Anxiety disorders are highly treatable with psychological therapies, medication, or both. Combination therapies are often used, for example a combination of anti-anxiety medication and cognitive behavioural therapy has been suggested to be more effective than either one alone; however the most effective treatment will depend on each individual person’s needs and associated genetic and environmental factors (www.emedicine.com).

In this article we explore a range of psychological approaches to treating anxiety disorders.

Breathing Retraining

Breathing retraining is based on the rationale that over breathing is a contributing factor in the development of panic. The abnormal breathing often goes unnoticed by the person but the effects include hyperventilation that incorporates such things as dizziness, tingling sensations, palpitations and tightness in the chest. This is the result of depleted carbon dioxide in the blood. Hyperventilation is not dangerous, although it can feel very frightening for those experiencing it. It is a normal part of the fight or flight response, which consequently sends a message to the brain that there is danger present.

A slow-breathing technique is used to counteract the effects of hyperventilation. It should be done at the first possible sign that anxiety is occurring, as this strategy of slow-breathing sends a signal to the brain that there has been a false alarm. It is a very effective first step in the treatment of anxiety, but can also be used as a preventative measure to lower a person’s baseline levels of anxiety prior to any stressor occurring.

Breathing Retraining – Exercise

• If possible, stop what you are doing and sit down or lean against something.  If driving, pull over and park in a safe place.
• Hold your breath and count to 10 (don’t take a deep breath).
• When you get to 10, breathe out and say the word “relax” to yourself in a calm, soothing manner.  Remember to breathe through your nose.
• Breathe in and out slowly in a six-second cycle.  Breathe in for three seconds and out for three seconds.  This will produce a breathing rate of 10 breaths per minute.  Say the word “relax” to yourself every time you breathe out.
• At the end of each minute (after 10 breaths), hold your breath again for 10 seconds and then continue breathing in the six-second cycle.
• Continue breathing in this way until all symptoms of over breathing have gone.
• If this is done at the first signs of over breathing, the symptoms will subside within a minute or two and an anxiety attack will not follow.

Source: Andrews et al., (1996)

Progressive Muscle Relaxation (PMR)

Muscle tension is commonly associated with stress, anxiety and fear. It is apart of the process that helps our bodies prepare for a perceived dangerous/threatening situation. Originally developed by Jacobson (Barlow, 1988), the PMR procedure teaches clients to relax their muscles in two steps. First, tension is deliberately applied to each muscle group, and then the tension is released while the client notices how the muscles feel when relaxed.

With regular practice clients learn to distinguish between tensed and relaxed muscles. With this knowledge, they can then relax muscles at the first sign of the tension that accompanies the fight or flight response.

PMR – Procedure and Sequence

Each tensing is for 10 seconds; each relaxing is for 10 or 15 seconds. Note that each step is really two steps–one cycle of tension-relaxation for each set of opposing muscles. Breathe slowly and evenly and think only about the tension-relaxation contrast. Do the entire sequence once a day if you can, until you feel you are able to control your muscle tensions.

Be careful: If you have problems with pulled muscles, broken bones, or any medical contraindication for physical activities, consult your doctor first.

