The

10 Best-Ever Anxiety Management Techniques



THE 10 BEST-EVER
ANXIETY MANAGEMENT
TECHNIQUES

Understanding How Your Brain Makes You Anxious

& What You Can Do to Change It

MARGARET WEHRENBERG
All case studies referred to in this book are composites. No client is meant to
reflect any individual person and all circumstances and names are altered to
protect identities.

Copyright © 2008 by Margaret Wehrenberg All rights reserved

Printed in the United States of America First Edition

For information about permission to reproduce selections from this book, write
to Permissions, W. W. Norton & Company, Inc., 500 Fifth Avenue, New York,
NY 10110

For information about special discounts for bulk purchases, please contact W. W.
Norton Special Sales at [email protected] or 800-233-4830.

Book design by Jonathan Lippincott

Manufacturing by R.R. Donnelley, Harrisonburg
Production Manager: Leeann Graham Library of Congress Cataloging-in-
Publication Data Wehrenberg, Margaret.
The 10 best-ever anxiety management techniques : understanding how your
brain makes you anxious and what you can do to change it / Margaret
Wehrenberg. — 1st ed.
p. cm.
Includes bibliographical references (p. 219) and index.
ISBN 978-0-393-70556-0 (pbk.)
1. Anxiety. 2. Brain. I. Title.
BF575.A6W44 2008
152.4'6—dc22 2008008387
ISBN 13: 978-0-393-70556-0 (pbk.) W. W. Norton & Company, Inc., 500 Fifth
Avenue, New York, N.Y. 10110 www.wwnorton.com
W. W. Norton & Company Ltd., Castle House, 75/76 Wells St., London W1T
3QT

1 2 3 4 5 6 7 8 9 0
 To Shannon Malone Burns and Susan Palo Cherwien,
for all the years of sharing in my life, all the love you give,
and all the encouragement to write down what I practice.
I would not be here without you.
 Contents

Acknowledgments
Introduction: What You Can Do About Your Anxious Brain

PART I UNDERSTANDING YOUR BRAIN

ONE
How Your Brain Makes You Anxious
TWO
Managing Your Brain With Medication

PART II MANAGING THE ANXIOUS BODY

THREE
Technique #1: Change Your Intake
FOUR
Technique #2: Breathe
FIVE
Technique #3: Practice Mindfulness With Shifting Awareness
SIX
Technique #4: Relax

PART III MANAGING THE ANXIOUS MIND

SEVEN
Technique #5: Stop Catastrophizing
EIGHT
Technique #6: Stop Anxious Thoughts
NINE
Technique #7: Contain Your Worry
TEN
Technique #8: Talk Yourself Into Changing Behavior

PART IV MANAGING ANXIOUS BEHAVIOR

ELEVEN
Technique #9: Control TMA (Too Much Activity)
TWELVE
Technique #10: Implement a Plan and Practice

Recommended Reading & Resources

References
Index
 Acknowledgments

Everyone should be so lucky. I have had the support and encouragement of some
amazingly talented women through my life. They have made my life easier and
have encouraged me to learn, to study and to share what I have learned. They
have turned sad life experiences into learning, doubled my delight in my
successes, made life fun, and turned me on to new ideas, perspectives, and
opportunities. They have taken me in: into their homes at times, into their hearts,
and into their lives. The blessing of knowing these particular women has brought
me to this point. In addition to Shannon Burns and Susan (Luigi) Palo Cherwien,
I have benefited from long discussions about faith, writing, psychotherapy,
relationships, and healing with Mary Jane Murphy, Deb Schwarz, Yonah Klem,
Gatchina Hessler, Nancy Hoffman, Laurel Coppersmith, Sandy Faulkner,
Lurlene McDaniel, and Mary Lou Carney.
Learning how to manage anxiety has been a professional trek as well as a
personal one. I have learned important aspects of this from so many different
teachers, mentors and colleagues along the way. Paul Bauer-meister, Dan
O’Grady, and Judy Flaxman are chief among so many who have been
instrumental in my path to this point.
A book does not get written without the help of the people who really know
what they are doing. I appreciate the generosity of Drs. Syed and Fatima Ali in
reviewing the chapters. I am also grateful to be working with my editor, Andrea
Costella. She has been exceptional in her listening and responsiveness
throughout this project. She gave exactly the kind of clear and competent
direction I needed. Thanks to Casey Ruble, an excellent copyeditor who made
this all read so much better. And, for the first encouragement to get this down in
writing, Rich Simon at the Psychotherapy Networker, a creative man and an
extraordinary editor, I owe a debt of gratitude.
The 10 Best-Ever Anxiety Management Techniques
 Introduction:
What You Can Do About Your Anxious Brain

“I don’t think I want to live if I have to go on feeling like this.” I hear this
remark all too often from anxiety sufferers. They may say it matter-of-factly or
dramatically, but they all feel the same way: If anxiety symptoms are going to
rule their lives, their lives don’t seem worth living. What is it about anxiety that
makes otherwise high-functioning people so frantic to escape? The sensations of
doom or dread or panic can be truly overwhelming. In fact, they are the very
same sensations that a person would feel if the worst really were happening.
Anxiety in this millennium is pervasive. Up to a third of the U.S. population
suffers a panic attack during their lifetime. Statistics from the website of the
Anxiety Disorder Association of America indicate that 40 million Americans are
afflicted with an anxiety disorder, and that these people are three to five times as
likely to seek medical help and six times more likely to be hospitalized for
psychiatric disorders as people without anxiety. Too often people who are
panicky or filled with dread feel driven to seek the instant relief of medication,
but this prevents them from learning about what is happening to them or
exploring other options to eliminate anxiety. Medication, considered by
insurance and drug companies to be the first line treatment for anxiety, is losing
public favor as people realize that they have unpleasant side effects and their
symptoms reemerge when they stop using the drugs.
The good news is that recent neurobiology research has changed the medical
therapeutic understanding of anxiety disorders forever. It is clear that anxiety is
generated from specific problems with structure and function in the brain. This
means that people have great power to use their brains to change their brains.
Medication is just one option of many—people can relieve their anxiety by
changing aspects of their lifestyle, thought, and behavior.
 TYPES OF ANXIETY AND ANXIETY SYMPTOMS
The symptom clusters of anxiety fall into three major groups: panic disorder,
generalized anxiety disorder, and social anxiety disorder.

• Panic disorder is marked by fear of having a panic attack: high

physical arousal, including rapid heart rate, hyperventilation,
dizziness, nausea, and so on.
• Generalized anxiety disorder is marked by 6 months or more of
excessive worry over normal things, so that daily life is robbed of
pleasantness, attention is impaired, and a sense of dread or doom is
frequently felt. This disorder can be seen in children, especially those
with worries about school performance (which is different from school
refusal).
• Social anxiety disorder (also called “social phobia”) is marked by an
avoidance of settings and activities that cause the person to visibly
blush, shake, or sweat, and in which the person subjectively feels very
anxious. School phobia in young children can develop into social
anxiety, so care should be taken to assess and treat the cause of school
anxiety.

Each of these disorders has physical, cognitive (mental), and behavioral

symptoms that can be treated through the use of the techniques in this book.
Therefore, instead of focusing on diagnosis, this book will focus on these
symptom clusters.

• The anxious body. Physical symptoms include negative physical

arousal such as terror of panic, the flushing, sweating, embarrassed
look of social anxiety, and the tension of people who are too “wired”
and worried. These symptoms can be managed by the techniques
discussed in Part II of this book.
• The anxious mind. Cognitive symptoms result from overactivity in the
brain, which creates mental tension and the mental anguish of
rumination and worry. The brain that won’t stop thinking distressing
thoughts creates an anxious mind. The techniques in Part III provide
ideas for calming that anxious mind.
• Anxious behavior. Behavioral symptoms include the avoidance
 behaviors of the panicky and socially anxious person and the intricate
and more subtle avoidance patterns of the general worrier. The
techniques in Part IV address changing the anxious behavior that is the
natural outcome of panic and fear.

Symptoms in the three clusters are the result of activity in different parts of
the brain. When something is not working efficiently in the brain, it affects how
a person feels, thinks, and acts. All physical, mental, and behavioral anxiety
symptoms can be controlled by techniques that use the brain to change the brain.
The techniques in this book are known to be effective for slowing and stopping
anxiety. Science can also now show why they work. Since the advent of brain-
imaging in research, we have learned more and more about how consistent
application of anxiety management techniques will calm an anxious brain. You
can achieve a calm brain when you know which methods to try and how to make
them really work.

WORKING ALONE OR WITH A THERAPIST

The techniques presented in this book are straightforward, proven ways to
diminish anxiety and are intended for symptom management. They can be used
by anyone. They are not, however, meant to replace psychotherapy if anxiety is
severe or persistent. They will not relieve anxiety that is the result of trauma, nor
will they take the place of long-term treatment for complicated mental health
disorders. Even when the anxiety is not caused by trauma or part of a
complicated mental health disorder, working with a therapist can be helpful, as
self-help may seem an overwhelming prospect. Many people appreciate the
guidance of therapy to help them discern how to apply these techniques.
Therapists are also necessary for making an accurate diagnosis. Diagnosing
anxiety disorders is important for several reasons:

• Specific diagnoses are required to claim insurance benefits, and

insurance companies want to know whether the treatment selection is
appropriate to the diagnosis.
• People are curious about what their diagnosis is. It is reassuring to
enter therapy knowing that the therapist has seen a problem like yours
before and knows what to do about it.
 • A good diagnosis it reflects the therapist’s theory about why a person is
suffering anxiety, based on brain information as well as life history.
This makes it is easier to choose which therapy method is the best to
start with.

For these many reasons, getting an evaluation and support from a

psychotherapist who knows how to treat anxiety is, for most people, the wisest
course of action.

WHAT YOU WILL GET FROM THE 10 BEST-EVER ANXIETY

MANAGEMENT TECHNIQUES
Writing down the 10 best-ever anxiety management techniques has both personal
and professional interest for me. I experienced panic attacks and bouts of
dreadful worry for most of my life until early in my career as a therapist, when I
found, by luck and by studying, techniques that helped me get rid of the anxiety.
Later, when research about brain function began to reveal how our brains
generate anxiety symptoms, I finally understood why therapy, which delves into
life history for insight or works out psychological conflicts, could help people
live better lives yet still leave them with anxiety symptoms. We didn’t yet know
enough about how our brains—our biology—contributed to that anxiety. Now, as
a psychologist who teaches clients to manage symptoms early in their treatment,
I can see how these techniques help people work toward their therapy goals with
less interference from panic, worry, or social fears. I want others—both
therapists and individuals—to benefit from what I have learned. You can
diminish or eliminate anxiety symptoms and start feeling better, even if you still
have deeper work to do in psychotherapy. With anxiety symptoms improved,
you can go on to more readily resolve conflicts, traumas, or problems in your life
that interfere with your mental health and interpersonal relationships.
Both individuals who suffer anxiety and therapists in their work with clients
can use the materials in this book. I have tried to write without professional
jargon, so that any person can benefit from the techniques. I begin this book by
discussing how the brain works and how medications affect it in Part I:
Understanding Your Brain. Chapter 1, How Your Brain Makes You Anxious,
describes brain basics. Knowing what is going on in the anxious brain will help
you understand why the methods presented in this book are going to work to
change an anxious brain to a calmer, more controlled brain.
Chapter 2, Managing Your Brain With Medication, discusses the role of
drugs in treating anxiety. Medications can be very useful and even necessary
under certain circumstances. They can relieve sensations that feel frightening
(like rapid heart beat or dizziness) or are hard to control (like rumination and
worry). By relieving these underlying sensations, medication can make it
possible to learn anxiety management techniques faster or apply them more
effectively.
Part II of the book, Managing the Anxious Body, offers techniques aimed at
relieving the physical symptoms of anxiety. Panic is the physical arousal that
sends people running for medication. The heart-thumping, pulse-racing, dizzy,
tingly, short-of-breath physical symptoms of panic may come out of the blue and
feel intolerable when not understood. Intense anxiety may not be as frightening
as outright panic, but it is still painful physically and mentally. Physical
symptoms of generalized anxiety include constant heightened tension in the jaw,
neck, and back, as well as an emotional-physical feeling of doom or dread in the
pit of the stomach. Those with social anxiety are more likely to experience
flushing, sweaty faces, quivering voices, and shaky knees—signs of
embarrassment that people are afraid will be noticed by others.
Bad as these symptoms are, there are techniques that, when followed
regularly as lifelong habits, offer tremendous relief. These techniques, covered in
Chapters 3–6, include:

• Technique #1: Change Your Intake

• Technique #2: Breathe
• Technique #3: Practice Mindfulness with Shifting Awareness
• Technique #4: Relax

Part III, Managing the Anxious Mind, suggests ways of controlling

cognitive, or mental, symptoms. Many people with generalized anxiety disorder
experience a high level of tension that is physically uncomfortable and makes
them feel as if something is very wrong (the feeling of dread). This sense of
dread causes people to begin a frantic search for a reason behind the feeling.
They believe that if they can find a reason, they will be able to “solve” the
problem and relieve the anxiety. But most anxious tension is not about a real
problem with a good solution, so people end up worrying but not problem-
solving.
People with anxiety also tend to overestimate the seriousness of a feeling or
a problem. Small things feel like catastrophes. Another very disturbing mental
symptom is ruminating—experiencing the same thoughts over and over again
without being able to shake them off.
Many types of worry and anxious mental activity have underlying
neurobiological causes. Whether tension stems from psychological causes or
neurobiological causes, there are ways to reduce the symptoms of chronic worry
and dread. Mental management methods most helpful for diminishing
catastrophizing, ruminating, worry, and dread are offered in Chapters 5–8 and
include:

• Technique #5: Stop Catastrophizing

• Technique #6: Stop Anxious Thoughts
• Technique #7: Contain Your Worry
• Technique #8: Talk Yourself Into Changing Behavior

Part IV, Managing Anxious Behavior, addresses the final symptom cluster:
behavior. “It’s so simple! If it makes you afraid, just don’t do it.” This is what
people with anxiety think about common tasks that trigger their anxiety, such as
driving on the highway, raising their hand in class, drawing attention to
themselves by speaking up in a meeting, or making a complaint about bad
service in a restaurant. But this kind of avoidance insidiously takes over
everyday life. For example, people with social anxiety become increasingly self-
conscious, as they avoid common encounters with other people. As self-
consciousness increases, they change their behavior even more to handle it.
After a while, the list of activities to be avoided impairs their social life, work
life, and even their personal freedom—they may not, for example, even be able
to go to the grocery store or walk through a park.
Another kind of anxious behavior is the highly active mind and body of the
person who is trying to avoid the possibility of anxiety. These types of people
are often workaholics and perfectionists. They may get a lot done and do it well,
but the overactivity takes a toll. Exhaustion and depression are predictable
outcomes of too much activity (TMA).
Chapters 9 and 10 offer techniques for managing the behavioral symptoms of
anxiety:
 • Technique # 9: Control TMA (Too Much Activity)
• Technique #10: Implement a Plan and Practice

These 10 techniques, clustered to address physical, mental, and behavioral signs

of anxiety, each include several different ways to achieve the desired goal, so
that they can be individualized most effectively. The “real life” examples in this
book are all based on the experiences of actual people, but they are composites
and do not represent any individual person I have treated. The examples
demonstrate the effectiveness of the techniques and the individual ways in which
people can apply them. Although most people will want to take advantage of all
the techniques, they should start with the techniques that work for the worst
aspect of their symptoms, and go on from there. There is no ideal order in which
to learn the 10 “best-ever” techniques for anxiety management. Select the
technique and method that works best for you.

PART I

UNDERSTANDING YOUR BRAIN

You can manage anxiety effectively whether or not you know about the brain.
The 10 techniques outlined in this book work, but their effectiveness does not
rely on understanding how they work. Nevertheless, an understanding of why
these techniques are effective from a neurobiological standpoint can maximize
how well they work. It will be easier to exert the effort to manage anxiety, even
when it seems hard to do, if you know you are changing your brain every time
you control the symptoms. You automatically gain a certain measure of control
over anxiety when you say to yourself, “This is my brain doing this. It is not me,
and I can control it.” Chapter 1 is intended to give you enough brain basics to
understand why these 10 techniques will work.

MEDICATION CONTROLS THE BRAIN BUT DOES NOT TEACH

TECHNIQUE
It is important to understand what medications do for anxiety and how they work
so that decisions to add medication to anxiety management are made with clarity
about the benefits and limits of drug therapy. What people usually don’t know
when they start taking meds for anxiety symptoms is that by relying solely on
pills, they will not learn how to control or eliminate their symptoms without
medication. They never develop the tools for managing the anxiety that, in all
likelihood, will turn up again whenever they feel undue stress or go through
significant life changes. What they should be told when getting medication is
that in many cases the right management techniques can offer relief from anxiety
in a matter of weeks—about the same amount of time it takes for some anxiety
medications to become effective. The best situation is when a therapist and a
physician work together with a person, integrating an initial medication protocol
with techniques people can use for effective anxiety management even after
medications are discontinued.
 ONE

How Your Brain Makes You Anxious

Without becoming an expert in brain chemistry, you can learn how your brain
makes you anxious so that you will know why the 10 best-ever anxiety
management techniques work. Of course, as I indicated, they work even if you
do not know why they work, but it is my belief that you will apply them more
effectively if you understand how doing these techniques will change your brain
in ways that will make you less anxious for life.

NEURONS, NEUROTRANSMITTERS, AND COMMUNICATION

IN YOUR BRAIN
Your brain is a complicated network of brain cells called neurons. You have 10
billion neurons, and each of them can connect with 10,000 other neurons. The
possibilities for how those cells connect and network are virtually endless. There
is more to know about how the brain works than we will learn in our lifetimes.
But what we know so far is that every function in your body, every thought you
have, every emotion you feel, is the result of activity in the brain. If your brain is
dead, then even with healthy organs, nothing will work. And just like you do not
feel your best if you have an organ in your body that is malfunctioning, your
thoughts and emotions can be troubled unless every part of the brain is working
well.
Neuroscience researchers have learned so much about the brain in recent
years that it is now possible to describe how some parts of the brain contribute to
feelings of anxiety. This has made quite a difference to the way those of us in the
mental health profession view the treatment of anxiety. Although many
techniques we have used for years remain effective, we now know why those
techniques work so well and we know more about when and how to use
techniques for your benefit. And we also know now that you can at least get
relief from anxiety symptoms even before you complete psychotherapy for other
problems. Again, remember that you can use your brain to change your brain.
The 10 best-ever anxiety management techniques are designed to diminish or
eliminate the most common problems of anxiety: panic attacks, worrying, and
social fears. They take advantage of what we know about how these symptoms
are caused by problems in brain functioning.

How Does Your Brain Communicate?

All those 10 billion neurons have to communicate with each other to create your
thoughts, behaviors, and emotions (among the other many tasks we are not going
to discuss here). So how do they do it? Neurons communicate by sending
messengers back and forth in the space between brain cells, called the synapse.
These messengers of the brain are called neurotransmitters. Different messages
are carried by different neurotransmitters. I will describe those shortly.
Every message needs to be received. How a message is interpreted and how
it affects brain function depends on where in the brain the message is received.
The meaning of a message being sent is determined by who is reading it. For
example, let’s say you send an email that communicates your love for a
coworker. If you send it to the object of your affections, it may be readily
received and induce a feeling of warmth and happiness, but what if you
accidentally send it to the person you just broke up with? The same message in
the wrong mailbox causes agitation for the heartbroken person who reads it. And
what if the boss gets that same note, and starts to fret about what you are doing
on your work time? Same message, different result, depending on the receiver.
Figure 1.1 Neurotransmitters, represented as diamonds, are released from a neuron into the synapse to be
received by another neuron.

In a way, this happens with neurotransmitters. Take dopamine, for example.

Dopamine is a neurotransmitter that is received in one part of your brain as “I
feel good.” (And not just ho-hum good, but the James Brown version, “I fee-eel
good!”) But, if it is received in the thinking part of your brain, it works more to
cause you to pay attention to what is going on. In yet another part of your brain,
dopamine helps you have smooth motor functioning. People with Parkinson’s
disease are losing dopamine. So, as you can see, dopamine produces different
results depending on where in the brain it is received.
When you learn about dopamine as it relates to anxiety, you will be
interested in that first function—pleasure—because it is what helps people feel
motivated to overcome anxiety. And when you want to learn how to decrease
your reactions to scary incidents, you might want to know how dopamine causes
you to pay extra attention when you are very scared. Certain therapy methods
help you un-learn scary situations by taking charge of what you pay attention to.
In order for messages to get sent from one neuron to another in the first
place, there needs to be enough neurotransmitters available to get the message
across. One reason people with anxiety might use medication is to increase the
number of neurotransmitters that will help get the message sent.
It is also possible that there are problems with transmission. Maybe there are
enough neurotransmitters to send the message, but they cannot get from one
neuron to another. One neurotransmitter called serotonin gets received in a lot of
different places, and if it has trouble getting through, one result is worrying. One
of the places in your brain where serotonin is needed is responsible for shifting
gears in your thoughts. When you get stuck on a thought—going over and over it
—you start to worry. You can use your decision-making ability to overrule
worry, thus taking charge of worry on purpose (as I will describe later in the
worry management techniques). This tries to make up for the effect of serotonin
not getting through to where it is needed. Of course, I will also discuss how to
make sure that serotonin has the best chance of getting through, so worry is less
of a problem to begin with.
Alternatively, there may be too many messages being sent. Excessive
amounts of neurotransmitters may cause you to make a big deal over nothing. It
will FEEL LIKE A BIG DEAL, but that is only because the flurry of
neurotransmitters is excessive. This happens to people who have too many stress
response neurotransmitters. The phrase “making a mountain out of a molehill” is
exactly what your brain may do—send out too many messages that communicate
“This is stressful!” Your brain and your body will overreact with lots of stress
because the extra neurotransmitters make the situation seem urgent. Techniques
to help you calm down on purpose will help with this kind of problem.

