Anxiety Management Package

ANXIETY MANAGEMENT PACKAGE

ANXIETY

•Overview •Generalized Anxiety Disorder •Your anxiety •Panic and panic attacks

INTERVENTIONS

•Coping skills •Unhelpful thinking styles •Untwisting your thinking •Challenging anxious thoughts •Accepting uncertainty

WORRYING

•How worry works •Rumination and worry •Postpone your worry •Worry thought record •Worrying well

SOCIAL ANXIETY

•Overview and strategies •Social anxiety thought record

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ANXIETY

Anxiety is the body's way of responding to being in danger. Adrenaline is rushed into our bloodstream to enable us to run away or fight. This happens whether the danger is real, or whether we believe the danger is there when actually there is none. It is the body's alarm and survival mechanism. Primitive man wouldn't have survived for long without this life-saving response. It works so well, that it often kicks in when it's not needed - when the danger is in our heads rather than in reality. We think we're in danger, so that's enough to trigger the system to go, go, go! People who get anxious tend to get into scanning mode - where they're constantly on the lookout for danger, hyper-alert to any of the signals, and make it more likely that the alarm system will be activated.

Thoughts that often occur relate to our overestimating or exaggerating the actual threat and underestimating or minimising our ability to cope:  I'm in danger right now  The worst possible scenario is going to happen  I won't be able to cope with it

www.get.gg © Carol Vivyan 2009-2015, permission to use for therapy purposes www.getselfhelp.co.uk/anxiety.htm

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Behaviours might include:

 Avoiding people or places  Not going out  Going to certain places at certain times, e.g. shopping at smaller shops, at less busy times  Only going with someone else  Escape, leave early  Go to the feared situation, but use coping behaviours to get you through: examples include: self talk, holding a drink, smoking more, fiddling with clothes or handbag, avoiding eye contact with others, having an escape plan, medication. These are called 'safety behaviours'.

Safety behaviours can also help to keep your anxiety going. Whilst you depend on them to help you cope, you don't get to find out that without them, the anxiety would reduce and go away on its own.

Whilst avoiding people or situations might help you feel better at that time, it doesn't make your anxiety any better over a longer period. If you're frightened that your anxiety will make you pass out or vomit in the supermarket aisle, you won't find out that won't actually happen, because you don't go. So the belief that it will happen remains, along with the anxiety.

Vicious Cycle of Anxiety

We all feel anxious some times. A certain amount of anxiety helps us to be more alert and focused. For example just prior to an exam, a few exam nerves have a positive effect - motivating us, helping us focus our thoughts on the job in hand, making us more alert. Too much anxiety, or constantly being anxious, is unhealthy and detrimental to our lives and relationships.

Vicious Cogs of Anxiety

By looking at the "cogs" that keep the central problem going, we can target and make positive changes in each of the cogs, which will at least, slow down, and at best, stop, the central problem, for example:

www.get.gg © Carol Vivyan 2009-2015, permission to use for therapy purposes www.getselfhelp.co.uk/anxiety.htm

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Print a blank Cogs PDF (www.getselfhelp.co.uk/docs/Cogs.pdf) and fill in the factors that keep your anxiety going

Identify your triggers

What or when are the times when you are more likely to get anxious? If you can see the patterns, then maybe you can do something about those situations, and do something different.

 Certain places?  Certain people?  Anytime, anyplace?  See certain things?  Hear certain things?  Think ahead to certain situation?

Doing things differently If avoiding situations and using safety behaviours helps to maintain our anxiety over the long-term, then it makes sense that learning to confront it might be uncomfortable in the short-term, but will help us take control and helps us feel better over time.

Make a plan to gradually do the things you normally avoid. For instance if you normally avoid going out to big social events at work, then start with a small dinner at a restaurant where you feel more comfortable, with few close colleagues - not the annual Christmas party! Whilst it will feel uncomfortable, you will learn that you can enjoy these events, and that the anxious feeling does go away.

If you have a fear of particular types of places (e.g. lifts), then you could start by listing different particular places (smaller, bigger lifts, taller, smaller buildings, glass walls or enclosed etc). You could start by standing next to a lift for a couple of minutes each day for a couple of weeks, then slowly build up to standing in the doorway with the doors open, then to getting in the lift without www.get.gg © Carol Vivyan 2009-2015, permission to use for therapy purposes www.getselfhelp.co.uk/anxiety.htm

Page 4 of 4 the doors closing, then to letting the doors close before opening them again, then to going up one floor etc. You can use breathing techniques or self-talk (challenging your unhelpful thoughts and repeating more realistic thoughts) to get you through these times.

If you normally depend on 'safety behaviours' to help you cope, then list them in order of importance, then start by dropping or not doing the least important, and gradually work your way up over time.

