Anxiety

"Bad with your nerves", "A worrier", "Stressed out", "Unable to relax", "Tense and nervous"... are all words we might use to describe someone who has a problem with anxiety. If someone has too much stress for too long anxiety is very often the result. This booklet is about anxiety, and aims to help you to: Recognise whether or not you may be suffering from symptoms of anxiety. Understand what anxiety is, what can cause it, and what can keep it going. Overcome your anxiety by learning better ways of coping with it.

What is Anxiety?
Anxiety is something we all experience from time to time. It is a normal response to situations that we see as threatening to us. For example, if we had to go into hospital for an operation, or had to sit a driving test, or take an exam, it would be natural to feel anxious. Anxiety at certain levels can even be helpful in some situations like when we need to perform well, or cope with an emergency. Some anxiety is not at all helpful because: Symptoms of anxiety whilst not dangerous, can be uncomfortable. Symptoms can also be frightening particularly if someone does not know that these symptoms are just signs of anxiety. Sometimes people with anxiety symptoms worry that they may have something seriously wrong with them. This worry can then produce more anxiety symptoms which of course increases the worry! When anxiety is severe and goes on for a long time it can stop people doing what they want to do.

Am I suffering from anxiety?
"I worry about everything, I get tense and wound up, and end up snapping at the children". " Even before I get there I start to worry about all the things that might go wrong. When I arrive my heart starts to pound, my legs turn to jelly and I just know I'm going to make a fool of myself. I have to get out". "It feels as though there is something in my throat. My mouth is dry and I can't swallow properly and then I begin to get panicky. I think I'm going to stop breathing. My mind starts to race, I feel like I'm going to lose control and go mad or something".
These are some typical experiences of people who suffer from anxiety. If you are suffering from anxiety you may have thoughts like these yourself. Sometimes it is possible to be suffering from anxiety and not even know it, particularly if you don't think of yourself as an anxious person. People often mistake symptoms of anxiety for a physical illness. Therefore, the first step in learning to deal with anxiety is recognising whether anxiety is a problem for you. Anxiety can affect us in at least four different ways. It affects: The way we feel. The way we think. The way our body works. The way we behave.

What is anxiety?
Anxiety is the feeling we get when our body responds to a frightening or threatening experience. It has been called the fight or flight response and is simply your body preparing for action either to fight danger or run away from it as fast as possible. The purpose of the physical symptoms of anxiety therefore is to prepare your body to cope with threat. To understand what is happening in your body, imagine that you are about to be attacked. As soon as you are aware of the threat your muscles tense ready for action. Your heart beats faster to carry blood to your muscles and brain, where it is most needed. You breath faster to provide oxygen which is needed for energy. You sweat to stop you body overheating. Your mouth becomes dry and your tummy may have butterflies. When you realise that the "attacker" is in fact a friend, the feelings die away, but you may feel shaky and weak after the experience. The fight or flight response is a really basic system that probably goes back to the days of cave men, and is present in animals who depend on it for their survival. Fortunately, nowadays we are not often in such life or death situations, but unfortunately many of the stresses we do face can't be fought or run away from, so the symptoms don't help. In fact they often make us feel worse, especially if we don't understand them.

What causes anxiety?
There may be many reasons why someone becomes anxious: Some people may have an anxious personality and have learned to worry. Others may have a series of stressful life events to cope with, for example bereavements, redundancy, divorce. Others may be under pressure, at work, or home, for example, because of family problems or bills.

What keeps anxiety going?
Sometimes anxiety can go on and on, and become a life long problem. There can be a number of reasons for this: If someone has an anxious personality and is a worrier, then they will probably be in the habit of feeling anxious. Sometimes people have ongoing stresses over a number of years which means they develop the habit of being anxious. Vicious circle of anxiety - as the bodily symptoms of anxiety can be frightening, unusual and unpleasant, people often react by thinking that there is something physically wrong, or that something truly awful is going to happen. This in itself causes more symptoms, and so a vicious circle develops

"Fear of Fear" - Someone who has experienced anxiety in a certain situation may start to predict feeling anxious, and become frightened of the symptoms themselves, this in turn actually causes the very symptoms that are feared. Fear of anxious symptoms coming on... Causes Bodily Symptoms.
Avoidance - once a vicious circle has developed with lots of anxious thoughts increasing the anxiety symptoms, avoidance is often used as a way of coping. It is natural to avoid something that is dangerous, but the sorts of things that people tend to avoid when they suffer from anxiety are most often not real dangers but busy shops, buses, crowded places, eating out, talking to people etc. Not only are these things not dangerous, but they are quite necessary. Avoiding them can make life very inconvenient and difficult. This sort of avoidance can also result in a great loss of confidence which can affect how good you feel a bout yourself, which in turn makes you feel more anxious - another vicious circle!

