Anxiety and Phobia Workbook (6e, Edmund Bourne) - Book Summary

    
Introduction (6 ed, 2015)

As of 2015: Approximately 18 percent of the population of the United States, or over fifty million people, have suffered from panic attacks, phobias, or other anxiety disorders in the past year. Nearly a quarter of the adult population will suffer from an anxiety disorder at some time during their life. Yet only a small proportion of these people receive treatment.

Ch 1: Anxiety Disorders

FOUR CASES:

1: Susan awakens suddenly almost every night, a couple of hours after going to sleep, with a tightness in her throat, a racing heart, dizziness, and a fear that she’s going to die. Although she’s shaking all over, she hasn’t a clue why. After many nights of getting up and pacing her living room floor in an attempt to get a grip on herself, she decides to go see her doctor to find out whether something is wrong with her heart.

2: Cindy, a medical secretary, has been having attacks like Susan’s whenever she’s in a confined public situation. Not only does she fear losing control over herself, but she dreads what others might think of her if this were to happen. Recently, she has been avoiding going into any kind of store other than the local 7-Eleven unless her boyfriend is with her. She has also needed to leave restaurants and movie theaters during dates. Now she is beginning to wonder whether she can cope with her job. She has been forcing herself to go into work, yet after a few minutes among her office mates, she starts to fear that she’s losing control of herself. Suddenly, she feels as though she has to leave.

3: Steve has a responsible position as a software engineer but feels he is unable to advance because of his inability to contribute in group meetings. It’s almost more than he can bear just to sit in on meetings, let alone offer his opinions. Yesterday his boss asked him whether he would be available to make a presentation on his segment of a large project. At that point, Steve became extremely nervous and tongue-tied.
He walked out of the room, stammering that he would let his boss know by the next day about the presentation. Privately, he thought about resigning.

4: Mike is so embarrassed about a peculiar fear he’s had over the past few months that he can’t tell anyone, not even his wife. While driving he is frequently gripped by the fear that he has run over someone or perhaps an animal. Even though there is no “thud” suggesting that anything like this has happened, he feels compelled to make a U-turn and retrace the route he’s just driven to make absolutely sure. In fact, recently, his paranoia about having hit someone has grown so strong that he has to retrace his route three or four times to assure himself that nothing has happened.
Mike is a bright, successful professional and feels utterly humiliated about his compulsion to check. He’s beginning to wonder if he’s going crazy.

Susan, Cindy, Steve, and Mike are all confronted by anxiety. Yet it is not ordinary anxiety.
Their experiences differ in two fundamental respects from the “normal” anxiety people experience in response to everyday life. First, their anxiety has gone out of control. In each case, the individual feels powerless to direct what’s happening. This sense of powerlessness in turn creates even more anxiety. Second, the anxiety is interfering with the normal functioning of their lives.

Susan’s sleep is disrupted. Cindy and Steve may lose their jobs. And Mike has lost the ability to drive in an efficient and timely manner.
The examples of Susan, Cindy, Steve, and Mike illustrate four types of anxiety disorder: panic disorder, agoraphobia, social phobia, and obsessive-compulsive disorder.

The Nature of Anxiety 

You can better understand the nature of anxiety by looking at both what it is and what it is not.
For example, anxiety can be distinguished from fear in several ways. When you are afraid, your fear is usually directed toward some concrete external object or situation. The event that you fear usually is within the bounds of possibility. You might fear not meeting a deadline, failing an exam, being unable to pay your bills, or being rejected by someone you want to please. Fear can be associated with a sudden surge of adrenaline, thoughts of immediate danger, and a need to escape. When you experience anxiety, on the other hand, you often can’t specify what it is you’re anxious about. The focus of anxiety is more internal than external. It seems to be a response to a vague, distant, or even unrecognized danger. You might be anxious about “losing control” of yourself or some situation. Or you might feel a vague anxiety about “something bad happening.”

Anxiety affects your whole being. It is a physiological, behavioral, and psychological reaction all at once. On a physiological level, anxiety may include bodily reactions such as rapid heartbeat, muscle tension, queasiness, dry mouth, or sweating. On a behavioral level, it can sabotage your ability to act, express yourself, or deal with certain everyday situations.
Psychologically, anxiety is a subjective state of apprehension and uneasiness. In its most extreme form, it can cause you to feel detached from yourself and even fearful of dying or going crazy.
The fact that anxiety can affect you on a physiological, behavioral, and psychological level has important implications for your attempts to recover. A complete program of recovery from an anxiety disorder must intervene at all three levels to: 

1. Reduce physiological reactivity 

2. Eliminate avoidance behavior 

3. Change subjective interpretations (or “self-talk”), which perpetuate a state of apprehension and worry 

Anxiety can appear in different forms and at different levels of intensity. It can range in severity from a mere twinge of uneasiness to a full-blown panic attack marked by heart palpitations, disorientation, and terror. Anxiety that is not connected with any particular situation, that comes “out of the blue,” is called free-floating anxiety or, in more severe instances, a spontaneous panic attack. The difference between an episode of free-floating anxiety and a spontaneous panic attack can be defined by whether you experience four or more of the following symptoms at the same time (the occurrence of four or more symptoms defines a panic attack):

• Shortness of breath 
• Heart palpitations (rapid or irregular heartbeat) 
• Trembling or shaking 
• Sweating 
• Choking 
• Nausea or abdominal distress 
• Numbness 
• Dizziness or unsteadiness 
• Feeling of detachment or being out of touch with yourself 
• Hot flashes or chills 
• Fear of dying 
• Fear of going crazy or out of control

If your anxiety arises only in response to a specific situation, it is called situational anxiety or phobic anxiety. Situational anxiety is different from everyday fear in that it tends to be out of proportion or unrealistic. If you have a disproportionate apprehension about driving on freeways, going to the doctor, or confronting your spouse, this may qualify as situational anxiety.
Situational anxiety becomes phobic when you actually start to avoid the situation: if you give up driving on freeways, going to doctors, or confronting your spouse altogether. In other words, phobic anxiety is situational anxiety that includes persistent avoidance of the situation.
Often anxiety can be brought on merely by thinking about a particular situation. When you feel distressed about what might happen when or if you have to face one of your phobic situations, you are experiencing what is called anticipatory anxiety. In its milder forms, anticipatory anxiety is indistinguishable from ordinary “worrying.” But sometimes anticipatory anxiety becomes intense enough to be called anticipatory panic.
There is an important difference between spontaneous anxiety (or panic) and anticipatory anxiety (or panic). Spontaneous anxiety tends to come out of the blue, peaks to a high level very rapidly, and then subsides gradually. The peak is usually reached within five minutes, followed by a gradual tapering-off period of an hour or more. Anticipatory anxiety, on the other hand, tends to build up more gradually in response to encountering—or simply thinking about—a threatening situation and then usually falls off quickly. You may “worry yourself into a frenzy” about something for an hour or more and then let go of the worry as you find something else to occupy your mind.

Anxiety vs. Anxiety Disorders

Anxiety is an inevitable part of life in contemporary society. It’s important to realize that there are many situations that come up in everyday life in which it is appropriate and reasonable to react with some anxiety. If you didn’t feel any anxiety in response to everyday challenges involving potential loss or failure, something would be wrong. This workbook can be of use to anyone experiencing normal, ordinary anxiety reactions (everyone, in other words). It is also intended for those of you who are dealing with specific anxiety disorders. Incorporating exercise, breathing skills, relaxation, and good nutritional habits into your daily life—as well as paying attention to self-talk, mistaken beliefs, feelings, assertiveness, and self-esteem can all contribute to making your life more balanced and less anxious, regardless of the nature and extent of the anxiety you happen to be dealing with.

Anxiety disorders are distinguished from everyday, normal anxiety in that they involve anxiety that: 
1) is more intense (for example, panic attacks),
2) lasts longer (anxiety that may persist for months or longer instead of going away after a stressful situation has passed), or 
3) leads to phobias that interfere with your life.

Next, we are going to talk about some forms of anxiety disorders: (Refer the book for in-depth details about each disorder)

1: Selective mutism 

Selective mutism is a severe anxiety disorder where a person is unable to speak in certain social situations, such as with classmates at school or to relatives they do not see very often. It usually starts during childhood and, if left untreated, can persist into adulthood.

2: Panic Disorder 

Panic disorder is characterized by sudden episodes of acute apprehension or intense fear that occur “out of the blue,” without any apparent cause. Intense panic usually lasts no more than a few minutes, but, in rare instances, can return in “waves” for a period of up to two hours.

Diagnosis: A diagnosis of panic disorder is made only after possible medical causes—including hypoglycemia, hyperthyroidism, reaction to excess caffeine, or withdrawal from alcohol, tranquilizers, or sedatives—have been ruled out. The causes of panic disorder involve a combination of heredity, chemical imbalances in the brain, and recent personal stress. Sudden losses or major life changes may trigger the onset of panic attacks.

Panic disorder is in part influenced by excessive activity in parts of the brain known as the amygdala and the hypothalamus.

Some statistics:  People tend to develop panic disorder during late adolescence or in their twenties. About half of the people who have panic disorder develop it before the age of twenty-four.
In about a third of cases, panic is complicated by the development of agoraphobia (as described in the following section). Between 2 and 3 percent of the population have “pure” panic disorder, while about 5 percent, or one in every twenty people, suffer from panic attacks complicated by agoraphobia.
Very few individuals develop panic disorder in childhood or after the age of sixty-five.
Women are about twice as likely as men to develop panic disorder. White Americans are more likely to be diagnosed with panic disorder than other ethnic groups.

Cigarette smoking increases the risk of panic disorder. About 30 percent of people with panic disorder use alcohol to self-medicate which often worsens their symptoms when the effects of alcohol wear off. Cannabis often precipitates panic in some people. About one-fourth of individuals who have panic attacks will have an occasional nocturnal panic attack (panic upon awakening from sleep).

Current Treatments: Relaxation Training, Panic-Control Therapy, Interoceptive Exposure, Medication, Lifestyle and Personality Changes

3: Agoraphobia

The word agoraphobia means fear of open spaces; however, the essence of agoraphobia is a fear of panic attacks. If you suffer from agoraphobia, you are afraid of being in situations from which escape might be difficult—or in which help might be unavailable—if you suddenly had a panic attack. You may avoid grocery stores or freeways, for example, not so much because of their inherent characteristics but because these are situations from which escape might be difficult or embarrassing in the event of panic. Fear of embarrassment plays a key role. Most agoraphobics fear not only having panic attacks but what other people will think should they be seen having a panic attack.

If you have agoraphobia, you are not only phobic about a variety of situations but tend to be anxious much of the time. This anxiety arises from anticipating that you might be stuck in a situation in which you would panic. What would happen, for example, if you were asked to go somewhere you ordinarily avoid and have to explain your way out of it? Or what would happen if you suddenly were left alone? Because of the severe restrictions in your activities and life, you may also be depressed. Depression arises from feeling in the grip of a condition over which you have no control or that you are powerless to change.

Just why some people with panic attacks develop agoraphobia and others do not is unknown at this time. (There are a few people who develop only agoraphobia without any panic attacks.) Nor is it understood why some people develop much more severe cases than others. What is known is that agoraphobia is caused by a combination of heredity and environment. Agoraphobics may have a parent, sibling, or other relative who also has the problem. When one identical twin is agoraphobic, the other has a high likelihood of being agoraphobic, too. On the environmental side, there are certain types of childhood circumstances that predispose a child to agoraphobia. These include growing up with parents who are:

1) perfectionist and overcritical,

2) overprotective, and/ or

3) overly anxious to the point of communicating to their child that the world is a “dangerous place.”

Agoraphobia affects people in all walks of life and at all levels of the socioeconomic scale. About 2 percent of adults and adolescents in the United States suffer from agoraphobia at any given time. Approximately 80 percent of agoraphobics are women, although this percentage has been dropping recently. It is possible to speculate that as women are increasingly expected to hold down full-time jobs (making a housebound lifestyle less socially acceptable), the percentage of women and men with agoraphobia may tend to equalize.

Agoraphobia has a higher risk of occurring in late adolescence and young adulthood. A second period of higher risk occurs later in life, after the age of forty. Unfortunately, agoraphobia tends to be a chronic and recurrent condition unless properly treated. Complete remission without treatment is rare, approximately only 10 percent.

Current Treatments: Relaxation Training, Panic Control Therapy, and Interoceptive Exposure, Exposure, Cognitive Therapy, Medication, Assertiveness Training, Group Therapy

4: Social Anxiety Disorder 

Social anxiety disorder (also known as social phobia) is one of the more common anxiety disorders.
It involves fear of embarrassment or humiliation in situations where you are exposed to the scrutiny of others or you must perform. This fear is much stronger than the normal anxiety most nonphobic people experience in social or performance situations. Usually it’s so strong that it causes you to avoid the situation altogether, although some people with social phobia endure social situations, albeit with considerable anxiety. Typically, your concern is that you will say or do something that will cause others to judge you as being anxious, weak, “crazy,” or stupid. This includes merely showing physical symptoms of anxiety, such as blushing or sweating.
Your concern is generally out of proportion with the situation, and you recognize that it’s excessive (children with social phobia, however, do not recognize the excessiveness of their fear).
To be diagnosed with social anxiety disorder, the fear must have been persistent for at least six months. Social anxiety disorder is associated with increased likelihood of dropping out of school, decreased satisfaction and productivity in the workplace, lower socioeconomic status, and generally poorer quality of life.

The most common social phobia is fear of public speaking. In fact, this is the most common of all phobias, affecting performers, speakers, people whose jobs require them to make presentations, and students who have to speak before their class. Public-speaking phobia affects a large percentage of the population and is equally prevalent among men and women.

Sometimes social phobia is less specific and involves a generalized fear of any social or group situation where you feel that you might be watched or evaluated. When your fear is of a wide range of social situations (for example, initiating conversations, participating in small groups, speaking to authority figures, dating, attending parties, and so on), the condition is referred to as generalized social phobia.

Common symptoms of social anxiety disorder include blushing, sweating, trembling, heart palpitations, and nausea. Many people who are unaware that they are socially phobic use alcohol to reduce these symptoms, which, in some cases, can lead to alcoholism. While social anxieties are common, you would be given a formal diagnosis of social phobia only if your avoidance interferes with work, social activities, or important relationships, and/or if it causes you considerable distress. As with agoraphobia, panic attacks can accompany social phobia, although your panic is related more to being embarrassed or humiliated than to being confined or trapped. Also, the panic arises only in connection with a specific type of social situation.

Social phobias tend to develop earlier than agoraphobia and can begin in late childhood or adolescence, often between ages eight and fifteen. They often develop in shy children around the time they are faced with increased peer pressure at school. Typically, these phobias persist (without treatment) through adolescence and young adulthood but have a tendency to decrease in severity later in life. Social phobia affects between 3 and 7 percent of the US population and may be more prevalent among women than men. However, gender rates for clinical samples are higher for men than for women. Though job parity for men and women is increasing, men still seek out treatment more frequently than women because of their jobs. Up to 14 percent of adults experience social phobia at some time in their lives.

A significant percentage of people with social anxiety disorder are clinically depressed, have another anxiety disorder such as panic disorder or generalized anxiety disorder, or are dealing with substance abuse. Up to 50 percent of people with social anxiety disorder may experience spontaneous remission within two to three years; the other 50 percent can continue to experience symptoms for much longer without treatment.

As with other anxiety disorders, there are both genetic and environmental components in the causes of social anxiety disorder. If one identical twin has the problem, the other twin is 30 to 50 percent more likely to have the problem. Heritability among first-degree relatives is five to six times higher than among unrelated people. At the same time, social anxiety in adoptive parents is significantly correlated with social anxiety in their children (Kendler, Karkowski, and Prescott 1999).

Current Treatments: Relaxation Training, Cognitive Therapy, Exposure, Staying on Task, Medication, Social Skills Training, Assertiveness Training

5: Specific Phobia 

A specific phobia typically involves a strong fear and avoidance of one particular type of object or situation. There are no spontaneous panic attacks, and there is no fear of panic attacks, as in agoraphobia.
There is also no fear of humiliation or embarrassment in social situations, as in social phobia. Direct exposure to the feared object or situation may elicit a panic reaction, however.
With specific phobia, fear is always out of proportion to the realistic danger posed by the object or situation. Typically, the fear and avoidance are strong enough to interfere with your normal routines, work, or relationships and to cause you significant distress for a period of six months or longer. Even though you recognize its irrationalities, a specific phobia can cause you considerable anxiety.
Among the most common specific phobias are the following:

Animal Phobias, Acrophobia (fear of heights), Elevator Phobia, Airplane Phobia, Doctor or Dentist Phobias, Phobias of Thunder and/or Lightning, Blood-Injury Phobia, Disease Phobia (hypochondria)

Specific phobias are common and affect approximately 10 percent of the population (rates go as high as 16 percent among adolescents). However, since they do not always result in severe impairment, only a minority of people with specific phobias actually seek treatment. Most types of phobias occur in men and women about equally. Animal phobias tend to be more common in women, while disease phobias are more common in men. In general, women are twice as likely to report specific phobias as men, but this may reflect a difference in who seeks treatment. As previously mentioned, specific phobias are often childhood fears that were never outgrown.

In other instances, they may develop after a traumatic event, such as an accident, a natural disaster, an illness, or a visit to the dentist—in other words, as a result of conditioning. A final cause is childhood modeling. Repeated observation of a parent with a specific phobia can lead a child to develop it as well.

Current Treatments: Relaxation Training, Cognitive Therapy, Exposure, Virtual Reality Exposure Therapy

6: Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is characterized by chronic anxiety that persists for at least six months but is unaccompanied by panic attacks, phobias, or obsessions. You simply experience persistent anxiety and worry without the complicating features of other anxiety disorders. To be given a diagnosis of generalized anxiety disorder, your anxiety and worry must focus on two or more stressful life circumstances (such as finances, relationships, health, work problems, or school performance) for a majority of days during a six-month period. It’s common, if you’re dealing with generalized anxiety disorder, to have a large number of worries and to spend a lot of your time worrying. Yet you find it difficult to exercise much control over your worrying. Moreover, the intensity and frequency of the worry are always out of proportion to the actual likelihood of the feared events happening.

In addition to frequent, hard-to-control worry, generalized anxiety disorder involves having at least three of the following six symptoms (with some symptoms present more days than not over the past six months):

• Tension—feeling keyed up 
• Being easily fatigued 
• Difficulty concentrating 
• Irritability 
• Muscle tightness 
• Difficulties with sleep

Generalized anxiety disorder is frequently associated with physical symptoms such as tension headaches, irritable bowel syndrome, high blood pressure, insomnia, and even osteoporosis.
However, the presence of any or all of these physical problems does not necessarily imply a diagnosis of generalized anxiety disorder, which is based primarily on the presence of ongoing worry.
You are likely to receive a diagnosis of generalized anxiety disorder if your worry and associated symptoms cause you significant distress and/or interfere with your ability to function occupationally, socially, or in other important areas.
If a doctor tells you that you suffer from generalized anxiety disorder, he or she has probably ruled out possible medical causes of chronic anxiety, such as hyperventilation, thyroid problems, or drug-induced anxiety (alcohol or benzodiazepine withdrawal). Generalized anxiety disorder often occurs together with depression, a condition sometimes referred to as “mixed anxiety-depressive disorder.” In such instances, a careful history will usually reveal which disorder—the generalized anxiety or the depression—came first.

Generalized anxiety disorder can develop at any age. In children and adolescents, the focus of worry often tends to be on performance in school or sports events. In adults, the focus can vary but is usually a common theme like finances, health, or job responsibilities. At any given time, about 4 percent of adults experience generalized anxiety disorder; a total of 9 percent experience it over their entire lifespan. Women are approximately twice as likely to experience the disorder as men. People of European decent are more likely to develop GAD than those of non-European decent.
Although there are no specific phobias associated with generalized anxiety disorder, one view propounded by Aaron Beck and Gary Emery suggests that the disorder is sustained by “basic fears” of a broader nature than specific phobias, such as

• Fear of losing control 
• Fear of not being able to cope 
• Fear of failure 
• Fear of rejection or abandonment 
• Fear of death and disease

Generalized anxiety disorder can be aggravated by any stressful situation that elicits these fears, such as increased demands for performance, intensified marital conflict, physical illness, or any situation that heightens your perception of danger or threat.
The underlying causes of generalized anxiety disorder are unknown. It is likely to involve a combination of heredity, neurobiology, and predisposing childhood experiences, such as excessive parental expectations, parental abandonment and rejection, or parents modeling worry behavior.

Current Treatments: Relaxation Training, Cognitive Therapy, Worry Exposure, Reducing Worry Behaviors, Problem Solving, Distraction, Medication, Mindfulness Practice, Lifestyle and Personality Changes

7: Obsessive-Compulsive Disorder

In the new DSM–5 formulation of psychiatric disorders, obsessive-compulsive disorder (OCD) is described in a separate chapter of its own apart from other anxiety disorders. It is listed with other OC spectrum disorders, such as body dysmorphic disorder (distorted perception of one’s body), trichotillomania (hair-pulling disorder), hoarding disorder, excoriation (skin-picking disorder), and substance/medication-induced obsessive-compulsive disorder.

The placement of obsessive-compulsive disorder in a new chapter of its own is based on both grouping OCD with its associated spectrum disorders as well as certain neurobiological differences in the causes of OCD (and spectrum disorders) from other anxiety disorders.

Some people naturally tend to be more neat, tidy, and orderly than others. These traits can be useful in many situations, both at work and at home. In obsessive-compulsive disorder, however, they are carried to an extreme and disruptive degree. Obsessive-compulsive people can spend many hours cleaning, tidying, checking, or ordering, to the point that these activities interfere with the rest of the business of their lives.

Obsessions are recurring ideas, thoughts, images, or impulses that seem senseless but nonetheless continue to intrude into your mind. Examples include images of violence, thoughts of doing violence to someone else, or fears of leaving on lights or the stove or leaving your door unlocked. You recognize that these thoughts or fears are irrational and you try to suppress them, but they continue to intrude into your mind for hours, days, weeks, or longer. These thoughts or images are not merely excessive worries about real-life problems and are usually unrelated to any real-life problems.

Compulsions are behaviors or rituals that you perform to dispel the anxiety brought up by obsessions. For example, you may wash your hands numerous times to dispel a fear of being contaminated, check the stove again and again to see if it is turned off, or look continually in your rearview mirror while driving to assuage anxiety about having hit somebody. You realize that these rituals are unreasonable, yet you feel compelled to perform them to ward off the anxiety associated with your particular obsession. The conflict between your wish to be free of the compulsive ritual and the irresistible desire to perform it is a source of anxiety, shame, and even despair. Eventually, you may cease struggling with your compulsions and give over to them entirely.

Obsessions may occur by themselves, without necessarily being accompanied by compulsions.
In fact, about 20 percent of the people who suffer from obsessive-compulsive disorder only have obsessions, and these often center around fears of causing harm to a loved one or having disquieting sexual thoughts.

The most common compulsions include washing, checking, and counting. If you are a washer, you are constantly concerned about avoiding contamination. You avoid touching doorknobs, shaking hands, or coming into contact with any object you associate with germs, filth, or a toxic substance. You can spend literally hours washing hands or showering to reduce anxiety about being contaminated. Women more often have this compulsion than men. Men outnumber women as checkers, however. Doors have to be repeatedly checked to dispel obsessions about being robbed; stoves are repeatedly checked to dispel obsessions about starting a fire; or roads are repeatedly checked to dispel obsessions about having hit someone. In the counting compulsion, you must count up to a certain number or repeat a word a certain number of times to dispel anxiety about harm befalling you or someone else.

Obsessive-compulsive disorder is often accompanied by depression. Preoccupation with obsessions, in fact, tends to wax and wane with depression. This disorder is also typically accompanied by phobic avoidance—such as when a person with an obsession about dirt or germs avoids public restrooms or touching doorknobs. Sometimes avoidance interferes with the person’s social or occupational functioning.

It is very important to realize that as bizarre as obsessive-compulsive behavior may sound, it has nothing to do with “being crazy.” You usually recognize the irrationality and senselessness of your thoughts and behavior, and you are very frustrated (as well as depressed) about your inability to control them.

Obsessive-compulsive disorder is different from compulsive behavior disorders such as gambling and overeating. People with compulsive behavior disorders derive some pleasure from their compulsive activities, whereas people with OCD neither want to perform their compulsions (except to reduce fear) nor derive any pleasure from doing so. In the new DSM–5, there are diagnostic specifiers to indicate the few people who have little or no insight into their OCD beliefs as being illogical.

Obsessive-compulsive disorder used to be considered a rare behavior disturbance. However, recent studies have shown that about 2 to 3 percent of the general population may suffer, to varying degrees, from obsessive-compulsive disorder. The reason prevalence rates have been underestimated up to now is that most sufferers have been very reluctant to tell anyone about their problem. Women seem to be affected slightly more than men, but boys are more commonly affected in childhood than girls. The average age of onset of OCD is 19.5 years. Onset of symptoms is typically gradual. Without treatment, remission of OCD in adulthood is low, typically less than 20 percent. With effective treatment, partial to full recovery is possible in up to 60 percent of cases.

The causes of obsessive-compulsive disorder are unclear. There is some evidence that a deficiency of a neurotransmitter substance in the brain known as serotonin, or a disturbance in serotonin metabolism, is associated with the disorder. This is borne out by the fact that many sufferers improve when they take medications that increase brain serotonin levels, such as clomipramine (Anafranil) or specific serotonin-enhancing antidepressants. It also appears that persons with OCD have excessive activity in certain parts of the brain, such as the prefrontal cortex and the caudate nucleus. OCD has a high degree of heritability, with 57 percent of identical twins both showing symptoms of the disorder versus 22 percent of fraternal twins.

Current Treatments: Relaxation Training, Cognitive Therapy, Exposure and Response Prevention (ERP), Medication, Lifestyle and Personality Changes

8: Obsessive-Compulsive Spectrum Disorders

OC spectrum disorders share commonalities in their neurobiological basis with OCD. The OC spectrum disorders vary in their manifestation.
These are the most common OC spectrum disorders:

• Body dysmorphic disorder: a preoccupation with perceived flaws or defects in physical appearance

• Excoriation: recurrent skin picking (resulting in lesions) with repeated attempts to stop

• Hoarding disorder: a difficulty with discarding possessions that results in significant clutter in one’s personal living area

• Trichotillomania: a recurrent pulling out of one’s hair (resulting in noticeable hair loss) with repeated attempts to decrease or stop pulling

• Hypochondriasis: a preoccupation about having a serious illness with excessive attention to bodily symptoms that are taken as evidence of that illness

OC spectrum disorders have become a specialty area of their own and are typically treated bytherapists who specialize in OCD, and who adopt exposure and response prevention techniques to the specific OC spectrum disorder involved.

9: Trauma-and Stressor-Related Disorders

As is the case with obsessive-compulsive disorder, DSM–5 presents post-traumatic stress disorder (PTSD) in a chapter of its own. The chapter, entitled “Trauma-and Stressor-Related Disorders,” includes several other stress-related problems. This new chapter unifies all psychiatric disorders thought to arise in response to a traumatic or highly stressful event (or events). In addition to post-traumatic stress disorder, acute stress disorder refers to the same constellation of symptoms as PTSD (including intrusive memories of the trauma, distressing dreams or nightmares, flashbacks, and dissociative symptoms such as depersonalization), except that these symptoms are apparent three days to one month following the initial stressor. When these symptoms persist past one month, a diagnosis of post-traumatic stress disorder is deemed appropriate.

% Flashbacks are psychological phenomena during which a person relives a past event or fragments of a past experience. They generally occur involuntarily, abruptly entering an individual's awareness without the aid of premeditation or conscious attempts to recall the memory, and they may be intense.

% Depersonalization, in psychology, a state in which an individual feels that either he himself or the outside world is unreal.

% Intrusive memories are memories that let the person know that something bad is going to happen. So these memories could be identified as having functional significance, as they serve as a way to warn for future trauma events as well as function as a signal when the situation/symptoms may become worse. [Ref: Counselling.org]

The DSM–5 chapter also includes the diagnostic category of adjustment disorders. The distinguishing characteristic of adjustment disorders is that they consist of a group of maladaptive symptoms following within three months of a significant life stressor. However, the symptoms are not in the same range or severity as PTSD symptoms, yet they do include marked distress out of proportion to the severity of the instigating stressor and impairment of social or occupational functioning. Adjustment disorders do not include dissociative symptoms such as depersonalization and derealization (see below), but they are specified in DSM–5 according to whether they include anxiety, depression, or mixed anxiety and depression.
Two other disorders affecting children under five years of age are mentioned in the chapter.
Reactive attachment disorder constitutes a pattern showing severe social withdrawal, and the child’s apparent lack of capacity to seek or respond to comfort when distressed. In contrast, disinhibited social engagement disorder reflects a pattern of behavior where the child approaches unfamiliar adults and fails to show normal social inhibition or reticence in doing so.

10: Post-Traumatic Stress Disorder 

The essential feature of post-traumatic stress disorder (PTSD) is the development of disabling psychological symptoms following a traumatic event. It was first identified during World War I, when soldiers were observed to suffer chronic anxiety, nightmares, and flashbacks for weeks, months, or even years following combat. This condition came to be known as “shell shock.”
Post-traumatic stress disorder can occur in anyone in the wake of a severe trauma outside the normal range of human experience. These are traumas that would produce intense fear, terror, and feelings of helplessness in anyone and include natural disasters, such as earthquakes or tornadoes; car or plane crashes; and rape, assault, or other violent crimes against you or your immediate family. It appears that the symptoms are more intense and longer lasting when the trauma is personal, as in rape or other violent crimes. Observation of someone else suffering a severe trauma can be sufficient to induce post-traumatic stress disorder. Even learning that a traumatic event has occurred to a close family member or significant other can be a source of trauma.
Among the variety of symptoms that can occur with post-traumatic stress disorder, the following nine are particularly common:

• Repetitive, distressing thoughts about the event, often intrusive and unwanted

• Nightmares related to the event

• Flashbacks so intense that you feel or act as though the trauma were occurring all over again

• An attempt to avoid thoughts or feelings associated with the trauma

• An attempt to avoid activities or external situations associated with the trauma—such as developing a phobia about driving after you have been in an auto accident

• Emotional numbness—being out of touch with your feelings

• Losing interest in activities that used to give you pleasure

• Persistent symptoms of increased anxiety, such as difficulty falling or staying asleep, difficulty concentrating, startling easily, or irritability and outbursts of anger

• Exaggerated negative beliefs such as “I’m ruined” or “Nobody can be trusted”

For you to receive a diagnosis of post-traumatic stress disorder, these symptoms need to have persisted for at least one month (with less than one month’s duration, the appropriate diagnosis is acute stress disorder). In addition, the disturbance must be causing you significant distress, interfering with social, vocational, or other important areas of your life. In DSM–5, PTSD can be diagnosed on the basis of the above symptom profile, or with the addition of dissociative symptoms such as depersonalization or derealization. Depersonalization is a sense of detachment from yourself, as though you are an outside observer of your own mental processes or body. Derealization is the perception of unreality, with your entire surroundings appearing unreal, dream-like, or distant. If you suffer from post-traumatic stress disorder, you tend to be anxious and depressed.

Sometimes you will find yourself acting impulsively, suddenly changing residence or going on a trip with hardly any plans. If you have been through a trauma where others around you died, you may suffer from guilt about having survived.

Post-traumatic stress disorder can occur at any age and affects about 9 percent of the population at some time in their life. Children with the disorder tend not to relive the trauma consciously but continually reenact it in their play or in distressing dreams. The highest rates of PTSD are found among survivors of rape, military combat, or ethnically motivated confinement and/or persecution. The onset of full-spectrum PTSD can be delayed by months or even years; however, at least some symptoms are typically evident one week to three months following the traumatic event.

There is some evidence that susceptibility to post-traumatic stress disorder is hereditary. For identical twins exposed to combat in Vietnam, if one identical twin developed the disorder, the odds were higher that the other identical twin would, as compared with fraternal twins.

Current Treatments: Relaxation Training, Cognitive Therapy, Exposure Therapy, Imagery Rescripting, Medication, Support Groups, EMDR (Eye-movement desensitization and reprocessing) or Hypnotherapy

The chapter next presents a self-diagnosis questionnaire IN THE BOOK that you can use for yourself.

Co-Occurrence of Anxiety Disorders

In the years that have passed since the first edition of The Anxiety & Phobia Workbook was published, it has become increasingly apparent that many people are dealing with more than one anxiety disorder. For example, one survey of people with panic disorder found that 15 to 30 percent also have social phobia, 10 to 20 percent have a specific phobia, 25 percent have generalized anxiety disorder, and 8 to 10 percent have obsessive-compulsive disorder. People with agoraphobia quite often have social phobias and/or obsessive-compulsive difficulties. If you find that your particular condition fits the description for more than one anxiety disorder, you are not alone.

Ch 2: Major Causes of Anxiety Disorders

The symptoms of anxiety disorders often seem irrational and inexplicable: it is only natural to raise the question “Why?” But before considering in detail the various causes of anxiety disorders, there are two general points you should bear in mind. First, although learning about the causes of anxiety disorders can give you insight into how these problems develop, such knowledge is not necessary to overcome your particular difficulty. The various strategies for overcoming anxiety disorders presented in this workbook—such as relaxation, exercise, exposure, changing self-talk and mistaken beliefs, or dealing with feelings—do not depend on a knowledge of underlying causes to be effective. However interesting the information in this chapter may be, it is not necessarily what “cures.” Second, be wary of the notion that there is one primary cause, or type of cause, for any of the anxiety disorders. Whether you are dealing with panic attacks, social phobia, generalized anxiety, or obsessive-compulsive disorder, recognize that there is no one cause which, if removed, would eliminate the problem. Anxiety problems are brought about by a variety of causes operating on numerous different levels: heredity, biology, family background and upbringing, conditioning, recent stressors, your self-talk and personal belief system, your ability to express feelings, and so on. The range of chapters in this book indicates the many different levels on which you can understand the causes of and the means of recovering from anxiety disorders.

