CBT For Anxiety

By | May 25, 2016

All of us feel anxious from time to time and in certain situations. It is a normal and natural emotion and can be useful as a stimulus to action. Unfortunately some of us feel excessively anxious in inappropriate situations, and this is not only unpleasant but can be a serious handicap in our lives.

Anxiety is part of the “Fight or Flight” response to perceived danger, a physiological reflex seen in a huge number of animals. This response physically prepares the animal to fight or run away from danger – it is a survival mechanism, and a very effective and successful one at that.

The basic physical mechanism underlying the response is a sudden release of the hormone adrenalin from the adrenal glands (situated on top of the kidneys). This hormone then rushes through the blood and around the body, acting on various organs and muscles to create the all too familiar physical sensations of anxiety – racing heart, breathlessness, dry mouth, flushed skin, dizziness, butterflies in the stomach, nausea, weak legs, trembling limbs etc. These sensations, which most people (but interestingly, not all!) find unpleasant and frightening, are actually side-effects of the body gearing up for fighting or running away. The racing heart pumps more blood to allow the muscles to work better, the fast breathing brings in more oxygen etc.

All of this is fine and good if your anxiety is based on a real physical threat – if you’ve got a lion taking a close interest in you, for example. Fortunately for most human beings, this would be an unusual event! Our “dangers” are rarely physical these days – they’re more likely to be the “danger” of failing an exam, or the “danger” of embarrassing yourself in front of others. Indeed, many of our “dangers” don’t even exist at all – they are purely in our heads. The “danger of perhaps, maybe, or what-if the lift breaks down and I’m stuck” or the “danger of my anxiety causing me to have a heart attack or pass out”.

Cognitive Behavioural Therapy (CBT) views anxiety (and all emotions) as the interaction of three areas of human experience – cognition (our thoughts and mental imagery), physical sensations (what we feel in or with our bodily senses such as feeling hot or short of breath), and behaviour (what we actually do with our bodies such as move in certain ways and interact with others and our environment).

These three areas – thoughts, sensations, behaviours – act together to make up an emotion. For example, when we feel anxious we will typically have certain anxious thoughts (“I’m going to collapse”, “I can’t stand it”), anxious sensations (nausea, wobbly legs) and anxious behaviours (we rush out of the room, we grab on to someone).

These three areas are linked to one-another in feed-back loops. This means that if our physical sensations of anxiety increase, then typically we will experience more frequent and pressing anxious thoughts, and the desire (indeed desperation) to engage in anxious behaviours will increase. This increase in anxious thoughts and behaviours then “loops” or “feeds-back” to increase our anxious physical sensations which then…well, you get the picture. A vicious cycle is set up where we simply get more and more anxious until (usually) we run away from whatever triggered the anxiety in the first place.

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This sounds a problem, but actually this is great news! The fact that the three components of anxiety interact and affect one another allow us to “access” the system and change it for the better!

How do we do this? By targeting those areas of the system over which we have (at least some!) conscious control – our thoughts and our behaviours. We can, to a greater or lesser extent, control or decide what to think. And we can, to an even greater extent, control or decide how to behave. Contrast this with trying to control your heart rate or your blood pressure – much trickier (though I wouldn’t say impossible…)

The theory of CBT for anxiety is that by controlling and reducing my anxious thoughts and behaviours I can provide “negative (or inhibitory) feedback” to the system, causing my physical sensations of anxiety to reduce. A reduction in anxious physical sensations will decrease my anxious thoughts and behaviours, which will then, in turn, decrease my anxious physical sensations, and so on. We’ve set up the opposite of a “vicious cycle” (a “virtuous cycle”?) and our anxiety fades away.

So much for the theory – what about the actual techniques and work involved? As you may have guessed, we can approach the problem of anxiety from two angles – we can tackle anxious thoughts and we can tackle anxious behaviours. In fact CBT therapists will usually tackle both simultaneously, though the emphasis may be more on thoughts than behaviour, or vice verse. In my experience, it is helpful to focus more on anxious thoughts when the anxiety is a result of thinking about a future event such as exams or an interview. On the other hand, tackling anxious behaviours is the priority in anxiety related to social situations, enclosed spaces or heights etc – situations that are easily replicated by the client and therapist.

Taking anxious thoughts first. People who experience severe and frequent bouts of anxiety often exhibit what CBT therapists call “Thinking Errors”. That is, their thoughts (and indeed their “ways of thinking”) are unrealistic and unhelpful, making their anxiety worse, and even being the initial cause of the anxiety in the first place.

Examples of common Thinking Errors in anxiety are “Fortune Telling” (thinking that you know what is going to happen in the future) and “Catastrophising” (assuming the worst possible scenario will come to pass): “I will fail the interview and never get a good job” or “I will pass out and my colleagues will laugh”. Thoughts like these will obviously increase a persons anxiety.