Receiving Messages

Even if the number of neurotransmitters and their transmission are fine, anxiety
can still occur if the message has problems at the receiving end. The neurons
whose role it is to pick up messages may not do so easily. If that is the case, a
neurotransmitter may not be received and the message (such as to calm down or
feel good) does not get received. In particular, a neurotransmitter called GABA
is responsible for slowing down activity in the brain so that you can stop brain
cells from firing off messages. The networks of communication have to get
cleared for new messages to be sent. So, if GABA is not being received very
well, you may end up feeling very anxious or even panicky, depending on where
in the brain the GABA is working (or not, as the case may be).
You know that there are radio waves and cell phone signals in the air all
around you, but you need to have your equipment tuned in to make sense of the
message. Once the signal is received, your equipment has to interpret and send
information along. That is where brain function comes in. Different parts of the
brain receive, send, interpret, and create responses to the signals they receive.
The parts of the brain that are of most interest in discussing anxiety play those
roles—receivers and relayers of information, coordinators and interpreters of
signals that help to form a coherent picture of information and parts of the brain
that create new responses to information as it comes in. Different parts of the
brain have different functions, but just like completing a call on a wireless phone
requires the phone to receive a signal, interpret it, and then reverse that to
transmit back what you say, the parts of your brain all need to function smoothly
for messages to be clearly received and sent.

Balance Is Necessary for Healthy Functioning

Before I discuss individual neurotransmitters and their role in creating anxiety

symptoms, you should think for a minute about how much the brain likes
everything to be in balance. You already know your brain carefully monitors
everything going on in your body, trying to keep your whole body balanced.
Think about what happens when you exercise. You increase the demand for
oxygen, and when you start to run out of oxygen, your respiration increases and
your heart rate may increase too. You can decide to direct your breathing on
purpose, as when you lift weights or do yoga or martial arts, but even if you do
not think about it, your brain will make sure you get the right balance of oxygen
by directing your body to breathe faster and telling your heart rate to pick up.
Similarly, your brain monitors the balance of neurotransmitters. If an
imbalance occurs, the brain initiates activity to achieve balance. It functions best
when only minor imbalances between levels of neurotransmitters exist. Just like
a deficiency of oxygen is felt as shortness of breath, excesses and deficiencies of
neurotransmitters produce symptoms too, and what kinds of symptoms you
experience depend on which neurotransmitter in which part of the brain is
having a problem. Insufficient or excessive amounts of neurotransmitters show
up as problems in mood, behavior, or thought. The techniques presented in this
book can help the brain to rebalance itself. When your brain cannot achieve
balance because you are sick, not eating right, not sleeping, or have some other
physical problem, then you will probably also have to make changes in your
eating or sleeping or get some medical help.
 Specific Neurotransmitters and Their Activities

The neurotransmitters that are of most interest in understanding anxiety are:

• Glutamate
• GABA (or gamma aminobutyric acid, but no one uses the long name)
• Serotonin
• Norepinephrine
• Dopamine

Briefly, the function of each neurotransmitter in relation to causing anxiety is

as follows:
Glutamate. Think of glutamate as the brain’s “go” signal. Glutamate signals
or excites neurons to fire, that is, to send out their neurotransmitters. It is
distributed through the whole brain, because all the neurons need signals to fire.
GABA. Every “go” signal needs a “stop” signal. GABA is the stop signal. It
slows and stops the firing of neurons. GABA is also found throughout the brain.
When GABA is not slowing things down effectively or if GABA and glutamate
are not in balance with one another and glutamate is too high, you may feel
agitated, which is a set-up for anxiety.
Serotonin. Serotonin neurotransmitters are few in number compared to
GABA and glutamate, but mighty in their effects. You need serotonin to regulate
your mood so you are not too negative, to keep appetite and sleep patterns stable,
to help with impulse control, and to modulate your pain perception. With so
many functions, it is clear that if serotonin is off balance, you could have a lot of
different problems. The kinds of problems you have depend on how seriously
serotonin is off balance and which part of the brain does not have enough of it.
Later in this chapter, as I discuss areas of the brain that affect anxiety, I will refer
to the problems that each neurotransmitter can cause in these areas.
Norepinephrine. If your brain had an energizer bunny, norepinephrine
would be it. Norepinephrine keeps you mentally alert, and your body energetic
in general. For example, it is important for keeping blood pressure balanced.
When you need fast energy to handle stress—like you are suddenly scared you
will miss the bus—you get a little help from norepinephrine for energy. When
you have too much norepinephrine (and there are many reasons why that might
be) you will feel jittery, “wired,” “uptight,” or generally too tense.
 Dopamine. As in my earlier example, dopamine’s message depends a lot on
which part of the brain is receiving it. In one part of your brain, dopamine can
send the message “mm-mmmm good,” so it is responsible for your feelings of
pleasure. But if it is received in the thinking part of your brain, it helps you to
pay attention. Knowing what pleasure feels like motivates you to do what felt
good, so dopamine is very important in anxiety. Getting motivated to achieve
your goals will help you face your fears to overcome anxiety. Paying attention is
also important because it can either cause anxiety by forcing you to concentrate
on what is negative or frightening, or it can help you stop anxiety by forcing you
to concentrate on what is positive or soothing.

THE STRUCTURES OF THE BRAIN AND ANXIETY

The messengers of the brain, the neurotransmitters, are received in different parts
of the brain, and where they are received affects the message. Your brain has
many different structures within it, and some of those work together in systems
to get a task done. Also, different systems can work together. Keeping it simple
and looking only at how your brain might generate anxiety, I am going to discuss
the parts of these systems:

• The nervous system, which has nerves that get your organs going and
nerves that calm down the activity in your organs
• The stress response system, which gets hormones such as adrenalin
pumping
• The limbic system, the center of emotion and memory
• The basal ganglia, which together coordinate motivation and
movement
• The cortex, which is responsible for language, thinking, decision-
making—essentially, all the conscious aspects of your brain

The Nervous System

The nervous system is all the nerves that run through the body and connect to the
spinal cord and the brain. Nerves tell your muscles to move and carry signals to
your brain about how your body is doing. Nerves carry messages to and from the
organs of your body. The nervous system has three major divisions of nerve
activity that are related to anxiety.
The peripheral nervous system (PNS). The PNS carries messages to and
from the skin. So when you blush, as people who are shy tend to do, this is the
system that is working.
The sympathetic nervous system (SNS). This is the system that tells organs
in your body to get busy and respond to a demand for action. If you walk up a
steep flight of stairs, the SNS will demand a little extra heart activity and
respiration so that your muscles can get more oxygen while they work harder. If
you think you are about to be mugged, your SNS will immediately get your heart
rate and respiration ready for a fight or a fast run out of danger.
The parasympathetic nervous system (PSNS). This part of the nervous
system kicks in to calm down action in the body. It takes over when you need to
calm down. You can initiate activity in the sympathetic system by deciding to
breathe faster, and you can initiate the parasympathetic system to calm down by
breathing more slowly and deeply. When talking about anxiety and how to
control it, it is important to understand that the nervous system is automatic and
operates without your control, but you can take it over on purpose. Mostly we
want to take over calming ourselves down, so the anxiety management
techniques aim at encouraging parasympathetic calming by focusing on self-
soothing through breathing, relaxation, and thought management.

The Stress Response System

In order for your body to have the energy it needs when the sympathetic nervous
system (SNS) cranks up the organs of your body, you need some chemical
assistance from hormones. Your hypothalamus, which I will discuss in the next
section, will send a message to your adrenal glands to release adrenalin and
cortisol, two of the hormones needed for stress. These hormones travel through
your bloodstream and mobilize your body to release stores of fuel (glucose and
fat) to be used in the energy-burning that muscles perform when they have to
work hard. This is the stress response: a system to get you energy when you need
it. It can work for any length of time, from brief and inconsequential little
releases of energy to short, powerful bursts of energy, to sustained and extended
stress response such as when you are under the burden of difficult emotions or
expectations. Whether you are sitting by a sick child in the hospital emergency
room or on your third day of 16-hour workdays to meet a project deadline, your
stress response is working to make energy available. As you might imagine, a
stress response cannot go on forever without relief. You can become very
anxious as the result of unremitting stress.

The Limbic System

The emotional work of the brain is done in the parts of the brain that together are
called the limbic system. The term “limbic” comes from a word that means ring,
and it refers to the location in the center of the brain where these various
structures are grouped. They work together to help form emotions and
memories. The names and basic functions of the parts of the limbic system are:

• Thalamus
• Hypothalamus
• Hippocampus
• Amygdala

Each part or structure in the limbic system plays a specific role in the
creation of emotional responses, and each part is connected to other parts of the
brain and the nervous systems so that some of their work can be done without
thinking about it. For example, if you are faced with an emergency, like a child
running away from you into traffic, you don’t want to take time to think about
whether you need energy. Your body gives it to you without intentional thought.
(I will discuss the relationship of thought and feeling in many places throughout
the book.) How these parts of the limbic system function are very relevant to
understanding how your brain makes you feel anxious, even when you do not
want to.
Thalamus. The thalamus has many important functions, but among the most
important is its role in receiving information from the outside world through the
senses, and sending that information where it needs to go. It might be considered
the quarterback for sensory information from the external environment. That is,
it receives information and relays it onward for another part of the brain to take
action on it. The “ball” of sensory information, hiked to your thalamus, is passed
on to the amygdala for immediate action. Among the many jobs the thalamus
does, it passes that information also to your thinking brain, the cortex.
Hypothalamus. The hypothalamus is like a quarterback for your internal
team, gathering information from your internal environment. It receives and
relays signals from and to the organs of the body. The hypothalamus is directly
responsible for starting your stress response by handing off the “ball” of
information that you are under stress. It passes that information to your adrenal
glands so it can run with the information and get you the energy you need. Your
hypothalamus may have too many of the neurons that respond to stress, so it
may send out of flood of demands for a stress response. This is one way that
small things feel very big to anxious people and may be a cause of overreacting
emotionally and physically to normal, not-so-big stresses. Because it is your way
of feeling things, you would probably need some convincing that the small
things really are small. But once you are convinced, you can take charge of
calming down your stress response by talking to the hypothalamus and providing
it with physical calming messages, like breathing.
Hippocampus. The hippocampus is the part of the limbic system that
registers details for you. It is without emotion, functioning like the Joe Friday of
your brain—“Just the facts, Ma’am.” It records details—data and facts—and
sends them up to your cortex, which thinks about them. If you need short-term or
long-term memory to be made from the details the hippocampus is recording,
then other parts of the brain get involved to make those memories happen.
Amygdala. Your amygdala is a key player in developing anxiety. It can be
like the Little Red Hen, whenever something negative shakes it up, it cries out,
“The sky is falling!” This is not detailed information. It is purely emotional.
Your amygdala is an importance meter, registering only tone and intensity and
notifying your brain instantaneously if it should prepare for problems. The
amygdala can set off the hypothalamus to get the stress response going and it can
immediately get norepinephrine (the “energizer” neurotransmitter) pumping to
prepare for fight or flight. All that excitement occurs long before the cortex of
the brain can form context so you can think about how serious the situation
might actually be.
The amygdala registers all emotions, not just negative ones, but it prefers
noticing the threatening, scary ones. The action of the amygdala is something
like a smoke detector for your body and brain. A smoke detector does not
respond to the pleasant aroma of baking bread, but if that bread starts to burn, it
causes quite an alarm. You do not have to be alert to incoming joy in order to
survive in this world. But if you want to survive, you better do a good job of
noticing incoming trouble, such as someone looking angry or intending to hurt
you. Once your amygdala learns what is dangerous, it tries ever after to protect
you from whatever scared you. This is how cues and triggers develop to cause
anxiety or panic, from the amygdala and the hippocampus working together to
learn what is dangerous.

The Basal Ganglia (BG)

A ganglia is a concentrated group of neurons. The basal ganglia (BG) are several
ganglia that work together to induce motivation, create energy to meet goals, and
even coordinate physical movement with emotion. The BG are located under the
cortex (covering) of the brain, where you do your thinking, and over the limbic
area. One part of the BG, called the nucleus accumbens, is specialized to
interpret pleasure when it receives the messenger dopamine. When you do
something that stimulates dopamine and it flows through to this part, you feel
good. This makes you want to repeat whatever you were doing that made you
feel good. For this reason, the BG strongly affect motivation and energy.
A person with a good supply of dopamine in the BG will feel motivated and
full of energy or high drive, but if GABA is not working effectively, then the
energy can get too high and result in tension. Additionally, even for no real
reason but just out-of-the-blue because GABA is not working as it should, over-
excited activity in the neurons of the BG can trigger panic attacks. In the case of
BG energy, some is good, a lot can give you drive but make you tense, and too
much can flip over into panic.

The Cortex

The structures of the limbic system work together to send messages to the
thinking parts of the brain—the cortex. Cortex means “bark” or covering, and in
human beings that covering on the lower brain is very thick. Such a thick cortex
is necessary to deal with social information. Our ability to think about thinking
and about emotions, and our ability to think about what others are thinking and
feeling, is possible because of the cortex. To understand anxiety, it will be useful
to look at activity in these parts of the cortex:

• The anterior cingulate gyrus (ACG), the filter and amplifier of

information
• The orbito frontal cortex (OFC), the place where working memory is
held
 • The prefrontal cortex (PFC), the CEO where all information is
ultimately received, analyzed, and responded to

A lot of information from your senses and from the organs of your body
needs review by the prefrontal cortex. To be efficiently handled, the information
has to be organized, so the responses from the cortex back to the emotional brain
can return swiftly and appropriately.
The anterior cingulate gyrus (ACG). This area of the cortex helps to
organize information. Located between the limbic system and the cortex, it is
like the vice-president in charge of forming context, preparing reports for the
CEO of the brain—the PFC—the left prefrontal cortex, and sending the CEO’s
recommendations back out. It takes the details sent in from the hippocampus and
the emotional tone from the amygdala. It also gathers data on the way your body
is feeling, which, when put together with the limbic system data, creates the
whole context of a situation for your thinking brain to work with. The details and
their importance, along with somatic (bodily) experience of the situation, get put
together for analysis. This filtering of incoming information has to occur
smoothly. When the ACG does not have a good balance of neurotransmitters, it
can get stuck on negative feelings and be unable to shift them forward, thereby
making it less efficient at sending analysis back on to the amygdala. If your
ACG gets stuck, qualities you may see and feel are worry and rumination on
negative thoughts, oppositional behavior, or inflexibility about trying new
options or responses to situations.
Figure 1.2 Lateral (side) view of the brain.

The orbitofrontal cortex (OFC). This area of the cortex is like the vice-
president in charge of brain-storming. It commands the process called working
memory, which holds pieces of information just long enough to use them to
complete tasks of everyday mental functioning. Also, working memory—or
short term storage—allows the OFC to compare information with other
memories of other similar situations. This work is necessary to generate several
possible, reasonable responses to problems, and then sends the data forward to
the prefrontal cortex for analysis and decision-making.
When this part of the cortex is functioning correctly people have good
impulse control; that is, they don’t jump the gun on “half-baked” ideas. Rather,
they make decisions based on information. When neurotransmitters are in
balance in the OFC, then your mood is optimistic and it seems things can be
explained or solved and are not hopeless. For this reason, the OFC is quite
important in anxiety because this solution-oriented part of the cortex helps
control fear by its optimistic, problem-solving activity.
The prefrontal cortex (PFC). The prefrontal cortex (PFC) is the CEO of the
brain. This is where all the information from your entire body and all the other
parts of your brain is ultimately received and where decisions are made about
how to respond to it. The buck stops here. When the PFC gets good data from
the rest of the brain, it has what it needs to analyze whether a situation is actually
threatening or not. It decides whether the data should be put into long-term
memory storage or dismissed as unnecessary. It creates new solutions to
problems and plans how to carry those out. The PFC needs clarity and energy to
do this. When it is short on neurotransmitters or they are out of balance or
excessive, then thinking is impaired.

You may have heard about differences between right-brain and left-brain activity
and wonder if this is important to anxiety as well. The short answer is that every
part of the brain described above has two sides, right and left. Your brain is
efficient—it does not double up on activity—so the right and the left sides,
called “hemispheres”, in effect have subspecialties within their individual
functions. For example, the right side of the amygdala (which, you will recall, is
overall responsible for noticing what is important, especially if it is threatening)
recognizes swiftly cues of danger. The left side of the amygdala compares the
current cue of danger to see if the situation is as dangerous as it seems. If the
situation turns out to be different than a former situation, it adjusts the reaction
accordingly, so the next time the cue comes in, the amygdala will be able to use
the new information.
The two hemispheres of the cortex also share the load of analyzing, although
the left prefrontal cortex is the final decision maker. In general, the right
hemisphere of your cortex handles nonverbal information. It hears the tone and
sees the facial expressions that communicate what the words you hear really
mean. It contributes to understanding spatial information. The left brain provides
the vocabulary of words and math symbols and the analytic work of the meaning
of experiences.
Anxiety management techniques aim to control your anxious symptoms
primarily through the left brain, using words, analysis, and decision-making to
control the rest of your brain and your body. Psychotherapy methods that
activate other parts of the brain are certainly available, and necessarily so,
because difficult problems such as resolving long-standing trauma, changing the
impact of childhood experiences, or altering dark moods such as despair, require
different work than just anxiety management techniques. If your anxiety stems
from a history of trauma, then you will likely need psychotherapy to release the
impact of that trauma. Your anxiety may be hard to diminish or it may repeatedly
return if deeper therapeutic work is not done. However, the 10 best-ever
techniques presented in this book will put your left prefrontal cortex to work.
 HOW THE PARTS OF THE BRAIN WORK TOGETHER TO
CREATE ANXIETY SYMPTOMS
The impact of the neurotransmitters in different parts of the brain affects what
kinds of anxiety symptoms you experience. Having described the
neurotransmitters and the parts of the brain relevant to understanding anxiety, I
want to review briefly how it may be that you do not have a good supply of
neurotransmitters. Then I will chart how symptoms of anxiety might be
generated by the activity of neurotransmitters in different parts of the brain.
A person may not have enough neurotransmitters for any number of reasons.
For example, you might just not have been born with a plentiful supply. You may
not have enough to feel good. This is likely true when people feel they have been
depressed or anxious most of their lives. Life circumstances can make that
problem worse. Trauma or illness can deplete the supply of some
neurotransmitters, like serotonin, or intensify levels of norepinephrine and
therefore intensify the impact of the trauma or illness, which, if left untreated,
can continue for years. Chronic stress uses up your extra supplies of
neurotransmitters and creates a deficit while preventing the opportunity to
rebuild your supply. Poor sleep and nutrition also diminish neurotransmitter
supplies. So, depending on your circumstances, there could be one or many
reasons your neurotransmitters get out of balance.
Take a look at the neurotransmitters, one at a time, to see how they interact
with the parts of the brain to cause anxiety symptoms (Table 1.1). The
neurotransmitter with the most wide-ranging impact in creating anxious
symptoms is serotonin (SE). When serotonin is low, it wreaks havoc in most of
the brain system. If serotonin’s main function is to regulate, then losing
regulation has predictable results for the calm, orderly assessment of a threat and
your response to it.

Table 1.1 How Brain Structures Are Affected When Serotonin Levels Are Low

Brain Structure Anxious Symptom

limbic system (amygdala) negativity, worry, sensitivity to
threat
prefrontal cortex (PFC) poor planning, unable to push
negativity away or find a positive
frame, loss of emotional control or
affect regulation
orbitofrontal cortex (OFC) poor impulse control, irrational
responses to problems
anterior cingulate gyrus (ACG) ruminating worry, inflexible
attitude

Table 1.2 How Brain Structures Are Affected When Norepinephrine Levels Are High

Brain Structure Anxious Symptom

throughout the brain general overarousal, inner
jitteriness, physical and mental
tension
prefrontal cortex (PFC) hypervigilance, scattered thoughts
basal ganglia (BG) restlessness, “wired” sensation
sympathetic nervous system panic attacks or acute anxiety,
sense of doom

The next neurotransmitter with powerful influence to create anxiety is

norepinephrine (NE). NE is trouble primarily when it is too high. The level of
NE sets a tone of tension throughout the brain and body. Like the energizer it is,
NE causes small stresses to trigger big responses. Because the level of tension in
an anxious person is already so high, it does not take much of a bump from NE
to push their tension level over the top into panic or acute anxiety. Table 1.2
shows some of the major ways high NE can result in anxiety.
Dopamine (DA) is an interesting neurotransmitter because it has implications
for anxiety when it is too low and when it is too high, again depending on where
its message is being received. In the basal ganglia (BG) it affects pleasure, which
translates into motivation. When levels are low there is an absence of good
feelings. When levels are too high, DA may foster too much drive. In the
prefrontal cortex DA is necessary for paying attention, so when it is low you
might be inattentive, but when it is sufficient you can pay attention and focus on
tasks. Dopamine can be temporarily high during a time of trauma, and during
that time it contributes to the creation of powerful cues for anxiety. The very
high, but temporary, levels of dopamine during crisis affect the brain differently
than chronically high levels of DA. Table 1.3 summarizes the impact of high or
low DA levels in different areas of the brain.
The final neurotransmitter that is very important in creating anxiety is
GABA. GABA neurons are found throughout the brain in vast numbers because
GABA is the brain’s “stop” signal, needed to slow down the firing of neurons in
your brain. It balances the effects of glutamate, the neurotransmitter that acts as
the “go” signal. When GABA is insufficient or is not being easily received by
neurons waiting for its signal to stop firing, the result is overactivity in whatever
part of the brain in which GABA is not working. Table 1.4 shows the most
significant disruptions from ineffective GABA.

