs and sold as anti-anxiety supplements or ‘stress formula’. Whether or not they are effective has not been established, as there have been few quality studies to support their efficacy.

We tend to assume that conventional medications can cause harm, while herbal remedies are safe, but this is not always the case. Herbal remedies have limited oversight by the Therapeutic Goods Administration (TGA), Australia’s regulatory agency for medical drugs and devices, and are therefore not subject to the strict monitoring and controls that apply to pharmaceuticals.

Kava, for example, a member of the pepper family, has been traditionally used by Pacific Islanders to make beverages for social, ceremonial and medicinal use. In Western countries, supplements containing kava are marketed for the treatment of anxiety, and a review of studies concluded that it is superior to placebo for treating GAD. Unfortunately, there have been several reports of liver damage associated with the consumption of kava, prompting the TGA to issue a voluntary recall of kava products.

The lesson here is that just because a product is ‘natural’ doesn’t mean it is always safe. As herbal remedies have far less research and safety testing compared to conventional medicines, their use should be approached with caution.

Another example is St John’s wort, which has been found to be helpful for mild to moderate depression. To date there has been little research into its effects for anxiety, although there is anecdotal evidence that it can be helpful. St John’s wort has been found to interact with certain prescription medicines (including antidepressant medications, oral contraceptives, a particular migraine medication and anti-seizure medication). This has prompted the TGA to issue a warning about its use. If you are planning to take it, and are already taking other medication, it is a good idea to check with your GP first.

Homeopathic medicines and Bach Flower remedies claim to use ‘vibrational energy’ to produce changes in a person’s energy field, and are promoted by advocates as safe treatments for anxiety. Most famously, Rescue Remedy, which is said to contain diluted ‘energy’ from five flowers, has a substantial following among consumers of complementary therapies. These substances are likely to be safe because they contain no active ingredients (beyond ‘vibrational energy’); however, their efficacy as a treatment for anxiety (beyond a placebo effect) has not been established.

Acupuncture, the ancient tradition of inserting needles into specific body points to manipulate the flow of energy, has been practised for thousands of years as part of traditional Chinese medicine. It is based on the concept of ‘Chi’, a vital energy force flowing around the body along certain meridians. Stimulation of points along these meridians is considered to balance opposing forces, ensuring energy flow and good health.

Studies that have examined the use of acupuncture for anxiety have been of moderate to poor quality, and have produced mixed results. While several studies showed reductions in anxiety following treatment, most did not include a sham condition (needles placed in random, incorrect locations). Of those that did, most found no difference between sham and authentic acupuncture, suggesting any reductions in anxiety may reflect placebo effects.

Anxiety and depression are both highly responsive to the placebo effect (a positive effect generated purely by the belief that what you are doing or taking will help). This means that even substances or treatments with no scientifically proven benefits can produce desired outcomes, although not through the mechanisms claimed. Does this matter? From a consumer point of view, perhaps not. In the scientific community, many have concerns about manufacturers of ‘natural therapies’ making unsubstantiated or misleading claims in order to sell their products.

It should be noted that pharmaceutical medications are also subject to placebo effects. However, pharmaceuticals have undergone more rigorous testing and evaluation than complementary therapies to make it to the stage of being a prescribed medicine, and will need to have demonstrated benefits over and above placebo. (Of course, these medications don’t always help either.) The side effects of conventional medicines are generally more extensive (and more thoroughly documented) than complementary therapies, which make the latter a more attractive option for people who worry about drug side effects.

IN SUMMARY

Medications should not be taken as a first line of treatment, before psychological therapy, e-therapy or bibliotherapy have been tried. They work best when combined with psychological therapy and self-help strategies.

There is a range of medication options for the treatment of anxiety. Most commonly prescribed are antidepressant medications, which need to be taken daily for at least several months. In addition, benzodiazepines and beta blockers can provide short-term relief in specific anxiety-provoking situations.

There are a number of unproven or ‘complementary therapies’, including herbal remedies, homeopathic preparations and acupuncture, which could also be helpful; however, their benefits are not well established. While side effects are usually fewer, there are still risks associated with some complementary therapies.

CHAPTER 13

Sleep and Lifestyle Habits

‘Take care of your body. It’s the only place you have to live.’

JIM ROHN

Our minds and bodies are interconnected parts of the self – behaviours that affect one also invariably affect the other. Adopting a healthy lifestyle can influence both our physical and mental wellbeing. Key aspects of a healthy lifestyle include a nourishing diet, regular exercise, social activity and good sleep habits. Reflecting on each of these may encourage us to adopt healthier habits.

The main focus of this chapter is on sleep, which is frequently disrupted during periods of anxiety. Disturbed sleep is also a common symptom of GAD.

SLEEP

It is widely acknowledged that getting sufficient sleep is vital for one’s mental and physical wellbeing. Insomnia – the inability to fall asleep or to get sufficient hours of sleep during the night – is a common problem for people who experience frequent anxiety. For some, insomnia is ‘comorbid’ (or associated) with a mental-health condition, such as an anxiety disorder, post-traumatic stress disorder, bipolar disorder or depression. For others, it may come and go, in response to stresses in our daily lives.

Frustratingly, reminders about the importance of sleep may fuel insomnia. In addition to the direct physical effects of sleep deprivation (including fatigue, impaired concentration and slower reaction times), worry about not getting enough sleep frequently exacerbates anxiety, and paradoxically perpetuates disturbed sleep.

Insomnia is associated with difficulty falling asleep (‘onset insomnia’) or staying asleep (‘middle insomnia’). In the latter case, we typically wake up in the middle of the night or early hours of the morning and can’t get back to sleep. While anxiety about a particular issue is a common cause of insomnia, sometimes it is agitation and restlessness that perpetuates anxiety and further insomnia. We might be lying in bed wide awake, urging ourselves to sleep, telling ourselves that there will be hell to pay tomorrow if we don’t!

Not all sleep disorders are caused by anxiety – some are due to physical factors. These include circadian rhythm disorders associated with irregular sleep patterns (e.g. due to shift work), restless legs syndrome, periodic limb movement disorder, obstructive sleep apnoea and insomnia caused by medical illness. Some medical conditions (like hyperthyroidism and arrhythmia) interfere with sleep directly, but more often it is the symptoms of the condition, such as pain, breathing difficulties, reflux, itching and frequent urination, that cause insomnia. Certain medications (such as steroids, beta blockers, decongestants and nicotine patches) can also interfere with sleep.

In response to insomnia, some people reach for sleeping pills. These may help for brief periods (e.g. the night before an important job interview); however, because they are tolerance-forming and addictive, they are inappropriate for use over more than a few days. Sleeping pills also interfere with REM (rapid eye movement) sleep, which may impact the quality of our sleep.

Alcohol, which is sedating in the short term, also produces poor-quality sleep, particularly when used frequently, and is therefore not recommended for insomnia.

Melatonin is an alternative non-addictive option that can be prescribed by GPs or bought over the counter at a low dose (reported results are mixed). Others swear by caffeine-free herbal teas, such as valerian root or chamomile, taken before bedtime. In addition, certain types of antidepressant medication are sedating, and are sometimes prescribed by GPs as an alternative, non-addictive option to sleeping pills.

While medications may sometimes be used as short-term measures, there are lots of things we can do to improve our sleep. Establishing healthy sleep habits gives us a greater sense of control, and will protect us from insomnia over time.

Useful strategies fall into two categories:

1.     Sleep hygiene: managing our own habits and environment to optimise sleep.

2.     Flexible thinking: changing the way we think in relation to sleep, both during the day and when lying awake in bed.

To understand the reasons why certain behaviours are particularly important, let’s first take a look at physiological factors that influence our sleep.

CIRCADIAN RHYTHM

Our circadian rhythm is our 24-hour internal body clock (actually 24 hours and 10 minutes, but environmental cues enable us to function on 24-hour cycles). It is also known as the ‘sleep–wake cycle’, because it moves us between sleepiness and wakefulness each day.

Our circadian rhythm is controlled by the suprachiasmatic nucleus (SCN) – a group of about 20,000 neurons, located in our hypothalamus. The SCN is sometimes referred to as the body’s ‘master clock’, because it determines when we feel sleepy and when we feel alert. Information about incoming light comes to the SCN from the eyes, via our optic nerves. When there is less light, the SCN signals the pineal gland to produce melatonin – a hormone that induces feelings of sleepiness. When light increases, the SCN signals our pineal gland to stop releasing melatonin, which increases feelings of alertness. For this reason, our circadian rhythm tends to coincide with the cycle of daytime and night-time. (For our primitive ancestors, who had no artificial source of light, it coincided more directly.) These days, artificial lighting and screens send light signals to our SCN after dark, resulting in delayed production of melatonin and delayed sleep.

