NHS Anxiety

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First Steps, Version 2, March 2013 - 1 - Anxiety

A First Steps guide to managing

Anxiety



First Steps - 2 - Anxiety

This booklet aims to give information on improving and maintaining emotionalwell-being for people who are experiencing anxiety.

“A nervous type”

“A bit of a worrier”

“Unable to relax”

“Always on edge”

…are just a few of the comments from people who are feeling anxious.

Anxiety is a normal and natural feeling but can have unpleasant symptoms and impact on theway a person manages their day to day life.

No two people are the same and everyone will cope differently. This is not to say that oneperson is any better or worse than another but just that what you are feeling is probablynormal. This does not mean that we have to accept that this is the way life is. When talkingabout managing emotions there are very few right or wrong ways of coping. However thereare some strategies that can help a person to feel better in themselves.

This booklet provides some ideas to try if your current way of managing is not working foryou as well as you might like.




What is in this booklet?

Page

What is anxiety? 4

Symptoms of anxiety 6

Cycle of anxiety 8

Breaking the vicious circle and changing thinking patterns 9

Our thoughts and core beliefs 13

Relaxation 16

Tackling avoidance 19

Setting goals 20

Lifestyle changes 21

Tips to improve sleep 22

Useful contacts 23




What is anxiety?

Anxiety is a normal healthy reaction experienced by everyone at one time or another. It is oursurvival mechanism known as the ‘fight or flight’ response. It is simply the body preparing foraction either to fight danger or run away from it as fast as possible. Anxiety becomes adifficulty when the response is triggered by events that pose no real threat to us. Our survivalmechanism dates back to our cave man days and our bodies still react today, in the sameway as our ancestors did thousands of years ago. However, our ‘threats’ have changedconsiderably. Most threats in modern life can not be fought or run away from, so thesymptoms are not helpful. In fact they often make us feel worse, especially if we don’tunderstand them.

Can you recall a time when you've been in danger, or feared that you could be in danger?

How did you feel?

What did you notice?

The likelihood is that these symptoms are similar to those experienced when you are notaware that your brain has perceived a threat. i.e. during unhelpful anxiety.

The symptoms of anxiety are unpleasant but are not harmful.

Anxiety becomes a problem when the symptoms are:- severe and unpleasant

- affect the things we do everyday

- going on too long

- occurring frequently

- 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 physical and emotional symptoms,thoughts and behaviour keep the anxiety going.

Physical symptoms

Worrying thoughts

Change in behaviours

Increased fear




Although the most common form of anxiety is generalised anxiety there are a number of ‘types’ of anxiety. Here are some of the common anxiety disorders:

Generalised anxiety

Physical symptoms include: difficulty breathing, tightness in chest or chest pains,

feeling faint, nausea, increased heart rate, dizziness, numbness or tingling in limbs,

butterflies in stomach, trembling, blurred vision, headaches, need to pass urine orempty bowels

Psychological symptoms include: poor concentration, negative thinking patterns, not

thinking rationally, loss of self confidence

Behavioural changes – avoidance

Panic attacks

Characterised by a sudden onset of intense feeling of fear or apprehension

Extreme physical sensations heighten sense of fear

Strong impulse to leave stressful situation. Avoidance brings temporary relief but in

the long term makes the condition worse

Phobias

Specific: an isolated experience of anxiety attached to a particular object or situation

eg spiders, blood, heights. The fear experienced is out of all proportion to the object or

situation. The person often recognises that it is irrational but feels powerless to do

anything about it

General: mixture of fears anxieties and avoidances – agoraphobia and social phobia

Social anxiety disorder

People who suffer from shyness or social anxiety often believe that other people willthink badly of them or that others are judging them

The person may also fear that they are not as good as other people and never will be.

Symptoms include tension, rapid heart beat and light- headedness when in socialsituations

Certain situations may seem to be more difficult than others. People may feel quite atease speaking to people they know but feel very anxious with strangers. Eating or

speaking in front of others can be very difficult, as can crowded places such ascanteens, pubs, shops or queues

Obsessive compulsive disorder (OCD)

Obsessive thoughts intrude repeatedly into the mind, despite all attempts to banish

them. They can be very distressing, eg thoughts of contamination, harm occurring to

self or others

Thoughts are accompanied by compulsive rituals, ie acts carried out again and again,

even though the person knows that they are irrational, eg hand washing, checking,

hoarding, special rituals




Post traumatic stress disorder (PTSD)

The after effect of a traumatic event. A traumatic event is a life threatening experience

and can have a lasting impact on memory and the way a person acts or feels

For some people this impact comes from experiencing the event first hand, while forothers they might be witness to, or have knowledge of, the event

Symptoms of anxiety

People respond to anxiety in many different ways. Here are some examples of the differentaspects of anxiety.