To summarise:
Anxiety is often the body's response to stress, although some of us may be a bit more prone to anxiety and worry than others. When we are suffering from anxiety, whilst it can be unpleasant it is our body's normal response to threat or danger is not dangerous. Anxiety symptoms are part of the fight or flight response and are intended to be helpful in spurring us into action. Anxiety becomes a problem when the symptoms are: severe and unpleasant; going on too long; happening too often; causing us to worry that there is something seriously wrong; stopping us doing what we want to do. Anxiety often becomes a vicious circle where our symptoms, thoughts and behaviour keeps the anxiety going. Now spend a few moments trying to write down any of these ways that your anxiety may be being kept going.

1) unpleasant/frightening symptoms you experience
2) your beliefs and thoughts about these symptoms
3) everyday things that you are avoiding
4) current stresses in your life

How Can I Manage My Anxiety Better?
As we have learned, anxiety is not an illness and so can't be cured. If we can break into the vicious circle, however, we can learn ways of reducing our anxiety and getting it to be more manageable. We can work on at least four different areas: Understanding our anxiety better. Reducing physical symptoms. Altering our thoughts related to anxiety. Changing our behaviours related to anxiety.

Understanding Anxiety - you may already by now have some ideas about what is causing your anxiety. The following sections will give advice on how to break out of the vicious circle that keeps anxiety going. Before you can do this though, it is really useful for you to understand your own anxiety better. Is your anxiety related to certain situations, places or people, is it worse at particular times of the day, are there realistic worries you have that would make anyone anxious? The following two exercises should help you to understand your anxiety better.

Anxiety Diary - for a period of two weeks (or longer if you prefer) keep an hourly diary of your anxiety and activity level. Rate your anxiety from 0-10. Note down anything that seems important. Were you at work or home, who were you with, what were you doing, what were you thinking about? You may start to become more aware of situations that make you anxious or that you may even be avoiding. What is your general level of stress like? This information will help you begin to tackle your anxiety.
If you become aware that you have a realistic worry or problem that you feel may be causing you anxiety, a problem solving approach may help. A good way to begin is to write down a problem. Define it as clearly as you can, for example "I never have any money", is too vague, something like "I owe £3000 to different credit card companies", is more helpful. Next, write down as many possible solutions as you can. It doesn't matter how silly you may think the solutions are, the point is to think of as many as you can. Try to think how you have solved similar problems in the past. Ask a friend what they might do. Think to yourself what you might advise a friend to do if they had the same problem, e.g. possible solutions: get all debts on one loan with less interest; agree on affordable payments; see a debt counsellor; get a part time job; sell car.

If you have a problem that may be making you anxious, try writing it down. Now list as many possible solutions as you can. Choose what seems like the best solution and write down all the steps it would take to achieve that solution. Who might help?, what might go wrong?, often it is helpful to think "what is the worst thing that could happen?" If you can think of a plan to cope with this, your anxiety might reduce. If you are trying to come up with a plan to tackle a problem that has been worrying you for some time, it is often helpful to discuss this with a friend or even your doctor.

Stressful lifestyle
Nowadays life is often stressful, and it is easy for pressures to build up. We can't always control the stress that comes from outside but we can find ways to reduce the pressure we put on ourselves: Try to identify situations you find stressful by noticing the beginnings of tension. Take steps to tackle what it is about these situations that you find stressful. Make sure you have time for things you enjoy. Take up a relaxing hobby. Make sure you get enough sleep. Eat a well balanced diet. Take regular exercise. Learn to relax.

