Anxiety is an Altered State of Consciousness:

In normal thinking, we understand the differences between thoughts and actions.  We know that thoughts and actions are independent:  In every aspect of our life, we are filled with thoughts that can involve planning activities, organizing our day, and imagining every variety of situation.  We can lose ourself in a novel or magazine article and  experience the excitement of travel, or the joys and pain of a love affair.  We can imagine the satisfaction of finishing a difficult task.  And, if someone hurts our feelings in real life, we can think about how we might want to respond to that person.

In normal thinking our thoughts help us plan what we want to do, and allow us to rehearse--in our minds only--the possible consequences of imagined actions.  In everyday life, our thoughts are a safe way to play out scenarios in our mind with no consequences in the real world.  

Anxiety changes all that. As we become more anxious, the gap between our thoughts and our behaviors seems to shrink. When we are highly anxious, thinking about something can feel close to doing it. The "what if" catastrophic thoughts that run through our mind feel like they can happen. As we approach panic levels, our thoughts start to feel dangerous.

This is Anxious Thinking. Anxious thinking is an altered state of consciousness. Anxious Thinking makes the scary thoughts feel like they can really happen. Anxious Thinking changes the rules. In normal thinking, we understand that nothing in life is risk free, and we accept reasonable risks. We continue our activities with reasonable assurances of safety. Anxious Thinking cannot accept any risks. It continually asks for reassurances, and it demands that we avoid situations that frighten us. Anxious Thinking makes no distinction between feeling frightened because of catastrophic images in our mind, and the fear of being in actual danger.

Here is a review: Anxiety tries to bluff us into believing that we are in danger, and that we should avoid the source of the anxiety. Anxious Thinking makes our catastrophic thoughts feel like they can really happen. We feel like we are in danger, even though the source of our fears are the images in our mind, made to feel real by the altered state of consciousness called Anxious Thinking.

One of your first jobs is to give this fear the label of anxiety, and your thinking as Anxious Thinking. Labeling anxiety means telling yourself something like: "This terror that I feel is my anxiety. I am not in danger, I do not have to avoid whatever is making me feel this way. There is no danger to confront. I just have to stay with the idea that my terror is anxiety. My anxiety makes the scary thoughts going through my mind feel like they can really happen. I therefore can't trust my feelings when dealing with anxiety. This is an example of anxiety trying to bluff me."

Suggestion: It isn't fair to expect yourself to remember this while you are feeling high levels of anxiety. Write your own version of what you want to tell yourself, and put them on a card that is easily available during these times.

This is a lot to say, and this can be a very difficult job to do. The feelings of fear triggered by real danger is the same as the feelings of fear that accompany high anxiety. The physiology is identical. Our feeling are therefore useless in helping us make the distinction between danger and anxiety.

So we need to rely on facts and not feelings. Labeling your fear as anxiety and labeling your thinking as Anxious Thinking requires that you get to know the facts about anxiety.

Remember:

• When you get feelings of terror, are you going to label it danger, or are you going to label it anxiety? This labeling is very important, because we deal with them in a totally different manner.
• The decision is difficult because there is no way to use your feelings to help you make a decision.
• The terror feelings associated with real danger is exactly the same as the terror you feel when you are experiencing anxiety. Feelings cannot help you make this decision.
• The anxiety makes the thoughts feels like the could really happen.
• Always try to label your anxious reactions as Anxiety.
• Even if you can't fight what the anxious thoughts are telling you to do, and even if you are forced to flee and avoid the feelings, you can still label them as Anxiety.

To Label is to Disable. Feelings Are Not Facts. Get the Facts about Anxiety

The Paradoxical Attitude Necessary to Overcome Anxiety

When working on overcoming your Anxiety Disorder, you will see that the normal, common-sense ways of coping with feelings' don't work. In general, we believe that we do best by following our feelings, using our emotions to guide our actions in life.

In contrast, we need to learn NOT to follow what our anxiety is telling us. I would like you to thing of anxiety as a pseudo-emotion; often it is best to try to do the opposite of what your anxious feelings are telling you to do.

Paradoxes in the Treatment of Anxiety

• When dealing with anxiety, don’t trust your feelings. Anxiety is a great bluffer, and will tell you that you are in danger, when you are perfectly safe.
• When confronting anxiety, less is more.
• Attempts to avoid anxiety make it stronger
• The energy used to fight anxiety adds to it’s intensity.
• Short-term anxiety reduction leads to long-term anxiety increase.
• Reduction of anxiety in the future requires an acceptance of increased anxiety in the present.
• Anything worth doing is worth doing poorly. Perfectionism, the need to avoid mistakes and the unwillingness to allow the feelings of awkwardness that accompany new activities--these all increase anxiety.
• Resistance Creates Persistence - the more you are able to accept your anxiety and allow it to be, the more quickly it will start to subside.

