Anxiety is a combination of physical symptoms, emotions, thoughts and responses/behaviours. Find out more about anxiety and how to worry well and manage stress.

Anxiety Hand-Out (Information handout)

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What is anxiety? What do you experience?

Anxiety is a combination of physical symptoms, emotions, thoughts and responses/behaviours.

Examples:

Physical symptoms	Emotions	Thoughts/Worries	Responses / Behaviours
Breathlessness Chest pain Butterflies	Fear Low mood Stressed	What if I’m attacked? What if I’m ill? What if I’m humiliated?	Avoidance Reduced activity Seek-reassurance

 

Anxiety is meant to be a response to threat. It can be useful to understand the underlying mechanisms of anxiety and the role worry and avoidance.

Physical symptoms:

The physical symptoms of anxiety are connected to the fight or flight response. This is the physical response our body activates when a threat to our safety is spotted. The idea is that the body is either going to run away or fight off an attack: either way, it is going to be involved in exercise!

The symptoms reflect the body’s response to danger being an anticipation of exercise

Increased breathing / breathlessness – body attempting to get more air / oxygen

Increased heart rate / chest pain – body pumping oxygen around the body

Tense / twitchy / weak muscles – oxygen / energy taken to muscles, ready for exercise

Sweating – body preparing to cool the body in anticipation of heat being generated

Going red / feeling hot – body preparing to cool the body in anticipation of heat being generated

Butterflies in stomach – non-essential systems (e.g. digestive system) slowed down temporarily

Anxiety is not dangerous, the symptoms are part of a normal, helpful process

Worry (Information Handout)

A worry is a thought, a negative thought about the future.

Worrying is the thinking part of anxiety and usually starts with a ‘What if…’ For example ‘What if I can’t get a job?’ What if someone attacks me? What if I have a terminal illness? What if I never get better? What if I am in an accident?

This type of thinking can impact upon our emotions and feel distressing. So why do we do it?? It is important to remember that we worry for a reason – people do it because they think it will be helpful or that it is the best way to cope.

Positive beliefs about worry

Worry will help me to be prepared for the worst

Worry will help me avoid bad things happening and keep me safe

I need to worry in order to cope

So if worry is so helpful, why don’t we just worry more and be really safe and prepared?

This is what some people do! The happy worriers! However, often when asked this question people say they do not want to worry too much because they think it might make them ill, it causes too much distress/discomfort, it’s distracting, it impacts upon sleep, it’s stressful and they don’t feel like they can control it… It is important to remember that anxiety is not harmful – it does not make you ill. It is also important to remember that worry is controllable!

The Dilemma!!

It is important to realise that this is a dilemma: should you worry to be safe OR not worry in order to be relaxed, focussed and happy? Worry is a strategy and it is controllable, you may just be using it ineffectively and inefficiently.

Resolving the Dilemma:

It is important to remember that thoughts (such as any involved in worry):

• Cannot harm you
• Are controllable

They only feel out of control because of the dilemma that you are in and the conflicting coping responses we use (i.e. do we focus towards such negative thoughts or away from them?). We need to use a better method of coping. This involves adding structure to your worry so that it does not intrude upon your entire day. That way you can actually be more effective and focussed with your worrying and preparation for danger.

 

 

 

 

 

Alternative to unstructured worry (a step by step guide)

 

How to worry well:

Step 1:

Begin to notice when you are worrying / ruminating. It will be such a habit that you may struggle to notice that you are doing it. The first step is to reflect on the process. Be aware of the difference between the trigger (the initial thought) and the process (the continued effort).

Step 2:

Begin to delay your worry. You can maintain all of the positive parts of worry by doing it at a specific point in the day (e.g. 6pm). During the rest of the day say to yourself ‘I will think about this properly later’.

Step 3:

Dismiss thoughts associated with the worry. You do not need to reassure yourself. Triggers my still pop into your mind, you do not need to respond to each one.

