David Baxter PhD
Late Founder
Ten Best-Ever Anxiety-Management Techniques
By Margaret Wehrenberg
?I don?t think I want to live if I have to go on feeling like this.? I hear this remark all too often from anxiety sufferers. They say it matter-of-factly or dramatically, but they all feel the same way: if anxiety symptoms are going to rule their lives, then their lives don?t seem worth living.
What is it about anxiety that?s so horrific that otherwise high-functioning people are frantic to escape it? The sensations of doom or dread or panic felt by sufferers are truly overwhelming?the very same sensations, in fact, that a person would feel if the worst really were happening. Too often, these, literally, dread-full, sickening sensations drive clients to the instant relief of medication, which is readily available and considered by many insurance companies to be the first line of treatment. And what good doctor would suggest skipping the meds when a suffering patient can get symptomatic relief quickly?
But what clients don?t know when they start taking meds is the unacknowledged cost of relying solely on pills: they?ll never learn some basic methods that can control or eliminate their symptoms without meds. They never develop the tools for managing the anxiety that, in all likelihood, will turn up again whenever they feel undue stress or go through significant life changes. What they should be told is that the right psychotherapy, which teaches them to control their own anxiety, will offer relief from anxiety in a matter of weeks?about the same amount of time it takes for an SSRI to become effective.
Of course, therapists know that eliminating symptomatology isn?t the same as eliminating etiology. Underlying psychological causes or triggers for anxiety, such as those stemming from trauma, aren?t the target of management techniques; they require longer-term psychotherapy. However, anxiety-management techniques can offer relief, and offer it very speedily.
The unpleasant symptoms most likely to be helped by medication are the very ones that the 10 best-ever anxiety-management techniques are intended to correct. They fall into three typical clusters:
A therapist armed with methods for addressing these clusters can offer her anxious client the promise of relief for a lifetime, if she knows which of these ?10 best? techniques work for which symptoms, and how to use them.
Cluster One: Distressing Physical Arousal
Panic is the physical arousal that sends many clients running for Xanax. Sympathetic arousal causes the heart-thumping, pulse-racing, dizzy, tingly, shortness-of-breath physical symptoms that can come from out of the blue, and are intolerable when not understood. Even high levels of acute anxiety that aren?t as intense as outright panic attacks can constitute very painful states of arousal. Physical symptoms of anxiety include constant heightened physical tension in the jaw, neck, and back, as well as an emotional-somatic feeling of doom or dread in the pit of the stomach. The feeling of doom will always set off a mental search for what might be causing it.
Bad as these symptoms are, there are methods that, when followed regularly as lifelong habits, offer tremendous relief.
Method 1: Manage the Body. Telling anxiety-prone clients to take care of their bodies by eating right, avoiding alcohol, nicotine, sugar, and caffeine, and exercising is a strikingly ordinary ?prescription,? but not doing these things can undermine the effectiveness of other antianxiety techniques. During the summer before Ellie went off to college, for example, she?d almost eliminated her anxiety by practicing deep, calm breathing and learning to stop her catastrophic thinking. She?d even been able to stop taking the antianxiety medication she?d used for years. But two months after starting college, her panic attacks came roaring back with a vengeance. She came back to see me, but quickly let me know that she was going to call her psychiatrist for another Xanax prescription. I suggested that, before she made the call, she spend a couple of weeks keeping a ?panic profile??a journal recording when and under what circumstances she suffered from panic attacks.
A couple of weeks later, she came to my office smiling broadly. ?I figured it out,? she said, grinning as she showed me her panic profile. She?d traced her panic attacks to days after she drank heavily and smoked cigarettes?neither of which had she done over the summer while living in her parents? house. Also, her caffeine use had risen dramatically while at school?to help her wake up for classes after partying at night?and her diet had devolved to pizza and doughnuts. She really didn?t want to give up these habits, but keeping the journal had reminded her that her anxiety symptoms are physical, and that calming her body had defused her panic triggers once before. Taking care again to eliminate CATS (caffeine, alcohol, tobacco, sugar + Nutrasweet), Ellie got back on track without returning to meds. The simple rule?manage the body?must remain a first priority throughout treatment for anxiety. Ellie had a major relapse when she let go of routine self-care.