Once you have labelled your fear as anxiety, your job is to accept and allow those feelings.

Accept Anxious Feelings

• Try not to avoid or push away the feelings.
• Try not to beat yourself up because you are feeling anxious feelings. Think of them as an "allergy" to your anxiety triggers
• Try not to get angry at yourself, be disappointed at yourself, or feel like a failure because you are feeling anxious feelings. Remember, you are sensitized.
• This is not a test, nor a measure of how good or successful you are as a person.

Allow Anxious Feelings

• Try not to run away from the feelings, or fight them off. Try to be gentle to yourself. When you are feeling anxiety, try to be as kind to yourself as you would be to a good friend.
• Fight the BEHAVIOR of avoidance and escape. Try not to flee. Try not to avoid. Try to be disciplined.
• Remember that you are allowing the feeling to be, but fighting what the feelings are telling you to do. This requires courage. This requires both gentleness and discipline.
• Remember that the best thing to do when you feel anxiety is also the hardest. The best way to cope with anxiety is to do nothing. Try to float with the feelings while you let time pass.
  
  

Read and Practice the Following. These are the facts about anxiety and your "tools" for coping with anxious feelings.

 

Marty’s Top 10 List

Top Ten Points for Dealing with Phobias and Panic

What I would like you to know within the first few sessions:

1. You have panic and phobias. You are not having a nervous breakdown. You are not going crazy.
2. Panics will not hurt you, although they can be very uncomfortable.
3. Panics are self-limiting. They will not go on forever.
4. When panicking, you won’t do what you are afraid you are going to do.
5. You are afraid of the feelings inside of you, not the external object or situation.
6. Initially, it may not be realistic for you to feel comfortable. Working on your anxiety can be uncomfortable
7. Avoidance is the name of the game in anxiety. Unfortunately, avoiding anxiety only intensifies anxiety.
8. Be tender to yourself. Panic can be looked at as a way of directing anger towards yourself.
9. When you experience anxiety, try to stay in the present. Make distinctions between “What is” and “What if?”
10. We want you to learn that, inadvertently and despite your best intentions, you are somehow creating this anxiety yourself. Once you learn how you do it, you can then learn how not to do it.

You can download and print a pdf version of this list.

 

 

Anxiety Management Techniques

1. Accept Expect and Allow Anxious Feelings: Try not to feel surprised, disappointed, or angry at yourself when anxious thoughts and feelings arise. These thoughts, while disturbing, are not dangerous. Allow them to exist, focus on functioning in spite of them, and they will soon dissipate. If you fight them, or try to get rid of them, your anxiety level will take more time to calm down.
   
   
2. Identify Your Anxiety Level on a Scale of 0 to 10: Zero means you are feeling no anxiety. Ten means are feeling panic. Identifying and recording your anxiety level makes you an active participant in learning to manage your anxiety, and it establishes a baseline against which you can measure your progress.
   
   
3. Monitor Your Anxiety Levels: Observe your anxiety level as it rises and falls in relation to what you focus on. Watch your level rise as you try to rid yourself of anxious feelings. Watch it fall when you accept and allow these feelings. Your level will fall even if you do nothing more than wait and let time pass. Once you get into the habit of identifying your levels and watching them change, you'll be pleasantly surprised to find how relatively infrequently really high levels occur and how quickly they pass when they do arise.
   
   
4. Anchor Yourself in the Present: The present is your safe harbor. Stay there by concentrating on "what is," rather than "what if?" Describe your surroundings, talk to someone, count backwards from 100 by threes, read, sing or listen to the radio. Don't get stuck in your future-oriented imagination. Stay in the here and now.
   
   
5. Don't Plan Your Escape: Planning your escape tends to intensify anxious thoughts and feelings. It projects you out of the present and into the future where you are most subject to catastrophic thoughts and disturbing feelings. Rather than immediately following your old impulse to avoid and flee, try instead to cautiously stay in contact with what frightens you, while practicing your skill at fear management.
   
   
6. You Can Function Well with High Levels of Anxiety: Try not to be so hard on yourself, don't go for perfectionism. You can still function even with high levels of anxiety. You are not likely to scream, faint, or do the embarrassing, outrageous, or dangerous things you sometimes picture in your mind. Remember that anxiety is disturbing but not dangerous. Take comfort in the fact that while you may be feeling shaky, your inner anxiety is rarely apparent to others.
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7. Catch Your Disturbing Thoughts as They Occur: "What if this elevator gets stuck?" is a thought. A thought of this kind will produce fear levels because you are sensitized. Even though such thoughts may be fleeting and barely noticeable, they can startle and frighten you all the same. Try to identify such thoughts as they occur, before your fears become intense. Once you recognize it as only a thought, you can begin to focus on comforting realities in the present, such as, "the elevator seems to be operating properly right now," or ,"there is sufficient air to breathe in any elevator," or, "I now have skills to better manage my anxiety levels."
   