Step 4:

During a ‘worry period’, you can focus on your worries for a specific amount of time. You may then be able to actively problem-solve and explore lessons from past mistakes. This may not be a pleasant moment in your day, however, it is only for a brief period and will be more likely to be useful.

 

 

Fear Beliefs and Avoidance (Information handout)

 

When we are scared of something happening, we often try to avoid it by avoiding people, places, situations, feelings, emotions, symptoms etc. Sometimes people stop going out the house entirely in an attempt to avoid the things they are scared of. The problem this causes is that we do not learn if the bad thing would happen or whether we would be able to tolerate or survive it.

For example, imagine that you were scared of cats. You believed that cats could not be trusted and would keep attacking and scratching you and maybe give you a disease. You might avoid all cats by changing direction when you see one in the street, not going to friend’s houses who have cats and generally refusing to go near them. You would never learn that cats do not go out of their way to attack you, they usually just don’t go near you. If a cat lets you stroke it or pick it up, then it is not very likely to scratch you at all. You would also never learn that a cat scratch is not particularly painful or damaging. The process goes like this:

 

 

 

 

 

The same progress can be applied to any fear belief:

 

 

 

 

This doesn’t mean that all thoughts are untrue or that you should behave recklessly! But it is helpful to make sure that if you believe something that affects large parts of your daily life, you are able to check whether or not it is true!

 

 

Relaxation Exercises and Strategies to Disengage from Worry: Exercise Handout

The relaxation exercises are designed to help you control the feelings of stress and tension in your body. But please remember: anxiety is not dangerous! Managing anxiety is about managing discomfort and efficient use of effort…

Breathing techniques (Relaxation)

Diaphragmatic breathing

Mindful breathing

Mindfulness (Relaxation)

Progressive muscle relaxation

Guided body scan

The constant observer

Detached Mindfulness (Disengaging from worry)

 

Diaphragmatic Breathing Exercises*

 

Belly breathing

Belly breathing is easy to do and very relaxing. Try this basic exercise anytime you need to relax or relieve stress.

1.Sit or lie flat in a comfortable position.

2.Put one hand on your belly just below your ribs and the other hand on your chest.

3.Take a deep breath in through your nose, and let your belly push your hand out. Your chest should not move.

4.Breathe out through pursed lips as if you were whistling. Feel the hand on your belly go in, and use it to push all the air out.

5.Do this breathing 3 to 10 times. Take your time with each breath.

6.Notice how you feel at the end of the exercise.

4-7-8 breathing

This exercise also uses belly breathing to help you relax. You can do this exercise either sitting or lying down.

1.To start, put one hand on your belly and the other on your chest as in the belly breathing exercise.

2.Take a deep, slow breath from your belly, and silently count to 4 as you breathe in.

3.Hold your breath, and silently count from 1 to 7.

4.Breathe out completely as you silently count from 1 to 8. Try to get all the air out of your lungs by the time you count to 8.

5.Repeat 3 to 7 times or until you feel calm.

6.Notice how you feel at the end of the exercise.

Roll breathing

Roll breathing helps you to develop full use of your lungs and to focus on the rhythm of your breathing. You can do it in any position. But while you are learning, it is best to lie on your back with your knees bent.

1.Put your left hand on your belly and your right hand on your chest. Notice how your hands move as you breathe in and out.

2.Practice filling your lower lungs by breathing so that your "belly" (left) hand goes up when you inhale and your "chest" (right) hand remains still. Always breathe in through your nose and breathe out through your mouth. Do this 8 to 10 times.

3.When you have filled and emptied your lower lungs 8 to 10 times, add the second step to your breathing: inhale first into your lower lungs as before, and then continue inhaling into your upper chest. Breathe slowly and regularly. As you do so, your right hand will rise and your left hand will fall a little as your belly falls.

4.As you exhale slowly through your mouth, make a quiet, whooshing sound as first your left hand and then your right hand fall. As you exhale, feel the tension leaving your body as you become more and more relaxed.