Thoughts and Beliefs Physical Reactions Moods Behaviours

Overestimation of

danger

Sweaty palms Nervous Avoiding situations where

anxiety may occur

Underestimation of ability to cope

Muscle tension Irritable Leaving situations whereanxiety begins to occur

Underestimation of helpavailable

Racing heart Anxious Trying to do things‘perfectly’

Worried andcatastrophic thoughts

Light headednessFlushed cheeks

Panicky Trying to control events toprevent danger




Pupils dilateBlurred vision

Dry mouth

Neck and shoulderstense as majormuscles prepare foraction

- Headaches- Back pain

Body needs to coolitself by sweating- Blushing

- Anus and bladderopening musclesrelax

- Frequent urination- Diarrhoea

Digestion slows downas blood is diverted tomajor muscle groups- Nausea- Butterflies- Indigestion

Rapid heart beat asblood is pumpedfaster to supply themajor muscles

Breathing becomesfaster and shallower asmore oxygen is need bythe major muscles- Rapid breathing- Gasping/trouble

catching breath- Palpitations- Chest pain

Liver stores sugar soit can provide energyquickly- Low blood sugar

levels- Feeling faint

Blood diverted to majormuscles and away fromextremities- Cold hands/feet- Pins/needles- Numbness

Mind focuses on resolvingdanger- Unable to concentrate- Panic- Poor memory- Lack of objectivity

- Overly sensitive tosymptoms




Cycle of anxiety

Case study example

Bill has been working on a company project and has completed a presentation that he has

worked on for many months. Today he is delivering the presentation to members of his team

along with managers within the company. Bill has been very anxious recently in the lead up

to this presentation. He has recurring unhelpful thoughts that “I’m going to mess up” and

worries about the reactions of others to this. The cycle below illustrates Bill’s cycle of anxiety:

Unhelpful thoughts

“I’m going to mess this up”“Everyone is going to belooking at me ”“I can’t cope with this”

“I need to get out of here”

Avoidance behaviours

Does not do presentation

or

Leaves room

Physical reactions

Heart rate increases

Clammy or sweaty

Feels sick

Moods/feelings

Anxious

Panicky

Scared




Breaking the vicious circle

In order to break the vicious circle, we need to tackle each part of it. We can change ourphysical reactions by practicing relaxation techniques, we can challenge our unhelpfulthinking patterns by completing a thought diary, and we can change our behaviours bytackling avoidance. By doing all of these things, we should start to notice changes in ourmood and in time feel less anxious.

Changing thinking patterns

Thoughts affect how you feel and feelings affect how you think. Changing negative thoughtsto a more positive way of thinking will help you to feel better.

The first step is to identify the ways you think

The second step is to challenge your thoughts and look for alternative ways of thinking

Completing thought records can be extremely helpful in achieving this

Distinguishing characteristics of anxious thoughts:

Often start with “What if…”

Typically related to a sense of vulnerability, or a belief that we are in danger or beingthreatened

May be accompanied by images of danger

To do with the future

Often predict catastrophe

The fear is always out of proportion to the actual level of threat. No one has everheard of tiger-phobia, because feeling a sense of panic after coming into contact witha tiger is a good idea!




Challenging anxious thoughts - things to think about…

What is the evidence?

What evidence do I have to support my thoughts?

What evidence do I have that does not support them?

What alternative views are there?

How would someone else view this situation?

How would I have viewed this situation in the past?

What is the effect of thinking the way I do?

Does it help me, or keep me from getting what I want? How?

Which thinking error might I be making?

a) Am I thinking in al l-or-noth ing terms (meaning that something is seen as onlyhaving two distinct categories - things are seen as black and white without any shadesof grey) ie. ignoring the middle ground

b) Am I awful is ing or catastrophizing – overestimating the chances of disaster?

c) Am I personalising – blaming myself for something which is not my fault?

d) Am I focusing on the negative – looking on the dark side; ignoring my strengths?

e) Am I jumping to conclusions – predicting the future and mind reading?

f) Am I living by fixed rules – fretting about how things ought to be; overusing thewords “should”, “must” and “can’t”?

g) Am I being a perfectionist – setting unreasonably high standards that I cannot reachand being hard on myself when I don’t achieve them

What action can I take?

What can I do to change my situation? Am I overlooking solutions to problems on theassumption they won’t work?

What is the worst possible outcome?

What is the worst thing that can happen and how bad would that really be? What isthe probability that that would be the case?