Therapists who remember that humans have bodies as well as minds are much likelier to inquire routinely about ongoing self-care, including sleep and exercise. They?re also more willing to help clients overcome their reluctance to follow a self-care routine. A tip to remember for female clients who experience a resurgence of symptoms in spite of the fact that they?re managing their body is to consider hormonal changes. Pregnancy, postpartum changes, hysterectomy, and interruptions in cycles may contribute to anxiety. The slow process of menopause, which may begin over a wide range of ages, is another factor to consider. Shifts in thyroid function also contribute to shifts in anxiety. They can occur at any age, and predominate in female clients. Therapists need to be particularly alert to what might be going on in the body when a client who was previously doing well starts having trouble.
Method 2: Breathe. Ellie and I next reviewed her use of diaphragmatic breathing to ward off the panic. As it turned out, she?d forgotten how helpful breathing had been when we first started working together, and had quit doing it. Now, not only did she suffer again from panic, but she thought it was too powerful to be relieved merely by breathing deeply. She?d begun to panic just thinking about feeling panic. I?ve often found that when clients say that breathing ?doesn?t work,? it?s because they haven?t learned to do it correctly. Or once having learned it, they?ve given it up when they felt better, believing that they no longer needed to do it. By the time they feel anxiety returning, they?re convinced that something so simple can?t possibly be really effective. Therefore, it?s important for therapists to emphasize and reemphasize that breathing will slow down or stop the stress response, if the client will just do it.
The biggest block to making breathing truly helpful is the time it takes to practice it until it becomes an ingrained habit. Most relaxation books teach clients to practice breathing once a day for 10 minutes, but I?ve never found a client who actually learned how to do it from this one, daily, concentrated dose. I don?t teach clients to breathe for lengthy periods until they?ve practiced it for very short periods many times a day. I ask them to do the conscious, deep breathing for about one minute at a time, 10 to 15 times per day, every time they find themselves waiting for something?the water to boil, the phone to ring, their doctor?s appointment, the line to move at the bank. This will eventually help them associate breathing with all of their surroundings and activities. This way, they?re more likely to actually remember to breathe when anxiety spikes. Ellie needed a review session in breathing to help her get back on track.
Method 3: Mindful Awareness. Since the return of her panic attacks, Ellie had also begun to fear that she?d always be afraid. ?After all,? she said, ?I thought I was cured when I went back to school, and now look at me! I?m constantly worried I?ll have another panic attack.? She?d started to give catastrophic interpretations to every small, physical sensation?essentially creating panic out of ephemeral and unimportant changes in her physical state. A slight chill or a momentary flutter in her stomach was all she needed to start hyperventilating in fear that panic was on its way, which, of course, brought it on. She needed to stop the catastrophic thinking and divert her attention away from her body.
Like most anxious people when they worry, Ellie was thinking about the future and wasn?t in the moment. She felt controlled by her body, which required her to be on the lookout for signs of panic. She?d never considered that she could manage her body?and prevent panic?by controlling what she did or didn?t pay attention to. But, in fact, by changing her focus, she could diminish the likelihood of another panic attack. A wonderful technique, this simple ?mindful awareness? exercise has two simple steps, repeated several times.
1. Clients close their eyes and breathe, noticing the body, how the intake of air feels, how the heart beats, what sensations they have in the gut, etc.
2. With their eyes still closed, clients purposefully shift their awareness away from their bodies to everything they can hear or smell or feel through their skin.
By shifting awareness back and forth several times between what?s going on in their bodies and what?s going on around them, clients learn in a physical way that they can control what aspects of their world?internal or external?they?ll notice. This gives them an internal locus of control, showing them, as Ellie learned, that when they can ignore physical sensations, they can stop making the catastrophic interpretations that actually bring on panic or worry. It?s a simple technique, which allows them to feel more in control as they stay mindful of the present.
Cluster Two: Tension, Stress, and Dread
Many clients with generalized anxiety disorder (GAD) experience high levels of tension that are physically uncomfortable and compel them to search frantically for the reasons behind their anxiety. They hope they can ?solve? whatever problem seems to be causing anxiety and thus relieve its symptoms. But since much of their heightened tension isn?t about a real problem, they simply waste time running around their inner maze of self-perpetuating worry. And even if their tension does stem from psychological or neurobiological causes, there are ways to eliminate the symptoms of chronic worry before addressing those dimensions. The following methods are most helpful for diminishing chronic tension.