What to do when you feel anxious  STOPP! Pause, take a breath, don't react automatically (www.getselfhelp.co.uk/stopp.htm)  Ask yourself:  What am I reacting to?  What is it that I think is going to happen here?  What's the worst (and best) that could happen? What's most likely to happen?  Am I getting things out of proportion?  How important is this really? How important will it be in 6 months time?  Am I overestimating the danger?  Am I underestimating my ability to cope?  Am I mind-reading what others might be thinking?  Am I believing I can predict the future?  Is there another way of looking at this? Is this fact or opinion?  What advice would I give someone else in this situation?  Am I putting more pressure on myself?  Just because I feel bad, doesn't mean things really are bad.  What do I want or need from this person or situation? What do they want or need from me? Is there a compromise?  What would be the consequences of responding the way I usually do?  Is there another way of dealing with this? What would be the most helpful and effective action to take? (for me, for the situation, for others)  Visualise yourself coping in the situation you feel anxious about. See the situation to a successful completion.

How to deal with the physical sensations of anxiety Counteract the body's adrenaline response - it's readiness for action, by using that energy healthily.  Practice calming or mindful breathing - this one act alone will help reduce the physical sensations, emotions and intensity of thoughts. (www.getselfhelp.co.uk/mindfulness.htm)  Visualisation: Breathe in blue (for calm), breathe out red  Exercise - Go for a walk, run or cycle, or do some gardening or housework.

www.get.gg © Carol Vivyan 2009-2015, permission to use for therapy purposes www.getselfhelp.co.uk/anxiety.htm

what is generalised anxiety? Feeling tense, stressed, and worried at certain times when under pressure is a normal human response. In fact 2 out of every 5 people report that they worry at least once every day. However, for some people their worry, feelings of anxiety and tension persists to the point that they significantly interfere with their daily life. If this sounds like you, then you may find the information in this sheet very helpful in understanding what generalised anxiety is and its relevance to you.

What is Worry? What are the causes?

Before you can understand generalised anxiety, you The causes of generalised anxiety are not need to have an understanding of worry. Worry is clearly understood. However, a number of generally regarded as a form of verbal mental problem vulnerabilities are considered to increase solving about potentially negative future events. It can the chance of developing generalised be triggered by a variety of external anxiety: events, or from thoughts that just pop into your head. Worry is characterised • An inherited general biological disposition to by a lot of “what if” statements such as: experience negative emotions. • Prolonged stress, and past experiences of “What if I fail my exam?” uncontrollable or traumatic events. “What if I can’t do the job?” • Direct or indirect messages from the people around “What if I can’t provide for my family?” you that the world is threatening or that worry is “What if I get anxious during my interview?” useful. • A coping style that involves avoiding challenges or Normal worry is relatively short-lived and leads to situations where there is the chance of experiencing positive problem-solving behaviour. Worry becomes negative emotions. unhelpful when it is about a number of things, is very frequent, and is difficult to control or dismiss. People Diagnosis and Treatment may think this type of worry is useful, that it helps with Generalised anxiety is not always easy to diagnose as problem solving and planning, or prevents future some of its symptoms overlap with depression and other negative outcomes. However, this is not the case, as anxiety problems. It is thus important to see a mental prolonged or frequent worry generates more anxiety health practitioner for a definite diagnosis. and more worry, which may actually prevent positive thinking and action. The recommended psychological treatment for generalised anxiety is cognitive-behaviour therapy. This What are the key symptoms? usually includes: relaxation to reduce chronic tension; techniques for dealing Generalised anxiety involves: with unhelpful beliefs about worry; 1,2,3,4…

• Anxiety or worry about several things has occurred learning to challenge and let go of for at least the past 6-months worries; learning more helpful coping • The worry is experienced as excessive and and problem solving strategies; and uncontrollable, is present most days, and interferes learning to be less focused on with the ability to focus on tasks. uncertainty, and more present focused.

At least 3 of the following symptoms also need to be Mindfulness training and meditation may also be helpful present for the past 6-months or longer: for some individuals to reduce worry and increase present moment focus. However more research is • Feeling restless, keyed up, on edge & unable to relax required to determine if it is as effective as cognitive- • Physical tension. behaviour therapy. • Sleep disturbance. Having trouble falling asleep, maintaining sleep, or experiencing unsettled sleep. • Problems concentrating and focusing on a task. • Feeling irritable. • Feeling tired or exhausted easily. entre for C linical CI nterventions •Psychotherapy•Research•Training This document is for information purposes only. Please refer to the full disclaimer and copyright statement available at http:// www.cci.health.wa.gov.au regarding the information from this website before making use of such information. See website www.cci.health.wa.gov.au for more handouts and resources. Introduction to Anxiety

Anxiety is the body’s response to situations that are interpreted as threatening. Without any anxiety, you would probably make bad decisions, such as driving too fast on the highway, or not paying your bills. However, too much anxiety can lead to avoidance or unpleasant physical, emotional, and cognitive symptoms.