• Hands. The fists are tensed; relaxed. The fingers are extended; relaxed.
• Biceps and triceps. The biceps are tensed (make a muscle–but shake your hands to make sure not tensing them into a fist); relaxed (drop your arm to the chair–really drop them). The triceps are tensed (try to bend your arms the wrong way); relaxed (drop them).
• Shoulders. Pull them back (careful with this one); relax them. Push the shoulders forward (hunch); relax.
• Neck (lateral). With the shoulders straight and relaxed, the head is turned slowly to the right, as far as you can; relax. Turn to the left; relax.  (Bringing the head back is not recommended–you could break your neck).
• Mouth. The mouth is opened as far as possible; then relax. The lips are brought together or pursed as tightly as possible; then relax.
• Tongue (extended and retracted). With mouth open, extend the tongue as far as possible; relax (let it sit in the bottom of your mouth). Bring it back in your throat as far as possible; relax.
• Eyes. Open them as wide as possible (crease your brow); relax. Close your eyes tightly (squint); relax. Make sure you completely relax the eyes, forehead, and nose after each of the tensing.
• Forehead. Raise your eyebrows as high as they will go, as though you were surprised by something. Then relax
• Back. With shoulders resting on the back of the chair, push your body forward so that your back is arched; relax. Be very careful with this one, or don’t do it at all.
• Thighs. Extend legs and raise them about 6″ off the floor or the foot rest–but don’t tense the stomach; relax. Dig your feet (heels) into the floor or foot rest; relax.
• Stomach. Pull in the stomach as far as possible; then relax completely. Push out the stomach or tense it as if you were preparing for a punch in the gut; relax.
• Calves and feet. Point the toes (without raising the legs); relax. Point the feet up as far as possible (beware of cramps-if you get them or feel them coming on, shake them loose); relax.
• Toes. With legs relaxed, dig your toes into the floor; relax. Bend the toes up as far as possible; relax.

(Source: Adapted from Jacobson, 1938)

Dealing with Avoidance

Relief brought about by avoidance of the anxiety-provoking situation is temporary and simply reinforces the fear, making it harder to face and potentially generalising it to other situations. Therefore confronting the anxiety-provoking situation, rather than avoiding it, is usually the best way to reduce its impact.

This needs to be done in a graded way in order to control the level of anxiety, starting with small steps and using strategies such as breathing and relaxation to remain in the situation until the anxiety subsides.

Graded Exposure

When a person has experienced anxiety in a certain place or situation previously, they are more likely to anticipate the anxiety recurring under similar circumstances. This can lead to avoidance, which further reinforces the anxiety and its association with the particular place or situation where the anxiety initially occurred. The decrease in anxiety, when the situation is avoided, tells the person that avoidance is a useful strategy.

Unfortunately the anxiety will remain whenever the person is faced with this situation, and it is likely that the number of situations in which the anxiety is anticipated will increase. Therefore, rather than avoiding the anxiety provoking situation, exposure to it can be used as a more effective long-term strategy in reducing the anxiety associated with the particular situation(s).

Exposure simply involves remaining in the situation long enough for the anxiety to eventually subside. If choosing to use exposure, it is particularly important to ensure that the exposure is graded whereby the client is incrementally introduced to the anxiety provoking situation in well thought out measured doses.  Respite from the specifically graded anxiety provoking situation is only permitted once the anxiety has decreased significantly. If the person does not remain in the situation until this occurs, they will negatively reinforce the avoidance behaviour instead.

The client also needs to be prepared for the exposure through being skilled up in key coping strategies such as slow breathing, muscle relaxation and straight thinking. Using these strategies in the time of exposure will help the client learn different ways of dealing with their anxiety when it heightens. It is important that the client practices these skills outside the context of the anxiety provoking situation first, to ensure they feel confident in their ability to apply the strategies in their time of distress while being exposed.

Grading the exposure is important to ensure the client gains experience of the anxiety without avoiding it and to practice the skilled responses learnt. The exposure is graded by establishing a hierarchy to order levels of exposure from small levels of anxiety provoking stimuli to larger doses of the anxiety provoking stimuli as a way of grading the exposure from less intense to more intense over time. For example a person with a fear of lifts might follow the hierarchy of graded exposure below:

1. Stand in front of a lift – until the anxiety subsides
2. Stand inside the lift with doors open – until the anxiety subsides
3. Stand inside the lift with doors closed accompanied by a friend – until the anxiety subsides
4. Stand inside the lift with doors closed alone – until the anxiety subsides
5. Take lift to first floor accompanied by a friend – until the anxiety subsides
6. Take lift to first floor alone – until the anxiety subsides

The person continues to practice each step until it no longer evokes excessive anxiety. They then repeat the same process with the next step. In this manner, the association between the situation and the anxiety is weakened. It is important that the client works the grades with the therapist rather than the therapist being too prescriptive. This because it is the client who will know the specific things that will evoke their anxious responses and the order of intensity in which they would fall.