We tackle these thoughts by challenging them, questioning them, and asking them to back themselves up with evidence. It’s a Court of Law for these thoughts and they’re charged with Irrationality! How can you see into the future? How do you know that you will fail the interview? Have you always failed every interview you’ve ever done? or How do you know you will pass out? Have you passed out every other time you’ve been in that situation?

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Or we can take a slightly different tack and question their assumptions of what will happen if things do in fact go poorly. What if you do happen to fail the interview? What will happen? Does everyone who fails an interview end up on the scrap heap? Is that what you’d tell a friend who’d failed an interview? or What if you do pass out? What will happen? Will your colleagues really laugh? Or will they be concerned for you?

By questioning our anxious thoughts we can stop simply assuming they’re right and begin to look for alternative ways of thinking about the situation. For example, you might remember that in fact you’ve always done pretty well in interviews in the past, or that a friend failed an interview for one job only to land an even better one a while later. So you might think instead that “Actually I’ve got a fair chance of doing OK in this interview, and even if I don’t get this job it’s not the end of the world”. This thought is not only more balanced and realistic, it will also diminish your anxiety.

Anxious behaviours are the behaviours that we consciously choose to do (or not to do!) as a result of our anxiety – they are NOT the physical sensations of anxiety (these aren’t under our immediate control). We engage in these behaviours in an attempt to reduce and alleviate our anxiety. There are two overlapping classes of anxiety-related behaviours. There are so-called “Safety Behaviours”, such as sitting down or grabbing hold of something when you feel anxious and dizzy. And there are “Avoidance Behaviours”, such as excluding yourself from social gatherings.

These behaviours seem to work in the short term – you’re fear of passing out diminishes, and you completely avoid the anxiety of the works do. But you’re storing up problems in the longer term. You’ll start to believe that you HAVE to sit down when you feel anxious or you WILL DEFINITELY pass-out, and the next time you’re invited to a social gathering you will be even more anxious.

Safety Behaviours prevent you from learning to cope with your anxious sensations, and Avoidance Behaviours prevent you from challenging your anxious thoughts.

There’s no denying that the physical sensations of anxiety can be unpleasant, but they are temporary and are not life-threatening. A racing heart, weak legs, nausea and light-headedness aren’t fatal. But they can feel certainly feel like it, so the way to prove to yourself that you won’t die or pass out or throw up or whatever it is you’re worried about, is to go out and get yourself some anxiety!

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Deliberately putting yourself in your anxiety-provoking situations (crowded shop, tall building, whatever) is the first step to recovery. You can do this in a “graded” way (i.e. start with less busy shops or less tall buildings) before moving on to bigger challenges. Or you can “go in at the deep end” and expose yourself to your worst nightmare. And you just stay there – in the shop or observation deck – and you refuse to do any Safety Behaviours. If you feel dizzy then you feel dizzy, but you refuse to hold on to anything. If you feel nauseous, you just let yourself feel nauseous. Remember: these sensations are side effects of adrenalin and will not harm you. Many people even find them pleasurable – hence roller-coasters and bungee-jumping!

And then you just stay there some more. And some more. And then a bit more. Your anxiety will probably be huge to start with. You’ll get the whole lot – feeling sick, feeling faint, feeling that your chest will explode, your mind is mind racing, ” I’ve got to get out of here!”, your legs seeming about to take you away anyway etc. But if you just stick with it – not fighting it but just “experiencing it” – you’ll find things start to change. It can take anything from a few minutes to even an hour, but eventually your anxiety will wane. It’s almost as if you get bored with being anxious! Here you are, all het-up and ready to go, and nothings happening. Indeed, in a way, your body does get bored. After all there’s only so much adrenalin that your body can produce at any one time, and if it’s not really needed (i.e. your not running from a lion) then it’ll stop making it. And less adrenalin means less anxious physical sensations.

By staying in your anxiety-provoking situation you give yourself a chance to “habituate” to it – you have become used to it. This is an incredibly powerful thing to do. Not only have you faced up to your fears but you have proven to yourself that anxiety is bearable. Unpleasant, yes, but temporary and non-fatal. Your anxious thoughts about dying or passing out are shown to be wrong.

So what do you do now? Well, as you may have guessed, you go out and do it again. And again. And again. The more you enter into – AND STAY – in your anxiety-provoking situations, the better you’ll become at coping with your anxiety. You (and your body) will stop fearing these situations and, eventually, they will fail to produce any anxiety in you.

Dr Steve Last is a psychiatrist and therapist who uses CBT in Edinburgh. Please visit http://www.drstevelast.co.uk for more information about CBT and anxiety.

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