Anxiety

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Anxiety is common
and treatable

Brochure developed by the World Health

Organization and Canadian experts.
Anxiety

Anxiety is common and treatable

An anxiety disorder does not mean that you are weak or that you are losing your mind or that
you have a personality problem. Severe anxiety is a disorder that can be overcome with
treatment. Effective treatments
are available.

What is anxiety?
The word 'anxiety' is used to describe the mental and physical response to feared and threatening
situations. This reaction may include trembling, choking, increased heart rate, sweating, feelings
of unreality and so on. Anxiety is a normal response experienced by everyone at times. Nearly
being hit by a car, sitting for an exam or giving a public talk are all examples of situations in
which most people would experience anxiety.

You are likely to be suffering from an anxiety disorder if you have any of the following:

 The anxiety reaction occurs frequently

 Your fears are out of proportion to the situation
 You start to avoid feared situations
 It interferes with your working, social or family life

Different forms of anxiety

1. Generalized anxiety
2. Panic disorder
3. Social phobia
4. Agoraphobia
(There are other anxiety problems not discussed here, like Post Traumatic Stress Disorder and
Obsessive Compulsive Disorder).

Try to work out which of the following descriptions best fit your situation

Generalized anxiety disorder

Generalized anxiety is different from the other anxiety disorders. The experience of anxiety is
not linked to specific situations or to a fear of having panic attacks. It is an ongoing general
anxiety, tension and excessive worrying about normal events and the future. While worry is a
feature of generalized anxiety, it is less common to experience the range of other psychological
symptoms common to different forms of anxiety.

Panic disorder
People who suffer from 'panic disorder' are likely to experience attacks of sudden and intense
anxiety. These panic attacks often cannot be associated with events occurring around the person.
The person is generally free from anxiety in between attacks.

Common symptoms of panic disorders include:

Psychological symptoms Physical symptoms

 fear of dying  tightness or pain in the chest  light-headedness
 fear of going crazy  shortness of breath  sweating
 feelings of unreality  choking sensation hot and cold flushes
 pounding heart  nausea
 trembling  dizziness and light-
 numbness/tingling headedness
 sensation in fingers and feet

Panic attacks are also common with the other anxiety disorders. However, those attacks are
easier to predict because they mostly occur in response to the feared situation(s).

Social Phobia (Also called Social Anxiety Disorder)

The main feature of 'social phobia', is the fear of being the focus of attention or subject of
criticism. People with this disorder may worry that they will do something silly or embarrassing
in front of others. Often social phobia is experienced in many different social situations.

Commonly feared situations include:

 speaking in front of others  being the centre of attention

 asking questions  social activities such as lunches, dinners, parties,
 eating in front of others marriages, religious gatherings/festivals etc.
 writing in front of others

Agoraphobia

People who have agoraphobia experience psychological and physical anxiety

and often panic attacks.

The anxiety tends to occur in situations in which:

 there is a risk of having a panic attack  it would not be easy to get help
should the need arise
 there is a sense of being trapped or being  the environment is different and
unable to escape unfamiliar

This leads to the avoidance of many situations and can severely affect day-to-
day life. In extreme cases people who suffer from agoraphobia find it difficult
to leave the house.
Examples of commonly feared or avoided situations are:
 leaving home, travelling alone, crowds, public places

What may trigger anxiety?

There are many possible triggers to anxiety. If often starts during periods of
psychological or physical stress.

Examples of psychological and physical stress include:

Psychological Physical
 relationship break-ups  lack of sleep  physical illness
 severe arguments  work pressure  excessive use of alcohol
 loss of someone close  financial problems  domestic violence
 loss of a job  physical and sexual abuse
 abuse of other drugs
 trauma

When people experience stress they have a natural tendency to breathe more quickly and deeply.
There is also a tendency to worry more than usual. These two factors are commonly found in
people who have an anxiety disorder. Often changing the way you breathe and reducing worry
can be useful for managing anxiety.

Breathing too quickly and deeply

It is surprising for people to learn that breathing too quickly and/or deeply (also known as
hyperventilation) can bring on anxiety. Breathing too quickly lowers the amount of carbon
dioxide in your lungs and by a complicated series of processes, this causes physical symptoms of
anxiety.

Other important things to note are:

• You can get physical anxiety by slightly over breathing for a long time.
Therefore, over breathing does not have to be obvious to you or to others.
• If you slightly over breathe, even a yawn or a sigh can trigger a panic attack or physical
symptoms of anxiety.
Over breathing is a habit and it takes time to change.