Some experts in the field of anxiety disorders propose “single-cause” theories. Such theories tend to greatly oversimplify anxiety disorders and are susceptible to one of two mistaken lines of reasoning: the biological fallacy and the psychological fallacy. The biological fallacy assumes that a particular type of anxiety disorder is caused solely by some biological or physiological imbalance in the brain or body. For example, there has recently been a tendency to reduce the causation of panic disorder, as well as obsessive-compulsive disorder, to a strictly biological level.
Panic disorder is viewed as arising from a dysfunction in parts of the brain, such as the amygdala and the locus coeruleus. Obsessive-compulsive disorder is thought to be caused by a deficiency in a particular neurotransmitter substance in the brain called serotonin—or a dysregulation in the serotonin system of neurons in the brain. (A neurotransmitter is a chemical substance that allows nerve impulses to be transmitted from one nerve cell to another.)

It is helpful to know that there may be physiological dysfunctions involved in panic disorder and obsessive-compulsive disorder. This certainly has implications for treatment of these problems.
But this does not mean that panic attacks and obsessive-compulsive disorder are physiological disturbances only. The question remains: What caused the physiological disturbance itself? Perhaps chronic stress due to psychological conflict causes the amygdala and locus coeruleus to malfunction in panic disorder. Or perhaps chronically suppressed anger sets up a disturbance in brain serotonin levels that is a contributing cause of obsessive-compulsive disorder. Psychological conflicts and repressed anger may, in turn, have been caused by a person’s upbringing. Because any particular physiological disturbance may have originally been set up by stress or other psychological factors, it is a fallacy to assume that anxiety disorders are solely (or even primarily) caused by physiological imbalances.
The psychological fallacy makes the same kind of mistake in the opposite direction. It assumes that, say, social phobia or generalized anxiety disorder is caused by having grown up with parents who neglected, abandoned, or abused you, resulting in a deep-seated sense of insecurity or shame that causes your current phobic avoidance and anxiety as an adult. While it may be true that your family background contributed in an important way to your current problems, is it reasonable to assume that this is the only cause? Again, not really. To do so overlooks the possible contributions of hereditary and biological factors. After all, not all children who grow up in dysfunctional families develop anxiety disorders. It is more plausible to assume that your problem is a result of both 1) a hereditary predisposition toward anxiety (and possibly phobia) and 2) early childhood conditions that fostered a sense of shame and/or insecurity.
In sum, the idea that your particular difficulties are just a physiological disturbance or just a psychological disturbance neglects the fact that nature and nurture are interactive. Biological disturbances may be “set up” by stress or psychological factors; psychological problems, in turn, may be influenced by inborn biological disturbances. There is simply no way to say which came first or which is the so-called “ultimate” cause. By the same token, a comprehensive approach to recovery from panic, phobias, or anxiety cannot restrict itself to treating physiological or psychological causes in isolation. A variety of strategies dealing with several different levels, including biological, behavioral, emotional, mental, interpersonal, and even spiritual factors, is necessary for a full and lasting recovery. This multidimensional approach to recovery is discussed in the next chapter and assumed throughout this book.
The causes of anxiety disorders vary not only according to the level at which they occur but also according to the time period over which they operate. Some are predisposing causes, which set you up from birth or childhood to develop panic or anxiety later on. Some are recent or short-term causes — circumstances that trigger the onset of, say, panic attacks or agoraphobia. Others are maintaining causes—factors in your current lifestyle, attitudes, and behavior that serve to keep anxiety disorders going once they have developed. The remainder of this chapter examines each of these types of causes in more detail. A section on biological causes is included to acquaint you with some of the better-known hypotheses about the role of the brain in causing panic attacks and anxiety.
An outline of the causes of anxiety disorders follows.

Causes of Anxiety Disorders Long-Term, Predisposing Causes 

1. Heredity

2. Childhood Circumstances 
• Your Parents Communicate an Overly Cautious View of the World 
• Your Parents Are Overly Critical and Set Excessively High Standards 
• Emotional Insecurity and Dependence 
• Your Parents Suppress Your Expression of Feelings and Self-Assertiveness

3. Cumulative Stress over Time

Biological Causes 

1. The Physiology of Panic 
2. Panic Attacks 
3. Generalized Anxiety 
4. Obsessive-Compulsive Disorder 
5. Medical Conditions That Can Cause Panic Attacks or Anxiety

Short-Term, Triggering Causes 

1. Stressors That Precipitate Panic Attacks 
• Significant Personal Loss 
• Significant Life Change 
• Stimulants and Recreational Drugs 

2. Conditioning and the Origin of Phobias 

3. Trauma, Simple Phobias, and Post-Traumatic Stress Disorder

Maintaining Causes 

1. Avoidance of Phobic Situations 

2. Anxious Self-Talk 

3. Mistaken Beliefs 

4. Withheld Feelings 

5. Lack of Assertiveness 

6. Lack of Self-Nurturing Skills 

7. Muscle Tension 

8. Stimulants and Other Dietary Factors 

9. High-Stress Lifestyle 

10. Lack of Meaning or Sense of Purpose

% The chapter next presents a 'Family Background Questionnaire' in the book.

% Life Events Survey (also known as The Social Readjustment Scale) to assess the number and severity of life events that occur in a two-year period.

% It is likely then that genes, cumulative stress, and childhood circumstances all contribute to the genesis of a particular anxiety disorder, as suggested in this diagram: 


Panic Attacks And Anatomy of Brain 

Your brain is by far the most complex system in your body, consisting of over one hundred billion brain cells or neurons. At any given moment in time, millions of nerve impulses are being transmitted along multiple pathways which interconnect various regions of your brain.
Every time a single nerve impulse moves from one nerve cell to the next, it must cross a space.
Individual nerve cells are not connected but are separated by tiny spaces called synapses. It has been known for some time that the process by which a nerve impulse moves across a synapse is chemical in nature. Microscopic amounts of chemicals secreted into the synapse allow transmission of a nerve impulse from one neuron to the next. These chemicals are called neurotransmitters; there are over twenty different types of them in the brain.
It appears that there are different systems in the brain that are especially sensitive to particular neurotransmitters. Each system consists of a vast network of nerve cells (neurons) that are sensitive to a particular neurotransmitter. One system, called the noradrenergic system, seems to be especially sensitive to a neurotransmitter substance called norepinephrine. Another system, the serotonergic system, contains neurons especially sensitive to a neurotransmitter substance called serotonin. Yet another system, the glutamatergic system, is especially sensitive to the stimulating neurotransmitter glutamate. These three systems have a large number of receptor sites (sites on nerve cells that respond to neurotransmitters) in some of the major structures of the brain that are activated during a panic attack. Specifically, the amygdala—a structure in your brain—is thought to play a key role in instigating panic. Research has found that the amygdala does not act alone but works in concert with a variety of other structures that all contribute to stimulating panic.
These structures include “higher” brain centers such as the prefrontal cortex and insula, which serve to modulate sensory information, interpreting it as “dangerous” or “safe.” Such information is stored in memory in a part of the brain called the hippocampus. The higher brain centers and the hippocampus interface directly with the amygdala. The amygdala, in turn, instigates panic by stimulating a variety of other brain structures, including 1) the locus coeruleus, which contributes to general behavioral and physiological arousal, 2) the hypothalamus, which regulates the release of adrenaline (via the pituitary gland, stimulating your adrenal glands) and also stimulates your sympathetic nervous system (see the previous section), 3) the periaqueductal gray region, which stimulates defensive and avoidance behavior, and, finally, 4) the parabrachial nucleus, which stimulates increased respiration.
Within your brain, panic attacks are more likely to occur when this entire system is overly sensitized, perhaps from having been previously activated too frequently, too intensely, or both.
Thus the neurological basis for panic is not exactly a “chemical imbalance,” as your doctor may have told you, but an overly sensitized “fear system,” including all of the above brain structures.
Researchers believe that deficiencies of the neurotransmitters serotonin and norepinephrine may contribute to insufficient inhibition of the amygdala, locus coeruleus, and associated structures that make up this fear system. That is why SSRI antidepressants and SNRI antidepressants that affect the metabolism of serotonin and/or norepinephrine available throughout your brain can diminish panic attacks (as well as other anxiety disorders). An older class of antidepressants, the tricyclic antidepressants, can also be effective in reducing the symptoms of anxiety disorders. (See chapter 17 for further information on these various types of antidepressant medications.) Over a period of two to four weeks, these medications seem to be able to stabilize and desensitize an overly sensitized amygdala, locus coeruleus, and associated fear system.
What causes the original oversensitization of the fear system remains unclear at this time. One hypothesis is that changes in this system can take place as a result of acute stress or as the long-term result of multiple stressors over time. Although this hypothesis remains unproven, it seems likely that cumulative stress contributes in an important way to the onset of panic attacks. If this hypothesis about stress altering the amygdala and the fear system turns out to be true, an important implication follows: the most effective long-term treatment for brain dysfunctions associated with panic disorder is a consistent and comprehensive program for reducing stress in your life. Medications can certainly help restabilize structures in your brain that contribute to panic and anxiety in the short run. Yet without changes in your lifestyle, such as regular relaxation and exercise, good time management, proper nutrition, personal support, and constructive attitudes—changes that allow you to live more simply and peacefully—panic and anxiety will tend to return after the medications are withdrawn.

An additional hypothesis for the causation of panic attacks has to do with the prefrontal cortex. This is a “higher” cortical brain center that comes into play after the amygdala surges with sudden fear in response to a potential threat. The prefrontal cortex helps you to evaluate your environment to see whether a legitimate threat really exists or not. If no threat appears to exist, the prefrontal cortex exerts a “top down” influence on the amygdala so that you can dismiss the potential threat and not continue further into panic. It is believed that this link between the prefrontal cortex and amygdala may be impaired in people prone to panic disorder. That is, the prefrontal cortex fails to adequately tone down the amygdala, allowing fear to continue to gain momentum until a full-blown panic attack occurs.

Anxious Self-Talk

Self-talk is what you say to yourself in your own mind. It is the internal monologue that you engage in much of the time, although it may be so automatic and subtle that you don’t notice it unless you step back and pay attention. Much of your anxiety is created by statements you make to yourself beginning with the words “what if”—for example, “What if I have another panic attack?” “What if I lose control of myself while driving?” “What will people think if I get anxious while standing in line?” This type of self-talk anticipates the worst before it even happens. The more common term for it is simply worry.
Self-talk can also contribute to creating a full-blown panic attack. Such an attack may start off with bodily symptoms such as tightness in the chest and heart palpitations. If you can accept and “flow with” these symptoms without letting them scare you, they will soon peak and then subside. However, all too often you tell yourself such things as “Oh no—I’m going to panic!”

“What if I have a heart attack?” “I’ve got to get out of here, but I can’t!” “People will think I’m weird if I have to rest or lean on something for a minute because my legs feel weak.” This scare-talk only aggravates the physical symptoms, which in turn produce even more extreme scare-talk, leading to a vicious circle that produces a full-blown panic attack.

The good news is that you can learn to recognize anxiety-provoking self-talk, stop it, and replace it with more supportive and calming statements to yourself.

Ch 3: Recovery: A Comprehensive Approach 

Heredity, physiological imbalances in the brain, childhood deprivation and faulty parenting, and the cumulative effect of stress over time can all work to bring about the onset of panic attacks, agoraphobia, or any of the other anxiety disorders. The maintaining causes of these disorders—what keeps them going—are many and varied as well. Such factors can operate at the level of your body (for example, shallow breathing, muscle tension, or poor nutrition), emotions (such as withheld feelings), behavior (avoidance of phobic situations), mind (anxious self-talk and mistaken beliefs), and “whole self” (such as low self-esteem or a lack of self-nurturing skills).

If the causes of anxiety disorders are so varied, then an adequate approach to recovery needs to be, too. It is the basic philosophy of this workbook that the most effective approach for treating panic, phobias, or any other problem with anxiety is one that addresses the full range of factors contributing to these conditions. This type of approach can be called “comprehensive.” It assumes that you can’t just give someone the “right” medication and expect panic or generalized anxiety to go away. Nor can you just deal with childhood deprivation, having someone work through the emotional consequences of bad parenting, and expect the problems to disappear. By the same token, you can’t just teach people new behaviors and new ways of talking to themselves and expect these things alone to resolve their problems. Some therapists still treat anxiety disorders solely as psychiatric conditions that can be “cured” by medication, or solely as childhood developmental problems, or solely as behavior problems; but the trend in recent years has been away from such single-gauged approaches. Many practitioners have discovered that problems with anxiety go away only temporarily when merely one or two contributing causes are dealt with.

Lasting recovery is achieved when you are willing to make basic and comprehensive changes in habit, attitude, and lifestyle.

This chapter outlines and illustrates a comprehensive approach to recovery that has evolved over the past twenty years. What makes this approach truly comprehensive is that it offers interventions addressing seven different levels of contributing causes. These levels are as follows:

• Physical 
• Emotional 
• Behavioral 
• Mental 
• Interpersonal 
• Whole Self 
• Existential and Spiritual

Physical Level:  
Physical-level causes include possible physiological imbalances in the brain and body. Such causes also include 
1) shallow breathing,
2) muscle tension,
3) bodily effects of cumulative stress, and 
4) nutritional and dietary factors (such as excess caffeine or sugar in your diet).

Emotional Level: 

Suppressed feelings—especially withheld anger—can be a very important contributing cause to both chronic anxiety and panic attacks. Often feelings of panic are merely a front for buried feelings of anger, frustration, grief, or desperation. Many people with anxiety disorders grew up in families that discouraged the expression of feelings. As an adult you may have difficulty just identifying what you are feeling, let alone expressing those feelings. Chapter 12 provides specific guidelines and strategies for:
• Recognizing symptoms of suppressed feelings 
• Identifying what you are feeling 
• Learning to express your feelings 
• Communicating your feelings to someone else

Behavioral Level: 

Phobias persist because of a single behavior: avoidance. As long as you avoid driving on freeways, crossing bridges, speaking in public, or being in your home alone, your fear about these situations will persist. Your phobia is maintained because your avoidance behavior is so well rewarded: you don’t have to reckon with the anxiety you’d experience if you confronted what you fear.

Mental Level:  What you say to yourself internally—what is called self-talk— has a major effect on your state of anxiety. People with all types of anxiety disorders tend to engage in excessive “what-if” thinking, imagining the worst possible outcome in advance of facing what they fear. Scaring yourself through what-if scenarios is what has traditionally been called “worry.” Self-critical thinking and perfectionist self-talk (statements to yourself that start with “I should,” “I have to,” or “I must”) also promote anxiety.

Beneath anxiety-provoking self-talk are mistaken beliefs about yourself, others, and the world that produce anxiety in very basic ways. For example, if you see yourself as inadequate compared to others—or view the outside world as a dangerous place—you’ll tend to remain anxious until you revise these basic attitudes.

Interpersonal Level 

Much of the anxiety people experience arises from difficulties in interpersonal relationships.
When you have difficulty communicating your real feelings and needs to others, you may find yourself swallowing frustration to the point where you’re chronically tense and anxious. The same is true when you’re unable to set limits or say no to unwanted demands or requests from others. Assertive communication provides ways to express what you want or don’t want in a manner that preserves respect for other people. Learning to be assertive is a very important part of the recovery process, especially if you’re dealing with agoraphobia or social phobia.
Being able to talk about your condition with others is also an important step in the recovery process.

“Whole Self” Level (Self-Esteem) 

Of all the contributing causes to anxiety disorders, low self-esteem is among the deepest. You may have grown up in a dysfunctional family, which, through various forms of deprivation, abuse, or neglect, fostered your low sense of self-worth. As a result, you may carry into adulthood deep-seated feelings of insecurity, shame, and inadequacy, which tend to show up, on a more noticeable level, as panic attacks, fear of confronting the outside world (agoraphobia), fear of humiliation (social phobia), or generalized anxiety. Frequently, low self-esteem is tied in with all of the various contributing causes described above—in particular, lack of assertiveness, self-critical or perfectionist self-talk, and difficulty expressing feelings.

There are many ways to build self-esteem. Developing a positive body image, working toward and achieving concrete goals, and countering negative self-talk with validating affirmations can all help. Many of my clients have found it particularly worthwhile to cultivate a relationship with their own inner child. The inner child is the part of you that is spontaneous and playful but also carries the insecurity, shame, or pain that may be left over from your childhood. It is quite possible to make up for the inadequate parenting you may have received by becoming a strong, nurturing parent to your own child within.

Existential and Spiritual Level 

Sometimes people can improve on all of the levels previously described and yet remain anxious and unsettled. They seem to have a vague sense of dissatisfaction, emptiness, or boredom about life, which can lead to panic or to chronic, generalized anxiety. Certain of my clients have found that the ultimate “solution” to their problem with anxiety was to find a broad purpose or direction that gave their life greater meaning. Frequently, this involved taking up a vocation that fulfilled their true talents and interests. In one case it involved developing an artistic talent that provided a creative outlet. Anxiety symptoms (as well as depression) can be the psyche’s way of pushing you to explore and actualize an unrealized potential in your life, whether this involves intellectual development, emotional development, or even getting more in touch with your body.
Instead of regarding your panic or phobias merely as a reaction to negative physical, emotional, or mental factors, you may be surprised to discover that they represent a call to realize your full potential.

For many individuals, a deep spiritual commitment and involvement provides a significant pathway to recovery from anxiety problems. Twelve-step programs have demonstrated the potency of spiritual awakening in the area of addictions—and the same is true for recovery from anxiety disorders. Developing a connection with a Higher Power (call it God, Spirit, or whatever you like) can provide a profound means for achieving inner security, strength, peace of mind, and an attitude that the outer world is a benevolent place.

Developing Your Own Recovery Program 

By this point, you’ve likely gained a better idea about three things: 
1) the wide range of strategies used in a comprehensive recovery program,
2) the specific types of strategies employed, and 
3) how such strategies are actually implemented in specific cases.

You can now begin to develop your own recovery program. The following two charts are designed to assist you with this. The first is the Problem Effectiveness Chart. It correlates different types of anxiety disorders with specific chapters in this workbook. Chapters that are particularly relevant for everyone with the disorder are marked with an “X.” Those chapters that are often relevant are marked with a lowercase “x.” Your choice of strategies will, of course, depend on the nature and causes of your particular difficulty. After reading the first three chapters of this workbook, you should have some idea of what strategies to emphasize.



Necessary Ingredients for Undertaking Your Own Recovery Program 

1. Taking Responsibility — In a Context of Support 

Do you feel responsible for your problem? Or do you attribute it to some quirk of heredity, abusive parents, or the stressful people in your life? Even if you feel you aren’t solely responsible for having created your disorder, you are the one who is ultimately responsible either for holding on to it or for doing something about it. It may be difficult initially to accept the idea that the decision is yours whether to maintain or whether to overcome your problem. Yet accepting full responsibility is the most empowering step you can take. If you are the one who keeps your condition going, you are also the one with the power to change and outgrow it.
Taking responsibility means you don’t blame anyone else for your difficulties. It also means that you don’t blame yourself. Is there truly any justification for blaming yourself that you have panic attacks, phobias, or obsessions and compulsions? Is it truly your fault that you developed these problems? Is it not more accurate to say that you’ve done the best you could in your life up to now with the knowledge and resources at your disposal? While it’s up to you to change your condition, there is simply no basis for judging or blaming yourself for having it.
And taking responsibility for overcoming your condition does not mean that you have to do it all alone. In fact, the opposite is true: you are more likely to be willing to change and to take risks when you feel adequately supported. A most important prerequisite for undertaking your own program for recovery is to have an adequate support system. This can include your spouse or partner, one or two close friends, and/or a support group or class specifically set up to assist people with anxiety disorders.

2. Motivation—Overcoming Secondary Gains 

Psychologist David Bakan once made the observation that “suffering is the great motivator of growth.” If you are experiencing considerable distress from your particular problem, you’re likely to be strongly motivated to do something about it. A basic belief in your self-worth can also be a strong motivation for change. If you love yourself enough to feel that you sincerely deserve to have a fulfilling and productive life, you simply won’t settle for being impeded by panic, phobias, or other anxiety symptoms. You will demand more of life than that.
This brings up the issue of what interferes with motivation. Any person, situation, or factor that consciously or unconsciously rewards you for holding on to your condition will tend to undermine your motivation. For example, you may want to overcome your problem with being housebound.
However, if consciously or unconsciously you don’t want to deal with facing the outside world, getting a job, and earning an income, you will tend to keep yourself confined. Consciously, you want to overcome agoraphobia, yet your motivation is not strong enough to overcome the unconscious “payoffs” for not recovering.
Many years ago, Sigmund Freud referred to the idea of unconscious payoffs as “secondary gains.” Wherever there is strong resistance to recovering from any chronic, disabling condition—whether it is an anxiety disorder, depression, addiction, or obesity—secondary gains are often operative. If you find that you have difficulty developing or sustaining motivation to do something about your condition, it’s important to ask yourself, “What payoffs am I getting for staying this way?” The list below enumerates some of the more common secondary gains that can keep you stuck:

• A deep-seated belief that you “don’t deserve” to recover and lead a normal life—that you’re unworthy of being reasonably happy. When self-punishment is a secondary gain, it is often the case that you’re punishing yourself to get back at someone else.
Self-punishment also can occur because you feel guilty about your condition. The way out of guilt and the tendency to hold yourself back is to work on your self-esteem.

• A deep-seated belief that “it’s too much work” to truly change.

• If you’re agoraphobic and relatively housebound, you may be attached to the payoffs you get from your spouse or partner. These include attention, being taken care of, and being financially supported, or, in general, not having to deal with adult responsibilities.

• The reverse of the last situation may also be true. Your spouse or partner may be getting payoffs from your being dependent on him or her. These can include the opportunity to take care of, control, and even take responsibility for your life (this is a case of codependency—see chapter 14). The payoff can also be assurance that you will never leave. That is, your partner may fear that if you fully recover and become more independent, you’ll leave. You need to realize that you won’t be held back by your partner’s secondary gains unless you are unconsciously colluding with him or her to maintain them.

3. Making a Commitment to Yourself to Follow Through 

4. Willingness to Take Risks

5. Defining and Visualizing Your Goals for Recovery 

Ideal Scenario for My Life After I’ve Recovered  

Practicing visualizing your goals for recovery on a daily basis (preferably in a relaxed state) will increase your confidence about succeeding. This practice will actually make a full recovery more likely. There is abundant philosophical evidence—both ancient and modern—that what you believe in with your whole heart and see with your whole mind has a strong tendency to come true.

Ch 4: Relaxation 

Relaxation is more than unwinding in front of the TV set or in the bathtub at the end of the day—though, without doubt, these practices can be relaxing. The type of relaxation that really makes a difference in dealing with anxiety is the regular, daily practice of some form of deep relaxation. Deep relaxation refers to a distinct physiological state that is the exact opposite of the way your body reacts under stress or during a panic attack. This state was originally described by Herbert Benson in 1975 as the relaxation response. It involves a series of physiological changes including:

• Decrease in heart rate 

• Decrease in respiration rate 

• Decrease in blood pressure 

• Decrease in skeletal muscle tension 

• Decrease in metabolic rate and oxygen consumption 

• Decrease in analytical thinking 

• Increase in skin resistance 

• Increase in alpha wave activity in the brain

Regular practice of deep relaxation for twenty to thirty minutes on a daily basis can produce, over time, a generalization of relaxation to the rest of your life. That is, after several weeks of practicing deep relaxation once per day, you will tend to feel more relaxed all the time.
Numerous other benefits of deep relaxation have been documented over the past twenty years. These include

• Reduction of generalized anxiety. Many people have found that regular practice also reduces the frequency and severity of panic attacks.

• Preventing stress from becoming cumulative. Unabated stress tends to build up over time. Entering into a state of physiological quiescence once a day gives your body the opportunity to recover from the effects of stress. Even sleep can fail to break the cumulative stress cycle unless you’ve given yourself permission to deeply relax while awake.

• Increased energy level and productivity. (When under stress, you may work against yourself and become less efficient.)

• Improved concentration and memory. Regular practice of deep relaxation tends to increase your ability to focus and keeps your mind from “racing.”

• Reduction of insomnia and fatigue. Learning to relax leads to sleep that is deeper and sounder.

• Prevention and/or reduction of psychosomatic disorders, such as hypertension, migraines, headaches, asthma, and ulcers.

• Increased self-confidence and reduced self-blame.

For many people, stress and excessive self-criticism or feelings of inadequacy go hand in hand. You can perform better, as well as feel better, when you are relaxed.

• Increased availability of feelings. Muscle tension is one of the chief impediments to an awareness of your feelings.

How can you achieve a state of deep relaxation? Some of the more common methods include: 
1. Abdominal breathing 
2. Progressive muscle relaxation 
3. Passive muscle relaxation 
4. Visualizing a peaceful scene 
5. Guided imagery 
6. Meditation 
7. Biofeedback 
8. Sensory deprivation 
9. Yoga 
10. Calming music

The book focuses on the first five and the last two of these methods.

Abdominal Breathing 

Your breathing directly reflects the level of tension you carry in your body. Under tension, your breathing usually becomes shallow and rapid, and your breathing occurs high in the chest. When relaxed, you breathe more fully, more deeply, and from your abdomen. It’s difficult to be tense and to breathe from your abdomen at the same time.
Some of the benefits of abdominal breathing include

• Increased oxygen supply to the brain and musculature.
• Stimulation of the parasympathetic nervous system. This branch of your autonomic nervous system promotes a state of calmness and quiescence. It works in a fashion exactly opposite to the sympathetic branch of your nervous system, which stimulates a state of emotional arousal and the very physiological reactions underlying a panic attack.

• Greater feelings of connectedness between mind and body. Anxiety and worry tend to keep you “up in your head.” A few minutes of deep abdominal breathing will help bring you down into your whole body.

• More efficient excretion of bodily toxins. Many toxic substances in the body are excreted through the lungs.

• Improved concentration. If your mind is racing, it’s difficult to focus your attention. Abdominal breathing will help to quiet your mind.

• Abdominal breathing by itself can trigger a relaxation response.

If you suffer from phobias, panic, or other anxiety disorders, you will tend to have one or both of two types of problems with breathing. Either

1. You breathe too high up in your chest and your breathing is shallow, or 
2. You tend to hyperventilate, breathing out too much carbon dioxide relative to the amount of oxygen carried in your bloodstream. Shallow, chest-level breathing, when rapid, can lead to hyperventilation. Hyperventilation, in turn, can cause physical symptoms very similar to those associated with panic attacks.

These two types of breathing are discussed in greater detail below.

Shallow, Chest-Level Breathing 

Studies have found differences in the breathing patterns of anxious and shy people as opposed to those who are more relaxed and outgoing. People who are fearful and shy tend to breathe in a shallow fashion from their chest, while those who are more extroverted and relaxed breathe more slowly, deeply, and from their abdomens.
Before reading on, take a minute to notice how you are breathing right now. Is your breath slow or rapid? Deep or shallow? Does it center around a point high in your chest or down in your abdomen? You might also notice changes in your breathing pattern under stress versus when you are more relaxed.

If you find that your breathing is shallow and high in your chest, don’t despair. It’s quite possible to retrain yourself to breathe more deeply and from your abdomen. Practicing abdominal breathing (described below) on a regular basis will gradually help you to shift the center of your breath downward from your chest. Regular practice of full abdominal breathing will also increase your lung capacity, helping you to breathe more deeply. A program of vigorous, aerobic exercise can also be helpful.

Hyperventilation Syndrome 

If you breathe from your chest, you may tend to overbreathe, exhaling excess carbon dioxide in relation to the amount of oxygen in your bloodstream. You may also tend to breathe through your mouth. The result is a cluster of symptoms, including rapid heartbeat, dizziness, and tingly sensations that are so similar to the symptoms of panic that they can be indistinguishable. Some of the physiological changes brought on by hyperventilation include: 

• Increased alkalinity of nerve cells, which causes them to be more excitable. The result is that you feel nervous and jittery.

• Decreased carbon dioxide in the blood, which can cause your heart to pump harder and faster as well as making lights seem brighter and sounds louder.

• Increased constriction of blood vessels in your brain, which can cause feelings of dizziness, disorientation, and even a sense of unreality or separateness from your body.

All these symptoms may be interpreted as a developing panic attack. As soon as you start responding to these bodily changes with panic-evoking mental statements to yourself, such as “I’m losing control!” or “What’s happening to me?” you actually do panic. Symptoms that initially only mimicked panic set off a reaction that leads to genuine panic. Hyperventilation can either

1) cause physical sensations that lead you to panic or

2) contribute to an ongoing panic attack by aggravating unpleasant physical symptoms.

If you suspect that you are subject to hyperventilation, you might notice whether you habitually breathe shallowly from your chest and through your mouth. Notice also, when you’re frightened, whether you tend to hold your breath or breathe very shallowly and quickly. The experience of tingling or numb sensations, particularly in your arms or legs, is also a sign of hyperventilation.
If any of these characteristics seem to apply to you, hyperventilation may play a role in either instigating or aggravating your panic reactions or anxiety.

The traditional cure for acute hyperventilation symptoms is to breathe into a paper bag.
This technique causes you to breathe in carbon dioxide, restoring the normal balance of oxygen to carbon dioxide in your bloodstream. It is a method that works. Equally effective in reducing symptoms of hyperventilation are the abdominal breathing and calming breath exercises described below. Both of them help you to slow your breathing down, which effectively reduces your intake of oxygen and brings the ratio of oxygen to carbon dioxide back into balance.
If you can recognize the symptoms of hyperventilation for what they are, then learn to curtail them by deliberately slowing your breathing, you needn’t react to them with panic.

The two exercises described below can help you change your breathing pattern. By practicing them, you can achieve a state of deep relaxation in a short period of time. Just three minutes of practicing abdominal breathing or the calming breath exercise will usually induce a deep state of relaxation. Many people have successfully used one or the other technique to abort a panic attack when they felt the first signs of anxiety coming on. The techniques are also very helpful in diminishing anticipatory anxiety you may experience in advance of facing a phobic situation. While the techniques of progressive muscle relaxation and meditation described later in this chapter take up to twenty minutes to achieve their effects, the following two methods can produce a moderate to deep level of relaxation in just three to five minutes.

Abdominal Breathing Exercise 

1. Note the level of tension you’re feeling. Then place one hand on your abdomen right beneath your rib cage.

2. Inhale slowly and deeply through your nose into the “bottom” of your lungs—in other words, send the air as low down as you can. If you’re breathing from your abdomen, your hand should actually rise. Your chest should move only slightly while your abdomen expands. (In abdominal breathing, the diaphragm—the muscle that separates the chest cavity from the abdominal cavity—moves downward. In so doing, it causes the muscles surrounding the abdominal cavity to push outward.)

3. When you’ve taken in a full breath, pause for a moment and then exhale slowly through your nose or mouth, depending on your preference. Be sure to exhale fully. As you exhale, allow your whole body to just let go (you might visualize your arms and legs going loose and limp like a rag doll).

4. Do ten slow, full abdominal breaths. Try to keep your breathing smooth and regular, without gulping in a big breath or letting your breath out all at once. It will help to slow down your breathing if you slowly count to four on the inhale (one-two-three-four) and then slowly count to four on the exhale. Remember to pause briefly at the end of each inhalation. Count from ten down to one, counting backward one number with each exhalation. The process should go like this:

Slow inhale... Pause... Slow exhale (“Ten.”) Slow inhale... Pause... Slow exhale (“Nine.”) Slow inhale... Pause... Slow exhale (“Eight.”) and so on down to one. If you start to feel light-headed while practicing abdominal breathing, stop for fifteen to twenty seconds, then start again.

5. Extend the exercise if you wish by doing two or three “sets” of abdominal breaths, remembering to count backward from ten to one for each set (each exhalation counts as one number). Five full minutes of abdominal breathing will have a pronounced effect in reducing anxiety or early symptoms of panic. Some people prefer to count from one to ten instead. Feel free to do this if it suits you.

Calming Breath Exercise 

The Calming Breath Exercise was adapted from the ancient discipline of yoga. It is a very efficient technique for achieving a deep state of relaxation quickly.

1. Breathing from your abdomen, inhale through your nose slowly to a count of five (count slowly “one... two... three... four... five” as you inhale).

2. Pause and hold your breath to a count of five.

3. Exhale slowly, through your nose or mouth, to a count of five (or more if it takes you longer). Be sure to exhale fully.

4. When you’ve exhaled completely, take two breaths in your normal rhythm, then repeat steps 1 through 3 in the cycle above.

5. Keep up the exercise for at least three to five minutes. This should involve going through at least ten cycles of in-five, hold-five, out-five. As you continue the exercise, you may notice that you can count higher when you exhale than when you inhale. Allow these variations in your counting to occur if they do, naturally, and just continue with the exercise for up to five minutes. Remember to take two normal breaths between each cycle. If you start to feel light-headed while practicing this exercise, stop for thirty seconds and then start again.

6. Throughout the exercise, keep your breathing smooth and regular, without gulping in breaths or breathing out suddenly.

7. Optional: Each time you exhale, you may wish to say, “Relax,” “Calm,” “Let go,” or any other  relaxing word or phrase silently to yourself. Allow your whole body to let go as you do this. If you keep this up each time you practice, eventually just saying your relaxing word by itself will bring on a mild state of relaxation.

The Calming Breath Exercise can be a potent technique for halting the momentum of a panic reaction when the first signs of anxiety come on. It is also useful in reducing symptoms of hyperventilation.

Progressive Muscle Relaxation 

Long-term effects of regular practice of progressive muscle relaxation include 
• A decrease in generalized anxiety 
• A decrease in anticipatory anxiety related to phobias 
• Reduction in the frequency and duration of panic attacks 
• Improved ability to face phobic situations through graded exposure 
• Improved concentration 
• An increased sense of control over moods 
• Increased self-esteem 
• Increased spontaneity and creativity

These long-term benefits are sometimes called generalization effects: the relaxation experienced during daily sessions tends, after a month or two, to generalize to the rest of the day. The regular practice of progressive muscle relaxation can go a long way toward helping you to better manage your anxiety, face your fears, overcome panic, and feel better all around.