What are three things that trigger your anxiety? 1.

What are three physical symptoms that you experience when you feel anxious? 1.

What are three thoughts you tend to have when you feel anxious? 1.

What are three things you do to cope when you are anxious? 1.

Provided by TherapistAid.com © 2012 biology + psychology of panic Panic attacks (the key feature of Panic Disorder) can be Psychological Reactions 1: seen as a blend of biological, emotional & psychological Thinking Associated with Panic reactions. The emotional response is purely fear. The We’ve described the physical symptoms of panic. People biological & psychological reactions are described in who panic are very good at noticing these symptoms. more detail below. They constantly scan their bodies for these symptoms. Biological Reactions 1: Fight or Flight This scanning for internal sensations becomes an When there is real danger, or when we believe there is automatic habit. Once they have noticed the symptoms danger, our bodies go through a series of changes called they are often interpreted as signs of danger. This can the fight/flight response. Basically, our bodies are result in people thinking that there is something wrong designed to physically respond when we believe a with them, that they must be going crazy or losing control or that they are going to die. threat exists, in case we need to either run away, or stand and fight. Some of these changes are: There are a number of types of thinking that often occur  an increase in heart rate and strength of heart beat. during panic, including: This enables blood and oxygen to be pumped around  Catastrophic thoughts about normal or anxious the body faster. physical sensations (eg “My heart skipped a beat - I  an increase in the rate and depth of breathing. This must be having a heart attack!”) maintains oxygen and carbon dioxide levels.  Over-estimating the chance that they will have a panic  an increase in sweating. This causes the body to attack (eg “I’ll definitely have a panic attack if I catch become more slippery, making it harder for a the bus to work”) predator to grab, and also cooling the body.  Over-estimating the cost of having a panic attack:  muscle tension in preparation for fight/flight. This thinking that the consequences of having a panic attack results in subjective feelings of tension, sometimes will be very serious or very negative. resulting in aches and pains and trembling and shaking.

When we become anxious and afraid in situations Psychological Reactions 2: where there is no real danger, our body sets off an Behaviours that Keep Panic Going automatic biological “alarm”. However, in this case it When we feel anxious or expect to feel has set off a “false alarm”, because there is no danger anxious, we often act in some way to control to ‘fight’ or run from. our anxiety. One way you may do this is by keeping away from situations where you might Biological Reactions 2: panic. This is called avoidance, and can include: Hyperventilation & Anxious Breathing  Situations where you’ve had panic attacks in the past When we breathe in we obtain oxygen that  Situations from which it is difficult to escape, or where can then be used by the body, and we it might be difficult to get help, such as public breathe out to expel the product of our transport, shopping centres, driving in peak hour traffic metabolic processes - carbon dioxide. The  Situations or activities which might result in similar body naturally maintains optimal levels of sensations, such as physical activity, drinking coffee, both oxygen and carbon dioxide. When we are anxious, having sex, emotional activities such getting angry the optimal level of carbon dioxide is disrupted because we begin to hyperventilate, or breathe too much. If the A second response may be to behave differently, or to body cannot return carbon dioxide levels to the use “safety behaviours”. The following are examples of optimal range, we experience further symptoms such as these; you might make sure you are near an escape dizziness, light-headedness, headache, weakness and route, carry medication with you, or ensure that you are tingling in the extremities, and muscle stiffness. For next to a wall to lean on. Or you may use other more people with panic, these physiological sensations can be subtle methods like trying to distract yourself from your quite distressing, as they may be perceived as being a anxiety by seeking reassurance, reading something, or sign of an oncoming attack, or something dangerous bringing music to listen to. Although this may not seem such as a heart attack. However these are largely harmful to begin with, if you become dependent on related to the fight or flight response and these behaviours you can become even more distressed overbreathing, not physical problems. if one day it’s not possible to use them.

entre for This document is for information purposes only. Please refer to the full disclaimer and copyright statement available at C linical http://www.cci.health.wa.gov.au regarding the information from this website before making use of such information. C nterventions See website www.cci.health.wa.gov.au for more handouts and resources. I •Psychotherapy•Research•Training What are Panic Attacks?

Panic attacks are brief periods of overwhelming fear or anxiety. The intensity of a panic attack goes well beyond normal anxiety, and can include a number of physical symptoms. During panic attacks, people often fear that they are having a heart attack, they cannot breathe, or they are dying.

Symptoms of a Panic Attack Note: A panic attack does not need to include all of the symptoms listed below.

 Pounding or racing heart  Breathing difficulties  Sweating  Sense of terror, or impending doom or death  Trembling or shaking  Chest pain or discomfort  Fear of “going crazy”  Nausea  Feeling of being detached from reality  Fear of dying

Panic Attack Facts

Panic attacks may feel scary, but they don’t actually cause physical harm. The most common fears associated with panic attacks (having a heart attack or fainting) are not actually a threat.