   
8. Separate Thoughts from Feelings: Thought is internal speech--what we tell ourselves. Feelings are made up of sensations experienced in some part of the body. "I feel I can't breathe" is really a thought, which may follow the feelings of tension in your neck, throat, and chest. The thought "I feel I can't breathe" makes the feelings of tension seem dangerous, and starts a series of scary future thoughts. Instead, try saying, "Although I feel that I can't breathe, I know that this is just a thought that seems scary because of the tension in my body. I know that my breathing will take care of itself automatically, so I can concentrate on using my skills to help bring my anxiety down."
   
   
9. Find the "Trigger" to Your Panic Spiral: Despite what you might sometimes feel, your panic does not come "out of the blue." In truth, it comes from a rapid interplay between thoughts and feared feelings. They may surprise you because you do not become aware of the spiral until your fear level gets very high. Learn to identify the "trigger" to this spiral, so you can begin to manage your fear when your number is a one or two, before it increases to a high level.
   
   
10. Stay inside yourself: Your tendency may be to think for others, to imagine how they perceive you. If you find that you are "looking" at yourself through the eyes of others around you, it is a sign that you are getting outside of yourself. Pay attention to how others look to you, notice what colors they are wearing, and whether you like the style of clothing they have on. Focus on what you think, not what others may be thinking.
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11. Remember to Take Care of Yourself: Define and limit your job. Don't try to manage the whole world. That will only increase your feelings of being overwhelmed. Let the pilot take care of the plane and let the driver take care of the bus. Your job is to take care of yourself. Make yourself comfortable, monitor your anxiety level, and do manageable things in the present.

You can download and print a pdf version of these suggestions

 

 

A Cognitive View of Panic

From a Cognitive perspective, people with panic and phobias have:

1. A consistent tendency to catastrophize, along with
2. A sensitivity to specific mental images and thoughts.

Let’s look at the (mis)interpretation, because it includes the “what if” thinking that is so terrifying.

This is where we say to ourselves things like, "What if I lose control?," "What if I have a heart attack?" "What if I embarrass myself?" "What if I begin to panic just when…….?

" Notice that these cognitions (1) are involved with events in the future; and (2) are preoccupied with disastrous outcomes.

This is called “catastrophizing.” Your job is to catch yourself when you begin to have these anxiety-raising thoughts, and to change your thoughts to ones that are focused on the present.

You can download and print a pdf version of this diagram

 

 

Diaphragmatic Breathing

The purpose of this exercise is to reestablish diaphragmatic breathing as your normal, everyday moment-to-moment resting breathing habit. If you do no other exercise, be sure to practice this one. It is that important. It will be most effective if you practice at least three times a day for ten to fifteen minutes each time; eventually, the easy rhythmic motion of the diaphragmatic breathing will begin to replace the strained, unnatural chest breathing to which you have become habituated. You can speed the process by being aware of your breathing pattern as much as possible during the day, for the more aware of it you became, the more often you correct it (change from chest breathing to diaphragmatic breathing), and the faster you will replace thoracic with diaphragmatic breathing.

To Practice: Before you go to sleep and just after you wake up, place your right hand on your upper abdomen, with the little finger directly above the navel and the fingers spread so that the thumb is almost touching the chest. Place your left hand on the upper chest with the little finger between the two breasts. As you breathe, concentrate on the air moving down into the upper abdomen (as if you are filling your stomach with breath). The right hand should rise with the inhalation and fall with the exhalation; the left hand should not move. You should feel a slight motion in the lower portion of the chest cavity, but the upper portion should remain still. Within a few moments you will become more rested and quiet. Do not try to force the breath. Allow the motion to be gentle and effortless. Notice how easy it is to breathe deeply and easily, without any effort.

Benefits: This will lead to autonomic balance and a relaxed state, generally. After some weeks, depending on the individual, you will begin to notice subtle and gradual changes in your daily breathing patterns. Its movement will be more relaxed and rhythmic. As was discussed earlier, this leads to a greater efficiency of the pulmonary process and reduces the amount of work required for proper ventilation perfusion.