For most adults, feelings of sleepiness peak in the middle of the night, somewhere between 2 am and 4 am, and after lunch, roughly between 1 pm and 3 pm. (Those times may vary, depending on whether you are naturally a ‘night owl’ or a ‘morning person’.) Feelings of wakefulness usually peak some time in the morning.

These physiological rhythms have important implications for healthy sleep habits. Operating in harmony with our circadian rhythm optimises our likelihood of getting adequate sleep, and feeling rested during the day.

SLEEP HYGIENE

Sleep hygiene involves managing aspects of lifestyle and behaviour, as well as environmental factors such as light, noise and temperature, in order to optimise our sleep. Following is a summary of key recommendations.

ESTABLISH A REGULAR ROUTINE

Our circadian rhythm works best when we have regular sleep habits. This means going to sleep and waking up at around the same time each day, including on weekends. Our circadian rhythm is reinforced by regular meal times, movement and social activity during the day, and reduced activity and stimulation in the evening.

Rising at the same time each day is important, even when we feel sleep-deprived, because it maintains circadian rhythm and sets the time when our body will be ready to go to sleep that night. Refrain from snoozing once you are awake. (For more information, see the online video ‘The science of snoozing’, produced by Mashable.)

It is normal to feel tired upon rising (called ‘sleep inertia’), but this will subside as we go about our day. Going for a walk soon after rising is an ideal remedy, because it combines exercise with exposure to light. Alternatively, you could do some early morning activity in a sun-drenched room or practise morning meditation on the balcony or in the garden. Other ways of increasing wakefulness in the morning include having a shower, listening to upbeat music or telephoning a friend (social activity stimulates the brain). Also, be aware of body temperature – cool temperature creates a state of alertness, while overheating makes us drowsy.

ESTABLISH A REGULAR WINDING-DOWN RITUAL

As bedtime approaches, a regular winding-down ritual will psychologically prepare you for sleep. This may involve things like brushing your teeth; having a bath; having a cup of herbal tea; writing in a journal and listing ‘gratitudes’ for the day; reading a book in bed; or listening to relaxing music, a podcast or a guided relaxation in bed.

USE THE LIGHT

Light stops the secretion of melatonin, the hormone that makes us feel sleepy, so this is useful when we want to feel more awake. In the morning, open the blinds or curtains and let the sunlight stream in. Go outside soon after rising – this provides the strongest source of light, even on a cloudy day.

Conversely, avoid exposure to bright light in the evenings and during the night. Avoid putting on lights when going to the bathroom in the middle of the night, or install very dim lights if you need to. Darkness stimulates the pineal gland to release melatonin, so being in a dark environment is conducive to sleep.

Beware of exposure to computer screens, phones and tablets close to bedtime, as these emit a blue light, which may interfere with melatonin release. (The research is not conclusive on this. It may possibly be mental stimulation from screen activity rather than blue light that delays onset of sleep.) For phones and tablets, there are apps that can be used to tone down the blue light after sundown, or you can enable the night mode function of your phone if it has one. If you watch TV before bed, avoid watching stimulating programs.

CREATE A RESTFUL BEDROOM ENVIRONMENT

Try to maintain a restful sleep environment in the bedroom: create a comfortable temperature (don’t overheat or overcool), make sure there’s low noise, remove excess clutter and use blinds or curtains to keep the room dark. Diffuse lavender oil in the bedroom can also create a calming atmosphere that psychologically prepares you for sleep.

EXERCISE REGULARLY

Regular daily exercise is extremely helpful for sleep and psychological health, but can be arousing in the short term, so avoid vigorous exercise two hours prior to sleep.

BEWARE BAD HABITS

Avoid daytime napping or dozing, including in front of the TV – a common cause of night-time insomnia. For the majority of people, the strongest appetite to sleep occurs around 11 pm. Naps reduce the natural pressure to sleep that builds in the lead-up to this time, and frequently cause onset insomnia.

Be aware that waking up during the night is normal, so no need to fret when that happens. Avoid checking the time during the night. Remove the bedroom clock if necessary, or turn it around to face away from you in order to avoid the temptation to peek. Do not keep your phone in the bedroom, or set it to block calls and notifications during sleep hours (many phones have a ‘do not disturb’ mode). Never check messages or social media during the night. Digital wrist monitors are to date not reliable indicators of length or depth of sleep, and, if worn, should never be checked during the night.

AVOID SLEEP-IMPAIRING SUBSTANCES

For most people, normal daytime caffeine consumption does not impair sleep, but depending on your degree of sensitivity, caffeine use may need to be moderated, and should be avoided between four and six hours before bedtime. Avoid alcohol after dinner and avoid smoking always, but particularly near bedtime. For some people, going to bed hungry can cause onset insomnia, and some report that a light pre-bedtime snack (e.g. banana, rice cakes or yoghurt) can be helpful.

DON’T FRET WHEN SLEEP WON’T COME

Apart from concerns about being tired the following day, many people find the boredom and agitation associated with lying awake at night highly aversive. One option is to listen to podcasts that give us something to focus on – ideally not too rousing in content. (I recommend Sleep With Me – see appendix.) Guided meditation or relaxation exercises (via CDs or online) can also increase relaxation and redirect our mind from worries.

An alternative approach is stimulus control, which involves breaking the association between lying in bed and wakefulness. If you cannot sleep, go into another room and do something mundane, such as reading a book, listening to a relaxing podcast or doing a simple task (like the ironing or knitting). Watching TV is OK, but avoid material that is rousing or suspenseful. Go back to bed when you feel sleepy. Many people find this technique extremely effective. In addition to getting us back to sleep when we return to bed, it also strengthens the mental association between going to bed and sleeping.

ENERGISE YOURSELF DURING THE DAYTIME

While we may dread the feeling of tiredness after a night of poor sleep, there are things we can do to increase our energy on the following day. Remember your energy-lifters: go outside, do physical exercise, be active, have a shower, phone a friend, listen to upbeat music, sing with the music or without it, and focus your attention on things happening in the external world, rather than how you feel. Also remember that even though you may feel tired during the day, you will probably be able to function, at least to some extent. If you focus on what you do rather than how you feel, you may find that the outcome is not as disastrous as you had believed.

FLEXIBLE THINKING

We are more likely to have difficulty sleeping when we are anxious, because threat perceptions put us on alert and prepare our body for action. Insomnia may begin with worry or anxiety about a specific issue. It could be about a strained relationship, a health problem, financial pressure, work stressors, concern about a family member or any of myriad other issues that arise. The amygdala sounds the alarm and activation of the sympathetic nervous system ensures a steady release of adrenaline, keeping us in a wakeful, prepared state. This is obviously not what we need when we are trying to sleep.

By employing flexible thinking strategies, however, we can change the way we think in relation to sleep, both during the night and in the daytime, thereby improving our sleep.

IN THE MIDDLE OF THE NIGHT . . .

When we feel anxious, our mind becomes vigilant for threat. In the darkness of night, in the absence of our usual distractions, worrying and catastrophic thoughts proliferate. Any pre-existing concerns can take on a magnified importance as we lie awake in bed. We try to reassure ourselves by thinking it through: ‘What could happen?’, ‘How can I prevent it?’, ‘Would that work?’, ‘But what about . . .’ Analysing, analysing, thinking, thinking . . . Going down various ‘rabbit holes’ keeps us engaged in our thoughts, aroused and awake.

PROBLEMS FEEL MAGNIFIED

Why do all of our problems seem so much greater in the middle of the night? For our Stone Age ancestors, threats to survival were greatest at night, when predators roamed and rival gangs were more likely to attack. During dangerous times, being vigilant and easily roused from sleep provided an obvious survival advantage.

While we no longer need fear being clubbed or eaten in the middle of the night, we have retained brain architecture that ensures our sleep is light during periods of perceived danger. If we are feeling anxious when we go to bed, pre-existing threat perceptions can blow up into catastrophic thoughts during the night. Perceptions of imminent danger make us want to solve the problem right now. High levels of neural activity within the amygdala and subdued prefrontal cortex activation means that we are responding to exaggerated threat signals. However, we cannot trust the content of our thoughts when we are lying awake in the middle of the night. Even if our concerns have some validity, this is not the time to workshop solutions. We will be able to see things far more objectively and make better decisions when daytime arrives. So here is the golden rule for night-time worrying: do not try to solve problems when lying awake in bed.

The best thing you can do in these situations is to keep a pad beside your bed and write down any issue that is troubling you. Then ‘park it’ for now and commit to revisiting the issue tomorrow. If it requires problem-solving, you can do that then. (It’s a bit like using the worry-delay pad, but the review happens the next day.)

