A Self Help Workbook for People with Anxiety
Acknowledgements
This workbook was produced by members of the South Worcestershire Primary Care Mental Health Team and Psychology Department. Special thanks to Sally Denham-Vaughan, Dr Andie Lees and Lynda Smith.
Disclaimer
How to use this pack
This anxiety management pack uses Cognitive Behavioural Therapy or CBT. CBT is a type of therapy used to help people cope with all sorts of problems, including anxiety and depression. The “cognitive” part deals with thoughts and how they are linked to anxiety. The “behavioural” part deals with how what we do affects our anxiety.
This workbook will enable you to work through your anxiety week by week. Each week you will be asked to complete worksheets. These will help you to stay motivated and show you how you are getting on.
The pack is divided into six parts and should take up to six weeks to work through:
Section 1 explains what anxiety is, helps you to set goals and explains relaxation and breathing techniques.
Section 2 explains the cognitive behavioural approach, relaxation techniques and lifestyle advice.
Section 3 explains avoidance and how to begin to confront the things that make us feel anxious.
Section 4 helps you identify, challenge and replace your worrying thoughts.
Section 5 explains life skills that can help to reduce your anxiety.
Section 6 explains how to cope with setbacks and bad days.
At the end of the pack there are suggestions for further reading and contact details of organisations that you may find helpful.
Contents
Section 1 What is anxiety 5-22
Goal Setting
Relaxation and breathing
Section 2 The CBT approach. 23-32
Lifestyle
Section 3 Avoidance and exposure 33-36
Section 4 Worrying thoughts 37-44
Section 5 Life skills 45-50
Section 6 Coping with setbacks 51-55
Further reading 56
Section 1
What is anxiety?
Anxiety and fear are normal human emotions. Fear is the natural response to danger or stress, and helps us survive by preparing our bodies to deal with threatening situations. It acts as the trigger for our bodies to release adrenaline, which makes the body work faster and harder so that it can cope with danger by either fighting or running away. This is known as the "fight or flight" response, which is automatic. As soon as you sense a threat, this response occurs. This was very useful in prehistoric times when there were many dangers such as wild animals, and prehistoric man needed to react to these quickly. The “fight or flight” response helped us to be ready to run away or fight immediately after sensing a threat, and so helped us to survive.
Today we don't have to worry about wild animals attacking us. However, there are other dangers, which mean we still need this response. For example, if you are crossing a road and see a car coming quickly towards you, the “fight or flight” response occurs.
These are some of the physical sensations and mental processes that can result from having all this adrenaline in our system.
These symptoms are very helpful in dealing with the threat as they are the body’s normal coping mechanism. However, fear becomes a problem when we have difficulty turning these reactions off. You may find that you have become trapped in a cycle of worrying about your feelings, and this can escalate into a habit of feeling anxious a lot of the time.
The diagram on page 8 shows how this habit can develop into a vicious circle of anxiety and panic.
Cycle of worry
Can lead to
Why me?
Everyone experiences anxiety and has anxious thoughts sometimes, but it is more of a problem for some people than for others. There are a number of reasons for this:
1. Personality
Some people may be more vulnerable to developing problems with anxiety because of aspects of their personality. For example:
· People who are self-critical and have very high standards.
· Those with low self-confidence who imagine others will judge them harshly.
· Those who tend to think negatively and imagine the worst.
· Those who are always rushing around (possibly looking after others) and never rest.
2. Family history
It is possible for anxiety to be learnt. For example, a child who sees his mother getting very anxious when seeing a spider may develop a phobia about spiders. However, it is important to remember that it is possible to overcome fears and worries, even when there is a long history of them.
3. Life stresses
Events in our lives, both present and past, can increase our chances of developing anxiety-related problems. Stressful events, either short-term, such as losing a job or taking an examination, or long-term such as ongoing physical illness, or financial worries, can all cause anxiety-related problems. We may deal with stressful situations by changing our habits, such as withdrawing from life. This can mean that, over time, anxiety about facing situations can increase. However, stressful events are not always negative. Moving house, going on holiday or the birth of a child can be just as stressful as negative events.