Even Breathing

While you are practicing diaphragmatic breathing, concentrate on making the breath very smooth and even. The inhalation and exhalation should be of the same length and have the same pressure. Do not exhale all the breath at the beginning of the exhalation. Concentrate on keeping the flow pressure even throughout the entire cycle. Eliminate all pauses, stops, and shakiness in the breath, including the pause between inhalation and exhalation. Imagine that the breath is like a large wheel moving through the body without any pauses or stops. It is often helpful to picture the breath flow as a completely smooth, even sine wave.

Benefits: The jerkier the breath, the more disruptive it is to the autonomic nervous system. When the breath is smooth and even, autonomic balance is achieved

Reference: Paul Neurnberger, Freedom From Stress: A Holistic Approach, Himalayan Institute Publishers, Honesdale, Pa, 1985

You can download and print a pdf version of this diagram

 

 

Relaxation Exercise:

The more relaxed we are, the less we are disturbed by anxiety and stress. This audio file is a progressive relaxation exercise. You will be asked to gently tense, and then relax, each part of your body. Relaxation is a skill that takes some time to learn, but can become a helpful stress reduction tool as your relaxation skills increase.

Click the play button below to start the tape.

Practice this exercise regularly

Remember the basic rule for beating anxiety:  Anxiety is maintained by avoidance; to overcome anxiety, you must move, in manageable steps, towards areas of greater discomfort.  The more you expose yourself to your anxiety triggers, and the longer you are able to stay in the situation without running away, the more you will eventually overcome your anxiety.

In other words, the active ingredient for overcoming your anxiety is exposure.  And practice is the way we get exposure.

But not all practice is the same.

I would like to introduce two types of practice: planned practice and incidental practice.

Incidental Practice

Let me start by explaining what I mean by incidental practice.  Let's suppose that you are afraid of taking elevators and you must attend a meeting in an office that requires you take one.  (Like any good phobic, let's assume that you have checked all the various ways of seeing if you can change the meeting location, whether you can take the stairs to the meeting, or if you can claim that you are ill and have someone else go in your place.  In other words, is there some way to avoid taking the elevator?!).  Since there doesn't seem to be any way to avoid the elevator, you screw up your courage, grin and bear it, and--anxiety be damned--put yourself on the elevator and press the button for the correct floor.  You do whatever you need to do to make it through that elevator ride, and then scoot out the door as soon it opens.

You have taken an elevator ride.  You have exposed yourself to the source of your anxiety.  But the exposure you have experienced is incidental to the larger goal---your real goal was to get to the meeting.  And, there is a high probability that you engaged in lots of little avoidance tricks to get yourself through the ordeal.  You probably breathed a huge sigh of relief when the ride was over.  Unfortunately, you may not have gained many therapeutic benefits from the anxiety you experienced during this type of exposure.

Planned Practice

I want to contrast this with planned practice.  In planned practice, your goal is to practice exposure to the anxious feelings themselves.  The triggers (such as the elevator) are important in that they cause you to feel levels of anxiety, but the goal has nothing to do with how many of these triggers you can tolerate.  With Planned Practice, you do not need to go anywhere specific, or even do anything specific.  Your goal is to experience anxiety for a planned period of time.

What is the optimal planned amount of time?  While there are individual differences, almost all studies suggest that ongoing exposure for 30 minutes to an hour is most effective.  If you are not a clock person, then your job is to try to stay in the situation until your anxiety starts to significantly decrease--although, as we shall see--there are lots of exceptions to this general rule.

Let me give you an example of how planned practice might proceed:  Suppose you have a fear of driving a distance from your home when you are driving by yourself.  You have a car that is parked in the driveway, but your fears have prevented you from driving for the past 6 months.  Every time you think of getting in the car, pulling out the driveway, and getting into traffic, you begin to panic.  You feel overwhelmed and completely unable to do something like that, so you simply "put off" that dreaded experience.

How would you begin to practice conquering this fear using the principles of planned practice?  

First, you would remind yourself that you are practicing in order to expose yourself to the anxious feelings themselves. This is the basic principle that underlies planned practice.

Second, you would try to disregard where and how far away from home you are going.  The only thing important here is the anxiety your are experiencing.

Third, you would decide how much anxiety you feel capable of tolerating that day.  On a scale of 0 - 10, let's say that you can deal with a 5.  (On other days, this number will change.  On certain days you will feel much less hardy, and decide that a 3 or 4 is all you can handle.  On still other days, you might feel like you can eat nails for breakfast, and a 7, 8 or even a 9 is tolerable).  The important point is that YOU decided your own intended level each time to go out to practice.

Fourth, you get into the car, turn on the engine, and start to back out the driveway.  As soon as you hit a level 5 anxiety (your previously chosen level), you stop the car and wait.  Your goal is to keep the anxiety level as close to 5 as possible, as you practice your anxiety management techniques.