On the following day, you are likely to have a different perspective. The prefrontal cortex is back ‘online’, and the issue may seem less important now. You may be philosophical about a problem that seemed critical just a few hours ago. Even if there are things you need to address, you will be in a better position to problem-solve once daytime has arrived.

NIGHT-TIME WORRY ABOUT NOT SLEEPING

In most cases of insomnia, it is our issue of concern (family, friends, health, work, etc.) that keeps us awake. Once the issue is resolved or we have adapted to our situation, threat perceptions fade and we relax. Usually we go back to our previous pattern of sleeping – at least until the next problem emerges.

Sometimes, however, days or weeks of insomnia may give rise to a second problem – the fact that we are not sleeping may become a separate threat. Lying awake at night when we believe we should be sleeping may generate further anxiety and worry, keeping our amygdala firing and our body aroused. Paradoxically, worry about not sleeping creates further insomnia. The more we fret, the less sleepy we feel, and the more we worry about not feeling sleepy, the greater the magnitude of our perceived problem: ‘Will I ever be able to get to sleep?’, ‘How terrible will I feel tomorrow?’, ‘I won’t be able to function’, ‘Why can’t I sleep?’, ‘What is the solution?’ . . .

Our response to not sleeping can become the problem. Fighting insomnia is a no-win game. Worrying and urging ourselves to sleep simply feeds the problem. Trying to resist insomnia is like trying to fight anxiety by telling ourselves that we must stop feeling anxious. The harder we try, the more elusive it becomes.

Some of the key principles of mindfulness are particularly helpful for managing insomnia. Release judgement, and allow yourself to experience whatever is present, including tiredness, arousal, frustration and agitation. Allow yourself to be awake if that is what your body needs to do.

When we give up the struggle, sleep may come, but even if it doesn’t, lying peacefully in bed without fussing and fretting provides rest and regeneration. You need not try so hard.

DAYTIME WORRY ABOUT NOT SLEEPING

In addition to night-time insomnia, you may find yourself preoccupied with sleep during the day. Worry about how you will sleep may become a central theme in your life. The question ‘Will I be able to sleep tonight?’ may pop into your mind repeatedly during the day. You may be dreading the possibility of another night of broken or inadequate sleep, and the resulting anxiety only adds to your arousal. Fear of insomnia is often maintained by a fear of tiredness on the following day – ‘If I don’t get enough sleep, I’m going to be SO tired tomorrow. I won’t be able to . . .’ We think about how bad we will feel, and how this will affect our ability to function. We imagine feeling terrible.

So now we have two problems.

The first one is insomnia, and it is possible that we will indeed feel tired tomorrow.

The second problem is the emotions we experience in response to insomnia. It is the anxiety, frustration, despair and other upsetting emotions that arise when we insist we should be sleeping. The gap between where we are and where we want to be maintains our suffering. Worrying, fretting, reminding ourselves how bad we will feel tomorrow, thinking about all the things we need to do, and how we will not be able to do them . . . It doesn’t help! Fighting and resisting our current reality creates anxiety and upsetting emotions. These add to our tiredness and perpetuate insomnia.

Mindful acceptance allows us to release resistance, and make peace with our present state (see chapter 7).

REFLECT

If you were able to release any emotional distress that arises in response to not sleeping (that is, the anxiety, worry and frustration), how would your experience of not sleeping be different?

‘I HAVEN’T HAD MY SLEEP QUOTA’

Some people believe they must get a certain number of hours of sleep each night in order to function. It might be six or seven or eight hours, but the assumption is, ‘Unless I get my quota, I will be a write-off tomorrow.’ You might find yourself keeping tabs on the amount of sleep you are getting, and worrying when you think you have not slept enough.

A few things to keep in mind here. First, most people underestimate the number of hours they sleep each night, so our appraisals are not reliable. (Digital sleep trackers are unreliable and reinforce unhelpful preoccupations with quotas.) Second, sleep requirements vary enormously over our lifetime, as well as between individuals, so our presumed quota may be unrealistic, particularly as we age. The more we monitor and focus on hours slept, the more likely we are to perceive shortcomings. These perceived shortcomings can negatively affect our mood and even our level of tiredness (‘I’ve only had five hours sleep tonight. That’s no good – I’m sleep-deprived!’).

The moral of the story? Drop the quota and drop the monitoring.

WHEN SHOULD YOU START TO SUFFER?

In previous chapters we saw that asking ‘When should I start to suffer?’ is a great way to remind ourselves that we don’t need to suffer in anticipation of negative events – we can wait, and deal with them if or when they happen. The same applies to worrying about insomnia. Even if it is true that you will feel tired tomorrow, when should you start to suffer?

You may or may not suffer from terrible tiredness tomorrow, but why suffer now? Why suffer twice? Why not wait until you feel terrible before you start to feel terrible? Worry about not sleeping, and all the bad feelings that may come from that, creates suffering now, and is a bigger problem than the fact that you are not sleeping. Drop the judgement and the problem is halved.

But why do people feel compelled to worry about their sleep, even when they are not trying to sleep right now? The answer can be found in chapter 8 on metacognitive beliefs. Unconscious assumptions about the benefits of worrying perpetuate the urge to worry, including worry about sleep. It may feel like worry about how bad we will feel prepares us for a bad day tomorrow, or focuses our mind on a problem that needs our attention now, and may therefore help us find a solution. But does it? Practising mindful acceptance of our current experience is the most helpful way to discover that by releasing judgement – simply allowing ourselves to not sleep – we can avoid unnecessary anxiety. This is the key to switching off the self-perpetuating cycle of insomnia.

REFLECT

If it is true that you will feel very tired tomorrow, when would you like to start feeling bad? Is there any advantage in suffering now?

Finally, if you have taken all reasonable steps to manage your sleep, and continue to experience insomnia, consider seeing your GP. They can provide a referral to a psychologist with expertise in treating sleep disorders, or to a sleep clinic. Getting more information about the nature of sleep and how we can improve it can also be helpful – see recommended books in the appendix.

HEALTHY DIET, HEALTHY MIND

For decades, a healthy diet has been associated with a reduced risk of physical illness and mortality from all causes, but could it also affect our mental health? There is a growing body of research suggesting this is the case. Numerous studies have shown that a diet high in fresh fruit and vegetables, and good-quality sources of protein contributes to healthy cognitive functioning (including the ability to concentrate, remember and solve problems), and reduces the risk of anxiety and depression. In contrast, diets characterised by a high consumption of red and/or processed meats, refined grains, sugar, high-fat dairy products, saturated fats, processed foods and low intakes of fruit and vegetables are associated with an increased risk. Even rodent studies have found that eating a highly processed, nutritionally poor diet increases anxiety-like and depressive-like behaviours in rats and mice.

Of the various eating regimes that have been studied, the Mediterranean diet is currently the most widely recognised option for protecting physical and mental health. Established benefits include a lowered risk of certain cancers, cardiovascular diseases, depression and dementia. The diet comprises a high intake of fruit, vegetables, legumes, fish, nuts and seeds, olive oil, yoghurt, a small quantity of other dairy products (cheese and milk) and white meat, and very small quantities of red meat. Wine in moderation (one standard drink a day) is included. While the established mental-health benefits associated with the diet are to date mainly in relation to depression, there are some suggestions that it may also assist with anxiety.

The reasons for these effects are not entirely clear, but may include anti-inflammatory properties of these foods affecting concentrations of monoamines (which play a role in the regulation of emotions and cognition). It has also been suggested that the antioxidant compounds in fruit and vegetables reduce oxidative stress-induced neuronal damage within the brain, which may therefore also affect mental health. High consumption of long-chain omega-3 fatty acids in oily fish are also believed to reduce depression risk. Finally, it may be the cumulative combined effect of all these nutrients and their biochemical properties that contribute to physical-and mental-health benefits.

In addition to a healthy, balanced diet, a new area of research is focusing on the role of gut bacteria in regulating mood and mental health. In recent years, neuroscience research has established the importance of microbiota in the development of brain systems that are vital to both stress reactivity and stress-related behaviours.

Human microbiome (the bacteria that live in various parts of the body, including the intestine, skin and lungs) are considered vital for maintaining physical health. The vast majority of these bacterial cells live in our intestinal tract, and play an important role in digestion, metabolism, manufacturing certain vitamins and regulating our immune systems. Our guts have their own separate nervous systems and generate many of the same neurotransmitters (including acetylcholine and serotonin) as the brain.