Guidelines for Practicing Progressive Muscle Relaxation (or Any Form of Deep Relaxation) 

The following guidelines will help you make the most use of progressive muscle relaxation.
They are also applicable to any form of deep relaxation you undertake to practice regularly, including self-hypnosis, guided visualization, and meditation.

1. Practice at least twenty minutes per day. Two twenty-minute periods are preferable. Once a day is mandatory for obtaining generalization effects. (You may want to begin your practice with thirty-minute periods. As you gain skill in relaxation technique, you will find that the amount of time you need to experience the relaxation response will decrease.)

2. Find a quiet location to practice where you won’t be distracted. Don’t permit the phone to ring while you’re practicing. Use a fan or air conditioner to blot out background noise, if necessary.

3. Practice at regular times. On awakening, before retiring, or before a meal is generally the best time. A consistent daily relaxation routine will increase the likelihood of generalization effects.

4. Practice on an empty stomach. Food digestion after meals will tend to disrupt deep relaxation.

5. Assume a comfortable position. Your entire body, including your head, should be supported.
Lying down on a sofa or bed and sitting in a reclining chair are two ways of supporting your body most completely. (When lying down, you may want to place a pillow beneath your knees for further support.) Sitting up is preferable to lying down if you are feeling tired and sleepy. It’s advantageous to experience the full depth of the relaxation response consciously, without going to sleep.

6. Loosen any tight garments and take off shoes, watch, glasses, contact lenses, jewelry, and so on.

7. Make a decision not to worry about anything. Give yourself permission to put aside the concerns of the day. Allow taking care of yourself and having peace of mind to take precedence over any of your worries. (Success with relaxation depends on giving peace of mind high priority in your overall scheme of values.)

8. Assume a passive, detached attitude. This is probably the most important element. You want to adopt a “let it happen” attitude and be free of any worry about how well you are performing the technique. Do not try to relax. Do not try to control your body. Do not judge your performance. The point is to let go.

Progressive Muscle Relaxation Technique 

Progressive muscle relaxation involves tensing and relaxing, in succession, sixteen different muscle groups of the body. The idea is to tense each muscle group hard (not so hard that you strain, however) for about ten seconds and then to let go of it suddenly. You then give yourself fifteen to twenty seconds to relax, noticing how the muscle group feels when relaxed in contrast to how it felt when tensed, before going on to the next group of muscles. You might also say to yourself, “I am relaxing,” “Letting go,” “Let the tension flow away,” or any other relaxing phrase during each relaxation period between successive muscle groups. Throughout the exercise, maintain your focus on your muscles. When your attention wanders, bring it back to the particular muscle group you’re working on. The guidelines below describe progressive muscle relaxation in detail:

• Make sure you are in a setting that is quiet and comfortable. Observe the guidelines for practicing relaxation that were previously described.

• When you tense a particular muscle group, do so vigorously, without straining, for seven to ten seconds. You may want to count “one-thousand-one,” “one-thousand-two,” and so on, as a way of marking off seconds.

• Concentrate on what is happening. Feel the buildup of tension in each particular muscle group. It is often helpful to visualize the particular muscle group being tensed.

• When you release the muscles, do so abruptly, and then relax, enjoying the sudden feeling of limpness. Allow the relaxation to develop for at least fifteen to twenty seconds before going on to the next group of muscles.

• Allow all the other muscles in your body to remain relaxed, as far as possible, while working on a particular muscle group.

• Tense and relax each muscle group once. But if a particular area feels especially tight, you can tense and relax it two or three times, waiting about twenty seconds between each cycle.

Once you are comfortably supported in a quiet place, follow the detailed instructions below:

1. To begin, take three deep abdominal breaths, exhaling slowly each time. As you exhale, imagine that tension throughout your body begins to flow away.

2. Clench your fists. Hold for seven to ten seconds and then release for fifteen to twenty seconds. Use these same time intervals for all other muscle groups.

3. Tighten your biceps by drawing your forearms up toward your shoulders and “making a muscle” with both arms. Hold... and then relax.

4. Tighten your triceps—the muscles on the undersides of your upper arms—by extending your arms out straight and locking your elbows. Hold…and then relax.

5. Tense the muscles in your forehead by raising your eyebrows as far as you can. Hold... and then relax. Imagine your forehead muscles becoming smooth and limp as they relax.

6. Tense the muscles around your eyes by clenching your eyelids tightly shut. Hold…and then relax. Imagine sensations of deep relaxation spreading all around the area of your eyes.

7. Tighten your jaw by opening your mouth so widely that you stretch the muscles around the hinges of your jaw. Hold…and then relax. Let your lips part and allow your jaw to hang loose.

8. Tighten the muscles in the back of your neck by pulling your head way back, as if you were going to touch your head to your back. (Be gentle with this muscle group to avoid injury.) Focus only on tensing the muscles in your neck. Hold…and then relax. (Since this area is often especially tight, it’s good to do the tense-relax cycle twice.)

9. Take a few deep breaths and tune in to the weight of your head sinking into whatever surface it is resting on.

10. Tighten your shoulders by raising them up as if you were going to touch your ears. Hold... and then relax.

11. Tighten the muscles around your shoulder blades by pushing your shoulder blades back as if you were going to touch them together. Hold the tension in your shoulder blades… and then relax. (Since this area is often especially tense, you might repeat the tense-relax sequence twice.)

12. Tighten the muscles of your chest by taking in a deep breath. Hold for up to ten seconds… and then release slowly. Imagine any excess tension in your chest flowing away with the exhalation.

13. Tighten your stomach muscles by sucking your stomach in. Hold…and then release. Imagine a wave of relaxation spreading through your abdomen.

14. Tighten your lower back by arching it up. (You can omit this part of the exercise if you have lower back pain.) Hold…and then relax.

15. Tighten your buttocks by pulling them together. Hold…and then relax. Imagine the muscles in your hips going loose and limp.

16. Squeeze the muscles in your thighs all the way down to your knees. You will probably have to tighten your hips along with your thighs, since the thigh muscles attach at the pelvis. Hold…and then relax. Feel your thigh muscles smoothing out and relaxing completely.

17. Tighten your calf muscles by pulling your toes toward you. (Flex carefully to avoid cramps.) Hold…and then relax.

18. Tighten your feet by curling your toes downward. Hold…and then relax.

19. Mentally scan your body for any residual tension. If a particular area remains tense, repeat one or two tense-relax cycles for that group of muscles.

20. Now imagine a wave of relaxation slowly spreading throughout your body, starting at your head and gradually penetrating every muscle group all the way down to your toes.

The entire progressive muscle relaxation sequence should take you twenty to thirty minutes the first time. With practice, you may decrease the time needed to fifteen to twenty minutes. You might want to make an audio recording of the above exercise to expedite your early practice sessions, download the version available at the website associated with this book (see the back of the book for more details), or obtain another professionally made recording of the exercise. Some people always prefer to use an audio recording, while others have the exercises so well learned after a few weeks of practice that they prefer doing them from memory.
Remember—regular practice of progressive muscle relaxation once a day will produce a significant reduction in your overall level of anxiety. It will also reduce the frequency and intensity of panic attacks. Finally, regular practice will reduce anticipatory anxiety that may arise in the course of systematically exposing yourself to phobic situations.

Passive Muscle Relaxation

Progressive muscle relaxation is an excellent technique for relaxing tight muscles. Passive muscle relaxation, an alternative technique, can induce a general state of relaxation throughout mind and body. Many people prefer it to progressive relaxation because it is effortless. There is no active tensing and relaxing of muscle groups, only focusing on each muscle group in sequence—from feet to head—and imagining each such group relaxing. Generally, it’s best to lie down with your eyes closed when you practice.

The Peaceful Scene

Guided Visualizations

Meditation 

Yoga 

Calming Music 

Some Common Obstacles to a Daily Program of Deep Relaxation 

There are many difficulties you may encounter in trying to practice any form of deep relaxation on a regular basis. You may start out enthusiastically, setting aside time to practice every day.
Yet after a week or so, you may find yourself “forgetting” to practice. In a fast-paced society that rewards us for speed, efficiency, and productivity, it’s difficult to stop everything and simply relax for twenty to thirty minutes. We are so used to “doing” that it may seem like a chore just to “be.”
If you find that you’ve broken your personal commitment to practice deep relaxation on a daily basis, take time to examine very carefully what you are saying to yourself—what excuses you make—on those days when you don’t relax. If you just “don’t feel like it,” there is usually some more specific reason for feeling that way that can be found by examining what you’re telling yourself.

Some common excuses for not practicing include:

• “I don’t have time to relax.”
What this usually means is that you haven’t given relaxation sufficient priority among all the other activities you’ve crowded into your schedule.

• “I don’t have any place to relax.”
Try creating one. You might let the kids watch their favorite TV show or play with their favorite toys while you go into another room, with instructions not to interrupt you. If you and the kids have only one room, or if they are too young to respect your privacy, then you need to practice at a time when they are out of the house or asleep. The same goes for a demanding spouse.

• “Relaxation exercises seem too slow or boring.”
If you’re telling yourself this, it’s a good indication that you are too speeded up, too frantically pushing yourself through life. Slow down—it’s good for you.

In some individuals, deep relaxation may bring up suppressed feelings, which are often accompanied by sensations of anxiety. If this happens to you, be sure to start off with relatively short periods of relaxation, working up gradually to longer periods. The moment you start feeling any anxiety, simply open your eyes and stop whatever procedure you’re practicing until you feel better. With time and patience, this particular problem should diminish. If it doesn’t, it would be helpful to consult a professional therapist skilled in treating anxiety disorders to assist you in exposing yourself to relaxation.

• “I just don’t have the discipline.”
Often this means that you haven’t persisted with practicing relaxation long enough to internalize it as a habit. You may have made similar statements to yourself in the past when you were attempting to acquire a new behavior. Brushing your teeth didn’t come naturally when you first started. It took some time and diligence to reach the point where it became an honored habit.

If you expend the effort to practice deep relaxation five to seven days per week for at least one month, it will likely become so ingrained that you won’t need to think about doing it anymore—you’ll just do it automatically.
Practicing deep relaxation is more than learning a technique: it involves making a basic shift in your attitude and lifestyle. It requires a willingness to give priority to your health and internal peace of mind over the other pressing claims of productivity, accomplishment, money, or status.

Downtime and Time Management

This chapter on relaxation would not be complete without a discussion of the concepts of downtime and time management. In fact, fully appreciating and implementing these ideas in your life is the most important thing you can do if you would like to achieve a more relaxed lifestyle.
You can practice deep muscle relaxation or meditation every day and feel a pleasant respite for twenty to thirty minutes. These practices can definitely enhance your overall feeling of relaxation if you practice them regularly. Yet if you’re on a treadmill the rest of the time, with too much to get done and no breaks in your schedule, you’re likely to remain under stress, prone to chronic anxiety or panic attacks, and ultimately headed toward burnout.
Downtime is exactly what it sounds like—time out from work or other responsibilities to give yourself an opportunity to rest and replenish your energy. Without periods of downtime, any stress you experience while dealing with work or other responsibilities tends to become cumulative.
It keeps building without any remission. You may keep pushing yourself until finally you drop from exhaustion or experience an aggravation of your anxiety or phobias. Sleep at night doesn’t really count as downtime. If you go to bed feeling stressed, you may sleep for eight hours and still wake up feeling tense, tired, and stressed. Downtime needs to be scheduled during the day, apart from sleep. Its primary purpose is simply to allow a break in the stress cycle—to prevent stress you’re experiencing from becoming cumulative. It’s recommended that you give yourself the following periods of downtime: One hour per day One day per week One week out of every twelve to sixteen weeks If you don’t have four weeks of paid vacation per year, then be willing to take time off without pay. During these periods of downtime, you disengage from any task you consider work, put aside all responsibilities, and don’t answer the phone unless it’s someone you would enjoy hearing from.
There are three kinds of downtime, each of which has an important place in developing a more relaxed lifestyle: 1) rest time, 2) recreation time, and 3) relationship time. It’s important that you provide yourself enough downtime so that you have time for all three. Often recreation and relationship time can be combined. However, it’s important to use rest time for just that—and nothing else.
Rest time is time when you set aside all activities and just allow yourself to be. You stop action and let yourself fully rest. Rest time might involve lying on the couch and doing nothing, quietly meditating, sitting in your recliner and listening to peaceful music, soaking in a Jacuzzi, or taking a catnap in the middle of the workday. The key to rest time is that it is fundamentally passive—you allow yourself to stop doing and accomplishing and just be. Contemporary society encourages each of us to be productive and always accomplish more and more every moment of the waking day. Rest time is a needed counterpoint. When you’re under stress, one hour of rest time per day, separate from the time you sleep, is optimal.
Recreation time involves engaging in activities that help to “re-create” you—that is, serve to replenish your energy. Recreation time brightens and uplifts your spirits. In essence, it is doing anything that you experience as fun or play. Examples of such activities might include puttering in the garden, reading a novel, seeing a special movie, going on a hike, playing soccer, taking a short trip, baking a loaf of bread, or fishing. Recreation time can be done during the workweek and is most important to have on your days off from work. Such time can be spent either alone or with someone else, in which case it overlaps with the third type of downtime.
Relationship time is time when you put aside your private goals and responsibilities in order to enjoy being with another person—or, in some cases, with several people. The focus of relationship time is to honor your relationship with your partner, children, extended family members, friends,
Relaxation 105 pets, and so on, and forget about your individual pursuits for a while. If you have a family, relationship time needs to be allocated equitably between time alone with your spouse, time alone with your children, and time when the entire family gets together. If you’re single with a partner, time needs to be judiciously allocated between time with your partner and time with friends.
When you slow down and make time to be with others, you’re less likely to neglect your basic needs for intimacy, touching, affection, validation, support, and so on (see the section called “Your Basic Needs” in chapter 14). Meeting these basic needs is absolutely vital to your well-being.
Without sufficient time devoted to important relationships, you will surely suffer—and the people you most care about are bound to, as well.
How can you allow for more downtime (all three kinds) in your life? An important prerequisite is to get past workaholism. Workaholism is an addictive disorder in which work is the only thing that gives you a sense of inner fulfillment and self-worth.
You devote all your time and energy to work, neglecting both your physical and your emotional needs. Workaholism describes an unbalanced way of life that often leads first to chronic stress, then to burnout, and ultimately to serious illness.
If you’re a workaholic, it’s possible to learn to enjoy nonwork aspects of your life, as discussed above, and achieve a more balanced approach in general. Deliberately making time for rest, recreation, and relationships may be difficult at first, but it tends to get easier and to become self-rewarding as time goes on.
Another important step is simply to be willing to do less. That is, you literally reduce the number of tasks and responsibilities you handle in any given day. In some cases, this may involve changing jobs; in others, it may merely involve restructuring how you allocate time for work versus rest and relaxation. For some individuals, this translates to a fundamental decision to make earning money less important and a simpler, more balanced lifestyle more important. Before you think about leaving your present job, however, consider how you can shift your values in the direction of placing more emphasis on the process of life (“how” you live) as opposed to accomplishments and productivity (“what” you actually do) within your current life situation.

Time Management

A very important skill to have if you want more time away from work and responsibilities is good time management. Time management describes the way in which you organize or structure your daily activities over time. Ineffective time management can lead to stress, anxiety, burnout, and, eventually, illness. Effective time management, on the other hand, will allow you more time for the three types of downtime described above: rest, recreation, and relationships.
Developing good time management skills may necessitate giving up some cherished habits.

Time management can be achieved through:

1. prioritization,

2. delegation,

3. allowing extra time (A common problem in time management is underestimating the amount of time required to complete a task.)

4. letting go of perfectionism,

5. overcoming procrastination, and

6. saying no

Ch 5: Physical Exercise

One of the most powerful and effective methods for reducing generalized anxiety and overcoming a predisposition to panic attacks is a program of regular, vigorous exercise. You have panic attacks when your body’s natural fight-or-flight reaction—the sudden surge of adrenaline you experience in response to a realistic threat—becomes excessive or occurs out of context. Exercise is a natural outlet for your body when it is in the fight-or-flight mode of arousal. A majority of my clients who have undertaken a regular exercise program are less vulnerable to panic attacks and, if they do have them, find them to be less severe. Regular exercise also diminishes the tendency to experience anticipatory anxiety toward phobic situations, expediting recovery from all kinds of phobias, ranging from fear of public speaking to fear of being alone.

Regular exercise has a direct impact on several physiological factors that underlie anxiety. It brings about:

• Reduced skeletal muscle tension, which is largely responsible for your feelings of being tense or “uptight”

• More rapid metabolism of excess adrenaline and thyroxine in the bloodstream, the presence of which tends to keep you in a state of arousal and vigilance

• A discharge of pent-up frustration, which can aggravate phobic or panic reactions

Some of the general physiological benefits of exercise include:

• Enhanced oxygenation of the blood and brain, which increases alertness and concentration

• Stimulation of the production of endorphins, natural substances which resemble morphine both chemically and in their effects: endorphins increase your sense of well-being

• Lowered pH (increased acidity) of the blood, which increases your energy level

• Improved circulation

• Improved digestion and utilization of food

• Improved elimination (from skin, lungs, and bowels)

• Decreased cholesterol levels

• Decreased blood pressure

• Weight loss, as well as appetite suppression, in many cases

• Improved blood sugar regulation (in the case of hypoglycemia)

Several psychological benefits accompany these physical improvements, including:

• Increased subjective feelings of well-being 

• Reduced dependence on alcohol and drugs 

• Reduced insomnia 

• Improved concentration and memory 

• Reduced depression 

• Increased self-esteem 

• Greater sense of control over anxiety

Symptoms of Being Out of Shape 

How do you know that you are out of shape and in need of exercise? Here are some common symptoms:

• Being out of breath after walking up a flight of stairs 

• Long recovery time after walking up a flight of stairs 

• Feeling exhausted after short periods of exertion 

• Chronic muscle tension 

• Poor muscle tone 

• Obesity 

• Muscles cramped and aching for days after participating in a sport 

• General tiredness, lethargy, boredom

The book next covers these topics:

% Checking Your Fitness Level

% Preparing for a Fitness Program

% Choosing an Exercise Program

% Getting Started With Exercises

% Optimizing the Anxiety-Reducing Effects of Exercise

% Obstacles to Implementing an Exercise Program

Ch 6: Coping with Panic Attacks

A panic attack is a sudden surge of mounting physiological arousal that can occur “out of the blue” or in response to encountering (or merely thinking about) a phobic situation. Bodily symptoms that occur with the onset of panic can include heart palpitations, tightening in the chest or shortness of breath, choking sensations, dizziness, faintness, sweating, trembling, shaking, and/or tingling in the hands and feet. Psychological reactions that often accompany these bodily changes include feelings of unreality, an intense desire to run away, and fears of going crazy, dying, or doing something uncontrollable.
Anyone who has had a full-fledged panic attack knows that it is one of the most intensely uncomfortable states human beings are capable of experiencing. Your very first panic attack can have a traumatic impact, leaving you feeling terrified and helpless, with strong anticipatory anxiety about the possible recurrence of your panic symptoms. Unfortunately, in some cases, panic does come back and occurs repeatedly. Why some people have a panic attack only once—or perhaps once every few years—while others develop a chronic condition with several attacks a week is still not understood by researchers in the field.
The good news is that you can learn to cope with panic attacks so well that they will no longer have the power to frighten you. Over time you can actually diminish the intensity and frequency of panic attacks if you are willing to make some changes in your lifestyle. Lifestyle changes that are most conducive to reducing the severity of panic reactions are described in other chapters of this workbook. They include:

• Regular practice of deep relaxation (see chapter 4)

• A regular program of exercise (see chapter 5)

• Elimination of stimulants (especially caffeine, sugar, and nicotine) from your diet (see chapter 15)

• Learning to acknowledge and express your feelings, especially anger and sadness (see chapter 12)

• Adopting self-talk and “core beliefs” that promote a calmer and more accepting attitude toward life (see chapters 8 and 9)

These five lifestyle changes vary in importance for different people. To the extent that you can cultivate all five of them, however, you will find that, over time, your problem with panic reactions will diminish.

It’s very common when undergoing panic to invent any (or all) of the following “dangers”. There is simply no basis for any of them in reality:

- In response to heart palpitations: “I’m going to have a heart attack” or “I’m going to die.”

- In response to choking sensations: “I’m going to stop breathing and suffocate.”

- In response to dizzy sensations: “I’m going to pass out.”

- In response to sensations of disorientation or feeling “not all there”: “I’m going crazy.”

- In response to “rubbery legs”: “I won’t be able to walk” or “I’m going to fall.”

- In response to the overall intensity of your body’s reactions: “I’m going to lose complete control over myself.”


Breaking the Connection Between Bodily Symptoms and Catastrophic Thoughts 

Development of Panic Attack

Phase 1: Initiating circumstances (internal or external)

Phase 2: Slight increase in unusual or unpleasant bodily symptoms (i.e., heart palpitations, shortness of breath, faintness or dizziness, sweating, etc.)

Phase 3: Internalization (increased focus on symptoms makes them more noticeable and easily magnified)

Phase 4: Catastrophic interpretation (telling yourself the symptom is dangerous—i.e., 
“I’ll have a heart attack,” 
“I’ll suffocate,” 
“I’ll go completely out of control,” 
“I must leave at once”)

Phase 5: Panic

Don’t Fight Panic 

Resisting or fighting initial panic symptoms is likely to make them worse. It’s important to avoid tensing up in reaction to panic symptoms or trying to make them go away by suppressing them or gritting your teeth. Although it’s important to act rather than be passive (as discussed below), you still shouldn’t fight your panic. Claire Weekes, in her popular books Hope and Help for Your Nerves and Peace from Nervous Suffering, describes a four-step approach for coping with panic:

1. Face the symptoms—don’t run from them.

Attempting to suppress or run away from the early symptoms of panic is a way of telling yourself that you can’t handle a particular situation. In most cases, this will only create more panic. A more constructive attitude to cultivate is one that says, “Okay, here it is again. I can allow my body to go through its reactions and handle this. I’ve done it before.”

2. Accept what your body is doing—don’t fight against it.

When you try to fight panic, you simply tense up against it, which only makes you more anxious. Adopting just the opposite attitude, one of letting go and allowing your body to have its reactions (such as heart palpitations, chest constriction, sweaty palms, dizziness, and so on) will enable you to move through panic much more quickly and easily. The key is to be able to watch or observe your body’s state of physiological arousal—no matter how unusual or uncomfortable it feels—without reacting to it with further fear or anxiety.

3. Float with the wave of a panic attack rather than try to force your way through it.

Claire Weekes makes a distinction between first fear and second fear. First fear consists of the physiological reactions underlying panic; second fear is when you make yourself afraid of these reactions by saying scary things to yourself like “I can’t handle this!” “I’ve got to get out of here right now!” or “What if other people see this happening to me?” While you can’t do much about first fear, you can eliminate second fear by learning to flow with the rising and falling of your body’s state of arousal rather than fighting or reacting fearfully to it. Instead of scaring yourself about your body’s reactions, you can move with them and make reassuring statements to yourself, such as “This, too, will pass,” “I’ll let my body do its thing and move through this,” or “I’ve handled this before and I can handle it now.” A list of such positive coping statements follows in the next section.

4. Allow time to pass.

Panic is caused by a sudden surge of adrenaline. If you can allow and float with the bodily reactions caused by this surge, much of this adrenaline will metabolize and be reabsorbed in three to five minutes. As soon as this happens, you’ll start to feel better. Panic attacks are time limited. In most cases, panic will peak and begin to subside within only a few minutes. It is most likely to pass quickly if you don’t aggravate it by fighting against it or reacting to it with even more fear (causing “second fear”) by saying scary things to yourself.

Next in the book are topics: 

% Coping Statements

% Ways to Work with Coping Statements

% Explore the Antecedents of Your Panic Attacks

Learn to Discriminate Early Symptoms of Panic 

It’s possible to distinguish among different levels or degrees of anxiety leading up to panic by using the 10-point.

Anxiety Scale:

7–10 : Major Panic Attack : All of the symptoms in level 6 exaggerated; terror; fear of going crazy or dying; compulsion to escape

6 : Moderate Panic Attack : Palpitations; difficulty breathing; feeling disoriented or detached (feeling of unreality); panic in response to perceived loss of control

5 : Early Panic : Heart pounding or beating irregularly; constricted breathing; spaciness or dizziness; definite fear of losing control; compulsion to escape

4 : Marked Anxiety : Feeling uncomfortable or “spacey”; heart beating fast; muscles tight; beginning to wonder about maintaining control

3 : Moderate Anxiety : Feeling uncomfortable but still in control; heart starting to beat faster; more rapid breathing; sweaty palms

2 : Mild Anxiety : Butterflies in stomach; muscle tension; definitely nervous

1 : Slight Anxiety : Passing twinge of anxiety; feeling slightly nervous

0 : Relaxation : Calm; a feeling of being undistracted and at peace

Coping Strategies to Counteract Panic at an Early Stage

- Practice Abdominal Breathing

- Repeat Positive Coping Statements

The way you respond to early physical symptoms of panic will be determined largely by what you say to yourself, as illustrated below.



- Use Abdominal Breathing in Combination with Coping Statements

- Talk to a Supportive Person Nearby or on the Phone

- Move Around or Engage in Some Physical Activity

- Stay in the Present

- Get Angry with Anxiety

Time-honored techniques for physically expressing anger include: 

• Pounding on a pillow on your bed with both fists 

• Screaming into a pillow—or in your car alone with the windows rolled up 

• Hitting a bed or a couch with a plastic baseball bat 

• Throwing eggs into the bathtub (the remains wash away) 

• Chopping wood

- Experience Something Immediately Pleasurable

The feeling of pleasure is also incompatible with an anxiety state. Any of the following may help to offset anxiety, worry, or even panic: 
• Have your significant other or spouse hold you (or give you a back rub).
• Take a hot shower or relax in a hot bath.
• Have a pleasurable snack or meal.
• Engage in sexual activity.
• Read humorous books or watch a comical DVD.

Next in the book are topics:

% Learn to Observe Rather than React to Bodily Sensations of Anxiety

% What to Do When Panic Goes Above Level 4 

% Sharing About Your Condition 

Ch 7: Help for Phobias: Exposure

The most effective way to overcome a phobia is simply to face it. Continuing to avoid a situation that frightens you is, more than anything else, what keeps the phobia alive.
Having to face a particular situation you have been avoiding for years may at the outset seem an impossible task. Yet this task can be made manageable by breaking it down into sufficiently small steps. Instead of entering a situation all at once, you can do it very gradually in small or even minute increments.
Phobias develop as a result of sensitization. This is a process of becoming sensitized to a particular stimulus. In essence, you learn to associate anxiety with a particular situation. Perhaps you once panicked while sitting in a restaurant or by yourself at home. If your anxiety level was high, it’s likely that you acquired a strong association between being in that particular situation and being anxious. Thereafter, being in, being near, or perhaps just thinking about that situation automatically triggered your anxiety: a connection between the situation and a strong anxiety response was established. Because this connection was automatic and seemingly beyond your control, you probably did all you could to avoid putting yourself in the situation again. Your avoidance was rewarded because it saved you from reexperiencing your anxiety. At the point where you began to always avoid the situation, you developed a full-­fledged phobia.
Exposure is the process of unlearning the connection between anxiety and a particular situation. For exposure to occur, you need to enter a phobic situation gradually in incremental steps.
With real-­life exposure, you confront a phobic situation directly, letting your anxiety rise and enduring the anxiety for a period of time to learn that you can actually handle your anxiety in a situation you’ve been accustomed to avoiding. The point is to: 

1) unlearn a connection between a phobic situation (such as driving on the freeway) and an anxiety response and 

2) gain confidence in your ability to handle the situation regardless of whether anxiety comes up. 

Repeatedly entering the situation will eventually allow you to overcome your previous avoidance.
Exposure is the single most effective available treatment for phobias. In many controlled studies, direct exposure to phobic situations has consistently been found to be more effective than other, nonbehavioral treatments, such as insight therapy, cognitive therapy by itself, or medication. Nothing works better toward overcoming a fear than facing it—­especially when this is done systematically and in small increments. Furthermore, improvement resulting from real-­life exposure does not typically disappear weeks or months later. Once you’ve fully completed exposure to a phobic situation in real life, you can remain free of fear. In some cases, however, you might need to complete a periodic “booster” exposure session to retain the results of your original exposure, particularly if the situation is one that you don’t deal with often (such as seeing snakes at the zoo, for example).

If real-­life exposure is such an effective treatment, why are there still so many phobic people around? Why hasn’t everybody availed themselves of a treatment that is so powerful? The answer is simple. For all its effectiveness, exposure isn’t a particularly easy or comfortable process to go through. Not everyone is willing to tolerate the unpleasantness of facing phobic situations or to persist with doing so on a regular basis. Exposure therapy demands a strong commitment on your part.
If you’re genuinely committed to your recovery, then you’ll be willing to:

• Take the risk to start facing situations you may have been avoiding for many years.
• Persist in practicing exposure on a consistent basis, despite possible setbacks, over a long enough period of time to allow your complete recovery (generally this can take from weeks to up to a year or more).

Tolerate the initial discomfort that entering phobic situations—­even in small increments—­ often involves.
If you’re ready to make a consistent commitment to exposure for as long as it takes, you will recover from your phobias.

Coping Exposure vs. Full Exposure

The exposure process can generally be divided into two stages, coping and full exposure. The coping stage involves relying on various supports to help you get started with exposure and negotiate the early steps in the process. Such supports might include a person to accompany you (referred to as a “support person”), a low dose of a tranquilizer, practicing deep abdominal breathing, or rehearsing positive “coping statements.” (See, for example, the list of coping statements in chapter 6.) As you progress beyond the early steps of your hierarchy (an incremental series of approaches to your phobic situation), you need to gradually wean yourself away from such coping strategies.
The second, “full exposure” stage follows. Full exposure means you enter into your phobic situation without relying on supports or coping strategies. Full exposure is necessary because it teaches you that you can handle a situation you previously avoided under any circumstances. Instead of learning “I can only handle driving on freeways if I take medication,” you learn that “I can handle driving on freeways regardless of my anxiety or anything I might use to mitigate it.” Full exposure leads to complete mastery of a previously phobic situation.
Full exposure, without reliance on any coping strategies, such as a support person or medication, is the fastest and most efficient way to overcome a phobia. Some people courageouslyHelp for Phobias: Exposure undertake full exposure to a phobia—for example, staying home alone, traveling to high places, or driving to the local supermarket—without using supportive coping strategies. Other people prefer the gentler approach of utilizing coping strategies to help them get started with exposure and negotiate its early stages. Gradually, as they proceed, they wean themselves away from these coping strategies in order to fully master the situation.

Coping vs. Mastery Approach to Exposure

The distinction just made between “coping exposure” and “full exposure” implies that there are really two approaches to dealing with phobias: simply coping versus full mastery. Complete mastery of a phobia—­for example, flying, riding elevators, or driving freeways—­is definitely desirable. In actual practice, however, some people opt for simply coping—­being able to negotiate their phobic situation with the use of whatever aids they feel they need. Their aim is just to cope with the situation, not to fully master it.
For many phobic people, the ability to ultimately negotiate a challenging situation without a support person is a significant accomplishment. So is the ability to confront a phobia without the assistance of medication. However, in practice, people vary quite a bit in their willingness to give up these kinds of assistance. Often, as would be expected, the critical variable is the frequency with which a situation needs to be confronted. If you have to deal with a situation frequently, such as driving on a freeway daily to save considerable time in getting to your work, you’re likely to aim for full mastery of the situation. Doing the exposure over and over every single day for weeks and months on end will make full mastery (without need of supportive coping strategies) more achievable. Phobic situations you encounter rarely are different. If flying or giving a presentation is a relatively rare event, then reliance on whatever resource is needed just to cope with the situation may be sufficient for some people (while others still seek full mastery over longer periods of time).

How to Practice Exposure

- Set Goals

- Create a Hierarchy for Each Goal (For each goal you’ve defined, you need to create a hierarchy of exposures. A hierarchy is an incremental series of approaches to your phobic situation.)

- Determine Scenes of Varying Intensity

Common variables include : Distance from the feared situation : Duration of the exposure : Proximity of an exit or way out of the situation : General complexity of the situation (such as number of cars or people) : Time of day

- Optional: Try Imagery Exposure First

A heirarchy consits of two pars: : Coping Exposure : Full Exposure

- Designing Your Own Hierarchies

Basic Procedure for Exposure

1. Enter and endure the situation.
2. Continue working up your hierarchy.

What to Do If You Start to Panic During Coping Exposure 

Some anxiety experts advocate continuing to expose to a phobic situation no matter how high anxiety rises, even to the point of panic. The problem with this is that, if you actually progress to a full-­blown panic attack during exposure, you could risk resensitizing yourself to the situation and reinforcing your fear of the phobia. This is particularly true during the early, coping phase of exposure. While it’s always best to try to endure the discomfort you feel with exposure, it’s also helpful to be able to have an “exit strategy” if a full-­blown panic attack seems to be coming on. If you suddenly feel you’re heading toward a full-­blown panic attack, consider temporarily retreating from the situation and then returning to it as soon as possible after your anxiety settles down to manageable proportions.
Retreat is a “fallback strategy” to be used only if you feel your anxiety is getting out of control. It’s always best to try to stay in the situation, accept and endure the discomfort you feel, and wait for the anxiety to pass. (Recall Claire Weekes’s four-­step process for dealing with high anxiety from chapter 6: face the symptoms; accept what your body is doing; float with the wave of anxiety; and allow time to pass.) However, if you feel you simply can’t endure your anxiety and are starting to move toward a panic attack, you can retreat and then return to the situation as soon as possible. In many situations, this is easy to do. If you’re driving on the freeway, you can pull over onto the shoulder or get off at the nearest exit. If you’re sitting in a restaurant, you can retreat to the restroom and then return. If you’re flying, you can’t leave the plane, but you can retreat to a safe place in your mind (using a recorded visualization—­see chapter 4) or get up and walk to the plane’s restroom. Remember that retreat is not the same thing as escape—­the idea is to temporarily leave the situation and then return.
During the full exposure stage, most often you are sufficiently accustomed to the situation that a full-­blown panic attack is unlikely to occur. In the unlikely instance that you start to panic during full exposure, you can choose to stop the exposure temporarily. Give yourself a few minutes to recover, but don’t go home. Once you are calmer, finish the exposure session. Also, it’s optimal if you can repeat an exposure to the same situation within the next day or two.