Table 1.3 How Brain Structures Are Affected When Dopamine (DA) Levels Are Low

Brain Structure Anxious Symptom

basal ganglia high DA high drive, high motivation,
perfectionism
low DA loss of interest or pleasure, low
motivation
prefrontal cortex (PFC) temporarily over-focus on detail may trigger
high DA subsequent panic or acute anxiety
chronically high DA psychosis or delusional states

Table 1.4 How Brain Structures Are Affected When GABA Is Ineffective

Brain Structure Anxious Symptom

entire brain agitation from glutamate imbalance
exacerbates other problems caused
by neurotransmitter imbalances
basal ganglia (BG) heightened energy tone, panic
attacks

CONCLUSION
When you feel anxious and are thinking over what to do to handle a situation,
you might remember what part of your brain is contributing to that feeling or
you might not. All you really need to remember is which techniques to apply to
manage the symptom. The more you apply the techniques, the better chance you
have of calming down your brain and decreasing the likelihood that the
symptoms will continue to bother you. So read on—the 10 best-ever anxiety
management techniques are in the chapters ahead!
 TWO

Managing Your Brain With Medication

Typically, people get medication for anxiety symptoms before they receive
psychotherapy to control their anxiety. When people have panic attacks they go
to the emergency room or consult their physician and get a prescription for
medication instead of a referral to a psychotherapist. When people see an M.D.
for a medical complaint, such as heart palpitations, shortness of breath, frequent
nausea, a lump in the throat, or temporomandibular joint pain (TMJ), they expect
to get a medical test or a prescription. They interpret these common anxiety
symptoms as problems with their heart, lungs, stomach, and so on, so consulting
a medical doctor is logical.
It may take some time and some negative test results before a physician feels
comfortable identifying the cause of the symptoms as anxiety, but once anxiety
is determined to be the culprit, the physician may prescribe one of several drugs
for relieving the anxiety. A primary care physician is medically trained and may
not know the efficacy of psychotherapy. Competent psychotherapy can help you
eliminate symptoms without medication; however, there are times when
medication is an important aid to feeling better and calming your brain so these
techniques can work faster and more effectively at the start. Medication can
make you start feeling better a little faster than psychotherapy, but it is
psychotherapy that will change your thoughts and behaviors and give you
strategies that you can use anywhere for the rest of your life without the side
effects of or need for medication (Blackburn & Moore, 1997; Clark et al., 2003;
Fava Rafanelli, Grandi, Conti, & Belluardo, 1998; Frank, 1991; Gould, Otto, &
Pollack, 1995; Kroenke, 2007).
How do you know if you should be using medication? Talk with your doctor,
of course. In my years of working with anxious people and reading research
results, I have noticed certain clues that indicate whether or not medication will
contribute to the effectiveness of psychotherapy. If you can answer “yes” to any
of the following questions, you may be helped by medication.
 • Are you having panic attacks a few times a week or more? My
experience with people who have panic disorder leads me to think that
if people are having attacks that frequently, they might benefit from
medication. Their brains may be so agitated that it will take some time
to calm the panic. It may thus be too discouraging to get their thoughts
and behavior in control without the help of medication.
• Are you able to push aside ruminating worry when you have
something important to concentrate on but find yourself worrying
again the minute you have nothing to focus on? You may do okay
without medication, but if it is a huge effort or you cannot draw your
attention away from worry even for short times, medications are in
order.
• Do you feel sick to your stomach with dread much of the time and find
it interferes with eating and sleeping? If so, you will probably respond
better to anxiety management techniques with the help of medication,
because this level of distress should be interrupted as quickly as
possible. Having an agitated brain without relief is not good for your
emotional or physical self.
• Do you immediately flush, have shaky legs, a quivering voice, and a
palpitating heart even at the thought that someone might watch you
leave a theater, watch you speak up at a business meeting, or observe
you ordering food or eating in a restaurant? You might benefit from
using medication on an as-needed basis while trying techniques to get
over those signs of social anxiety.
• Do you feel so terrified of attending a party or being in a busy public
place like a shopping mall, airport, or school that you refuse to go?
You will probably benefit the most from a combination of medication
and treatment methods, because this is about the most difficult
situation in which to calm yourself. Medication will allow you to focus
on using new anxiety-controlling skills and social skills that will help
you in your interactions with others.

IF YOU ARE ALREADY ON MEDICATION BEFORE STARTING

THERAPY
Often people are given prescriptions for medications before they decide to try
techniques to manage anxiety. Whether you are trying techniques on your own or
working with a therapist, it is not a good idea to stop taking medication abruptly.
Always discuss with your prescribing physician if you decide to reduce or
discontinue your medication. Many medications have withdrawal effects. And if
you are benefiting from your medication it just means that you will have a head
start on feeling better. The major downside to using medication while practicing
anxiety control techniques is that it is harder to know what it is like to feel and
control anxiety without the effects of the medication in your system. But you can
plan for that. Be aware that you will feel different when you stop taking the
medication, so planning to review these techniques or go back for a few “booster
sessions” of psychotherapy is a good idea.

WHAT DO MEDICATIONS DO FOR YOUR BRAIN?

Medications are used to change specific brain or neurotransmitter functions.
There are several mechanisms by which they work to control anxiety. The most
common kinds of medications that might be prescribed are SSRIs,
benzodiazepines, and buspirone.

Selective Serotonin Reuptake Inhibitors

When serotonin (SE) levels are insufficient, people can be negative, worry
excessively, lack concentration and attention, and have trouble suppressing
worry and panic. They may have trouble paying attention, feel preoccupied, be
overly tense, and have trouble seeing good solutions to their problems. The
limbic system becomes overactive in producing negative, worrying thoughts and
the cortex lacks energy to suppress the negativity. The anterior cingulate gyrus
gets stuck on worry thoughts and does not efficiently transfer information
between the limbic system and the cortex for modulating worry and negativity.
The orbito-frontal cortex can be inefficient in its work to compare and evaluate
new situations with old ones, which contributes to negative appraisals of new
situations and trouble coming up with new, creative solutions to problems.
Improving serotonin levels or action in the brain promotes regulation of
thoughts and mood, making the brain work more effectively so that techniques
can be learned faster. Selective serotonin reuptake inhibitors (SSRIs) are
intended to make serotonin more available in your brain. They are not mood-
altering, in that a person will not immediately feel relief when taking them.
Therefore, they are not addictive. These medications help your brain increase its
production of SE by enhancing the growth of new SE neurons and blocking the
return of SE molecules into the cell that released them. When the cell that
releases the serotonin does not pick any back up from the synapse (gap) between
cells, it gets a message that there is not enough serotonin, so the brain goes to
work to make more serotonin neurotransmitters in the cells. Figure 2.1 shows a
neuron releasing serotonin (drawn as little diamonds) into the synapse, with its
receptor sites blocked by short black lines.
The most commonly prescribed SSRIs are:

• Prozac (fluoxetine)
• Zoloft (sertraline)
• Paxil (paroxetine)
• Luvox (fluvoxamine)

Figure 2.1 SSRIs function to block the return of serotonin into the cell.

• Celexa (citalopram)
• Lexapro (escitalopram)
 The following three medications are also commonly prescribed, but are
SNRIs (serotonin and norepinephrine reuptake inhibitors):

• Effexor (venlafaxine)
• Cymbalta (duloxetine)
• Pristiq (desvenlafaxine)
Although SSRIs and SNRIs have a very small impact on serotonin
availability right away, it usually takes weeks for the brain to start producing
enough additional serotonin neurotransmitters to change anxiety. It takes months
for the brain to maintain that level of production without the medication, and it
requires nutrients and sleep during that time to produce the serotonin. People
taking SSRIs or SNRIs should expect to be on these medications for some time,
typically for a year or more. These medications should be discontinued only
under the supervision of your doctor.
If a physician prescribed one of these medications before a person started
learning anxiety management techniques, it is usually best to continue using it
until it has had enough time to work—usually several months. When the drug is
discontinued too soon the symptoms may come right back. In fact, reemerging
symptoms indicate that it was doing a good job. A person can keep on learning
techniques while getting help from the medication. If the physician agrees it is
time to try handling anxiety without medication, he or she will suggest a
medication withdrawal plan to prevent feeling sick from discontinuing too
quickly. This is a good time to work with a therapist, who can help you use the
techniques without medication to make sure the transition is smooth.

Benzodiazepines

Benzodiazepines are potentially addictive, but this should not be viewed as a

reason not to use them, except in people who have been addicted to alcohol.
Benzodiazepines greatly increase the effects of alcohol, so they should never be
used with alcohol. Also, people who have been addicted to alcohol, even if they
no longer drink, may develop an addiction to these drugs quickly. Therefore,
more caution in using benzodiazepines is needed in this population. Many
people who use these medications to decrease anxiety try hard not to use them
too often, and that is not always a good idea. They work best to decrease the
high degree of physical arousal that goes with panic attacks or intense levels of
acute anxiety, and typically they will be prescribed in tandem with an SSRI for
the first few weeks on that medication. Benzodiazepines should not be
discontinued abruptly but rather weaned off to avoid potentially unpleasant or
serious effects of discontinuation, depending on the length of time they have
been used.
The most commonly prescribed benzodiazepines include:

• Xanax (alprazolam)
• Ativan (lorazepam)
• Klonopin (clonazepam)
Benzodiazepines are typically prescribed for use on an “as needed” basis to
people who have visited an M.D. or emergency room for panic symptoms. If a
person is taking these medications on an as-needed basis, it would help to talk
with a psychotherapist to decide how to coordinate medication use with learning
techniques. There are some cases when as-needed medications are helpful to
mastering anxiety in social settings. Planning to use medication to promote
mastery over anxiety is the best idea when using these mood-altering drugs.
They can be extremely helpful to gain control over your anxious body—
eventually without medications.
The benzodiazepines work on GABA, a neurotransmitter that slows down
the firing between brain cells. The activity in the basal ganglia that leads to
symptoms of panic, tension, and social anxiety is slowed down to reduce those
symptoms. The calming effects of benzodiazepines work within 20 to 30
minutes and last for several hours, depending on the person’s response to the
specific medication. That is why they are considered mood-altering. They help
GABA to do its job, but only while they are active in your system.
The best recommendation for taking a benzodiazepine is to take it daily for
several weeks. There is great benefit in calming the brain on a consistent basis
over a period of a few weeks. Often people decide on their own to take the
medication only when they think they need it, but this inconsistency won’t yield
the desired calming effect, and is likely to trigger more tension, panic, and
anxiety. If you don’t take the drug the prescribed number of times per day, you
lose the benefit of soothing the brain. Typically your doctor will prescribe this
drug for a brief period of time—weeks, not months.

Buspirone (BuSpar)
Buspirone is an atypical anti-anxiety drug in the class of medications called
azapirones. These medications work on the serotonin system differently than the
SSRIs. Buspirone has some impact on the dopamine system and is more likely to
“take the edge off” anxiety than to eliminate it. It does not work immediately,
but rather takes a few weeks. People with generalized anxiety may benefit from
using this medication for a period of months.

Other Medications

Some medications are used “off label” to control the symptoms of social anxiety.
(“Off label” means that the drug is not marketed for the use the physician is
prescribing it for. Many drugs have been found to help treat problems other than
those they were developed and marketed to treat.) Heart medications called beta-
blockers may occasionally be prescribed on as-needed basis for limiting the
palpitations of heart and the flushing of the skin that goes with the physical
discomfort of social anxiety. When people are practicing techniques to be more
comfortable in front of others, benzodiazepines or beta-blockers may be used
prior to a practice session to make the practice more effective. This, however,
should be very carefully planned with the therapist and medical doctor.
Additionally, the class of medications called anti-convulsants may be used for
people with social anxiety to diminish the physical symptoms they experience.

COMPLICATED SITUATIONS
Medication choices may become more complicated when other psychiatric
problems overlap with anxiety. People who have obsessive-compulsive disorder
may experience severe rumination; other people may have depression or other
kinds of mental health problems. In those cases, other types of drugs that can
improve thought clarity and improve mood stability may be used to augment the
other medications. Because these are complex individual situations, I will
suggest to you what I suggest to my clients with complicated situations: “See a
psychiatrist.” Psychiatrists, more than other M.D.s, know how these medications
affect people at different ages or with different symptom expressions, as well as
what medications work best for people who have more than one anxiety problem
or who have other mental health conditions. They are also more aware of trends
and new ideas regarding augmenting medication for mental illness. It is well
worth a visit to get medication right.

Medication is a first-line treatment according to insurance companies and

medical protocols for all kinds of anxiety disorders. But medication will not
teach techniques that will help a person to use the brain to change the brain.
Medication can, however, calm the brain enough to learn and effectively use
anxiety management techniques. The best use of medication occurs when a
psychotherapist and an M.D. work together to plan how to effectively integrate
medication and anxiety management techniques that will diminish or eliminate
anxiety symptoms altogether.

PART II

MANAGING THE ANXIOUS BODY

People with panic fear the physical feeling of being afraid. The intensity of the
experience of having a panic attack is so unpleasant and scary that they never
want to have the feeling again. Your heart races, your breathing becomes rapid
and shallow, your chest may hurt, and you may feel dizzy, dry-mouthed, shaky,
or unpleasantly tingly. When people become afraid of having another panic
attack and begin to curtail their activities because of it, panic disorder sets in. It
is completely understandable that you would never want to have a panic attack.
They are physically painful and terrifying. However, as I will discuss later, they
are not lethal. You can control many factors that will reduce the frequency and
duration of panic attacks.
If you have panic disorder you may feel: • Rapid heart rate • Shallow
respiration or hyperventilation • Nausea
• Tingling
• Ringing ears
• Lump in throat
• Dizziness

Other types of anxiety have unpleasant physical symptoms as well. People

with generalized anxiety (the worry warts among us) suffer significantly from
tension-related problems. Temporomandibular joint (TMJ) or jaw joint pain,
neck pain and headache, and stomach and gastrointestinal pain are just a few
examples. In addition, the sensation of acute anxiety—the physical sensation that
something is very wrong—is decidedly painful as well. Managing the body is
very relevant to helping those with generalized anxiety to suffer less physical
discomfort and to reduce the feeling of being anxious as well. If a person has
generalized anxiety you will see some of the following symptoms: • Sense of
doom or dread • Achiness
• Muscle tension
• Agitation or restlessness Social anxiety sufferers squirm at the very
idea that others could perceive them as looking frightened.
Macdonald’s (2005) research demonstrating that emotional pain is felt
physically centers around social anxiety pain. Flushing, sweating,
heart palpitations, and quivering muscles or quavering voices are
transient symptoms—uncomfortable but not long-lasting if you can
escape the feared scrutiny of others. But there is also evidence that the
discomfort of knowing that others may observe these symptoms hurts,
and that ongoing fear may keep the discomfort prominently in your
thoughts. Our mental representations of emotional pain make us feel
pain. People who have social anxiety tend to be overly sensitive to
their own feelings as well as to events outside themselves (Aron, 1996;
Lonegan & Philips, 2001; McNally, 2002). This creates more physical
pain than they would have simply from the outward signs of their
anxiety. Social anxiety sufferers may experience: • Flushing or
blushing • Sweating
• Quivering muscles • Quivering voice
• Heart palpitations A person may have any or all of these symptoms,
and the intensity may vary dramatically from one person to the next.
For many with anxiety there is a vicious circle wherein the body
triggers anxiety and anxiety triggers physical arousal. Interrupting this
cycle helps to slow down the arousal and diminish the frequency and
intensity of anxious symptoms.

BEFORE YOU START PSYCHOTHERAPY, GET A MEDICAL

CHECKUP
Too many possible physical causes of anxiety exist to list them all here, and it
would just make you more anxious if I did. Even if you have always been prone
to worry, nervousness, or shyness, it is important to get a medical check for
heart, hormonal, and blood-sugar issues, especially if your symptoms have
worsened recently. For example, changes in thyroid function can mimic anxiety,
and mitral valve prolapse can trigger panic. Changes in estrogen and
progesterone can affect the way your brain receives neurotransmitters, and when
neurotransmitters change, so do physical sensations, mood, thought, and
behavior. If you have a medical problem causing anxiety, you may have limited
success with the techniques in this book because that underlying medical
problem will not be addressed.
More typically, when people consult their family physician or go to the
emergency room with a panic attack, they are given a battery of tests that come
back negative (i.e., show no physical problems). They are told there is no
evident medical cause for their symptoms. In frustration, they turn to therapy.
These people may be hard-pressed to believe that definite physical symptoms
can be managed with psychological techniques. They believe if no medical
treatment is required, they must not have really experienced the physical
symptoms at all. But anxiety really is felt in the body. The brain initiates definite
physical symptoms, and when you are clear that no disease or medical condition
is causing the symptoms, the techniques I provide will make a world of
difference.
This section reviews methods that calm the physiology (physical symptoms)
of anxiety. Research shows that calming the body calms the brain, which is, after
all, part of the physical body (Amen, 1998; Benson, 1975; Childre, 1999; Gallo,
2005; Schwartz, 2005). When it comes to anxiety, implementing physical
changes can make a big difference in the way people think and feel. The physical
organ of the brain responds to all the stressors from outside and inside the body.
Phones ringing can be as disturbing as eating the wrong foods. Whatever
disturbs your brain is going to show up in your physiology, your thoughts, and
your behavior.
There are many methods for managing the anxious body, including energy
therapies, eye movement desensitization and reprocessing (EMDR),
neurofeedback, heartmath, and biofeedback. (Further information on these kinds
of resources can be found in the Recommended Reading & Resources at the end
of the book.) But these techniques require specialists. Fortunately, several tried-
and-true techniques exist that you can practice completely on your own. This
section identifies four that will help you change intakes that negatively arouse
your body, get rid of stressors and the impact of stress, and calm down your
body once it starts to feel anxious symptoms: • Technique #1: Change Your
Intake • Technique #2: Breathe • Technique #3: Practice Mindfulness with
Shifting Awareness • Technique #4: Relax These four techniques will calm brain
activity and, consequently, arousal in the body. The calmer your brain is, the less
you will feel the unpleasant physical sensations that are the hallmark of all types
of anxiety—the goal of managing the anxious body.
 THREE

Technique #1: Change Your Intake

Your body has to process whatever you take in. Whether you are taking in
chemicals or whether you are taking in high stimulation from the environment,
your body (including your brain as an organ) responds to restore balance in all of
your systems. Physical symptoms of anxiety are one cost of being out of
balance. Calming the anxious body starts with changing your intake. Changing
intake includes intake of foods or drugs that trigger anxiety, as well as intake of
stimulation and the demands that stress your brain and body. Technique #1 is one
you can start practicing today. It will have a major impact on calming your
anxious body.

LIMIT C.A.T.S.
C.A.T.S. stands for caffeine, alcohol, tobacco, and sugar and sweetener.
Research demonstrates that these substances play a role in causing physical
anxiety, and when a person changes intake of these substances, the body
immediately becomes less anxious. Knowing how limiting intake of C.A.T.S.
can modify the physical symptoms of anxiety will help you decide if limiting
your intake of one or all of these substances is a good first step.

Caffeine

Avoiding caffeine may be a choice that seems like a no-brainer if you notice that
you do not like the jittery, overstimulated feelings you get when you drink
coffee, tea, or soft drinks with caffeine. But you may not realize how these
caffeinated substances are affecting you. Research has demonstrated that out-of-
the blue panic that is caused by a person’s genetic makeup tends to be triggered
by caffeine consumption (Alsene, Deckert, Sand, & de Wit, 2003; Nardi, 2007).
Even fairly small amounts of caffeine can trigger panic. One young man, who
saw me because he was having panic sensations daily and occasional major
panic attacks that drove him to the emergency room, stated that he could not
believe that caffeine was a cause of his panic because he consumed so little of it.
He drank only one cup of regular coffee in the morning and occasionally a soda
in the afternoon. He made some improvements in the frequency and severity of
his panicky feelings by using other techniques, but after another terrible panic
attack he finally decided to eliminate caffeine altogether. To his amazement, he
could immediately tell the difference—his panicky feelings decreased
considerably, and he did not have another big panic attack.
Caffeine does more, however, than just trigger panic. People who are
worriers, who may have generalized anxiety, are typically physically tense, and
their tension levels will increase with the intake of caffeine due to its effect on
the nervous system (Fisone, Borgkvist, & Usiello, 2004; Fredholm, Bättig,
Holmén, Nehlig, & Zvartau, 1999). Caffeine also has an impact on people with
the social anxiety symptoms of flushing, sweating, and shakiness. By
heightening the arousal of their nervous system with caffeine, they become more
likely to experience the signs of distress that they do not want the world to see.
In general, caffeine is a contributor to all kinds of anxiety. Notice the
amounts of caffeine in the everyday products you may use, such as soda, coffee,
tea, chocolate, and energy drinks or tablets. It is easy to find the milligrams of
caffeine in these products on the Internet. People vary widely in their tolerance
to caffeine, and some cannot consume even small amounts, but if you keep track
of your changes in mood, tension, and anxiety after consuming it, you will
quickly be able to find your limit and alter your intake accordingly.