Panic attacks are usually brief but intense. The symptoms of panic typically peak within 10 minutes, and end within 30 minutes. However, some lingering symptoms can last over an hour.

Panic attacks can seem to occur randomly, or they can be closely linked to a specific source of anxiety such as driving, crowded places, or simply leaving home.

Panic disorder occurs when a person has frequent worry or fear of future panic attacks, or when they change their behavior in to avoid attacks (such as avoiding a feared situation).

How are Panic Attacks Treated?

Cognitive Behavioral Therapy Exposure Therapy

Cognitive behavioral therapy (CBT) is a During exposure therapy, the patient is common and well-supported treatment for intentionally exposed to the symptoms of panic panic attacks and panic disorder. CBT works in a safe environment. As exposure continues, by identifying and changing unhealthy thinking the symptoms become more familiar and less patterns that trigger panic attacks. The terrifying. Exposure therapy may also involve benefits of CBT can be long-lasting. gradual exposure to feared situations.

Medication Relaxation Techniques

Medication for panic attacks can act as a Much like how muscles become stronger with short-term treatment for severe cases. exercise, the body’s relaxation response can be Because medication does not treat the improved with practice. Frequent use of underlying issues that cause panic disorders, it relaxation techniques such as deep breathing, should be accompanied by another form of meditation, and progressive muscle relaxation treatment such as psychotherapy. can help to combat panic attacks.

All or nothing Over- thinking Sometimes called ‘black generalising and white thinking’ Seeing a pattern based “everything is upon a single event, or If I’m not perfect I have failed always rubbish” being overly broad in the “nothing good conclusions we draw x Either I do it right or not at all ever happens”

Mental lter Disqualifying Discounting the good Only paying attention to the positive things that have happened certain types of evidence. or that you have done for some reason or another Noticing our failures but +++ not seeing our successes That doesn’t count

Jumping to There are two key types of Magni cation Blowing things out of conclusions jumping to conclusions: (catastrophising) & minimisation proportion • Mind reading (catastrophising), or (imagining we know what inappropriately shrinking others are thinking) something to make it seem • Fortune telling less important 2 + 2 = 5 (predicting the future)

Emotional Using critical words like reasoning Assuming that because we should ‘should’, ‘must’, or ‘ought’ feel a certain way what we can make us feel guilty, or think must be true. like we have already failed

I feel embarrassed so I must If we apply ‘shoulds’ to be an idiot must other people the result is often frustration

Labelling Assigning labels to Personalisation Blaming yourself or taking ourselves or other people responsibility for something that wasn’t I’m a loser “this is completely your fault. I’m completely useless Conversely, blaming other STUPID They’re such an idiot people for something that my fault” was your fault.

PSYCHOLOGYT LS http://psychology.tools TEN WAYS TO UNTWIST YOUR THINKING*

1. Counter the Distortion: Write down your negative thoughts so you can see which of the cognitive distortions you're involved in. This will make it easier to think about the problem in a more positive and realistic way.

2, Examine the Evidence: Instead of assuming that your negative thought is true, examine the actual evidence for it. For example, if you feel that you never do anything right, you could list several things you have done successfully.

a J. The Double-standard Method: Instead of putting yourself down in a harsh, condemning way, talk to yourself in the same compassionate way you would talk to a friend with a similar problem.

4. The Experimental Technique: Do an experiment to test the validity of your negative thoughts. For example, if, during an episode of panic, you become tenified that you're about to die of a heat attack, you could jog or run up and down several flights of stairs. This will prove that your heart is healthy and strong.

5. Thinking in Shades of Gray: Although this method might sound drab, the effects can be illuminating. Instead of thinking about your problems in all-or- nothing extremes, evaluate things on a range from 1 to 100. When things don't work out as well as you hoped, think about the experience as apartral success rather than a complete failure. See what you can learn from the situation.

6. The Survey Method: Ask people questions to find out if your thoughts and attitudes are realistic. For example, if you believe that public speaking anxiety is abnormal and shameful, ask several friends if they ever felt nervous before they gave a talk.

7. Define Terms: When you label yourself "inferior" or "a fool" or "a loser", ask "What is the definition of 'a fool'?" You will feel better when you see that there is no such thing as "a fool" or "a loser".

8. The Semantic Method: Simply substitute language that is less colorful and emotionally loaded. This method is helpful for "should statements". Instead of telling yourself "I shouldn't have made that mistake", you can say, "It would be better if I hadn't made that mistake."

9. Re-attribution: Instead of automatically assuming that you are "bad" and blaming yourself entirely for a problem, think about the many factors that may have contributed to it. Focus on solving the problem instead of using up all your energy blaming yourself and feeling guilty.