Making the Most of Exposure

1. Be willing to take risks.
2. Deal with resistance.
3. Be willing to tolerate some discomfort.
4. Avoid flooding—­be willing if necessary to retreat 5. Utilize a support person.
6. Utilize coping strategies during the early, coping exposure phase to get started.
7. Plan for contingencies when first undertaking exposure.
8. Plan your exposures in advance.
9. Trust your own pace.
10. Let go of the need for complete control.
11. Reward yourself for small successes.
12. Practice regularly.
13. Expect and know how to handle setbacks.
14. Be prepared to experience stronger emotions.
15. Follow through to completion.

Maintaining the Right Attitude 

- Accept Bodily Symptoms of Anxiety

- Stay Grounded in the Present Moment

- Know That Fear Always Passes

- If You’re Anxious About Something, You’re Already Beginning Exposure to It

- Exposure Always Works—­with Practice

Factors That Can Promote or Impede Your Success

What Promotes Success 

1. Cooperation of your partner or spouse.
2. Willingness to tolerate some discomfort.
3. Ability to handle the initial symptoms of panic.
4. Ability to handle setbacks.
5. Willingness to practice regularly.
6. Doing follow-up exposures and varying the context of exposure.

What Interferes with Success

1. Depression.

These are common symptoms of clinical depression:

• Fatigue and lack of energy 
• Self-­reproach and feelings of worthlessness 
• Loss of interest or pleasure in usual activities 
• Difficulty concentrating 
• Reduced appetite 
• Difficulty sleeping 
• Suicidal thoughts

2. Alcohol and tranquilizers.

Next in the book are topics: 
% Guidelines for Your Support Person 
% Using Medications 
% Imagery Exposure 
% Visualization for Mastering a Phobia

Ch 8: Self-Talk

Imagine two individuals sitting in stop-­and-­go traffic at rush hour. One perceives himself as trapped, and says such things to himself as “I can’t stand this,” “I’ve got to get out of here,” and “Why did I ever get myself into this commute?” What he feels is anxiety, anger, and frustration.
The other perceives the situation as an opportunity to sit back, relax, and listen to music. He says,
“I might as well just relax and adjust to the pace of the traffic” or “I can unwind by doing some deep breathing.” What he feels is a sense of calm and acceptance. In both cases, the situation is exactly the same, but the feelings in response to that situation are vastly different because of each individual’s internal monologue, or self-­talk.
The truth is that it’s what we say to ourselves in response to any particular situation that mainly determines our mood and feelings. Often we say it so quickly and automatically that we don’t even notice, and so we get the impression that the external situation “makes” us feel the way we do. But it’s really our interpretations and thoughts about what is happening that form the basis of our feelings. This sequence can be represented as a timeline:

External Events --> Interpretation of Events and Self-Talk --> Feelings and Reactions

In short, you are largely responsible for how you feel (barring physiological determinants, such as illness). This is a profound and very important truth—­one that sometimes takes a long time to fully grasp. It’s often much easier to blame the way you feel on something or someone outside yourself than to take responsibility for your reactions. Yet it is through your willingness to accept that responsibility that you begin to take charge and have mastery over your life. The realization that you are mostly responsible for how you feel is empowering once you fully accept it. It’s one of the most important keys to living a happier, more effective, and anxiety-­free life.

Anxiety and Self-­Talk 

People who suffer from phobias, panic attacks, and general anxiety are especially prone to engage in negative self-­talk. Anxiety can be generated on the spur of the moment by repeatedly making statements to yourself that begin with the two words “what if.” Any anxiety you experience in anticipation of confronting a difficult situation is manufactured out of your own “what-­if statements” to yourself. When you decide to avoid a situation altogether, it is probably because of the scary questions you’ve asked yourself: “What if I panic?” “What if I can’t handle it?” “What will other people think if they see me anxious?” Just noticing when you fall into “what-­if thinking” is the first step toward gaining control over negative self-­talk. The real change occurs when you begin to counter and replace negative what-­if statements with positive, self-­supportive statements that reinforce your ability to cope. For example, you might say, “So what,” “These are just thoughts,” “This is just scare-­talk,” “I can handle this,” or “I can breathe, let go, and relax.”
I want you to consider some basic facts about self-­talk. Following these facts is a discussion of the different types of self-­defeating inner monologues.

Some Basic Points About Self-­Talk

1. Self-­talk often appears in telegraphic form.

2. Anxious self-­talk is typically irrational but almost always sounds like the truth.

3. Negative self-­talk perpetuates avoidance.

4. Self-­talk can initiate or aggravate a panic attack.

5. Negative self-­talk is a series of bad habits.

Types of Negative Self-­Talk

Not all negative self-­talk is the same. Human beings are not only diverse but complex, with multifaceted personalities. These facets are sometimes referred to as “subpersonalities.” Our different subpersonalities each play their own distinct role and possess their own voice in the complex workings of consciousness, memory, and dreams. Below you will find four of the more common subpersonality types that tend to be prominent in people who are prone to anxiety: the Worrier, the Critic, the Victim, and the Perfectionist. 1 Since the strength of these inner voices varies for different people, you might find it useful to rank them from strongest to weakest in yourself.

The Worrier (promotes anxiety)

Characteristics: This usually is the strongest subpersonality in people who are prone to anxiety.
The Worrier creates anxiety by imagining the worst-­case scenario. It scares you with fantasies of disaster or catastrophe when you imagine confronting something you fear. It also aggravates panic by reacting to the first physical symptoms of a panic attack. The Worrier promotes your fears that what is happening is dangerous or embarrassing (“What if I have a heart attack?!”
“What will they think if they see me?!”).
In short, the Worrier’s dominant tendencies include 1) anticipating the worst, 2) overestimating the odds of something bad or embarrassing happening, and 3) creating grandiose images of potential failure or catastrophe. The Worrier is always vigilant, watching with uneasy apprehension for any small symptoms or signs of trouble.
Favorite expression: By far the favorite expression of the Worrier is “what if...?”
Examples: Some typical dialogue from the Worrier might be: “Oh no, my heart’s starting to beat faster! What if I panic and lose complete control of myself?” “What if I start stammering in the middle of my speech?” “What if they see me shaking?” “What if I’m alone and there’s nobody to call?” “What if I just can’t get over this phobia?” or “What if I’m restricted from going to work for the rest of my life?”
These subpersonalities are based on Reid Wilson’s descriptions of the Worried, Critical, and Hopeless Observers in his book Don’t Panic: Taking Control of Anxiety Attacks.

The Critic (promotes low self-­esteem) 

Characteristics: The Critic is that part of you that is constantly judging and evaluating your behavior (and in this sense may seem more “apart” from you than the other subpersonalities).
It tends to point out your flaws and limitations whenever possible. It jumps on any mistake you make to remind you that you’re a failure. The Critic generates anxiety by putting you down for not being able to handle your panic symptoms, for not being able to go places you used to go, for being unable to perform at your best, or for having to be dependent on someone else. It also likes to compare you with others and usually sees them coming out favorably. It tends to ignore your positive qualities and emphasizes your weaknesses and inadequacies. The Critic may be personified in your own dialogue as the voice of your mother or father, a dreaded teacher, or anyone who wounded you in the past with their criticism.
Favorite expressions: “What a disappointment you are!” “That was stupid!”
Examples: The following would be typical of the Critic’s self-­talk: “You stupid...” (The Critic relishes negative labels.) “Can’t you ever get it right?” “Why are you always this way?” “Look at how capable is,” or “You could have done better.” The Critic holds negative self-­beliefs, such as “I’m inferior to others,” “I’m not worth much,” “There’s something inherently wrong with me,” or “I’m weak—­I should be stronger.”

The Victim (promotes depression) 

Characteristics: The Victim is that part of you that feels helpless or hopeless. It generates anxiety by telling you that you’re not making any progress, that your condition is incurable, or that the road is too long and steep for you to have a real chance at recovering. The Victim also plays a major role in creating depression. The Victim believes that there is something inherently wrong with you: you are in some way deprived, defective, or unworthy. The Victim always perceives insurmountable obstacles between you and your goals. Characteristically, it bemoans, complains, and regrets things as they are at present. It believes that nothing will ever change.
Favorite expressions: “I can’t.” “I’ll never be able to.”
Examples: The Victim will say such things as “I’ll never be able to do that, so what’s the point in even trying?” “I feel physically drained today—­why bother doing anything?” “Maybe I could have done it if I’d had more initiative ten years ago—­but it’s too late now.” 

The Victim holds such negative self-­beliefs as:
“I’m hopeless,” 
“I’ve had this problem too long—­it will never get better,” or 
“I’ve tried everything—­nothing is ever going to work.”

The Perfectionist (promotes chronic stress and burnout)

Characteristics: The Perfectionist is a close cousin of the Critic, but its concern is less to put you down than to push and goad you to do better. It generates anxiety by constantly telling you that your efforts aren’t good enough, that you should be working harder, that you should always have everything under control; that you should always be competent, should always be pleasing, should always be (fill in whatever you keep telling yourself that you “should” do or be). The Perfectionist is the hard-­driving part of you that wants to be best and is intolerant of mistakes or setbacks. It has a tendency to try to convince you that your self-­worth is dependent on externals, such as vocational achievement, money and status, acceptance by others, being loved, or your ability to be pleasing and nice to others, regardless of what they do. The Perfectionist isn’t convinced by any notions of your inherent self-­worth, but instead pushes you into stress, exhaustion, and burnout in pursuit of its goals. It likes to ignore warning signals from your body.
Favorite expressions: “I should.” “I have to.” “I must.”
Examples: The Perfectionist may provide such instructions as “I should always be on top of things,” “I should always be considerate and unselfish,” “I should always be pleasant and nice,” or “I have to (get this job, make this amount of money, receive ’s approval, and so on) or I’m not worth much.” (See the discussion of “should statements” at the end of the next section.)

Next in the book are topics: Exercise: What Are Your Subpersonalities Telling You? And How to Manage Them. 

Countering Negative Self-­Talk

The most effective way to deal with the negative self-­talk of your Worrier and other subpersonalities is to counter it with positive, supportive statements. Countering involves writing down and rehearsing positive statements that directly refute or invalidate your negative self-­talk. If you’re creating anxiety and other upsetting emotional states through negative mental programming, you can begin to change the way you feel by substituting positive programming. Doing this will take some practice. You’ve had years to practice your negative self-­talk and naturally have developed some very strong habits. Your Worrier and other subpersonalities are likely to be very well entrenched.
By starting to notice when you’re engaging in negativity and then countering it with positive, supportive statements to yourself, you’ll begin to turn your thinking around. With practice and consistent effort, you’ll change both the way you think and the way you feel on an ongoing basis.
Sometimes countering comes naturally and easily. You are ready and willing to substitute positive, reasonable self-­statements for ones that have been causing you anxiety and distress.
You’re more than ready to relinquish negative mental habits that aren’t serving you. On the other hand, you may object to the idea of countering and say, “But what if what my Worrier (Critic,
Victim, or Perfectionist) says is true? It’s hard for me to believe otherwise.” Or you may say, “How can I substitute positive self-­statements for negative ones if I don’t really believe them?”
Perhaps you’re strongly attached to some of your negative self-­talk. You’ve been telling yourself these things for years and it’s difficult to give up both the habit and the beliefs. You’re not someone who’s easily persuaded. If that’s the case, and you want to do something about your negative self-­talk, it’s important that you subject it to rational scrutiny. You can weaken the hold of your negative self-­statements by exposing them to any of the following Socratic questions, or rational investigation.
1. What is the evidence for this? 2. Is this always true? 3. Has this been true in the past? 4. What are the odds of this really happening (or being true)? 5. What is the very worst that could happen? What is so bad about that? What would you do if the worst happened? 6. Are you looking at the whole picture? 7. Are you being fully objective?

The validity of your negative self-­statements has nothing to do with how attached you are to them or how ingrained they might be. Rather, it has to do with whether they stand up under careful, objective scrutiny.

Rules for Writing Positive Counterstatements

• Avoid negatives in writing your counterstatements. Instead of saying, “I’m not going to panic when I board the plane,” try “I am confident and calm about boarding the plane.” Telling yourself something will not happen is more likely to create anxiety than giving yourself a direct affirmation.

• Keep counterstatements in the present tense (“I can breathe and let these feelings pass” is preferable to “I will feel better in a few minutes”). Since much of your negative self-­talk is in the here and now, it needs to be countered by statements that are also in the present tense. If you’re not ready to directly affirm something, try beginning your positive statement with “I am willing to...” or “I am learning to...” or “I can...”

• Whenever possible, keep your statements in the first person. Begin them with the pronoun “I” or refer to yourself somewhere in the statement. It’s okay to write a sentence or two explaining the basis for your counterstatement (see the previous examples of counterstatements for the Worrier and Critic), but try to end with an “I-­statement.”

• It’s important that you have some belief in your positive self-­talk. Don’t write something down just because it’s positive if you don’t actually believe it. If appropriate, use Socratic questions to challenge your negative self-­talk first, and then follow this up with a positive counterstatement that holds some personal credibility for you.
To get you started, here are some more examples of positive counterstatements you can use with each of the above subpersonalities: The Worrier Instead of “what if...” you can say, “So what,” “I can handle this,” “I can be anxious and still do this,” “This may be scary, but I can tolerate a little anxiety, knowing that it will pass,” or “I’ll get used to this with practice.”
The Critic Instead of putting yourself down, you can say, “I’m okay the way I am,” “I’m lovable and capable,” “I’m a unique and creative person,” “I deserve the good things in life as much as anyone else,” “I accept and believe in myself,” or “I am worthy of the respect of others.”
The Victim Instead of feeling hopeless, you can say, “I don’t have to be all better tomorrow,” “I can continue to make progress one step at a time,” “I acknowledge the progress I’ve made and will continue to improve,” “It’s never too late to change,” or “I’m willing to see the glass as half full rather than half empty.”
The Perfectionist Instead of demanding perfection, you can say, “It’s okay to make mistakes,” “Life is too short to be taken too seriously,” “Setbacks are part of the process and an important learning experience,” “I don’t have to always be...” or “My needs and feelings are as important as anyone else’s.”

Next in the book is topic: Working with Counterstatements

Changing Self-­Talk That Perpetuates Specific Fears and Phobias 

Three factors tend to perpetuate fears and phobias: sensitization, avoidance, and negative, distorted self-­talk. Chapter 7 focused on the first two conditions. A phobia develops when you become sensitized to a particular situation, object, or event—­ in other words, when anxiety becomes conditioned or associated with that situation, object, or event. If panic suddenly arises while you happen to be driving on the freeway or while you’re home alone, you may start feeling anxious every time you’re in either of these situations. Becoming sensitized means that the mere presence of—­or even thoughts about—­a situation may be enough to trigger anxiety automatically.
After sensitization occurs, you may start to avoid the situation. Repeated avoidance is very rewarding, because it saves you from having to feel any anxiety. Avoidance is the most powerful way to hold on to a phobia, because it prevents you from ever learning that you can handle the situation.Self-­Talk 199
The third factor that perpetuates fears and phobias is distorted self-­talk. The more worry and anticipatory anxiety you experience about something you fear, the more likely you are to be involved in unconstructive self-­talk connected with that fear. You may also have negative images about what could happen if you had to face what you fear or about your worst fears coming true.
Both negative self-­talk and negative images serve to perpetuate your fears, guaranteeing that you remain afraid. They also undermine your confidence that you can ever get over your fear. Without negative self-­talk and negative images, you would be much more likely to overcome your avoidance and confront your fear.
Fears come in many forms, but the nature of fearful self-­talk is always the same. Whether you are afraid of crossing bridges, speaking up in a social situation, the sensation of rapid heartbeat, the possibility of serious illness, or your children getting into trouble, the types of distorted thinking that perpetuate these fears are the same. There are three basic distortions: 

1. Overestimating a Negative Outcome Overestimating the odds of something bad happening is one type of distortion. Most of the time your worries consist of “what-­if statements” that overestimate a particular negative outcome.
For example, “What if I panic and lose complete control of myself?” “What if they see me panic and think I’m weird?” “What if I flunk the exam and have to drop out of school?”

2. Catastrophizing The second distortion is thinking that if a negative outcome did occur, it would be catastrophic, overwhelming, and unmanageable. Catastrophic thoughts contain such statements as “I couldn’t handle it,” “I’d be overwhelmed,” “I’d never live it down,” or “They’ll never forgive me.”

3. Underestimating Your Ability to Cope The third distortion is not recognizing or acknowledging your ability to cope if a negative outcome did, in fact, occur. This underestimation of your ability to cope is usually implicit in your catastrophic thoughts.
If you take any fear and examine the negative thinking that contributes to maintaining that fear, you’ll probably find these three distortions. To the extent that you can overcome them with more reality-­based thinking, the fear will tend to drop away. In essence, you can define fear as the unreasonable overestimation of some threat, coupled with an underestimation of your ability to cope.
Here are some examples of how the different types of distortions operate with various fears.
In each example, the three types of distorted thoughts are identified. The distortions are then challenged in each case and modified with more appropriate, reality-­based counterstatements.

Other Types of Distorted Thinking (Cognitive Distortions) 

Overestimating and catastrophizing, along with underestimating your ability to cope, are the most common types of distortions in thinking that contribute to most phobias and fears. There are other types of distortions, however, that can skew the ways in which you perceive and evaluate both yourself and innumerable situations in everyday life. These distortions can contribute not only to anxiety but also to much of the depression, guilt, self-­criticism, and/or cynicism you might feel. Learning to identify and counter these unhelpful modes of thinking with more realistic and constructive self-­talk can go a long way toward helping you handle everyday stresses in a more balanced, objective fashion. This, in turn, will significantly reduce the amount of anxiety, depression, and other unpleasant emotional states you experience. Remember that your immediate experience of the outside world is largely shaped and colored by your own personal thoughts about it. Change your thoughts and you’ll change the way your world appears.
Four additional cognitive distortions that are especially relevant to people dealing with anxiety disorders are described in the pages that follow. Use the examples given under each one to help you identify these distortions when they occur in your own self-­talk. Then write out both your distorted thoughts and appropriate counterstatements, using the Cognitive Distortion Worksheet, which follows. You’ll want to make or download additional copies of this worksheet, reserving several sheets for each of the four types of cognitive distortions.

Overgeneralizing To overgeneralize is to assume (usually falsely) that because you’ve had one bad experience in a particular situation, your bad experience will always repeat itself in similar situations. This happens automatically in the process of developing a phobia—­you have a panic attack in one store, and after a while you start to avoid all stores. (The generalizing of a phobia from one to all instances of a situation is also influenced by a conditioning phenomenon that behavioral psychologists call stimulus generalization.) For example, you conclude that because you’ve had one bad experience with public speaking, you’ll never be able to speak in public successfully. Or because you had one panic attack where you felt terrified and out of control, you assume that the next one and every one thereafter will be equally bad. Or because one person made an unflattering remark about your performance at work or school, you conclude that everyone must see it that way (which then leads you to believe that your work is “objectively” substandard).
The essence of overgeneralizing consists of jumping from one instance in the present to all instances in the future. You can tell that you’re overgeneralizing when your self-­talk includes words such as never, always, all, every, none, no one, nobody, everyone, and everybody, or absolute statements incorporating those words (“I’ll never be able to drive again” or “No one would remain my friend if they really knew me”).

Three types of Socratic questions are effective for rationally challenging and refuting overgeneralizations: 
• What is the evidence for this? 
• What are the odds of this really happening (or being true)? 
• Has this been true in the past?

Filtering Filtering involves selecting and focusing on one negative aspect of a situation so that you ignore any positive aspects. It is a favorite tactic of the Critic. Applied to yourself, you focus on a single fault and ignore any of your assets and strengths. Or at times you may filter out anything positive in your view of a personal relationship.
Filtering commonly occurs in the course of exposure to a phobic situation, when you focus on one setback and ignore all the progress you’ve made. Just because you were able to drive to work alone last week but can’t do it this week, you begin to question the entire process of real-­life exposure. Or because you have one bad panic attack, you ignore the fact that you’ve had fewer panic attacks in the last two months than you did before. Another example would be if you received a job performance evaluation that was mostly positive, but you focused exclusively on the one or two criticisms it contained. It is as if you were wearing a special pair of eyeglasses that filtered out anything positive. It’s like the old joke about the mother who gives her grown son two ties. When he shows up at her house wearing one of them, she asks him, “So what’s wrong with the other tie?”
Be wary of filtering when the following words crop up in your self-­talk: worthless, pointless, hopeless, stupid, failure, dangerous, unfair. In fact, any word you use that is globally negative in scope may indicate that you’re filtering. If you describe someone or something in such terms, reexamine your thinking to see whether you’re viewing things in a balanced way—­one that takes both positive and negative aspects into full account.
Two Socratic questions are often helpful in challenging cognitive distortions due to filtering: 
• Are you looking at the whole picture? (Or: Are you taking both sides of this into account?) 
• Are there positive aspects of this situation (or person, or object) that you’re ignoring?

Emotional Reasoning Emotional reasoning refers to the tendency to judge or evaluate something illogically, totally on the basis of your feelings. There may, of course, be some instances when relying on feelings alone can be useful and appropriate. For example, if you simply don’t feel good about someone you’re just meeting, interviewing, or dating, that may be sufficient reason for you to decide not to proceed with the relationship. In many other cases, though, going solely on feelings and suspending your reason can lead to erroneous conclusions.
One common example of this is to conclude that because you feel a certain way, then you necessarily are that way as well (“I feel useless, therefore I must be useless,” “I feel incompetent, therefore I am incompetent,” or “I feel ugly, therefore I am ugly”). To conclude from one negative feeling or a mood that you inherently and for all time possess that negative quality is like concluding from one rainy day that the sun never shines. “I feel, therefore I am” simply isn’t accurate or true.
An indication of emotional reasoning is when you make decisions totally on impulse, without the mediation of reasoning. While spontaneity argues in favor of doing this on certain occasions, there are many situations where impulsive decisions can create problems. Be wary about making such snap judgments.

Questions you can use to challenge emotional reasoning include: 

• Are you going solely by your feelings? 
• Are you looking at this objectively? 
• What is the evidence that your judgment (based on feelings) is completely accurate?

General Guidelines for Identifying and Countering Self-­Talk

Negative self-­talk is nothing more than an accumulation of self-­limiting mental habits. You can begin to break these habits by noticing occasions when you engage in unconstructive dialogues with yourself and then countering them, preferably in writing, with more positive, rational statements. It took repetition over many years to internalize your habits of negative self-­talk; it will likewise take repetition and practice to learn more constructive and helpful ways of thinking.
Follow the steps below: 
1. Notice. “Catch yourself in the act” of engaging in negative self-­talk. Be aware of situations that are likely to be precipitated or aggravated by negative self-­talk: 
• Any occasion when you’re feeling anxious, including the onset of a panic attack (watch for the Worrier and the cognitive distortions of overestimating and catastrophizing) 
• When you anticipate having to face a difficult task or a phobic situation (again, the Worrier, overestimating, and catastrophizing play a large role) 
• Occasions when you’ve made some kind of mistake and feel critical of yourself (watch for the Critic and overgeneralizing, filtering, and “should statements”) 
• Occasions when you’re feeling depressed or discouraged (watch for the Victim, overestimating, catastrophizing, filtering, and overgeneralizing) 
• Situations where you’re angry at yourself or others (watch for the Critic, the Perfectionist, and any of the above-­described cognitive distortions) 
• Situations where you feel guilty, ashamed, or embarrassed (watch especially for the Perfectionist and “should statements”) 

2. Stop. Ask yourself any or all of the following questions: “What am I telling myself that is making me feel this way?”
“Do I really want to do this to myself?”
“Do I really want to stay upset?”
If the answer to the last two questions is no, proceed to step 3.
Realize that sometimes your answers may actually be yes. You may actually wish to continue to be upset rather than change the underlying self-­talk. Often this is because you’re having strong feelings that you haven’t allowed yourself to fully express. It’s common to stay anxious, angry, or depressed for a period of time when there are strong feelings that you haven’t fully acknowledged—­let alone expressed.

If you’re feeling too upset to easily undertake the task of identifying and countering self-­talk, give yourself the opportunity to acknowledge and express your feelings. If there’s no one available to share them with, try writing them down in a journal. When you’ve calmed down and are ready to relax, proceed with the steps below. (See chapter 12 for more guidelines and strategies.) Another reason you may maintain your anxiety is because you perceive a strong need to “keep everything under control.” Often you’re overestimating some danger or preparing for an imagined catastrophe—­and so staying tense and vigilant is the way in which you give yourself a sense of control. Your vigilance is validated by the feeling of control it gives you. Unfortunately, in the process you can make yourself more and more tense, until you reach a point where your mind seems to race out of control and you dwell on danger and catastrophe almost to the exclusion of anything else. This, in turn, leads to more anxiety and tension. The only way out of this vicious circle is to let go and relax.

The next step, relaxation, is crucial for you to be able to slow down your mind and sort out patterns of negative self-­talk.

3. Relax. Disrupt your train of negative thoughts by taking some deep abdominal breaths or using some methods of distraction. The point is to let go, slow yourself down, and relax.
Negative self-­talk is so rapid, automatic, and subtle that it can escape detection if you’re feeling tense, speeded up, and unable to slow down. You’ll find it difficult to recognize and undo such self-­talk by merely thinking about it: it’s necessary to physically relax first.
In extreme cases, it may take fifteen to twenty minutes of deep relaxation, using breathing, progressive muscle relaxation, or meditation, to slow yourself down enough so that you can identify what you’ve been telling yourself. If you’re not excessively wound up, you can probably do this step in a minute or two.

4. Write down the negative self-­talk or inner dialogue that led you to feel anxious, upset, or depressed. It’s often difficult to decipher what you’re telling yourself by merely reflecting on it. The act of writing things down will help to clarify what specific statements you actually made to yourself. Use the Daily Record of Dysfunctional Thoughts in the exercise following this section to write down your self-­talk.
This step may take some practice to learn. It’s important in identifying self-­talk to be able to disentangle thoughts from feelings. One way to do this is to write down just the feelings first and then uncover the thoughts that led to them. As a general rule, feeling statements contain words expressing emotions, such as “scared,” “hurt,” and “sad,” while self-­talk statements do not contain such words. For example, the statement “I feel stupid and irresponsible” is one in which thoughts and feelings are entangled. It can be broken down into a particular feeling (“I feel upset” or “I feel disappointed”) and the thoughts (or self-­ talk) that logically produce such feelings (“I’m stupid” or “I’m irresponsible”).
To give another example, the statement “I’m too scared to undertake this” mixes a feeling of fear with one or more thoughts. It can be broken down into the feeling (“I’m scared”) which arises from the negative self-­statement (“This is unmanageable” or “I can’t undertake this”). You can ask yourself first, “What was I feeling?” and then ask, “What thoughts were going through my mind to cause me to feel the way I did?”
Always keep in mind that self-­talk consists of thoughts, not feelings. Most of the time these thoughts are judgments or appraisals of a situation or yourself. The feelings are emotional reactions that result from these judgments and appraisals.

5. Identify the type of negative self-­talk you engaged in. (Is it from the Worrier, the Critic, the Victim, or the Perfectionist?) Also, look for any cognitive distortions that were present (such as overestimating, catastrophizing, overgeneralizing, and filtering). After doing this for a while, you’ll become aware of the particular types of negative inner dialogue and particular types of cognitive distortions you’re especially prone to use. With practice, you’ll identify them more quickly as they come up.

6. Counter—that is, answer or dispute—your negative self-­talk with positive, rational, self-­ supportive statements. Answer each negative statement you’ve written by writing down an opposing, positive statement. These counterstatements should be worded so that they avoid negatives and are in the present tense and first person. They should also be believable and feel good to you (in other words, you should feel comfortable with them).
In many cases, you’ll find it helpful to question and refute your negative statements with the Socratic questions enumerated earlier in this chapter.
In other instances, you may imagine a positive counterstatement immediately, without going through a process of rational questioning. This is fine, so long as you have some degree of belief in your counterstatement.

Disrupting Negative Self-­Talk: Short Form

Using the Daily Record of Dysfunctional Thoughts will go a long way to help you overcome long-­ established mental habits that produce anxiety, depression, and low self-­esteem. In many situations, however, you may have neither the time nor the opportunity to write down negative self-­talk and positive counterstatements. Follow the three steps below whenever you wish to disrupt a negative train of thought “on the spot.”

1. Notice that you are engaging in negative self-­talk. The best time to catch yourself involved in negative inner dialogue is when you are feeling anxious, depressed, self-­critical, or upset in general.

2. Stop.

Ask yourself any or all of the following questions: 
“What am I telling myself that is making me feel this way?”
“Do I really want to do this to myself?”
“Do I really want to stay upset?”

3. Relax and engage in some other activity.

In order to break a train of negative self-­talk, you need to switch gears. This can be accomplished by slowing yourself down with deep, abdominal breathing or by finding some other activity in which you can immerse yourself. Often doing something physical (such as exercise, dancing, or household chores) will have the greatest power to supplant negative thinking because it moves you out of your head and into your body. Other coping tactics include engaging in conversation, reading, hobbies and games, relaxation recordings, and music. You can also try a thought-­stopping technique such as shouting “Stop!” or “Get out!” Or you can try a disruptive act like stomping your foot or snapping a rubber band against your wrist.

The purpose of this section is to suggest convenient methods for disrupting negative self-­talk “on the spot.” It is not intended as a substitute for writing out counterstatements or using the Daily Record of Dysfunctional Thoughts. Only by using the latter and practicing over a period of weeks can you begin to effectively change your lifelong habits of negative thinking that arise from the subpersonalities and cognitive distortions described in this chapter.

Ch 9: Mistaken Beliefs

By now you may have asked, “Where does negative self-­talk come from?” In most cases, it’s possible to trace negative thinking back to deeper-­lying beliefs or assumptions about ourselves, others, and life in general. These basic assumptions have been variously called “scripts,” “core beliefs,” “life decisions,” “fallacious beliefs,” or “mistaken beliefs.” While growing up, we learned them from our parents, teachers, and peers, as well as from the larger society around us. These beliefs are typically so basic to our thinking that we do not recognize them as beliefs at all—­we just take them for granted and assume them to reflect reality. Examples of mistaken beliefs that you might hold are “I’m powerless,” “Life is a struggle,” or “I should always look good and act nice, no matter how I feel.” There is nothing new about the idea of mistaken beliefs—­they are a part of what people have in mind when they refer to your “attitude” or “outlook.”
Mistaken beliefs are at the root of much of the anxiety you experience. As discussed in the preceding chapter, you talk yourself into much of your anxiety by anticipating the worst (what-­if thinking), putting yourself down (self-­critical thinking), and pushing yourself to meet unreasonable demands and expectations (perfectionist thinking). Underlying these destructive patterns of self-­talk are some basic false assumptions about yourself and “the way life is.”
You could save yourself quite a bit of worrying, for example, if you let go of the basic assumption, “I must worry about a problem before there’s any chance it will go away.” Similarly, you would feel more confident and secure if you discarded the mistaken belief “I’m nothing unless I succeed” or “I’m nothing unless others love and approve of me.” Once again, life would be less stressful and tense if you would let go of the belief “I must do it perfectly or it’s not worth bothering to try.” You can go a long way toward creating a less anxious way of life by working on changing the basic assumptions that tend to perpetuate anxiety.
Mistaken beliefs often keep you from achieving your most important goals in life. You might ask yourself right now, “What is it that I really want out of life? What would I attempt to do if I knew I could not fail?” Take a few minutes to seriously reflect on this and write your answer in the space below. (Use a separate sheet of paper if you need more room.) Now, if you don’t yet have what you want, ask yourself the simple question, “Why not?” List what reasons you can come up with in the space below or write them on another sheet of paper.

In the process of doing the above exercise, you may have discovered certain beliefs or assumptions that have been holding you back. Are these assumptions truly valid? Examples of assumptions that people hold themselves back with might include “I can’t afford to have what I want,”
“I don’t have the time to go back to school and study the subject that interests me,” or “I don’t have the talent to succeed.” At a more unconscious level, you might even feel “I don’t deserve to have what I truly want.” None of these ideas necessarily reflects the true nature of reality—­they all involve assumptions that might well turn out to be false if actually tested. Often you don’t realize how such assumptions are affecting your behavior until someone else points it out to you.
Mistaken beliefs often set limits on your self-­esteem and self-­worth. Many such beliefs involve the idea that your self-­worth depends on something outside yourself, such as social status, wealth, material possessions, the love of another person, or social approval in general. If you don’t have these things, somehow you believe that you are not worth much. The belief that “Success is everything” or “My worth depends on what I accomplish” places the basis of your self-­esteem outside of you. So does the belief “I’m nothing unless I’m loved (or approved of).”
The truth that takes some people a long time to realize is that self-­worth is inherent. You have an essential value, worth, and dignity just by virtue of the fact that you’re a human being.
You have many qualities and talents, regardless of your outer accomplishments or the approval of others. Without thinking, we respect the inherent value of dogs and cats as animals. So, too, human beings have inherent value just as they are, apart from what they accomplish, what they possess, or whose approval they enjoy. As you grow in self-­esteem, you can learn to respect and believe in yourself apart from what you have accomplished and without relying on others for your good feelings (or making others reliant on you).
Examples of Mistaken Beliefs There are innumerable mistaken beliefs. You have your own collection as a result of what you learned from your parents, teachers, and peers during childhood and adolescence. Sometimes you take on a false belief directly from your parents, such as when you are told “Big boys don’t cry” or “Nice girls don’t get angry.” At other times, you develop an attitude about yourself as a result of being frequently criticized (thus “I’m worthless”), ignored (thus “My needs don’t matter”), or rejected (thus “I’m unlovable”) over many years. The unfortunate thing is that you may live out these mistaken attitudes to the point where you act in ways—­and get others to treat you in ways—­ that confirm them. Like computers, people can be “preprogrammed,” and the mistaken beliefs of childhood can become self-­fulfilling prophecies.
Below are some examples of fairly common mistaken beliefs that tend to influence many people. Following each are counterstatements that replace the negative belief with a positive one, much in the way negative self-­talk was countered by positive self-­statements in the preceding chapter. Positive statements that counter mistaken beliefs are known as affirmations.