First Steps - 11 -

Thought record (with prompts)

Situation:Who / what / where /when?

What was I thinking just before I fel t l ikethis?

Proof that thethought is true

Other possibilities or What would I say to afriend?

Who were you with?

What were you doing?

When was it?

Where were you?

Answer some or allof the followingquestions:

What was goingthrough my mind justbefore I started to feelthis way?

What does this sayabout me?

What does this mean

about me, my future,and my life?

What is the worst thatcan happen if this istrue?

Write factualevidence to supportthis thought.

What would a friendsay?

What would you advisea friend?

Has there been asituation where this hasnot occurred?



First Steps - 12 -

Situation:Who / what / where /when?

What was I thinking jus tbefore I felt like this?

Proof that the thought istrue

Other possibilitiesWhat would I say friend?




Our thoughts and core beliefs

Our thoughts about the event or situation are often closely linked to our core beliefs andoften create and maintain a large proportion of the anxiety that we experience. It is commonfor a person experiencing emotional distress to think negatively and negative thinking willcreate and maintain emotional distress (see page nine for information on negative thinking).Our core beliefs are strongly held beliefs about ourselves that influence what we think and

how we feel. They usually influence us subconsciously and we rarely ever challenge if thesebeliefs are true.

Common negative core beliefs are:

I am not worthy

I am the only person I can trust

I am unlovable

I am not good enough

Our core beliefs also relate to how we believe the world ‘should’ be and include our ethicsand values. Examples of these could be:

People should be courteous and polite

I should always do the best that I can do

Life should be fair

I must not let people down

We all hold these beliefs and they are central to our being. Quite often just awareness thatthese core beliefs may be shaping your thoughts and feelings can be helpful in challengingyour view of the situation. The ABC method shown on page 15 can be helpful in identifyingthis.

I am notworthy




Case studyEmma is taking the children to school. She turns the corner and there is a long traffic jam.Emma begins to feel stressed.

Core beliefs“I am not goodenough”“I should always getthings right”“I must ensure thatpeople always thinkwell of me”

Importance of situation/eventEmma feels that it is veryimportant to get the children toschool on time

Negative thoughts“The children will be late, it is allmy fault”(personalising)

“The teachers will think that I ama bad mum” (jumping toconclusions)“I should be able to get them toschool on time” (shouldstatements)

Effect on Emma Emotional well-beingPhysical well-beingBehaviours

Thoughts about

future situations

SituationEmma is taking the children to school

Event There is a traffic jam






Relaxation

Deep breathing

If you can restore your breathing to a slower, more even and calmer pace, your body willbegin to relax. As your lungs move rhythmically – IN and OUT – gently, this has a soothingeffect on the muscles of your whole body.

How to control your breathing

Instead of using the upper chest area, you need to learn to breathe from the stomach area,using your diaphragm. Correct breathing will help to relax you. To learn to do this:

1. Sit back comfortably in a chair before beginning breathing control.

2. Become aware of your breathing. Breathe gently and slowly.

3. Place one hand on your upper chest and the other over your tummy.

4. Transfer most of your breathing to your tummy so that the movement occurs there. Your stomach muscles should rise and fall as you breathe. As you inhale yourstomach moves out slightly. As you exhale your stomach moves in slightly.

5. It will help to count as you breathe. Concentrate on the number three. Breathe in forthree counts and out for four counts. Maintain a steady, comfortable rhythm and try toavoid holding your breath in between each count.

6. Imagine that as you exhale you are breathing out tension from your body and letting it

go. And when you inhale that you are breathing in fresh strength and energy.

7. In order for this technique to become beneficial you will need to practice it regularlyso that your body can benefit from its value. Practice twice a day for 5 minutes at atime. Return to normal breathing if you start to feel dizzy.

When you are familiar with the exercise you will be able to apply it routinely in situationswhere you notice the physical symptoms of anxiety starting within you.




Square breathing

This is a simple exercise that helps you to control your breathing whilst distracting yourself from your thoughts or the situation. Look at something square or imagine a square in yourhead.

Breathe in to the count of four. Imagine moving up along the side of the square

Pause briefly whilst you imagine moving across the top of the square Then breathe out to the count of six, whilst imagining moving down the side and

across the bottom of the square

Continue as above

Visualisation

A quick way of getting away from a situation without physically leaving.

Imagine yourself walking to a door

Open the door and walk down the three steps, taking a deep breath for each of thesteps

You walk into an environment where you feel relaxed and calm. This could be afamiliar place, a happy memory, or somewhere in your dream

What can you see?

What can you hear?

What can you smell?

What can you touch?