5.Practice breathing in and out in this way for 3 to 5 minutes. Notice that the movement of your belly and chest rises and falls like the motion of rolling waves.

6.Notice how you feel at the end of the exercise.

 

Mindful Breathing Exercise*

 

1.Find a relaxed, comfortable position. You could be seated on a chair or on the floor on a cushion. Keep your back upright, but not too tight. Hands resting wherever they’re comfortable. Tongue on the roof of your mouth or wherever it’s comfortable.

2.Notice and relax your body. Try to notice the shape of your body, its weight. Let yourself relax and become curious about your body seated here—the sensations it experiences, the touch, the connection with the floor or the chair. Relax any areas of tightness or tension. Just breathe.

3.Tune into your breath. Feel the natural flow of breath—in, out. You don’t need to do anything to your breath. Not long, not short, just natural. Notice where you feel your breath in your body. It might be in your abdomen. It may be in your chest or throat or in your nostrils. See if you can feel the sensations of breath, one breath at a time. When one breath ends, the next breath begins. 

4.Now as you do this, you might notice that your mind may start to wander. You may start thinking about other things. If this happens, it is not a problem. It's very natural. Just notice that your mind has wandered. You can say “thinking” or “wandering” in your head softly. And then gently redirect your attention right back to the breathing.

5.Stay here for five to seven minutes. Notice your breath, in silence. From time to time, you’ll get lost in thought, then return to your breath. 

6.After a few minutes, once again notice your body, your whole body, seated here. Let yourself relax even more deeply and then offer yourself some appreciation for doing this practice today.

 

Progressive muscle relaxation*

 

Find yourself a quiet place to relax. Turn off your phone and dim the lights. This is your time...a time for complete and utter relaxation.

For this relaxation, you can either sit or lie down. Just make sure that you are warm enough, and that you are comfortable. Let your hands rest loosely in your lap, or by your side. Now close your eyes.

Become aware of your breathing, and notice how your abdomen rises and falls with each breath...

Now take a long slow deep breath in through your nose, all the way down into your stomach. Hold the breath for just a moment, and then exhale through your mouth. Allow your breath to carry away all stress and tension as the air floods out of your lungs.

Take another slow breath in through your nose. Fill your lungs completely. Hold it for a moment...and release the breath through your mouth. Empty your lungs completely.

Take a third deep breathe in. Hold it for a moment, and then let it go.

Feel that your body has already undergone a change. The tension in your body has begun to loosen and subside.

Now let your breathing rhythm return to normal...and relax....

During this relaxation I will ask you to tense various muscles throughout your body. Please do this without straining. You do not need to exert yourself, just contract each muscle firmly but gently as you breathe in. If you feel uncomfortable at any time, you can simply relax and breathe normally.

Bring your awareness to your feet and toes. Breath in deeply through your nose, and as you do, gradually curl your toes down and tense the muscles in the soles of your feet. Hold your breath for just a few seconds and then release the muscles in your feet as you breathe out. Feel the tension in your feet wash away as you exhale. Notice how different your feet feel when tensed and when they are relaxed.

Take another deep breath in again, tense the muscles in the soles of your feet and hold this position for a few seconds.

Now release. Feel yourself relaxing more and more deeply with each breath. Your whole body is becoming heavier, softer and more relaxed as each moment passes.

Now bring your awareness to your lower legs...to your calf muscles. As you draw in a nice deep breath, point your toes up towards your knees and tighten these muscles. Hold for just a moment, and then let those muscles go limp as you exhale.

Once again, draw in a deep breath...and tighten your calf muscles. Hold for a few seconds, and then let it all go. Feel your muscles relax, and feel the tension washing away with your out-breath.

In a moment you will tense the muscles in the front of your thighs. If you are lying down, you can do this by trying to straighten your legs. You’ll feel the muscles pulling your kneecap upwards. If you are seated, you can tense these muscles by pushing your heels down onto the floor.