• I’m powerless. I’m a victim of outside circumstances.
I’m responsible and in control of my life. Circumstances are what they are, but I can determine my attitude toward them.

• Life is a struggle. Something must be wrong if life seems too easy, pleasurable, or fun.
Life is full and pleasurable. It’s okay for me to relax and have fun. Life is an adventure—­and I’m learning to accept both the ups and the downs.

• If I take a risk, I’ll fail. If I fail, others will reject me.
It’s okay for me to take risks. It’s okay to fail—­I can learn a lot from every mistake. It’s okay for me to be a success.

• I’m unimportant. My feelings and needs are unimportant.
I am a valuable and unique person. I deserve to have my feelings and needs taken care of as much as anyone else.

• I always should look good and act nice, no matter how I feel.
It’s okay simply to be myself.

• If I worry enough, this problem should get better or go away.
Worrying has no effect on solving problems; taking action does.

• I can’t cope with difficult or scary situations.
I can learn to handle any scary situation if I approach it slowly, in small enough steps.

• The outside world is dangerous. There is safety only in what is known and familiar.
I can learn to become more comfortable with the world outside. I look forward to new opportunities for learning and growth that the outside world can offer.
Just recognizing your own particular mistaken beliefs is the first and most important step toward letting go of them. The second step is to develop a positive affirmation to counter each mistaken belief and continue to impress it on your mind until you are “deprogrammed.”

Next in the book are: Mistaken Beliefs Questionnaire

Refer to the questionnaire to identify some of your own unconstructive beliefs.

Countering Mistaken Beliefs

Now that you have an idea of those mistaken beliefs that have the greatest impact on you, how do you go about changing them? The first step is to ask yourself this question: How strongly do I believe in them? There are three possible ways to maintain a mistaken belief: 

• You don’t really believe it. The belief is simply a conditioned habit that you are ready to give up. You recognize the uselessness of the belief and you realize that it has no strong emotional hold on you. If that is the case, you are ready to develop a positive affirmation to counter the belief. You can proceed directly to the section “Guidelines for Constructing Affirmations” and follow the suggested steps for developing affirmations to counter a particular belief. You may also want to see the section “Examples of Affirmations” at the end of the chapter to get ideas for specific alternatives to any of the beliefs on the Mistaken Beliefs Questionnaire.

• You don’t really subscribe to the belief on an intellectual level, but it still has an emotional grip on you and influences the way you act. You don’t want to believe that “it’s always important to be pleasing to others,” for example, but you find that you continue to feel and act as if it were true. It’s hard to “get the belief out of your system.”
If that is the case, it’s important to subject the belief to questions 4 and 5 under “Five Questions for Challenging Mistaken Beliefs” listed below. Identify any belief you rated 3 or 4 that still affects you despite your intellectual doubts. Then use questions 4 and 5 to examine whether the belief is beneficial to your well-­being and whether it developed out of your own choice or from your family history.

• You may really have faith in a particular belief. You’re not convinced that it’s inaccurate; you’ll need some persuading before you’ll consider giving it up. The idea of substituting a positive affirmation in place of an attitude you’ve long believed in seems superficial or naively optimistic. If that is the case, it’s important to subject the belief to questions 1, 2, and 3 under “Five Questions for Challenging Mistaken Beliefs” listed below. These first three questions are taken from the Socratic questions described in chapter 8 and are especially useful for challenging a mistaken belief on a strictly logical level. If you discredit your belief on purely rational grounds, then proceed to questions 4 and 5. These questions will enable you to see how the belief affects your personal well-­being and to determine whether it’s your own belief or was acquired— perhaps from your parents, or in some other way.

Five Questions for Challenging Mistaken Beliefs

1. What is the evidence for this belief? Looking objectively at all of your life experience, what is the evidence that this is true? 

2. Does this belief invariably or always hold true for you? 

3. Does this belief look at the whole picture? Does it take into account both positive and negative ramifications? 

4. Does this belief promote your well-­being and/or peace of mind? 

5. Did you choose this belief on your own or did it develop out of your experience of growing up in your family?

Guidelines for Constructing Affirmations 

• An affirmation should be short, simple, and direct. “I believe in myself” is preferable to “There are a lot of good qualities I have that I believe in.”

• Keep affirmations in the present tense (“I am prosperous”) or present progressive tense (“I am becoming prosperous”). Telling yourself that some change you desire will happen in the future always keeps it one step removed.

• Try to avoid negatives. Instead of saying “I’m no longer afraid of public speaking,” try “I’m free of fear about public speaking” or “I’m becoming fearless about public speaking.” Similarly, instead of the negative statement “I’m not perfect,” try “It’s okay to be less than perfect” or “It’s okay to make mistakes.” Your unconscious mind is incapable of making the distinction between a positive and a negative statement. It can turn a negative statement, such as “I’m not afraid,” into a positive statement that you don’t want to affirm—­that is, “I’m afraid.”

• Start with a direct declaration of a positive change you want to make in your life (“I am making more time for myself every day”). If this feels a little too strong for you just yet, try changing it to “I am willing to make more time for myself.” Willingness to change is the first step you need to take in order to actually make any substantial change in your life. A second alternative to a direct declaration is to affirm that you are becoming something or learning to do something. If you’re not quite ready for a direct statement such as “I’m strong, confident, and secure,” you can affirm “I am becoming strong, confident, and secure.” Again, if you’re not ready for “I face my fears willingly,” try “I’m learning to face my fears.”

• It’s important that you have some belief in—­or at least a willingness to believe in—­your affirmations. It’s by no means necessary, however, to believe in an affirmation 100 percent when you first start out. The whole point is to shift your beliefs and attitudes in favor of the affirmation.

Next are topics: 
% Ways to Work with Affirmations 
% Increasing the Power of an Affirmation (through repetition and feeling) 
% Examples of Affirmations 

Ch 10: Personality Styles That Perpetuate Anxiety

People who are prone to anxiety disorders tend to share certain personality traits. Some of these traits are positive—­such as creativity, intuitive ability, emotional sensitivity, empathy, and amiability. Such traits as these endear anxiety-­prone people to their friends and relatives. Other common traits tend to aggravate anxiety and interfere with the self-­confidence of people with anxiety disorders. This chapter focuses on four of these traits, all of which need to be addressed at some point in the process of recovery.
• Perfectionism 
• Excessive need for approval 
• Tendency to ignore physical and psychological signs of stress 
• Excessive need for control 

You may not possess all four of these traits. But if panic, phobias, or generalized anxiety have been part of your life for any length of time, you probably identify with at least two or three of them.

Next in the book is topic: Origins of Anxiety-­Provoking Traits

10.1. Perfectionism 
% Let Go of the Idea That Your Worth Is Determined by Your Achievements and Accomplishments 
% Recognize and Overcome Perfectionistic Thinking Styles 
% Stop Magnifying the Importance of Small Errors 
% Focus on Positives 
% Work on Goals That Are Realistic 
% Cultivate More Pleasure and Recreation in Your Life 
% Develop a Process Orientation

10.2. Excessive Need for Approval 
% Develop a Realistic View of Other People’s Approval

% Deal with Criticism in an Objective Fashion

An excessive need for approval is often accompanied by an inability to handle criticism.
You can learn to change your attitude toward criticism, ignoring those critical remarks that are unfounded and accepting constructive criticism as a positive learning experience.
The following three guidelines may be helpful:

-- Evaluate the source of the criticism.

If you find yourself criticized, it’s important to ask who is making the criticism. Is this person qualified to criticize you? Does he or she know enough about you, your skills, or the subject involved to make a reasonable assessment? Does this person have a bias that would make it impossible for him or her to be objective? (The more emotionally charged the relationship, the more likely this is to be true.) Is this person speaking emotionally or rationally? You can often soothe the sting of criticism by exploring the answers to these questions.

-- Ask for details.

This is especially important if you receive a blanket criticism, such as “That was a lousy job” or “I don’t think you know what you’re doing.” Don’t accept a global judgment. Ask the person offering the criticism to indicate specific behaviors or issues that seem to fall short.
Ask that person’s point of view about what actions you can take to improve your performance or correct the situation.

-- Decide whether the criticism has some validity.

You’ve evaluated the source of criticism and also, in the case of a global criticism, asked for details. The next question to ask is whether the criticism has some merit. Usually when a criticism has some truth to it, it has a little more sting—­you may feel somewhat pained or disturbed by it. If a criticism has no validity, you’re likely to have little emotional reaction to it at all: you may dismiss it as irrelevant, absurd, or uninformed.
The best way to handle criticism that rings true is to view it as important feedback that can help you learn something about yourself. Also be sure to remind yourself that the criticism is—­or should be—­directed toward only one aspect of your behavior, not toward you as a total person.
Here are some good affirmations to help cultivate a positive response:

• This criticism is a good opportunity to learn something.
• This criticism concerns only a few of my actions, not my entire being.
• Although this criticism feels uncomfortable, it doesn’t mean that I’m totally rejected or disapproved of.

% Recognize and Let Go of Codependency

10.3. Tendency to Ignore Physical and Psychological Signs of Stress

This topic has followig subtopics: 
-- Stress Symptom Checklist 
-- 24 Positive Coping Strategies for Stress

10.4. Excessive Need for Control

Overcoming the excessive need for control takes time and persistence. Four strategies that have been helpful to many people are described in the sections below.
10.4.1. Acceptance 
10.4.2. Cultivating Patience 
10.4.3. Trusting That Most Problems Eventually Work Out 
10.4.4. Developing a Spiritual Approach to Life

Ch 11: Ten Common Specific Phobias

A specific phobia involves a fear of one particular type of object or situation—­for example, flying, a type of animal, or going to the dentist. You tend to avoid the situation altogether or else endure it with dread. The fear is of the situation itself, not of having a panic attack. If you avoid a situation primarily out of fear of having a panic attack, you are more likely to be dealing with agoraphobia (see chapter 1). Yet panic can occur if you unexpectedly find yourself confronted with a specific phobic situation you’ve routinely avoided.
Specific phobias affect many people. More than half of the population in the United States has some degree of performance anxiety, and fear of flying affects approximately 20 percent of the population. To be diagnosed with a specific phobia, however, not only do you have a strong fear and avoidance of a specific situation, but your phobia also interferes significantly with your occupational and/or social functioning. Using this stronger criterion, about 10 percent of the population has a diagnosable specific phobia that causes impairment at some time in their life.
There are many types of specific phobias, and phobia lists enumerate over a hundred types with exotic names. This chapter provides descriptions of ten common types of specific phobias, along with proposed causes and common approaches to their treatment. Resources such as books and audio programs relevant to a particular type of phobia are mentioned, when available. Although the list of common phobias described here is by no means complete, the cognitive behavioral principles and treatment strategies described can be applied to any type of phobia.

The phobias described include the following:

• Performance anxiety 
• Fear of death 
• Fear of flying 
• Claustrophobia 
• Fear of disease (hypochondria) 
• Dental phobia 
• Blood/injection phobia 
• Fear of vomiting (emetophobia) 
• Fear of heights 
• Animal and insect phobias

Follow this chapter in the book for more information such as: "Causes, Treatment, Medication, Learning Resources" on each phobia.

Ch 12: Dealing with Feelings

As you progress in your recovery, you may notice unaccustomed emotions and feelings beginning to surface. This is particularly true if you’re beginning to confront your phobias. It’s entirely normal to experience feelings more intensely when you begin to face situations you’ve been avoiding for a long time. If this is happening to you, you’re on the right track.
Many people who are phobic and prone to anxiety tend to have difficulty with feelings. You may have a problem just knowing what you’re feeling. Or you may be able to identify your feelings but unable to express them. When feelings begin to come up in the course of facing phobias or dealing with panic, there is often a tendency to withhold them, which only aggravates your stress and anxiety. The purposes of this chapter are: 
1) to help you to increase your awareness of feelings and 
2) to give you some tools and strategies for identifying and expressing them more readily.

Some Facts About Feelings

• Feelings, unlike thoughts, involve a total body reaction. They are mediated both by a part of your brain called the limbic system and by the involuntary, autonomic nervous system in your body. When you’re emotionally excited, you “feel it all over” and experience bodily reactions such as increased heart rate, quickened respiration, perspiration, and even shaking or trembling. (Note the similarity to panic, which is another type of intense emotional state.) 

• Feelings do not come out of the blue but are influenced by your thoughts and perceptions. They arise from the way you perceive or interpret outer events and/or the way you react to your own inner thought processes or “self-­talk” (see chapter 8), imagery, or memories. If you can’t identify a stimulus for a particular emotional reaction (for example, a spontaneous panic attack), that stimulus may be unconscious. Feelings are also affected by stress. When you’re under stress, your body is already in a state of physiological arousal similar to that which accompanies an emotion. Since you’re already primed to have emotional reactions, it may not take much to set you off. The particular type of emotion you happen to experience will depend on your view of external events and what you tell yourself about them.

• Feelings can be divided into two groups—­simple and complex. There is much controversy and disagreement about how to do this—­and even whether it can be done—­but for our purposes here, a distinction will be made between basic emotions such as anger, grief, sadness, fear, love, excitement, or joy, and more complex feelings such as eagerness, relief, disappointment, or impatience. Complex feelings may involve a combination of more basic emotions and are also shaped by thoughts and imagery.
Many of the feelings on The Feeling List presented later in this chapter are complex.
Complex feelings can last a long time and are more tied to thought processes, while basic emotions tend to be short-­lived, more reactive, and more tied to involuntary physical reactions mediated by the autonomic nervous system. Fear or panic is a basic emotion, while free-­floating anxiety (anxiety without an object) is an example of a more complex feeling.

• Feelings are what give you energy. If you’re in touch with your feelings and can express them, you’ll feel more energetic. If you’re out of touch with your feelings or unable to give them expression, you may feel lethargic, numb, tired, or depressed. As you’ll see shortly, blocked or withheld feelings can lead to anxiety.

• Feelings often come in mixtures rather than in pure form. Sometimes you may experience a simple, basic emotion such as fear, sadness, or rage. More often, though, you’ll find that you feel two or more emotions at the same time. For example, it’s common to feel anger and fear at the same time when you’re threatened. Or you may feel anger, guilt, and love all at the same time in response to arguing with your partner, parent, or close friend. The common expression sorting out feelings reflects the fact that you can feel several things at once.

• Feelings are often contagious. If you’re close to someone who is crying, you may start to feel sad or even cry yourself. Or you may pick up on another’s excitement or enthusiasm. Phobic and anxiety-­prone individuals are often particularly susceptible to taking on the feelings of people around them. The more you learn to be in touch with and comfortable with your own feelings, the less prone you’ll be to “catch” those of others.

• Feelings are not right or wrong. As reactions, feelings simply exist. Fear, joy, guilt, and anger are not in and of themselves valid or invalid—­you just happen to have these feelings and usually will feel better if you can express them. The perceptions or judgments you made that led to your feelings, however, may be right or wrong, valid or invalid. Be careful not to judge yourself or anyone else as wrong for simply having a feeling, whatever that feeling may be.

• Feelings are often subject to suppression. Sometimes you may actively control or “hold in” your feelings. For example, you’re still upset from an argument with your spouse and then you have to talk to a colleague at work. You deliberately and consciously hold back your feelings, because you know that it would be inappropriate for them to carry over into your work situation. On other occasions, you may start to experience feelings that are unpleasant and decide that you don’t want to deal with them.
Instead of deliberately suppressing them, you just get busy and put your mind on something else—­in essence, you ignore them. This avoidance or evasion of feelings is a subtler form of suppression (which some people speak of as “repression”). Over time, the practice of continually suppressing your feelings can lead to increased difficulty in expressing or even identifying them. When the process of suppression begins in childhood, you tend to grow up being out of touch with your feelings and going through life experiencing a certain numbness or “emptiness.”

Why Phobic and Anxiety-­Prone People Have a Tendency to Suppress Their Feelings

People with anxiety disorders tend to withhold their feelings. There are several reasons for this.
First, many such people tend to have a very strong need for control and/or a fear of losing control. It’s difficult to surrender to the partial loss of control involved in the full experience of your feelings. When feelings have been chronically denied for a long time, they can loom very large and overwhelmingly when they first begin to surface. You can even experience irrational fears of “going crazy” or “coming apart” when you give in to the full force of these long-­withheld feelings. Note that these are the very same fears that occur during a panic attack. In fact, in some cases panic itself may be a signal that suppressed feelings are trying to emerge. Instead of dealing with feelings that seem overwhelming, you panic instead. It’s important to learn that feelings only seem overwhelming or scary at the point when they first begin to surface. This scariness goes away as soon as you allow yourself to accept and feel them. It’s simply not possible to “go crazy” by fully feeling your emotions. In fact, “craziness”—­or severe emotional disturbance—­is more likely to develop as an outcome of not experiencing your feelings.
A second reason why phobic people have difficulty expressing their feelings is because often they grew up in families with overly critical parents who set unrealistically high or perfectionist standards. In such a situation, a child doesn’t feel free to express her or his natural impulses and feelings. Parental approval is so essential to every one of us that we will always suppress our natural reactions and feelings if they are in conflict with parental expectations. As adults, many of us continue to make that choice. Anger is typically the most common feeling to be withheld because it was frequently not tolerated in childhood or its expression was punished. To the child, anger becomes truly dangerous if its expression threatens the continued approval and affection of the parents, on whom that child is completely dependent for survival. More will be said about anger later in this chapter.

Identifying, Expressing, and Communicating Feelings

Because phobic people, by their very nature, tend to be emotionally reactive and have very strong feelings, it is especially important for them to learn to express rather than withhold what they feel. Actually, a three-­stage process is involved here.

Perhaps you have so withheld your emotions that much of the time you don’t even know what you’re feeling. An important first step is to learn how to identify your feelings. Once this awareness and your ability to identify feelings have both developed, the second step is learning to express them. This usually involves being willing to share your feelings with another person.
Alternatively, you may choose to “write out” your feelings in a journal, or physically discharge them (for example, by crying or venting anger into a pillow).
Once you’ve given some expression to your feelings, you’re ready for the third and final step: communicating them to whomever you perceive to have contributed to “triggering” these particular emotions. For the purposes of this chapter, “communicating” a feeling means to let someone know that your feeling involves something he or she said or did. While expressing anger means simply finding a way to discharge it—­for example, telling a neutral friend that you feel angry about something—­ communicating anger means to let someone know that you’re angry about something he or she said or did.
The good news is that identifying, expressing, and communicating your feelings is something that can be learned—­and something that can be improved upon with practice. It does take some time and perseverance, however, if you’ve been accustomed to withholding or ignoring feelings for much of your life.
To sum up, your ability to gain awareness of and express your feelings is an essential part of the process of recovering from anxiety disorders. It is just as important as relaxation, exposure, and the cognitive skills discussed in previous chapters.

Identifying Your Feelings

How can you identify what you’re feeling? It will help to follow these three steps:

1. Recognize the symptoms of suppressed feelings.

2. Tune in to your body.

3. Identify the exact feeling.

Recognize the Symptoms of Suppressed Feelings

Held-­in feelings frequently make themselves known through several types of bodily and psychological symptoms:

% Free-­floating anxiety.

Anxiety arises from many sources. Sometimes it’s simply fear in the face of uncertainty. Sometimes it’s the result of anticipating a negative outcome (“what-­if” thinking). If anxiety doesn’t seem to relate to any specific situation—­if it’s only a vague, undefined uneasiness—­this may be because it arises from strong but unexpressed feelings. Every feeling carries a charge of energy. When we hold that energy in and do not give it expression, it may create a state of tension or vague anxiety. The next time you hold in your anger toward someone, notice whether you feel anxious afterward. Holding in enthusiasm or excitement about something can also produce anxiety.

% Depression.

In his well-­known book The Road Less Traveled, M. Scott Peck defines depression as “stuck feelings.” Often we feel depressed when we’re holding in unexpressed grief or sadness over some loss. Letting out tears and crying often helps us to feel better—­we effectively mourn the loss. Depression can also result from holding in anger. Gestalt psychologists were the first to point out that depression can mask anger turned in against the self. If you find yourself feeling depressed without any obvious recent loss, it may help to ask yourself what you’re angry about.
This is an especially good question if you find that you’re attacking and criticizing yourself.

% Psychosomatic symptoms.

Common psychosomatic symptoms such as headaches, ulcers, high blood pressure, and asthma are often the end result of chronically withheld feelings. While psychosomatic symptoms can arise from any type of chronic stress, the holding in of feelings over many years is a form of stress that is especially likely to take its toll on your body. Learning to identify and express strong feelings can lead to a reduction or even a remission of many types of psychosomatic symptoms.
Muscle tension. Stiff, tight muscles are an especially common symptom of chronically withheld feelings. We tend to tighten certain groups of muscles when we suppress and hold in what we feel. Different feelings are held in by tightening different muscle groups. Anger or frustration is often suppressed by tightening the back of your neck and shoulders. (These are the areas, incidentally, where tension is most commonly experienced in our society.) Grief and sadness can be held in by tightening muscles in the chest and around the eyes. Fear can be held in through tightening up in the stomach/diaphragm area. Withheld sexual feelings may be indicated by a tightening up of muscle groups in the pelvic region.
These correlations between areas of the body and suppression of specific feelings should not be viewed as absolute. Anger, for example, can be held in by tightening many different muscle groups from the eyes to the pelvis. The point is that tight muscles and physical tension in any region may be a sign of chronically bottled-­up feelings. This relationship between suppressed feelings and muscular tension has been explored in great depth by the school of therapy known as bioenergetics. The books of Dr. Alexander Lowen provide a good introduction to this approach.
Any of the above four symptoms may indicate that you’ve been withholding strong feelings.
Once you’ve recognized this, the next step is to tune in to exactly what it is you’re feeling.

Tune In to Your Body

Staying in your head, preoccupied with daily worries and concerns, tends to keep you out of touch with your feelings. To switch gears and gain access to your feelings, it’s necessary to shift your focus from your head to your body. Again, feelings tend to be held in the body. Our use of language reflects this in expressions such as “heartbroken,” “pain in the neck,” and “gut-­level feeling.” By making time to tune in to your body, you can learn to get in touch with and identify your feelings. Many people have found the following steps to be useful.

1. Physically relax. It’s difficult to know what you’re feeling if your body is tense and your mind is racing. Spend five to ten minutes doing progressive muscle relaxation, meditation, or some other relaxation technique to slow yourself down.

2. Ask yourself, “What am I feeling right now?” or alternatively, “What is my main problem or concern right now?”

3. Tune in to that place in your body where you feel emotional sensations such as anger, fear, or sadness. Often this will be in the area of your heart or your gut (stomach/diaphragm), although it may be other areas higher or lower in the body. This is your “inner place of feelings.”

4. Wait and listen to whatever you can sense or pick up on in your place of feelings. Don’t try to analyze or judge what’s there. Be an observer and allow yourself to sense any feelings or moods that are waiting to surface. Simply wait until something emerges.

5. If you draw a blank on steps 3 and 4 or are still stuck in your head (that is, your thoughts are racing), go back to step 1 and start over again. Most likely you need more time to relax. A few minutes of slow, deep breathing will often help to increase your awareness of your feelings.

6. Once you’ve obtained a general sense of what you’re feeling, it may help you to make it seem more concrete by answering the following questions:

• Where in my body is this feeling? 
• What is the shape of this feeling? 
• What is the size of this feeling? 
• If this feeling had a color, what would it be?

If, after taking the time to relax and tune in to what you’re feeling, you still have only a vague sense of what’s there, it may be useful to look at a list of “feeling words” to help you to identify the exact feeling you’re experiencing.

Identify the Exact Feeling: The Feeling List The list of feeling words later in this chapter may help you to identify exactly what you’re feeling. Use the list anytime you have a vague sense of some feeling but are unsure of exactly what it might be: read down the list until a particular feeling word stands out and then check to see if it matches your inner experience.

The Feeling List:

Positive Feelings

Affectionate Great Alive Happy Amused Hopeful Accepted Joyful Beautiful Lovable Brave Loved Calm Loving Capable Loyal Caring Passionate Cheerful Peaceful Cherished Playful Comfortable Pleased Competent Proud Concerned Quiet Confident Relaxed Content Relieved Courageous Respected Curious Safe Delighted Satisfied Desirable Secure Eager Self-reliant Energized Sexy Excited Silly Forgiving Special Friendly Strong Fulfilled Supportive Generous Sympathetic Glad Tender Good Grateful

Negative Feelings 
Afraid, Hostile, Angry, Humiliated, Anxious, Hurt, Apprehensive, Ignored, Ashamed, Impatient, Awkward, Inadequate, Bitter, Incompetent, Bored, Indecisive, Confused, Inferior, Contemptuous, Inhibited, Defeated, Insecure, Dejected ,Irritated, Dependent, Isolated, Depressed, Jealous, Despairing, Lonely, Desperate, Melancholy, Devastated, Miserable, Disappointed, Misunderstood, Discouraged, Muddled, Disgusted, Needy, Distrustful, Outraged, Embarrassed, Overwhelmed, Exasperated, Panicky, Fearful, Tired, Foolish, Touchy, Frantic, Trapped, Frustrated, Troubled, Furious, Unappreciated, Guilty, Unattractive, Hateful, Uncertain, Helpless, Uncomfortable, Hopeless, Uneasy, Horrified, Unfulfilled

Discharging Sadness 
You might want to ask yourself the following questions: 
• Do you ever cry? 
• Under what circumstances do you cry? 
• Do you cry because someone hurt you? Because you feel lonely? Because you’re scared? 
• Do you cry for no apparent reason? 
• Do you cry only when alone or do you permit someone else to see you crying? Sometimes you may have a feeling of being on the verge of tears. You feel like you would like to cry but are having difficulty “getting it out.” At this point, you may find that a particular artistic prompt will help. Evocative pieces of music that have personal significance can often help to elicit tears. Watching an emotional movie, reading poetry or literature, or even certain television commercials may also bring an initially vague sense of sadness to the surface.


Discharging Anger 

Often you may feel angry or frustrated but are reluctant to express it for fear of hurting others. It’s quite possible, and often healthy, however, to discharge your anger in ways that are not destructive—­ways that do not involve “dumping” your anger on someone else. Going through the physical motions associated with aggression will usually bring anger to the surface. The target of these motions, however, always needs to be an inanimate object. All of the following have been helpful to many people in ventilating angry feelings: 
• Hitting a large pillow with both fists 
• Screaming into a pillow 
• Hitting a punching bag 
• Throwing eggs against a wall or into a bathtub 
• Yelling within the confines of a car 
• Chopping wood 
• Hitting a life-­size inflatable doll 
• Hitting an old tennis racket or a plastic bat against the bed 
• Having a vigorous physical workout 

It’s not recommended that you engage in any of the above (with the exception of physical exercise) on a daily basis. There is evidence, reported by Carol Tavris in her book Anger: The Misunderstood Emotion, that excessive ventilation of anger only tends to produce more anger.
The popular term “rageaholic” describes the type of person who has become addicted to anger through excessive expression of it. On the other hand, many phobic and anxiety-­prone people have a tendency to withhold or deny angry feelings under any circumstances. Anger may be such a difficult emotion for you that some additional comments are warranted here.

Dealing with Anger

Of all the different emotions that can give rise to anxiety, anger is the most common and pervasive one. Anger comprises a continuum of emotions ranging from rage at one extreme to impatience and irritation at the other. Frustration is perhaps the most common form of anger that most of us experience.
A proneness to phobias and obsessive-­compulsive behavior is often associated with withheld anger. Your preoccupation with phobias, obsessions, and compulsions increases during those times when you’re feeling most frustrated, thwarted, and otherwise angry with your situation in life. Frequently, however, you are entirely (or almost entirely) unaware of these angry or frustrated feelings.
Why should people suffering from phobias and other anxiety disorders be predisposed to deny or withhold anger? There are several reasons: 

• Individuals who are prone to phobias and anxiety tend to be “people pleasers.” They want to think of themselves—­and appear to others—­as pleasant and nice. That leaves very little room for experiencing, let alone expressing, anger.

• Such people, especially if they suffer from agoraphobia, are often unusually dependent on relationships with significant others. Outward expressions of anger are taboo because they might threaten to alienate the very person on whom the agoraphobic feels dependent for survival.

• People who are prone to anxiety have a high need for control. But anger, when full-­ blown, is probably the least rational and least controllable of our feelings. Giving in to anger, with the attendant loss of control, is very frightening if you are someone who always feels the need to “keep a grip” on yourself.

The consequences of withholding anger over time have been discussed in the previous section detailing the symptoms of suppressed feelings. Generalized anxiety can be a sign of suppressed anger. So can depression or psychosomatic symptoms such as ulcers, neck and upper back tension, or tension headaches. Some additional signs of withheld anger include 

• An increase in phobic concerns or sensitization to new situations without any obvious reason 

• An increase in obsessive thoughts and/or compulsive behaviors 
• Self-­defeating behaviors, such as excessive self-­criticism, maximizing what’s wrong with your life while discounting the good, complaining about problems without taking any action, passive-­aggressive behavior such as procrastination or always being late, blaming others, and worrying about the future instead of enjoying the present

Some Guidelines for Learning to Deal with Anger

1. Be willing to let go of the standard of always having to be nice or pleasing in all situations.
2. Work on overcoming “what-­ifs” about what might happen if you let your anger out.
3. Work on overcoming fears about alienating people you care about when you allow your anger to show.
4. Learn to communicate angry feelings assertively rather than aggressively.
5. Learn to discriminate different modes of expressing anger, depending on the intensity of your feelings.

A Caveat

This section on dealing with anger is intended for you if you have difficulty being aware of or expressing angry feelings. If you tend to withhold your anger, even when you are being taken advantage of or abused, then learning to be more in touch with your angry feelings can be empowering. If you have difficulty standing up for yourself in the face of manipulation or when your boundaries are violated, then appropriate, assertive communication of your anger is something that you will certainly want to learn.
On the other hand, if you feel angry often and find that your angry feelings interfere with your relationships, then obviously you don’t need instructions on how to identify and express your anger! If you’re tired of the emotional and physical toll that frequent anger can take, you’re looking for a different solution. When any emotion is excessive or destructive, the solution lies not in expressing it more but in changing the self-­talk and mistaken beliefs that aggravate that emotion. In brief, while this chapter will be useful if you have difficulty acknowledging or expressing feelings, a more cognitive approach is needed for any feeling that is excessive or destructive to you (for example, anxiety itself). Thus it may be useful, if anger comes too easily and interferes with your relationships, to review chapters 8 and 9.
Anger, like all other emotions, is determined by your perceptions and your internal monologue. Other people and situations don’t, in themselves, “make” you angry: it is your interpretations of what others do and say and your internal commentary about them that stimulate anger.
Often these interpretations and this self-­talk contain an element of distortion. Any of the following cognitive distortions can trigger anger:

• Global labeling.

When you describe someone to yourself as a “bum” or a “jerk,” you write her or him off in a way that ignores the whole person.Dealing with Feelings

• Black-­or-­white thinking.

You see things in extreme terms, so that people or situations are either all good or all bad; there are no shades of gray. You thus often lose sight of the truth of a situation.

• Magnification.

When you blow something out of proportion, you increase your sense of being wronged and victimized. This is a common way of fueling and maintaining anger.

• Entitlement.

When you believe that you should always get what you want, everything should come easily, or life should always be fair, your thinking rests on the mistaken belief that you are naturally entitled to complete gratification of your needs all the time.
This kind of misconception can lead to a lot of self-­defeating anger and blame.

The above examples are just four among several types of distorted thinking that can lead to excessive and destructive anger. A more complete discussion of the mistaken beliefs that can trigger anger may be found in the book When Anger Hurts by Matthew McKay, Peter Rogers, and Judith McKay. If excess anger is interfering with your well-­being and relationships, this book can help.

Communicating Your Feelings to Someone

Communicating your feelings, for the purposes of this chapter, means letting others know that your feelings have something to do with what they said or did. This level of dealing with your feelings is usually riskier than simply expressing them to a third party or setting them down on paper. Yet when you let someone know how you feel toward him or her, you have the greatest likelihood of being able to work through or “complete” the feeling—­in short, to be done with it. You can live in fear or anger toward someone for a long time without any change until you finally let the person know how you feel. Once you do, you no longer need to “hold” the feeling in secret or silence. Sometimes the person you have feelings toward is no longer available or alive, in which case you can still communicate your feelings by writing a letter (see exercise 3 at the end of this chapter).

There are two important rules for communicating your feelings: 

1. Be sure that the person you disclose your feelings to is willing to hear you out and listen.
2. Avoid blaming or belittling the person you’re addressing.

The first rule is important because your feelings are an intimate part of you that deserves respect. If someone isn’t truly ready or willing to hear you, you’re likely to go away feeling discounted and misunderstood. Your sadness, fear, or anger toward the person may even increase.
When you’re ready to tell someone how you feel, ask her or him to make time to listen to you.
You might say, “I have something important to say and I’d appreciate it if you would listen.” If the other person interrupts you, you might say, “Would you please wait until I’m finished?” When others truly listen to you, it means that they give you their undivided attention, don’t interrupt, and don’t offer any advice, opinions, or judgments. They just listen—­silently and attentively. If they have any comments, these can wait until after you’re finished with your communication.
The only appropriate interruption by the other person would be an occasional summary of what you’ve said, just to confirm that he or she heard you accurately. This occasional summarizing by the listener is called active listening and is a skill that you can learn about in any basic book or course on communication. Good listening skills on the part of the person you’re addressing will actually enhance your ability to disclose and communicate what you’re feeling.
The second rule is important because the person you’re speaking to can best listen if you respect him or her and refrain from blaming or making him or her responsible for your feelings.
Three skills are needed to accomplish this: 
1) using first-­person statements, 
2) referring how you feel to the other’s behavior rather than to him or her personally, and 
3) avoiding judging the other person.