Worry and negative thinking

Worry and unrealistic or negative thinking can be triggers of anxiety. People who get anxious
sometimes think in ways that bring on the anxiety or make it worse.
For example,
• You can think of an unpleasant situation and then make it worse by dwelling on it
• You can spend a lot of time worrying about something that never happens anyway
• You can misinterpret the behaviours and thoughts of other people around you
How to treat anxiety
The presence of anxiety does not necessarily signify a problem. It is a universal human emotion
that appears as a normal response to certain situations. However, anxiety is not always
functional; sometimes it reaches disabling proportions. Furthermore, the anxious person may
develop means of dealing with anxiety that is ineffective or counterproductive, such as alcohol
abuse.

The end point in the management of anxiety is not the removal of all anxiety but rather to
reduce it to manageable proportions.

The best way to manage anxiety is through psychological help (counseling), social support and
medication. With different treatment methods, it is possible to:

Control and stop panic attacks

Confront feared situations previously avoided
Change negative and unrealistic thinking and reduce worry
Reduce physical symptoms anxiety
Function and feel better

Antianxiety Medications include:

First Line Agents: These are not addictive. These were traditionally called antidepressants but
we now know are effective for anxiety disorders. These are thought to reverse the chemical
abnormalities in brain transmitters early in the anxiety cycle. This prevents the anxiety cascade
and production of psychological, physical and behavioral symptoms. These medications take
time to work, usually 3-6 weeks once titrated to an effective dose. You will not feel any
improvement after any single dose. They work by their cumulative effect over time. Some
people experience initial side effects, which often fade after a few weeks. If severe, you may
need to decrease the dose or try a different first line agent. Speak with your physician.

Adjunctive agents: These are sometimes used as "band-aid" solutions until the first line agents
take effect. These can be addictive and can cause drowsiness. Do not mix these with alcohol.
These medications work quickly after a single dose but the benefit weans of after a few hours.
Using them on an as needed basis may paradoxically increase the likelihood of becoming
addicted. This is because you start to believe you need a pill on every occasion you feel or
expect anxiety. Instead, a regular dosing schedule is recommended. For some people these have
a role in longer -term treatment.

Another very effective way of reducing anxiety is physical exercise. Specifically, aerobic
exercise if the form of exercise most consistently shown to reduce anxiety, and the duration
should be of more than twenty minutes. Anxiety reduction achieved through aerobic exercise is
similar to the reduction achieved through meditation or relaxation.
How to overcome anxiety

1 Identify your symptoms of anxiety

Mark on the scale how much you experience each symptom. If you have other symptoms write
them on another piece of paper and also rate them.
Symptoms severity score
Symptom Not at all Mild Moderate Severe

Psychological
Worry ________ ________ _________ _______
Fear of loss of control ________ ________ _________ _______
Fear of dying ________ ________ _________ _______
Fear of going crazy ________ ________ _________ _______
Feelings of unreality ________ ________ _________ _______

Physical

Trembling ________ ________ _________ _______

Tightness/pain in the chest ________ ________ _________ ______
Shortness of breath/choking ________ ________ _________ _______
Sweating ________ ________ _________ _______
Pounding heart ________ ________ _________ _______
Hot and cold flushes ________ ________ _________ _______
Dizziness/light-headedness ________ ________ _________ _______

2 Identify situations or places that you fear or avoid

It is common for people to experience anxiety in certain situations or places but not in others. It
is also common for people to avoid those situations so that they can avoid the feeling of anxiety.

Do you fear or avoid anything? If you do, write them down and discuss them with your doctor
and/or counsellor. e.g. speaking in front of a group
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Now add to the list below any other situations or places that you fear or avoid. Mark on the scale
how much you fear or avoid each of the items. It well help you to overcome your anxiety if you
repeat this task every time you think of a new situation or place that you fear or avoid. Discuss
these with your doctor and/or counsellor.

Fear of avoidance severity score

Places/situations Not at all Mild Moderate Severe

Eating or drinking with other people _______ _______ _______ ______

Being watched or stared at _______ _______ _______ ______
Talking to people in authori _______ _______ _______ ______
Speaking in public _______ _______ _______ ______
Being criticized _______ _______ _______ ______
Asking for directions in the street _______ _______ _______ ______
Ordering in a restaurant _______ _______ _______ ______
Asking for help in a shop _______ _______ _______ ______
Travelling alone or by bus _______ _______ _______ ______
Walking alone on busy streets _______ _______ _______ ______
Going into crowded shops _______ _______ _______ ______
Going to the movies _______ _______ _______ ______
Taking elevators _______ _______ _______ ______
Others _______ _______ _______ ______

3 Getting to know your breathing habits

You have learned so far that breathing too much or too quickly can bring on anxiety symptoms.
The following exercises will help you learn more about your breathing habits. First, check to see
if you have any of the following symptoms of over breathing.

You breathe more than 10-12 breaths a minute at res yes…….❒ No……❒ Not sure…..❒
Your chest sometimes feels over-expanded or tight yes…….❒ No……❒ Not sure…..❒
You or others have noticed that you sigh or yawn
quite a bit yes…….❒ No……❒ Not sure…..❒
You often gasp or take deep breaths
particularly in situations that make you anxious yes…….❒ No……❒ Not sure…..❒

If you are positive to any of these, then it is likely that you over breathe.