Alcohol

Many people regularly use alcohol as a way to reduce stress, handle fear, and
avoid unpleasant emotional states. A moderate amount of alcohol can quickly
and temporarily induce a relaxed state of mind or body. However, the impact of
alcohol on the anxious body is more complicated than it initially seems.
People under stress tend to consume alcohol in larger quantities or with more
frequency than they might when not stressed. At times of unremitting stress—
such as during a divorce, a particularly difficult project that requires long hours
of work, or caring for a family member who is ill—people may use more
alcohol. All of these situations can interfere with relaxing or getting to sleep, and
alcohol may help induce sleep. Alcohol can also ameliorate social fears. It can
make a person feel less anxious about facing a social demand, like attending an
office party. Trying to get rid of unwanted feelings or to create states of
relaxation they desire, people use alcohol and unwittingly create a bigger anxiety
problem.
Although alcohol may temporarily help people relax, it is actually a profound
anxiety-causing agent. When it leaves the body, detoxified by your liver, alcohol
actually leaves nerves in an agitated state. People who have a couple of drinks at
night may find it easier to get drowsy and fall asleep, but they often awaken
halfway through the night and can’t get back to sleep. This is because the alcohol
is leaving the nervous system in an agitated state. The best solution to middle-of-
the-night awakening, if one is not going to eliminate alcohol altogether, is to
restrict alcohol consumption to earlier in the evening, so this phase of
detoxification is complete before heading to bed.
A better solution is to use herbal teas with calming properties (such as kava,
chamomile, catnip, lemon balm, hops, and valerian) at bedtime to achieve the
drowsiness without the rebound. The herbs in these teas help calm the brain and
promote sleep with no “hangover” effects in the morning. Whenever using
herbal substances make sure you have checked how they might interact with
each other and with other medications you are taking. Even though the FDA
does not control these substances, they still work with or against other herbs or
drugs you are taking.
A more obvious problem with alcohol and anxiety is the hangover effect
when too much is consumed. Young people commonly drink excessive amounts
of alcohol. Binge drinking is dangerously popular, often starting in late
adolescence. This is not “social drinking” and has consequences that should be
assessed as a risk factor for addiction as well as for anxiety, both of which may
develop from frequent alcohol use. Alcohol addiction, when present, requires
separate treatment from anxiety management—addiction will not disappear just
because a person can control their anxiety.
The point of assessing alcohol use in the case of an anxious body is to
identify how it triggers—rather than soothes—anxiety. The agitated brain trying
to recover from the consumption of alcohol is primed to experience more anxiety
and panic. One way of identifying the impact of alcohol on your body is to keep
an anxiety or panic diary. Keep track of how much alcohol you drink the night
before, and record your overall level of anxiety or occurrence of panic the next
day. Regularly maintaining this diary over the course of a few months will tell
you a lot about how alcohol affects your system.

Tobacco

Tobacco use has so many downsides that it is hard to even discuss why a person
might logically use it. However, people do smoke. Those who do find tobacco to
be relaxing, and the actions associated with using it contribute to that relaxation.
The rituals of tobacco use—lighting up the cigarette, pipe, or cigar, or the act of
chewing—are often strongly associated with creating a space of calm and
separation from stress in which the smoker has time to step out, relax, think, and
soothe him-or herself. There is no faster way to make an anxious person more
anxious than to announce he has to quit smoking.
A better strategy is to track the relationship between the sensations of anxiety
and the use of the tobacco. Many anxiety-provoking effects of smoking exist,
among which are sensations of dizziness, tingling, shortness of breath, or just the
nagging belief that you should not be smoking because of the health concerns
associated with it. You cannot predict exactly how smoking affects a person until
you track that person’s reactions. A smoking record can be as simple as an index
card like the one shown in Figure 3.1.
You will quickly be able to see if your tobacco use has a relationship with the
intensity of your anxiety. One client recently reported that the constant edge of
anxiety that made him fear he was about to have a panic attack disappeared
immediately when he quit smoking. He thinks it was because he felt guilty about
every cigarette but did not want to openly acknowledge it. Several of my clients
have noted that smoking decreases their anxiety while they’re doing it, but
increases it afterwards. When you are working on managing the physical
sensations of anxiety, a positive way to change your intake of tobacco is to do
some diaphragmatic breathing or one of the quick breathing relaxers (see
Chapter 4) before you light that cigarette. These exercises may help to relieve
your underlying anxiety so you feel less compelled to pick up the cigarette in the
first place.
Figure 3.1 Smoking Record. Rate anxiety levels 1–10, with 10 being extremely anxious. Rate each tobacco
event, regardless of how often you use the tobacco.

Sugar and Sweeteners

Intake of sugar and non-nutritive sweeteners poses a variety of anxiety-

stimulating problems. First of all, sugar can create anxiety-mimicking effects for
people who might be hypoglycemic. Hypoglycemia is low blood sugar, and the
symptoms of low blood sugar (e.g., sweating, flushing, nausea, shakiness) are
quite similar to most of the physical sensations that accompany all kinds of
anxiety. Like most health problems that go through a fad in which they are over-
diagnosed, hypoglycemia was at one time blamed for a lot of physical and
mental problems. Andrew Weil (1998) wrote that unstable blood sugar is
unusual because your brain depends on a stable supply of blood sugar and the
body has many different ways to ensure that levels stay within an appropriate
range. But some people do have hypoglycemia and some people are more
sensitive to the effects of changes in their blood-sugar levels. Many people with
anxiety feel physical symptoms more intensely and pay more attention to them
than others might. When someone with hypoglycemia ingests foods that turn to
sugar quickly (e.g., simple carbohydrates like a donut or plate of pasta), the level
of blood sugar rises quickly. Shortly thereafter, the blood-sugar level drops
quickly, causing symptoms that feel very much like anxiety. Eating complex
carbohydrates rather than simple ones, balancing your meals with protein, and
minimizing caffeine are good ways to counteract this problem.
The issue of non-nutritive sweeteners, aspartame in particular, is complicated
because the research on its negative effects is controversial. Many studies report
no consistent negative reactions to these substances, but other studies
demonstrate a connection between increased anxiety and intake of aspartame.
There is convincing research that aspartame affects nerves directly by changing
the myelin sheath (the protective covering on the nerves) (Blaylock, 2004;
Muller, Peterson, Sonnewald, & Unsgard, 1995; Walton, 1988). Additionally, a
large number of anecdotal reports citing the negative responses to aspartame,
including many from my own clients, suggests eliminating aspartame to control
any role it plays in triggering anxiety or panic symptoms.
On the subject of non-nutritive sweeteners in general, judicious use of sugar
may be the wisest choice; however, if you need to avoid sugar altogether because
you are sugar-sensitive, a non-chemical, non-nutritive sweetener made from the
stevia plant is widely available in natural foods stores. Chemicals in our foods
challenge our physical ability to process them, and many people with anxious
bodies react not only to aspartame but to other chemicals as well. For health in
general, reducing intake of all chemicals is just sensible, and eliminating
aspartame is an obvious way to do that. Again, keep track of your anxiety levels
after using aspartame or sugar, and if you notice an increase in symptoms, it
would simply make sense to use less or eliminate it.

CREATE DEMAND DELAYS

Our current culture has created a special category of stress—the demand for an
instantaneous response to communication. Many of us have become accustomed
to the idea that we should immediately answer the phone, respond to an email, or
send back a fax rather than a “snail mail” letter. You might be among the people
who have high drive—lots of energy to keep on going and doing, no matter what
activity you undertake—so you may not be aware of the toll this communication
demand takes.
Every time the computer or phone “dings” to tell us there is a waiting
message, our brains register an alert. The amygdala hears a ding as a demand for
attention. That alert is not calmed until we respond to it, and if we do not
respond right away, it takes mental energy to push away the urge to respond.
Even hearing someone else’s phone ringing creates mental (and therefore,
physical) tension. All of our communication-related technology has created an
artificial “on call” status that we live with daily—a constant level of alertness
and readiness to respond promptly. It is easy to feel the demand of email,
voicemail, text messages, instant messages, and so on. Workplace expectations
increase that feeling. “Oh?” the boss says with arched eyebrow. “You didn’t get
the message? I sent you an email at 9 o’clock last night to tell you the meeting
this morning was to start an hour early.” The implication is that you should be
checking in with work at all hours of the day. Many companies directly instruct
employees to check email on weekends, and healthcare professionals, especially
mental health professionals, are often expected to be on call without a break,
sometimes for days on end. The stress of remaining alert is subtle but constant,
and it plays a definite role in creating physical tension.
It may be a good idea to reduce “response demand” stress in order to see
how it is affecting you. Mike, a client of mine who used to joke that his
Bluetooth earpiece had been surgically implanted, forgot his phone one day on a
business trip. He realized that it felt great being unable to answer the phone and
email while he spent the day with his customer. He was attentive to the customer,
focused on his work, and felt that he did a better job than he could have if he had
been responding to the rings and dings of his web-enabled phone. He felt some
anxiety without the phone, but because he had no choice, he was able to set the
anxiety aside, and he felt calmer on the job than he had in a long time. Even
traveling home he felt better, being able to listen to music rather than return calls
during the commute. Because changing your pattern of responding to
communication demands may briefly increase anxiety before it provides relief,
create a fair test period in which to observe this. As many a “crackberry” user (a
person who is addicted to checking voicemail and email) will attest, turning off
contact makes you anxious about what you are missing. You will have to get
used to the sensation of being out of touch.
To reduce the impact of this stress, make a deliberate choice to limit your
availability to answer the phone, email messages, instant messages, faxes, pager
calls, and so on, and see how your anxiety level changes. This is called creating
demand delays. Try one of the following ideas for at least a full week, choosing
the one that fits best with your work life. The ultimate goal is to be in control of
when you will respond to all of your technology demands, but start with one
thing at a time. Rate your anxiety level each day on a scale of 0 to 10 (with 10
being high) before, during, and after the technology-free time you create.

• Wait to check email for at least an hour into your workday. Try getting
some work done first.
• Try checking voicemail at specific times in the workday when it suits
your schedule to take messages and return calls. (You may want to let
callers know about these times—when they can expect a return call—
on your outgoing message.)
• Turn off things that ring and ding while you are focusing on work.
 • Turn off everything at home that rings, including cell phones, while
you eat your meal. Make mealtimes a “no calls zone.”
• Leave your cell phone in the car when you go into a restaurant, or at
least turn the ringer to silent (not on vibrate) so that your attention is
completely with your meal and your companions. (Do the same thing
in movies, theaters, meetings, churches, lectures, and so on.)
• If you carry a pager for work, make sure you take it off when you are
not on call, and do not encourage people to page you as a means of
reaching you when you are not on call.
• To a reasonable degree, don’t mix personal and work-related numbers,
so that you can elect to not answer the work phone without missing
family or friends’ calls. Additionally, don’t answer work calls on
personal time.
• If you are required to take a computer home or to work from home,
make a specific agreement with your supervisor about exactly which
hours you are expected to work. Don’t respond to messages from work
except during those hours. The temptation to be at work nonstop will
not be discouraged by your boss; you have to set the boundaries.

Track the impact of communication demands and how they affect your
anxiety level. This may be perceived as tension or alertness rather than
nervousness. It is also helpful to track how anxious it makes you to step away
from communication availability. Both versions of anxiety can keep your brain
revved up and ready to be anxious over seemingly unrelated things. One method
of rating anxiety and how its levels change when you try to create some
communication boundaries is to create demand delays and track the results. You
can use an ordinary index card to do this. Figure 3.2 shows an example of a
partially filled-out card.

Figure 3.2 Demand Delays. Rate your anxiety level each day 0–10 (with 10 being high) before, during, and
after the technology-free time you create.

LOWER STIMULATION INTAKE

Getting a break from high-stimulation environments at work can be extremely
helpful to lowering stress (Schaubroeck & Ganster, 1993). Although people do
not always report feeling stressed from the noise of working in an open
workplace, their bodies reveal the impact of constantly having to block out the
noise, showing stress hormones at higher levels than people who are in less
noisy offices (Evans & Johnson, 2000). For people who are very sensitive to
high degrees of stimulation, these kinds of breaks from being on demand can be
lifesavers for lowering stress and tension levels (Aron, 1996).
If you are not conscious of the impact of stimulation in your environment,
you might need to take breaks even without feeling the pressure to do so. The
more sensitive you are, the higher the toll the environment takes on you, so time
out from stimulation can really pay off in calmer physiology. Try some of these
breaks at least every 90 minutes at work:

• Take a moment to look outside.

• Go outside, even for a few minutes.
• Have a picture of your favorite people or place handy, and when you
look at it, take a moment to feel deep appreciation and love.
• Walk up and down a hallway, take a drink of water, or take a trip to the
bathroom, even if you don’t need it, just to move and be away from
your work station.
• Try a 2-minute mental vacation. This is great for any age. Close your
eyes and imagine a place you love. Then run through what you
experience there in each of your five senses. By the time you have set
the scene, it will be about 2 minutes, and you can come back to the
present with the feeling that you have had a small break.

People feel stress in environments other than work as well. Students may feel
crabby or act overexcited as the result of too much stimulation in the classroom,
cafeteria, or hallways of school. After spending a day with children in the house,
most parents want to send them outside to play, but those who are sensitive to
stimulation really need to do this if they want to avoid anxiety-provoking
tension. Shopping (especially in malls), commuting on busy streets by car or
public transportation, attending conferences with lots of people and new
information, or being exposed to noise, fluorescent lighting, or other kinds of
environmental irritants may all create the need for a stimulation break. If you
have an option to limit the amount of time you spend in situations that will be
too stimulating, that can be a big help. Plan breaks in a day of shopping like
taking time to sit down for lunch or have a cup of tea. If there are too many
people around the house, disappear into a quiet room for a break. If you notice
yourself becoming more irritable, tired, angry, or anxious, take time to calm
down your body after situations that stimulate you. Rest, read, listen to music,
nap in quiet space, breathe, or distract yourself with an activity that draws you in
but does not require intensity.
Making time between activities is also important to give your nervous
system a chance to regroup and rejuvenate itself. To that end, make sure that rest
and quiet are part of your après-fun plans and you will find that the fun is much
more pleasing. Create transitions between activities to give yourself a chance to
shake off the stimulation and refocus. Disorganization stresses people who are
sensitive to overstimulation. Highly energetic people with that basal ganglia–
generated drive to get things done may not need as much time as the person who
is more affected by stimulation, but they do need the transition. Transitions are
very important to keep that drive level focused and thus less stressful. Make sure
you take time to rest and get organized after a big event—like a vacation—
before returning to work. Always finish one activity before beginning the next.
There are many different ways to take a break in general. For example:

• Sit in a quiet space and do something quiet like reading, meditating, or

just breathing.
• Get away from the stimulation, even for just 15 minutes.
• Take a bath or run cool water over your hands while exhaling slow
breaths.
• Listen to music that soothes you.
• Spend a few minutes playing a computer game that draws all of your
concentration.
• If you are creative, spend some time alone drawing, doing needlework,
or playing an instrument.
• Switch from the indoors to outside—get a look at trees or gardens if
 possible.
• If you cannot get out of the indoor environment, try breathing (see
Chapter 4) or focusing on the most important part of the activity you
must do and keep refocusing to screen out the extraneous stimulation.

All of the following will help you lower your stimulation intake.

• Take regular breaks at work. Don’t skip times just because you are not
feeling stressed at the moment.
• Limit time in overstimulating venues, such as shopping malls or
sporting events. Take time off or time alone after big events.
• Concentrate on something that requires focus but is not intense, like
playing an instrument or doing needlework.
• Create transitions between stimulating activities such as school and an
after-school social event.
• Make sure you take time between big events like a vacation and return
to work to rest and get organized. Disorganization stresses people
sensitive to overstimulation.
• Take mental breaks in situations where you cannot physically leave.

INCREASE INTAKE OF NUTRITIOUS

FOODS
Your brain makes neurotransmitters from the nutrients in the food you eat. And
most of the production of brain cells and neurotransmitters occurs while you are
sleeping. Your brain needs protein from animal or plant sources (Delgado et al.,
1994; Golberg, 1997) while you are sleeping, and the digestive process requires
12 to 15 hours in order for the proteins to become available in the brain
(DesMaisons, 1998). This is yet another reason why a good breakfast is a good
idea! To make protein available throughout the night, eat protein three times a
day, but you only need 3 or 4 ounces per serving. That portion is about the size
of a deck of cards.
You also need vitamins to make sure your brain is operating as it should and
producing necessary neurotransmitters (Amen, 2003; DesMasions, 1998; Weil,
1998). The best route is to get nutrients from food itself, but vitamin
supplements can be a good idea if you’re lacking in some areas. Remember that
calories and nutrients are not the same thing. What you eat is much more
important than how much you eat when it comes to brain health. Folic acid from
dark green vegetables like spinach is essential to producing serotonin (Delgado
et al., 1994; Wolfersdorf, Maier, Froscher, Laage, & Straub, 1994) and, if you
are on SSRI medication, for making the medication work at its optimal level.
Make sure you get other vitamins by selecting colorful orange, red, and yellow
vegetables and fresh fruits. Healthy fats from olive oil and from fish, like the
omega 3 oils, have a good reputation for helping your brain do its work.
Then, get some sleep! Your brain wants 8 hours a night, not just to manage
stress but to repair and grow new cells. (See the work of Andrew Weil, Daniel
Amen, and Kathleen DesMaisons for additional information in this area.)
Chapter 6 explores ideas to promote better sleep.
The following tips will help you increase your intake of nutritious foods.

• Add protein, which builds brain neurotransmitters.

• Add dark green, leafy vegetables that help the brain build new brain
cells.
• Take a multivitamin to make sure you have all the trace elements you
need.
• Eat regular meals so nutrients are available to you consistently.
• Pay attention to consuming healthy fats and avoiding hydrogenated
oils.
• Get enough sleep so the body can use the nutrients for building and
repairing cells.

CONCLUSION
Taking charge of the things that make your body anxious is not always easy, but
it is always productive. Soothing physical arousal occurs with mental effort but
also by making changes in your physical environment, both the inside
environment of your body and the outside environment of the world around you.
In the next three chapters, I’ll present other significant techniques for calming
the overaroused brain and anxious body.
 FOUR

Technique #2: Breathe

As singer Faith Hill croons, “Breathe. Just Breathe.” To manage the anxious
body, there is no single technique as effective as breathing. It is almost
miraculous what control of breath can do to calm your physiology. The beauty of
breathing is that it works even if you don’t believe it is going to. You already
know how to breathe, so you are not starting from scratch when you learn to
apply breathing to feelings of anxiety. No matter what physical arousal
symptoms you experience, breathing will make you more comfortable
immediately if you learn how to apply it and remember to use it. Different
aspects of breathing have applications for all kinds of anxiety. Some breathing
methods include:

• Diaphragmatic breathing to interrupt panic before it starts

• Breathing to diminish and then stop panic when it has already started
• Associating deep breathing with progressive muscle relaxation, so
taking a breath can relieve tension by cueing muscle relaxation
• Using breathing to keep the body calm as a way to avoid stress from
building

PRACTICING DIAPHRAGMATIC
BREATHING
Try this before you read any further: Take a nice deep breath and slowly release
it. If you tried it, you just demonstrated how diaphragmatic breathing works its
magic. You made an executive decision in the prefrontal cortex (PFC) of your
brain to breathe, and the cortex sent instructions to the parts of your brain that
will make sure the breathing is carried out by all the muscles and organs
necessary to execute a breath. In your medulla, a primitive part of your brain,
respiration and heart rate are constantly directed and monitored without any
conscious effort on your part. But you can, by making a conscious decision,
change the rate of that respiration. That slows sympathetic arousal and stimulates
activity of your parasympathetic nervous system—the part of your nervous
system that calms down physical arousal. If you keep it up, your panic
symptoms will subside.
Diaphragmatic breathing is the most reliable way to stop a panic attack once
it has begun. It is the only thing a person can do as an act of will, even without
believing it can work. Breathing changes physiology immediately. When the
body is tense, breathing is affected even before panic starts. But in panic,
breathing gets shallow and rapid instantly and often without warning, and can
change into gulps or gasps. This rapid breathing can become hyperventilation,
which causes dizziness. Diaphragmatic breathing is the counter to
hyperventilation.
Getting ready to start, carefully observe your breathing. Write down these
observations so they don’t get lost. Answer these questions: Is your breathing
pace regular on inhaling and exhaling? Do you pause in your breathing? When?
Do you feel short of breath or rushed? Can you tell if you are filling your lungs
or breathing into your chest only? What do you notice?

Figure 4.1 The Effect of Diaphragmatic Breathing

The next time you are under pressure, set aside a part of your attention to
observe how your breathing changes when you are tense. If you have to speak at
a meeting and that makes you nervous, notice your breathing. If you are having a
disagreement, note how you breathe. Even if you are feeling time pressure, take
a moment to feel your breathing. It may surprise you to find that you have not
been filling your lungs or that you have been holding your breath when you
inhale.
Make a chart, such as the one shown in Figure 4.2, to observe your
breathing. Put a check mark next to all of the items that apply and add a note if
you find any other observations about your breathing.
Breathing can be done anywhere, anytime. Whether you are tense at work or
home, whether in public or private, you can breathe without being obvious. If
you practice this rigorously you will be able to use it for panic attacks right
away. You will immediately notice a reduction in the length of a panic attack.
Over a period of a few weeks, if you are successfully diminishing the impact of a
panic attack, you will see a decrease in frequency of the panic. Stopping panic in
its tracks calms the basal ganglia and causes it to trigger panic less often.
Practice the first time by lying down or standing—after that, you can breathe
anywhere without anyone noticing. Be aware, the goal is not to change the way
you breathe as you go about your daily activities, but rather to consciously
change the way you breathe when you begin to feel panic coming on.