1. Use first-­person statements.

When you communicate how you feel to someone, begin what you say with the expression “I feel...” or “I’m feeling...” In this way, you take responsibility for your feelings rather than putting them off onto the other person. The moment you tell someone “You make me feel...” or “You caused me to feel...” you relinquish your responsibility and put the other person on the defensive. Even if part of you wants to cast blame, you’ll get your feelings across more easily and get a better hearing if you begin with “I feel...”

2. Refer to the other person’s behavior rather than making a personal attack.

What do you have feelings about? Although initially it may seem that you’re angry at or scared of the other person, this almost invariably turns out to be an overgeneralization. On further reflection, you’ll find that you’re angered or frightened by something specific that was said or done.
Before communicating your feelings, it’s important to determine what that something was. Then, when you actually speak, complete your first-­person statement with a reference to that specific behavior or statement.

“I’m feeling angry because you didn’t call when you said you would.”
(Not “I had a panic attack because you didn’t call—­not that you’d care” or “You didn’t call, you jerk, and it made me feel awful.”) “I felt threatened when I saw you dancing with your secretary at the party.”
(Not “How could you dance with her when you knew how humiliated I’d feel?” or “You’re so completely insensitive to my feelings.”) “I feel scared when you talk about leaving.”
(Not “I’m scared” or “How can you talk to me like that when you know how vulnerable I am?”) Although right and wrong ways of stating your feelings can involve little more than a difference in wording, it is an important difference. Referring your feelings to people rather than their behavior results in putting either them or yourself in a one-­down position. In the first example, dumping anger on the other person is likely to make him or her feel guilty or angry. Calling someone a jerk will certainly put him or her on the defensive.
In the third example, telling someone you’re afraid of her or him is likely to make you feel more defensive and to promote distance in the relationship. In brief, referring your feelings to a specific statement or behavior lets other people know that you’re upset with something they can change—­rather than with whom they are personally.

3. Avoid judgments.

This point speaks for itself and is an extension of the previous point.
When telling people how you feel about what they said or did, avoid judging them. Your problem is with their behavior, not them. Refraining from judging others will greatly increase the likelihood of their hearing you out.

Looking for the Need Behind Your Feelings

Strong feelings are often a clue to unmet needs. Perhaps you’re feeling anxious because you’re afraid of what other people will think of you if you show signs of panic. The need for acceptance underlies your fear. You experience sadness or grief because you’re alone after the departure of someone you felt close to. The need beneath your grief is for companionship and affection. Or you’re feeling angry because your partner broke an important agreement you had. The need behind your anger is for respect and consideration. Or you may be feeling bored, empty, or depressed because your life seems too dull or routine. The need behind your boredom is for a greater sense of meaning and purpose in your life.
By looking for the need behind your feelings, you give your feelings a new and deeper perspective. You’re not just feeling anger or sadness without reason: you know you have a particular need. Once you’ve gained more insight into your needs, you can begin to address how to go about meeting them. If you ignore or fail to address the needs behind a feeling, you’ll find that the feeling will come up more and more, to the point that it feels as if it will never leave you. Once again, you can view your excessive feelings as a sign rather than a problem. When it gets to the point that you’re asking yourself why you feel sad all the time—­or angry all the time—­that is a sure sign that you need to uncover some unmet need or needs. The subject of how to ask for what you need is dealt with in detail in the following chapter on assertiveness. More will be said about the nature of human needs and the importance of acknowledging and addressing them in the chapter on self-­esteem. If anxiety plays too big a part in your life, take that as a sign that you’re denying some of your basic needs.

Self-­Evaluations 

Self-­Evaluation 1: Developing Awareness of Anger 

Self-­Evaluation 2: Developing Awareness of Sad Feelings 

Exercise 1: Establish a Listening Partner 

Exercise 2: The Feeling Journal 

Exercise 3: Write a Letter Communicating Your Feelings

Ch 13: Being Assertive

Assertiveness is an attitude and a way of acting in any situation where you need to

• Express your feelings 
• Ask for what you want, or 
• Say no to something you don’t want

Becoming assertive involves self-­awareness and knowing what you want. Behind this knowledge is the belief that you have the right to ask for what you want. When you are assertive, you are conscious of your basic rights as a human being. You give yourself and your particular needs the same respect and dignity you’d give anyone else’s. Acting assertively is a way of developing self-­respect and self-­worth.
If you are phobic or anxiety-­prone, you may act assertively in some situations but have difficulty making requests or saying no to family members or close friends. Having perhaps grown up in a family where you felt the need to be perfect and please your parents, you’ve remained a “people pleaser” as an adult. With your spouse or others, you often end up doing many things you don’t really want to do. This creates resentment, which in turn produces tension and sometimes open conflict in your relationships. By learning to be assertive, you can begin to express your true feelings and needs more easily. You may be surprised when you begin to get more of what you want as a result of your assertiveness. You may also be surprised to learn that assertive behavior brings you increased respect from others.

Alternative Behavior Styles

Assertiveness is a way of acting that strikes a balance between two extremes: aggressiveness and submissiveness.

Nonassertive or submissive behavior involves yielding to someone else’s preferences while discounting your own rights and needs. You don’t express your feelings or let others know what you want. The result is that they remain ignorant of your feelings or wants (and thus can’t be blamed for not responding to them). Submissive behavior also includes feeling guilty—­or as if you are imposing—­when you do attempt to ask for what you want. If you give others the message that you’re not sure you have the right to express your needs, they will tend to discount them. Phobic and anxiety-­prone people are often submissive because, as previously mentioned, they are overly invested in being “nice” or “pleasing” to everybody. Or they may be afraid that the open expression of their needs will alienate a spouse or partner on whom they feel dependent.

Aggressive behavior, on the other hand, may involve communicating in a demanding, abrasive, or even hostile way with others. Aggressive people typically are insensitive to others’ rights and feelings and will attempt to obtain what they want through coercion or intimidation. In being aggressive, one succeeds by sheer force, creating enemies and conflict along the way. This often puts others on the defensive, leading them to withdraw or fight back rather than cooperate. For example, an aggressive way of telling someone you want a particular assignment at work would be to say, “That assignment has my name written on it. If you so much as look at the boss when she brings it up during the staff meeting, you’re going to regret it.”
As an alternative to being openly aggressive, many people are passive-­aggressive. If this is your style, instead of openly confronting an issue, you express angry, aggressive feelings in a covert fashion through passive resistance. You’re angry at your boss, so you’re perpetually late to work.
You don’t want to comply with your spouse’s request, so you procrastinate or “forget” about the request altogether. Instead of asking for or doing something about what you really want, you perpetually complain or moan about what is lacking. Passive-­aggressive people seldom get what they want because they never get it across. Their behavior tends to leave other people angry, confused, and resentful. A passive-­aggressive way of asking for a particular assignment at work might be to point out how inappropriate someone else is for the job or to say to a coworker, “If I got more interesting assignments, I might be able to get somewhere in this organization.”
A final nonassertive behavior style is being manipulative. Manipulative people attempt to get what they want by making others feel sorry for or guilty toward them. Instead of taking responsibility for meeting their own needs, they play the role of victim or martyr in an effort to get others to take care of them. When this doesn’t work, they may become openly angry or feign indifference. Manipulation only works as long as those at whom it is targeted fail to recognize what is happening. The person being manipulated may feel confused or “crazy” up to this point; afterward they become angry and resentful toward the manipulator. A manipulative way of asking for a particular assignment at work would be to tell your boss, “Gee, if I get that assignment, I think my boyfriend will finally have some respect for me,” or to tell a coworker, “Don’t breathe a word about this—­but if I don’t get that assignment, I’m going to finally use those sleeping pills I’ve been saving up.”
Assertive behavior, in contrast to the above-­described styles, involves asking for what you want (or saying no) in a simple, direct fashion that does not negate, attack, or manipulate anyone else. You communicate your feelings and needs honestly and directly while maintaining respect and consideration for others. You stand up for yourself and your rights without apologizing or feeling guilty. In essence, assertiveness involves taking responsibility for getting your own needs met in a way that preserves the dignity of other people. Others feel comfortable when you’re assertive because they know where you stand. They respect you for your honesty and forthrightness. Instead of demanding or commanding, an assertive statement makes a simple, direct request, such as “I would really like that assignment” or “I hope the boss decides to give that particular assignment to me.”
Which of the above five descriptions (nonassertive/submissive, aggressive, passive-­aggressive, manipulative or assertive) fits you most closely? Perhaps more than one behavior style applies depending on the situation.

Next in the book is: The Assertiveness Questionnaire

Learning to Be Assertive

Learning to be assertive involves working on yourself in six distinct areas: 1. Developing nonverbal assertive behaviors 2. Recognizing and being willing to exercise your basic rights as a human being298   The Anxiety & Phobia Workbook 3. Becoming aware of your own unique feelings, needs, and wants 4. Practicing assertive responses—­first through writing and role-­playing and then in real life 5. Assertiveness on the spot 6. Learning to say no

Developing Nonverbal Assertive Behaviors

Some of the nonverbal aspects of assertiveness include

• Looking directly at people when addressing them. Looking down or away conveys the message that you’re not quite sure about asking for what you want. The opposite extreme, staring, is also unhelpful because it may put the other person on the defensive.

• Maintaining an open rather than closed posture. If you’re sitting, don’t cross your legs or arms. If standing, stand erect and on both feet. Face the person you’re addressing directly rather than standing off to the side.

• While communicating assertively, do not back off or move away from the other person.
The expression “standing your ground” applies quite literally here.

• Stay calm. Avoid getting overly emotional or excited. If you’re feeling angry, discharge your angry feelings somewhere else before you attempt to be assertive. A calm but assertive request carries much more weight with most people than an angry outburst.
Try practicing the above nonverbal skills with a friend by using role-­playing in situations that call for an assertive response. A list of such situations can be found at the end of the section “Assertiveness on the Spot.”

Recognizing and Exercising Your Basic Rights

Personal Bill of Rights:

1. I have the right to ask for what I want.
2. I have the right to say no to requests or demands I can’t meet.
3. I have the right to express all of my feelings, positive or negative.
4. I have the right to change my mind.
5. I have the right to make mistakes and not have to be perfect.
6. I have the right to follow my own values and standards.
7. I have the right to say no to anything when I feel I am not ready, it is unsafe, or it violates my values.
8. I have the right to determine my own priorities.
9. I have the right not to be responsible for others’ behavior, actions, feelings, or problems.
10. I have the right to expect honesty from others.
11. I have the right to be angry at someone I love.
12. I have the right to be uniquely myself.
13. I have the right to feel scared and say “I feel afraid.”
14. I have the right to say “I don’t know.”
15. I have the right not to give excuses or reasons for my behavior.
16. I have the right to make decisions based on my feelings.
17. I have the right to my own needs for personal space and time.
18. I have the right to be playful and frivolous.
19. I have the right to be healthier than those around me.
20. I have the right to be in a nonabusive environment.
21. I have the right to make friends and be comfortable around people.
22. I have the right to change and grow.
23. I have the right to have my needs and wants respected by others.
24. I have the right to be treated with dignity and respect.
25. I have the right to be happy.

Becoming Aware of Your Own Unique Feelings, Needs, and Wants

Developing an awareness and the ability to express your feelings was discussed in chapter 12.
Being in touch with your feelings is an important prerequisite for becoming assertive. Learning to recognize and take care of your needs and wants will be considered in some detail in the following chapter, on self-­esteem.
It’s difficult to act assertively unless you’re clear about: 
1) what it is you’re feeling and 
2) what it is you want or don’t want.

Assertiveness involves saying how you feel inside and saying directly what changes you would like—­such as “I’m feeling upset right now and I would like you to listen to me.” If you’re feeling confused or ambivalent about your wants or needs, take time to clarify them first by writing them out or talking them out with a supportive friend or counselor. You might also use role-­playing with a friend to ask for what you want in advance. Be sure not to assume that other people already know what you want: you have to make your needs known. Other people aren’t mind readers.

Practicing Assertive Responses

In learning to be more assertive it is often very helpful to play out your responses first on paper.
Write out a problem situation that calls for an assertive response on your part. Then formulate in detail how you’ll handle it. A trial run in writing can allow you to feel more prepared and confident when you actually confront the situation in real life.

Describing Your Problem Situation

In their book Asserting Yourself, Sharon and Gordon Bower suggest that you first select a problem situation from The Assertiveness Questionnaire. Write a description of that situation, including the person involved (who), the time and setting (when), what bothers you about the situation, how you would normally tend to deal with it, what fears you have about consequences that would follow if you were to be assertive, and finally, your behavior goal.
It’s important to be specific in these descriptions. For instance, the following description of a problem situation is too vague: Usually I have a lot of trouble persuading some of my friends to listen to me for a change.
They never stop talking, and I never get a word in edgewise. It would be nice for me if I could participate more in the conversation. I feel that I’m just letting them run over me.
Notice that the description doesn’t specify who the particular friends are, when this problem is most likely to occur, how the nonassertive person acts, what fears are involved in being assertive, and a specific goal for increased involvement in the conversation. A more well-­defined problem situation might be as follows:

My friend Joan (who), when we meet for coffee after work (when), often goes on nonstop about her marriage problems (what). I just sit there and try to be interested (how). If I interrupt her, I’m afraid she’ll think I just don’t care (fear). I’d like to be able to change the subject and talk sometimes about my own life (goal).
Exercise: Specifying Your Problem Situations On a sheet of paper, write up two or three of your own problem situations. Be sure to specify the “who,” “when,” “what,” “how,” “fear,” and “goal,” as described above. If possible, choose situations that are current for you. Begin with a situation that’s not very uncomfortable or overwhelming.
Developing an Assertive Response Now that you’ve defined your problem situations, the next step is to develop an assertive response for each one. For the purposes of learning assertiveness skills, such a response can be broken down into six steps (adapted from the Bowers’ work): 

1. Evaluate your rights within the situation at hand.
2. Designate a time for discussing what you want.
3. Address the main person involved and state the problem in terms of its consequences for you.
4. Express your feelings about the particular situation.
5. Make your request for changing the situation.
6. Tell this person the consequences of gaining (or not gaining) his or her cooperation.

Let’s consider each of these points in greater detail:

1. Evaluate your rights. Refer back to the Personal Bill of Rights. What do you have a right to ask for in this situation?

2. Designate a time. Find a mutually convenient time to discuss the problem with the other person involved. This step, of course, would be omitted in situations when you need to be spontaneously assertive on the spot.

3. State the problem situation in terms of its consequences for you. Don’t make the mistake of expecting other people to be mind readers. Most people are wrapped up in their own thoughts and problems and will have very little idea about what’s going on with you unless you state your case explicitly. Clearly outline your point of view, even if what you’re describing seems obvious to you. This will allow the other person to get a better idea of your position. Describe the problem as objectively as you can, without using language that blames or judges.

Examples “I’m having a problem with your stereo. I need to study for an exam tomorrow and the stereo is so loud I can’t concentrate.”
“I don’t have any way to get to the grocery store today. My support person is sick and I’m out of milk, vegetables, and meat.”
“It seems to me that you do most of the talking when we’re together. I’d like to have the chance to tell you some of my thoughts and feelings, too.”

4. Express your feelings. By telling other people about your feelings, you let them know how greatly their behavior affects you and your reactions. Even if the person you’re addressing completely disagrees with your position, he or she can at least appreciate your strong feelings on an issue.

Each of us owns our personal feelings. Though it might at first seem hard to believe, nobody else causes you to have feelings of fear, anger, or sadness. Other people say and do all kinds of things, but it is your perception—­your interpretation—­of their behavior that is ultimately responsible for what you feel. You don’t necessarily choose how you react to people—­yet your reaction is based on your perception of the meaning of what they say or do.

In expressing feelings, always be sure to own your reactions rather than blame them on someone else. You can still point out what the other person did to stimulate your feelings, but be willing to take ultimate responsibility for them.
The best way to do this is to own your feelings by speaking about them in the first person (for example, “I felt sad when you forgot to call me at the time you said you would”). First-­person statements acknowledge your responsibility for your feelings while second-­person statements generally accuse or judge.

Examples

- Instead of saying, “You make me angry when you don’t hear what I say,” you can say, “I feel angry when you don’t listen to me.”

- Instead of saying, “You show that you have no respect for me or this household when you leave things lying around,” you can say, “I feel demeaned and devalued when you leave things lying around.”

- Instead of saying, “You don’t care about me or my getting better—­you don’t ever help,” you can say, “I feel very sad and unloved when you don’t seem to be helping me in my attempt to get better.”

5. Make your request.

This is the key step to being assertive. You simply ask for what you want (or don’t want) in a direct, straightforward manner. Observe the following guidelines for making assertive requests:

• Use assertive nonverbal behavior.

Stand squarely, establish eye contact, maintain an open posture, and work on staying calm and self-­possessed.

• Keep your request simple.

One or two easy-­to-­understand sentences will usually suffice: “I would like you to take the dog out for a walk tonight,” or “I want us to go to a marriage counselor together.”

• Avoid asking for more than one thing at a time.

• Be specific.

Ask for exactly what you want—­or the person you’re addressing may misunderstand. Instead of saying, “I’d like you to help me with my practice sessions,” specify what you want, such as “I’d like you to go with me when I practice driving on the freeway every Saturday morning.” Or instead of “I would like you to come home by a reasonable hour,” specify “I would like you to come home by twelve midnight.”
• Use “I-­statements” of the following forms: “I would like...”
“I want to...”
“I would appreciate it if...”
It’s very important to avoid using “you-­statements” at the point of actually making a request. Statements that are threatening (“You’ll do this or else”) or coercive (“You have to...”) will put the person you’re addressing on the defensive and decrease the likelihood of your getting what you want.

• Object to behaviors—­not personalities.

When objecting to what someone is doing, object to the specific behavior—­not to the individual’s personality. Let the person know you’re having a problem with something he or she is doing (or not doing), not with who he or she is as a person.
It’s preferable to say, “I have a problem when you don’t call to let me know you’re going to be late,” rather than “I think you’re inconsiderate for not calling me to let me know you’ll be late.”
Referring to the problem behavior preserves respect for the other person. Judging others personally usually puts them on the defensive. When objecting to someone’s behavior (for example, a lack of trustworthiness), always follow up your complaint with a positive request, such as “I would like you to keep your agreements with me.”

• Don’t apologize for your request.

When you want to ask for something, do so directly. Say, “I would like you to...” instead of “I know this might seem like an imposition, but I would like you to...” When you want to decline a request, do so directly but politely. Don’t apologize or make excuses. Simply say,
“No, thank you,”
“No, I’m not interested,” or “No, I’m not able to do that.”

If the other person’s response is one of enticement, criticism, an appeal to guilt, or sarcasm, just repeat your statement firmly until you’ve made your point.

• Make requests, not demands or commands.

Assertive behavior always respects the humanity and rights of the other person. Thus an assertive response is always a request rather than a demand. Demanding and commanding are aggressive modes of behavior based on the false assumption that you are always right or always entitled to get everything your way.

6. State the consequences of gaining (or not gaining) the other person’s cooperation. With close friends or intimate partners, stating positive consequences of their compliance with your request can be an honest offer of give-­and-­take, rather than manipulation.
Examples:

“If you take the dog out, I’ll give you a back rub.”
“If you give me the time to finish this project, then we’ll have more time to do something special together.”

In cases where you are dealing with someone with a history of being resistant and uncooperative, you may describe the natural consequences (usually negative) of a failure to cooperate. If at all possible, any negative consequences should naturally flow out of the objective reality of the situation rather than represent something that you arbitrarily impose. The latter will likely be perceived as a threat and may increase the other person’s resistance.

Examples: “If we can’t leave on time, then I’ll have to leave without you.”
“If you keep talking to me like this, I’m going to leave. We’ll talk again tomorrow.”

Next in the book is: Exercise: Developing an Assertive Response

Assertiveness on the Spot

Many situations arise in the course of everyday life that challenge you to be assertive spontaneously. Someone smokes right next to you, making you uncomfortable. Someone blasts loud music while you’re trying to go to sleep. Someone cuts in front of you in line. (Many of the situations listed in the Your Assertive Style questionnaire at the beginning of this chapter fall into this category.) What do you do? Here are the steps you need to take to be assertive on the spot:

1. Evaluate your rights. Often you’ll go through this step automatically, without the need to pause for reflection; the violation of your rights is obvious and perhaps flagrant. At other times, you may need to pause and think about which of your rights is at stake.

2. Make your request. This is the key step in on-­the-­spot assertiveness. In many cases your assertive response will consist only of this step. Someone interferes with your rights and you simply ask them, in a straightforward manner, for what you want or don’t want. As discussed previously, your statement can begin with such words as “I would like...”
“I want...”
“I would appreciate...”
“Would you please...”

Your statement needs to be: 
• Firm • Simple and to the point 
• Without apology 
• Nonjudgmental, nonblaming 
• Always a request, not a demand

If the person doesn’t immediately cooperate or pretends not to notice, simply repeat your statement. Repeating your request in a monotonous fashion will work better in getting what you want than becoming angry or aggressive if the person you’re dealing with is a stranger. Avoid monotonous repetition if you’re dealing with family or close friends (with the exception of small children).

3. State the problem in terms of its consequences. This step is optional but can be helpful in on-­the-­spot assertiveness. If you feel that the person you’re addressing might be puzzled by your request, you might want to explain why his or her behavior has an adverse effect on you. The other person may gain empathy for your position in this way, leading to a greater chance of cooperation. Here are some examples: “Everyone here, including myself, has been waiting in line” (as a prelude to “Would you go to the back of the line, please?”).
“I am allergic to cigarette smoke” (as a prelude to “Would you please smoke somewhere else?”).

4. Express your feelings. If you’re dealing with a stranger with whom you don’t wish to have any further relationship, it’s usually okay to omit this step. The only occasion for using it with a stranger is if the person involved doesn’t cooperate after you’ve made your assertive request (for example, “I’ve told you twice that I’m not interested in your product and you’re still trying to sell it to me. I’m starting to feel really irritated”). On the other hand, it’s often a good idea to express your feelings when you need to be assertive on the spot with your spouse, child, or close friend (“I’m really disappointed that you didn’t call when you said you would” or “I’m feeling too tired to clean up the kitchen right now”).

5. State the consequences of gaining (or not gaining) cooperation. In situations with strangers, this step usually won’t be necessary. On rare occasions, with someone resistant, you may choose to state negative consequences, although it will be difficult to keep this from coming across as a threat (for example, “If you continue smoking, I may have an asthma attack”). With family and friends, a statement of positive consequences may be used to strengthen your request (“If you get in bed by eight-­thirty, I’ll read you a story”). 1
The gist of being assertive on the spot is simply to make your request in as simple, specific, and straightforward a manner as possible. Whether you choose to mention your feelings or the consequences of the other person’s behavior will largely depend on the situation. Mention consequences when you want the other person to better appreciate your position. Express your feelings when you want the other person to understand how strongly you feel about what he or she is doing (or not doing).

Next in the book is: On-­the-­Spot Assertiveness Exercises

Learning to Say No

An important aspect of being assertive is your ability to say no to requests that you don’t want to meet. Saying no means that you set limits on other people’s demands for your time and energy when such demands conflict with your own needs and desires. It also means that you can do this without feeling guilty.
In some cases, especially if you’re dealing with someone with whom you don’t want to promote a relationship, just saying “No, thank you” or “No, I’m not interested” in a firm, polite manner should suffice. If the other person persists, just repeat your statement calmly without apologizing. If you need to make your statement stronger and more emphatic, you may want to 1) look the person directly in the eyes, 2) raise the level of your voice slightly, and 3) assert your position: “I said no, thank you.”
In many other instances—­with acquaintances, friends, and family—­you may want to give the other person some explanation for turning down the request. Here it’s often useful to follow a three-­step procedure:

1. Acknowledge the other person’s request by repeating it.
2. Explain your reason for declining.
3. Say no.
4. Optional: If appropriate, suggest an alternative proposal where both your and the other person’s needs will be met.

The following suggestions may also be helpful in learning to say no (adapted from Matthew McKay, Peter Rogers, and Judith McKay’s When Anger Hurts): 1. Take your time.
If you’re the type of person who has difficulty saying no, give yourself some time to think and clarify what you want to say before responding to someone’s request (for example, “I’ll let you know by the end of the week” or “I’ll call you back tomorrow morning after sleeping on it”).

2. Don’t overapologize.

When you apologize to others for saying no, you give them the message that you’re “not sure” that your own needs are just as important as theirs. This opens the door for them to put more pressure on you to comply with what they want. In some cases, they may even try to play upon your guilt to obtain other things or to get you to “make it up to them” for having said no in the first place.

3. Be specific.

It’s important to be very specific in stating what you will and won’t do. For example, “I’m willing to help you move, but because of my back I can only carry lightweight items” or “I can take you to work, but only if you can meet me by eight-­fifteen.”

4. Use assertive body language.

Be sure to face the person you’re talking to squarely and maintain good eye contact. Work on speaking in a calm but firm tone of voice. Avoid becoming emotional.

5. Watch out for guilt.

You may feel the impulse to do something else for someone after turning down a request. Take your time before offering to do so. Make sure that your offer comes out of genuine desire rather than guilt. You’ll have fully mastered the skill of saying no to others when you reach the point that you can do so without feeling guilty.

Ch 14: Self-esteem

Self-­esteem is a way of thinking, feeling, and acting that implies that you accept, respect, trust, and believe in yourself. When you accept yourself, you can live comfortably with both your personal strengths and weaknesses without undue self-­criticism. When you respect yourself, you acknowledge your own dignity and value as a unique human being. You treat yourself well in much the same way you would treat someone else you respect. Self-­trust means that your behaviors and feelings are consistent enough to give you an inner sense of continuity and coherence despite changes and challenges in your external circumstances. To believe in yourself means that you feel you deserve to have the good things in life. It also means that you have confidence that you can fulfill your deepest personal needs, aspirations, and goals. To get a sense about your own level of self-­esteem, think of someone (or imagine what it would be like to know someone) whom you fully accept, respect, trust, and believe in. Now ask yourself to what extent you hold these attitudes toward yourself. Where would you place yourself on the following scale:

Very Low Self-­Esteem at Score '0'
To Very High Self-­Esteem at Score '10'

A fundamental truth about self-­esteem is that it needs to come from within. When self-­ esteem is low, the deficiency creates a feeling of emptiness that you may try to fill by latching on—­often compulsively—­to something external that provides a temporary sense of satisfaction and fulfillment. When the quest to fill your inner emptiness by appropriating something from outside becomes desperate, repetitive, or automatic, you have what is called an addiction.
Broadly defined, addiction is an attachment to something or someone outside yourself that you feel you need to provide a sense of inner satisfaction or relief. Frequently, this attachment substitutes preoccupation with a substance or activity for healthy human relationships. It may also substitute a temporary feeling of control or power for a more lasting sense of inner confidence and strength.
A healthy alternative to addiction is to work on building your self-­esteem. Growing in self-­ esteem means developing confidence and strength from within. While still enjoying life fully, you no longer need to appropriate or identify with something or someone outside yourself to feel okay. The basis for your self-­worth is internal. As such, it is much more lasting and stable.

Ways to Build Self-­Esteem

There are many pathways to self-­esteem. It is not something that develops overnight or as a result of any single insight, decision, or modification in your behavior. Self-­esteem is built gradually through a willingness to work on a number of areas in your life. This chapter considers—­in three parts—­a variety of ways to build self-­esteem:

• Taking care of yourself 
• Developing support and intimacy 
• Other pathways to self-­esteem

Most fundamental to your self-­esteem are your willingness and ability to take care of yourself. This means first that you can recognize your basic needs as a human being and then do something about meeting them. Taking care of yourself also involves cultivating a relationship with that part of yourself known as the “inner child.” Your inner child is a place deep inside that is the origin of your needs. It is the playful, spontaneous, and creative side of you—­yet it also carries any emotional pain, fear, or sense of vulnerability you acquired from your childhood.
By becoming a good parent to your own inner child now, you can overcome the limitations and deficiencies of your upbringing years ago. As a popular saying aptly states, “It’s never too late to have a happy childhood.”

Part I of this chapter focuses on this theme of taking care of yourself. It begins by enumerating a variety of dysfunctional family situations that can cause low self-­esteem. Following this is a discussion of basic human needs, to help you identify those needs that are most important to address in your life right now. Finally, a variety of methods for cultivating a relationship with your inner child is offered. Learning to meet your needs—­to care for and nurture yourself—­is the most fundamental and important thing you can do to build your self-­esteem.
Part II of this chapter is an extension of part I. Finding support and intimacy in your life is obviously a major part of taking care of yourself. Other people can’t give you self-­esteem, but their support, acceptance, validation, and love can go a long way toward reinforcing and strengthening your own self-­affirmation. This part is divided into four sections. The first addresses the importance of developing a support system. The second presents ten conditions that are critical to genuine intimacy. The third section offers a discussion of interpersonal boundaries. Having boundaries in your relationships is essential both to intimacy and to self-­esteem. A final section underscores the relevance of assertiveness to self-­esteem.

Part III presents four additional aspects of self-­esteem: 
• Personal wellness and body image 
• Emotional self-­expression 
• Self-­talk and affirmations for self-­esteem 
• Personal goals and a sense of accomplishment

Part I: Taking Care of Yourself 
It’s possible to overcome deficits from your past only by becoming a good parent to yourself.

Some Causes of Low Self-­Esteem: 
1. Overly Critical Parents 
2. Significant Childhood Loss 
3. Parental Abuse 
4. Parental Alcoholism or Drug Abuse 
5. Parental Neglect 
6. Parental Rejection 
7. Parental Overprotectiveness 
8. Parental Overindulgence

Your Basic Needs

Basic human needs conjures an association with shelter, clothing, food, water, sleep, oxygen, and so on—­in other words, what human beings require for their physical survival. It was not until the last few decades that higher-­order psychological needs were identified. While not necessary for survival, meeting these needs is essential to your emotional well-­being and a satisfying adjustment to life. The psychologist Abraham Maslow proposed five levels of human needs, with three levels beyond primary concerns for survival and security. He arranged these levels into a hierarchy, as follows:

Level 5: Self-­Actualization Needs (fulfillment of your potential in life, wholeness)

Level 4: Esteem Needs (self-­respect, mastery, a sense of accomplishment)

Level 3: Belongingness and Love Needs (support and affection from others, intimacy, a sense of belonging)

Level 2: Safety Needs (shelter, stable environment)

Level 1: Physiological Needs (food, water, sleep, oxygen)

In Maslow’s scheme, taking care of higher-­level needs is dependent on having satisfied lower-­ level needs. It’s difficult to satisfy belongingness and esteem needs if you’re starving. On a subtler level, it’s difficult to fulfill your full potential if you’re feeling isolated and alienated for lack of having met needs for love and belongingness. Writing in the 1960s, Maslow estimated that the average American satisfied perhaps 90 percent of physiological needs, 70 percent of safety needs, 50 percent of love needs, 40 percent of esteem needs, and 10 percent of the need for self-­actualization.

Although Maslow defined esteem narrowly in terms of a sense of accomplishment and mastery, full self-­esteem is dependent on recognizing and taking care of all of your needs.
How do you recognize what your needs are? How many of the following important human needs are you aware of?

1. Physical safety and security 

2. Financial security 

3. Friendship 

4. The attention of others 

5. Being listened to 

6. Guidance 

7. Respect 

8. Validation 

9. Expressing and sharing your feelings 

10. Sense of belonging 

11. Nurturing 

12. Physically touching and being touched 

13. Intimacy 

14. Sexual expression 

15. Loyalty and trust 

16. A sense of accomplishment 

17. A sense of progress toward goals 

18. Feeling competent or masterful in some area 

19. Making a contribution 

20. Fun and play 

21. Sense of freedom, independence 

22. Creativity 

23. Spiritual awareness—­connection with a Higher Power 

24. Unconditional love

Now go back over the list carefully and ask yourself how many of these needs you are actually getting fulfilled at this time. In what areas do you come up short? What concrete steps can you take in the next few weeks and months to better satisfy those needs that are going unmet? Working up your exposure hierarchies to overcome your phobias will help you meet needs 17 and 18. Going dancing or to a movie will help in a small way with your need for fun and play.
The point is that learning to take care of yourself involves being able to 1) recognize and 2) meet your basic needs as a human being. The above list may give you ideas on areas of your life that need more attention. Use the following chart to plan what you will actually do in the next month about five (or more) of your needs that could be better met.

Cultivating a Relationship with Your Inner Child 
The concept of the inner child—­the childlike part of yourself—­has been around for many decades. The psychologist Carl Jung referred to it as the “divine child,” while the religious thinker Emmet Fox called it the “wonder child.” But what is it? How would you recognize your own child within? Some characteristics of the inner child include:

• That part of you that feels like a little girl or boy.

• That part of you that feels and expresses your deepest emotional needs for security, trust, nurturing, affection, touching, and so on.

• That part of you that is alive, energetic, creative, and playful (much as real children are when left free to play and be themselves).

• Finally, that part of you that still carries the pain and emotional trauma of your childhood. Strong feelings of insecurity, loneliness, fear, anger, shame, or guilt—­even if triggered by present circumstances—­belong to the inner child. Actually, there are very few new feelings. Especially when they are strong, most of our feelings reflect ways we reacted or failed to react a long time ago as a child.