A link between gut microbiota and behaviours that indicate anxiety and depression has been found in mice and rats. Several studies have demonstrated a reduction of anxiety-like and depression-like behaviours in response to probiotic administration in rodents. Studies investigating possible mental-health benefits of probiotic supplements in humans have to date been inconclusive. Some found statistically significant, albeit small, reductions in anxiety and/or depression, while others did not. Many studies have been limited by methodological shortcomings.

An alternative to probiotic supplementation is eating probiotic-rich foods, which some people argue is a cheaper and more natural way of establishing healthy gut bacteria. Foods that are high in probiotics include yoghurt, pickles, sauerkraut, kimchi, kefir, tempeh, miso and kombucha. At this stage, the effect of these foods on psychological wellbeing is unknown.

PHYSICAL EXERCISE

Regular exercise is a well-established component of a physically healthy lifestyle. In recent decades, it has also been recognised as critical for maintaining mental health and cognitive functioning. Unlike antidepressant medication, exercise rarely produces negative side effects (except sore muscles on occasion). While it requires a degree of discipline, some form of exercise is affordable and accessible to all.

The benefits of exercise for the prevention and treatment of depression are well documented. Some studies have found daily exercise equivalent to antidepressant medication in treating mild to moderate depression. More recently, studies have found significant reductions in anxiety associated with regular exercise. Beneficial effects exist for both aerobic exercise (like brisk walking, jogging, cycling and swimming), and resistance-training exercise (like push-ups, sit-ups, weightlifting or using the machines at the gym to strengthen muscles).

Researchers have speculated on the underlying processes that might explain improved mental health. One theory is that exercise reverses this reduction in levels of serotonin and norepinephrine that normally accompanies ongoing anxiety. Animal models have shown that regular aerobic exercise increases serotonin and norepinephrine levels in the brain. These changes are similar to those that occur with the use of antidepressant medication, and comparable effects are believed to also occur in humans.

Some research has focused on the role of endogenous opioids, known as ‘endorphins’. These are produced in the pituitary gland, spinal cord and other parts of the brain and nervous system. Endorphins interact with receptors in cells found in regions of the brain responsible for blocking pain and enhancing emotional wellbeing. The endorphin hypothesis suggests that exercise triggers the release and binding of endorphins to their receptor sites in the brain, which results in improved mood and reduced anxiety.

Exercise alone is not a cure for anxiety disorders such as GAD, panic disorder and phobias; however, it is an important adjuvant therapy for their management. Although the underlying biological processes are not fully understood, the benefits of exercise for improving mental health are well established.

SOCIAL CONNECTION

While a healthy diet, regular exercise and adequate sleep are widely known protections for physical and mental health, the importance of social connection is not always well appreciated. A large body of scientific research has found that having satisfying relationships and feeling connected to others is associated with reduced risk of physical illness, and is as protective to health as regular exercise, not smoking or being in a healthy weight range. Indeed, the World Health Organization (WHO) includes ‘social support networks’ as one of the key determinants of physical health.

Throughout human history, our brains evolved in the context of living in tribes, and for most of that time, connections with others ensured our safety and survival. Although our existence is no longer at stake, we remain inherently social creatures and continue to feel drawn to interactions with others. These may be individuals, or those we connect with as part of our ‘tribe’. Modern tribes may be our family, friendship groups, work colleagues or members of a sports team or interest group. Belonging to a particular tribe can also be part of our identity.

Close, trusting relationships create feelings of safety and security, and provide a sense of shared meaning and purpose. They also play an important role in protecting our mental health. Social interactions improve our mood, contribute to self-esteem and reduce our likelihood of developing a mental disorder, including depression and anxiety-related disorders. They can boost our energy levels, and distract us from ongoing problems or rumination. Relationships are a resilience resource that helps us cope during stressful periods and difficult life transitions. They also enable us to recover more quickly should we develop a mental illness.

Connecting and talking to others can enable us to take a different perspective when our thinking is biased or unreasonable. During periods of emotional turmoil, we can learn from the experience of others, or just feel better from the realisation that others have been through similar experiences, and that we are not alone. Other people may also provide useful information or practical help (such as picking up the kids, cooking a meal or tidying the house), thereby easing the burden of our responsibilities.

There are different ways of conceptualising our degree of social connectedness, which has been reflected in the research. We can look at the presence or absence of a spouse (or partner), whether we live alone or with others, the number of people we interact with each week or our level of active engagement in social activity. Or we can focus on the way we feel – the perceived quality of our relationships, and the frequency of feelings such as loneliness or a sense of belonging. Seeing lots of people each week does not in itself create feelings of connection, and, for some, a small network comprising just a few close friends or family members is all that is needed. For others, seeing lots of friends and participating in regular social activity each week does not assuage feelings of loneliness, or a longing for meaningful connection.

The reality is that many of us do feel lonely at times. Australian research suggests that about a third of the population don’t feel part of a group of friends, and over 50 per cent experience periods of loneliness. Studies in the US found that between 20–43 per cent of adults over age 60 experience frequent or intense loneliness. Smaller families, growth of cities, breakdown of community groups and greater geographical mobility (where family members settle in different states or countries) have all contributed to increasing social disconnection. Digital technology and widespread use of smartphones have also been found to diminish the quality of interpersonal exchanges.

While having a supportive family helps to increase feelings of connectedness, research suggests that the presence of supportive friendships is an equal or stronger predictor of mental wellbeing in older age. So building and nurturing friendships can make a difference to our mental and physical health.

There is no simple method for reversing social disconnection; however, there are things we can do to make a difference. Here are some things you could do to improve your social connections:

Join groups with a shared interest or purpose. Consider sporting groups like golf, cycling, jogging (see Parkrun Australia), rowing or tennis. Consider becoming a volunteer or joining a social advocacy group for a particular cause. Other types of groups include book clubs, film groups, bridge, dancing, or community education courses. (See Meetup.com for a myriad of social-connection activities and places to connect.)

Initiate contact with existing friends and acquaintances. Be proactive. Suggest activities such as going to the movies, walks, lunch or brunch, or attending festivals or shows. Prioritise social relationships and make time for other people, even when your life is busy. Sharing a regular activity, such as a weekly walk, movies, concerts, dinners, sporting events, or a regular game of tennis, provides a structure for social connection and ensures routine contact.

Develop an open and honest communication style. Self-disclosure – talking honestly about our experiences, feelings, thoughts and beliefs – is the stuff that builds trust and creates connection. Being excessively polite, formal, reserved or overly agreeable builds walls between people – you might see the same person every day for ten years, but never really know them because there is no genuine communication.

IN SUMMARY

The body and mind are interconnected parts of the self. A healthy lifestyle protects both our physical and mental health.

Many people with anxiety disorders experience insomnia at times. Worry about not getting enough sleep (both during the night and during the day) may exacerbate anxiety, and paradoxically perpetuate the problem.

Insomnia can be improved by practising good sleep hygiene. This includes maintaining regular sleep routines that involve going to bed and rising at the same time each day. This can be facilitated by daily winding-down rituals, creating a conducive bedroom environment, and avoiding unhelpful sleep habits like daytime napping, checking the time and monitoring hours slept during the night, and exposure to bright light in the evening.

Developing a flexible attitude during periods of insomnia helps to break the self-perpetuating cycle. Learning to release judgement about not sleeping and avoiding the temptation to engage with worry thoughts during the middle of the night are conducive to better sleep.

Maintaining a healthy diet, incorporating largely nutritious, unprocessed foods can be protective for both physical and mental health.

Regular physical exercise, using either aerobic activity or resistance training, is also protective for mood and mental health.

Humans are inherently social creatures, and social connections are also important for maintaining mental and physical health. We can increase our social network and level of social connectedness by joining sporting or interest groups, being more proactive in initiating social contact with people we already know and using an open and honest communication style.

Summary of Key Strategies for Releasing Worry

I am sometimes asked what I believe to be the most important ideas and strategies for releasing the worry habit. While your own specific history, experiences and thinking style will determine the things that stand out for you, there are some key strategies that I would like to reiterate. They are described in detail in this book, and are also summarised below.

Educate yourself about worry and anxiety. Understand their nature and how they affect your thoughts, body sensations and behaviours. Notice worry when it arises, and reflect on why you feel drawn to engage with it. Remember that worry is about trying to be safe by considering all negative possibilities, but it rarely brings you the reassurance that you seek.

The content of our thoughts varies, depending on our current emotional state. When you are anxious, your thoughts become catastrophic. You cannot trust the content of your thoughts when you are in an anxious state.

Don’t confuse thoughts for reality. Just because you think something doesn’t mean it’s true. If you are anxious, your perspective is likely to be biased or unrealistic.