Take a deep breath in, and tense the muscles in your thighs. Hold for just a moment, and then release everything. As you do this, the blood flow to your muscles increases, and you may notice a warm tingling sensation. Enjoy this feeling of soothing relaxation in your thighs. Again, breathe in deeply and tighten your thigh muscles. Hold for a moment. Now release. Focus on letting your muscles go limp and loose. Draw in a nice deep breath and gradually tighten the muscles in your buttocks. Hold this contraction for a few seconds, and then release your breath. Feel the tension leaving your muscles. Feel them relaxing completely. Once more, breathe in deeply and tighten the muscles in your buttocks. Hold for a moment. Now release them. You are becoming more and more deeply relaxed. Take another breath, and this time, gradually tighten all the muscles in your legs, from your feet to your buttocks. Do this in whatever way feels natural and comfortable to you. Hold it...and now release all these large strong muscles. Enjoy the sensation of release as you become even more deeply relaxed. Now bring your awareness to your stomach. Draw in a nice deep breath and then tighten these muscles. Imagine you are trying to touch your belly button to your spine. Now release your breath and let your muscles relax. Notice the sensation of relief that comes from letting go. Once again, draw in a deep breath and then tighten your stomach muscles. Hold for a few seconds... and then let them relax as you exhale and release all tension.

Bring your awareness to the muscles in your back. As you slowly breathe in, arch your back slightly and tighten these muscles....Now release your breath and let your muscles relax. Again, draw in a deep breath and then tighten your back muscles. Hold for a few seconds...and then let

them relax and release. Now give your attention to your shoulder muscles and the muscles in your neck. As you slowly draw in a nice deep breath, pull your shoulders up towards your ears and squeeze these muscles firmly. Now breathe out completely, and allow your contracted muscles to go loose and limp. Again, pull your shoulders up towards your ears and squeeze these muscles firmly.

Now feel the tension subside as you relax and breathe out. Feel the heaviness in your body now. Enjoy the feeling. Feel yourself becoming heavier and heavier. Feel yourself becoming more and more deeply relaxed. You are calm, secure, at peace. Now it’s time to let go of all the tension in your arms and hands. Let’s start with your upper arms. As you breathe in, raise your wrists towards your shoulders and tighten the muscles in your upper arms. Hold that breath and that contraction for just a moment...and then gently lower your arms and breathe all the way out. You may feel a warm, burning sensation in your muscles when you tighten them. Feel how relaxing it is to release that tightness and to breathe away all tension.

As you curl your upper arms again, tighten the muscles as you breathe in. Breathe in deeply. Now relax your arms and breathe out. Now bring your awareness to your forearms. As you breathe in, curl your hands inwards as though you are trying to touch the inside of your elbows with your fingertips. Now feel the tension subside as you relax and breathe out. Again, take a deep breath in, and tighten the muscles in your forearms. Hold it for a moment, and then release them. Feel the tension washing away.

Now, take another breath in and tightly clench your fists. When you have finished breathing in, hold for just a few seconds, and then release. Notice any feelings of buzzing or throbbing. Your hands are becoming very soft and relaxed. Take another deep breath in and clench your fists again. Hold for just a few seconds, and then release. Let your fingers go limp. Your arms and hands are feeling heavy and relaxed. Take a couple of nice long slow breaths now, and just relax. Feel yourself slipping even deeper into a state of complete rest. Now tighten the muscles in your face by squeezing your eyes shut and clenching your lips together. As you do, breathe in fully. Hold it...now breathe out and relax all your facial muscles. Feel your face softening. Once more, breathe in deeply while you scrunch the muscles in your eyes and lips....and release. Now bring your awareness to the muscles in your jaw. Take a deep breath in, and then open your mouth as wide as you can. Feel your jaw muscles stretching and tightening. Now exhale and allow your mouth to gently close. Again, fill your lungs with air and then open your mouth wide. Now let your mouth relax and let your breath flood all the way out. You are now completely relaxed from the tips of your toes to the top of your head.