4 Slow breathing to reduce anxiety

When you get physical symptoms of anxiety, for example breathlessness, it feels like you are not
breathing
enough. The natural response is to breathe in more. However, if you do try to get more air by
breathing in more, it just makes the problem worse. The best solution is to slow down your
breathing even though you may feel that you should speed it up. Now we suggest a slow
breathing technique to stop the unpleasant feelings of anxiety.

Remember to breathe in using your abdomen (not your chest) and through your nose.
 breathe in slowly to the count of 3 seconds
 when you get to 3, slowly breathe out to the count of 3 seconds
 pause for 3 seconds before breathing in again
 continue this exercise for 10 minutes or so
practice twice a day for 10 minutes (5 minutes is better than nothing)
try to check and slow down your breathing during the day
use the slow breathing technique whenever you get anxious

Remember the technique of slow breathing sounds very simple and it is very effective, but it
well take practice to master the technique. Consider other relaxation strategies such as yoga,
tai chi, massage therapy, and muscle relaxation exercises (alternating tensing and relaxing
muscle groups).

5 Identify unrealistic negative thinking

When people are depressed, they tend to think negatively about themselves, events and their
future. Unrealistic and negative thinking can also trigger anxiety and slow down recovery.

Can you relate to the example below?

Disagreement with a colleague…

Person A Person B
"She doesn't agree with me; "So we have a different point of view. That is OK"
she thinks what I said was stupid"

"I am a fool, I should not talk" "It was interesting to discuss our different ideas"

"I can not handle it;

I am getting out of here" "If she has a problem, then too bad"

Anxiety/panic Interested/stimulated

6 Identify unrealistic negative thinking

Here are some more examples of other unrealistic thoughts or beliefs. Mark the statements that
apply to you.

❒ when people look at me, they are examining what I do

❒ if I get criticized it means that I am wrong
❒ if I don't agree with people, they won't like me
❒ if I make a mistake that means that I am stupid
❒ to be a good person I have to be nice to everyone
❒ I am a bad person if I hurt someone
❒ if I show emotion, it means that I am weak
❒ people will think that there is something wrong with me if they see that I am anxious
❒ the opinions of other people about me are very important
❒ I am afraid that I look or sound silly to other people
❒ I can tell that people will evaluate me negatively
❒ I have to be very careful about what I say in case I offend someone
❒ approval is very important to me
❒ being anxious is a sign of weakness
❒ when people see me behave like this, they will talk badly of me to others

Now if you have other unrealistic/negative beliefs write them below or use a separate sheet of
paper.
e.g. If someone is late, I assume there has been an accident.
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7 How do you change the way that you think?

It is likely that you have been thinking in an unrealistic or a negative way for some time now.
Remember, you can learn to think more realistically. It will take practice to change you ways
but you can do it.

First, ask yourself, is this belief that I have true? In order to do this, it may help to…

h consult someone outside the situation for his/her opinion

h ask yourself whether everyone would have the same belief in this situation
h ask yourself if the belief is true in every situation
h examine the other similar situations
h examine other explanations for the event occurring

Second, counter each unrealistic/negative thoughts with more realistic ones

h these should be opposite to the unrealistic belief

h they should be realistic statements
h there should be as many counters as possible

8 How do you change the way that you think?

Please read the following example and then try to create your own examples. Try to find
solutions to them using the same method.

The following example shows how unrealistic and realistic thoughts can lead to different
reactions to the same situations.

SITUATION: Anxious eating in a restaurant

Unreasonable negative thoughts:
h I am sure they know that I am anxious and my fork is shaking
h They will think that I am strange
h They will think that I am a fool
h I hope they will not tell anyone
h I wish I could get out of here

Resulting feelings: Panic

Reasonable positive thoughts:

h It is unlikely that they have noticed my anxiety
h It is more noticeable to me than to them
h If they were to think anything, they would probably think that I was shy
h Even if they did think that I was anxious, they would not think badly of me
h I will try to stay focused on the meal and our conversation

Resulting feelings: Manageable anxiety

9 Exposing yourself to feared situations

Here are some general guidelines:

4 Build up slowly: start with easy tasks and build up to harder tasks
4 Only move on to a harder task when you feel comfortable with the task you are working on
4 Practice tasks regularly, once a day is better than twice a week
4 Do not give in to setbacks
4 Discuss your problems with your doctor and/or counsellor
4 Get someone to help and encourage you

Specific guidelines:

4 Always stay in the situation until your anxiety level drops. If you leave the situation while
your anxiety
is high or when you are in a panic, you will experience relief. This will make you anxiety
worse the
next time you are confronted with a similar situation.
4 Use slow breathing strategies to control physical anxiety
4 Use the new 'rational thinking' strategies to replace unrealistic/negative thinking
Here you will find some examples to help you work out your exposure plan.

