IntroductionAnxiety OverviewAnxiety is one of the most distressing emotions that people feel. It is sometimes called fear or nervousness and is an emotion that everyone experiences at some point in time. It can be difficult to overcome anxiety without learning what exactly anxiety is and without learning helpful coping strategies. This course is designed to provide you with those types of learning opportunities with the goal being to decrease your anxious feelings. There are 5 lessons within this course that have been adapted from Greenberger and Padesky (1995) and Barlow (2008), which are both based on Cognitive Behavioral Therapy (CBT) principles. CBT is popular for treating many psychological problems, including anxiety.When to Seek Professional Anxiety HelpIf your symptoms persist and significantly interfere with your day to day life, it is important to seek professional help.Understanding & Overcoming AnxietyGoalTo be able to understand anxiety, how it is impacting you, and how it can be overcomeWhat is Anxiety?(Greenberger & Padesky, pp. 174-175)The word anxiety describes a number of problems includingphobias(fear of specific things or situations, such as heights, elevators, insects, flying in airplanes),panic attacks(intense feelings of anxiety in which people often feel like they are about to die or go crazy),posttraumatic stress disorder(repeated memories of terrible traumas with high levels of distress),obsessive-compulsive disorder(thinking about or doing things over and over again), andgeneralized anxiety disorder(a mixture of worries and anxiety symptoms experienced most of the time). Anxiety also describes brief periods of nervousness or fear experienced when faced with difficult life experiences. Numerous cognitive, behavioral, physical, and emotional symptoms are associated with anxiety. This course is designed for general anxiety problems.Cognitive Symptoms Overestimation of danger Underestimation of your ability to cope Underestimation of help available Worries and catastrophic thoughtsBehavioral Changes Avoiding situations where anxiety might occur Leaving situations when anxiety begins to occur Trying to do things perfectly or trying to control events to prevent dangerEmotional Symptoms Nervous Irritable Anxious PanickyPhysical Symptoms Sweaty palms Muscle tension Flushed cheeks Light-headednessAll of the physical, behavioral, and thinking changes we experience when we are anxious are part of the anxiety responses called fight, flight, or freeze. These three responses can be adaptive when we face danger. Unfortunately, we also experience these reactions when danger is not present, when danger is not as serious as you might think, or when too much anxiety interferes with good coping.Identifying & Assessing Symptoms Exercise(Greenberger & Padesky, pp. 177-179)Instructions:To help identify the symptoms of anxiety you are experiencing, rate the symptoms listed in the anxiety inventory table below. Circle one number for each item that best describes how much you have experienced each symptom over the last week.Fill out this anxiety inventory once or twice per week as you complete this course to assess how your anxiety is changing and which interventions are most worthwhile. Score the inventory by adding up the numbers you circled for all the items. For example, if you circled 3 for each item, your score would be 72 (3 X 24 items). If you couldnt decide between two numbers for an item and circled both, add only the higher number. To chart change, record your anxiety inventory scores in the tracking table on page 3. Mark each column with the date you completed the anxiety inventory. Then put an X in the column across from your score.Anxiety Inventory
SymptomNot at allSometimesFrequentlyMost of the time
1. Feeling nervous0123
2. Frequent worrying0123
3. Trembling, twitching, feeling shaky0123
4. Muscle tension, muscle aches, muscle soreness0123
5. Restlessness0123
6. Easily tired0123
7. Shortness of breath0123
8. Rapid heartbeat0123
9. Sweating not due to the heat0123
10. Dry mouth0123
11. Dizziness or light-headedness0123
12. Nausea, diarrhea, or stomach problems0123
13. Frequent urination0123
14. Flushes (hot flashes) or chills0123
15. Trouble swallowing or lump in throat0123
16. Feeling keyed up or on edge0123
17. Quick to startle0123
18. Difficulty concentrating0123
19. Trouble falling or staying asleep0123
20. Irritability0123
21. Avoiding places where I might be anxious0123
22. Frequent thoughts of danger0123
23. Seeing myself as unable to cope0123
24. Frequent thoughts that something terrible will happen0123
Score(of total circled numbers) = _____
Anxiety Inventory Tracking
Score
72
69
66
63
60
57
54
51
48
45
42
39
36
33
30
27
24
21
18
15
12
9
6
3
0
Date:
Overcoming Anxiety(Greenberger & Padesky, pp. 184-189)Anxiety can almost always be helped. The treatment approaches that have been shown to be most effective in reducing anxious feelings include cognitive restructuring, relaxation training, overcoming avoidance, and medication.Cognitive RestructuringAnxiety can be reduced by decreasing your perception of danger or by increasing your confidence in the ability to cope with threat. Evaluating anxious thoughts is helpful in order to more quickly and accurately evaluate the danger and its consequences. Anxiety may decrease if you examine the evidence and discover that the danger you face is not as bad as you thought. When threats or dangers are present, it is helpful to figure out what strategies will best help cope with them.Relaxation TrainingRelaxation can be accomplished through either physical relaxation or mental relaxation. Both methods can be equally effective. When we are physically relaxed, mental relaxation follows and when we are mentally relaxed, physical relaxation follows. Relaxation training can alleviate anxiety because it is difficult for the body or mind to be simultaneously relaxed and anxious. If you develop the ability to relax before and during stressful situations, then you can substantially reduce the frequency and severity of the anxiety you experience.Overcoming AvoidanceAvoidance is a hallmark of anxiety. When we avoid a difficult situation, we initially experience a decrease in anxiety. Ironically, the more we avoid a situation, the more anxious we become about facing it in the future. In this way, avoidance in the long run actually feeds anxiety, even though it seems to help anxiety in the short run. To overcome anxiety, we need to learn to approach the situations or people we avoid.MedicationThe use of medication to treat anxiety is controversial due to the addiction potential many anxiety medications possess. They can also potentially interfere with developing coping skills to overcome avoidance and managing anxiety without medication. Medication to treat anxiety is appealing, however, since it produces relaxed, calming sensations. Some antidepressant medications are used to treat anxiety but they are not always effective.Anxious Thinking
GoalTo be able to more readily identify anxious thoughtsAnxious Thinking(Greenberger & Padesky, p. 177, 180)Anxiety is accompanied by the perception that we are in danger or that we are threatened or vulnerable in some way. A threat or danger can be physical, mental, or social. A physical threat occurs when you believe you will be physically hurt (e.g., a snake bite, a heart attack, being hit). A social threat occurs when you believe you will be rejected, humiliated, embarrassed, or put down. A mental threat occurs when something makes you worry that you are going crazy or losing your mind.The perception of these threats varies from person to person. Some people, because of their life experiences, may feel threatened very easily and will often feel anxious. Other people may feel a greater sense of safety and security. Growing up in chaotic and volatile surroundings may lead a person to conclude that the world and other people are continually and constantly dangerous.Anxious thoughts are future oriented and often predict catastrophe. Anxious thoughts often begin with What if... and end with a disastrous outcome. Anxious thoughts also frequently include images of danger. Here are some examples of anxious thoughts: What if I stumble over my words? What if I have a traffic accident on the freeway? What if I get hurt? What if I am rejected?Interpretation of Problems(Greenberger & Padesky, p. 4)How we understand our problems has an effect on how we cope. Our interpretation of the problems is influenced by thoughts (beliefs, images, memories), moods, behaviors, physical reactions, and environment (past and present). Notice that the five areas are interconnected as shown in the image below. The connecting lines convey that each different aspect of a persons life influences all the others. For example, changes in our behavior influence how we think and also how we feel (both physically and emotionally). Behavior changes can also change our environment. Likewise, changes in our thinking affect our behavior, mood, physical reactions, and can lead to changes in our social environment. Some thoughts are automaticmaking it difficult to understand the influence it is having on the other areas. With practice, however, even automatic thoughts can be improved.Understanding Automatic ThoughtsWatch this video to better understand automatic thoughts:http://www.youtube.com/watch?v=m2zRA5zCA6MIdentifying Anxious Thoughts Exercise(Greenberger & Padesky, pp. 180-181)Instructions:To identify the thoughts that are associated with anxiety or fear in your own life, complete the table below. Think about a recent time when you were anxious, fearful, or nervous. Recall the thoughts you had (in words, in images). If you had a visual image, describe it. If your thoughts were in words, notice if the thoughts began with What if....SituationMoodsAutomatic Thoughts/Images
Who?What?When?Where?a. What did you feel?b. Rate each mood (0-100%)a. What was going through your mind just before you started to feel this way? Any other thoughts? Images?b. Circle thoughts implying danger, vulnerability, or a prediction of catastrophe.
