What is Anxiety?
Anxiety can be described as a feeling of nervousness, fear or unease. It is completely normal to feel anxious from time to time. Most people feel anxious before sitting an exam, giving a presentation, or doing a job interview. This is is because our body is releasing the right hormones such as adrenaline and cortisol that will help us to rise to a challenge or do something that is important to us.
When we feel anxiety in the body it is a response to the fight or flight response. The symptoms of anxiety are the same as the effects of adrenaline in the body such as feeling dizzy/lightheaded, shallow breathing, racing heartbeat, feeling sweaty, cold hands, shaky knees, feeling nauseous or butterflies in the stomach. These experiences of adrenaline or anxiety can be extremely distressing if they are ongoing and persistent in our lives.
However, when anxiety feels ongoing, overwhelming and distressing to the extent that it is preventing us from doing the things in life that matter the most to us, then it might be time to seek support from a therapist.
What is Worry?
Worry is a future-focused thinking style that often accompanies anxiety. It is characterised by “what if…something bad happens” or “what if…I won’t be able to cope”. Worrying is a normal thinking style that our mind uses from time to time to help us solve problems and respond to our fight or flight responses in order to stay safe. However, when worry becomes persistent, excessive and feels uncontrollable then it can become overwhelming and debilitating in a person’s life. When we believe our worry is uncontrollable, it can lead us to start ‘worrying about our worry’, such that that it is harmful to our wellbeing, both physically and mentally.
Anxiety and Uncertainty
Dugas and Robichaud compare the sensations of anxiety we experience in our body as having a feeling of ‘uncertainty’. It is that feeling in the belly or chest that something is wrong or that something bad is going to happen to you. Having a ‘fear’ or ‘intolerance’ of ‘uncertainty’ is what keeps worry and anxiety going for us. We when we notice that feeling of uncertainty in the body our response is to try to figure out what the problem is in order to avoid or control the feeling. We then start to worry by asking ‘what if…?. Often we will go through as many future scenarios as possible both real and imagined in order to prevent something bad from happening, and to control that feeling of uncertainty or anxiety in the body.
People who worry excessively spend a lot of time trying to gain certainty. Dugas and Robichaud describe it as like having an allergy to pollen. Even a small exposure to pollen for someone who is allergic can have a strong reaction. Similarly, someone who is ‘allergic’ or ‘intolerant to uncertainty’ will have a strong urge to find ways to seek certainty. The problem is that it is impossible to have 100% certainty in this life. In CBT, we aim to teach excessive worriers the skills to become more tolerant to uncertainty in order to reduce worry and anxiety in their lives.
TYPES OF ANXIETY
There are many different types of anxiety and CBT as an evidence-based psychotherapy is recommended by the Nice Guidelines for all anxiety disorders (https://www.nice.org.uk/guidance/qs53).
Generalized Anxiety Disorder (GAD)
According to DSM 5 Generalized Anxiety disorder involves ‘persistent and excessive worry’ about a number of events or activities (e.g. finances, work, school, family) to the extent that it affects our daily activities. It can manifest in our lives through symptoms such as restlessness, feeling on edge or easily fatigued, difficulty concentrating, muscle tension or problems sleeping. As mentioned above, worrying is a normal activity involving future focused ‘what if….’ questions that can help us to solve problems. This is provided it results in us taking an action and we no longer need to dwell on the problem.
Excessive worry is persistent, often distressing and and the impact is that it prevents us doing the things in life that matter to us the most. When your anxiety is generalized you will notice that there are certain things that you worry about in your life repeatedly, such as finances, relationships, your performance at work and so on. You might notice that you catastrophize about the these situations, imagining the worst possible outcomes. What you worry about involves both real and hypothetical situations. We have different pathways in CBT to work with both real-life problems and future hypothetical scenarios that will probably not happen.