Example 1 - Getting used to speaking and asking for assistance in front of others

With a friend

go to a shop and ask for an item that you wish to buy

go to a flower shop and ask for a special arrangement of flowers
go to a clothes store and try on different types of clothes
ask for directions in the street
- repeat tasks varying the items that you ask for
- vary the shops that you go to
- repeat the activities on your own
- repeat activities with an acquaintance

Example 2 - Eating in public

With a friend

go to a coffee shop and order coffee

have morning tea with a friend
have a sandwich in a coffee shop with a friend
have dinner in a restaurant with a friend
- vary the time of day that you go
- go into quiet and then busy shops/cafes
- go to informal and formal places
- repeat activities on your own

Example 3 - Feeling comfortable with groups of people

organize and go to a social event with a group of friends

organize and go to a social event with a group of friends and some acquaintances
organize and go to a social event with acquaintances only
organize and go to a social event with work colleagues
- vary the social events
- vary the time of day
- vary the formality of the events

Example 4 - Conversation with people

say what you think rather than going along with what others think
say 'No, I think…..'
say 'No, I would prefer to…..'
- repeat activities with friends
- repeat activities with acquaintances
- repeat activities with people with whom you feel uncomfortable

Keep a record of progress

As part of the treatment, it is useful to keep a record of your anxiety levels in difficult situations.
You can see more clearly, how the breathing exercises, thinking techniques, and exposure
exercises have helped you. We have developed three record forms for you to use.

1. The symptom severity form: We recommend you use this every week to monitor your
symptoms of anxiety.

2. The exposure form: We recommend that you use this every week to monitor you symptoms
of anxiety for
situations in which you have carried out exposure exercises.

3. Personal progress chart: We recommend that each week you mark your overall rating on the
graph provided.

Symptom severity form and overall rating of how you feel

Week___________
Severity score

Symptom not at all mild moderate severe

Psychological

fear of loss of control __________ __________ __________ ________

fear of dying __________ __________ __________ ________
fear of going mad __________ __________ __________ ________
feelings of unreality __________ __________ __________ ________

Physical

trembling __________ __________ __________ ________

tightness/pain in the chest __________ __________ _________ _________
shortness of breath/choking __________ __________ __________ ________
pounding heart __________ __________ __________ ________
sweating __________ __________ __________ ________
hot and cold flushes __________ __________ __________ ________
nausea __________ __________ __________ ________
dizziness/light-headedness __________ __________ __________ ________
 numbness/tingling

0 1 2 3 4 5 6 7 8 9 10

Not at all Somewhat Extremely

Exposure form and overall rating of how you feel

Situation: Example: getting used to speaking & asking for assistance

Fear of avoidance severity score

0 1 2 3 4 5 6 7 8 9 10

Not at all Somewhat Extremely

Anxious anxious anxious
 Personal progress chart--Show your Doctor regularly

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Mo Tu We Th Fr Sa Su Mo Tu We Th Fr Sa Su Mo Tu We Th Fr Sa Su Mo Tu We Th Fr Sa Su Mo Tu We Th Fr Sa Su

Week 1 Week 2 Week 3 Week 4 Week 5

0 1 2 3 4 5 6 7 8 9 10

Not at all Somewhat Extremely

depressed depressed depressed

Personal progress chart

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Mo Tu We Th Fr Sa Su Mo Tu We Th Fr Sa Su Mo Tu We Th Fr Sa Su Mo Tu We Th Fr Sa Su Mo Tu We Th Fr Sa Su

Week 1 Week 2 Week 3 Week 4 Week 5

0 1 2 3 4 5 6 7 8 9 10

Not at all Somewhat Extremely

depressed depressed depressed
This page will be filled by local centers or attending PCPs

Notes
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Medication Information____________________________________________________
Caffeine ____________________________________________________
Alcohol ____________________________________________________
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Self-help groups ____________________________________________________
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Counsellors ____________________________________________________
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Doctors ____________________________________________________
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Help Lines ____________________________________________________
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Suggested Reading ____________________________________________________
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Other Materials ____________________________________________________
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References

1. (GAD) Bourne, E.J. (1995) The anxiety and phobia workbook

2. (Panic) Craske, M.S. and Barlow, D.H. (2000)
3. (Social Phobia) Antony, M.M. and Swinson, R.P. (2000) The shyness and social anxiety workbook.

Websites

1. NIMH Anxiety Disorders Education Program— www.nimh.nih.gov/anxiety

2. Cognitive therapy website: www.academyofct.org
3. Canadian Network for Mood and Anxiety Treatment: www.canmat.org