Individuals with blood injection injury phobias would need to begin graded exposure lying down to avoid fainting or to avoid injury if fainting. Exposure would increase to more difficult situations including watching blood being taken and finally having his or her own blood taken.

Systematic Desensitisation

This is a similar process to graded exposure however it uses visualisation instead of actual exposure to the relevant anxiety provoking situation. As with graded exposure, the client is taught relevant coping skills, like progressive muscle relaxation, and then develops a graded hierarchy. Only this time the hierarchy is of imagined scenes. The client then uses progressive muscle relaxation to keep their anxiety to a minimum while visualising the anxiety provoking stimuli.

While systematic desensitisation has a demonstrated efficacy in reducing anxiety (Curtis, Nesse, Buxton, Wright, & Lippman, 1976) studies suggest that graded exposure is preferable (Barlow, 1988). Systematic desensitisation is often used when real world exposure would be difficult, for example overcoming anxiety related to flying. Imagined exposure is slower than graded exposure but is a useful way of creating small steps towards all-or-nothing activities.

Systematic Desensitisation that is done in real life rather than imagined is often referred to as in vivo systematic desensitisation which is really just another term for graded exposure. Graded exposure can begin with imagined scenarios and then progress on to in vivo or real life.

Distraction

Distraction is a temporary strategy used to alleviate anxiety caused by chronic worrying, allowing the person to work on developing problem-solving skills so that distraction is no longer needed. It is difficult to stop unhelpful thoughts by trying to push them away; a more useful approach is to focus thoughts on something else instead. As it is not possible to successfully focus on more than one thing at a time, clients are encouraged to focus attention on such things as crosswords, books, physical exercise or having a conversation, rather than focusing intently on and ruminating over their irrational thoughts.

Problem Solving

Structured problem solving offers a useful framework for people with excessive anxiety to apply when dealing with anxiety provoking circumstances and situations. This technique helps provide a plan of action that draws on successful strategies used in the past as well as new strategies that require practice. The following process should be used for small problems at first, and only applied to one problem at a time until each step is well practiced.

Problem Solving Process

• Problem Definition: Decide what you want to achieve and write it down. Often people keep the problem in their head as a vague idea and can so often get lost in what they are trying to achieve.
• Generate Possible Solutions: At this stage you should concentrate on generating as many solutions as possible without evaluating any of them. You should not pre-judge any potential solutions by treating each idea as worthy of consideration. Write them down.
• Analyse the Solutions: Note down the good and bad points relevant to each solution. Consider which ones you would be most willing to try.
• Choose a Solution: Decide which solutions to keep and which to discard. Choose the one you think would be most effective first. Alternatively at this point you might consider re-evaluating the problem because the problem may not be as well defined as you originally thought.
• Plan a Course of Action: Write down what you will do next – how you will make the solution happen. If this solution does not work out, choose the next most effective one on your list.

Source: (Robson, 2002).

Summary

Treatment for anxiety includes a variety of approaches, including cognitive behaviour therapy and medication. The prognosis for recovery depends on the specific disorder, the severity of the person’s symptoms, the specific causes of the anxiety, and the suitability of the treatment administered. Anxiety is a natural aspect of human existence, however factors which contribute to excessive levels of anxiety can be managed and ‘unlearned’.

Source: www.mentalhealthacademy.com.au

References

• Andrews, G., Crino R., Hunt, C., Lampe, L., & Page, A. (1996). The treatment of anxiety disorders. New York: Cambridge University Press.
• Barlow, D. H. (1988). Anxiety and its disorders: The nature and treatment of anxiety and panic. New York: Guilford Press
• Curtis, G.C., Nesse, R.M., Buxton, M., Wright, J., & Lippman, D. (1976). Flooding in vivo as a research tool and treatment method for phobias: A preliminary report. Comprehensive Psychiatry, 17, 153-160
• Robson, M. (2002).Problem solving in groups. Aldershot, UK: Gower