This is extreme self-consciousness due a fear of being judged negatively or embarrassed in social situations. It is also known as social phobia or excessive shyness. If you are socially anxious then you will tend to avoid social situations. You might notice that you use safety strategies to control your anxiety and to protect yourself when in social settings. This can include avoiding eye contact, looking at your phone or standing near the door to escape quickly if you need to. It also involves what we call pre-anticipatory anxiety or worry at the thought of having go to into a social situation. For example, imagining what it will be like and how you will look to others. Afterwards, you might notice that you are focusing negatively on what might have gone wrong or how you think you looked to others. Some of the thoughts that people experience when they fear being in social situations include ‘they will laugh at me’, ‘they know I’m embarrassed’ or ‘I looked like an idiot’. Self consciousness or self focus is at the core of social anxiety and our greatest fear is how we think we look to other people. ‘What if I stammer’ or ‘look ‘awkward’? Social anxiety can often accompany difficulties with self-criticism and low self-esteem.
CBT treatment for social anxiety helps you to understand what causes social anxiety and how it has become a vicious cycle in your life. It addresses the triggering thoughts and beliefs that maintain your social anxiety. You will learn skills to help you to shift from an inward self-focus on the strong sensations of anxiety in your body, and instead to be able to focus outwardly on what is happening in the world around you. This helps to challenge our beliefs about what both we and others are like in social settings. It also helps us to see social situations as less threatening.
CBT for social anxiety will help through learning experiments to reintroduce you to social situations that you tend to avoid but would rather participate in. We will put our both our heads together to come up with ideas for experiments that you can try into your life. You decide what you are comfortable with to try out and it will always be in small, manageable steps. These learning experiments aim to help to build your self-confidence to reduce the self-focus or self-consciousness that keeps social anxiety going in your life.
DSM 5 describes Panic disorder as an intense experience of fear or discomfort lasting for up to ten minutes, whereby symptoms can appear to occur suddenly. It can also be understood as a ‘catastrophic’ misinterpretation of bodily sensations which includes an intense fear that something awful will happen. Thoughts include ‘What if I’m dying?’ or ‘What if I’m going crazy?’.
The problem with panic is that instead the brain sets of a false alarm that something extremely and immediate bad is going to happen. However, it is a perceived threat rather than a real one, but it feels so intense and frightening that the person will start to avoid activities that where they fear they may have a panic attack. It can be extremely distressing and debilitating for someone to experience recurrent panic attacks. It can really prevent someone from doing the things in life that matter to them.
Symptoms of panic can include accelerated heart rate, palpitations, sweating, trembling, shaking, shortness of breath, choking sensation, chest pain, dizziness. It also includes a fear of losing control, going crazy or fear of dying. It is important to note that these symptoms of panic or anxiety are the same as the physiological symptoms of heightened adrenaline levels in the body.
CBT Treatment involves gaining a fuller understanding of the causes and triggers of a panic attack. In addition, we look at what keeps the vicious cycle of panic going in your life. This vicious cycle includes a habitual interchange between our thoughts, feelings and behaviours (what we do). If we are able to interrupt the cycle in any of these areas then it will automatically reduce symptoms in the other areas. For example, addressing the things you do to avoid panic attacks in your everyday life can result in a reduction in anxiety, and also challenge our beliefs about threatening situations. Or similarly, learning to understand what causes the physical sensations of panic and how they relate to anxiety can help to alleviate emotional distress. By developing skills to mindfully accept the physical sensations that accompany these emotions we can gain the courage to stop avoiding the situations that we fear and reclaim the ability to do the things in life that matter to us. Learning to step back and think clearly in times of emotional difficulty and to mindfully accept thoughts exactly as they are (as just thoughts and not facts) can also alleviate the symptoms of panic.
Agoraphobia involves a fear of being in both open or enclosed spaces, being in public places or in crowds, getting stuck in a lift, or using public transport, especially where escape may be difficult or embarrassing (DSM 5). It is a strong anticipatory fear of being trapped, feeling helpless or that you could have a panic attack if you go into the feared situation. Someone experiencing agoraphobia will often avoid going to public places alone and sometimes have difficulty leaving their home. Even the thought of getting stuck in the feared situation can feel overwhelming to them. Panic disorder often goes hand in hand with agoraphobia. Fear of having another panic attack can lead to someone avoiding where they had the initial panic attack or similar places. CBT therapy for agoraphobia is similar to treatment for panic disorder.
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