Fifth, let's suppose that you reach a level 5 as soon as you turn on the ignition.  (A level 5 is your maximum for that day.)  So, you have already reached your goal, and all you need to do is stay in the car with the engine running for 30 to 45 minutes.  You are then finished with a successful planned practice.  This is one possibility.

Sixth, a much more probable outcome is that you start the engine, get a whoosh of anxiety, and soon feel much calmer.  Let's say you get down to a 2 or 3.  Remember that your goal is to spend your practice time learning how to cope with a 5.  So, your job is to do whatever you need to do to get your anxiety a little higher.  You might begin to back the car down the driveway.  Let's imagine that your anxiety stays pretty low until you have to back into the street, and at that point it spikes to a 7.  Now your job is to just stay there, waiting to see if your anxiety goes down to the targeted level 5, or if it stays at a 7. If your anxiety goes down to the 5, you don't need to do anything else.  If it stays above a 5, put the car into Drive and return up the driveway until you anxiety level comes down to the 5.  Then you should stop and practice coping with the anxiety.

Here is the general rule.  Try to keep your anxiety at or near the level you have chosen for the day.  Sometimes you will expand your "safety zone" while doing this. Sometimes you will stay very close to home.  That is not important.  You are moving only to adjust your anxiety level as it changes up and down.

After about a half hour--when you are at your predetermined level of anxiety--it is time to stay at that same physical location and allow your anxiety level to begin to decrease.  By merely staying at that same location for a period of time, you will begin to habituate to the anxiety producing stimuli.  You will start to feel less anxious.  When your anxiety level decreases by a very noticeable amount (at least one third), you are finished with your planned practice session.

Advantages of Planned Practice 

The major advantage of planned practice is that it provides you with a systematic and manageable method to maximize your exposure to the feared situation.  We have seen how incidental practice often minimizes exposure, and that we usually engage in a variety of avoidances during that type of exposure.

Planned practice also helps you cope with a phenomenon that I call the "raising the bar" syndrome.  This is very common in these situations.

"Raising the bar" syndrome occurs after we manage to reach a specific behavioral target during our practice sessions.  This can happen any time we practice exposure in a way that is not consistent with the principles of planned practice.  As soon as we have reached that behavioral goal, from that point onward, we often feel pressure to at least reach that target in subsequent practice sessions.  Paradoxically, that pressure acts to raise anxiety, and makes it harder to reach the same goal the next time.  In effect, each time we accomplish a goal, we inadvertently raise the bar for future practices.

Let me be specific.  Suppose you have managed to drive your car out of the driveway, and have reached the school that is 5 blocks away.  The next time you practice, you feel a pressure to at least reach that school, and that pressure increases your anticipatory anxiety.  As you back out of your driveway, you might feel a spike of anxiety.  You might say to yourself, "Oh, no! I'll never make it to the school if I feel this much anxiety and I'm not even out of my driveway yet."  These sorts of thoughts are the fuel that generates anxiety, especially anticipatory anxiety.  You are getting away from the present and thinking scary thoughts about the future.  

Other Benefits of Planned Practice

Planned practice helps you cope with anticipatory anxiety while practicing.  As I have mentioned, anticipatory anxiety is a huge bugaboo in overcoming your anxiety disorder, and it adds to the difficulty of practice.  Just imagine, for example, that you are claustrophobic and you are comfortably sitting in your living room.  You remind yourself that you should practice the exposure of going on an elevator. Because of anticipatory anxiety, merely imagining going into an elevator brings high levels of anxiety, and you might think that you just aren't up to dealing with such high anxiety.  So, you put off the practice and have the experience of avoiding the (in this case, anticipatory) anxiety once again. Your avoidance has strengthened the anxiety, and compliance with your practice schedule goes down. 

Planned practice also helps you keep you eye on your goal: Remember that your goal of practice is exposure:  you want to keep in contact with your anxiety triggers so that you have the chance to habituate or desensitize yourself to them.  Anything that takes you away from exposure is leading you in the wrong direction.  If you focus on a behavioral goal (such as a location or a distance or a type of transportation), then it is natural to do what you need to do in order to get there.  You will be strongly tempted to look for avoidances, safeties and reassurances in order to get to your goal.  And let's remember that all these avoidances tend to reinforce your anxiety, which is the exact opposite of our goal.