Reducing Physical Symptoms - Relaxation. In order to reduce the severity of physical symptoms it is useful to "nip them in the bud", by recognising the early signs of tension. Once you have noticed early signs of tension you can prevent anxiety becoming too severe by using relaxation techniques". Some people can relax through exercise, listening to music, watching TV, or reading a book. For others it is more helpful to have a set of exercises to follow. Some people might find relaxation or yoga classes most helpful, others find tapes useful. You can obtain a relaxation tape from your GP, and there are also a wide number of relaxation tapes available in the shops.
Relaxation is a skill like any other which needs to be learned, and takes time. The following exercise teaches deep muscle relaxation, and many people find it very helpful in reducing overall levels of tension and anxiety.

Deep muscle relaxation. It is helpful to read the instructions first and to learn them eventually. Start by selecting quite a warm, comfortable place where you won't be disturbed. Choose a time of day when you feel most relaxed to begin with

1. Lie down, get comfortable, close your eyes. Concentrate on your breathing for a few minutes, breathing slowly and calmly: in two-three and out two-three. Say the words "calm" or "relax" to yourself as you breath out
2. The relaxation exercise takes you through different muscle groups, teaching you firstly to tense, then relax. You should breath in when tensing and breath out when you relax. Starting with your hands, clench one first tightly. Think about the tension this produces in the muscles of your hand and forearm. Study the tension for a few seconds and then relax your hand. Notice the difference between the tension and the relaxation. You might feel a slight tingling, this is the relaxation beginning to develop
3. Do the same with the other hand. Each time you relax a group of muscles think how they feel when they're relaxed. Don't try to relax, just let go of the tension. Allow your muscles to relax as much as you can. Think about the difference in the way they feel when they're relaxed and when they're tense
4. Now do the same for the other muscles of your body. Each time tense them for a few seconds and then relax. Study the way they feel and then let go of the tension in them. It is useful to stick to the same order as you work through the muscle groups: Hands -clench first, then relax. Arms - bend your elbows and tense your arms. Feel the tension especially in your upper arms. Remember, do this for a few seconds and then relax
5. Neck - press your head back and roll it from side to side slowly. Feel how the tension moves. Then bring your head forward into a comfortable position. Face - there are several muscles here, but it is enough to think about your forehead and jaw. First lower your eyebrows in a frown. Relax your forehead. You can also raise your eyebrows, and then relax. Now, clench your jaw, notice the difference when you relax
6. Chest - take a deep breath, hold it for a few seconds, notice the tension, then relax. Let your breathing return to normal. Stomach - tense your stomach muscles as tight as you can and relax. Buttocks - squeeze your buttocks together, and relax. Legs - straighten your legs and bend your feet towards your face. Finish by wiggling your toes. You may find it helpful to get a friend to read the instructions to you. Don't try too hard, just let it happen

To make best use of relaxation you need to: Practise daily. Start to use relaxation in everyday situations. Learn to relax without having to tense muscles. Use parts of the relaxation to help in difficult situations, e.g. breathing slowly. Develop a more relaxed lifestyle. This relaxation exercise is available on tape from your GP. Remember relaxation is a skill like any other and takes time to learn. Keep a note of how anxious you feel before and after relaxation, rating your anxiety 1-10.

Controlled Breathing. Over-breathing: it is very common when someone becomes anxious for changes to occur in their breathing. They can begin to gulp air, thinking that they are going to suffocate, or can begin to breath really quickly. This means they end up with the wrong amount of carbon-dioxide. This has the effect of making them feel dizzy and therefore more anxious. Try to recognise if you are doing this and slow your breathing down. Getting into a regular rhythm of in two-three and out two-three will soon return your breathing to normal. Some people find it helpful to use the second hand of a watch to time their breathing. Other people have found breathing into a paper bag or cupped hands helpful. For this to work you must cover your nose and mouth. It takes at least three minutes of slow breathing or breathing into a bag for your breathing to return to normal.

Distraction. If you take your mind off your symptoms you will find that the symptoms often disappear. Try to look around you. Study things in detail, registration numbers, what sort of shoes people are wearing, conversations. Again, you need to distract yourself for at least three minutes before symptoms will begin to reduce. Whilst relaxation, breathing exercises and distraction techniques can help reduce anxiety it is vitally important to realise that anxiety is not harmful or dangerous. Even if we did not use these techniques, nothing awful would happen. Anxiety cannot harm us, but it can be uncomfortable. These techniques can help reduce this discomfort.