Identify frequent safety behaviours that you use, and work on releasing them over time. Create behavioural experiments to test whether they are really helpful. Behavioural experiments are the most powerful way of learning because they provide experiential learning.

Don’t get caught up in the content of your worry thoughts. Observe thought processes, and notice when your mind keeps pulling towards worry thoughts.

Don’t confuse worry for problem-solving. You can problem-solve without worrying. Worry does not add value to problem-solving.

Don’t assume that worry prevents good or bad things from happening. Worry makes no difference to life events.

Identify your own metacognitive beliefs about the protections of worrying (e.g. ‘Worry makes me prepared/gives me control/protects me/helps me to cope if things go wrong/motivates me to act’, etc.) These beliefs maintain your urge to worry.

Challenge metacognitive beliefs both logically and via behavioural experiments. Test whether your feared predictions happen when you drop worrying for a period.

Use worry delay, either with a pad or app, to discover that you can release worry. It’s incredibly helpful for breaking the worry habit, because it provides experiential learning that it is safe to do so.

Try metaphors, like ‘don’t swallow that hook’, to help you disengage from the content of worry thoughts.

Build meta-awareness using mindful observation. Observe your current experience, including the contents of your mind. Identify and label worry thoughts in action. Recognise that thoughts are just thoughts. They are not you, and they are not reality.

Practise mindful acceptance of current experience, including unpleasant emotions and body sensations. Drop the judgement. Sitting with current experience without resistance builds tolerance for unpleasant emotions, including anxiety.

Practise relaxation techniques to help identify physical tension as it emerges, and learn how to release it.

Many problems resolve themselves. You don’t always need to intervene. Give them time.

Problem-solve if appropriate, but if it is out of your hands, wait until you are suffering before you start to suffer. Remember to ask yourself, ‘When should I start to suffer?’

Many things are not within your control. Uncertainty is a normal part of life. Relax into uncertainty.

When we feel bad, it feels like this is our new reality, and things will never change. But upsetting emotions pass. Sometimes the situations themselves change, but if they don’t, we adjust to the new reality. Time heals.

Appendix

FURTHER READING: BOOKS

ANXIETY

Antony M, Norton P (2009). The Anti-Anxiety Workbook: Proven strategies to overcome worry, phobias, panic and obsessions. Guilford Press, NY.

Forsyth JP, Eifert GH (2007). The Mindfulness and Acceptance Workbook for Anxiety: A guide to breaking free from anxiety, phobias, and worry using acceptance and commitment therapy. New Harbinger Publications, Oakland, CA.

Leahy RL (2010). Anxiety Free: Unravel your fears before they unravel you. Hay House, US.

ATTACHMENT

Levine A, Heller RSE (2010). Attached: The new science of adult attachment and how it can help you find – and keep – love. Penguin Random House, NY.

Siegal DJ (2012). The Developing Mind: How relationships and the brain interact to shape who we are, 2nd edition. Guilford Press, NY.

Siegal DJ, Hartzell M (2003). Parenting from the Inside Out: How a deeper self-understanding can help you raise children who thrive. Penguin Random House, NY.

COGNITIVE BEHAVIOUR THERAPY

Edelman S (2013). Change Your Thinking, 3rd edition. HarperCollinsPublishers, Sydney.

Greenberger D, Padesky, CA (2015). Mind over Mood: Change how you feel by changing the way you think, 2nd edition. Guilford Press, NY.

GENERALISED ANXIETY DISORDER / WORRY

Clark DA, Beck AT (2012). The Anxiety and Worry Workbook: The cognitive behavioral solution. Guilford Press, NY.

Leahy RL (2005). The Worry Cure: Seven steps to stop worry from stopping you. Harmony, NY.

Meares K, Freeston M (2008). Overcoming Worry: A self-help guide using cognitive behavioural techniques. Constable & Robinson, London.

Robichaud M, Dugas MJ (2015). The Generalized Anxiety Disorder Workbook. New Harbinger Publications, Oakland, CA.

MINDFULNESS

Brantley J (2007). Calming Your Anxious Mind: How mindfulness and compassion can free you from anxiety, fear and panic. New Harbinger Publications, Oakland, CA.

Kabat-Zinn J (2012). Mindfulness for Beginners. Sounds True, Boulder, CO.

Williams M, Penman D (2011). Mindfulness: Finding peace in a frantic world. Piatkus, London. (Comes with a free CD of excellent guided meditations.)

Williams M, Teasdale J, Segal Z, Kabat-Zinn J (2007). The Mindful Way through Depression. Guilford Press, NY.

TRAUMA

Callis K (2015). Complex PTSD Recovery Workbook: An informed patient’s perspective on complex PTSD. Createspace Independent Publishing Platform, US.

Schiraldi G (2009). The Post-Traumatic Stress Disorder Sourcebook. McGraw-Hill/Lowell House, Chicago.

Van der Kolk B (2014). The Body Keeps the Score. Penguin Books, UK.

PANIC

Aisbett B (2013). Living with It: A survivor’s guide to panic attacks. HarperCollinsPublishers, Australia.

Fox B (2010). Power over Panic, 2nd edition. Pearson Education, Australia.

Wilson R (2009). Don’t Panic: Taking control of anxiety attacks, 3rd edition. HarperCollinsPublishers, US.

INSOMNIA

Espie CE (2006). Overcoming Insomnia and Sleep Problems: A self-help guide using cognitive behavioural techniques. Robinson Publishing, London.

Glovinsky P, Spielman A (2006). The Insomnia Answer: A personalized program for identifying and overcoming the three types of insomnia. Penguin, NY.

Winter WC (2017). The Sleep Solution: Why your sleep is broken and how to fix it. Berkley, NY.

ONLINE INFORMATION

CENTRE FOR CLINICAL INTERVENTIONS
www.cci.health.wa.gov.au

Select ‘Looking after yourself’ on the resources page. Excellent information available for free downloading. Topics include worry, panic, anxiety, shyness, self-esteem, sleep, depression, health, anxiety, assertiveness, perfectionism, procrastination, bipolar disorder, body dysmorphia, self-compassion and more.

ANXIETIES.COM

Free information and self-help modules on anxiety disorders. Provided by Reid Wilson, psychologist and head of the Anxiety Disorders Treatment Center in North Carolina. Information modules include generalised anxiety disorder (GAD), panic attacks, obsessive-compulsive disorder, simple phobias, fear of flying, social anxiety disorder and post-traumatic stress disorder (PTSD).

ONLINE INTERACTIVE SELF-HELP PROGRAMS

MINDSPOT
mindspot.org.au

Developed by Macquarie University, Sydney.

Free programs include managing emotions, including anxiety disorders (GAD, OCD, PTSD, panic); depression; chronic pain; and Indigenous mental health. Programs are managed by a team of psychologists, psychiatrists and other mental-health professionals.

MY COMPASS
www.mycompass.org.au

Developed by Black Dog Institute, Sydney.

Free programs to address mild-to-moderate symptoms of anxiety, depression and stress. Includes psychoeducation and learning modules; real-time self-monitoring of thoughts, feelings and behaviours; SMS or email self-monitoring reminders; graphical feedback about self-monitoring information and helpful facts; mental-health care tips and motivational statements (sent via SMS or email).

MOODGYM
moodgym.com.au

Developed by Centre for Mental Health Research, Australian National University, Canberra.

Free program that teaches how to use cognitive behaviour therapy for managing distressing emotions. Not diagnosis specific, but helpful for depression, anxiety and stress management.

E-COUCH
www.ecouch.anu.edu.au

Developed by Australian National University, Canberra (by creators of Moodgym).

Free self-help programs for depression, worry and GAD, social anxiety, relationship breakdown, loss and grief.

MENTAL HEALTH ONLINE
www.mentalhealthonline.org.au

Developed by National eTherapy Centre, Swinburne University, Hawthorn, Vic.

Specific self-help programs for depression, GAD, panic disorder (with or without agoraphobia), PTSD, OCD and social anxiety disorder. Optional free access to additional support from e-therapists via email or instant messaging.

THIS WAY UP
thiswayup.org.au

Developed by Clinical Research Unit for Anxiety and Depression (joint facility of St Vincent’s Hospital and the University of New South Wales). Available for purchase: self-help programs for various conditions including depression, anxiety, mixed anxiety and depression, social anxiety, health anxiety, panic, obsessive-compulsive disorder, GAD, chronic pain, post-traumatic stress disorder and insomnia. Fee is around $60 per program.

BRAVE ONLINE
www.brave4you.psy.uq.edu.au

Developed in collaboration between researchers at Griffith University and University of Southern Queensland.

Free self-help program for children, teenagers and their parents for managing anxiety and worry. Separate programs for 8–12 years, and 12–17 years.