10. Cost-Benefit Analysis: List the advantages and disadvantages of a feeling (like getting angry when your plane is late), a negative thought (like "no matter how hard I try, I always screw up"), or a behavior pattern (like overeating and lying around in bed when you're depressed). You can also use the Cost-Benefit Analysis to modify a self-defeating belief such as "I must always try to be perfect".

Anxiety can be a healthy emotion—it forces us to focus on our problems, and work hard to solve them. But sometimes, anxiety grows out of control, and does just the opposite. It cripples our ability to solve problems. When this happens, irrational thoughts often play a role.

In this exercise, we will practice catching our irrational thoughts, and replacing them with rational alternatives. With enough practice, this will become a natural process that can help you manage anxiety.

Describe a common situation that triggers your anxiety: example: “giving a speech in front of a crowd” or “driving in rush hour traffic”

Anxiety distorts our thinking by causing us to overestimate the likelihood of something going wrong, and imagine the potential consequences as worse than they really are. Sometimes, just taking a moment to think about these facts can help us recognize our irrational thoughts.

Imagine you are faced with the anxiety-producing situation from above. Describe the…

Worst outcome: Best outcome: Likely outcome:

Imagine the worst outcome comes true. Would it still matter…

1 week from now: 1 month from now: 1 year from now:

Usually, anxious thoughts focus on the worst possible outcomes, even when they aren’t likely. For example, a person who is nervous about giving a speech might think: “I am going to forget everything and embarrass myself, and I’ll never live it down”.

As an outside observer, we know that an alternate, more rational thought might be: “My speech might only be OK, but if I do mess up, everyone will forget about it soon enough”.

Using your own “worst outcome” and “likely outcome” from above, describe your…

Irrational thought: Rational thought:

© 2016 Therapist Aid LLC Provided by TherapistAid.com accepting uncertainty The inability to tolerate uncertainty is an • Do you tend to predict bad things will happen just attitude many people have towards life. because they are uncertain? Is this a reasonable thing When one has this attitude, to do? What is the likelihood of positive or neutral uncertainty, unpredictability, and doubt are outcomes? seen as awful and unbearable experiences • How likely is it that things you predict will happen? Is that must be avoided at all costs. it possible to live with the small chance that If you hate uncertainty, then you may perceive worrying something negative may happen, given its likelihood is to be useful to you. You may think that worrying is a very low? way of preparing yourself for the worst – getting you • Can you live with some of the uncertainties of life? ready for anything that might happen. Worrying might How do you do this? And can you do this in other be seen as a way of attempting to predict life so that situations you find diffiult? there are no nasty surprises. As such, worrying • Ask a friend how they cope with uncertainty, see if reduces your experience of uncertainty and you can learn a few tips from them? unpredictability. And because worrying reduces your feelings of uncertainty, you will continue worrying and 2. Acceptance and Mindfulness worrying and worrying. In other words, worrying helps you believe that you have more control and certainty in When you are intolerant of uncertainty, your mind tends life. to be focused on the future. An antidote to this style of

In reality, has your worrying thinking is to practice becoming more present focused made anything more certain or and accepting of your current experience. That is, more more predictable? Does mindful. The steps to being more accepting and mindful worrying really change the are explained in the infosheets What is Mindfulness? and Mindfulness & Letting Go. Three basic steps to follow are: outcome of what will happen? Unfortunately, life is still as • Being aware of what you are currently thinking and uncertain and unpredictable as it what you are feeling in your body. Use the feeling of ever was, it is only your perception that you somehow your breath to remain present. What are you have more control that has changed. But is this really noticing when you are needing certainty? true? In fact, all you have done is think of all the worst Acknowledge these thoughts and feelings, maybe case scenarios, worked yourself up, made yourself feel saying “ah, so that's how it is”. really bad in the process and often paralysed yourself • Letting go of the need for a quick fix, by saying from taking any action. So, ask yourself, is worrying something to help you let go of the need for about uncertainty really worth it? Maybe it is time to certainty. Maybe “its only a consider a different way? need for certainty thought, just

let it go”. There are two main strategies for learning how to accept uncertainty and thus reduce worry. • Being Non-judgmental, by bringing a gentle curiosity to the thoughts that drift by 1. Challenging Intolerance of without judging them or trying Uncertainy to change them. Then return your focus to the here

Ask yourself the following questions and write down and now of your experience. Focus your attention your responses. See if you can come to an fully on sounds around your or sensations in the understanding of the disadvantages and problems of body, or your breath, or the task at hand. being intolerant of uncertainty.