Method 4: Don?t Listen When Worry Calls Your Name. Colleen feared I?d think she was crazy when she said, ?It?s as if my anxiety has a voice. It calls to me, ?Worry now,? even when there?s nothing on my mind. Then I have to go looking for what?s wrong.? And she was very good at finding something wrong to worry about. An executive who had a lot of irons in the fire, she had no shortage of projects that needed her supervision. On any day, she could worry about whether a report had been correct, or projected figures were accurate, or a contract would generate income for her firm. In describing the voice of worry, she was describing that physical, pit-of-the-stomach sense of doom that comes on for no reason, and then compels an explanation for why it?s there. This feeling of dread and tension, experienced by most GAD clients, actually comprises a state of low-grade fear, which can also cause other physical symptoms, like headache, temporo-mandibular joint (TMJ) pain, and ulcers.
Few realize that the feeling of dread is just the emotional manifestation of physical tension. This ?Don?t Listen? method decreases this tension by combining a decision to ignore the voice of worry with a cue for the relaxation state. Early in treatment, GAD clients learn progressive muscle relaxation to get relief. I always teach them how to cue up relaxation several times throughout the day by drawing a breath and remembering how they feel at the end of the relaxation exercise. We usually pair that deeply relaxed state with a color, image, and word to strengthen associations with muscle relaxation and make it easier to cue the sensation at will.
We then use that ability to relax to counteract the voice of worry. Clients must first learn that worry is a habit with a neurobiological underpinning. Even when a person isn?t particularly worried about anything, an anxiety-prone brain can create a sense of doom, which then causes hypervigilance as the person tries to figure out what?s wrong. Colleen smiled with recognition when I said that, when she was in this state, it was as though her brain had gone into radar mode, scanning her horizons for problems to defend against. I asked her to pay attention to the order of events, and she quickly recognized that the dread occurred before she consciously had a worry. ?But,? she announced, ?I always find something that could be causing the doom, so I guess I had a good reason to worry without realizing it.?
She believed the doom/dread must have a legitimate cause, and was relieved to learn that her need to find the cause (when there really wasn?t one) stemmed from a brain function. This cause-seeking part of her brain, triggered by changes in her physiology that made her feel dread, in effect, called out, ?Worry now!?
To stop listening to that command to worry, I suggested that she say to herself, ?It?s just my anxious brain firing wrong.? This would be the cue for her to begin relaxation breathing, which would stop the physical sensations of dread that trigger the radar.
By Margaret Wehrenberg
?I don?t think I want to live if I have to go on feeling like this.? I hear this remark all too often from anxiety sufferers. They say it matter-of-factly or dramatically, but they all feel the same way: if anxiety symptoms are going to rule their lives, then their lives don?t seem worth living.
What is it about anxiety that?s so horrific that otherwise high-functioning people are frantic to escape it? The sensations of doom or dread or panic felt by sufferers are truly overwhelming?the very same sensations, in fact, that a person would feel if the worst really were happening. Too often, these, literally, dread-full, sickening sensations drive clients to the instant relief of medication, which is readily available and considered by many insurance companies to be the first line of treatment. And what good doctor would suggest skipping the meds when a suffering patient can get symptomatic relief quickly?
But what clients don?t know when they start taking meds is the unacknowledged cost of relying solely on pills: they?ll never learn some basic methods that can control or eliminate their symptoms without meds. They never develop the tools for managing the anxiety that, in all likelihood, will turn up again whenever they feel undue stress or go through significant life changes. What they should be told is that the right psychotherapy, which teaches them to control their own anxiety, will offer relief from anxiety in a matter of weeks?about the same amount of time it takes for an SSRI to become effective.
Of course, therapists know that eliminating symptomatology isn?t the same as eliminating etiology. Underlying psychological causes or triggers for anxiety, such as those stemming from trauma, aren?t the target of management techniques; they require longer-term psychotherapy. However, anxiety-management techniques can offer relief, and offer it very speedily.
The unpleasant symptoms most likely to be helped by medication are the very ones that the 10 best-ever anxiety-management techniques are intended to correct. They fall into three typical clusters:
- the physical arousal that constitutes the terror of panic;
- the ?wired? feelings of tension that correlate with being ?stressed out? and can include pit-of-the-stomach doom;
- the mental anguish of rumination?a brain that won?t stop thinking distressing thoughts.
A therapist armed with methods for addressing these clusters can offer her anxious client the promise of relief for a lifetime, if she knows which of these ?10 best? techniques work for which symptoms, and how to use them.