How do you feel about the little child within you? If you are willing to allow the little girl or boy inside some freedom of expression, you’ll find it easier to be more playful, fun loving, spontaneous, and creative. You’ll find it natural to give and receive affection, to be vulnerable, and to trust. You’ll be in touch with your feelings and free to grow. On the other hand, to the extent that you suppress and deny your inner child, you will likely find it difficult to be playful or have fun.
You may tend to be conventional and conforming and act out painful patterns repeatedly. You may feel constricted and inhibited, unable to let go and expand. It will be hard to be vulnerable or trusting, hard to give and receive affection. Finally, you will likely be out of touch with your feelings, inclined to be overly logical or overly in need of keeping everything under tight control.
How can you bring out and cultivate a healthy relationship with your inner child? In my experience there are four steps to this process:

1. Overcoming attitudes of criticism, rejection, and/or denial of your child within 

2. “Bringing out” your inner child 

3. Reevaluating negative feeling states in terms of the positive needs of your inner child 

4. Nurturing your inner child on a daily basis

Overcoming Negative Attitudes Toward Your Inner Child

A basic truth is that you tend to treat your own inner child in much the same way that your parents treated you as a child. For better or worse, you internalize your parents’ attitudes and behaviors. If they were overly critical toward you, you likely grew up overly self-­critical, especially of your “childish” or less rational, more impulsive side. If they neglected you, you likely grew up324   The Anxiety & Phobia Workbook tending to ignore or neglect the needs of your own inner child. If they were too busy for you as a child, you’re likely to be too busy for your inner child as an adult. If they abused you, you may have become self-­destructive as an adult or else may be abusive of others. If your parents placed a taboo on acknowledging and expressing your feelings and impulses, you may have grown up denying your feelings. The list goes on. To cultivate a healing, caring relationship with your own inner child—­to become a good parent to yourself—­you need to overcome any internalized parental attitudes that cause you to criticize, abuse, neglect, or deny the needs and feelings of your child within.

Bringing Out Your Inner Child

While learning to overcome negative patterns internalized from your parents, you may wish to begin bringing out your inner child. It’s useful to begin this even before you work through all of the limitations you’ve imposed on your child within. There are a number of good ways to go about doing this, including 1) visualizations, 2) writing a letter to your inner child, 3) using photos as a reminder, and 4) real-­life activities that give your inner child expression. You may be surprised to find that caring for your own inner child is a lot less timeand energy-consuming than bringing up a real one!

Next in the book are topics: 
    
% Visualization: to help you foster a closer relationship with your own inner child 

% Write a Letter to Your Inner Child 

% Photographs (of yourself as a child) 

% Real-­Life Activities (to get into the spirit of being a child) 

% Reevaluating Negative Feelings as the Positive Needs of Your Inner Child 

% Examples of Disguised Pleas for Help from Your Inner Child 

% Nurturing Your Inner Child on a Daily Basis 

Self-­Nurturing Activities

The following list has been very helpful to many of my clients who suffer from anxiety disorders or depression. By performing at least one or two items from the list every day, or anything else you find pleasurable, you will grow in the important skill of becoming a good parent to yourself. You have nothing to lose but your sense of insecurity and inadequacy—­and nothing to gain except increased self-­esteem.

1. Take a warm bath or shower.
2. Have breakfast in bed.
3. Take a sauna.
4. Get a massage.
5. Buy yourself a rose.
6. Take a bubble bath.
7. Go to a pet store and play with the animals.
8. Walk on a scenic path in a park.
9. Visit a zoo.
10. Have a manicure or pedicure.
11. Stop and smell some flowers.
12. Wake up early and watch the sunrise.
13. Watch the sunset.
14. Relax with a good book and/or soothing music.
15. Go rent a funny video.
16. Play your favorite music and dance to it by yourself.
17. Go to bed early.
18. Sleep outside under the stars.
19. Take a “mental health day” off from work.
20. Fix a special dinner just for yourself and eat by candlelight.
21. Go for a walk.
22. Call a good friend—­or several good friends.
23. Go out to a fine restaurant just with yourself.
24. Go to the beach.
25. Take a scenic drive.
26. Meditate.
27. Buy new clothes.
28. Browse in a book or record store for as long as you want.
29. Buy yourself a cuddly stuffed animal and play with it.
30. Write yourself a love letter and mail it.
31. Ask a special person to nurture you (feed, cuddle, and/or read to you).
32. Buy yourself something special that you can afford.
33. Go see a good film or show.
34. Go to the park and feed the ducks, swing on the swings, and so on.
35. Visit a museum or another interesting place.
36. Give yourself more time than you need to accomplish whatever you’re doing (let yourself dawdle).
37. Work on your favorite puzzle or puzzle book.
38. Go into a hot tub or Jacuzzi.
39. Make a recording of affirmations.
40. Write out an ideal scenario concerning a goal, then visualize it.
41. Read an inspirational book.
42. Write a letter to an old friend.
43. Bake or cook something special.
44. Go window shopping.
45. Buy a meditation CD or download one.
46. Listen to a positive, motivational recording.
47. Write in a special diary about your accomplishments.
48. Apply fragrant lotion all over your body.
49. Masturbate.
50. Exercise.
51. Sit and hold your favorite stuffed animal.

Part II: Developing Support and Intimacy

While self-­esteem is something we build within ourselves, much of our feeling of self-­worth is determined by our significant personal relationships. Others cannot give you a feeling of adequacy and confidence, but their acceptance, respect, and validation of you can reaffirm and strengthen your own positive attitude and feelings about yourself. Self-­love becomes narcissistic in isolation from others. Let’s consider four pathways to self-­esteem that involve relationships with others:

• Close friends and support 
• Intimacy 
• Boundaries 
• Assertiveness

Close Friends and Support

When surveys of human values have been done, many people rank close friends near the top, along with career, a happy family life, and health. Each of us needs a support system of at least two or three close friends in addition to our immediate family. A close friend is someone you can deeply trust and confide in. It is someone who comfortably accepts you as you are in all your moods, behaviors, and roles. It is also someone who will stand by you no matter what is happening in your life. A close friend allows you the opportunity to share your feelings and perceptions about your life outside your immediate family. Such a person can help bring out aspects of your personality that might not be expressed with your spouse, children, or parents.
At least two or three close friends of this sort, whom you can confide in on a regular basis, are an essential part of an adequate support system. Such friends can help provide continuity in your life through times of great transition, such as moving away from home, divorce, or the death of a family member.
How many close friends of the type just described do you have? If you don’t have at least two, what could you do to cultivate such friendships?

Intimacy

While some people seem content to go through life with a few close friends, most of us seek a special relationship with one particular person. It is in intimate relationships that we open ourselves most deeply and have the chance to discover the most about ourselves. Such relationships help overcome a certain loneliness that most of us would eventually feel—­no matter how self-­sufficient and strong we may be—­without intimacy. The sense of belonging that we gain from intimate relationships contributes substantially to our feelings of self-­worth. However, self-­worth cannot be derived entirely from someone else. A healthy intimate relationship simply reinforces your own self-­acceptance and belief in yourself.
Much has been written on the topic of intimacy and on what ingredients contribute to lasting intimate relationships. Some of the most important of these are listed below (not ranked in any order):

1. Common interests, especially leisure time and recreational interests. (A few differences in interests, though, can add some novelty and excitement.)

2. A sense of romance or “magic” between you and your partner. This is an intangible quality of attraction that goes well beyond the physical level. It’s usually very strong and steady in the first three to six months of a relationship. The relationship then requires the ability to renew, refresh, or rediscover this magic as it matures.

3. You and your partner need to be well matched in your relative needs for togetherness versus independence. Conflict may arise if one of you has a much greater need for freedom and “space” than the other, or if one of you has a need for protection and coziness that the other doesn’t want to provide. Some partners may hold a double standard—­in other words, they’re unwilling to allow you what they require for themselves (such as trust and freedom).

4. Mutual acceptance and support of each other’s personal growth and change. It is well known that when only one person is growing in a relationship, or when one person feels invalidated in his or her growth by the other, the relationship often ends.

5. Mutual acceptance of each other’s faults and weaknesses. After the initial romantic months of a relationship are over, each partner must find enough good in the other to tolerate and accept the other’s faults and weaknesses.

6. Regular expressions of affection and touching. An intimate relationship cannot be healthy without both partners being willing to overtly express affection. Nonsexual expressions such as hugging and cuddling are just as important as a sound sexual relationship.

7. Sharing of feelings. Genuine closeness between two people requires emotional vulnerability and a willingness to open up and share your deepest feelings.

8. Good communication. Entire books and courses are devoted to this subject. While there are many different aspects to good communication, the two most important criteria are that:

• The partners are genuinely willing to listen to each other, and

• Both are able to express their feelings and ask for what they want directly (as opposed to complaining, threatening, demanding, and otherwise attempting to manipulate the other to meet their needs).

9. A strong sense of mutual trust. Each person needs to feel that he or she can rely on the other. Each also trusts the other with his or her deepest feelings. A sense of trust does not come automatically; it needs to be built over time and maintained.

10. Common values and a larger sense of purpose. An intimate relationship has the best opportunity to be lasting when two people have common values in important areas of life such as friendships, education, religion, finances, sex, health, and family life. The strongest relationships are usually bound by a common purpose that transcends the personal needs of each individual—­for example, raising children, running a business, or a commitment to a spiritual ideal.
How many of the above ten characteristics are present in your intimate relationship? Are there any, in particular, that you would like to work on?

Boundaries

Just as important as intimacy is the need for each of us to maintain appropriate boundaries within both intimate and other relationships. Boundaries simply mean that you know where you end and the other person begins. You don’t define your identity in terms of the other person. And above all, you don’t derive your sense of self-­worth and self-­authority by attempting to take care of, rescue, change, or control the other person. The term “codependent” (or expressions like “women who love too much”) has often been used to define those people who, because they lack a solid, internal basis of self-­worth, attempt to validate themselves through taking care of, rescuing, or simply pleasing another person. The classic case of this is the person who attempts to organize his or her life around “rescuing” an alcoholic or otherwise addicted spouse or close relative. But loss of boundaries can occur in any relationship in which you attempt to gain self-­worth and security by overextending yourself to take care of, control, rescue, or change someone else. Your own needs and feelings are set aside and discounted in the process. A good indication of loss of boundaries is when you spend more time talking or thinking about another’s needs or problems than your own.
Two excellent books are recommended if you want to further explore boundary issues in your own relationships. In her best-­selling book Women Who Love Too Much, Robin Norwood advocates the following steps in overcoming codependency in a close relationship:

1. Going for help—­giving up the idea you can handle it alone

2. Making recovery from codependency your highest priority

3. Finding a support group of peers who understand the problem

4. Developing a personal spiritual life that allows you to let go of self-­will and rely on a Higher Power

5. Learning to stop managing, controlling, or “running the life” of another or others you love

6. Learning to let go of playing the game of “rescuer” and/or “victim” with the other person

7. Facing and exploring your own personal problems and pain in depth

8. Cultivating yourself: developing a life of your own and pursuing your own interests

9. Becoming “selfish”—not in the unhealthy sense of egoism but in the sense that you put your well-­being, desires, work, play, plans, and activities first instead of last

10. Sharing what you have learned with others

Another excellent book that carefully defines codependency and provides a series of steps for overcoming the problem is Codependent No More by Melody Beattie. Some of her recommendations include

1. Practicing “detachment”—­letting go of obsessively worrying about someone else

2. Letting go of the need to control someone else—­respecting that person enough to know that he or she can take responsibility for his or her own life

3. Taking care of yourself, which includes finishing up “unfinished business” from your own past and learning to nurture and cherish the needy, vulnerable child within

4. Improving communication—­learning to state what you want and to say no

5. Dealing with anger—­giving yourself permission to feel and express anger at loved ones when you need to

6. Discovering spirituality—­finding and connecting with a Higher Power.

Is codependency an issue for you? Have you considered joining a support group that focuses on codependency issues, such as Al-­Anon or Codependents Anonymous?

Assertiveness

Cultivating assertiveness is critical to self-­esteem. If you’re unable to clearly get across to others what you want or do not want, you will end up feeling frustrated, helpless, and powerless.
If you do nothing else, the practice of assertive behavior in and of itself can increase your feeling of self-­respect. Honoring your own needs with other people in an assertive manner also increases their respect for you, and quickly overcomes any tendency on their part to take advantage of you.
The concept of assertiveness, along with exercises for developing an assertive style of communication, is presented in chapter 13 of this workbook.

Part III: Other Pathways to Self-­Esteem

The first two parts of this chapter focused on taking care of your needs through honoring your inner child and developing support and intimacy in your relationships. In this final part, four other pathways to self-­esteem that involve different levels of your whole being are described.

• Body: physical well-­being and body image 

• Feelings: emotional self-­expression 

• Mind: positive self-­talk and affirmations for self-­esteem 

• Whole self: personal goals and a sense of accomplishment

Although these areas have been considered elsewhere in this workbook, they are discussed briefly here for their relevance to self-­esteem.

Physical Well-­Being and Body Image

Physical health and a sense of personal wellness, vitality, and robustness compose one of the most important foundations of self-­esteem. It’s often difficult to feel good about yourself when you’re feeling physically weak, tired, or ill. Current evidence points to the role of physiological imbalances—­often caused by stress—­in the genesis of panic attacks, agoraphobia, generalized anxiety, and obsessive-­compulsive disorder. Improving your physical well-­being will have a direct impact on your particular problem with anxiety, as well as contribute substantially to your self-­esteem. The chapters on relaxation, exercise, and nutrition relate directly to physical well-­being. Reading them and putting into practice the suggestions and guidelines offered will go a long way toward upgrading your personal wellness. The questionnaire below is intended to give you an overview of how you are doing in this area.

Next in the book are topics: 
    
% Personal Wellness Questionnaire 

% Emotional Self-­Expression 

% Self-­Talk and Affirmations for Self-­Esteem 

% Personal Goals and a Sense of Accomplishment 

% List your Personal Accomplishments 

When you catch yourself engaging in self-­critical or self-­victimizing inner dialogues, follow these three steps:

1. Disrupt the chain of negative thoughts with some method that diverts your attention away from your mind and helps you to be more in touch with your feelings and body. Any of the following may work: 

• Physical activity—­for example, household chores or exercise 

• Taking a walk outside 

• Abdominal breathing 

• Five minutes of progressive muscle relaxation 

• Shouting “Stop!” aloud or silently 

• Snapping a rubber band against your wrist

The point is to do something that slows you down and gives you a bit of distance from your negative thoughts. It’s difficult to counter negative self-­talk when you’re tense and your mind is racing.

2. Challenge your negative self-­talk with appropriate questioning, if necessary. Good questions to raise with your Critic or Victim might be “What’s the evidence for this?” “Is this always true?” and “Am I looking at both [or all] sides of this issue?” Review the list of Socratic questions in chapter 8 for other examples of questions.

3. Counter your negative inner dialogue with positive, self-­supportive statements. You may want to design your own positive statements specifically tailored to refute your Critic’s or Victim’s statements, one by one. Alternatively, you can draw positive counterstatements from the following list of affirmations.

Ch 15: Nutrition

Relatively little has been written on the subject of nutrition and anxiety disorders. Yet if it is assumed that there is at least some biological basis for panic attacks and anxiety, the subject of nutrition becomes important. What you eat has a very direct and significant impact on your physiology and biochemistry.
In the last twenty years, the relationship between diet, stress, and mood has been well documented. It’s known that certain foods and substances tend to create additional stress and anxiety, while others promote a calmer and steadier mood. Certain natural substances have a directly calming effect and others are known to have an antidepressant effect. You may not yet recognize connections between how you feel and what you eat. You simply may not notice that the amount of coffee or cola beverages you drink aggravates your anxiety level. Or you may be unaware of any connection between your consumption of sugar and your anxiety, depression, or PMS symptoms. This chapter may clarify some of these connections and help you to make positive changes in the way you feel.

The discussion of nutrition in this chapter covers three main topics:

• Foods, substances, and conditions that aggravate anxiety 

• Dietary guidelines for reducing anxiety 

• Supplements for reducing anxiety

The information in these sections is based on my personal experience and reading in the field of nutrition. It is intended to be suggestive only—­not prescriptive. If you wish to make an in-­depth assessment and reevaluation of your diet, consult with a nutritionist, or a holistic physician who is knowledgeable about nutrition.

Substances That Aggravate Anxiety

Stimulants: Caffeine

Of all the dietary factors that can aggravate anxiety and trigger panic attacks, caffeine is the most notorious. Several of my clients can trace their first panic attack to an excessive intake of caffeine. Many people find that they feel calmer and sleep better after they’ve reduced their caffeine consumption. Caffeine has a directly stimulating effect on several different systems in your body. It increases the level of the neurotransmitter norepinephrine in your brain, causing you to feel alert and awake. It also produces the very same physiological arousal response that is triggered when you are subjected to stress—­increased sympathetic nervous system activity and a release of adrenaline.
In short, too much caffeine can keep you in a chronically tense, aroused condition, leaving you more vulnerable to generalized anxiety, as well as panic attacks. Caffeine further contributes to stress by causing a depletion of vitamin B 1 (thiamine), which is one of the so-­called antistress vitamins.
Caffeine is contained not only in coffee but in many types of tea, cola beverages, chocolate candy, cocoa, and over-­the-­counter drugs. Use the chart on the next page to determine your total daily caffeine consumption in milligrams (mg).
Use the Caffeine Chart provided in this chapter to track your caffeine intake. If you are prone either to generalized anxiety or to panic attacks, consider reducing your total caffeine consumption to less than 100 mg per day. For example, one cup of percolated coffee or one diet cola beverage a day would be a maximum. For coffee lovers, this may seem like a major sacrifice, but you may be surprised to find how much better you feel if you can wean yourself down to a single cup in the morning. The sacrifice may well be worth it if you have fewer panic attacks. If you are very sensitive to caffeine, eliminating it altogether would be advisable.
Please note that there are tremendous individual differences in sensitivity to caffeine. As with any addictive drug, chronic caffeine consumption leads to increased tolerance and a potential for withdrawal symptoms. If you have been drinking five cups of coffee a day and abruptly cut down to one a day, you may have withdrawal reactions including fatigue, depression, and headaches.
It’s better to taper off gradually over a period of a few months—­for example, from five cups to four cups per day for a month, then two or three cups per day for the next month, and so on. Some people like to substitute decaffeinated coffee, which has about 3 mg of caffeine per cup, while others drink herbal teas such as green tea. At the opposite extreme of the sensitivity continuum are people who are made jittery by a single cola or cup of tea. Some of my clients have found that even small amounts of caffeine predispose them to panic or a sleepless night. So it’s important that you experiment to find out what your own optimal daily caffeine intake might be. For most people prone to anxiety or panic, this turns out to be less than 100 mg per day, and sometimes none at all.

% Nicotine 
% Stimulant Drugs (drugs that contain amphetamines)

Substances That Stress the Body 
% Salt 
Excessive salt (sodium chloride) stresses the body in two ways: 1) it can deplete your body of potassium, a mineral that’s important to the proper functioning of the nervous system, and 2) it raises blood pressure, putting extra strain on your heart and arteries and hastening arteriosclerosis. You can reduce the amount of salt you consume by avoiding the use of table salt, using a natural salt substitute (such as tamari) both in cooking and on the table, and limiting, as much as possible, salty meats, salty snack foods, and other processed foods containing salt. As a rule of thumb, it’s good to limit your salt intake to one gram or teaspoon per day. If you must buy processed foods, choose those that are labeled low sodium or salt-­free.

% Preservatives 
% Hormones in Meat

Stressful Eating Habits

Stress and anxiety can be aggravated not only by what you eat but by the way you eat. In our modern, fast-­paced society, many of us simply do not give ourselves enough time for eating. Any of the following habits can aggravate your daily level of stress:

• Eating too fast or on the run

• Not chewing food at least fifteen to twenty times per mouthful (food must be partially predigested in your mouth to be adequately digested later)

• Eating too much, to the point of feeling stuffed or bloated 

• Drinking too much fluid with a meal, which can dilute stomach acid and digestive enzymes; one cup of fluid with a meal is sufficient.

All of the above put a strain on your stomach and intestines in their attempt to properly digest and assimilate food. This adds to your stress level in two ways: 

• Directly, through indigestion, bloating, and cramping 

• Indirectly, through malabsorption of essential nutrients

Sugar, Hypoglycemia, and Anxiety

Among nutritionally conscious people these days, sugar has become somewhat of a dirty word.
The fact is, however, that your body and brain need glucose—a naturally occurring product of the breakdown of sugar—­in order to operate. Glucose is the fuel your body burns; it provides the energy that sustains life. Much of this glucose is derived from carbohydrate foods in your diet such as bread, cereal, potatoes, vegetables, fruits, and pasta. The starches in these foods are broken down into glucose.

Simple sugars, on the other hand, such as refined white sugar, brown sugar, and honey, break down very quickly into glucose. These simple sugars can cause problems because they tend to overload your system with too much sugar too quickly. Our bodies are simply not equipped to process large amounts of sugar rapidly; in fact, it was not until the twentieth century that most of us (other than the very wealthy) consumed large amounts of refined sugar. Today, the standard American diet includes sugar in most beverages (coffee, tea, cola), sugar in cereal, sugar in salad dressings, and sugar in processed meat, along with one or two desserts per day and perhaps a donut or a cookie on coffee breaks. In fact, the average American consumes about 120 pounds of sugar per year! The result of continually bombarding the body with this much sugar is the creation of a chronic disregulation in sugar metabolism. For some people, this disregulation can lead to excessively high levels of blood sugar, or diabetes (the prevalence of which has increased dramatically in this century, to nearly one in five). For other individuals, the problem is just the opposite—­periodic drops in blood sugar level below normal, a condition that is popularly termed hypoglycemia.
The symptoms of hypoglycemia tend to appear when your blood sugar drops below 50 to 60 milligrams per deciliter—­or when it drops very rapidly from a higher to a lower level. Typically, this occurs about two to three hours after eating a meal. It can also occur simply in response to stress, since your body burns up sugar very rapidly under stress. The most common subjective symptoms of hypoglycemia are

• Light-­headedness 
• Anxiety 
• Trembling 
• Feelings of unsteadiness or weakness 
• Irritability 
• Palpitations

Do the symptoms look familiar? All of them are symptoms that can accompany a panic attack! In fact, for some people panic reactions may actually be caused by hypoglycemia. Generally, such people recover from panic simply by having something to eat. Their blood sugar rises and they feel better. (In fact, an informal, nonclinical way to diagnose hypoglycemia is to determine whether you have any of the above symptoms three or four hours after a meal, and whether they then go away as soon as you have something to eat.) The majority of people with panic disorder or agoraphobia find that their panic reactions do not necessarily correlate with bouts of low blood sugar. Yet hypoglycemia can aggravate both generalized anxiety and panic attacks that have been caused for other reasons.
What causes blood sugar to fall below normal is an excessive release of insulin by the pancreas.
Insulin is a hormone that causes sugar in the bloodstream to be taken up by the cells. (Insulin is used in the treatment of diabetes to lower excessive blood sugar levels.) In hypoglycemia, the pancreas tends to overshoot in its production of insulin. This can happen if you ingest too much sugar, with the result that you feel a temporary sugar high followed a half hour later by a crash.
This can also happen in response to sudden or chronic stress. Stress can cause a rapid depletion of blood sugar. You then experience confusion, anxiety, spaciness, and tremulousness because 1) your brain is not getting enough sugar and 2) a secondary stress response occurs. When blood sugar falls too low, your adrenal glands kick in and release adrenaline and cortisol, which causes you to feel more anxious and aroused and also has the specific purpose of causing your liver to release stored sugar in order to bring your blood sugar level back to normal. So the subjective symptoms of hypoglycemia arise from both a deficit of blood sugar and a secondary stress response mediated by the adrenal glands.
Hypoglycemia can be formally diagnosed through a clinical test called the six-­hour glucose tolerance test. After a twelve-­hour fast you drink a highly concentrated sugar solution. Your blood sugar is then measured at half-­hour intervals over a six-­hour period. You will likely get a positive result on this test if you have a moderate to severe problem with hypoglycemia. Unfortunately, many milder cases of hypoglycemia are missed by the test. It’s quite possible to have subjective symptoms of low blood sugar and to test negative on a glucose tolerance test. Any of the following subjective symptoms are suggestive of hypoglycemia: • You feel anxious, light-­headed, weak, or irritable several hours after a meal (or in the middle of the night); these symptoms disappear within a few minutes of eating.

• You get a high feeling from consuming sugar, and this changes to a depressed, irritable, or spacey feeling twenty to thirty minutes later.

• You experience anxiety, restlessness, or even palpitations and panic in the early morning hours, between four and seven. (Your blood sugar is lowest in the early morning because you have fasted all night.) How do you deal with hypoglycemia? Fortunately, it’s quite possible to overcome problems with low blood sugar by: 

1) making several significant dietary changes and 

2) taking certain supplements. 

If you suspect that you have hypoglycemia or have had it formally diagnosed, you may want to implement the following guidelines. Doing so may result in a calmer disposition—­ less generalized anxiety, less emotional volatility, and less vulnerability to panic. You may also notice that you are less prone to depression and mood swings.

Next in the book are topics: 
% Dietary Modifications for Hypoglycemia (low sugar) 
% Supplements for maintaining blood sugar levels.
% Food Allergies and Anxiety

% Move Your Diet in the Direction of Vegetarianism

How can vegetarianism lead to a calmer disposition? Earlier in this chapter, it was mentioned that steroid hormone residues in red meat can exert an effect not unlike the body’s own steroid hormones, activating natural defenses against stress and suppressing immunity. Another reason, however, is that meat, poultry, dairy and cheese products, and eggs—­along with sugar and refined flour products—­are all acid-­forming foods. These foods are not necessarily acid in composition, but they leave an acid residue in the body after they are metabolized, making the body itself more acid. This can create two kinds of problems: When the body is more acid, the transit time of food through the digestive tract can increase to the point where vitamins and minerals are not adequately assimilated. This selective underabsorption of vitamins—­especially B vitamins, vitamin C, and minerals—­can subtly add to the body’s stress load and eventually lead to low-­grade malnutrition. Taking supplements will not necessarily correct this condition unless you are able to adequately digest and absorb them.
Acid-­forming foods, especially meats, can create metabolic breakdown products that are congestive to the body. This is especially true if you are already under stress and unable to properly digest protein foods. The result is that you tend to end up feeling more sluggish or tired and may have excess mucus or sinus problems. Although it’s true that this congestion is not exactly the same thing as anxiety, it can certainly add stress to the body, which in turn aggravates tension and anxiety. The freer your body is from congestion due to acid-­forming foods, the lighter and more clear-­headed you’ll be likely to feel. Be aware, also, that many medications have an acid reaction in the body and may lead to the same types of problems as acid-­forming foods.

% Increase Protein Relative to Carbohydrates

What to Do When You Eat Out

The pressures and constraints of modern life require that many of us eat lunch or dinner out.
Unfortunately, most restaurant food, even at its best, provides too many calories, too much saturated fat, and too much salt, and often includes food that has been cooked in stale or rancid oils.
Much restaurant food is less fresh than what you can obtain on your own. For the most part, eating in restaurants is not optimal for taking care of your health.

If you need to eat in restaurants often, observe the following guidelines: 

• Avoid all fast food or “junk food” concessions.

• Whenever possible, eat out at natural food or health food restaurants that use whole, preferably organic foods.

• If natural food restaurants are unavailable, go to high-­quality seafood restaurants and order fresh wild fish, preferably broiled without butter or oil. Accompany the fish with fresh vegetables, potatoes or rice, and a green salad. On the salad, avoid creamy or dairy-­based dressings.

• As a third choice, try a high-­quality Chinese or Japanese restaurant and have a meal consisting of rice, vegetables, and fresh fish or tofu (bean curd). In Chinese restaurants, be sure to ask your server to leave off MSG (monosodium glutamate), a flavor enhancer to which many people are allergic.

• As a general rule, when eating out, have no more than one roll with one pat of butter, and minimize ordering cream-­based soups, such as clam chowder. Get your salad dressings on the side, using oil and vinegar or a low-­fat Italian dressing. Stick with simple entrées such as chicken (preferably organic) or whitefish without elaborate sauces or toppings. If possible, try to avoid high-­fat desserts. Don’t hesitate to ask your server for assistance in having food prepared according to your needs. Learn to enjoy the subtle tastes of simple foods. You’ll find this becomes easier and desirable after a while when you omit rich, high-­fat, and sugary foods.
As you think back over all of the guidelines for improving your nutrition, keep in mind that it’s unnecessary to try to adopt them all at once. Begin by decreasing your caffeine and sugar consumption, which will have the most direct impact on reducing your vulnerability to stress and anxiety. Beyond these suggestions, go at your own pace in upgrading your diet. You’re more likely to maintain a dietary change that you’ve decided you truly want to make, instead of one you’ve pressured yourself into.

Supplements for Anxiety

- B Vitamins and Vitamin C
- Calcium 
- Antioxidants 
- Relaxing Herbs 
- SAM-­e: Fast-­Acting Natural Antidepressant 
- Amino Acids 
- Omega-­3 Fatty Acids 
- Hormone Supplements

Ch 16: Health Conditions That May Contribute to Anxiety

Adrenal Exhaustion

Prolonged and unremitting stress taxes your adrenal glands. In The Stress of Life, stress expert Hans Selye describes how protracted stress on the adrenal glands results in a state of chronic underfunctioning or exhaustion. Insufficient adrenal resources, in turn, tend to affect how you handle stressful situations, making it more likely that you will become anxious in the face of stress. Inadequate sleep; prolonged exposure to heat or cold; exposure to toxins, pollutants, or substances you’re allergic to; and taking cortisone over a period of time can also contribute to adrenal exhaustion. Sudden trauma or severe physical illness can initiate or worsen adrenal exhaustion. Notice that many of these factors, particularly sudden trauma such as losses or life transitions, also play a role in the onset of anxiety disorders. Anxiety disorders and adrenal exhaustion frequently occur together.
Adrenal exhaustion develops in stages. When you’re combating stress, the adrenal glands tend to hyperfunction, producing large amounts of adrenaline and noradrenaline, as well as steroid hormones such as cortisol. As stress becomes prolonged, the glands begin to be overtaxed and go into a state of temporary underfunctioning. If you are relatively healthy, the glands 374 The Anxiety & Phobia Workbook will try to compensate and can actually rebuild themselves to the point of hypertrophy (growing larger). However, if high levels of stress continue, the glands will eventually exhaust themselves again and then remain in a chronic state of underfunctioning. At this stage, they can oscillate between overproducing adrenaline, which can cause panic or mood swings, and underproducing adrenaline. The ultimate outcome of prolonged adrenal exhaustion can be chronic fatigue syndrome, fibromyalgia, chronic bronchitis or sinusitis, and autoimmune disorders, ranging from lupus to rheumatoid arthritis.

Symptoms of adrenal exhaustion include:

• Low stress tolerance (little things that didn’t use to bother you get to you) 
• Lethargy and fatigue (often manifested in difficulty getting up in the morning) 
• Light-headedness when standing up quickly (called postural hypotension) 
• Light sensitivity (difficulty adjusting to bright light outdoors) 
• Difficulties with concentration and memory 
• Insomnia 
• Hypoglycemia 
• Allergies (to foods, environmental substances, pollens, molds, and so on) 
• Increased symptoms of premenstrual syndrome 
• More frequent colds and respiratory conditions

Recovery from Adrenal Exhaustion

To recover from adrenal exhaustion, you have to address it on a few different fronts. Certain lifestyle changes, supplementation, and dietary modifications can be helpful. These are outlined below:

1. Simplify your life.

Ask yourself which of your habits, practices, and obligations clutter your life rather than enrich it.

2. Regularly practice your preferred form of relaxation.

Whether this is progressive muscle relaxation, guided visualization, yoga, or meditation, try to commit to practicing it daily.
Give yourself downtime daily. Remember that downtime is not a luxury, it is necessary for maintaining a vibrant, fulfilling life (see chapter 4). Break up your day with two or three twenty-to-thirty-minute periods of relaxation.

3. Strive to get eight hours of sleep at night.

Sufficient sleep is not a luxury, either. Turn in by ten or eleven at night if possible. Whenever you can sleep late in the morning, let yourself do so.
Exercise regularly. Get twenty to thirty minutes of moderate exercise every day, preferably outdoors.

4. Eliminate caffeine, nicotine, alcohol, and recreational drugs.

Substitute herb teas for caffeinated beverages. Licorice tea is especially good if you’re hypoglycemic.

5. For three months, eliminate all forms of sugar except xylitol or stevia.

This includes white and brown sugar, honey, chocolate, molasses, refined fructose corn syrup, maple syrup, and dried fruit. Substitute fresh fruits in moderation. Xylitol is a sugar that is made from the fiber of the birch tree. It produces only a small increase in blood sugar and no rise in insulin levels. Stevia is derived from a South American herb and is many times sweeter than sugar. It has no calories and is much safer than artificial sweeteners like aspartame and saccharin. Both xylitol and stevia are available at most health food stores. After three months, you can reintroduce natural sugars such as honey in very small amounts.

6. Eat a healthy, balanced diet.

As much as possible, eliminate processed foods and foods to which you’re allergic. Emphasize whole grains, fresh vegetables, and fresh fruits in your diet. Eat protein in the form of beans and grains; eggs; organic poultry; free-range, hormone-and-antibiotic-free meat; or wild fish. Do not overeat carbohydrates. Reduce your consumption of simple starches: pasta, bread, chips, potatoes, cereal, crackers, rolls, and so on. Combine a fat, protein, and complex carbohydrate source at every meal. Avoid eating just fruit first thing in the morning and avoid processed fruit juices (see chapter 15).

7. If you have hypoglycemia, eat the appropriate diet.
Be sure to eat a protein-carbohydrate snack two to three hours after each main meal (see chapter 15).