Please take a few more minutes to rest. Relax. Listen to the sound of your breathing and enjoy the lovely, warm sensation of physical relaxation. If you have the time, feel free to fall asleep. You will wake feeling completely rejuvenated and relaxed.

 

Guided Body Scan (A Mindfulness Exercise)*

 

Begin by bringing your attention into your body.

You can close your eyes if that’s comfortable for you.

You can notice your body seated wherever you’re seated, feeling the weight of your body on the chair, on the floor.

Take a few deep breaths.

And as you take a deep breath, bring in more oxygen enlivening the body. And as you exhale, have a sense of relaxing more deeply.

You can notice your feet on the floor, notice the sensations of your feet touching the floor. The weight and pressure, vibration, heat.

You can notice your legs against the chair, pressure, pulsing, heaviness, lightness.

Notice your back against the chair.

Bring your attention into your stomach area. If your stomach is tense or tight, let it soften. Take a breath.

Notice your hands. Are your hands tense or tight. See if you can allow them to soften.

Notice your arms. Feel any sensation in your arms. Let your shoulders be soft.

Notice your neck and throat. Let them be soft. Relax.

Soften your jaw. Let your face and facial muscles be soft.

Then notice your whole body present. Take one more breath.

Be aware of your whole body as best you can. Take a breath. And then when you’re ready, you can open your eyes.

 

The Constant Observer (A mindfulness exercise)*

Close your eyes, get settled in your chair, and simply follow the instructions. If you ever find

your mind wandering, just gently come back to the exercise/sound of the voice. There’s no need to think, do, or imagine anything in particular—so whatever comes up is just right.

Before we start, take a couple of gentle breaths—in … and out … in … and out. As you’re doing so, notice the sound and feel of your own breath. Now turn your attention to being just where you are, here in this room sitting in a chair.

Now imagine you’re watching yourself in a mirror. The eyes looking back at you now are the very same eyes that were also there on your first day of school. Can you still remember that day? What did you see with your eyes then? And what was happening inside of you that day? Do you notice any emotions you were having … any thoughts? Now I want you to notice that, as you noticed these things, there was a part of you noticing them. A part of you noticed those sensations … those sounds … thoughts … and feelings. And that part of you we will call the “observer you.” There is a person in here, behind those eyes, who is aware of what I am saying right now. And it is the same person you’ve been all your life. In some deep sense, this observer you is that you, which you call “you.”

Now I want you to remember the day you met your first girlfriend or boyfriend, or if your memory of that event is too faint, then remember the day you met your current partner … The eyes looking back at you from the mirror are the very same eyes that were there with you then, noticing everything that was happening. Remember all the things that were happening then … Remember the sights … the sounds … the smells … your feelings … your thoughts … and as you do, see if you can notice that you were there then, noticing what you were noticing. See if you can catch the person behind your eyes who saw, heard, smelled, felt, and had thoughts. You were there then, and you are here now. We’re just asking you to notice the experience of being aware and to check and see if in some deep sense, the you who is here now, was also there then … The person aware of what you are aware of now is here now, and that person was also there then. 

Behind those eyes you see in the mirror now is the same you who was with you when you were a

kid on vacation with your family, later in high school, in college, and still later on the job. It’s also the same you who is with you today when you leave the house in the morning, when you check your cell phone, go shopping, and when you’re having dinner together with friends.

What is important here is this: during all these moments you saw different things, had different

thoughts, and experienced different feelings. Your looks have changed a lot over time as well. But one thing hasn’t changed: it has always been the same pair of eyes that during all these different experiences looked at these experiences and watched everything. The observer behind your eyes was there then, and it is here now—and that observer was the same then as it is now. Again, we’re asking you not to believe this; just see if you notice this basic continuity––in some deep sense at the level of experience, not at the level of belief.  This observer has always been the same. You have been you your whole life.

Your roles are constantly changing too. Sometimes you’re a friend, a parent, a colleague, a business partner, a romantic partner. But no matter what role you happen to be playing at any given time, there is a you there behind your eyes who is not changing but simply observing how you move through life playing out all those different roles.