SHUTI
www.myshuti.com

Developed by US company BeHealth Solutions.

Online program for insomnia, available for purchase. Comprehensive CBT self-help program for insomnia; teaches techniques to break the cycle of thoughts, emotions and behaviours that impede sleep. Efficacy for use with onset and middle insomnia is supported by clinical trials.

PODCASTS

‘ANXIETY COACHES’ PODCAST
www.theanxietycoachespodcast.com

The mellifluous, reassuring voice of anxiety coach Gina Ryan provides information and tips on managing anxiety and panic. Podcasts include occasional input from other coaches and guests. Gina’s lived experience of anxiety comes through in her empathy and knowledge. Two shows produced each week, and hundreds of episodes are available.

‘SLEEP WITH ME’ PODCAST
www.sleepwithmepodcast.com

The creaky American voice of Drew Ackerman tells stories in a long-winded way that is surprisingly sleep-inducing. According to the website, ‘Drew has dedicated himself to help those who feel alone in the deep dark night and just need someone to tell them a bedtime story.’

MINDFULNESS MEDITATION PODCASTS

Sam Harris, ‘The mirror of mindfulness’ – two guided meditations. samharris.org/podcasts/mindfulness-meditation.

Tara Brach podcasts and guided meditation: excellent guidance; beautiful, calming, natural voice. www.tarabrach.com/talks-audio-video.

Also, printed online information ‘How to Meditate’ at www.tarabrach.com/howtomeditate.

UCLA Mindful Awareness Research Centre (Search online, and then select ‘Free Meditation Podcasts’).

CDS AND GUIDED RELAXATION AND MEDITATION EXERCISES SPOKEN BY SARAH EDELMAN

Available in stores and online.

Letting Go

Letting Go of Anxiety

Mindfulness Meditation

Moments of Stillness

Sleep Soundly

Magic Moments

APPS

FREE

Breathe2Relax: Slow down breathing rate via pacing with moving bars, music and imagery.

ReachOut Breathe: Measures heart rate, paces you to slow down breathing rate and then measures heart rate again.

ReachOut WorryTime: Gives you a place to store your worries, and alerts you when it’s time to think about them. When a worry no longer matters to you, you can ditch it and move on.

ReachOut Recharge Sleep: This app focuses on improving mood, energy and wellbeing by putting in place good sleep/wake patterns.

What’s Up?: Provides strategies for managing anxiety, depression, anger and stress.

Smiling Mind: Guided mindfulness meditation.

AVAILABLE ONLINE FOR PURCHASE

Worry Watch: Record your catastrophic predictions, and then record what happened. Provides data and graphs demonstrating discrepancy between our fears and reality.

FINDING A PSYCHOLOGIST

Personal recommendation is best. Alternatively, you could use the ‘Find a Psychologist’ facility on the website of the Australian Psychological Society (www.psychology.org.au). By entering information about your geographical location and a few general details about your needs, the website will provide contact details and brief information about psychologists in your area.

Index

The pagination of this digital edition does not match the print edition from which the index was created. To locate a specific entry, please use your ebook reader’s search tools.

acceptance

mindfulness, and 110–12

social, seeking 14
acceptance and commitment therapy (ACT) 3, 4, 103
acetylcholine 19
acupuncture 201
adolescence 13
adrenal glands 18, 19, 22, 30
adrenaline 17, 18, 19, 22, 30, 176, 209
agomelatine (Valdoxan) 198
agoraphobia 27, 173–4
agreeability 10
alcohol 16, 72, 204, 208
alprazolam (Xanax) 193
ambivalent/anxious attachment style 11–12
amitriptyline (Tryptanol, Endep) 197
amygdala 17, 19, 22, 25, 28, 30, 144, 154, 176, 209, 211
anchor 105, 107, 113, 164
anger 10
antidepressant medications 194–8, 202, 217
antipsychotic medications 198–9
anxieties.com 227
anxiety 1–2, 28

anxiety about 24

attention, and 25

behaviours, and 25–6

benefits 15

common threats 14

definition 9

disorders 2, 27–8

disposition to 8, 10, 28

duration of 9

effects 24–6

fear versus 21–2

frequent or chronic 13

further reading 225

illness see illness anxiety

managing 9

normal human experience 8–9

panic disorder see panic disorder

physiology 16–24

relationships see relationships

sensitivity 180–1

social see social anxiety

thoughts, and 24–5

trait see trait anxiety

unconscious triggers 15–16, 31

worry, distinguished 30–1, 45
anxiety disorder due to a medical condition 27
applied relaxation 161–3

stages 162
apps 190, 231

Worry Watch 98

WorryTime 142, 149, 152
arousal 17, 26

autonomic 21

chemically induced 16

physical 2, 9, 19, 23–4, 153–5
arousal control strategies 3
attachment 11–12

ambivalent/anxious 11–12

avoidant 12

disorganised 12

further reading 225

secure 11
attention

anxiety and 25
attention deficits 13
attentional bias towards threat 36–7
autism spectrum 8
autonomic nervous system (ANS) 18–19
avoidance 3, 25, 70–2, 76, 78

exposure to situations 182–6, 187

worry as avoidance strategy 41
avoidant attachment style 12
awareness of internal state 115–16

‘awfulising’ 52

Bach Flower remedies 201

‘back of the mind’ thoughts 115

Baillie, Andrew 176

Barlow, Professor David 180
behavioural exercises 79
behavioural experiments 3, 80–6, 87, 141, 151–2, 221–2

case study (example) 82–4, 150–1

metacognitive beliefs 146–52

negative consequences 85

practising 84

sections, analysis of 81–2, 148–50
behaviours

anxiety and 25–6

Benson, Dr Herbert 156–7
benzodiazepines 72, 193–4, 199
beta blockers 199
bibliotherapy 190, 202
bipolar disorder 8, 198
black-and-white thinking 53–4, 64
blocking imagery 41
body sensations 105

awareness of 115–16, 120

hypervigilance 171

relaxation and 159

Borkovec, Tom 41
brain 16–18, 28

maturation 13
brainstorming 95, 117, 128

Brave Online 229
breathing 3, 189

diaphragmatic 160

panic attacks, and 169–70, 175

panic surfing, and 179–80, 187

relaxation 159–60, 165

slow rhythmic 160

Buddhist tradition 103, 107, 109, 110–11
bullying 13
bupropion (Zyban) 198
catastrophe, predicting 51, 64

Centre for Clinical Interventions 227
chamomile 200, 204
childhood experiences 12

complex trauma 13
circadian rhythm 205–6
citalopram (Cipramil) 195
clomipramine (Anafranil) 197
clonazepam (Rivotril) 193
coffee 16, 169, 208
cognitions 48
cognitive avoidance 139
cognitive behaviour therapy (CBT) 3, 48, 162, 180, 186

further reading 225

third-wave CBT therapies 3–4
cognitive bias 48–9, 64
cognitive flexibility 64
cognitive reframing 3, 49
cognitive safety behaviours 68–9, 72, 141–2, 152
comparing 55–6
complementary therapies 201–2
concentration difficulties 3, 122

GAD, and 37
concentration meditation 112
confronting anxiety-provoking situations 78
conscientiousness 10
consistent parental style 11–12
control, need for 26, 75
coping

underestimating our ability 41–2
cortisol 17, 18, 19, 22, 30
covering all bases 131–2

Craske, Professor Michelle 80, 180
cue-controlled relaxation 160–1, 165

applied relaxation 162
deep relaxation, methods 159–63, 165
demands 1
depression 2, 8, 10

frequent or chronic 13

GAD, and 36
desvenlafaxine (Pristiq) 196

Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 27
dialectical behaviour therapy (DBT) 3, 103
diazepam (Valium) 193, 194
diet 214–16, 220
differential relaxation 162
difficulties 1
disappointment, coping with 85
disapproval 1
disassociation 13
disorganised attachment style 12
disputing 49
dizziness 170, 175
dothiepin (Dothep, Prothiaden) 197
doxepin (Sinequan) 197
drugs 16, 72, 169

medication see medication
duloxetine (Cymbalta) 196
dysfunctional relationships 12

E-couch 228–9
e-therapy 190, 202
eating disorders 8
education 221
emotions 4, 42, 223

emotional responses 17

fear of distressing 40–1, 46

limbic system, and 17, 28

multiplying distressing 110–11

rational versus emotional 124

thoughts, and 3, 115

tolerance of unpleasant 114
endogenous opioids ‘endorphins’ 217
environmental stressors 10
epinephrine 197
equanimity 109
errors of reasoning see reasoning errors
escitalopram (Lexapro) 195
exercise, physical 216–17, 220

sleep, and 208, 209
expectancy violation 80, 86, 87
experiential learning 86–7, 93
experimenting 89
exposure exercises 3

avoided situations 182–6, 187

graded 183

non-graded 183

ongoing exposure 87
exposure schedule 183–6

train travel (example) 185–6
extraversion 10
failure 1
false alarms 25, 48, 128
fatigue 3