• Is it possible to be certain about everything in life? This document is for information purposes only. Please refer to the full disclaimer and copyright statement available at http://www.cci.health.wa.gov.au regarding the infor- • What are the advantages of requiring certainty, mation from this website before making use of such information. versus the disadvantages? Or, how is needing See website www.cci.health.wa.gov.au for more handouts and resources. certainty in life helpful and unhelpful? entre for C linical CI nterventions •Psychotherapy•Research•Training how worry works

Worry and Problematic Worry Negative Beliefs About Worrying Worry is generally regarded as a form of verbal mental In addition to the specific things people worry about, problem solving about potentially negative future events. people with generalised anxiety disorder may also worry Normal worry is generally short-lived and leads to about the fact that they are worrying. In this case, positive problem-solving behaviour. Worry becomes such worriers are often concerned that worrying is “bad” unhelpful when it is about a number of things, is very and may believe that: frequent, and is difficult to control or dismiss. Prolonged • Worrying is uncontrollable, and will take over and or frequent worry generates more anxiety and more result in a loss of control (e.g., “I won’t be able to control worry, which may actually prevent positive thinking and my worrying, and it will never stop”). action. • Worrying is dangerous, and will cause

either physical or mental harm (e.g., “If I What Triggers Worry? keep worrying like this I will go crazy/ Worrying can be triggered by various things. Some have a breakdown/become ill”). triggers may be more obvious and linked to external things, for example: Holding these (false) negative beliefs about worrying makes • Seeing a certain image (e.g. in the the process of worrying very distressing for you, and this newspaper or on TV) will even keep your worrying going. • Hearing certain information (e.g., on the radio or in a conversation) Positive Beliefs About Worrying • Being put in a certain situation (e.g., Worriers often hold (false) positive beliefs that worrying is having to make decisions, perform a beneficial and “good,” which can keep worriers worrying. task, lead others, or face uncertainty) Some positive beliefs may be:

• Worrying motivates me to do things Some triggers may be less obvious. These may be • Worrying helps me find solutions to problems thoughts or images that seem to just pop into your head • Worrying prepares me for the worst out of the blue. An initial “What if…” question that • Worrying helps me avoid bad things comes to mind for no apparent reason, can even be a • Worrying prevents bad things trigger for worrying. For example, the thought “What if I left the iron on?” might pop into my head. If I think “I probably didn’t” and decide not to worry about it, Avoidance and Thought Control chances are I will forget about it, and the thought will slip Avoidance may take the form of avoiding a feared outcome my mind. However, if instead I start to ‘chase’ the (e.g., passing up a promotion to avoid the feared outcome thought further (e.g., “The ironing board might catch fire of not doing a good job) or avoiding worrying itself (e.g., and that will spread to the whole house.” “The house not watching the TV news in case a worry is triggered, or might burn down and then I will lose everything!”), then asking for reassurance from loved ones that nothing bad the original “What if…” question has now triggered a will happen to you). Avoidance limits a person’s worry episode. opportunity to have experiences that disconfirm their worries and their beliefs about worrying. IN a sense, not confronting your worries keeps the worrying going. What Maintains Worry? People who describe themselves as chronic worriers are People who worry often attempt unsuccessfully to control often disturbed that they seem to spend much of their their worrisome thoughts in a number of ways. These may waking hours worrying excessively about a number of include trying to suppress their worries, trying to reason different life circumstances. They do not understand why with their worrisome thoughts, distracting themselves or this activity continues. They often ask, “Why do I do it?” thinking positively. These attempts at thought- and “What keeps my worrying going?” control rarely work, as trying to suppress a thought usually has the opposite effect of There are two types of thoughts or beliefs about worry making that thought occur more, which in turn which work to maintain the worry, in a vicious cycle. fuels the belief that worries are uncontrollable. These are negative beliefs about worrying, and positive beliefs about worrying. Unhelpful strategies such as In other information sheets, we can explore some better avoidance and thought control also maintain worry. strategies to manage worry.

Centre for This document is for information purposes only. Please refer to the full disclaimer and copyright statement available at linical http://www.cci.health.wa.gov.au regarding the information from this website before making use of such information. C nterventions See website www.cci.health.wa.gov.au for more handouts and resources. I •Psychotherapy•Research•Training Rumination & Worry  Worry o Future focused – danger and our own inability to cope o Leads to: anxiety, stress, fear . What if? . Imagining the worst will happen  Rumination o Past focused – loss and personal failings o Leads to: depression, sadness, shame . If only . Regret. I should have…., I shouldn’t have… Thinking style  Similar to what we do in ‘problem solving’ – but in overdrive!  Constantly chewing things over, regurgitating. Repeatedly thinking about the same thing. Circular thinking patterns. More  Thoughts keep returning - difficult to get Worry & anxious & out of the thinking habit. Ruminate depressed How does it affect us?  In ruminating and worrying, we’re trying to reduce the distress and overcome problems, but we end up increasing and Worry & prolonging our distress, and making the Anxious Ruminate problem bigger. Depressed more  Interferes with clear thinking, daily activity, our ability to cope.  Often leads to unhelpful behaviours to help us escape from our thoughts (self-harm, drinking, drugs, comfort eating etc)  The more we ruminate or worry, the stronger the habit becomes, and the harder it is to change. The less we ruminate or worry, the weaker the habit becomes. What can I do?  Notice that the mind is going down that rumination/worry route  Tell yourself: o I don’t have to think about that right now. It can wait until I feel stronger. o There’s nothing I can do about my thoughts – I can’t stop them, but I can choose not to focus on them.  Do something that will take up your attention and help you feel better o What can I do right now, that will help me feel better, and be effective for this situation? o Right now, what can I do that will take me one step in the right direction?