Additionally, if you do not use planned practices, the anxiety that you feel can easily turn into a test.  Let me explain: Most people who practice are hoping reach their goal with lower anxiety, and are testing themselves to see how much they will react in the practice situation.  If their anxiety is low, then they feel positive about the practice, and look at that as passing the test; if it is high, then there is a tendency to feel disappointed in themselves, to wonder what is wrong, and to give themselves a low or failing grade on this test.  The interesting point here is that people grade themselves in a way that values getting lower levels of anxiety.  This is exactly the opposite of what we want:  we want to maximize your exposure to anxious stimuli.  Once again, the basic rule we are working with says that we move to areas of greater discomfort in order to overcome anxiety. 

Finally, the principles of planned practice completely change the definitions of success and failure.  In general, people who are practicing feel like they have done better when they are able to reach their target with little or no anxiety. They feel like a failure, either when they feel extremely high levels of anxiety, or when they are simply unable to reach their goal. If you think about it, this is precisely the opposite of what is most therapeutic for you.  The object of practice is to allow exposure to anxiety so that you can learn better ways of coping with it, and to allow your body to desensitize and habituate to your triggers.  

However, with planned practice, there is only one way to fail:  You fail a planned practice when you do not experience anxiety. Any practice that creates anxiety, no matter where that anxiety occurs, counts as a success.  Anxiety is the mark of a successful practice.  A successful planned practice maximizes the therapeutic benefits of exposure.

A Review of Planned vs. Incidental Practice

This table outlines the major differences between planned and incidental practice.

Anticipatory Anxiety is the anxiety that we experience in anticipation of exposure to our frightening triggers.  If you are claustrophobic, when you worry about taking an elevator later in the day, that is anticipatory anxiety.  If you have a fear of contamination, when you worry about having to sit in a dirty seat tomorrow, that is anticipatory anxiety.  And if you have a fear of public speaking, when you worry that your anxiety will ruin your presentation next week, that is yet another example of anticipatory anxiety. 

This simple phenomena plays an enormous role in creating and maintaining virtually all anxiety disorders.  Anticipatory anxiety drives our desire to avoid contact with our sources of anxiety.  It pushes us to stay away from our phobias, worries, and obsessions.  It is extremely powerful and difficult to eradicate.

The irony here is that, like every aspect of anxiety, anticipatory anxiety is entirely paradoxical.  Our attempts to avoid the anxiety makes it stronger. We feel like we are avoiding in order to reduce anxiety, but the truth is that anticipatory anxiety generates additional anxiety.

Some Facts About Anticipatory Anxiety

First, anticipatory anxiety is not a true predictor of how much anxiety we will feel in the actual situation.  Although it is impossible to predict with total accuracy, the fact is that 95% of the time, anticipatory anxiety is much greater than the anxiety we experience when we actually make contact with what frightens us.

This fact flies in the face of our common sense.  Here is a typical way we experience anticipatory anxiety:  Suppose you are frightened of flying.  Despite these fears, you schedule yourself to fly in a week.  When you imagine yourself flying, you think catastrophic thoughts about the flight and your anticipatory anxiety soars.  You think to yourself, “Here I am a week before the flight and just thinking about the flight in the comfort of my living room brings my anxiety up to a level 8.  If I am that anxious just thinking about the flight, imagine how freaked out I am going to be when I am actually on the airplane.  I have to cancel that flight.”

But our anticipatory anxiety gets it all wrong. In truth, we encounter the majority of our anxiety before and at the very beginning of our contact with anxiety producing situations. If you can stay in the situation past that surge of anxiety, you will remain relatively comfortable for the remainder of the time.   In the case of flying, I tell my patients that--if they have a good understanding of the phobic process and have some solid tools for coping with their anxiety--by the time the plane has reached level flight, they will have experienced 80% or more of all their anxiety.  By that time, anticipatory anxiety will have largely passed, and they will begin to benefit from the therapeutic effects of exposure.

Second, anticipatory anxiety is real anxiety, but it is very different from the anxiety we experience in the triggering situation.  There is considerable evidence that anticipatory anxiety and situational anxiety are generated in different parts of our brain. 

We know, for example, that different classes of medications have significantly different effects on these types of anxiety.  SSRI’s (selective serotonin re-uptake inhibitors)  significantly reduce panic, phobic and obsessional anxiety, but have little effect on anticipatory anxiety.  Conversely, the Benzodiazepine class of medications (Valium, Xanax, Klonopin, etc.) can reduce anticipatory anxiety greatly, but have relatively little impact (except at impractically high dosages) on panic, phobias, and obsessional disorders.

Third, anticipatory anxiety is quick to appear and slow to go away.  It is this persistence that makes it one of the most difficult parts of an anxiety disorder to get over.  For example, there are many people who have worked on their phobia or other anxiety disorder to the point that they can make contact with their feared triggers and experience virtually no anxiety.  However, these same people can feel considerable fear when anticipating contact with these same triggers.  In other words, thinking about exposure to the previously feared situation creates anxiety, while making contact with the same situation creates none.