Cluster One: Distressing Physical Arousal
Panic is the physical arousal that sends many clients running for Xanax. Sympathetic arousal causes the heart-thumping, pulse-racing, dizzy, tingly, shortness-of-breath physical symptoms that can come from out of the blue, and are intolerable when not understood. Even high levels of acute anxiety that aren?t as intense as outright panic attacks can constitute very painful states of arousal. Physical symptoms of anxiety include constant heightened physical tension in the jaw, neck, and back, as well as an emotional-somatic feeling of doom or dread in the pit of the stomach. The feeling of doom will always set off a mental search for what might be causing it.
Bad as these symptoms are, there are methods that, when followed regularly as lifelong habits, offer tremendous relief.
Method 1: Manage the Body. Telling anxiety-prone clients to take care of their bodies by eating right, avoiding alcohol, nicotine, sugar, and caffeine, and exercising is a strikingly ordinary ?prescription,? but not doing these things can undermine the effectiveness of other antianxiety techniques. During the summer before Ellie went off to college, for example, she?d almost eliminated her anxiety by practicing deep, calm breathing and learning to stop her catastrophic thinking. She?d even been able to stop taking the antianxiety medication she?d used for years. But two months after starting college, her panic attacks came roaring back with a vengeance. She came back to see me, but quickly let me know that she was going to call her psychiatrist for another Xanax prescription. I suggested that, before she made the call, she spend a couple of weeks keeping a ?panic profile??a journal recording when and under what circumstances she suffered from panic attacks.
A couple of weeks later, she came to my office smiling broadly. ?I figured it out,? she said, grinning as she showed me her panic profile. She?d traced her panic attacks to days after she drank heavily and smoked cigarettes?neither of which had she done over the summer while living in her parents? house. Also, her caffeine use had risen dramatically while at school?to help her wake up for classes after partying at night?and her diet had devolved to pizza and doughnuts. She really didn?t want to give up these habits, but keeping the journal had reminded her that her anxiety symptoms are physical, and that calming her body had defused her panic triggers once before. Taking care again to eliminate CATS (caffeine, alcohol, tobacco, sugar + Nutrasweet), Ellie got back on track without returning to meds. The simple rule?manage the body?must remain a first priority throughout treatment for anxiety. Ellie had a major relapse when she let go of routine self-care.
Therapists who remember that humans have bodies as well as minds are much likelier to inquire routinely about ongoing self-care, including sleep and exercise. They?re also more willing to help clients overcome their reluctance to follow a self-care routine. A tip to remember for female clients who experience a resurgence of symptoms in spite of the fact that they?re managing their body is to consider hormonal changes. Pregnancy, postpartum changes, hysterectomy, and interruptions in cycles may contribute to anxiety. The slow process of menopause, which may begin over a wide range of ages, is another factor to consider. Shifts in thyroid function also contribute to shifts in anxiety. They can occur at any age, and predominate in female clients. Therapists need to be particularly alert to what might be going on in the body when a client who was previously doing well starts having trouble.
Method 2: Breathe. Ellie and I next reviewed her use of diaphragmatic breathing to ward off the panic. As it turned out, she?d forgotten how helpful breathing had been when we first started working together, and had quit doing it. Now, not only did she suffer again from panic, but she thought it was too powerful to be relieved merely by breathing deeply. She?d begun to panic just thinking about feeling panic. I?ve often found that when clients say that breathing ?doesn?t work,? it?s because they haven?t learned to do it correctly. Or once having learned it, they?ve given it up when they felt better, believing that they no longer needed to do it. By the time they feel anxiety returning, they?re convinced that something so simple can?t possibly be really effective. Therefore, it?s important for therapists to emphasize and reemphasize that breathing will slow down or stop the stress response, if the client will just do it.
The biggest block to making breathing truly helpful is the time it takes to practice it until it becomes an ingrained habit. Most relaxation books teach clients to practice breathing once a day for 10 minutes, but I?ve never found a client who actually learned how to do it from this one, daily, concentrated dose. I don?t teach clients to breathe for lengthy periods until they?ve practiced it for very short periods many times a day. I ask them to do the conscious, deep breathing for about one minute at a time, 10 to 15 times per day, every time they find themselves waiting for something?the water to boil, the phone to ring, their doctor?s appointment, the line to move at the bank. This will eventually help them associate breathing with all of their surroundings and activities. This way, they?re more likely to actually remember to breathe when anxiety spikes. Ellie needed a review session in breathing to help her get back on track.