1. Lie down flat on your back or stand in a relaxed manner, feet slightly
apart, knees loose. This is so you can sense the movement in your
abdomen, which should move out when you inhale and should pull in
when you exhale.
2. Rest your hand on your abdomen. This will help you to notice if you
are breathing deeply enough and whether your chest is tight.
Figure 4.2 Breathing Observations Checklist

3. Next, exhale the air in your lungs so you are completely empty to start
the practice.
4. Breathe in through your nose. Inhaling must be done evenly, as if you
can fill your lungs from bottom to top in equal, even amounts. One
way to imagine this is to think about how a balloon fills with water
when you attach it to a faucet. The bottom fills and widens first and
then the water expands the upper portion. Form an image of your
breath filling a balloon in your abdomen, becoming heavy and warm
as you inhale. It will help you to breathe evenly if you find a pace that
works to measure your breathing in and out. Count until you feel
exactly full (e.g., a slow 1, 2, 3, 4) to help you get a measured, even
 breath. Chances are you will take between 3 to 6 counts to fill your
lungs with smooth inhalations. For those who do not like the idea of
counting, breathe while thinking a sentence with an even rhythm such
as, “I am steadily filling my lungs with air. I am emptying my lungs
slowly and evenly.” Fill up evenly, no gulps or gasps, so the top is
reached physically (in your image of the balloon) just in time to
release the breath at the same even, measured pace.
5. Exhale evenly, taking longer than you did to inhale, at a slow pace
until your lungs feel empty. The pace of exhaling should be slow and
steady. Imagine you are blowing at the flame of a candle enough to
move it but not blow it out. Your body needs time to exchange the
oxygen and carbon dioxide or you can get dizzy—a symptom you are
trying to eliminate, not encourage!
6. If you are getting dizzy, exhale for two counts longer or pause for two
counts at the end of the exhalation of your breath before you start to
inhale again.
7. Practice! Diaphragmatic breathing is for you to use to calm down a
panic attack. Most people who panic immediately forget their panic
control measures unless they have practiced them. It is essential to use
diaphragmatic breathing the moment you sense a panic attack
beginning, so you must practice frequently, whether or not you are
sensing panic at the moment.

Create “Breathing Minutes”

For 30 days, try this “breathing minutes” exercise 10 or more times per day. For
a minute at a time, practice diaphragmatic breathing whenever you are waiting
for something. Remember, you don’t need to be standing or lying down. You can
do this whenever:

• You are stopped at a stoplight

• You are on hold on the phone
• You are waiting in line at a store
• You are watching the commercials during a television show
• You are waiting for the microwave to heat some food
 • You are waiting for a friend at work or school
• You are waiting in the car to pick someone up
• You are waiting for the computer to boot
• You are waiting for the teacher to hand out the test papers
• You are waiting for an instant message or a phone or text message
• You are waiting for a meeting to start

After practicing for 7 days, pick one time of day when you can predict that
you will be uninterrupted for a few minutes. For most people it works best to
pick early morning, late evening, or your lunch break. During this one
uninterrupted period per day, you are going to add one minute of breathing. For
the next 7 days, you will continue the 1-to 2-minute practices 7 to 9 times a day,
but you will add 1 minute each day to the time you picked when you can be
uninterrupted. By the end of the week, you may be practicing for 7 to 8 minutes
one time per day. Once you can breathe for this long, you have set the stage to
breathe for other important purposes such as for profound relaxation, for
meditation, and for cueing the stress response to turn itself off.
As you become better at automatically using diaphragmatic breathing when
you feel panic symptoms set in, you can eventually stop practicing. However, if
you suffer from the tension and tightness that goes with being “uptight” or
“wired,” you can continue to use daily breathing for a different reason—to
trigger muscle relaxation. By consciously noticing how your muscles relax as
you breathe, you create a cue for relaxing. Later, when you deliberately breathe
in that slow, deep way, your muscles will automatically let go of the tension they
have acquired. Chapter 6 discusses the technique for cued muscle relaxation.

Obstacles to Diaphragmatic Breathing

Without exception, people will encounter obstacles before they can make
diaphragmatic breathing work for them. But practice is necessary to make it a
habit. Some common obstacles include:
Forgetting to practice or forgetting to breathe when anxiety strikes. This is
why I suggest linking breathing to several times, places, and activities
throughout the day. It might be easier to remember if you:

• Visualize yourself practicing, for example, breathing at the sink, in the

 car, in front of the computer while it boots up, on the phone, or in front
of the television. This will help remind you to practice in those places.
• Keep track. Some people remember better if they write it down. You
might keep an index card handy and write down what time of day you
practice. The reinforcement of noticing when you practice will also set
it more clearly in your mind and help you remember the next practice
more readily.
• Remind yourself to breathe with a note. Forgetting to breathe when
anxiety strikes is common, but the best solution lies in the frequency
of practice throughout the day, so keep a reminder in a prominent spot.
Write the word “breathe” on a note card and take it out of your pocket
or purse whenever you start to feel anxious.

When breathing creates anxiety. Some people get anxious when they start to
breathe deeply. Some are afraid of their breath because they fear they will panic
while doing something new. For others, the act of breathing reminds people of
their panic. Most often, this is caused by incorrect technique and by giving in to
anxious thoughts, so you need two kinds of help. Work with someone who can
watch you breathe and correct your technique. If that does not eliminate your
fear, you will want to explore whether trauma or another, deeper cause of fear
makes it too hard for you to do breathing exercises without anxiety.
When breathing does not seem to help. It is very rare for diaphragmatic
breathing to have no positive impact on panic reduction whatsoever. Observe
how you are practicing. You may be filling your chest while keeping your
abdomen tight or holding your breath during part of the breathing. I once
debated two graduate students in my class who insisted they had to suck in their
stomachs while breathing in. They were doing the exact opposite of what their
bodies would have done naturally, but they had breathed in this wrong way for
so long that they kept reversing the action. They were amazed to see how
different it felt when they learned to let their abdomen expand while inhaling. It
may be helpful to have someone watch you while you breathe, as it can be hard
to recognize what you are doing on your own.
When you have difficulty concentrating. When practicing breathing,
everyone has distracting thoughts that flit through the mind. This is especially
likely when you are adding a minute a day to one of your breathing practices.
The best way to handle distractions is to:
 • Notice that you have been distracted, and mentally say to yourself,
“Oh. A thought.” Just notice, with no judgment against yourself for
getting distracted. Do not feel upset with yourself or impatient with the
breathing. Consider thoughts as clouds in the sky, just drifting by. You
have no need to stop them, examine them, or be irritated that they are
there.
• Redirect your attention to your breath.
• Focus on the physical sensation of breathing, noticing the feeling of
your lungs expanding, the sensation of your waist-band against your
abdomen, or how your back shifts against a chair. Feel your breath
move through your nostrils or out of your mouth.
• Count to measure your pace and help keep your focus on the breath.

When inhaling feels restrictive. You may feel as if you are tight or have an
obstruction, as if there is a block in your airflow, or you may feel unable to fill
your lungs completely. This is typical when you are feeling anxious. First, make
sure you are upright and loosen any restrictive clothing, such as tight jeans or
neckties. If the problem is not as obvious as this, the source may be emotional,
and it would be best to practice breathing in a therapy session to examine your
emotional responses to the breath. Ask yourself:

• Where is the restriction or obstruction located?

• How does it feel? Is there a word or phrase that describes it?
• What does it look like? What is its shape or color or size?

Then:

• Visualize the block clearly.

• Send your breath to the center of that block.
• Watch what happens as you breathe and pay attention. Obstructions or
restrictions that have an emotional basis will often disappear when you
become aware of them, as long as you do not fight to push them away.
• Ask yourself what it would take to make the block smaller or disappear
and imagine doing that.
 When you have physical limitations. Some people have difficulty breathing
due to asthma or other lung diseases. If this is the case, you may need to work
with your pulmonary specialist to find a faster breathing pace, a shorter duration,
and a less intense breath to make it work. Decreasing intensity and duration of
breath are usually the keys to making diaphragmatic breathing useful for those
with chronic lung disease or pulmonary problems.

A Last Word About Diaphragmatic Breathing

You will notice more about your breathing as you practice. This technique is
simple to do, but not easy to master. For breathing to effectively reduce tension
you first have to remember to use it! Until it becomes a habit, you may forget to
breathe under anxiety or tension. It takes some time for this process to become
smooth and easy. Breathing effectively requires practice and attention until it
comes naturally. As the ads used to say about driving a VW Beetle stick shift,
“After a while, it’s automatic!”

BREATHING FOR MINIMAL AROUSAL

When people are in situations that make them uncomfortable, they tense up and
try not to show it. They tend to hold still, making their breathing shallow and
tightening their bodies. In other words, they create incredible muscle tension and
set a hair trigger on their anxiety, getting ready to produce flushing, sweating,
shaking, and quivering as soon as they think anyone is looking their way. They
may even have a panic attack as soon as they start to think that they are not
going to be able to control the situation. With that degree of tension, it is
important to take preventive action, keeping the brain calm by breathing and
helping yourself stay relaxed as you prepare to do what you fear. If you focus on
your breath you are less likely to focus on your fears, and if you are breathing,
your parasympathetic nervous system can help you avoid unnecessary physical
arousal. The less tense you are, the less likely you are to experience symptoms of
anxiety.
For example, you may be in a business meeting where you are expected to
give a report on your activities and you do not like the feeling you have when
everyone is looking at you. While you wait to speak you can breathe to avoid
getting too tense. Perhaps you are getting ready to try something you have not
done before—try out for a sports team or give a speech or speak up to your
manager at work about a problem you are having. In such situations, you can do
diaphragmatic breathing preventively. You will stay calm physically, even if you
are in situations that are trying.
A particularly good 1-minute breathing exercise that is helpful when you
have only a short amount of time and have to be subtle is the “In 2, Out 2-4-6-8-
10” method of relaxation breathing. It goes like this:

1. Inhale to the count of 2.

2. Exhale to the count of 2.
3. Inhale to the count of 2.
4. Exhale to the count of 4.
5. Inhale to the count of 2.
6. Exhale to the count of 6.
7. Inhale to the count of 2.
8. Exhale to the count of 8.
9. Inhale to the count of 2.
10. Exhale to the count of 10.

You may also find yourself in hectic or emotionally trying situations from
which you need a break but can only get a short time away. A breathing method
called the “5-Count Energizing Breath” works well, but it is hard to do subtly. It
is a good option if you can take a moment to leave the room or go to the
restroom. In fact, if you are washing your hands it is ideal to do this breathing
method and shake water off your hands with 5 short shakes on the exhale.

1. Inhale smoothly to a quick count of 5.

2. Exhale by huffing your breath out in short bursts to the count of 5:
huh-huh-huh-huh-huh.

After taking a few minutes out of the high-stimulation environment and

breathing off the tense energy you have accumulated, you can reenter with less
tension but also with the energy to cope. You will be less likely to get too
anxious to handle the situation and your mind will be clearer to respond to
whatever is happening.
CONCLUSION
Breathing is easy to learn but not always so easy to remember when you are
panicking, tense, or frightened about what is happening next. Practice breathing
until it comes naturally, because anxiety has a way of making you forget what
you are supposed to do. Even when you become a master of anxiety control,
breathing techniques remain useful, as they form a basis for meditation,
relaxation, and otherwise dealing with the normal tensions of life in a very
positive way.
 FIVE

Technique #3: Practice Mindfulness With Shifting

Awareness

Although a technique called mindfulness may not sound related to managing the
anxious body, it is a powerful way to accept the presence of disturbing physical
sensations without alarm, and to shift the focus of awareness away from them.
Mindfulness is a state of awareness that can be created in many ways and has
benefits far beyond its use as a technique to manage anxiety. Mindfulness is
finally getting the attention it deserves from psychotherapists in research and
practice (Kabatt-Zinn, 2005; Siegel, 2007). It is a way of being fully present in
the moment you are living in. Such presence is the antithesis of anxiety. Anxiety
by its very nature is worrying about what was or what will be. It is rarely
focused on the moment. If something bad is happening right now, you are
probably not anxious about it. You are probably dealing with it. Of course,
something happening right now could scare you, but even then you are still
dealing with it somehow, not actually worrying about it.
People who have researched the impact of mindfulness on the brain and body
can demonstrate that practicing mindfulness has a calming effect on the brain.
Mindfulness diminishes the physical impact of stress by allowing people to be
more focused, more able to see solutions to problems, and more able to remain
peaceful in the face of the normal wear and tear of life (Benson, 1996; Kabat-
Zinn, 2005; J. Schwartz et al., 2005; Siegel, 2007; Williams, Teasdale, Segal, &
Kabat-Zinn, 2007).
Deriving the full benefits of mindfulness requires you to be disciplined and
practice various techniques to master this very rewarding way of meditating and
living in the world. The works of Thich Nhat Hanh (1999), Kabat-Zinn (2005),
Benson (1996), and Siegel (2007), among others, can help you learn what
mindfulness can do for you and how to begin practicing it. This chapter,
however, deals with only one aspect of mindfulness: shifting awareness.
 Even without devoting a life change in this direction, there is a mindfulness
exercise that can bring immediate benefit to those who are excessively focused
on worrying about what is happening in their bodies. This exercise will assist
you over time to tell the difference between what is real and what is imagined,
and it will help you to ignore fleeting and inconsequential physical sensations.

WHAT MINDFULNESS WITH SHIFTING AWARENESS CAN DO

FOR YOU
Sara, a client of mine who had developed debilitating panic attacks in adulthood,
began to master the techniques of breathing, which helped diminish her fear of
dying while having a panic attack. However, she developed another problem as
well. She began to fear that she would always be afraid. “After all,” she said,
“this panic took total control over me, and I was always so strong.” Sara paid too
much attention to every small physical sensation, believing each tingle heralded
a panic attack getting started. She was essentially creating panic out of small,
normal changes in her physical state. A slight chill or a momentary flutter in her
stomach was all she needed to start hyperventilating in fear that panic was on its
way, which of course it would be with her attention riveted to the sensation.
She needed to learn to turn her attention away from her physical state to the
other aspects of her life as it was at that moment. It was important for her to
learn to notice the outer world rather than her inner world. Remember that our
brains are registering data from all of our senses at the same time the
hypothalamus is monitoring information from our organs and bloodstream.
Paying attention to the outer world can be mindful in a complete way and
learning to direct focus and attention are important aspects of mindfulness.
By focusing your attention on what is happening around you, you gain some
sense of control over how you are experiencing life. You are choosing what to
attend to. You also enhance your ability to observe yourself. Self-observation
requires prefrontal cortex activity to use the brain to observe your thinking and
feeling. Our uniquely human capacity to use the brain to control the brain is at
the heart of anxiety management, and it is most obvious in selecting what to pay
attention to. When physical sensations are troubling and there is no real purpose
served by focusing on them, focusing away from those physical sensations to
observations of the outer world is a good way of calming yourself. This is called
“self-soothing” and it is an important life skill.
 Mindfulness with shifting awareness will help to minimize the importance of
physical sensations and to take the focus off of them effectively. People who
suffer panic attacks are particularly aware of physical sensations and changes.
People with flushing, sweating, or shaking associated with the fear that other
people are watching and judging them are also highly aware of how they feel.
Any time a person focuses on these kinds of sensations they are dooming
themselves to having the physical reaction they most fear. By teaching you how
to control your awareness, this technique will help you immediately stop
focusing attention on sensations so that you won’t develop the symptoms you
fear. You will learn to shift from awareness of your inner sensations to awareness
of the world around you.

PRACTICING MINDFULNESS WITH

SHIFTING AWARENESS
It is helpful to do this technique for the first time with a partner who can lead
you through the exercise while you devote attention to your own awareness, and
don’t have to divide it by reading the instructions. Have your partner read aloud
the following steps:

1. With eyes closed, follow your breath into your body as you inhale
through your nose. Notice each sensation of inhaling.
• Notice the coolness of the air.
• Notice the pressure of airflow.
• Notice how the movement feels through your nose, throat, trachea,
and into your lungs.
• Notice the feel of your body shifting against your clothing and the
chair you are sitting on.
• Follow the breath out of your body, exhaling through your nose or
mouth.
• Notice the warmth of the air.
• Notice the pressure of airflow reversed past your throat, sinuses,
and nose or mouth.
• Notice how the movement of air feels through your lungs, trachea,
throat, and nose or mouth.
• Notice the change in the feel of your body shifting against your
 clothing and the chair you are sitting on.
2. Exhale your awareness to the world around you without opening your
eyes.
• Direct your awareness to every sound in the environment, paying
special attention to location and intensity.
• Shift your awareness to the smells in the environment.
• Shift your awareness to the sense of movement in the environment
if you are in a place with other people nearby.
3. Now, shift awareness back to your body, and inhale again.
• Notice the coolness of the air.
• Notice the pressure of airflow.
• Notice how the movement feels through your nose, throat, trachea,
and into your lungs.
• Notice the feel of your body shifting against your clothing and the
chair you are sitting on.
• Add this awareness: Feel your heart beating.
• As you exhale, notice the warmth of the air.
• Notice the pressure of the airflow reversed past your throat, sinuses,
and nose or mouth.
• Notice how the movement of air feels through your lungs, trachea,
throat, and nose or mouth.
• Notice the change in the feel of your body shifting against your
clothing and the chair you are sitting on.
4. Now, with eyes remaining shut, exhale your awareness into the room.
• Direct your awareness to every sound in the environment, paying
special attention to location and intensity.
• Shift your awareness to the smells in the environment.
• Shift your awareness to the sense of movement in the environment
if you are in a place with other people nearby.
5. Now, shift your awareness back to your body as you inhale.
• Notice the coolness of the air.
• Notice the pressure of airflow.
• Notice how the movement feels through your nose, throat, trachea,
and lungs.
• Notice the feel of your body shifting against your clothing and the
chair you are sitting on.
 • Feel your heart beating.
• Add this awareness: Feel the movement of blood or energy through
your body or limbs.
• Notice the warmth of the air.
• Notice the pressure of the airflow reversed past your throat, sinuses,
and nose or mouth.
• Notice how the movement of air feels through your lungs, trachea,
throat, and nose or mouth.
• Notice the change in the feel of your body shifting against your
clothing and the chair you are sitting on.
6. One more time, shift your awareness to the external world as you
exhale.
• Direct your awareness to every sound in the environment, paying
special attention to location and intensity.
• Shift your awareness to the smells in the environment.
• Shift your awareness to the sense of movement in the environment
if you are in a place with other people nearby.
7. Prepare to open your eyes by becoming aware of light coming
through your eyelids, and then gradually allow your eyes to open,
taking in the color of the light and then the things you can observe
with your vision as you become fully present and aware of the
situation you are in.

MINDFULNESS AND PANIC ATTACKS

Mastering this mindfulness technique helps you to stop fearing physical
sensations that trigger worry about whether an anxiety attack is headed your
way. People control panic by avoiding situations in which they previously
panicked. When they are trying to reenter those situations, they commonly state
that they are on the look-out for panic to recur. Sometimes these people are
actually afraid of the consequences of ignoring panicky sensations. It seems
funny, but they actually ask, “How can I do this? What if I panic and I don’t
notice it coming?” I always ask right back, “Have you ever had a panic attack
that you failed to notice?”
If a panic attack is coming on and you are not yet practiced enough with
breathing or mindfulness to ward it off, the attack may in fact develop. The next
section—Part III—will discuss the techniques to control the thoughts that go
with this. However, it is a good idea to develop the attitude: Don’t be afraid of
panic happening. All you need to do is make a plan for what to do if the panic
attack develops. You should write this plan down and carry it with you in case
you need a reminder. Clearly, identifying options for situations such as driving,
being in a public place, and so on is necessary. Then, you can review the written
options before entering the situation for the first few times. The confidence you
get from having a plan can reduce the likelihood of feeling anxiety. Often, the
best option is just to stay where you are and breathe until the panic is gone.
Driving is a little different in that you want to be sure that you don’t endanger
anyone, so the plan might be to pull over and breathe until the anxiety passes.
A client of mine responded very well to this wonderfully simple technique.
Diverting her attention to the external world was particularly helpful when she
started to drive on the highway again. As she started to feel sensations that might
be the harbinger of a panic attack, she did some diaphragmatic breathing and
diverted her attention back to the road and the actions of controlling the car.
Even though her plan allowed her to stop if the symptoms increased, shifting her
focus of attention to the road was sufficient to avoid a full-blown panic attack. It
only took a couple of trips on the road without panicking for her to regain
confidence that she could resume her driving without fear.

MINDFULNESS AND FLUSHING, SWEATING, OR

EMBARRASSED ANXIETY
As stated earlier, warding off the anxiety that others will notice—small signs of
flushing, sweating, or shaking—is a critical part of having fewer attacks of
nervousness. These symptoms are triggered by the peripheral nervous system,
and once underway they are harder to interrupt than panic itself, in part due to
the fact that others do notice these symptoms. Ultimately, if you stop caring
whether you flush, you diminish the tendency to do so, but the best way to keep
these symptoms at bay is to learn how to discreetly stay calm in situations that
could provoke anxiety. Mindfulness with shifting awareness can take you either
inward or outward, depending on which is the most helpful direction at the
moment. Staying focused on inner breathing rather than on the surrounding
hubbub can help shy people to avoid the overstimulation that can trigger
blushing, sweating, or flushing if they feel flustered.
CONCLUSION
Because mindfulness with shifting awareness can be done in any setting without
obviousness—as long as you simply keep your eyes downcast and not closed—it
is a terrific tool for pulling the mind away from worry or panic and simply
directing your attention to the present moment. As I said earlier, the antithesis of
worry is to be in the moment and not in the future or past. Whether you’re
feeling worried, anxious, or panicky, the technique itself does not vary—you can
use it in any of these situations—but the timing of it may. Because worry and
panic occur anywhere for any reason, this “do it anywhere” technique is terrific
for those of us who fret.
 SIX

Technique #4: Relax

Relaxation has many applications for managing the anxious body. It can be used
to stay calm in anxiety-provoking situations, to shift gears at the end of a trying
day, to calm the mind and improve thought clarity, to relieve the impact of stress
on the body, and more. Technique #4, Relaxation, offers several approaches for
the different kinds of tension and anxiety people feel.
The description “uptight” is very apt for people who are stressed out. Most
people react to stress by literally tightening up physically. And they don’t notice
the tension until they have knots in their backs or headaches. Physical relaxation
does not come naturally to people suffering anxiety. People with high-arousal
and tense anxiety won’t notice how they have tightened up in the neck or
shoulders, lower back, buttocks, or legs until they have pain somewhere. Tension
headaches are born of tense muscles in the head and neck that restrict blood flow
or affect nerves.
Tension in the body often stems from mental tension. For example:

• People who are prone to panic tend to anticipate trouble, which causes
tightness.
• People with social anxiety fear they are going to be humiliated,
causing them to feel tension prior to being in a public situation.
• People with generalized anxiety are in mental overdrive. This also
produces tightness.