Cognitive Restructuring Part I
GoalTo be able to challenge faulty thinkingFaulty ThinkingThoughts are not always accurate. What we tell ourselves may or may not be correct. Anxious thoughts create ruts in our brains, which can automatically lead us down a path toward feelings of fear or nervousness. It is time to get out of the rut and be on a new path with more realistic, accurate, and truthful thoughts and beliefs. One of the ways you can do this is by challenging your existing thoughts.Challenging Faulty Thinking Exercise(Barlow, p. 101)Instructions:Identify a single faulty thought or belief and answer the following questions on a separate piece of paper:1. What is the evidence for and against this idea?2. Is your belief a habit or based on facts?3. Are your interpretations of the situation too far removed from reality to be accurate?4. Are you thinking in all-or-nothing terms?5. Are you using words or phrases that are extreme or exaggerated? (i.e., always, forever, never, need, should, must, cant, and every time)6. Are you taking the situation out of context and only focusing on one aspect of the event?7. Is the source of information reliable?8. Are you confusing a low probability with a high probability?9. Are your judgments based on feelings rather than facts?10. Are you focused on irrelevant factors?Example:You may believe that others will reject you. Consider the evidence for and against this belief. Yes, people may have rejected you in the past, but that does not mean that everyone will reject you.Thinking Mistakes ExerciseInstructions:Read through the table on the next page of 12 common thinking mistakes. Put a check mark next to the mistakes that you frequently experience. For the checked items, write an example of when you have made the thinking mistake.Thinking MistakeDescriptionExampleYour Example
All-or-nothing thinkingYou see things in only two categories when it is really on a continuum.Either Im perfect or Ive completely failed.
Jumping to conclusionsYou take one observation and are sure it has only one implication.Since I didnt meet the deadline, trying to improve my performance is impossible.
Negative fortune-tellingYou make a negative prediction without recognizing it is not the only possible outcome.I wont go to the party since no one will talk to me anyway.
Positive fortune-tellingYou are overly optimistic about the most likely outcome.I will be able to complete my 10 page paper in an hour.
Discounting the positiveYou unreasonably discount your positive actions or qualities.It doesnt matter if Ive lost a few pounds. I deserve credit only after Ive lost all of the weight I need to lose.
Emotional reasoningYou think your thoughts must be true because they feel true, even if there is conflicting evidence.Since I feel so hopeless about my marriage improving, it really must be hopeless.
LabelingYou label yourself (or someone else) in a globally negative way without really considering the whole person.Im bad for not taking my dog for a walk today.
Mind readingYou are sure you know what others are thinking, even in the absence of compelling data.Everyone will think I am stupid if I ask a question.
Self-deluding thinkingYou tell yourself things that you really do not believe at other times.I dont deserve a speeding ticket for going 20 mph over the speed limit since I was in a hurry.
Dysfunctional (unhelpful) rulesYou mandate what you/others must/must not do without considering circumstances.I can only express happy, positive feelings.
IrrelevanceYou link two unrelated concepts.Its okay to go shopping because Im so stressed out.
ExaggerationYou make a sweeping statement on the basis of a small set of data.My kids are totally out of control.
(Adapted from Beck, 2007, pp. 146-147)Next StepIdentify additional faulty thoughts or beliefs and evaluate them using the questions from the challenging faulty thinking exercise.Learn more about thinking mistakes by watching the following video:Cognitive Restructuring Part II
GoalTo be able construct alternative thoughts and beliefsAlternative Thoughts & BeliefsOnce the faulty thoughts or beliefs are challenged, new truths need to be identified. By practicing the new and more realistic way of looking at life experiences, over time your feelings will positively respond to your new way of thinking.Thought Record Exercise(Barlow, p. 105)Instructions:Use the table on the next page to construct alternative thoughts to various situations. Complete the exercise once per day for the next 7 days. Identify and rate your thought(s)/belief(s) and emotion(s) about a situation and challenge your thought(s) just like you did in prior lessons. Next, determine if you are making a thinking mistake. Then, ask yourself what else you could say instead of your original thought(s). Lastly, rerate your original thought(s) and reexamine your feeling(s) about the situation. Keep in mind that if you do not make a thinking mistake, you likely will not experience a change in your feeling(s).
Thought Record
SituationThought(s) & Emotion(s)ChallengeThinking MistakeAlternative Thought(s)
Describe what led to the unpleasant emotion(s).List your primary thought(s) about the situation and specify your emotion(s). Rate how strongly you feel the emotion(s) from 0-100%.Use the questions in lesson 4 to examine your initial thought(s).Use the thinking mistakes table in lesson 4 to determine if this is a particular pattern of thinking.What else can I say instead of my initial thought(s)? How else can I interpret the event? Rate your belief in the alternative thought(s) from 0-100%.Rerate how much you now believe your initial thought(s) from 0-100%.List the emotion(s) you are experiencing about the situation now and specify how strong it is from 0-100%.