Method 3: Mindful Awareness. Since the return of her panic attacks, Ellie had also begun to fear that she?d always be afraid. ?After all,? she said, ?I thought I was cured when I went back to school, and now look at me! I?m constantly worried I?ll have another panic attack.? She?d started to give catastrophic interpretations to every small, physical sensation?essentially creating panic out of ephemeral and unimportant changes in her physical state. A slight chill or a momentary flutter in her stomach was all she needed to start hyperventilating in fear that panic was on its way, which, of course, brought it on. She needed to stop the catastrophic thinking and divert her attention away from her body.
Like most anxious people when they worry, Ellie was thinking about the future and wasn?t in the moment. She felt controlled by her body, which required her to be on the lookout for signs of panic. She?d never considered that she could manage her body?and prevent panic?by controlling what she did or didn?t pay attention to. But, in fact, by changing her focus, she could diminish the likelihood of another panic attack. A wonderful technique, this simple ?mindful awareness? exercise has two simple steps, repeated several times.
1. Clients close their eyes and breathe, noticing the body, how the intake of air feels, how the heart beats, what sensations they have in the gut, etc.
2. With their eyes still closed, clients purposefully shift their awareness away from their bodies to everything they can hear or smell or feel through their skin.
By shifting awareness back and forth several times between what?s going on in their bodies and what?s going on around them, clients learn in a physical way that they can control what aspects of their world?internal or external?they?ll notice. This gives them an internal locus of control, showing them, as Ellie learned, that when they can ignore physical sensations, they can stop making the catastrophic interpretations that actually bring on panic or worry. It?s a simple technique, which allows them to feel more in control as they stay mindful of the present.
Cluster Two: Tension, Stress, and Dread
Many clients with generalized anxiety disorder (GAD) experience high levels of tension that are physically uncomfortable and compel them to search frantically for the reasons behind their anxiety. They hope they can ?solve? whatever problem seems to be causing anxiety and thus relieve its symptoms. But since much of their heightened tension isn?t about a real problem, they simply waste time running around their inner maze of self-perpetuating worry. And even if their tension does stem from psychological or neurobiological causes, there are ways to eliminate the symptoms of chronic worry before addressing those dimensions. The following methods are most helpful for diminishing chronic tension.
Method 4: Don?t Listen When Worry Calls Your Name. Colleen feared I?d think she was crazy when she said, ?It?s as if my anxiety has a voice. It calls to me, ?Worry now,? even when there?s nothing on my mind. Then I have to go looking for what?s wrong.? And she was very good at finding something wrong to worry about. An executive who had a lot of irons in the fire, she had no shortage of projects that needed her supervision. On any day, she could worry about whether a report had been correct, or projected figures were accurate, or a contract would generate income for her firm. In describing the voice of worry, she was describing that physical, pit-of-the-stomach sense of doom that comes on for no reason, and then compels an explanation for why it?s there. This feeling of dread and tension, experienced by most GAD clients, actually comprises a state of low-grade fear, which can also cause other physical symptoms, like headache, temporo-mandibular joint (TMJ) pain, and ulcers.
Few realize that the feeling of dread is just the emotional manifestation of physical tension. This ?Don?t Listen? method decreases this tension by combining a decision to ignore the voice of worry with a cue for the relaxation state. Early in treatment, GAD clients learn progressive muscle relaxation to get relief. I always teach them how to cue up relaxation several times throughout the day by drawing a breath and remembering how they feel at the end of the relaxation exercise. We usually pair that deeply relaxed state with a color, image, and word to strengthen associations with muscle relaxation and make it easier to cue the sensation at will.
We then use that ability to relax to counteract the voice of worry. Clients must first learn that worry is a habit with a neurobiological underpinning. Even when a person isn?t particularly worried about anything, an anxiety-prone brain can create a sense of doom, which then causes hypervigilance as the person tries to figure out what?s wrong. Colleen smiled with recognition when I said that, when she was in this state, it was as though her brain had gone into radar mode, scanning her horizons for problems to defend against. I asked her to pay attention to the order of events, and she quickly recognized that the dread occurred before she consciously had a worry. ?But,? she announced, ?I always find something that could be causing the doom, so I guess I had a good reason to worry without realizing it.?
She believed the doom/dread must have a legitimate cause, and was relieved to learn that her need to find the cause (when there really wasn?t one) stemmed from a brain function. This cause-seeking part of her brain, triggered by changes in her physiology that made her feel dread, in effect, called out, ?Worry now!?
To stop listening to that command to worry, I suggested that she say to herself, ?It?s just my anxious brain firing wrong.? This would be the cue for her to begin relaxation breathing, which would stop the physical sensations of dread that trigger the radar.