Now finally, let’s look at your emotions. Notice how your emotions are constantly changing. Sometimes you feel joyful, sometimes you feel sad. At other times, you feel tense … and then comes boredom … excitement … relaxation. And yes, while these emotions come and go, notice that in some real sense the you who is registering all these changing emotions does not change. The same is true for your thoughts. They come and go, seemingly out of nowhere, and then go back there again. Sometimes you think about others, sometimes you think about yourself. Sometimes your thoughts make sense to you, and sometimes they don’t.

So, as a matter of experience, not of belief, can you sense that you’re not just your body … your

roles … your emotions … your thoughts? All of these are the content of your life, while you are the arena … the place … the space in which they unfold. Notice that the worries you’ve been struggling with and trying to change are not you. See if you can take advantage of this perspective to let go of your worries just a little bit, secure in the knowledge that you have been you through it all, and that you need not be so invested in your emotional weather as a measure of your life. Instead, just notice the experiences in all the areas of your life that show up, and as you do, notice that you are still here, being aware of what you are aware of. That does not change.

Take a moment longer and just stay with this silent unchanging constant witness. Then when you’re ready, picture yourself sitting on your chair in your room. And after a moment or two, come back to your room and open your eyes.

 

Detached mindfulness*

 

It can help to learn how to disengage from thoughts. This is so that you can disrupt or delay the worry process until you have decided to worry / problem-solve on purpose in a focussed effective way.

Clouds metaphor

It is sometimes useful to experience your thoughts as you would experience clouds passing you by in the sky. The clouds are part of the Earth’s self-regulating weather system, and it would be impossible and unnecessary to try and control them. Try to treat your thoughts like you would treat passing clouds and allow them to occupy their own space and time in the knowledge that they will eventually pass you by.

Train metaphor

It is helpful to think of yourself as a passenger waiting for a train. Your mind is like a busy station and your thoughts and feelings are the trains passing through. There is no point in trying to stop and climb aboard a train that is passing by. Just be a bystander and watch your thoughts pass through. There is no point in climbing aboard to be whisked away to the wrong place.

Misbehaving Child Metaphor

You can think of detached mindfulness as similar to the way you might deal with a child. How would you manage a child misbehaving in a store? You could pay a great deal of attention to the child and try to control the child’s behaviour. But if the child craves attention this response could make things worse. It is better not to actively engage with the child but to keep watch over the child without doing anything. Your negative thoughts and beliefs are like that child. If you pay them a great deal of attention, if you control them or use punishment, they misbehave even more. It is better not to try and control or actively engage with them, just keep a watching manner over everything. As you do this, try to be aware of yourself as the observer of these things.

Healing Metaphor

Overcoming a psychological injury caused by trauma is very much like overcoming a physical injury such as a cut to the skin. If you think of a physical injury the body has its own way of healing itself over time. But what would happen if you tried to make the injury heal, say by picking at the scar and repeatedly cleaning the wound? How quickly would it heal? Trauma symptoms are like this. Over time the mind can heal itself and this often occurs. However, just like a flesh wound, if you interfere with the healing process it can take longer and symptoms can persist. You are interfering with the healing process by engaging in worry / rumination, by avoiding thoughts, and by keeping attention focussed on threat. The goal of treatment is to remove these unhelpful responses so that normal healing can be resumed.

 

Problem-solving: Exercise Handout

In order to make ‘worry periods’ more useful and protective, the following process of problem-solving can be used.

The steps for problem-solving are:

1.      Identify the problem / dilemma and define it as specifically as possible

2.      Think of all the possible solutions or options available

3.      One by one, consider the advantages, then disadvantages of each solution / option

4.      Weigh up the option and make a decision regarding which one to go for

5.      Carry out the plan

6.      Review whether it has been a success (bear in mind that you will need to consider how to decide whether it was a success or not)