It is not uncommon for many of us to live with day to day, moment to moment worries and concerns, especially when we feel threatened by internal or external pressures. These might be nerves around a new job, a dinner date or that speech we have been asked to make. These pressures are usually dealt with in appropriate ways, often passing as quickly as the original events themselves. Our reactions and responses to these pressures are pivotal in how they impact us in the short term and long term.
For some individuals such worries, fears and anxieties are a daily preoccupation becoming insurmountable and growing in size, intensity and charge. This can be debilitating, crushing, limiting, frustrating and overwhelming.
The World Health Organisation estimated the total number of people living with anxiety disorders (AD’s) in 2015 was 264 million individuals across the globe. In Britain, the National Institute of Clinical Excellence (NICE) highlight Anxiety Disorders are a common mental health problem.
Anxiety Disorders include social anxiety, PTSD, obsessive compulsive disorders, panic disorder and generalised anxiety disorder. It is not uncommon for dual diagnosis to occur. The prevalence and incidence of anxiety and depression in the UK as stated by the Mental Health Foundation was 19.7% of individuals above the age of 16 in 2014.
With developments in neuroscience and brain imaging, we have now come to better understand the areas in the brain associated with anxiety. We have even developed a clearer understanding of how best to work with the symptoms of AD’s (Martin et al, 2009).
For many, living with anxiety stretches out upon a spectrum of bearable to unbearable, mild to severe. Anxiety is both precocious and irreverent, dragooning sufferers into falsely heightened and overwhelmed states of being. Often individuals do not see their anxiety and their relationship to it as something that can change. But it can. It may seem interminable but there is hope that agency and control can be achieved.
The main areas involved with anxiety responses reside in the ‘limbic region’ of the brain (Martin et al, 2009). This area includes the amygdala and hippocampus. We could say the amygdala is our ‘emotional’ response centre, the amygdala responds to a perceived threat (internal or external). Neurotransmitters, such as cortisol and adrenaline are released carrying forward the impulse to our sympathetic nervous systems. This increases heart rate, breathing, blood pressure, sweating etc. In effect they prepare us for a potential crisis, most commonly known as the flight, fight, or flee response, a term coined by psychologist Walter Cannon in the 1920’s.
In short this preparation of our bodies and minds to be alert to danger can be useful in some contexts. However, it becomes destructive when this response is switched on too often, when it behaves disproportionately and seemingly beyond our control. So threats and our perception of being threatened creates our anxieties.
We may normalise anxious states to such an extent that we forget the original causes for having experienced them thus our perceptions can become distorted. We forget that we are experiencing a physiological response that can be reduced and place value and meaning upon the experience (Williams, 2011 and Joyce and Sills, 2013).
A consensual view in psychological literature illustrates anxiety as having roots in our developmental years and can be viewed as a biological, relational and attachment issue. The infamous child psychiatrist John Bowlby put emphasis on the basis of anxiety and earlier attachments. Additionally we may experience anxiety because our internal experiences and landscapes are not being communicated and shared ((Cooper and Mearns, 2004). So goes the old adage ‘a problem shared is a problem halved’.
A widely held view in psychological literature highlights the way we view ourselves as an important contributing factor. Self esteem, self worth and confidence may all play a part in living with insurmountable anxieties. In life there can be experiences that affect our sense of self and sense of trust and safety in the world. Being bullied, abuse, development of negative or critical thinking, ideas of perfectionism, comparisons with others, internalised homophobia, toxic masculinity, stress, the list goes on. Furthermore, alienation, guilt and shame may all contribute to this repetitious whirr of thinking and feeling.
Whilst symptoms of anxiety are similar across a wide breadth of people it is important to remember individual contexts matter. Anxiety is an amalgamation of many psychological contributors and no one way fits all. Therapy in part is about seeking understanding of those psychological contributors.
There is a clear evidence base that better breathing reduces our sympathetic nerve responses. These responses are the very symptoms experienced in states of panic or anxiety, which include increased heart rate, breathing, blood pressure etc. In this context an important and integral part of working with anxiety centres around an individual's capacity to regulate thought, emotion and to acquire techniques that help ground and stabilise their psychophysiology.
Through breathing we can alter our physiology, making the distinction between our ‘in’ breaths, which activate the sympathetic nervous system, and ‘out’ breaths which activate the parasympathetic nervous system (Burdick, 2013).
A familiar breathing technique used is diaphragmatic breathing and breath counting. Breathe in and out and whilst doing so notice how your belly rises and falls. Take deep inhalations through the nose and prolonged exhalations through the mouth. Try counting your in-breaths to the count of 4 and exhaling through your mouth with pursed lips for the count of 8 - repeat this a few times.
There is evidence that simply discussing one’s anxieties and having a compassionate ear to talk to may be helpful. It is incredibly difficult to change what we may consider as being normal or a ‘given’, and unfortunately anxiety can be seen in this way. Learning the underpinning thoughts, feelings, processes that may exacerbate one's anxiety and identifying and exploring the experiences and sense of self that contributes to its charge can be a turning point for many. These dynamics can be explored in the ‘therapeutic relationship’, which is said to be the underlying healing factor in therapy regardless of approach, technique and or intervention.
Mindfulness-based cognitive therapy has also garnered a broad ground in the treatment and prevention of anxiety and is recommended by NICE (2011).