Next topics discussed in book are: 
% Supplements for Adrenal Exhaustion 
% Thyroid Imbalances 
% Candidiasis 
% Body Toxicity 
% Premenstrual Syndrome 
% Menopause

Seasonal Affective Disorder

When the seasons change from spring and summer to fall and winter, do you develop the following symptoms? Check off the symptoms that are familiar.
• Lower energy than usual 

• Awakening feeling tired, although you sleep more 

• Mood changes such as feeling more anxious, irritable, sad, or depressed 

• Diminished productivity or creativity 

• Feeling that you have little control over your appetite or weight 

• More memory and concentration problems 

• Lowered interest in socializing 

• Lessened ability to cope with stress 

• Less enthusiasm about the future or reduced enjoyment in your life 

If you checked off two or more of these, you may be one of the many people affected by seasonal affective disorder (SAD) or a milder form of this disorder known as subsyndromal SAD.
Seasonal affective disorder is a cyclical depression that occurs during the winter months, typically between November and March. It’s brought on by insufficient exposure to light. As the days get shorter and the angle of the sun changes during the fall, the symptoms of SAD begin to appear. An estimated 20 percent of the American adult population, or 36 million people, are affected by SAD and subsyndromal SAD. The farther from the equator you happen to live, the more susceptible you are.

Anxiety and SAD

Many individuals dealing with anxiety disorders experience an aggravation of their condition during the late fall and winter. Panic attacks may occur more often, and generalized anxiety may increase along with depression. It’s not surprising that this is so, because the same systems of the brain that contribute to the neurobiological basis of depression, the noradrenergic system and the serotonin system, are also implicated in anxiety disorders, particularly panic disorder, generalized anxiety disorder, and obsessive-compulsive disorder. Biochemical imbalances in these systems tipped one way may cause depression; tipped the other way, they may aggravate anxiety disorders.
For many individuals, unfortunately, problems with anxiety and depression coexist, both becoming aggravated during the winter months.
Whether they manifest as depression or anxiety, the symptoms of SAD are caused by decreased availability of light. SAD can be aggravated not only by reduced light outside during the winter 390 The Anxiety & Phobia Workbook months but by spending too much time in indoor environments that have low levels of light, whether at home or work. SAD symptoms have been reported even in the summer among people who work in environments without windows. They can also occur in sensitive individuals at any time of year after a succession of cloudy days.
It used to be thought that SAD was caused by insufficient suppression of a hormone in the brain called melatonin. Melatonin is secreted by the pineal gland in the brain at night after several hours of darkness. It is one of the mechanisms by which your brain lets you know it is time to go to sleep. With light in the morning, melatonin secretion is suppressed, and you know that it’s time to wake up. Although popular for many years, the hypothesis that SAD is caused by insufficient melatonin suppression has not been borne out by systematic research. Results of studies have been mixed, and researchers have looked in other directions to find clues to the cause of SAD.
The hypothesis that is currently receiving the most attention is that light insufficiency can cause a reduction in levels of serotonin in the brain. Norman Rosenthal, one of the leading researchers in this field, writes in Winter Blues that when susceptible individuals are exposed to too little environmental light—such as during winter—they produce too little serotonin. Rosenthal and others believe that these low levels of serotonin are responsible for the symptoms of SAD.
Serotonin deficiencies are frequently associated with symptoms of depression, anxiety, or both; that is why drugs that block the reuptake of serotonin in the brain—drugs such as Prozac (fluoxetine), Zoloft (sertraline), or Paxil (paroxetine)—often alleviate depression and many of the anxiety disorders. But why should reduced light affect serotonin? And why only in certain individuals?

The answer to the first question is still being researched. In answer to the second question, there is some evidence that people who are susceptible to SAD may have difficulty receiving or processing light at a neurological level.
During the winter, people with SAD tend to crave sweets and carbohydrates. Eating large amounts of carbohydrates usually increases the amount of tryptophan (an essential amino acid derived naturally from protein foods) that gets into the brain. Once in the brain, tryptophan becomes serotonin, the neurotransmitter that is so critical to psychological well-being.

Eating sweets and carbohydrates gives tryptophan a competitive edge over the body’s other amino acids in getting into the brain. So, if you tend to be drawn to sweets and starches in the wintertime, it may be your body’s attempt to raise your levels of serotonin.

Light Therapy for SAD

The treatment that most effectively reduces the symptoms of SAD is light therapy. In principle, it would be possible to reduce SAD in the winter by spending prolonged periods of time outdoors every day. Unless you’re a ski instructor or a snowplow operator, however, this is pretty impractical. Light therapy involves the use of one or more specific devices indoors to increase your exposure to bright light. Sometimes light-sensitive individuals can experience an improvement simply by increasing normal room light or installing brighter lightbulbs. However, most SAD sufferers seem to require exposure to higher light levels—at least four times brighter than normal household and office light.
Light boxes are commonly used to alleviate symptoms of SAD. A light box is a set of fluorescent bulbs in a box, with a diffusing plastic screen. Most of these devices deliver between 2,500 and Health Conditions That May Contribute to Anxiety 391
10,000 lux of light energy—considerably above the usual range of indoor lighting (approximately 200 to 1,000 lux). A typical light therapy session involves sitting within two or three feet of a light box for a period of half an hour to two hours in the morning. It’s neither necessary nor advisable to look directly at the light; rather, you can use the time to read, write, eat, sew, or do whatever you need to do. The amount of daily light exposure needed to achieve a reduction in symptoms varies from one person to another. Experiment with varying the duration of exposure according to your own needs.
Other devices used in light therapy are dawn simulators and light visors. The dawn simulator creates an artificial dawn in your bedroom by having a light come on very dimly at, say, six in the morning, and gradually brighten until seven o’clock. The light visor is a lightweight source of light that you can wear on your head. It allows you to have more mobility than with the light box.
Light therapy is very effective when administered properly, as Norman Rosenthal documents.
In experimental trials, it has been shown to help 75 to 80 percent of SAD sufferers within a week if used regularly. Before undertaking light therapy on your own, you should consult with a physician or another health professional who is knowledgeable about this therapy and its application.
Although light therapy devices are available without a prescription, you can save yourself time—as well as such possible side effects as headache, eyestrain, irritability, or insomnia—by getting assistance in using them properly.

Coping with SAD

The National Organization for Seasonal Affective Disorder (NOSAD) offers the following suggestions:

• Discuss your symptoms with your physician. You may be referred to a psychiatrist who may diagnose seasonal affective disorder or subsyndromal SAD and prescribe special light treatments to help relieve your symptoms. Certain SSRI antidepressants also can be helpful in treating some people with seasonal depression.
• If you have a medical diagnosis of SAD or subsyndromal SAD and your doctor prescribes light treatment, do not skip or shorten treatment because you’re feeling better; you may relapse. Work with your doctor in adjusting the length of time, time of day, distance, and intensity of light for your own individualized treatment.

• Get as much light as possible and avoid dark environments during daylight hours in winter.

• Reduce mild winter depressive symptoms by exercising daily, preferably outdoors, to take advantage of natural light.

• If you are unable to exercise outdoors in the winter due to extreme cold, exercise inside. If possible, try sitting in sunlight from a south-facing window for short but frequent periods during the day.

• Rearrange work spaces at home, and work near a window, or set up bright lights in your work area.

• Stay on a regular sleep/wake schedule. People with SAD report being more alert and less fatigued when they get up and go to sleep at preset hours than when they vary their schedules.

• Be aware of cold outside temperatures and dress to conserve energy and warmth. Many people affected by seasonal changes report sensitivity to extreme temperatures.

• Arrange family outings and social occasions for daytime and early evening in winter. Avoid staying up late, which disrupts your sleep schedule and biological clock.

• Conserve energy by managing time wisely and avoiding or minimizing unnecessary stress.

• Try putting lights on a timer in your bedroom or use a dawn simulator set to switch on a half hour or more before you get up. Some people with SAD report that this light technique has an antidepressant effect and helps them awaken more easily.

• When possible, postpone making major life changes until spring or summer.

• Share experiences regarding SAD as a way to get information, understanding, validation, and support.

• If you are able, arrange a vacation during the winter to a warm, sunny climate.
During the winter months you may find it helpful to boost your serotonin levels either naturally or with prescription medication. For the natural approach, try taking 5-hydroxytryptophan (5-HT).

You can start with 50 mg per day and go as high as 300 mg per day (see chapter 15 for more information on tryptophan). If you feel you’re not getting help from 5-HT, consult with your doctor about trying a selective serotonin reuptake inhibitor (SSRI) medication such as Zoloft, Celexa, Luvox, or Paxil (see chapter 17 for more information on SSRIs).

Insomnia

Insomnia affects about 30 percent of adults and is the most common condition that can aggravate anxiety disorders. Anxiety problems of all kinds are generally worse after a poor night’s sleep.
Most of us need seven to eight hours of sleep per night, at least six of which are uninterrupted.
It is during the early hours of the night that we get the deep sleep needed to replenish our body systems for another day, while during the latter part of the night we get proportionately more REM (rapid eye movement) or dream sleep, which is necessary for the brain to integrate and work through “unfinished business” from the previous day. Sleep actually goes through a series of stages: four stages of progressively deeper sleep, followed by one stage of REM sleep.
This five-stage cycle repeats itself three or four times during the night.
If you can’t sleep, the problem may be either with getting to sleep, in which case it takes you more than twenty minutes to fall asleep, or in staying asleep, where you may fall asleep easily but awaken hours before dawn and not be able to get back to sleep. Typically anxiety is more associated with the first type of problem, while depression is associated with “early morning Health Conditions That May Contribute to Anxiety 393 awakening.” However, it’s not uncommon to have both types of problems if you’re anxious or depressed.
Ten Common Problems Why is it that you are unable to sleep? Insomnia is complex and can have a very large variety of causes. In most cases there are, in fact, several causes operating at once. What follows are ten of the more common origins of sleeplessness.

1. Too much caffeine during the day. Excessive consumption of coffee, tea, cola beverages, and other foods or medicines containing caffeine is a very common culprit behind insomnia.
Everyone, of course, is different. You may be so highly sensitive to caffeine that even one cup of coffee in the morning can keep you awake the following night. At the opposite extreme, you may be able to have coffee at bedtime. As a general rule, it’s best to avoid caffeine after noon if you’re having problems with sleep, and you may even want to consider cutting down your consumption in the morning. (See the Caffeine Chart in chapter 15 to determine how much caffeine you consume in a day.) 

2. Insufficient exercise. One of the best remedies for insomnia is to do an aerobic workout during the day. Vigorous exercise helps to release muscle tension and burn off excess stress hormones (such as adrenaline and thyroxine), both of which can interfere with sleep. It can also release pent-up frustration that can keep your mind racing at night. If you’re not working out during the day, you may be surprised to find how much such a workout can help your sleep and help you with your anxiety, as well (see chapter 5). The one precaution is to avoid vigorous exercise within three hours of bedtime, as it can be overstimulating and interfere with getting to sleep.

3. Excess stimulation in the evening. Anything that overstimulates you after eight in the evening can keep you from getting to sleep (or staying asleep) later that night. This could include a dramatic or violent TV show, surfing the Web, doing difficult tasks (including difficult reading), a stimulating phone conversation, or a domestic quarrel. You can also keep yourself awake by exposing yourself to bright light (such as a computer screen) late at night. It’s best to turn yourself down during the last two or three hours of the day with soothing TV programs, reading, or conversation. Better yet, try a warm bath or shower before bedtime to unwind.

4. Excess worry about sleep. Sleep is an automatic process that requires letting go. The more you try to pursue it, the more it tends to get away from you. In general, worrying about sleep will prevent you from falling asleep, whether at bedtime or at four in the morning.
Telling yourself to stop worrying probably won’t be very helpful, so the best solution is some kind of diversionary tactic. The various relaxation techniques described in chapter 4 can all be helpful toward that end. Progressive muscle relaxation is helpful if your muscles feel tight, while mantra meditation or a guided visualization can be useful for a racing, anxious mind. For some people, just listening to soothing music or the drone of 394 The Anxiety & Phobia Workbook the TV can put them to sleep, while for others a boring novel does the trick. If you find yourself worrying, experiment with different diversionary tactics to redirect your mind away from it.
A famous, time-honored sleep principle is that if you’re lying awake in bed for very long (more than thirty minutes to an hour), don’t stay there. Get up and do a relaxation technique, meditation, or light reading in an easy chair or on the couch until you feel genuinely drowsy. Then get back in bed. That way your bed will become associated only with sleep—instead of with wakefulness.

5. Serotonin and/or melatonin deficiency. 

Over time, stress can deplete your brain’s stores of the neurotransmitter serotonin and the hormone melatonin. Both are needed for sleep.
Serotonin is needed to activate the parts of the brain that are responsible for sleep onset, and it’s also needed to make melatonin. Melatonin is made from serotonin by your pineal gland, usually late in the day with the onset of darkness. It’s the chemical your brain uses to signal to itself that it’s time to sleep. In short, without melatonin, it’s hard to get to sleep, and without serotonin, it’s hard to make melatonin.
It’s easy to increase your supplies of serotonin or melatonin with natural supplements available at your health food store or drugstore. Tryptophan, in the form of 5-hydroxytryptophan (5-HT; 50 to 150 mg) or L-tryptophan (500 to 1500 mg), is an amino acid that naturally converts to serotonin in your brain. Try 5-HT first at the suggested dose at bedtime, and if you aren’t satisfied with the results, try L-tryptophan, which is available at some health food stores and over the Internet. The effect of tryptophan can be enhanced by taking it with a carbohydrate snack (such as orange juice or crackers) along with 100 mg vitamin B6 and 100 mg vitamin B3. The hormone melatonin is available in health food stores in tablets ranging from 0.5 to 5 mg. Experiment with the dose to determine what is best for you, since people vary a lot in what constitutes an optimal dose. If doses of 2 to 5 mg give you side effects, then lower the dose down to 0.5 or 1 mg. Keep in mind that it’s okay to take both tryptophan and melatonin at bedtime to enhance your sleep.
If you find that natural supplements are ineffective in helping you to sleep, you may want to consult your doctor about prescription medications that boost serotonin. Any of the selective serotonin reuptake inhibitors (SSRIs, for example Celexa or Zoloft)—medications commonly used to treat anxiety disorders—can also be helpful for insomnia. (See chapter 17 for a more detailed description of SSRIs.) Particularly if you’re dealing with protracted depression along with insomnia, you may benefit from trying an SSRI.
Generally when you take SSRIs, you need to take them on a daily basis for a period of six months to one year (or longer). If you are looking for a medication that can help you sleep without having the addictive problems associated with prescription sedatives (such as Restoril or Ambien), you may want to try trazodone, 25 to 100 mg, at bedtime.

6. Excess levels of stress hormones. Your adrenal glands manufacture two types of stress hormones.
Adrenaline and noradrenaline give you a sudden burst of energy necessary to respond to an emergency with a quick reaction of fight or flight. As explained in chapter 2, these hormones are implicated in panic attacks. The other type of stress hormones includes the steroid hormones, of which cortisol is perhaps the most important. You need cortisol to help you wake up and address the various challenges life brings you throughout the day. The problem is that under high stress, your cortisol can stay too high day and night, with the consequence that you’re too activated round the clock to sleep easily.
If your cortisol is too high at bedtime, you may have difficulty falling asleep; if it’s too high early in the morning, you may wake up prematurely.
With the assistance of your doctor, you can have your cortisol levels measured at various intervals throughout the day to assess whether elevated cortisol is interfering with your sleep. If so, you can try a cortisol-regulating supplement called “phosphorylated serine” (not the same as phosphatidylserine), which can be obtained under the brand name Seriphos. In consultation with your doctor, take Seriphos at dinnertime for about one month to gradually turn down your cortisol levels. Beyond this, it’s important to utilize all the stress reduction measures described earlier in this chapter in the section on adrenal exhaustion.
A common reason for high levels of cortisol during the night is nocturnal hypoglycemia.
When there is a drop in blood glucose levels during the night, you release hormones that regulate glucose levels, such as adrenaline, glucagon, cortisol, and growth hormone.
If too much of these hormones is released, it may wake you up. By following the recommendations listed in chapter 15 for hypoglycemia, you may help your sleep. If you wake up in the early morning hours feeling hungry, or feeling that your blood sugar level is down, try having a protein-carbohydrate snack, such as bread and nut butter or cheese and crackers.

7. Irregular bedtimes. A very common problem for people who suffer insomnia is going to bed and getting up at irregular times. The body sleeps better when it has a routine, going to bed and getting up at approximately the same time every day. If you sleep in too late, you may find it hard to get to sleep the following night. That’s why many people have difficulty sleeping Sunday night before Monday, having stayed up late on the two weekend nights. The extreme case of sleep disruption is working different shifts back to back.
Unless you must, it’s best to avoid jobs that require you to continually change your shift.
Over time, you will lose a lot of sleep and compromise your health.
The body has a sleep-wakefulness cycle, called the circadian cycle, which it goes through every day—ideally about sixteen to seventeen hours out of bed and seven to eight in bed. This cycle will function much more smoothly, ensuring better sleep, if you retire and get up at the same times every day.

8. Inadequate sleep environment. There may be problems with your sleep environment that subtly undermine your sleep without your realizing it. A common problem is a mattress that is either too soft or too firm. If at all possible, invest in a quality mattress that feels truly comfortable to you. The same applies for pillows (you want something more comfortable than what you’d find in the average motel). Room temperature is also an important variable; many people have problems sleeping if the temperature of their room is over 80 degrees. If you don’t have air conditioning, use a fan to cool your room. The optimal temperature for sleep is about 70 degrees. Noise and light can also be problems.
If you can’t escape noise, get a fan or “white noise” machine to help mask it. In the case of excess light, dark curtains or eye shades will often help.

9. Noisy partners. One critical part of your sleep environment is your bed partner, if you have one. Loud snoring is a very common disrupter of sleep that affects millions of people who simply lie there and put up with it. There are many solutions to snoring, including sprays and nose guards that you can get at your local drugstore. On the Internet, you’ll find hundreds of devices that can help snoring. Or you may want to go to an otolaryngologist who specializes in the treatment of snoring. For more severe cases, laser surgery or surgical techniques using high-frequency radio waves have been used effectively. Snoring is not something you have to live with. For more information, see the books No More Snoring and Snoring from A to ZZzz listed at the end of the chapter.

10. Sleeping pills. Sleeping pills include benzodiazepine tranquilizers and sedatives, such as Xanax, Ativan, Klonopin, Valium, Librium, Restoril, and Dalmane, as well as nonbenzodiazepine sedatives, such as Ambien, Lunesta, and Sonata. Millions of people use sleeping pills, and they can be a lifesaver on certain occasions, such as night flights, or when negotiating highly stressful times. The problem comes when they are used on a long-term regular basis. They all have three major problems. One is that they can eventually lose their effectiveness when used nightly. If you take them every night, you’ll find that sooner or later they don’t work as well. Also, even though they put you to sleep, they interfere with the quality of your sleep by reducing the amount of time you spend in deeper stages of sleep (or increasing your time in shallower sleep stages). Finally, they are all highly addictive unless used on only an occasional basis. Whether Xanax, Klonopin, Ambien, or Lunesta, if you take a prescription sedative for more than a few weeks, you’re likely to become hooked on it. You may find you are unable to sleep without it.
So these are some of the more common problems that can interfere with sleep. Others, beyond the scope of this section, include specific sleep disorders such as sleep apnea and restless leg syndrome, or specific health conditions, such as asthma and allergies, acid reflux, or chronic pain. For an in-depth discussion of sleep, sleep problems, and measures for improving sleep, see the books No More Sleepless Nights by Peter Hauri and Shirley Linde, or The Promise of Sleep by William Dement.
General Guidelines for a Good Night’s Sleep Sleep is as integral to physical and mental well-being as proper nutrition and regular exercise.

The guidelines below are designed to help you maintain a healthy sleep routine.

Do:

• Exercise during the day. Twenty minutes or more of aerobic exercise midday or in the late afternoon before dinner is optimal. At minimum, forty-five minutes to an hour of brisk walking daily will suffice. Many people find a short walk (twenty to thirty minutes) before bedtime to be helpful.

• Go to bed and get up at regular times. Even if you’re tired in the morning, make an effort to stick to your scheduled wake-up time, and don’t vary your nightly bedtime. The next day, you can resume whatever you’re working on or doing. Your body prefers a regular cycle of sleep and wakefulness.

• Turn yourself down during the last hour or two of the day. Avoid vigorous physical or mental activity, emotional upsets, and so on.
• Try a hot shower or bath before bedtime.
• Develop a sleep ritual before bedtime. This is some activity you do nightly before turning in.
• Reduce noise. Use earplugs or a noise-masking machine, like a fan, if necessary.
• Block out excess light.

• Keep your room temperature between 65 and 70 degrees. Too warm or cold a room tends to interfere with sleep. Use fans for a hot room if air conditioning is unavailable. Your room should be ventilated, not stuffy.

• Purchase a quality mattress. Try varying the firmness of your mattress. Invest in a new one or insert a board underneath one that sags or is too soft. For a mattress that is too hard, place an egg-crate foam pad between the mattress surface and the mattress cover.

• Pillows should not be too high or too puffy. Feather pillows, which compress, are best.
• Have separate beds if your partner snores, kicks, or tosses and turns. Discuss this with him or her and decide on a mutually acceptable distance.
• Have physically and emotionally satisfying sex. This often aids sleep.

• See a psychotherapist if necessary. Anxiety and depressive disorders commonly produce insomnia. Talking to a competent psychotherapist can help. Getting more emotional support and expressing your feelings to someone you trust often helps sleep.

Don’t:

• Try to force yourself to sleep. If you’re unable to fall asleep after twenty to thirty minutes in bed, leave your bed, engage in some relaxing activity (such as watching TV, sitting in a chair and listening to a relaxation recording, meditating, or having a cup of herbal tea), and return to bed only when you’re sleepy. The same applies for waking up in the middle of the night and having difficulty going back to sleep.

• Have a heavy meal before bedtime, or go to bed hungry. A small, healthy snack just before bedtime can be helpful.

• Indulge in heavy alcohol consumption before bedtime. For some people, a small glass of wine before bed may help, but your alcohol consumption should not exceed this.

• Consume too much caffeine. Try to limit caffeine intake to the mornings. If you’re sensitive to caffeine, avoid it altogether and try decaf coffee or herb teas.

• Smoke cigarettes. Nicotine is a mild stimulant, and apart from its more publicized health risks, it can interfere with sleep. If you are a smoker, talk to your doctor about the best ways to curtail this habit.

• Engage in nonsleep activities in bed. Unless they are part of your sleep ritual, avoid activities such as working or reading for extended times in bed. This will help to strengthen the association between bed and sleep.

• Nap during the day. Short catnaps (fifteen to twenty minutes) are okay, but long naps of an hour or more may interfere with sleep the following night.

• Let yourself be afraid of insomnia. Work on accepting those nights when you don’t sleep so well. You can still function the next day, even if you had only a couple of hours of sleep. The less you fight, resist, or fear sleeplessness, the more it will tend to go away.

In General:

• With your doctor’s or health practitioner’s approval, try natural supplements that can foster sleep. Herbs such as kava and valerian, in higher doses, can induce sleep. (See chapter 15 for more detailed information on these herbs.) Do not exceed recommended doses and be sure to discuss all herbs with your doctor before taking them.

• Some people find 0.5 to 3 mg of the hormone melatonin at bedtime to be helpful.
Experiment with the dose to determine the amount that works best for you.

• The amino acid tryptophan is very helpful for many people in getting to sleep. You can obtain it at most health food stores either in the form of 5-hydroxytryptophan or in L-tryptophan. If you try 5-HT, take 50 to 150 mg at bedtime; for tryptophan, try 500 to 1500 mg before going to bed. The effects of either form of tryptophan can be enhanced by taking it with a carbohydrate snack and 100 mg of vitamins B6 and B3.
You can take tryptophan every night if you need to. Finally, the amino acid GABA, 500 to 1000 mg before bedtime, may induce sleep for some people. Vary the dose, as some people find higher doses to cause agitation.

• For relaxing tense muscles or a racing mind, use deep relaxation techniques. Specifically, progressive muscle relaxation or recorded guided visualization exercises can be helpful (see chapter 4). Use a device that can play the recording in a continuous loop.

• If pain is causing sleeplessness, try an analgesic. In the case of pain, this is more appropriate than a sleeping pill.

• Avoid sleeping pills such as Restoril or Ambien except for occasional emergencies.
Prescription sedatives such as these can interfere with your sleep cycle and ultimately aggravate insomnia. If you must take a prescription medication for sleep, try trazodone at 25 to 100 mg.

• If you’re dependent on a sleeping pill and feel that it’s interfering with your sleep, consult a competent physician or psychiatrist experienced with helping people discontinue these medications.

Ch 17: Medication for Anxiety (Not Covered Here)

Ch 18: Meditation

Meditation has been practiced for over three thousand years for the purpose of training and calming the mind. As you may know, it originated as a spiritual practice within Hinduism and Buddhism, though it was later practiced in various forms in many other religions. Eastern philosophy has taught that the origin of human suffering is in our automatic, conditioned thoughts (the term “automatic thoughts” in cognitive therapy is similar to this notion). Nothing in life is inherently bad except that we think about it or react to it as such. The purpose of meditation practice is to learn to step back and simply witness your automatic thoughts and reactive patterns without judgment. If you are caught up in your mind’s automatic patterns, regular meditation practice can help you to become gradually freer of them.
How does meditation help to achieve this freedom? In a word, you can say that it is by the enlargement or “expansion” of awareness. Awareness can be defined as a pure, unconditioned state of consciousness that you can experience deep within yourself. It exists “beneath” or prior to the conditioned patterns of thinking and emotional reactivity you’ve learned over a lifetime.
This unconditioned awareness is always available to you, but most of the time it’s clouded over by the incessant stream of mental chatter and emotional reactions that make up your ordinary, moment-tomoment experience. Only when you become very quiet and still, willing to “just be,” observing your inner experience in the present moment without judgment and without striving to do anything, can this uncluttered awareness that underlies your thoughts and feelings begin to reemerge.
When you experience this unconditioned state of awareness, you simply feel a deep sense of peace. Out of this place of inner peace can arise other unconditioned states such as unconditional love, wisdom, deep insight, and joy. In itself, this state of inner peace is nothing you need to develop. You were born with it. It’s always there, deep inside of you. You can discover it if you simply become still and quiet long enough to allow it to emerge. The practice of meditation is one of the most direct, straightforward ways to do this.
Meditation practice allows you to expand your awareness to the point where it’s larger—or more “spacious”—than your fearful thoughts or emotional reactions. As soon as your awareness is larger than your fear, you are no longer claimed by the fear but can stand outside of it (in your mind) and merely witness it. It’s as though you’re identified with a part of your inner being that’s larger than the part that’s constricted by fearful thoughts. As you continue to practice meditation and enlarge your awareness, it becomes easier on an ongoing basis to observe the stream of thoughts and feelings that make up your experience. You are less prone to get “stuck” or lost in them.

You might be concerned that increasing your ability to observe your inner thoughts and feelings sounds like becoming internally divided rather than more connected with yourself. In fact, the opposite is true. It’s your reactive thoughts and conditioned emotional patterns that tend to pull you away from your own center—to lead you away from your deeper inner self and into what has been popularly termed “mind trips” or “personal dramas.” To practice meditation is to cultivate greater self-integration and wholeness. As you deepen and enlarge your awareness, you begin to be in touch with more of yourself. Your reactive thoughts and feelings still occur, but you’re not so strongly swept up by them. You’re more free to truly enjoy your life because you don’t get quite as stuck—or stuck as long—in any particular state of anxiety, worry, anger, guilt, shame, grief, and so on. Rather, you’re able to simply acknowledge your reaction, allow it to move through your experience, and let it go. Your inner consciousness becomes spacious enough that you can observe a worried thought, then take action if it’s reasonable to act or choose to let the thought go if it’s unreasonable. You begin to have more choice over what you think and experience.
You are not quite so scattered by your mind’s endless cascade of reactive thoughts and feelings.
While these thoughts and feelings still occur, your relationship to them is different. Your inner awareness becomes spacious enough that you can more easily step back and accept your thoughts and feelings rather than be carried away by them.

Ch 19: Personal Meaning

The chapters of this book up to this point have considered the physical, emotional, behavioral, and mental aspects of anxiety disorders. Guidelines have been offered for dealing with these various levels of the problem. On a bodily level, anxiety, panic, and phobias can be helped through abdominal breathing, relaxation, exercise, and/or medication. Emotionally, learning to identify and express feelings can relieve the tension that lies behind anxiety. Behaviorally, exposure can overcome phobic avoidance. On a mental level, replacing fearful self-talk and mistaken beliefs with realistic thoughts and assumptions can help reduce anxiety in all of its diverse forms.

For many people, the wide range of approaches presented up to this point will be enough to ensure recovery. Making a commitment to follow through with the program outlined in this book, whether on your own or with a therapist, will help you to take back your life from anxiety. You may require a bit more, however. All the techniques described so far can help a great deal, yet for certain people they aren’t quite enough. An underlying level of anxiety remains—an anxiety that comes from not having answered basic questions about the meaning and purpose of your life.

Existential psychologists such as Rollo May have used the term “existential anxiety” to refer to the type of anxiety that arises from having been unable to reach your full potential in life.
This anxiety consists of a vague sense of tension, boredom, and perhaps even “quiet desperation” that arises from feeling held back, for one reason or another, from being all that you can be. You live with a feeling of incompleteness—a sense that something vital is missing—although you may not consciously recognize what it is. If someone were to ask you, “Where is your life going?” or “What do you think your life is about?” you would tend to have trouble answering. Or you might think of things that, on further reflection, don’t seem “quite enough” to make your life as meaningful as you would like it to be.

For some people, a lack of purpose or meaning in life can provide fertile ground for the development of panic attacks and phobias. Although panic may be caused by a number of factors, it sometimes reflects a sudden revelation (and desperation) that your life has no obvious direction.
Similarly, the fear of being trapped or confined, or “unable to escape,” that underlies so many phobias may reflect a deeper fear of being trapped by your current circumstances in life, whether involving a dead-end career, a relationship, or any other situation that feels confining yet would require substantial risks to move out of. Phobic avoidance, in turn, may reflect a deeper avoidance of the very risks that are necessary to realize your full potential and life purpose. It has been my experience with a number of clients that their anxiety disorders (it doesn’t seem to matter which particular type) did not fully resolve until they found something that could give their life a greater sense of meaning and they took the necessary risks to embrace it. In one case, this involved a career change, and in still another it meant cultivating a creative talent with music.
This chapter gives you the opportunity to reflect on the question of your life’s meaning, purpose, and goals, as well as to explore whether spirituality might provide at least one direction in which to find answers. Spirituality is a universal concept. It refers not to any particular religion but to a basic sense of there being a larger purpose to life, as well as a larger power—a “Higher Power,” if you will—that transcends the human order of things. Not only may spirituality provide life with greater meaning, but it can help overcome anxiety directly because it leads to qualities such as inner peace, serenity, faith, and unconditional love.

Finding and Fulfilling Your Unique Purpose

Each of us has one or more special purposes to fulfill that can give our life a sense of completeness.
Those people who fully realize their special purpose often say, by the time they reach their senior years, that they feel satisfied with their life—that they did as much as they could to accomplish what they set out to do. Common examples of life purposes might include raising a family, succeeding in a fulfilling career, making a contribution to your community, developing and expressing an artistic talent, completing an educational goal and using what you’ve learned to serve others, overcoming an addiction or the problems of a dysfunctional childhood, and conveying what you’ve learned to others. Life purposes appear to have a twofold function: 1) allowing you to feel more complete and whole, and 2) allowing you in some way to serve or contribute to the betterment of others. Realizing what truly gives your life meaning and purpose is likely to carry you beyond your own personal needs and to have a beneficial impact on someone else—whether that someone is a child, the people you work for, your community, or anyone to whom you convey what you’ve learned from your experience. In discovering your true purpose and potential, you move beyond immediate concerns for personal security and satisfaction toward making a meaningful contribution.

If you currently feel out of touch with your life purpose, how do you go about discovering what it is? The questionnaire that follows is designed to stimulate your thinking in ways that can help you to formulate your own unique values. Your answers to the questions may give you some insights into what it is that is most important for you to do with your life. Give yourself at least one full day to reflect on these questions and write out your answers. You may even want to ponder these questions for a week or a month. After you’ve arrived at the answers for yourself, continue on through the sections of this chapter describing how to set goals, break each goal into a sequence of steps, and finally take committed action on each goal. Then you might want to share your answers to these questions (your personal values, goals, and timelines) with a close personal friend or counselor and get that person’s input and feedback. If realizing your purpose involves making a career change, it might be helpful to work with a career counselor.
If it involves going back to school, you’ll want to talk to an academic guidance counselor at the school you’re considering.

Personal Values Inventory

1. Does the work you’re presently doing express what you truly want to be doing? If not, how can you begin to take steps toward discovering and doing work that would be more personally fulfilling?

2. Are you satisfied with the education you’ve obtained? Would you like to go back to school and increase your education and training? If so, how can you begin to move in that direction?

3. Do you have creative outlets? Are there any areas of your life where you feel you can be creative? If not, what creative activities could you develop?

4. What kinds of interests or activities spark your enthusiasm? What do you naturally enjoy doing alone, with friends or family, outdoors or indoors?

5. What would you like to do with your life if you could do what you truly wanted? (Assume, for the purpose of this question, that money and the responsibilities of your current job and family are not a limitation.)

6. What would you like to accomplish with your life? What would you like to have accomplished by the time you reach seventy in order to feel that your life has been productive and meaningful?

7. What are your most important values? What values give your life the greatest meaning? Some examples of values include 

• Happy family life and Material success 

• Intimacy and Career achievement 

• Friendship and Creative expression 

• Good health and Personal growth 

• Peace of mind and Spiritual awareness 

• Serving others and Dedication to a social cause

8. Is there anything that you deeply value and yet feel you haven’t fully experienced or realized in your life? What changes do you need to make—or what risks do you need to take—to more fully realize your most important values? 

9. Do you have any special talents or skills that you haven’t fully developed or expressed? What changes do you need to make—or what risks do you need to take—in order to develop and express your special talents and skills? 

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Tags: Behavioral Science, Medicine, Book Summary, Psychology, Science