Altering your Thoughts Related to Anxiety. We have seen the role that thoughts have in keeping going the vicious circle of anxiety. Sometimes there may also be pictures in your mind. To give an example, imagine you are running for a bus one day. All of a sudden you get a pain in your chest and feel really breathless. The thought goes through your mind, "I'm having a heart attack". This thought is of, course, very frightening, and so your heart starts to beat faster which makes you think "there really must be something wrong with my heart". You may very well have a picture of the ambulance on its way and you on a stretcher. Now think about the following questions and write down the answers:

1) What are the thoughts that most often go through your mind when you feel anxious?
2) Do you have any pictures of what might happen?
3) Are there any thoughts that make you feel worse?

It isn't always that easy to know what you are thinking that is making your anxiety worse. The sort of thoughts that make people anxious can come and go in a flash, and may be so much of a habit that they are automatic. They may be so familiar that they just feel like part of you. Try to keep a diary over the course of two weeks. Write down your own thoughts in situations where you are anxious. Now, try to imagine the last time you felt very anxious. Try to run through it like a film, in as much detail as you can. See if you can write down any frightening thoughts now. Remember any thoughts can count. No thought is too small or too silly. Even "oh no" or "here we go again" can increase tension and anxiety.

Frightening thoughts: Once you know what it is you are thinking, you can begin to fight back, and break the vicious circle. In particular, ask yourself:

1) Am I exaggerating, e.g."everything is bound to go wrong it always does".
2) Am I jumping to conclusions, e.g."I have a pain in my chest therefore it must be my heart".
3) Am I focusing just on the bad things, e.g."I had a really bad day yesterday" (ignoring that this followed a few good days)

Use these questions to help yourself answer back. A good way of doing this is to write two columns - one for your thoughts that make you anxious, and the other for a more balanced thought, eg:

Write down some of your thoughts now and write as many answers as you can. This question might also help. What would you say to a friend who was thinking that way? The aim is to get faster at "catching" these anxious thoughts and answering back almost instantly. It takes a lot of practice, but really does work

Changing Behaviour Related to Anxiety
Try to recognise when you are avoiding things and wherever possible try to tackle these fears, not all at once but in a gradual way. Set yourself very small goals. Write down here goals that you would like to tackle. Start with the easiest first and tick off any activity you achieve

People often get into the habit of escaping from situations that make them anxious. Instead of escaping try gradually to increase how long you stay in a situation that makes you anxious. Anxiety often reaches a peak, then starts to go away naturally. If you stay in an anxious situation what do you predict will happen to your anxiety? People often think it will just keep getting worse and worse. This is not the case. It will start to come down

People not only avoid situations and try to escape, they also often do things to make themselves feel more safe, e.g. hanging on to a shopping trolley, lying down. These "safety behaviours" may help at the time, but they also help to keep the anxiety going because the anxious person never learns that nothing awful would have happened even if the trolley wasn't there. Also, imagine how frightening it would be if no trolley was available

Try to do things to test out whether your anxious thoughts are realistic, e.g."would I really faint if I didn't get out?". It really is very important to recognise that the more you avoid something, the more difficult it will seem to overcome, which will in turn make you more anxious

What Treatment is Available for Anxiety?
Most people with anxiety can benefit from self help such at this leaflet. Your family doctor, health visitor or practice nurse may also be able to give you further help in dealing with anxiety. Occasionally, doctors prescribe tablets for anxiety. There should only be taken for short spells to get over specific anxiety provoking situations. Your doctor may also refer you to a mental health worker or counsellor if your anxiety does not respond to self-help alone. Anxiety Management Groups or classes are often run in local surgeries or Community Health Centres. Please let your doctor know if you would be interested in such classes

Where Can I Find Help if I Think I Am Suffering From Anxiety?
First, we hope you will use the advice in this booklet. You should find it helpful. If having used the booklet you feel you need more help, you should discuss this with your GP, who will tell you about alternative treatments and local services. There are a number of self help books that other people have found helpful

These books may be available from your local library

• Helen Kennerley: Managing Anxiety
• David Burns: The Feeling Good Handbook
• Dr Clare Weeks: Self Help for your nerves
• Susan Jeffers: Feel the Fear and Do it Anyway

Source: Northumberland Mental Health NHS Trust

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Last revision: June 2006