Cognitive behavioural therapy has been shown to be helpful in a) learning of ones cognitive distortions, b) being able to challenge them as and when they occur c) helping individuals rediscover inner agency and control. Furthermore a safe supportive environment in which to explore past, present and future tense experiences can be incredibly beneficial in developing one's own awareness and understanding.
Keeping a journal of one's anxieties, or any thoughts and feelings, has been suggested to be cathartic (Thompson, 2004). Journaling acts as a container for intense feelings. Expressive writing activities have long been shown to help reduce anxiety symptoms (Bolton and Latham, 2004).
It may also be helpful to keep track of one's moods and triggers by keeping a diary of one's anxieties (Joyce and Sills, 2013). Additionally, using a scaling system to log the intensity of one's feelings can be useful. These methods can help to identify patterns of thought, feeling and behaviour that may remain latent under the surface.
Try the cognitive behavioural ABC Approach. Filling in a cognitive journal can be very helpful. Try your own following this template:
A = Activating event/s - what happened?
B = Beliefs regarding the event - what did you assume and believe about it?
C = Consequences of A and B (emotional and behavioural consequences) - what was the result in your mood and actions?
D = Disputing (challenging one’s beliefs and behaviours)
This can help to put into perspective how thoughts, feelings and behaviours have a symbiotic, triadic relationship. We can begin to identify, challenge and recognize our underlying cognitive distortions - negative beliefs that may exacerbate how we react and respond. This can be very empowering and revelatory.
A technique that has become popular for anxiety and panic is 54321, a mindfulness technique. Its aim is to bring attention to our senses, grounding us in the present. The Mayo Clinic highlight the use of this technique and the benefits in shifting our focus and reducing stress responses.
5: Name 5 things you can see
4: Name 4 things you can touch
3: Name 3 things you can hear
2: Name 2 things you can smell
1: Name 1 thing you can taste
The suggestion is to follow this process through a few times. After which individuals usually report feeling more ‘grounded’, as if their original feelings shifted or changed in intensity or size in some way.
Another mindfulness technique is that of R.A.I.N: an acronym which stands for Recognise, Allow, Investigate and Natural awareness. Brach (2019) promotes the benefits of using this technique in emotional and psychological overwhelm. The aim of is to build one's emotional resilience through accepting a feeling and being compassionate towards it. This may sound aversive, but we know problems are more likely to occur and prolong themselves through avoidance.
Anxiety can be said to be an amalgamation of biological, social and psychological dynamics that often create distress and disorientation in individuals. Exploring these underlying dynamics can be useful. There are a number of approaches that can be utilised when working with anxiety. There are neurophysiological processes occurring in anxiety that can be altered with better breathing. Underlying these psychophysiological responses may be thoughts and feelings that exacerbate what is going on. Therapy can be important to explore these dynamics, in a safe setting, whilst acquiring new ways of processing and regulating ones' psychophysiological processes at the same time.
Bolton, G., and Latham, J., (2004). ‘Every poem breaks a silence that had to be overcome’; the therapeutic role of poetry writing. In: G.Bolton, S.Howlett, C.Lago, JK.Wright. Writing Cures: An introductory handbook of writing in counselling and therapy. Hove: Brunner-Routledge.
Brach, T., (2019) Feeling Overwhelmed? Remember “RAIN”. Mindful healthy mind, healthy life. [accessed 3/10/19] available from: https://www.mindful.org/tara-brach-rain-mindfulness-practice/
Burdick, D., (2013) Mindfulness Skills Workbook For Clinicians and Clients: 111 Tools, Techniques Activities and Worksheets. Pesi Publishing and Media Ltd: USA.
Cooper., M., and Mearns., D. (2004). Working at Relational Depth in counselling and psychotherapy. London: Sage.
Ellis, A., (1957). Rational Psychotherapy and Individual Psychology. Journal of Individual Psychology, 13:38-44.
Elizabeth I. Martin, PhD, Kerry J. Ressler, MD, PhD, [...], and Charles B. Nemeroff, MD, PhD (2009). The Neurobiology of Anxiety Disorders: Brain Imaging, Genetics, and Psychoneuroendocrinology.
Joyce, P., and Sills, C., (2013) Skills in Gestalt Counselling and Psychotherapy. 2nd Ed. Sage: London.
Mayo Clinic. (2017) 5, 4, 3, 2, 1: Countdown to make anxiety blast off. [accessed 3/10/19] available from: https://mayoclinichealthsystem.org/hometown-health/speaking-of-health/5-4-3-2-1-countdown-to-make-anxiety-blast-off
Mental Health Foundation. (2016). Fundamental Facts About Mental Health 2016. Mental Health Foundation: London.
NICE. (2011). Common mental health disorders: Guidance and guidelines. Retrieved from nice.org.uk/guidance/cg123 [Accessed 20/9/19].
Thompson, K., (2004). Journal writing as a therapeutic tool. In: G.Bolton, S.Howlett, C.Lago, JK.Wright. Writing Cures: An introductory handbook of writing in counselling and therapy. Hove: Brunner-Routledge.
WHO. (2017). Depression and Other Common Mental Disorders: Global Health Estimates. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO.
Williams, M., and Penman, D., (2011). Mindfulness: a practical guide to finding peace in a frantic world. Great Britain: Piatkus.