www.getselfhelp.co.uk © Carol Vivyan 2010. Permission to use for therapy purposes. www.get.gg Postpone your Worry

This approach involves postponing your worry to a ’worry period’ that is the same time, place, and duration each day. It is important to practice this approach as it will take some time to develop your skill and gain some benefits. It may be best to start by practicing with minor concerns before moving onto major worries. Read the information sheet Postpone your Worry before tackling this exercise.

What was the worry ? Were you able to What happened in the worry period? What did you learn from postponing your (Did you notice any triggers, postpone the worry? (Did you still need to worry? Did you use problem solv- worry? (Was the worry more or less bothersome Basic steps: such as places, times or (How did you cope?) ing, a thought diary, or mindfulness? How did it work? after you postponed it? Could you control your worry? events linked to your worry? What feelings or reactions did you notice?) How did you feel after the worry period?) 1) As soon as you become aware of a worry, postpone it to your worry period.

2) Briefly write down the topic of your worry and any triggers on the sheet so you can refer to it later.

3) Use mindfulness to focus on the present moment and the activities of

the day to help let go of the worry until your worry period. Then decide what is the most important and best

thing you can practically do for yourself right now. Take immediate action

to do something that is either practi- cal, positive, or nurturing.

4) When your ‘worry period’ arrives,

use it for problem-solving or thought diary work on only the worries from

the day that still bother you.

5) Complete the sheet and make any comments about what you noticed about the process of postponing your worry.

entre for C linical CInterventions • Psychotherapy • Research • Training This document is for information purposes only. Please refer to the full disclaimer and copyright statement available at http://www.cci.health.wa.gov.au regarding the information from this website before making use of such information. See website www.cci.health.wa.gov.au for more handouts and resources. Worry Thought Record Situation What is my What am I predicting? Emotion What is the evidence for my What is the evidence against How likely is it Date & Time worrisome (Rate how much you (Rate intensity prediction? my prediction? that what I thought? believe it will 0-100%) am predicting happen 0-100%) will happen? (Rate belief 0-100%)

PSYCHOLOGYT LS http://psychology.tools

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Social Anxiety

Social Anxiety is an anxiety disorder where we believe that others will judge us negatively (e.g. "they'll think I'm an idiot"), and it is therefore experienced most acutely in situations when we are with other people. Our attention is very self-focussed - on what we must look like to others, what they might be thinking of us, trying to interpret every glance or other unspoken gesture or expression and what it might say about what they think about us. We become 'mind-readers' and imagine that we can correctly assume what others are thinking about us.

Because we don't want to experience this anxiety (and it's normal body response), we tend to avoid situations when it might happen, and therefore are unlikely to learn that it could be ok and we could actually enjoy ourselves.

If we do have to go, then we use 'safety behaviours' to help us cope, such as trying not to be noticed, avoiding eye contact, holding or fiddling with something, trying to hide (e.g. sit in corner, hair over face), don't talk, and maybe have an escape plan (e.g. sit by door or in aisle, make excuse to leave early). This all increases the self-focus.

Cognitive Behaviour Therapy helps us learn to challenge the unhelpful thoughts and beliefs, learn to control our focus of attention, and change what we do.

Example of a vicious cycle of Social Anxiety

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Self Help for Social Anxiety

In order to break the vicious cycle of social anxiety, we need to change the way we think, and change what we do. Firstly, we can learn about how any anxiety affects our body:

 Read Alarming Adrenaline

Thinking Differently - Challenging Thoughts

If we can change the way we think about a situation, then we will not feel so anxious. We can learn to challenge those anxiety-provoking thoughts. Thoughts are not statements of fact. Don't believe everything you think!

 Learn more About Automatic Thoughts  Learn Fact or Opinion skill  Learn about The Mind Bully

What we believe deep down about ourselves, influences and distorts the way we think other people will think about us. Just because we think others think negatively about us, doesn't mean that is how it really is! We are looking at social situations, at other people and their judgement of us, through those very distorted lenses.

 Read: Different Perspectives

Learn to challenge the unhelpful and distorted thinking:

 Use the Vicious Cycle & Alternatives to map out your own thoughts, feeling and behaviours, and generate some healthier alternative thoughts and behaviours.  Use this Social Anxiety Thought Record Sheet  Practise STOPP skill  Learn to use Positive Coping Statements

Thinking Differently: Re-Focus

When we're in a social situation with a group of people, our focus of attention becomes totally caught up in our own thoughts and feelings. We see everyone around us, but all we can think about is how they might be thinking critically about us! The adrenaline response of anxiety makes us feel terrible too, so we're thinking about how horrible that is, and how we just want to escape the situation.