GAD, and 38
fear 1

anxiety versus 21–2

distressing emotions, fear of 40–1, 46

experiential learning 86–7

facing 78–9

ongoing exposure 87

outcome of feared events 95–8, 101
feelings see emotions
fight-or-flight response 19–20, 22, 28, 157, 199

panic attacks 169, 176
filtering 57–8
fleeing 71
fluoxetine (Prozac, Lovan) 195
fluvoxamine (Luvox) 195
freeze response 20–1
gambling 72
generalised anxiety disorder (GAD) 2–3, 7, 27, 33–5, 45, 125

attentional bias towards threat 36–7

depression, and 36

DSM-5 criteria 35

excessive worry, distinguished 35

fatigue 38

fear of distressing emotions 40–1, 46

further reading 226

intolerance of uncertainty 3, 38–9, 45

‘magical thinking’ 44–5

observing thought processes 50

overestimating negative consequences 40

poor concentration 37, 122

poor problem-solving 42–3, 46

relaxation techniques 161–2

stress in relationships 43–4

triggers 34

underestimating ability to cope 41–2

worry thoughts, challenging 49–50
guilt 10
gut bacteria 215–16
haloperidol (Haldol) 198
heart palpitations 8, 170, 175
herbal remedies 200–2
high startle reflex 22
hippocampus 17
homeopathic medicines 201
hook (metaphor) 99, 114
hyperventilation 22, 169–70, 187

control 178–9

interoceptive exposure 181
hypervigilance 2, 171–2
hypothalamus 17, 19, 30, 154
illness anxiety 3, 27
imipramine (Tofranil) 197
immediate danger 21
insight 90, 113

outcome of feared events 95–8, 101
insomnia see sleep
interoceptive exposure 180–2, 187

naturalistic 182
interoceptive feedback 154
intolerance of uncertainty 3, 38–9, 45, 75
irritability 10, 26, 122
isocarboxazid (Marplan) 197

Jacobson, Edmund 155
jealousy 10
judgement, releasing 109–10, 119, 213, 222
kava 200
labelling 55
lavender 200
lemon balm 200
lifestyle 203, 220
likelihood 61–2
limbic system, and 17, 28, 30, 158
long-term memory 17
lorazepam (Ativan) 193, 194
loxapine (Loxitane) 198

‘magical thinking’ 44–5
magnifying 52, 64
marginalisation 13
martial arts 163
massage 163
medication 189–90, 202

antidepressant 194–8, 202, 217

antipsychotic 198–9

appropriateness, considerations 191–2

atypical 198

effectiveness 192–3

herbal 200–2

non-prescription 200–2

side effects 194, 195, 196, 197, 198–9

sleep 204–5

supplements 200–2

types 193–9
meditation

calming effect 113

concentration 112

intrusive thoughts 107

mindfulness 103, 104, 119, 157–8

practice 105–7

relaxation 163–4, 165

Transcendental Meditation (TM) 157–8

two-minute 106
melatonin 204, 207

Mental Health Online 229
mental-health practitioners 5, 232
mental reviewing 68
meta-awareness 90, 100, 112, 113–14, 222
metacognitive beliefs 4, 124–7, 140, 222

behavioural experiments 146–52

benefits of worry 124–36

challenging 134–6, 140

covering all bases 131–2

identification of 126–7

negative 136–40

preparing for the worst 129–31

preventing bad things happening 132

worry and problem-solving 127–8

worry as motivator 127–8, 132

worry exposure 137–40

worrying as caring 133–4
metacognitive therapy (MCT) 3, 4
metaphors

detaching worry, for 99–100, 101, 222

releasing thoughts 108

Metzinger, Professor Thomas 107
mind, rational versus emotional 124
mind-reading 54
mindfulness 103–4, 119–20, 212, 222

acceptance, and 110–12

anxiety and worry, managing 112–14

awareness of internal state 115–16

commencing practice 105–7

current needs, responding to 116–17

daily-life, in 103, 104

further reading 226

judgement, releasing 109–10, 119, 213, 222

meditation 103, 104, 157–8

panic surfing, and 179

present-moment experience 104–9, 118

problem-solving 117
mindfulness-based cognitive therapy (MBCT) 3, 4, 103

Mindspot 228
mirtazapine (Avanza) 198
molindone (Moban) 198

‘monkey mind’ 107
monoamine oxidase inhibitors (MAOIs) 197–8
mood 115

Moodgym 228
motivation 17
muscle tension 2, 9

My Compass 228
nefazodone (Serzone) 198
negative consequences

overestimating 40, 78

tolerating 85, 87
negative thoughts see also thoughts

challenging 59–64

conclusions, jumping to 58–9, 98

reasoning errors see reasoning errors
neural networks, development of 12
neuroticism 10–11
neurotransmitter GABA (gammaaminobutyric acid) 193
nitrazepam (Mogadon) 193
norepinephrine 194, 197, 217
nortriptyline (Allegron) 197
not fitting in 1
objective evidence 59
objects in visual field 105
observing thought processes 50
obsessive-compulsive disorder (OCD) 7, 8, 44
olanzapine (Zyprexa) 198
online information 227–30
openness to experience 10

Ost, Lars-Goran 161
outcome of feared events 95–8, 101

case study (example) 97
overanalysing 32, 37, 49, 50, 68, 136
overplanning 66, 68
overthinking 1, 32, 37, 50, 68, 117, 132
oxazepam (Serepax) 193
panic 1

further reading 226–7

managing 176–87
panic attacks 3, 7, 22–3, 35, 167–9, 186–7

agoraphobia 173–4

catastrophic thoughts, correcting 175–6

dizziness 170, 175

exposure to avoided situations 182–6

fear of physical sensations 180–2

heart attack, and 170

hyperventilation 169–70, 178–9, 187

initial trigger 169

interoceptive exposure 180–2, 187

responding to 176–80

threat perception, reducing 174–6, 187

unprovoked 172–3
panic disorder 3, 27, 170–2, 186
panic surfing 176–8, 187

breathing, and 179–80
parasympathetic nervous system 19, 155, 157, 160
parenting 11–12
paroxetine (Aropax) 195
passionflower 200
past, reflecting on 118
perception of threat 9
perfectionism 67–8
personalising 56–7
phenelzine (Nardil) 197
phobias 3, 27
physical exercise 216–17, 220

sleep, and 208, 209
physical symptoms 3, 23–4, 28, 153–4

body sensations, awareness of 115–16, 120

interoceptive exposure 180–2, 187

present-moment experience 104
pituitary gland 17, 18, 217
placebo effect 201–2
podcasts 190, 230
post-natal depression 8
post-traumatic stress disorder (PTSD) 8

complex 13
predicting catastrophe 51
prefrontal cortex 17, 18, 30, 210
preparing for the worst 129–31
present-moment experience 104–9, 118
pressures 1
preventing bad things happening 132
problem-solving 8–9

appropriate 93–4, 117, 120

poor 42–3, 46

relaxation and 164–5

sleep, and 210–11

solutions, exploring 95

worry and 127–8, 222, 223
procrastination 15, 70
progressive muscle relaxation (PMR) 3, 155–6, 161, 165, 189

applied relaxation 162
propranolol (Inderal) 199
psychoeducation 3
psychological therapy 190–1