Overcoming Avoidance(Greenberger & Padesky, p. 187)Learning to approach and cope with situations in which we feel anxious is a lasting and powerful way of eliminating anxiety. Use the various relaxation strategies that you will learn in lesson 5 to reduce your anxiety about situations you tend to avoid. By gradually approaching what you fear, you can gather evidence about the accuracy of your catastrophic expectations and replace avoidance with engagement.Overcoming Avoidance Exercise(adapted fromhttp://www.anxietybc.com/resources/anxiety.php)Instructions:To help you identify situations that you avoid, try to come up with as many answers as possible to the following questions: If you woke up tomorrow morning and all your anxiety had magically disappeared, what would you do?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
How would you act?______________________________________________________________________________________________________________________________________________________________________________________________________________________________
How would someone close to you know you werent anxious?______________________________________________________________________________________________________________________________________________________________________________________________________________________________
Finish this sentence: My anxiety stops me from______________________________________________________________________________________________________________________________________________________________________________________________________________________________
Finish this sentence: When I am not anxious, I will be able to______________________________________________________________________________________________________________________________________________________________________________________________________________________________Next StepIt takes time for a new thought to replace the original, problematic thought. Once you have completed this exercise, you may find it helpful to re-read what you wrote down to help solidify your shift in thinking.Learn how to complete a thought record by watching the following video. We apologize for the visual quality of the video:
Relaxation Training
GoalTo be able to feel relaxed after completing a relaxation exerciseDiaphragmatic BreathingDiaphragmatic breathing can be a highly effective relaxation strategy. In order to do it properly, it is important to breathe from your diaphragm (abdomen) rather than from your chest muscles. It takes practice to learn how to breathe properly. The following video introduces diaphragmatic breathing and begins a three part training on how to do it properly.Video 1:http://www.youtube.com/watch?v=8-_NNCrrdusDeep Muscle Relaxation(adapted from Martin & Pear, 2002, pp. 382-383)Deep muscle relaxation is an additional form of relaxation and consists of relaxing all of your muscles completely and to recognize when they are relaxed. This is done by alternately tensing and relaxing your muscles while attending closely to the internal activities and sensations you are feeling at the time.In order to learn how to do deep muscle relaxation effectively, it is helpful to have someone with a soothing voice read a muscle relaxation script to you. Record them reading the script so you will always have it. Alternatively, use a pre-recorded script that can be found online, such ashttp://www.youtube.com/watch?v=HFwCKKa--18.Script:Listen closely to these instructions. They will help you to increase your ability to relax. Each time I pause, continue doing what you were doing before the pause. Now, close your eyes and take 3 deep breaths (pause for 10 seconds). Make a tight fist with your left hand. Squeeze it tightly. Note how it feels (pause for 5 seconds). Now relax (pause for 5 seconds). Once again, squeeze your left hand tightly and study the tension that you feel (pause for 5 seconds). And once again, just relax and think of the tension disappearing from our fingers (pause for 10 seconds). Make a tight fist with your right hand. Squeeze it as tightly as you can and note the tension in your fingers and your hand, and your forearm (pause for 5 seconds). Now relax (pause for 5 seconds). Once again, squeeze your right fist tightly (pause for 5 seconds). And again, just relax (pause for 10 seconds).Make a tight fist with your left hand and bend your arm to make your left biceps hard. Hold it tense (pause for 5 seconds). Now relax totally. Feel the warmth escape down your biceps through your forearm, and out of your fingers (pause for 10 seconds). Now make a tight fist with the other hand and raise your hand to make your right biceps hard. Hold it tightly, and feel 16 the tension (pause for 5 seconds). Now relax. Concentrate on the feelings flowing through your arm (pause for 10 seconds). Now, squeeze both fists at once and bend both arms to make them totally tense throughout. Hold it, and think about the tension you feel (pause for 5 seconds). Now relax, and feel the total warmth and relaxation flowing through your muscles. All the tension is flowing out of your fingertips (pause for 10 seconds).Now, wrinkle your forehead and squint your eyes very tight and hard. Squeeze them tight and hard. Feel the tension across your forehead and through your eyes. Now relax. Note the sensations running through your eyes. Just relax (pause for 10 seconds). Okay, squeeze your jaws tight together and raise your chin to make your neck muscles hard. Hold it, bite down hard, tense your neck, and