Spend a few minutes in this place, enjoying the feeling of relaxation

When you feel ready, start to make your way back up the steps, taking a breath for each of the three steps. Make your way back through the door and back into thepresent situation

Breathe in

Pause

Breatheout




Muscle relaxation

Sit comfortably and take a few deep breaths. Now focus on your body, tensing and relaxingeach of the muscle groups in the following order:

Feet – point your toes away from your body, hold, then relax

Calves – bend your foot at the ankle towards you, hold, then relax

Thighs – push your knees together, hold, then relax Bottom – clench your buttocks together underneath you, hold, then relax

Stomach – pull in your stomach muscles, hold, then relax

Hands – clench your fists, hold, then relax

Hands (again) stretch the fingers wide apart, hold, then relax

Arms – bend your arms at the elbow, bringing your hands up towards the shoulders,hold, then relax

Shoulders – hunch your shoulders up towards your ears hold, then relax

Neck – pull your chin forwards on to your chest hold, then relax

Neck (again) stretch your chin up, pushing your neck back, hold, then relax

Jaw – clench teeth together, hold, then relax

Lips – press tightly together, hold, then relax

Eyes – screw up eyes tightly, hold, then relax

Forehead – frown hard, wrinkle forehead, hold then relax

In each case, as you relax the muscles feel the tension draining away. Notice the differencebetween tension and relaxation.




Tackling avoidance

Each time we avoid a situation to minimise anxiety, we make it more likely that we will avoidit again the next time that the feared situation arises. Avoidance of a situation only helps usto feel better in the short-term, but can make us feel worse in the long-term.

Overcome patterns of avoidance and regain self-confidence step by step by facing the

anxiety-provoking situations a day at a time. Draw up a list of things you avoid, prioritisingthe ones that interfere with everyday life the most, and then break down the problem intospecific stages. At each step, ask yourself what you’re predicting will happen and what thelikelihood is that the prediction is accurate. After the fact, reflect back and ask if theprediction was right, or if it was an example of assuming the worst, jumping to conclusions,or catastrophising. By achieving smaller targets one-by-one, the whole problem will soon bemastered.

For example, a person may be avoiding:

1. Going to a supermarket alone

2. Getting on a bus3. Being in social situations, like going to the pub4. Looking for another job, because of fears about the interview

So, they can take each one in turn and break it down…

Goal – to go to a supermarket alone

1. Go to a supermarket in a car with a friend but don’t go in2. Go to a supermarket in a car with a friend and walk around shop with the friend3. Go to a supermarket in a car with a friend, get the friend to wait outside and walk around

on your own4. Go to a supermarket on your own

Repeat each step until you feel that it is manageable, before moving on to the next step.

It is not always realistic to feel comfortable in these situations, but it’s about feelingcomfortable with feeling uncomfortable!

The goal setting technique can be helpful with overcoming avoidance (see next page).




Setting goals

Goals give us a sense of purpose and allow us to achieve tasks that may feel overwhelmingor unachievable. The key to effective goal setting is to be realistic. It is easy to make themistake of trying to achieve a goal that is vague and unrealistic. By setting realistic, clearlydefined goals, you can measure and take pride in the achievement of those goals. You cansee forward progress in what might previously have seemed a long pointless grind. Your self-confidence will increase as you achieve your goals and as you recognize your ability andcompetence in your achievements.

There are five components to consider when setting yourself a goal. These goals are knownas SMART Goals. These are:

Component Ask yourself …..

S Specific What exactly do I want to achieve?

M Measurable How will I know when I have completed the goal?

A Achievable Is this possible given more current situation/ performance?

R Relevant The goal has to make sense to you and be something youfeel is worthwhile and that applies to your views and lifestyle

T Time bound When do I plan to finish the task?

Once you have set your goal, you then need to break the main goal down into achievable‘steps’ called sub goals. You are far more likely to be successful if you plan a series of smallstages which will help you to reach your ultimate goal. By working on and achieving smalltargets, your confidence will increase far more than if you are trying to achieve goals whichare too difficult, and where you run the risk of failing.

Once your time frame has expired you should then add a further 2 components to your goal,making it a SMARTER goal:

Component Ask yourself …..

E Evaluate What have I achieved so far? Have I completed my goal?

R Re-do What further stages should I set for myself or is this goal nowfully achieved? What is my next goal?




Lifestyle changes

Our lifestyle can impact on the anxiety that we experience. Altering our lifestyle can be asimple way of improving the way that you feel.

Exercise

Physical activity is an important means of reducing stress levels and preventing

some of its damaging effects on the body Exercise uses up the adrenalin and other hormones that the body produces under

stress, and relaxes the muscles

It will help to strengthen the heart and improve blood circulation

Exercise lifts your mood through the release of endorphins

Exercise does not have to be at a gym or sports club. Take the stairs instead of thelift or walk to the shops, etc.