Here is an excellent example, and it is a true story.  Some years ago I was working with a man who was afraid of driving over bridges.  More specifically, he was afraid of getting stuck in traffic while driving over a bridge.  He feared feeling trapped on the bridge, becoming panicky and then doing something impulsive or dangerous , like jumping out of his car or causing a motor accident.  (By the way, these are common “what if” thoughts.  The anxiety makes the thoughts feel like they can really happen, but they never occur in reality.)

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We practiced by repeatedly driving across a major bridge that connected Manhattan to other parts of New York City.  Two things were very fortunate for us that day.  First, the traffic on the bridge was extremely heavy in BOTH directions.  My patient was driving and I sat next to him.  The traffic was so heavy that he had to drive a few feet, stop for a minute, then pull up another few feet when the car ahead of him moved up.  It was literally bumper to bumper.  It was a cloudy, overcast day, and we could see a sea of red brake lights ahead of us crossing the bridge span.  Although I was pleased about the chance to practice anxiety management techniques, my patient was horrified.  He said  to me, “Well, you may be happy, but I’m freaking out here.”  So the word “fortunate” needs to be looked at in the context of creating a great opportunity to practice.

The second fortunate aspect was that the span of this particular bridge is curved in such a way so that you can see the entire row of cars coming at you as you drive over the span.  Remember that there was stop and go traffic in both directions.  So here is the picture:  we are going over the bridge span bumper to bumper, looking at the sea of red brake lights in front of us.  And, by shifting the view a little to our left, we can simultaneously witness the mass of bright headlights coming over the bridge towards us.  Red lights ahead of us leaving Manhattan.  Headlights to the left of us, entering Manhattan.

In the middle of the span, my patient said to me, “Marty, I’m really shocked.  This stop and go traffic is my worst nightmare.  I thought I would be totally freaked out, but my anxiety really isn’t that bad--maybe a 2 or a 3.  I can’t believe it.”   Then there was a silence and my patient continued, “Now you’re going to think I’m really crazy.  I told you when I look at the traffic ahead of us, my level is maybe a 2 or a 3.  But--listen to this--when I look at the traffic coming back into Manhattan, and I think to myself that pretty soon I’ll be part of that line of cars, my anxiety level goes up to a 7 or an 8.  How weird is it that? I’m much more frightened of thinking about what I have to do, even though I’m doing that exact same thing right this minute!”

Actually, this wasn’t weird at all.  It turned out that this particular practice situation allowed my patient to “switch” quickly between phobic anxiety and anticipatory anxiety.  When he looked at the line of cars in front of him, he was exposing himself to phobic anxiety.  When he looked a little to the left and noticed the cars coming back into Manhattan, he was experiencing anticipatory anxiety.  By switching back and forth that way, he was able to isolate and clarify the difference between these two forms of anxiety. 

Besides highlighting the differences, we were able to put a spotlight on the persistence of anticipatory anxiety.  My patient was experiencing very little fear while going over the bridge--his phobia was slight.  But he felt a great deal of anxiety while anticipating the exact same activity in the reverse direction.  We will return later to this point when we look at ways of managing anticipatory anxiety.

The fourth fact about anticipatory anxiety is that it increases with our indecision.  Anticipatory anxiety generally becomes more pervasive as we get closer to the feared activity, as we find it harder to just “put off” thinking about it.  The anxiety we feel often makes us waiver in our determination to pursue the activity.  So, for example, suppose you are afraid of heights and you have to go to meeting on the 43rd story of a building.  As the day of the meeting nears, you will become ever more aware of your anticipatory anxiety.  You might start to waver about attending the meeting.  Can you reschedule the meeting to an office on a lower floor?  Could you call in sick that day?  Could a colleague take your place in the meeting?  This sort of “should I or shouldn’t I” wavering will drive up your anticipatory anxiety even more.  However, as soon as you commit yourself to either bailing on the meeting (which, in the short term, would be a great relief; in the long term, however, you are reinforcing your fear and feeling less able to manage it) or attending it no matter what the anxiety, you will start to experience some relief in your anticipatory anxiety.

I’m not saying that it will go away.  But the internal debate that drives up your anticipatory anxiety will be turned off, and you will notice at the very least a leveling off of it’s intensity.  By freeing yourself of the “should I or shouldn’t I?” debate going on inside of you,  you will be more able to stay connected to the present and focus on manageable tasks. 