Physical tension is the result of too much norepinephrine (NE) in the pons
(see Figure 1.2), which causes vigilance and enhances the “wired” feeling in the
basal ganglia. Anyone can benefit from muscle relaxation, but the person with
generalized anxiety is most likely to need to practice relaxation as a lifelong
habit. In addition to experiencing the tension of vigilance and high drive, they
also cope with the mental tension of the ruminating anterior cingulate gyrus
(ACG; see Figure 1.2) that makes muscles gradually tighter and tighter. Worriers
can learn to cue relaxation on a frequent basis to defeat the tension that
accumulates during the day. People with social anxiety need to relax their bodies
before they enter into a public situation they fear.

TENSE-AND-RELEASE PROGRESSIVE MUSCLE RELAXATION

Progressive muscle relaxation for tension release is a “first line” treatment for
the physical tension of the anxious body. It directly counteracts the symptoms
and ailments that go with continual tightness in the neck, back, jaw, and so on.
The intentional relaxation of muscles with slow, deep breathing helps the
parasympathetic nervous system to slow the heart rate and respiration and to
lower blood pressure. This not only eliminates tension-related stiffness and
aches, but also lowers arousal levels so it is harder to trigger anxious physical
symptoms. Methods such as yoga or meditation, or even some of the martial arts,
are good ways to learn deep relaxation, but they require specific training from a
practitioner of those arts. The form of progressive muscle relaxation offered here
is a method everyone can learn and is the best option for people with generalized
anxiety.
The basic goal of this technique is to relax all muscle groups in a systematic
manner. It will take 10 to 15 minutes. The following script provides directions
for this particular method (I present others later in the chapter). Feel free to
expand the instructions to include reminders to feel warmth as the muscles
release. Imagery can be added if you prefer. People who are very logical and
pragmatic do better without the imagery, but if you want to enhance this
technique, you can add imagery to steps 3 and 5. Adding imagery works
especially well with children. However, if you are leading relaxation, check
before starting that the relaxation imagery you use is soothing to the other
person.

1. Make sure you are in a relaxed position, lying flat or sitting with your
neck upright.
2. Close your eyes. Focus entirely on the sensations of each muscle
group.
3. Add an image to the process. For example, imagine you are lying
 outside and the sun is gradually shining on you, touching your toes
first and then moving along your body as you go through this
exercise. (Other images such as ice cream melting or Jello or butter
softening in a patch of sun work, too.)
4. If you are sitting up, begin at your head and move down. If you are
lying down, begin at your feet and move up, working one group of
muscles at a time.
• Tense, hold, and then relax the muscle group. For example, tense
your toes—curl them tight, tight, tight. Now release.
• Feel the warmth flood into them. Feel the energy and warmth
suffuse those muscles. With each exhalation of breath, feel the
warmth flow into your toes.
• Repeat the tense, hold, and release three times. (It is amazing how
much tension remains after just one or two tightenings.)
5. With each muscle group, notice the warmth and then energy that
suffuses the muscles as you release the tension. If you are using a
specific image, such as the sun beginning to touch each part of you,
think of that image as you go through each group.
6. The order of muscle groups named may be:
• Scalp—raise your eyebrows to tighten the scalp.
• Forehead—wrinkle your brow.
• Face—squint your eyes, wrinkle your nose, and purse your mouth
to tighten the face.
• Neck—don’t do neck circles, as they are hard on the spine.
Try this instead:
Let your head drop forward with the weight pulling your chin
toward your chest. You will feel the stretch down your back,
even as far as your lower back if you are very tight.
Return your head to a full upright position before leaning it back
in the opposite direction.
Tilt your head to one side, with the ear moving directly toward
the shoulder, and you will feel the stretch as far down as your
shoulder blade. When your head returns upright, feel the warmth
flow in where the stretching was.
• Shoulders—raise your shoulders up, hunching them, and then
release the tension.
• Arms—tighten your forearm, wrist, and hand by clenching your
 fist.
• Back and abdomen—tighten this area by imagining a string pulling
your belly button (navel) toward the spine and then release slowly.
• Buttocks—tighten by squeezing together.
• Thighs—tighten by tensing and releasing your quad muscles.
• Calves and shins—tighten by pointing your toes and feel the stretch
down the shin and the contraction in the calf. Then reverse, by
pulling the toe up and pushing the heel down. Feel the stretch down
your calf and the contraction in the shin.
• Feet and toes—tighten by either curling the toes or pushing the foot
into the earth.
7. If you did the exercise from the top down, end with an awareness of
the soles of your feet feeling connected to the earth through the floor.
If you did it from the bottom up, end with an awareness of feeling
completely relaxed, from head to toe.
8. Notice how totally relaxed, warm, and peaceful you are. Give
yourself permission to remain relaxed as long as desired, or, if you
are going on to another activity, give yourself permission to remain
physically relaxed, yet refreshed, alert and fully present, while doing
it.

Muscle Relaxation With Children and Elderly Adults

Because this technique can be done seated or lying down, there is no reason that
older adults cannot do it. As with all exercises, an important reminder is to never
do anything that hurts. Sometimes stretching out tense muscles can feel a bit
achy, but it’s more like “good soreness” than outright pain. Be sure you, or those
you’re instructing, understand this distinction.
If you are using this technique with children, you can improve their attention
by making the stretching and relaxing of muscle groups into a game. Children
don’t usually have sore muscles from tension, but learning to relax is a good way
of developing healthy habits. With younger children, use images of animals they
can relate to such a cat stretching out in the sun or a lion opening its mouth to
yawn. Using the language of “stretch and release” instead of “tense and release”
works very well with these images. In a classroom setting, stretching as a group
exercise can help children and adolescents relax before doing stressful things
like taking a test.

SPHERE OF LIGHT IMAGERY FOR RELAXATION

As I indicated above, imagery for muscle relaxation works very well for many
people. It has the same benefits of slowing down respiration and heart rate,
opening capillaries, and inducing parasympathetic calming.
There are many different imageries for relaxation, but the “sphere of light”
works particularly well.

1. Imagine that there is a sphere of light and energy above your head.
2. The light is the color you most associate with peace, calm, healing, or
energy. It is in abundant supply and cannot be depleted, so you can
draw as much as you want into yourself.
3. As you inhale, breathe this beautiful, warm, vibrant, colorful energy
through the top of your head.
4. As you exhale, feel the flow of energy streaming through your scalp.
5. Repeat this with each of your body parts (face, head, neck, shoulders,
arms, hands, fingers, torso, hips, buttocks, thighs, knees, shins,
calves, ankles, feet, and toes), breathing energy and light to each of
the muscle groups as you inhale and feeling the energy flow through
those muscles as your exhale.
6. Become aware of each body part feeling the flow of the beautiful,
warm, vibrant, colorful energy.
7. Imagine the energy flowing through your spine and out, as if you
were sending roots into the earth.
8. Imagine energy flowing through the soles of your feet and into the
earth, which can absorb any amount of energy and turn it all into the
energy of life.
9. Experience the energy exuding from your pores to surround your
body.
10. Find a word that you associate with the sensation of total relaxation,
such as “calm” or “peace,” or even a sound such as “ah” or “mmm.”
11. This energy provides a barrier to negativity for the day, preventing all
criticism, disapproval, harsh words, or ill treatment from penetrating
 your heart. The barrier is permeable to all positive energy, so that
words of praise, approval, and affection can immediately be received
in the heart.
12. As the envelope of energy fades through the day, you can renew it
with a deep breath, imagining the energy and light, and saying or
hearing the relaxing sound or word you chose.

ONE-BREATH MUSCLE—OR “CUED”—RELAXATION

While practicing muscle relaxation techniques, diaphragmatic breathing occurs
almost automatically. It is natural to breathe evenly while relaxing the tension in
each group of muscles. Start noticing, as you practice any form of muscle
relaxation, how your body feels when it is relaxed. You are likely to notice as
you finish a relaxation that your breath is even and deep, as relaxed as your
muscles.
Muscle relaxation is a lifelong method of handling physical tension. Because
physical tension may result from activity in the basal ganglia or excess
norepinephrine, it is not going to disappear with one session of relaxation. It is
going to reappear constantly and not necessarily as the result of overt stress. The
tension level resulting from activity in the basal ganglia can only be interrupted
with muscle relaxation, which has to be learned and then integrated into an
ongoing symptom-control plan. Relaxing the muscles reduces the high tension
level and resulting pain in people with anxious bodies.
“One breath” or “cued” relaxation also helps people with social anxiety or
panic. People who need to stay calm in situations in which they have previously
panicked or in social settings that set off embarrassed flushing and sweating can
use cued relaxation as a tool to keep their bodies calm prior to entering a difficult
situation.
Once you have learned diaphragmatic breathing and progressive muscle
relaxation, you can pair them to produce cued relaxation. The pairing of
breathing and muscle relaxation has many effects:

• Breathing encourages parasympathetic calming of the organs and the

neuroendocrine system, which is activated in stress. In people who
have excess activity of norepinephrine, sympathetic nervous system
arousal is easily set off and contributes to higher degrees of physical
and emotional tension. The decision to breathe is the best example of
 harnessing the brain (the prefrontal cortex decision-making function)
to control the body.
• For people who have overactivity of the stress-response system, such
as those with social anxiety or those who have been traumatized,
breathing with muscle relaxation can help interrupt or diminish the
stress response.
• Pairing breathing and deep muscle relaxation forms an association
between one or two full diaphragmatic breaths and total relaxation.
Once that association is made it will allow a person, at any time or in
any place, to cue relaxation by taking a controlled deep breath.

Once you have learned diaphragmatic breathing and muscle relaxation it is

fairly simple to expand that experience into a cued relaxation:

1. Several times a day, encourage physical release by taking a deep,

diaphragmatic breath, recalling the way you feel when deeply
relaxed.
2. Use an image that represents letting tension go—such as plugging
your feet into the earth—and as you exhale, send negative energy out
of your body and let relaxation flow in behind it throughout the
whole body. Another good image is to send roots from your feet into
the earth to draw calm in and send tension off into the atmosphere.
3. Accompany a slow, deep breath in with a calming statement, such as
“Now I am breathing in all that is of peace. Now I am breathing out
all that is not of peace.” Whether using an image or a phrase, draw
peaceful relaxation inward as you inhale, and exhale the negative
energy.
4. When you exhale, send the energy off or out in the way you have
imagined it. Note how the muscles from your scalp to your toes are
letting go of tension. Repeat this many times a day to discharge the
muscle tension that accumulates from the normal stresses of life as
well as from the extra tension of the anxious body.

As you get comfortable with this pairing, you will be able to take one breath
and feel all your muscles release. In this way you can cue muscle relaxation on
demand, anywhere or anytime, without anyone noticing the change from tight to
relaxed.

EXERCISE TO RELAX
Physical pain, muscle soreness, headaches, digestive upset, and so on are
particularly evident signs of an anxious body in people with high levels of stress.
People who are worriers suffer the physical outcome of tightness throughout
their bodies. If you are a “worry wart” you are likely to take stressful
circumstances more seriously than others. Worriers not only suffer more from
everyday stress, but also bring on extra amounts of it. Ongoing stress for any
person can result in physical tension, higher blood pressure, or problems in
almost any system in the body (Hafen, Karren, Frandsen, & Smith, 1996), and
these problems will be worse in those who have the tendency to worry
excessively. Exercise can be a great way to get rid of the impact of stress and
worry.

The Circular Nature of Pain and Stress

Under stress, people can develop illness and pain that intensifies any anxiety
they might have. This is a circular problem. For example, increased tension can
cause irritable bowel syndrome (IBS) to become much worse, and the IBS then
compounds the tension by making people afraid of the pain of the stomach
cramps and the disruption of their activities. Learning to relax and get rid of
stress will reduce the impact or frequency of these kinds of illnesses.

Exercise Is a Prime Stress Reliever

A stunning amount of research demonstrates the many ways exercise is good for
your mind and body. Exercise also has a positive impact on relaxing. For the
high-energy person with a tense, anxious body, physical activities are better
sources of physical relaxation than sitting still. Aerobic exercise is the best. At
times of high stress, vigorous activity uses up the adrenalin of the stress response
and helps to rid the body of toxic cortisol. It also helps the body to avoid the
weight gain caused by constant stress (Talbott, 2002). Finally, vigorous exercise
promotes relaxation because muscles that are used are stretched and relaxed
afterward. There is really no downside to exercise.
Exercise also promotes many aspects of mental health Bartholomew, 2005;
Bremner, 2005; Dunn, 2005) and is as important for children as it is for older
adults (Larson, 2006; Nelson et al., 2007). It fosters a sense of self-efficacy that
promotes a willingness to take charge of one’s life in other ways (Craft, 2005).
Physical exercise is critical for overall health, and the significance of exercise is
so broad that it should be considered a major intervention to reduce the impact of
stress on both the brain and body.
Exercise increases blood flow to the brain, which is associated with many
aspects of brain health, and it can benefit your neurotransmitter levels as well as
the overall functioning of parts of the brain. Therapists are beginning to
understand that exercise is as important to recovering from mental illness as
many other interventions (Bartholomew, 2005; Cynkar, 2007; Penedo & Dahn,
2005). It may affect serotonin levels more positively in people who have
problems with serotonin to begin with, as seen in research with depressed
persons (Kiive, Maaroos, Shlik, Toru, & Harro, 2004). Considering that about
50% of people with anxiety suffer comorbid depression, it may be reasonably
extrapolated that what will help with depression is also going to be important to
treating anxiety.
Similar recommendations as those for general physical health have been
shown to have a positive impact on anxiety (Lancer, 2005; Manger & Motta,
2005). Michael O’Riordan (2007) quoted a recent study: “To promote and
maintain health, the ACSM/AHA [American College of Sports Medicine;
American Heart Association] writing group recommends that ‘all healthy adults
aged 18 to 65 years need moderate-intensity aerobic physical activity for a
minimum of 30 minutes on five days each week or vigorous-intensity aerobic
activity for a minimum of 20 minutes on three days each week.’” Combining
exercises is also acceptable, with people allowed to meet the recommendations
by walking briskly or performing an activity that noticeably accelerates the heart
rate for 30 minutes twice during the week and then jogging for 20 minutes, or
performing any activity that causes rapid breathing and a substantial increase in
heart rate on two other days.
Another ACSM and AHA report states that less than 50% of adults in the
U.S. meet standards for minimum physical activity for heart health (Haskell et
al., 2007). Of course, it is also important to remember that overexercising can be
as damaging as underexercising (Talbott, 2002). To get the best effect for anxiety
relief, try the following amount of exercise: 5 to 7 days a week for 25 to 45
minutes at 70% of your maximum heart rate, a pace that will make conversation
hard, but not leave you breathless (Amen, 2000; Sobel & Ornstein, 1996b).

Getting Started With Exercise

For people who are not already regular exercisers, the biggest problem is getting
started. Start by getting educated about how important exercise is. Remember
that the anterior cingulate gyrus (ACG) and the orbitofrontal cortex (OFC) in
your brain (see Figure 1.2), both of which are involved in creating new options
to problems, sometimes fail in those tasks. The ACG can get stuck on the “I
can’t” and the OFC can fail to generate solutions. The brain can fail in its role to
connect motivation to the process of exercise. This is when creating an intention
(the work of the executive decision-maker, the prefrontal cortex) even in the
absence of motivation, is a necessary part of getting the ball rolling for exercise.
Take time to develop both the understanding and motivation to try this method.
A big step for someone who is not exercising might be to walk the dog for
one extra block or 5 extra minutes, or it might be getting off the bus one stop
early. Start by figuring out what activity will work and then make a commitment
to try it. The following questions and guidelines will help you establish an
exercise plan.

• What physical things do you like to do? (If the answer is “nothing,” ask
yourself “What do I remember liking to do?) Don’t exclude anything
at first. Remember playing sports? Playing in the yard as a kid?
Remember riding bikes for fun? Did you play tennis or racket sports or
swim?
• What opportunities do you have to do this activity? Look for
something that is similar to what you enjoy, even if you cannot do
exactly that. Maybe you played basketball when you were in school.
Can you shoot baskets in the park? In your yard? Join a community
team for adults? Get creative about what could work. Talking this over
in therapy, or talking it over with a friend or family member, can
provide ideas that otherwise may elude the distracted, anxious person.
• Who might do this activity with you? An exercise partner can increase
both motivation and accountability. This is can be problematic if you
are starting from scratch. You might feel some embarrassment,
 especially if you have some social anxiety, at the thought that you are
not as good as someone else. If you can afford it, working with a
trainer can be a great place to start, because that person will know how
far you can go physically. But even agreeing to meet a friend at the
gym to start and finish at the same time or meet at the local track and
not necessarily go at the same pace will encourage you to get started
and keep at it. Even if you can only make a commitment to your dog to
take longer walks, having someone—a pet or person!—depend on you
will make you more likely to get out and do it.
• Decide! What is the biggest possible step you can take in the direction
of exercise? Answer this question each week until you have achieved
the goal of 25 to 45 minutes of aerobic exercise at 70% of your
maximum heart rate. The weekly goal should produce increases, even
though they may be slight, which will also promote motivation, as
success encourages people to do more.
• Make a commitment to an action plan. It is best to do it with another
person, who will ask how it went. But a commitment should be made
with someone who will ask about whether or not it has been kept, and
what you plan to commit to next week.
• How will you be accountable? One simple way to be accountable is to
use a simple record-keeping method, such as that in Figure 6.1.
• Evaluate your success and set the next week’s goal in writing. Aerobic
exercise is best for short-term stress reduction and relaxation of tight
muscles. It is also great for short-term boosts in neurochemicals. Over
time it promotes the healthy production of brain chemicals and may
help with improved neurological function through increased blood
flow to the brain.

STRETCH TO RELAX
Staying loose physically also helps with all kinds of anxiety:

• For panic, staying physically calm helps the brain cool down. This
makes it harder for panic to occur.
• When people have social anxiety, the more relaxed they feel, the less
 likely the peripheral nervous system will set off the palpitating heart
and flushing face they fear. The state of physical calm translates into
brain calm.
• For the worrier, loosening tensed muscles is especially helpful.
• In general, stretching increases blood flow and readjusts tensed-up
posture, which results in greater muscle relaxation.

Figure 6.1 Exercise Record

Follow this simple, general rule about stretching for release of tension: Never
do anything that hurts! If it hurts, stop immediately. The stretches can be done
anywhere. Several of the stretches below can be practiced while at work or
sitting in school or sitting in any confined place such as a car or airplane seat.
Plus, they take relatively little time to do. You can do a stretch while thinking
about the next question on a test, or while you’re making call and waiting for the
person to answer the phone, or while you wait for your computer to perform a
function. One 15-second stretch is sufficient, but some stretching experts
recommend several 2-second stretches to loosen up. Do what feels best to you.
Following is a list of stretches that can be done anywhere.

• Arm stretch. Simply yawn, stretch your arms upward, and release.
Repeat.
• Back stretch. For gentle back stretching, try torso relaxation. With your
feet comfortably spread apart for support, try letting your torso fall
forward with your head gently leading the way down, bending at the
waist, and coming back into an upright position by reversing the
motion. Try imagining that you are a puppet being released and then
drawn upright by a string.
• Overhead stretch. Try continuing the back stretch into an overhead
 stretch once you are upright. Lift up your arms, reaching high
overhead, and gently tilt your head by lifting your chin until you gaze
directly up. Make this and all releases gentle.
• Leg lunges. If you get up to walk somewhere, pause for a moment and
try some gentle leg lunges when you have been sitting too long or are
too tight.
• Calf stretch. If you have the opportunity to go up or down a few stairs,
pause and, with your toes balanced on the edge of the stair, let your
heel drop, thereby stretching the back of the leg. Do this for 2 seconds
and then release. Repeat it a few times. You can do this one leg at a
time with the other foot firmly planted on the stair so you don’t have to
worry about balance.
• Seated-at-your-desk head tilt. You can do a simple head-tilt stretch
while on the phone, looking at the computer, or reading, and not even
lose time from work. Do not rotate your neck in a circle. Let your ear
fall toward your shoulder as far as it can without hurting. Then raise
your head upright. Now let your chin drop slowly to your chest, feel
the stretch down your back, and raise your head upright again. Then
drop other ear toward the other shoulder and, again, raise your head
before letting your head feel heavy and drop slowly backward. Return
your head to an upright position before you go on to repeat this.
• Seated-at-your-desk arm stretch. Raise one arm straight overhead and
then bend it at the elbow, reaching with that hand down and toward the
other side of your body, as if you were going to scratch your other
shoulder blade. Then relax. Take the same arm and reach across your
chest and wrap your hand around the opposite shoulder. Using the
unoccupied hand, grasp the elbow of the reaching arm and gently exert
pressure to increase the stretch in the shoulder and upper arm.
• Seated posture change. One other way to prevent inadvertently
tightening up is the seated posture change. This preventive measure
can be practiced constantly if your job requires you to sit all day. It
involves regularly rotating through changed positions. Have a stool (or
just a box) by your feet on which to rest them. For 15 minutes in each
position, sit with one foot raised, then the other, then both, then
neither. Put a back pillow or rolled towel behind your lower back, then
your middle back, and then do without it.
 Practicing these stretches will help keep you loose when work or life
intervenes to make you uptight.