It is very helpful to learn how to change our focus of attention and take more control over how we react to thoughts. We can learn to just notice the thoughts, acknowledge them, then let them pass. Notice the Mind Bully and let it go - turn your focus of attention to something else. First of all, you might learn to focus on your breathing.

 Practise Mindful Breathing

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Mindfulness of everyday activity

 Choose an activity to do mindfully throughout the day, for one, two or five minutes. For example: Drink a cup of tea. Walk. Wash the dishes.  Be in that moment, right now. See, hear, smell, touch, feel, breathe.  Simply notice whenever other thoughts and sensations come to mind, then re- focus on your chosen mindful activity.  Be patient and compassionate with yourself.  Describe… rather than judge good or bad, pleasant or unpleasant.  It is as it is.

Use the NOW acronym for mindful moments during the day

 Notice where your attention is right now  Observe what you are doing: “I am sitting”, “I am looking”, “I am breathing”  Wise Mind: What shall I do now? Continue being mindful? Do something else?

See the Mindfulness handout for more examples

The more we practice, perhaps the more, initially at least, we will notice those thoughts intruding, and that's ok. The only aim of mindful activity is to continually bring our attention back to the activity, noticing those sensations, from outside and within us.

Doing Differently

Our usual strategy for dealing with social anxiety, is to avoid social situations. However, that just serves to keep the social anxiety going because we never find out that we could cope and that we could enjoy ourselves.

Use the Avoidance worksheet to gradually face your fears.

In the vicious cycle example diagram above, you will notice a list of what are called "safety behaviours" that we might use when we feel anxious in a social situation. It's helpful to identify what you do in those situations, such as: plan your exit (book a taxi), sit in a corner (to hide), sit on the end (to allow quick exit), check where the exits or toilets are, fiddle with something, drink more, not talk, avoid eye contact and so on.

Slowly, we can change what we do. Use the Avoidance worksheet and identify some healthy coping strategies to use in those situations, and gradually, reduce and stop those safety behaviours. So part of your list of feared situations might be changing where you sit, who you sit by, not booking a taxi etc.

It's important that you see the situations through - stick with the anxiety - it will pass.

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Use STOPP skill to incorporate the strategies

STOP

 Just pause for a moment

Take a breath

 One slow deep breath

Observe

 There's the mind bully again.  My body and mind are reacting to the thoughts that others might be critical and I feel anxious.

Pull back

 This is just the anxiety talking.  The thoughts are just thoughts.  Don't believe everything you think!  Let's stick with the facts - these thoughts are just opinions (Fact or Opinion).  I don't have to react right now.  There's another explanation for this...(there is no evidence that others are thinking critically of me, my friends wouldn't invite me if they didn't want me there, others won't even notice me etc)  I can let the thoughts go.

Practise / Proceed - What can I do right now? I can use my coping strategies, e.g.

 Avoidance Worksheet  Social Anxiety Thought Record Sheet  Mindful Breathing  Shift focus - Where can I put my focus of attention right now? (Mindfulness & mindful activity).  What else can I do that would help me tolerate these thoughts and feelings without reacting to them?

Complete your own STOPP Worksheet

www.get.gg/socialanxiety.htm © Carol Vivyan 2015. Permission to use for therapy purposes. www.getselfhelp.co.uk Social Anxiety - Thought Record Sheet

Situation Feelings: Unhelpful thoughts Self-focus Safety Behaviours Balanced more rational Outcome & Trigger Emotion/s or images response to thoughts and What I did – how that Rate 0 – 100% self-focus helped. Physical sensations Re-rate Emotion 0-100%

What could I do differently? STOPP! Take a breath…. What would be more Is this fact or opinion? effective? What would someone else say What went through my about this situation? What’s the Outer-focus: look around, mind? What disturbed What did I do that helped me bigger picture? listen – move focus of What emotion did I me? As I felt anxious, where cope? Is there another way of seeing attention away from self feel at that time? What’s the worst that was my focus of What did I do to hide it or it? What advice would I give a What happened? What else? How could happen? attention? prevent others from noticing? friend? Do what works! Act wisely. Where? When? intense was it? What did I think others What did I notice about What did I do to try to stop it Is my reaction in proportion? Who with? How? would notice or think myself? happening? If I was seeing this as an What would be most When I felt about me? What do I imagine I Did I have an urge to do outsider, what would I notice helpful for me or best for What did I notice? anxious, what did I What would that mean look like, or how others anything? about other people? What’s the situation? What will the What did I react notice in my body? to me, or say about see me? How do I How did what I did affect my REALLY happening? consequences be? (long to? Where did I feel it? me? picture myself looking? anxiety? Change focus! and short term)