Healthy eating

Base your meals on starchy (carbohydrate) foods for energy eg. wholegrainbread/cereal/pasta, brown rice, jacket potatoes

Eat lots of fruit and vegetables

Eat more fish – including one portion of oily fish per week

Cut down on saturated fat and sugar – reduces risk of high blood cholesterol anddeveloping cardiovascular disease

Try to eat less salt – 6g max for adults – the effects of excess salt, sugar andcaffeine can mimic stress responses

Drink plenty of water or other fluids

Cut down on caffeine as it can increase symptoms of anxiety and interfere with sleep– try herbal teas instead

Do not use alcohol, drugs or cigarettes to cope

Do not skip breakfast!




Tips to improve sleep

Establish a regular routine. Go to bed only whenyou are tired and get up at the same time each day.Avoid napping during the day

Check your sleeping arrangements. Think aboutcomfort, temperature, light and noise levels

Learn to de-stress before bed. Dismiss nagging thoughts by writing them down.Have a warm bath, practise a relaxation technique, or listen to a relaxation tape

Do not eat late. Avoid rich, spicy or sugar-rich foods, red meat and cheese.Choosing wholemeal, low-fat, magnesium-rich foods (green salads, broccoli, nutsand seeds) may encourage sleep, as may drinking hot milk and honey

Get enough exercise. Fit people sleep better

Try out complementary remedies. Yoga, meditation, homeopathy or herbalremedies, such as lavender or valerian, may help

Keep a sleep diary. This helps you identify potential causes for your sleeplessness

Try some reverse psychology: keep your eyes open and tell yourself to resist sleep,but if you feel you are falling asleep, do not purposefully wake yourself up!

Interrupt unwanted thoughts: repeat a soothing word to yourself. For example,repeat the word ‘the’ once or twice every second in your head for around 5 minutesor until you fall asleep

Visualise a scene or landscape that has pleasant memories for you

Talk to your GP. Long-term use of sleeping pills can present problems, but a brief course is sometimes appropriate. Melatonin can be helpful for some sleep disordersand has few side effects than the sedative sleeping medication




Useful contacts

First Steps

0808 801 0325 - Monday and Wednesday 10 to 4.30pm and Thursday 11 to 5.30pm. Thehelpline will be open on a Tuesday following a Bank Holiday

[email protected] www.firststeps-surrey.nhs.uk

Anxiety UK

08444 775 774

National self-help organisation for panic/phobias and anxiety, run groups locally. Visitwebsite or call for more info

www.anxietyuk.org.uk

Mind Infoline

08457 660163

www.mind.org.uk

Triumph Over Phobia

0845 600 9601

A registered charity which aims to help sufferers of phobias, obsessive compulsive disorder

and other related anxiety to overcome their fears and become ex-sufferers

www.topuk.org

NHS Direct (health advice and information)

0845 46 47

www.nhsdirect.nhs.uk/

Get Self-Help

www.getselfhelp.co.uk

National Sleep Foundation

www.sleepfoundation.org

Improving Access to Psychological Therapies (IAPT) servicesSurrey now has a number of services providing guided self-help and therapeutic

interventions for people with mild to severe mental ill health. All require a GP referral



Local Surrey groups

Surbiton OCD Support Group

Contact: Les on 020 8390 2648 (This is an answering machine only. I will returnenquiries as soon as possible. Sorry cannot reply to mobile numbers.)

Address: Surbiton, Surrey

Phone: 020 8390 2648

Email: [email protected]

Release: Contact: Paul Field/Ray Pettit

Address: Addlestone Community Centre, Garfield Road, Addlestone, Surrey, KT15

2NJ

Phone: 01483 757461


Website: www.anxietyrelease.org.uk/

Obsessive Compulsive Anonymous (OCA) Contact: Rob

Address: Guildford United Reform Church, 83 Portsmouth Road, Guildford, Surrey

GU2 4BS

Phone: 07968 196377


Website: www.obsessivecompulsiveanonymous.org

Books

The Surrey County Council Library has a very helpful list of self-help books that can beaccessed from the following libraries:

Camberley, Dorking, Epsom, Farnham, Godalming, Guildford, Horley, Oxted, Redhill,

Staines, Walton-on-Thames, Woking

You can find the list at www.surreycc.gov.uk if you search “Read Yourself Well”. Many of these libraries also have a self-checkout option, which means you can take out a bookwithout anyone knowing the book that you choose.

Documents

NHS Anxiety