Anticipatory anxiety gets you coming and going.  Let’s say that you are afraid of taking public transportation and you are booked on Amtrak from New York to Boston.  You are frightened of the upcoming trip--that is your anticipatory anxiety.  However, sometimes you don’t feel that familiar anxiety prior to a trip.  When that happens, you worry whether something is wrong, and that maybe the absence of fear right now means that you are going to get super-anxious when you are on the train. That is what I mean when I say that it gets you coming and going.

Suggestions for Coping With Anticipatory Anxiety

Let’s face it.  By now you must realize that there is no easy way to get rid of anticipatory anxiety.  But there are a few suggestions for making that anxiety more manageable.

First, label your anticipatory anxiety as just that--anticipatory anxiety.  It is real anxiety, but it is different from the anxiety you will experience when you make contact with what frightens you. Remind yourself that anticipatory anxiety has a life of its own, and can remain a potent source of fear even after you have otherwise conquered your phobia.

Second, remember that anticipatory anxiety is not an accurate indicator of how anxious you will be when you encounter your anxiety triggers.  Stay with the fact that 95% of the time your anticipatory anxiety will be much greater than the anxiety you experience when you are in the situation. As you practice exposing yourself to your fears, you will see that a pattern begins to emerge:  anticipatory anxiety will generally be much higher than your situational anxiety.  Make note of this patterns as they emerge, and try to use these facts to anchor yourself.

Third, you can use judicious amounts of benzodiazepines (minor tranquillizers) to help you manage anticipatory anxiety.  This class of medications seems to target this sort of anxiety quite specifically. There is a down side to this, however.  Studies have shown that in addition to reducing anticipatory anxiety, these medications also reduce the therapeutic effectiveness of exposure.  So you will have to weigh benefits against the negative.

Fourth, try to commit yourself to the activity you are worried about.  Remember that your “should I or shouldn’t I?” debate will intensify your anticipatory anxiety, while a commitment to follow through will allow it to stop increasing.

Fifth, try to turn your anticipatory anxiety into a learning experience about the power of your brain to affect your feelings.  Again, remember that while anticipatory anxiety is real anxiety, it a type of anxiety that is 100% generated by images in your mind.  There are no physical or behavioral triggers to this anxiety.  It is independent of external causes.  You will usually think of worse case scenarios when anticipating how terrifying your future experience will be; these scenarios sometimes have nothing to do with external reality.  Observing your own anticipatory anxiety will help you grasp how powerfully your brain can create it’s own version of reality.

Here is an example.  One of my patients had a severe phobia of vomiting, and was so terrified about it that she limited her life enormously.  She avoided anyone whom she believed might be ill, since that person might pass on a stomach virus and cause her to throw up.  She lived in an apartment with a roommate with whom she was friendly, but not very close.  Each of them had their own bedroom and their own bathroom.  One morning she and her roommate lingered over breakfast, and both went to work at the same time.  That evening she returned home to find that her roommate’s door was shut and she could hear definite signs that her roommate was coughing, retching, and throwing up.  “What if,” she thought, “she caught her roommate’s stomach virus and would soon start getting nauseous and vomiting herself?”  That night was a horror.  She was afraid to knock on the door and contact her roommate.  She couldn’t sleep, and spent most of the night with intense anticipatory anxiety, waiting for her own nausea and vomiting to begin. Finally, out of exhaustion, she fell asleep until the morning.  When she awoke, she saw her roommate walking around the apartment, smiling pleasantly, sipping coffee, eating breakfast, and reading the paper. “But I thought you were sick last night, my patient asked?  “How did you recover so quickly?”  Her roommate looked a little surprised, then laughed a bit, and said that she had been fine all night, but saw the movie “Detroit Rock City”  on a CD before going to bed.  There was a scene in the movie where someone throws up, and she guessed that my patient had overheard that scene.

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My patient immediately realized that her roommate had never been ill, and she, my patient, had never been in danger of catching her stomach virus.  The entire experience was based on mis-information, and entirely generated in the mind of my patient.  For her, it was the beginning of a profound realization that her phobia was based on images in her brain, and not on the external reality. 

Sixth, and finally, the best way to overcome anticipatory anxiety is to understand that this anxiety bluffs you into believing that you won’t be able to handle your fear in the upcoming situation. Once you gain confidence that you can handle the anxiety that arises there, you will be able to treat anticipatory anxiety for what it is--real anxiety that has it’s own life, but has nothing to do with the fears you are anticipating. 

So, for example, suppose you are overcoming your fear of flying, and you have had many flights under your belt with minimal anxiety each time.  When you purchase your tickets, you might still feel high levels of anticipatory anxiety.  But, if you can tell yourself that you feel confident of coping with any anxiety that might arise during the flight, you can put this anxiety in the background of your awareness, where it will become gradually less intense.

Coming Soon