SLOW DOWN TO RELAX

Some people just find it very challenging to begin an exercise routine. All is not
lost. There are other ways to diminish the impact of stress and relax tension.
Practicing yoga is also a way to promote peacefulness, as it specifically assists in
centering awareness in the body, stretching out tension, breathing, and
mindfulness. While they require the instruction of a skilled practitioner,
heartmath (Childre & Martin, 2000) and neurofeedback (Demos, 2005) are other
methods that you can learn to bring about deep relaxation and stress relief while
setting the stage for a better understanding of your emotions. Biofeedback can be
very helpful for anxiety sufferers who also suffer from chronic pain.
It is also a good idea to remember that you can be slow and leisurely without
feeling anxious about what you ought to be doing. Some activities that involve
leisurely use of time will ultimately calm the anxious body. The person with
anxiety often needs a good reason to do something that seems lazy or
unproductive, so here are some good reasons behind a few obviously relaxing
activities:

• Get a massage. The therapeutic value of massage has been recorded in

several studies. It has been shown to reduce stress and anxiety; relax
muscles; aid in circulation, digestion, and excretion; and reduce pain
perception. Being touched stimulates oxytocin, a hormone involved in
feelings of being soothed and calm (Field, 2002; Kosfeld, Heinrichs,
Zak, Fischbacher & Fehr, 2005). There are many different types of
massage—effleurage, deep-tissue, and relaxation massage. Even the
simplest massage from a family member may convey a feeling of
being cared for and literally reduce the impact of stress. A study by
Field (2002) in postpartum mothers showed how massage corrected
the effects of stress. The massage group had statistically significant
changes in saliva cortisol levels after their sessions and was the only
group to show decreases in anxiety scores.
• Take a warm bath and use aromatherapy. A warm bath also stimulates
oxytocin and warmth relaxes muscles. Aromatherapy is the practice of
 using essential oils to reap therapeutic benefits of the plants from
which they are derived. Essential oils are commonly used to enhance
relaxation or to target symptoms of tension and anxiety. The oils are
highly concentrated substances distilled from plants known to have
therapeutic benefit. The mechanism of action of topically applied
essential oils is not clear, although the oils possibly may work by
absorption through the skin or by inhalation of airborne,
physiologically active compounds. The oils most consistently used for
depression and anxiety are lavender, jasmine, ylang-ylang,
sandalwood, bergamot, and rose. Several of these oils have been
shown to have muscle-relaxant and sedative properties.
• Stroll in the sun. The skin should be protected from the UV rays of the
sun, but our brains need the stimulation of light to develop good
circadian rhythms (promoting sleep) and to prevent depressed and
anxious states. Thirty minutes of walking outside provides enough
light stimulation to help prevent loss of serotonin in gray weather
seasons. Being in the warmth of the sun is also a good muscle relaxer.
• Spend time near lapping or running water—a lake, a river, an ocean—
and breathe. The sounds are soothing, and the ionization of the air near
bodies of water allows for greater relaxation.

SLEEP !
This is really slowing it down! Good sleep underlies good health, including good
mental health. It is impossible to be relaxed when you are exhausted. When a
person suffers anxiety, sleep suffers for several reasons, depending on the cause
of the anxiety. A number of brain components are involved in this. When
serotonin levels are low, the production of melatonin by the pineal gland can also
be disrupted. Melatonin governs getting drowsy and reawakening and is linked
to daylight/nightfall. When anxiety interferes with sleep, the natural rhythm of
melatonin production goes off track. When norepinephrine levels are too high,
the arousal makes it hard to get to sleep and moreover, makes it hard to get
deeply asleep. Doing things that reduce physical arousal will help to achieve a
deeper sleep. When the basal ganglia contribute to high drive, settling down at
night might be very hard. Focus attention on how you handle evening activities,
long before your actual bedtime, so the basal ganglia overdrive can be settled
with activities that promote calming at the physical and mental levels.
Suffering from stress can affect everyone, but people with anxiety who are
also under stress from other sources have a “double whammy” to deal with when
it comes to their sleep. Learning stress coping skills will help sleep. See the ideas
in Chapter 9 on containing worry for calming the brain before sleep.
The profound mental relaxation promoted by good rest is not obtainable in
any other way. Even meditation, which can give many positive results for mental
and physical health, is not a substitute for sleep. Restless sleep or short nights
due to overwork and trying to keep up with activities can make everything else
about having anxiety harder. Following are some simple ways of improving the
quality of your sleep.

Set a Pattern of Sufficient Sleep

People find it easier to fall asleep, stay asleep, and wake up rested when they are
regular about the times they sleep. Sleep is part of the rhythm of the body,
governed by the pineal gland, melatonin secretion, and circadian rhythm. When
the anxious body is forced out of its rhythm by anxiety conditions or by caffeine
ingestion, overwork, or staying up too late, those rhythms are disrupted and are
hard to reestablish. To get back on track, go to sleep and get out of bed at the
same time every day. This will take a while to work, so don’t get discouraged
and quit trying too soon. Even on weekends or days off from work you should
not vary your sleep schedule by more than an hour.
Another aspect of getting sufficient sleep is making time for it. People in the
U.S. seem to think that sleeping is a sign of weakness, but most adults need 7½
to 8 hours, adolescents need 9 to 10 hours, and children need more hours
depending on their age. Anxious individuals who typically sleep very short hours
may have trouble accepting this idea or accomplishing staying asleep even if
they try it. But there is a real payoff, mentally and emotionally, to sleeping more.
Research indicates that the well-rested person gets as much work done as the
person who is awake longer because that person is more energetic and efficient
during the day.
To start getting enough sleep, you have to go to bed early enough to stay in
bed for a full 8 hours, even if you wake sooner than that for a while. Until you
can sleep for 8 hours, you should plan to stay in bed and rest while practicing the
sleep hygiene methods (listed on the following pages) that will eventually help
you stay asleep. Once you are sleeping on a regular schedule, and fairly well,
you will find that you naturally awaken when you are rested, and you will
discover exactly how much your body needs to sleep to feel rested.
With adolescents, it is useful to remember that they are in a special category
regarding their circadian rhythms. Biologically, they may not be ready for sleep
until midnight (unless exhausted) and not ready to awaken until 9. School is at
exactly the wrong time for the adolescent body! A bigger problem is establishing
time limits on using the computer, phone, or playing video games in the evening
in order to finish homework and school activities in time to sleep.
Elderly persons may sleep more restlessly for a range of reasons, including
needing to use the bathroom frequently or no longer producing sufficient
melatonin to maintain sleep cycles. Many older adults live in extended care
environments that may be too noisy or too light. Changing components of their
environment and lifestyle to make them more conducive to sleep can help. If
health will permit, try herbal teas such as spearmint or chamomile, or a brief trial
of supplements such as L-tryptophan or melatonin to calm the brain or produce
melatonin before using meds (Weill, 1998).

Make the Environment Conducive to Sleep

Sleep in a room that is as cool and dark as possible. These are the best conditions
for establishing a good circadian rhythm that will promote sleep on a regular
cycle. The amygdala functions in sleep as in waking, staying alert to warning
signals that danger might be near. It responds to variances in sound, smell, and
so on, so the brain wakes up when it notices a change. Screening out
environmental noises (like people talking in another room or noise from the
street) is very important to eliminating the amygdala response.
Although a quiet room without television or lights is generally better, many
people say they need light or noise (like television or radio) to block out other
sounds. But there are better things than television for this purpose. A television
changes in pitch, tone, and volume, causing too much alertness in the amygdala.
If you must use television to fall asleep, remember that most televisions have
sleep timers. Set the timer and then have a white-noise background to block
environmental noises.

Make the Anxious Brain Ready for Sleep

 Below are several ways to get your anxious brain ready for sleep.

• Eliminate violent or exciting television for several hours before sleep

—that means skipping late-night news programs! Television comes
complete with amygdala-jarring music, unexpected and often
gruesome visuals, and overexcited voices. Its sole purpose is to keep
people watching for fear of missing something important.
• Take a warm bath for 20 minutes before sleep. It relaxes tight muscles
and stimulates oxytocin, a hormone that soothes.
• The brain heals itself from stress and anxiety and rebuilds itself best
during sleep. It needs a full night’s sleep to do that, but it needs
nutrition too. You can help your brain build cells by eating well during
the day and then having a small high-carbohydrate snack before sleep.
This gives the brain the insulin and blood sugar levels necessary to use
the proteins and nutrients that build neurotransmitters during sleep.
• Create a drowsy brain with herbal teas such as catnip or chamomile. To
get the full benefit of the herb, steep the tea in boiling water for 5 to 10
minutes.
• Keep caffeine as low as possible, especially after noon, because it is a
stimulant. If you suffer from restless sleep, examine all your beverage
intake—you may not realize the places that caffeine hides or the small
amounts that can disrupt you. People who suffer panic disorder have a
higher likelihood of caffeine sensitivity than others.

Make a Plan for How to Get Back to Sleep

Anxiety can cause restless sleep for several reasons, but not sinking into deep
dream sleep, called rapid eye movement sleep, or REM, is particularly
troublesome. People who are worriers or are very tense do dream, but differently.
They tend to have what I call “worry dreams”—restless sleep with dreams about
daily problems that seem insoluble during the night. It is generally recommended
that restless sleepers should stay in bed and try to go back to sleep if they
awaken, but when it comes to worry dreams, staying in bed and trying to go
back to sleep usually results in the dream continuing in its ruminative, never-
ending way. It works better to awaken fully for a few minutes and shake the
dream off by consciously finishing the topic, dispelling its importance, and then
focusing on something pleasant while falling back to sleep.
Restless sleepers can also benefit from planning for awake times. Each night
before sleep, pick a topic to think about in case you awaken. You may awaken
with a sense of foreboding that is caused by your brain chemistry rather than
anything being actually wrong. (See Chapter 9 for a discussion of the chemistry
of foreboding feelings.) It is best to refuse the urge to think about what might be
wrong, and rather immediately direct your thoughts to the topic you selected for
the night and try to fall back to sleep with the pleasing thought.

CONCLUSION
Relaxation can be achieved in many different ways, and learning what works
best may be a process that takes time. Working to understand the way anxiety is
personally affecting you, and learning the types of distraction and tips for
calming and relaxing that work best, will help you to manage it. This may be
some of the most productive time and effort you will ever put into managing
anxiety for a lifetime.

PART III

MANAGING THE ANXIOUS MIND

Techniques for managing the anxious body do not actually require people to
believe that the techniques will work; they work if you do them. But managing
the anxious mind goes into the territory of willingness and belief. The anxious
mind persistently generates worry and fear. A willingness to put in consistent
effort is necessary if a person wants to master the techniques for managing the
anxious mind, described in this section.
Believing the techniques can work is also necessary to staying motivated,
and learning how these techniques can change the brain promotes the belief that
relief is possible. Psychotherapy can often be important for successfully
managing the anxious mind. A therapist can provide necessary information about
the brain, and therapy is the best place to get direction on how to use the
techniques, which greatly enhances necessary willingness. A therapist is a
consistent source of encouragement, help, and support to apply the techniques,
which promotes success and carries a person forward when progress seems to
slow down. Without knowledgeable support, it is harder to apply the techniques
and to keep up the effort when anxiety is strong.
The anxious mind shows itself in a variety of ways. For people who panic,
the symptoms of the anxious mind include: • Catastrophizing the outcome of
panic • Catastrophizing the outcome of any physical sensation • Fearing feeling
panic in the future

The worrier with generalized anxiety suffers much more from the persistence of
negative thoughts but also suffers catastrophizing. Additionally, worriers suffer:
• The tendency to catastrophize feeling angry • Guilt
• Perfectionism
• Inability to plan
 • Reassurance-seeking
• Dread, even without a good reason

Social anxiety sufferers have a different relationship to worry. They tend to

worry about whether they will experience their symptoms in settings where they
previously felt and looked anxious. Their thought process specifically promotes
behaviors that avoid rather than confront anxiety. They suffer: • Catastrophizing
that everyone will reject them • Catastrophizing that their problems are
unavoidable • Self-talk about incompetence and lack of confidence, which leads
to avoidance behavior This section covers four techniques that address the
typical problems of the anxious mind.

• Technique #5, Catastrophizing, deals with the tendency to

catastrophize, which hits all the different kinds of anxiety that people
suffer—panic, generalized anxiety, and social anxiety. Assuming the
worst about a situation actually makes a person’s symptoms worse.
• Technique #6, Stop Anxious Thoughts, entails acquiring cognitive
control and shaping the direction and frequency of thoughts.
• Technique #7, Contain Your Worry, focuses on worry management.
There are ways to worry that really work better than others.
• Technique #8, Talk Yourself Into Changing Behavior, deals with the
mental process of social anxiety and the intense avoidance generated
by that condition.
 SEVEN

Technique #5: Stop Catastrophizing

This technique is intended to stop anxiety-producing thought processes. When a

thought begins with “Oh, no!”—what is known as “catastrophizing”—your mind
will perceive the situation as awful or terrible or assume that the worst is about
to happen.
Catastrophizing is definitely engendered by brain activity. If someone with
panic disorder notices a change in her physical sensations and immediately
worries that a panic attack is coming on (“Oh, no!”), she is likely to actually
panic, thus “proving” her belief that panic was starting. The brain remembers
strong emotion, and panic is about as strong as it gets. Overwhelming physical
arousal, with a racing heart, shallow, rapid breathing, dizziness, nausea, tingling,
and the emotion of terror, is a state that will be instantly memorized.
When some situation—for example, that a mistake might have occurred—
triggers a worry, the sensitive, overactive limbic system goes into “Oh, no!”
mode. A stab of adrenalin strikes almost immediately in response to the “Oh,
no!” thought and causes the sensation of stomach-sinking fear. So, if a man with
primary worry symptoms is concerned over whether he made a mistake, his “Oh,
no!” can quickly skyrocket to acute anxiety, making the mistake seem like an
insoluble catastrophe rather than just a mistake.
When people suffer the hallmark blushing, sweating, and trembling
symptoms of being afraid of how others will react to them, the brain is at work.
The amygdala may be enlarged or overly sensitive to subtle changes in the faces
of people. This means that when interacting with others, people with social
anxiety will notice small changes that someone else might ignore. Plus, the
oversensitive amygdala overinterprets negativity in others. It quickly generates
an “Oh, no!” at the slightest change in the face it sees, and it triggers fear
responses that set off the embarrassed, flushed appearance. If the socially
anxious person believes that blushing will immediately cause social rejection, he
or she will catastrophize that normal and minor interaction between people.
Catastrophic thinking in this situation is coupled with an unspoken belief that
there is no escape.
The success of technique #5 depends on using the left prefrontal cortex
(PFC) to take control of the catastrophic interpretations of
feelings/thoughts/situations and calm down the rest of the brain activity
triggering such mental anxiety. Figure 7.1 demonstrates how the PFC can control
thoughts and even automatic reactions, deliberately calming and eliminating
them.
Technique #5 addresses various kinds of catastrophizing thoughts. Several
different methods exist to interrupt catastrophizing and begin to control the way
you think.

LEARN THAT A FEELING IS JUST A FEELING

If someone with any variety of anxiety begins to fear how the anxiety feels,
remembering that “a feeling is just a feeling” can really help. It does not matter
if the feeling is a racing heart, upset stomach, and dizziness, or if the anxiety
causes red splotches all over the neck and face with heart palpitations and
obvious sweating. These sensations of intense anxiety are not lethal. They are
simply sensations. Are they unpleasant? Absolutely. Annoying? Sure.
Unwelcome? Yes. Distracting? No doubt. But they are nothing more than that.
The belief that these sensations cannot be tolerated causes more trouble than the
actual sensations themselves, because the belief not only intensifies the
sensations but creates a sense of helplessness that interferes with taking control.
A primary goal of managing anxiety is understanding that a pounding heart, a
sinking stomach, or a flushing face are all just feelings.
Figure 7.1 The Prefrontal Cortex Can Stop Catastrophic Thinking

Panic Is Unpleasant But Not Lethal

Stop panic in its tracks. When sensations that are reminiscent of panic attacks
begin, immediately stop catastrophizing that it is awful. Self-talk is important
here, and you should repeat, “Panic is unpleasant. It is not lethal.” It is vital to
use that message. You can then add diaphragmatic breathing to calm whatever
alarming sensations you’re experiencing. Coming to believe that “a feeling is
just a feeling” requires paying attention to outcomes. Even a full-fledged panic
attack is eventually going to stop and leave you unharmed. When you can stop
the catastrophizing belief that panic is awful and practice breathing exercises to
manage the anxious body, this method becomes a very effective means of
diminishing the feelings that are so troubling.

Dread Is Just a Feeling That Can Occur Even When Nothing Is Wrong

Sometimes the high levels of norepinephrine that contribute to hypervigilance

end up causing a feeling in the gut that is a lot like the feeling you get when
something is about to go wrong—that “uh oh” feeling of dread. People who tend
to be too tense are most susceptible to this. The brain of the worrier looks for
reasons to explain the feelings felt in the worried body; a queasy gut may not be
an urgent feeling, like danger, but it sends a signal to look out for something. It
activates the thought process to scan, like a radar dish, recent experiences to find
out what you ought to be worrying about. A hypervigilant worrier will definitely
find something.
Once you can identify that the sensation of doom or dread actually precedes
the thought that something is wrong, you can begin to ward it off by declaring to
yourself, “A feeling is just a feeling. It does not mean that something is wrong.”
Then the goal becomes to stop looking, to distract yourself (see Chapter 8 for
ideas to distract from worry), or to shift to breathing or mindfulness.
I have seen clients who fight this idea of distraction from the feeling. They
often ask, “But what if something really is wrong and I ignore it?” The trick is to
ask yourself if the feeling preceded the need to look for something. If the answer
is yes, then attempts to distract from the feeling are in order. “But,” you might
object, “what if I should be feeling dread about something about to happen and I
ignore it?” I would answer that real trouble is not so elusive that you have to go
looking for it. Real trouble usually presents itself without equivocation. We get a
document spelling it out, a blast from someone complaining about what we did
(or didn’t do), or some other very clear sign that we are in trouble. Also, it is
fairly common that once we get adjusted to the need to fix the problem, we feel
better. A real problem that is in the process of being solved is less anxiety-
producing than a potential problem.
I don’t want to minimize dread, however. There are times when dread signals
something we ought to pay attention to. In those cases your unconscious mind is
noticing trouble and you physically feel it faster than your conscious, thinking
brain can recognize it. This is what psychotherapy will help sort out—whether
the problem stems from unfounded feelings of dread or whether the unconscious
mind is picking up on real trouble. That said, people with anxiety are usually so
overfocused on that physical “uh oh” feeling that they rarely overlook signals of
trouble. As you learn to identify all the different kinds of sensations that
accompany emotions, you will get better at reading your body and will not
confuse anxiety with other emotions. Then, if dread is a true warning sign, you
will pick up on it and will not be confused about whether you should feel it.
Until that is sorted out, it is safe to assume that the “uh oh” of dread is more
like a brain glitch, a sort of mental short circuit. Stop catastrophizing this feeling
by responding to it with the statement, “Dread is just a feeling that can occur,
even when nothing is wrong.” Then immediately distract yourself from these
feelings, as catastrophizing about hypothetical problems never does anyone any
good.

Embarrassment Is Just a Feeling

The flushing, trembling, sweaty feelings that social anxiety sufferers experience
when they are in public are very hard to control. Stopping the catastrophizing
about these symptoms entails disputing what you believe will happen and then
ignoring the physical sensations. Tell yourself, “Being noticed is not the same
thing as being rejected.” It is true that typical signs of embarrassment—blushing,
sweating, shaking—are obvious and that people can notice them if they are
looking at you. What is not true is that others care about whether you are red or
sweaty. It is not true that they will dislike you, or reject you, or laugh at you.
Most people have been in situations in which they have seen someone look
embarrassed, and they just ignore it. Most likely, they will feel some sympathy
for you, especially if you appear troubled about it. The only real exception to this
is adolescents, who are often unkind to each other and may indeed make a big
deal out of flushing or sweating.
Several women in my practice have used the strategy one of my clients,
Ingrid, used. In our first session, Ingrid preempted any discussion about her
splotchy, flushed neck by saying, “You will notice that my neck gets all red
when I talk about things that I have feelings about, but don’t worry about it. It
doesn’t mean anything. My mother and grandmother had that, too.” She
completely decatastrophized the splotchiness by telling me not to worry, and in
that way she stopped herself from worrying about it as well. Her neck got red,
but I already knew she knew and accepted it without difficulty, so I could ignore
it. Her plan was to just announce it would happen and be done with it.
Men seem to have more trouble announcing that these symptoms may
happen before they actually do. It is easier for women to declare a foible in
advance, because women often bond with each other over trouble or
embarrassing situations. Men usually feel safer when they know where they
stand in the hierarchy, and they do not like to acknowledge any possible flaw
that could make them seem weak in the eyes of another man. If this is the case,
they can minimize their distress by deciding they are going to ignore their
symptoms if they happen. (Chapters 10 and 12 discuss ways of stopping fear and
controlling physical signs of social anxiety.) They can remind themselves that
flushing, sweating, and shaking aren’t the end of the world, and that using
breathing to stay as calm as possible will help greatly.
Blushers who are in middle school or high school may have to go farther
than simply planning what to do if they experience these signs of embarrassment
when others are around. They need to desensitize themselves to feeling the fear
of being embarrassed. Techniques #8 and #10 (in Chapters 10 and 12) will help
by explaining what to do to control physiology and reduce the fear of being
embarrassed. In the meantime, repeating the mantra “A feeling is just a feeling.
It does not mean that something is wrong” will minimize the symptoms.
To recap, remember that:

• Panic is just a feeling. It is unpleasant but not lethal. Remind yourself

of this at the first sign of a panic sensation. Then practice
diaphragmatic breathing.
• Dread is just a feeling that can occur even when nothing is wrong.
Reinforce that mental statement. Then distract your attention away
from the dread.
• Embarrassment is just a feeling. Plan for what you will do if you show
signs of embarrassment. Repeat to yourself that being noticed does not
mean you will be rejected.