Anxiety can also be triggered by past events. If a similar situation is encountered again it can stir up the same feelings of distress. Anxiety may be triggered following a life event such as bereavement, divorce or by moving house. After such events people may not be able to express difficult feelings and this can lead to anxiety.
4. Coping skills
People have different ways of coping with problems. Some people find it helpful to keep busy and distract themselves. Avoiding the problem, or using smoking, drugs or alcohol to cope, can bring short-term relief, however, this can actually increase the problem in the long-term.
Types of anxiety
Anxiety affects people differently. The following are the most common forms of anxiety and you may recognise yourself in the descriptions that follow:
Generalised Anxiety
People with generalised anxiety feel tense, anxious and uneasy most of the time. They worry about a variety of situations and events and tend to overreact even to mild stresses. Physical symptoms include:
· Restlessness
· Fatigue
· Problems concentrating
· Tense muscles
· Insomnia
Phobias
People with phobias have specific and intense fears triggered by particular objects or situations. Even though the sufferer may know their fear is irrational it still causes them to feel anxious.
There are three types of phobias.
· Simple phobias - fear of a particular object, animal or situation. E.g. fear of spiders.
· Agoraphobia - fear of unfamiliar settings, such as open spaces, crowds and travelling. This may lead to a fear of leaving the home.
· Social phobia or social anxiety – fear of public or social situations. For example eating or drinking in public, going to the shops and parties.
Health anxiety
People with health anxiety are preoccupied with the fear of becoming ill. This results in an increased sensitivity and awareness of bodily sensations. Sufferers of health anxiety may worry these symptoms are indicators of a serious illness, such as cancer. Where health related fears are a problem, you may find yourself making repeated trips to the GP to gain reassurance that you are not physically ill. It is important to check out possible physical causes with your doctor. However, once your GP is satisfied that there is no physical cause, it is more helpful to focus on treating your anxiety.
Panic disorder
Panic disorder is characterised by sudden, distressing attacks of anxiety (panic attacks). Symptoms include:
· Nausea
· Dizziness
· Difficulty breathing
· Heart palpitations
· Chest pain
Panic attacks may last for a few minutes and may occur frequently during the day or night. Some people experience feelings of being outside the body, of the world not being real, and of losing control and may feel as if they are dying.
Problems with compulsive behaviours
Some people become focused on certain mental images, which may have been triggered by events or situations, which seem threatening and are anxiety provoking. In order to avoid these situations, they carry out certain acts or “rituals”, which may be very time consuming. Common rituals include:
· Avoiding or touching certain objects
· Washing excessively
· Repeatedly checking things e.g. whether the door is locked
Whilst these rituals can reduce anxiety in the short-term, they can keep it going in the long-term, and may therefore interfere with normal daily life.
What do I want to change?
The first and most important part of any self-help program is to recognise that there is a problem and set goals for what you want to achieve. By working hard to achieve these goals you could change your life for the better. Accept that it will take time to change and begin to take small steps towards the end goal of being more in control of your anxiety.
· Your goal must be important to you.
· Make your goal small enough to be achievable but still a challenge.
· Your goal needs to be concrete and specific. For example, avoid goals such as, "I want to be more sociable and happy", as this is too big and it will be difficult to measure the achievement.
· Break your goal down and be as specific as possible. For example, "I aim to meet my friends once a week."
· State what you will do instead of what you won't do. For example "I will spend 10 minutes everyday practicing relaxation exercises," rather than, "I will not rush around anymore."
Goals involve hard work but the rewards are worth it. With perseverance and practice you can get there!
Write down at least three (and no more than five) goals to work on during this programme. These may change over time but it is important that you think clearly now about what you are trying to achieve.
1._______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2._______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3._______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
We understand that you cannot change things until you know more about the problem and chapter 2 explains anxiety in more detail.