Qi Gong 163
quetiapine (Seroquel) 198

Rapee, Ron 176
rational versus emotional 124
reading, further 225–7
reality testing 59–61, 221
reasoning errors 3, 50–9, 64

acknowledging 49

black-and-white thinking 53–4

comparing 55–6

filtering 57–8

labelling 55

magnifying 52, 64

mind-reading 54

negative conclusions, jumping to 58–9

personalising 56–7

predicting catastrophe 51, 64

‘shoulds’ 52–3
reassurance-seeking behaviours 66–7
rejection, social 14
relationships

adolescents 13

anxiety, and 14, 26

parent-child 11–13

social connections 217–19

stress 43–4
relaxation 153–5, 165, 223

applied 161–3

body sensations, noticing 159

breathing 159–60, 165

cue-controlled 160–1, 162, 165

deep, methods for 159–63, 165

differential 162

internal resistance 158–9

martial arts 163

massage 163

meditation, and 163–4, 165

problem-solving, and 164–5

progressive muscle relaxation (PMR) 155–6, 161, 165

rapid 162

‘relaxation response’ 156–8

release-only muscle 162

visual imagery 161, 165

yoga 163
releasing thoughts (metaphors) 108

Rescue Remedy 201
risperidone (Risperdal) 198
rumination 1, 30, 110, 118, 218
sadness 10
safety-behaviour log 73–4
safety behaviours 3, 25, 66–7, 76, 221–2

actions 68

avoidance see avoidance

behavioural exercise 79–80

cognitive 68–9, 72, 141–2, 152

common 72

monitoring 72–5, 76

problems associated with 69–70

uncertainty, and 75–6

St John’s wort 200

Salkovskis, Professor Paul 44, 129
schizophrenia 8
secure attachment style 11
selective serotonin reuptake inhibitors (SSRIS) 195–6
self-help 3, 4, 190, 202

online interactive programs 228–30
sensory experience

mindfulness 104–5
separation anxiety disorder 27
serotonin 194, 196, 197, 217
serotonin and norepinephrine reuptake inhibitors (SNRIS) 196
sertraline (Zoloft) 195
shame 10

‘shoulds’ 52–3

Shuti 229–30

Sirens on the rocks (metaphor) 100
sleep 203–5, 220

bad habits 208

circadian rhythm 205–6

day-time worry about not sleeping 212

disorders 204

exercise, and 208, 209

flexible thinking 290–14, 220

further reading 227

hygiene 206–9, 220

insomnia 3, 13, 193, 203–4, 209, 211–12, 220

light, and 207

magnification of problems 210–11

night-time worry about not sleeping 211–12

restful sleep environment 207–8

routines 206–7

sleep-impairing substances 208

sleep quota 213

stimulus control 209

unconscious assumptions 213–14

winding-down ritual 207
sleep inertia 206
smells 105
smoking 72, 169, 208
social anxiety 3, 7, 27
social connection 217–19, 220

tips 219
solutions, exploring 1, 95
somatic sensations 23–4, 28, 122
sounds 105
substance-related disorders 8, 27
suprachiasmatic nucleus (SCN) 205
sympathetic nervous system 19, 22, 23, 157

Taekwondo 163

Tai Chi 163
tastes 105
temazepam (Normison, Temaze) 193
thalamus 17
thioridazine (Mellaril) 198

This Way Up 229
thoughts 48, 64, 221

anxiety and 24–5

awareness of internal state 115

‘back of the mind’ 115

black-and-white thinking 53–4, 64

changing our thinking 49

content to process, moving from 98–9, 101

feelings, and 3, 115

‘magical thinking’ 44–5, 132

negative see negative thoughts

observing thought processes 50

reasoning errors see reasoning errors

releasing 108

thought-monitoring form 63–4

‘to-do’ 108–9
threat

attentional bias towards 36–7

common 14

magnification of problems 210–11

perceived future 21–2, 28, 30

‘to-do’ thoughts 108–9
trait anxiety 10, 26

Transcendental Meditation (TM) 157–8
tranylcypromine (Parnate) 197
trauma

complex 13

further reading 226
trazodone (Desyrel) 198
tricyclic antidepressants (TCAs) 197
triggers 32–3

GAD 34

panic attacks 169

unconscious 15–16, 31
trimipramine (Surmontil) 197
uncertainty 223

intolerance of 3, 38–9, 45, 75

safety behaviours and 75–6
unconscious triggers 15–16, 31
understanding your thoughts 89
unrealistic assessment of threat 2
urges 115
vagus nerve 113, 154
valerian 200, 204
venlafaxine (Effexor) 196
vigilance response 22, 28, 35
visual imagery 161, 165
vortioxetine (Brintellix) 198

Weekes, Dr Claire 177

Wells, Dr Adrian 4, 99, 137

Williams, Mark 110
worries log 90–1, 100

case study (example) 92–3

worry-delay pad 142–3, 149, 152
worry 1, 2, 30, 45, 122

anxiety, distinguished 30–1, 45

benefits of 122, 125–7

conscious thought process, as 30–1

further reading 226

GAD, distinguished 35

habitual 122–3

metacognitive beliefs see metacognitive beliefs

motivator, as 127–8, 132

normal versus excessive 31–2

strategies for releasing 221–3

thoughts, challenging 49–50, 64

triggers 32–3

worrying as caring 133–4
worry awareness 89, 100–1

content to process, moving from 98–9, 101

metaphors for detaching 99–100, 101

outcome of feared events 95–8, 101

problem-solving, and see problem-solving
worry delay 142–3, 149, 152, 222

lessons 144

review time 144–5
worry experiments 141–2
worry exposure 137–40
worry train (metaphor) 100, 114

Worry Watch app 98, 231

WorryTime app 142, 149, 152, 231
worst, best, most likely 61–2, 64
yoga 163

About the Author

DR SARAH EDELMAN is a clinical psychologist, author and trainer. She previously worked as a researcher and lecturer at the University of Technology Sydney. In addition to her clinical work Sarah conducts training programs for mental health professionals and business organisations, and runs workshops on ‘Changing Your Thinking’ at Sydney University Centre for Continuing Education. She has published articles in professional and mainstream journals, and is a regular guest on ABC radio. Her book, Change your Thinking, is a best seller in the self-help genre. She is also co-author of Good Thinking: A teenagers’ guide to managing stress and emotions using CBT.

Also by Sarah Edelman

Change Your Thinking is the bestselling guide to managing upsetting emotions by learning to think in a healthy and balanced way. It provides practical strategies for overcoming negative thoughts and behaviours, and taking control of emotions such as anxiety, depression, frustration, anger and guilt. It also describes techniques for enhancing self-esteem, improving communication skills and developing greater personal happiness.

Normally I don’t think books like this are very helpful, but Change Your Thinking is really helping me to change my life. When I started reading it, I immediately felt like I could get back in control and actually improve what I had accepted as the status quo. the author gives a lot of simple tips that work, and the exercises are a big help. I highly recommend this book to anyone suffering from anxiety or depression.

(One of the many positive customer reviews.)

Also by Sarah Edelman

(with Louise Rémond)

Although most of us pay little attention to our emotions, feelings like anxiety, anger, frustration, guilt and sadness can have a huge impact on our lives. Sometimes we get stuck in negative ways of thinking that perpetuate these emotions, even when what is happening in our lives is not that bad.

Teenage years can be a particularly challenging time. There are lots of changes happening – physical, social and mental, and emotional ups and downs are common. Upsetting emotions can lead to self-defeating behaviours, such as avoidance, irritability, withdrawal and brooding.

Cognitive Behavioural Therapy is an approach used by therapists all over the world to help people learn to think in a healthy and balanced way, and to bounce back more quickly from stressful events. It provides techniques to help overcome stress, negative emotions and self-defeating behaviour. Sarah Edelman, and Louise Rémond, a specialist in therapy for teenagers, explain how to use these skills with clarity and compassion. The book contains plenty of real-life examples, practical tools and exercises. These strategies have a proven track record, and are valuable skills for a happier and more confident life.

Copyright

The ABC ‘Wave’ device is a trademark of the Australian Broadcasting Corporation and is used under licence by HarperCollinsPublishers Australia.

First published in Australia in 2019
by HarperCollinsPublishers Australia Pty Limited

ABN 36 009 913 517
harpercollins.com.au

Copyright © Sarah Edelman 2019

The right of Sarah Edelman to be identified as the author of this work has been asserted by her in accordance with the Copyright Amendment (Moral Rights) Act 2000.

This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced, copied, scanned, stored in a retrieval system, recorded, or transmitted, in any form or by any means, without the prior written permission of the publisher.

HarperCollinsPublishers

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ISBN: 978 0 7333 3977 6 (paperback)

ISBN: 978 1 4607 1093 7 (ebook)

A catalogue record for this book is available from the National Library of Australia

Cover design by Gemma Banks, HarperCollins Design Studio

Contents

1. Contents
2. Introduction
3. One: The Nature of Anxiety

4. Two: Worry and Generalised Anxiety Disorder

5. Three: Healthy, Balanced Thinking
6. Four: Safety Behaviours
7. Five: Facing Our Fears
8. Six: Building Worry Awareness
9. Seven: Mindfulness
10. Eight: Metacognitive Beliefs
11. Nine: Worry Experiments
12. Ten: Learn to Relax
13. Eleven: Managing Panic Attacks
14. Twelve: Medications
15. Thirteen: Sleep and Lifestyle Habits

16. Summary of Key Strategies for Releasing Worry

17. Appendix
18. Index
19. About the Author
20. Also by Sarah Edelman
21. Copyright

Guide

1. Cover
2. Contents
3. One: The Nature of Anxiety

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