squeeze your lips really tight (pause for 5 seconds). Now relax (pause for 10 seconds). Now, all together, wrinkle up your forehead and squeeze your eyes tight, bite down hard with your jaws, raise your chin and tighten up your neck, and make your lips tight. Hold them all and feel the tension throughout your forehead, and eyes, and jaw, and neck, and lips. Hold it. Now relax. Just totally relax and enjoy the tingling sensations (pause for 15 seconds).Now, squeeze both your shoulders forward as hard as you can until you feel your muscles pulling tightly right across your back, especially in the area between your shoulder blades. Squeeze them. Hold them tight. Now relax (pause for 10 seconds). Now squeeze your shoulders forward again and, at the same time, suck your stomach in as far as you can and tense your stomach muscles. Feel the tension throughout your stomach. Hold it (pause for 5 seconds). Now relax (pause for 10 seconds). Once more, squeeze your shoulder blades forward again, suck in your stomach as far as you can, tense your stomach muscles, and feel the tension throughout your upper body. Now relax (pause for 10 seconds).Now, we are going to review all of the muscle systems that we have covered so far. First, take three deep breaths (pause for 10 seconds). Ready? Tighten up both fists and bend both of your arms to squeeze your biceps tight. Wrinkle your forehead and squeeze your eyes tight. Bite down hard with your jaws, raise your chin, and hold your lips tight. Squeeze your shoulders forward and suck in your stomach and push your stomach muscles against it. Hold them all. Feel the tremendous tension throughout. Now relax. Take a deep breath. Just feel the tension disappearing. Think about the total relaxation throughout all of your muscles-in your arms, in your head, in your shoulders, in your stomach. Just relax (pause for 10 seconds).Now, lets go to your legs. Bring your left heel in tight toward your chair, push it down hard, and raise your toes so that your calf and your thigh are extremely tense. Squeeze your toes up and push your heel down hard (pause for 5 seconds). Now relax (pause for 10 seconds). One more time, bring your left heel in tight toward your chair, push it down hard, and raise your toes so that your calf and your thigh are extremely tense. Push down on the heel and raise your toes. Now relax (pause for 10 seconds). Now, bring your right heel in tight toward your chair and push it down and raise your toes so that your calf and your thigh are extremely tense. Push your heel down, squeeze your toes up, and squeeze your leg in tight (pause for 5 seconds). Now relax (pause for 10 seconds).Now, lets do both legs together. Squeeze your heels in tight toward your chair, push down on your heels, and raise your toes as high and as tight as you can. Hold it (pause for 5 seconds). Now relax (pause for 10 seconds). Now, take 3 deep breaths (pause for 5 seconds). Now, tense all the muscles as they are named, exactly as you have practiced: left fist and biceps, right fist and biceps, forehead, eyes, jaw, neck, lips, shoulders, stomach, left leg, right leg. Hold it (pause for 5 seconds). Now relax (pause for 10 seconds). Breathe in deeply 3 times and then repeat the total tensing and then the total relaxing, and while you are breathing in deeply and then tensing and then relaxing, notice how relaxed all of your muscles feel. Now tense (pause for 5 seconds) and relax (pause for 5 seconds). Now, breathe normally and enjoy the completely tension-free state of your body and muscles (pause for 5 seconds). Now turn the recording off.Deep Muscle Relaxation ExercisePractice deep muscle relaxation by either playing the recording of the muscle relaxation script or watching thevideo. Make sure you are in a quiet, dimly lit setting with as few of distractions as possible.Imagery(Greenberger & Padesky, pp. 185-186)Imagery involves visualizing scenes that are tranquil and relaxing to you. Scenes may be actual places you know that feel safe and relaxing, or they may be scenes you create to be tranquil, safe, and relaxing. The specific scene is less important than how the image makes you feel. The more senses you can incorporate into your image, the more relaxing imagery is likely to be. If you can imagine the smells, sounds, and tactile sensations as well as the visual aspects of the scene, you will improve your ability to relax.Imagery ExerciseInstructions: Watch this guided imageryvideoand reflect on the experience by thinking about your answers to the following questions: How did you feel before, during, and after the exercise? What thoughts did you have during the exercise? Did your feelings of anxiety decrease after completing the exercise?Distraction(Greenberger & Padesky, p. 186)When anxious, we tend to focus on physical sensations or thoughts connected to our anxiety. Distraction works because our attention is focused away from the thoughts or physical sensations that contribute to our anxiety. To the degree that you can become absorbed in other activities or thoughts you will shut off the cognitive fuel for your anxiety, thereby decreasing or eliminating your anxiety symptoms. Practice distraction for at least 4 minutes before expecting a decrease in anxiety.Next StepTo determine which relaxation methods work best for you, rate your level of anxiety or tension on a 0-100 scale before and after completing them. Practice the one or two methods that work best for you regularly to make them fully effective.
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