Relaxation
When we are anxious, we experience uncomfortable sensations. These physical symptoms can cause us to feel even more anxious.
Symptoms of anxiety Worry about symptoms
Relaxation techniques can help to break this cycle. For example, you may find that watching television or listening to music helps you to relax. However, in order to completely relax your body it is important to learn and use relaxation techniques. Learning to relax is not always easy and is a skill that takes practice. The exercises below will help you to learn to relax step by step.
Before you begin:
· Decide when you will practice the relaxation exercise and try to keep to this time every day.
· Choose a quiet place to practice where nobody will disturb you.
· Do not practice if you are hungry or have just eaten; or if the room is too hot or too cold.
· Start the exercise by lying down in a comfortable position, wearing comfortable clothes. As you become more practised you may wish to try the exercise sitting or standing.
· Try not to worry about whether you are relaxing successfully. Just have a go and let it happen.
· Try to practice the relaxation technique at least once every day. The more you practice the easier it will become to relax.
· You may find it helpful to record your progress. Use the sheets provided at the end of this chapter to record your experiences. This will help to see whether the technique is working for you.
Exercise 1: Progressive muscle relaxation
Before you begin read through the exercise so that you are familiar with the routine. You may find it helpful to record the instructions onto a tape, get a friend to read them to you or try to memorise them.
This exercise aims to help you learn to recognise when your muscles are tense and when they are relaxed. The exercise begins with the hands and arms and works through different groups of muscles, ending with the feet. At each stage you should try to focus on the feelings in the part of the body you are working on. Tense the muscles as hard as you can and concentrate on the feeling of tension, taking care not to strain any muscular injuries or vulnerable parts of the body. Hold this for about five seconds and let go for about ten seconds, relaxing the muscles as much as possible and concentrate on the feeling of relaxation.
1. HANDS Make a tight fist with your right hand.
Relax.
Make a tight fist with you left hand.
Relax.
2. ARMS Keeping your hands relaxed, bring your lower arms
up towards your shoulders.
Relax.
Let your arms and hands rest by your sides or be supported by the chair.
3. SHOULDERS AND NECK
Rest your chin on your chest. Shrug your shoulders as hard as you can. Circle your shoulders and then let them drop.
Relax and repeat.
4. FACE Tense your face by screwing your eyes up and tense your jaw by biting your teeth together.
Relax and repeat.
5. CHEST AND ABDOMEN
Tense you stomach muscles by pulling your tummy in tightly. Slowly breathe out.
Relax and repeat.
6. LEGS AND LOWER BACK
Keeping the rest of your upper body relaxed, squeeze your thighs and buttocks together.
Relax.
Point your toes towards the floor and then bring
them back up.
Relax.
7. WHOLE BODY
Scan your whole body, from head to toe, for any tension. Relax any muscles that feel tense. Continue breathing calmly and evenly.
MIND
Think of something soothing and restful. For example lying on a warm beach, a place that makes you feel safe, or anything that helps you to relax. Breathe slowly and feel yourself becoming heavier and heavier.
Do not stand up straight away. Continue to rest for a few minutes and when you are ready, move slowly and gently stretch. This exercise needs to be practised regularly until you always feel relaxed at the end. When this happens you may wish to try using the exercise whilst sitting or standing, or in different situations. This may help you to cope with symptoms of anxiety when they occur in daily life.
Exercise 2: Cued Relaxation
As you become more experienced in using Exercise 1(usually after around 4-6 weeks), you will find it easier to tell when your muscles are relaxed and when they are tense. At this point you can try Cued Relaxation. This involves using your relaxation skills when you need them throughout the day. When you begin to feel your muscles becoming tense, this may be your cue, or reminder, to use your relaxation skills. You may find it useful to build up cues around your home and work. For example, you could put a rubber band around your wrist so that every time you see it you will be reminded to check how relaxed you are. However, it is important to develop cues that suit your lifestyle. Cues will remind you to: