Invest Your Anxiety in a Calmer Future

John R. Cook, Ph.D.
Registered Psychologist

I'm going to talk about the some of the things that can erode and eventually destroy peace and calm in our lives. Then I'm going to tell you what you can do about it. Perhaps the best place to start is the definition of terms. For me the antithesis of peace and calm is stress. I define stress as our response to any kind of psycho social or physical demand placed on us. These demands come in many forms.

Sometimes they take the form of challenges in our external world. These sources may include our job, family, personal lives, social situations, environmental stress, and financial pressures. Our ability to cope with these challenges depends on the amount of change and disruption they cause in our lives.

At the other extreme are forms of stress that are out of our own creation. That is, the source is internal. These internal sources are generated by our own appraisals of ourselves in relation to what is going on around us. They take the form of self chatter or what we tell ourselves about everything we notice, whether it is the crowd at the shopping mall or our heart skipping a beat. This self chatter is often scary or worrisome so it frequently sets off a false alarm when it occurs. We experience this false alarm as anxious upset.

If the false alarm is about some future, anticipated threat or danger, we call it worry or generalized anxiety. If the false alarm is about a threat or danger that is immediate, we call it panic. If the false alarm is about some future or immediate threat or danger in our social environment, we call it social anxiety. In general, we do our best to hide our condition, no matter what form the false alarm takes.

In the middle of the Stress continuum we have stress coming from a combination of external and internal sources. That is, there are external challenges, but we exacerbate them through certain personal characteristics or behavioural tendencies, such as Type A personality.

Stress is not altogether bad insofar as we need it in moderation to be able to function effectively in our daily lives. Without it we become under-aroused, and we risk mediocre performance. On the other hand, if there is too much stress, our performance begins to break down.

How do you know when you have crossed the line with stress in your life? In general, you know you have a problem when you aren't performing up to your usual standards at work, in school or in social relationships.

Hans Eysenck proposed anxiety sufferers tend to be cortically over-aroused, and to have especially sensitive autonomic nervous systems. This predisposition for having anxiety seems to run in families. People with this predisposition are often described as "high strung", "nervous", or "overly emotional".

Drawing on my own clinical experience, and a simple checklist published by the Midwest Center for Stress and Anxiety (Open Harbor, Ohio), I have arrived at a similar set of predisposing personality characteristics.

difficulties saying "no" or asserting oneself
easily taken advantage of
easily made to feel guilty
need to analyze, figure things out, know why
need to believe in a fair and reasonable world
perfectionistic, unrealistic expectations of self
desire for greater self control
super responsible and self-sacrificing
concern about what others think
sees self differently (less capable) than others do

Generalized anxiety is a condition of excessive, misplaced and difficult-to-control worry. The worries are about anything and everything, and occur almost nonstop, like the rapid fire of a machine gun, one worry chained to the next in quick succession.

The thoughts rarely stop, and when they do this is cause for the anxiety sufferer to worry about not worrying. The worries are accompanied by symptoms of heightened arousal such as muscle tension, restlessness, and difficulties concentrating. About five percent of the population (one in twenty) will suffer from generalized anxiety.

Panic is a sudden (cresting in 10 minutes or less), relatively short (lasting 30 minutes or less), all-or-none attack of intense arousal accompanied by fear, and an urge to escape.

At least some of these episodes occur unexpectedly or "out of the blue". The intensity of arousal is comparable to what we might experience in life or death situations, hence the term "fight or flight response". As many as 1/4 of us experience panics at one time or another, but fewer than 4 percent go on to develop panic disorder, characterized by apprehension about having more attacks or "fear of the fear".

Social anxiety is a fear of negative evaluation. It is an exaggerated version of the "jitters" many of us get when we perform or think about having to perform in public.

We worry about not dong well and becoming so nervous that people will notice and think poorly of us. It is the most prevalent anxiety disorder, and the third most prevalent psychiatric disorder overall. It's lifetime prevalence of 13 percent follows only depression and alcohol dependence at 17 and 14 percent, respectively.

Care must be taken in diagnosing anxiety to distinguish it from a number of physical disorders that mimic its symptoms such as hyperthyroidism, cardiac arrhythmia, pulmonary embolism, congestive heart failure and hypoglycemia. Your family physician can make this determination.

Some of the better known medical consequences of stress are hypertension, heart attacks, strokes, cancer, diabetes, asthma and arthritis. These are also common concerns among people with anxiety. Will my worry or panic undermine my health and eventually kill me?

The answer has to do with lifestyle. People who suffer from stress typically make poor choices in responding to challenges in their external environment. These choices involve lifestyle decisions about the amount of exercise they get, how well they pace themselves and the food they eat. Anxiety sufferers may also make these same poor choices, but are in my experience less likely to do so. Instead, they are more concerned with challenges from their internal environment, are more tuned into their bodies, and take better care of themselves.

Cognitive behavioural therapy is a highly effective, research-proven treatment for anxiety that starts by breaking anxiety into its three main components: symptoms of physical arousal, anxious thoughts or cognitions, and behavioural effects.

Each of these components is then targeted separately. The treatment itself is a form of talking therapy that guides the client into new ways of thinking and behaving by teaching them the necessary techniques, and having them practice extensively through homework exercises.

Managing Physical Symptoms The first step of the active intervention is to learn methods for controlling some of the fear-provoking physical sensations. The major techniques that are taught for doing this are diaphragmatic breathing and progressive relaxation.

These techniques won't stop a panic, but can alter the early phase of an attack.

Clients are encouraged to challenge the beliefs that cause them anxiety by questioning the supporting evidence.

This is done by teaching them to identify common forms of irrational beliefs, dispute these beliefs using dispute handles, and replace these beliefs with healthier, more adaptive ones.

1. Collect your thoughts. Try to determine what it was you were thinking that made you feel anxious. This is sometimes difficult to do because our appraisals of threat or danger occur very quickly. If you are really stuck, engage in backward reasoning: What kind of thought might have made you feel that way?

2. Identify and challenge logical mistakes. Identify the things you say to yourself that make you feel anxious. There are two main types of thinking errors that cause us anxiety: probability overestimation and catastrophizing.

Probability overestimation involves jumping to conclusions about things, making terrible outcomes seem more likely than they really are. Catastrophizing is about making mountains out of mole hills by thinking the worst is going to happen. Which of these thinking errors is the pilot using?

We combat these thinking errors and the terrible effect they have on us through the use of dispute handles. Notice there are two main lines of inquiry following the two main types of thinking errors: one directed at arriving at a more realistic probability estimation, and the other directed at decatastrophizing.

3. Provide a rational alternative. You may be surprised to find the evidence supports an explanation that does not make you feel anxious.

4. Use these alternatives proactively. You will find the same thinking errors come up repetitively in situations where you feel anxious. It therefore makes sense to incorporate some of your rational alternatives into your self-talk.

The most powerful part of any anxiety treatment program involves exposing ourselves to sensations, situations or memories we are afraid of, while simultaneously preventing avoidance, until the fear subsides. This is known as confronting your fears, and is done in different ways depending on the form of anxiety.

1. Generalized anxiety. Clients are given worry exposure -- taught to interrupt their rapid-fire thoughts by exposing themselves to one worry at a time for up to 30 minutes each, until they no longer find them disturbing. They are also shown how to eliminate safety checking and avoidance behaviours, and they are instructed in time management, goal setting and problem solving skills.

2. Panic. Interoceptive exposure is used to help panic sufferers overcome their fear of physical symptoms. It is done by exposing ourselves to at least 30 seconds of full sensation. It is important to accept and even enhance the experiencing of these sensations until they are no longer feared.

Interoceptive is combined with imaginal and real life or in-vivo exposure to the activities or situations associated with panic attacks. These exposures follow a progression. That is, they are hierarchically arranged from least to most anxiety-producing.

3. Social anxiety. Exposure techniques for social anxiety are similar to those for panic. They follow a progression known as a fear and avoidance hierarchy.

At each level of this hierarchy the client begins by imagining the social interaction as vividly and in as much detail as possible. This is followed by role playing the social interaction with a therapist or fellow client and finally a real-life or in-vivo exposure.

Exposure is arguably the single most effective approach to treating many anxiety problems, including social phobia.

While cognitive behavioural therapy is certainly available on an individual basis, there are some compelling reasons to consider the group option.

First, there is a sense of universality clients get in group from realizing they are not alone in suffering from their problems. Participants enjoy meeting other people with similar problems, and participating in group learning experiences.

Second, the group provides opportunities for vicarious learning from witnessing other people solve similar problems e.g., working together on disputing irrational thoughts.

Third, the client's attendance in group for he first time is like a public declaration of their commitment to change. Last but not least, although group cognitive behavioural therapy is in many cases as effective as individual therapy, its cost is roughly one third.