DEBUNK THOUGHTS ABOUT DYING, GOING CRAZY, OR

LOSING CONTROL
“I am dying!” “I am going crazy!” “I am losing control!” It never ceases to
amaze me, even after all these years of doing therapy with people who have
anxiety, that these thoughts trouble nearly every panic sufferer. It would be great
if it were as easy as just telling people they are not dying, going crazy, or losing
control. The problem is that they already know that. Their left prefrontal cortex
is already aware that they have gone through this many times and have not yet
died, gone crazy, or lost control. But their right brain is still waiting for that
catastrophe to happen. The left brain just cannot connect with the right brain’s
emotionality of the terror when it is happening. The emotion is far too powerful
and convincing.
Just recently I was reminded of this when a very competent, intelligent man
being seen for panic had a panic attack relapse and took himself to the hospital.
He said to himself, “I know it is probably just panic,” but he believed the
catastrophic fear that this time it was a heart attack. Thousands of dollars and
many medical tests later, his right-brain limbic structures finally believed his left
prefrontal cortex and settled the panic down.

Step #1: Search for the Exact Image or Thought

So, what works to stop the catastrophizing of a panic attack? Psychotherapy will
probably be needed because people who have been panicking are not usually
able to identify their thoughts during panic. It is essential to get very specific
about what people are envisioning when they declare “I am dying!” “I am going
crazy!” or “I am losing control!” Searching for this exact image is the first step
in debunking these panicky thoughts.
Let’s begin by looking at “I am dying!” Start by identifying the exact
physical sensations that are the most troubling, such as shortness of breath, pain
in the chest, pain in the arm, tingling, or nausea. Then, find an exact image,
played in the mind like a movie, of what you fear, such as collapsing in the street
or being in the ICU at a hospital. Most people do not have any specific image of
dying. Even if you imagine collapsing, that is not the end of the situation, so
don’t stop there. Ask yourself, “What happens next?” This question is very
important and may be difficult to answer at first. But it is important to keep
pushing to imagine how the full scenario plays out. At every step in the process
of imagining dying—“They hook me up to machines” or “My chest hurts worse”
or “I am blacking out”—keep asking, “Then what happens?” until you get to
“Then I die.” And then ask again, “What happens next?” At this point most
people laugh and recognize that the panic would at least be over. But your
answer to this question will lead to a better understanding of your relationships,
your hopes and aspirations, and even what the panic means to you.
For the person who fears losing control, again, getting the image is an
important part of beginning to stop catastrophizing the panic symptoms. Ask, “If
someone were observing you, what exactly would you look like? What would
you be doing or saying?” Go step by step through what it would look like to an
observer. This should be done in detail. For example, if you are talking about
what would happen if you lost control in a public place such as a bus or
restaurant, you might report, “Well, I would look like I was frightened.” But that
is not enough. You need to go all the way through to the end of what you would
look like, and what you would do, asking yourself, “Then what?” Most people
need to learn this by working with a therapist who can guide them to clarify their
images of losing control.
For example, when I asked one of my clients, Shirley, to describe what
would happen if she lost control on the bus, she said, “I would look scared!” So I
asked, “Then what?” Shirley looked confused, as if she did not know what I
meant, but then replied, “I don’t think I would really scream at the driver to let
me off in the middle of the block. He would have to pull over anyway, so I
guess, in reality, I would get off the bus as soon as I could.” So I pursued with,
“Then what?” Shirley considered this seriously, and said, “People might look at
me just standing on the street.” To which I of course asked, “Then what?” and
she went on to say that those people would quickly be out of sight as the bus
pulled away. And (you guessed it) I asked, “Then what?” At that point Shirley
burst out laughing, “I would be stuck paying for a cab if I wanted to get to work
on time!” She realized that her fear of losing control disappeared when she really
followed the image of panic all the way through to the end of the scenario.
Of all the fears, that of “going crazy” is least likely to have a vivid, realistic
image. It is more often an expression of the fear that having a panic attack means
you already are crazy. But sometimes that is not the case, and it is wise to follow
it through to the end of the image: “What does going crazy look like?” This can
be done in the same way that the images for the other two fears are explored. I
did this with a client named Norman, who described his fear of going crazy by
saying that he imagined himself pacing around, saying things that had no
meaning, and waving his arms. He imagined that other people would be
frightened of him and he would be carried off to a mental hospital. This sounded
like a pretty clear picture of being “crazy” and it described much of how he
thought he looked when he panicked. So, we moved on to step #2 to fully
debunk his catastrophizing thoughts.

Step #2: Ask Yourself If This Is Like Any Other Experience You Have Had

Remembering a real experience allows you to logically compare your panic to

the feared catastrophe. For example, you have the catastrophic fear “I am
dying.” This is typically triggered by specific physical symptoms, such as chest
pain or shortness of breath. Figuring out which symptom triggers your fear of
dying will provide useful information about what the cause of that fear really is.
It often relates to the illness or death of another person. For instance, a woman
whose father died of a heart attack in front of her may indeed fear that her chest
pain is the same as her father’s. A mother who rushed her child to the hospital
with asthma may immediately feel helpless when she has shortness of breath.
Understanding what you associate your experience of panic to will help you
desensitize the fear.
For example, when I asked Norman what other experiences his panic attacks
were like, he replied that they reminded him of his uncle, who was schizophrenic
and had lived with Norman’s family when Norman was young. The uncle was
often irrational and paced a lot, and on more than one occasion he had been
removed from the house when he “went crazy.” This was scary to young
Norman. By talking through the image of going crazy, Norman realized he was
not his uncle, and his fear of going crazy disappeared.

When the Catastrophic Fear Is Rooted in a Trauma

Sometimes the catastrophic fears of “I am going crazy, losing control, or dying”

are rooted in a traumatic experience from childhood, and the person who has
these fears may not recognize triggers in the environment or in relationships that
set them in motion. A person can explore what could be triggering fear by
following these steps:

• Keep a panic diary with careful attention to the details of what

preceded the panic attacks.
• Identify a pattern either in the emotional state or in the events that
precede the panic.
• Then, look for the earliest experience of such a feeling or event.

Discovering the trigger for panic can help you to avoid the panic attacks
altogether. However, discovering the trigger may not be enough, and a person
with a history of trauma should probably explore the impact of the original
trauma in psychotherapy. The therapist’s approach to resolving the underlying
trauma will depend on his or her training and experience. If the trigger to panic
cannot be discovered, a psychotherapist will have suggestions for working on
that in therapy.

To recap, you can debunk your panic thoughts about dying, going crazy, or
losing control by following these steps:

1. Identify exactly how you envision this fear playing out.

2. Find out if this fear has a basis in reality—is it like any other
experience you have had? Logically comparing your experience of
panic to the feared catastrophe may be enough to end your tendency
to catastrophize.
3. If step #2 does not debunk the panic thoughts, identify the first
experience of this fear or idea and determine whether it has roots in
an earlier traumatic experience.
4. Psychotherapy may be needed to identify and resolve the panic
trigger.

PLAN TO PANIC
This method is simple and will help you successfully return to being able to do
the activities you did when the panic attacks occurred. It involves carefully
preparing to go back into situations in which you previously panicked. This is
important because it is easy to become afraid of the things you were doing when
you felt panic, even if the situations themselves did not cause the fear. The mind
is so swift in making connections and so profound in the way it constructs
symbols that if you panic while you are driving on a highway in the rain, you are
likely to feel afraid of panicking the next time you drive in the rain.
Subsequently, you might panic not only when you are driving on the highway in
the rain, but also anytime it rains or anytime you drive, no matter how dry the
road is.
It is only natural for people to avoid any activity in which the panic might
come back. Avoiding driving is common, but other common situations that
people avoid include being in crowds, at parties with a lot of people, and in
grocery stores at high-traffic times of day. These are not symptoms of social
anxiety but rather a fear of panicking when escape is not possible.
Rather than preparing not to panic, preparing to panic and cope with it
becomes a safety net for these situations. It is unlikely that a person can avoid
every potential panic trigger in a situation in which she or he previously
panicked. So, just plan on panicking.
Preparation involves simple steps.
 1. Learn to breathe away panic (technique #2).
2. Review each aspect of the situation or scenario that you have been
avoiding.
3. Desensitize every aspect of the situation that you fear could trigger
you. Note any aspect of the activity that caused you to feel nervous
and apply a method to calm down while imagining it. Systematic
desensitization, EMDR, energy therapy, and other methods can help
you to imagine the aspect of the situation that makes you feel panicky
and calm down prior to going into it. (See the Recommended
Reading & Resources for more information on these therapy
methods.)
4. Practice. Try a mini-version of the event or activity. For example,
plan to get on a short stretch of highway at a time when it is not too
busy and you can get off and go back home or continue on to your
destination without using the highway. Stop the practice session at
the planned end time, even if it is going well.
5. Write down exactly what you will do if or when you panic. Carry
your plan with you on an index card or in a notebook that you always
have with you.
6. Review your plan before you go into the situation, and have it handy
so you can grab it should you panic.
7. Then try it for real, knowing that if you panic, you have a plan.
8. Evaluate how it went.
• Commend yourself for handling difficulties.
• Praise yourself for entering a situation without panic.
• Decide how to amend your plan if you had a problem.
• Notice that you lived through it no matter how it went.

LEARN TO KNOW (AND CHOOSE TO SHOW) ANGER

The goal of this method is to stop catastrophizing the feeling of anger. Usually
when people think of anger as a problem, they think of needing to calm anger
down and learn anger management. But sometimes anger is so anxiety-
producing that people do not even recognize feeling angry about something—
they feel the physical arousal and go straight to anxiety. They find it hard to
dispel that sense of anxiety because they do not know what they are anxious
about and, despite their assumptions about why they are so anxious, nothing
seems to work to diminish it. This is because the anger causing the perception of
anxiety is unrecognized.
People can face genuine risks if they show they are angry. In the past they
may have been hurt or abused or emotionally rejected, so the memory of anger
causes fear. They may run similar risks in the present—they could risk being
hurt or losing a relationship or job if they show they are angry. In these
situations, not even knowing you are angry becomes a good mechanism to stay
safe. Unfortunately, however, the anger manifests in other ways, contributing to
your anxiety. It thus becomes important to identify it.
Even after you know you are angry, you may not know how to be angry. If
you’ve had no good experience with being angry in your past, you may not have
had much practice with appropriately expressing anger. You may be too quiet or
blow up, both of which are ineffective. If you know that you are prone to
excessive anger (anxiety can prompt some pretty startling displays of excessive
anger), you can use anger management books to help you learn to tone down
angry expression. There are also excellent books on assertiveness, which are
helpful for both people who are prone to excessive anger and people who are
reluctant to express anger.

6 Steps for Decatastrophizing Anger

This method is not about showing anger; it is about knowing anger. And this is
where the method starts, with reassurance that knowing you are angry is not the
same as showing you are angry. It is a symptom-control method intended to
decrease tension while raising conscious awareness of anger.
The method is simple. When you are in the grip of strong sensations of
tension, worry, stomach-squeezing doom, and so on, look for unrecognized
anger underneath the anxiety.

1. The next time you feel strong anxiety, immediately sit down and in
single words or brief phrases write as long a list as possible in answer
to this specific question: “If I were angry, about what might I be
angry?” The hypothetical nature of the question is a key feature. You
do not have to feel committed to being angry about anything on the
 list—you are only being speculative about it.
2. Reflect on what it felt like to write the list down. How does it feel to
see what you have? What happened to your anxiety level?
3. Review the list. Is there anything on the list that needs action? What
can you let go?
4. If something requires action because you are being hurt, taken
advantage of, ignored, or worse, talk over your intended action with
someone so that you do not put yourself at risk with a badly handled
situation. After all, you were feeling your anger as anxiety, so there is
a good chance you might not be good at handling anger.
5. Skill-building for expressing anger might be very useful. Learning to
be assertive instead of aggressive is a good start for people who are
either reluctant or excessive in their anger expression.
6. You can then destroy the list or discuss it in therapy. I ask my clients
to discuss with me their reactions to writing this list, and if they feel
comfortable it can be helpful to hear the whole list. When they do
review the list and their reactions to writing it, they gain insight into
the connection between anger and anxiety. This opens the door to
deeper levels of psychotherapy to resolve psychological problems
with being angry.

CONCLUSION
Stopping every sort of catastrophizing will take you a long way toward
managing your anxious mind. Thoughts of “Oh, no!”, “uh oh,” or “I’m going
crazy!” in any situation can trigger anxiety that ranges from up-tight tension to
intense panic. When you practice the methods of decatastrophizing you will be
able to side-step experiences of anxiety before they start.
 EIGHT

Technique #6: Stop Anxious Thoughts

“What will happen if I panic?” “How will I stop these worries that go through
my mind?” “How can I face other people without making a fool of myself?” The
anxious mind challenges the sufferer to cope over and over with the very things
they fear, and the circular nature of anxious thinking affects people with any type
of anxiety. Learning to cope with anxiety and diminish it requires every anxious
mind to master the methods in this chapter for stopping anxious thoughts and
interfering with their return.

WHY DO I HAVE SO MUCH TROUBLE STOPPING MY

ANXIOUS MIND?
Recalling some of the brain and neurotransmitter information from Chapter 1
may help you recognize what is going on with hard-to-control thoughts, and may
explain why the thought-stopping methods in this chapter are going to work.

• Ruminating worry or getting mentally “stuck” stems from anterior

cingulate gyrus (ACG) overactivity. It becomes necessary to use the
prefrontal cortex’s (PFC) decision-making power to take charge and
say, “Stop!”
• The amygdala, a part of the limbic system, is specialized to pay
attention to any stimulus that presents a potential danger or threat. The
amygdala may start causing problems for worriers early in their lives
by shaping its own tendency to screen for the worst.
• Hypervigilance to mistakes, to onset of panic, or to potential rejection
or humiliation is probably the result of elevated norepinephrine (NE)
or overactivity in the basal ganglia (Pliszka, 2003). The brain is in a
radar-like scanning mode, examining all incoming stimuli for signs of
 a problem. Stopping the “scan mode” requires intention to divert it,
planned ahead by the executive brain (PFC), which is what this
technique is all about.
• When the limbic system is short on serotonin (SE), it readily
contributes to worry in the anxious brain by focusing on what is wrong
or difficult or bad.
• Serotonin (SE) deficits contribute to rumination, despair, and
anticipating trouble.

THOUGHT-STOPPING AND THOUGHT

REPLACEMENT
There are two elements to the technique of stopping anxious thoughts: (1)
thought-stopping and (2) thought replacement. Thought-stopping is critical, but
it is insufficient on its own. You must also divert your attention to a preplanned
thought replacement. Your brain makes a decision that the thoughts are
unnecessary and then exerts control over them. When the executive brain (PFC)
consistently takes charge to interrupt and divert anxious thoughts, several things
happen over a period of time:

• The anterior cingulate gyrus (ACG) that ruminates and worries cools
off.
• The limbic system becomes less active and thus less negative.
• The stress response becomes less reactive to worry.

The Easiest Method in the Book: “Self! Stop It!”

Why do we need thought-stopping? Any thought we think repeatedly makes a

sort of neurobiological rut in our brains. Once a neuron pathway is set, it takes
some time to change that pathway, so stopping and then interrupting thoughts
must be done repeatedly to eliminate the worry tendency over time. Worriers
have all heard, “Stop worrying! Relax!” If a person could stop worrying, he
would! But this statement is a necessary first step to replacing negative thoughts.
When you have out-of-control anxious thoughts, you say to yourself, “Self! Stop
it!” Truly, it is that simple. It is just not easy to do. This is where the next step—
thought replacement—comes into play.

Replace Negative Thoughts

Thought replacement is the key to successfully interrupting the anxious

cognitions that burden the worried person. The replacement thought has to match
the intensity of the negative thought, and it must be planned ahead. A worrier
cannot wait until he or she is stuck in the middle of a rumination to figure out
what to think about instead. What you choose for a thought replacement will
simply be based on what works best for your style and personality. Basic
replacements come in several categories:

• Alternate a negative, obsessive thought with a positive one. This is

useful if the worry thoughts are very obsessive. In this case, the
replacement should be fairly simple and often repeated. If you are
going to establish a rut in your brain, it might as well be a positive rut.
Try a scripture passage, an affirmation, a poem, or song lyrics that you
can keep reciting over and over, out loud if possible. You want to
completely edge out the negative thought, and saying the replacement
aloud will add the dimension of speech and hearing to occupy more of
your attention. Although it is best not to encourage rumination, there
are times when you must counter intense, negative rumination, and an
alternative, positive rumination may be needed to defeat the negative
one.
• Compete with the anxious thoughts. Sing, talk, or recite something.
Making the replacement thought take up more space in your brain will
make it more likely to win your attention. Singing uses more parts of
your brain, and singing out loud uses even more, as it adds the
dimension of hearing to your positive thought. Speaking or reciting
aloud likewise adds power to the replacement. Plan your songs or the
recitation you want to use ahead of time.
• Distract yourself from the anxious thoughts. After saying “Stop!”
immediately distract your attention to something that will help your
brain hold its focus away from the anxiety. Watch television, play a
video game, read, work on a hobby, call a friend (and talk about his or
 her life, not yours), or do anything else that can distract you. Many
people use the computer for distraction—games, email, IMs, chat
rooms, blogging, and so on. Keep an eye on this to be sure it does not
become obsessive, consume so much time that the balance of your life
is compromised, or contribute to anxiety (such as if you are using it to
search for information as a way to reassure yourself).
• Refocus on the work or task you were doing when the anxious thoughts
began. Pay conscious, intentional attention to what you are doing. This
thought replacement method may be the most effective at work, where
singing or going for a walk may be out of the question and when it
would be to your advantage to stay with the task at hand. You may
need to intentionally refocus repeatedly if the work-related tasks are
not sufficiently compelling.

Again, the best way to stop anxious thoughts is to:

1. Say to yourself, “Self! Stop it!”

2. Replace the negative thought by
• substituting a positive repetitive thought, such as an affirmation,
poem, or prayer.
• competing with it by singing out loud or reciting out loud.
• distracting yourself by watching television, playing a video game,
reading, or changing locations.
• refocusing on the work or activity you were doing when the anxiety
hit.

USE THE BODY TO CHANGE THE MIND

When the anterior cingulate gyrus (ACG) is stuck (one cause of repetitive
worrying thoughts), it is often a help to actually move your body. Moving, along
with a mental attention to the activity, can help to displace anxiety and let your
mind change to another thought. Moving the body can be done in many ways. If
you have to complete some work that allows you to move around, get up and do
it. Or you can do something aerobic, such as go out for a walk or run, listening to
music or podcasts for extra distraction. Music occupies the right side of the mind
with its melody and rhythm and pulls you away from anxious thinking more
completely. Turn on music and dance while you do some chores like sweeping,
vacuuming, or cleaning the garage. Or turn on music and just dance. Or consider
using any currently popular video game that gets you moving for a few minutes
of positive distraction.
Another way to move the brain around is to literally change locations. When
you change locations, pay attention to where you are going and what you will do
there. You can make something more compelling by consciously and
deliberately paying attention to what you are doing in the moment, noticing
every detail. In this way you are practicing mindfulness as thought replacement.
You could create conscious focus by acting as an “eye witness” with the
intention of noticing everything around you as if something wonderful and
important is about to happen and you are going to be called on to describe what
everything looked like the moment before. This level of absorption is necessary
to create enough pull to oppose the anxious mind.
Playing musical instruments requires you to move but is not so active
physically. For kids and teens, you can also try other popular games such as
Guitar Heroes, which is subtle physically but very captivating. Even creating a
CD mix of music to exercise or dance to involves modest amounts of physical
actions to complete the process; plus, thinking about whether the music makes
you want to move produces the mental shift that moving itself does, so it will
work to shift you away from anxiety. Making a CD of your favorite songs or
working to compile songs you want to share has the double benefit of cheering
you with music and distracting you with the activity.
Moving the body is also a big help with children, who can show a great deal
of oppositionality when they get anxious. Suggest it before you confront them
about anything. Teenagers do not always have the self-reflection to undertake
other methods, so movement works well with them, too. Find out how they like
to move best. They may prefer music and video games that make them move.
But what else do they like? Shooting baskets in the driveway? Riding their bike?
Make a list for yourself or help your anxious child or teen make a list of ways
they can move when their minds are anxious. This method is even more
important than it is for adults because children and adolescents have more
energy and need ways to discharge it when they are anxious.

THE “TWO P” THOUGHT REPLACEMENT LIST FOR THE DAY

As you get better at thought replacement, it needs to become a habit in-grained
in your approach to the day. Having a replacement ready works for daylight
worries as well as for the worries that spring up during the night. The best habit
to get into for persistently fighting ruminating worry is making a daily thought
replacement list centered around the “Two Ps”: pleasant and productive. Anxiety
is generally unpleasant and unproductive, not moving you toward successful
completion of any action or thought process. But you can use your prefrontal
cortex (PFC) to plan specific thoughts to replace negativity and change the
anxious mind in the direction of being productive.
This is how it works:

1. Every day, take 60 seconds to identify things that you could think
about during the day—what books to take out at the library, what
homework to do first, what order to run errands in after work, what
phone calls to return first, what Hawaiian Island to visit first on
vacation, whether you would rather buy a Mercedes or a BMW if you
had the money, and so on. Do not include any thoughts that aren’t
pleasant or productive. Record these pleasant or productive thoughts
on a post-it note or an index card, using a single reminder word for
each thought. These thoughts will probably change daily, so each
morning, for one minute, make a list.
2. Then, put the list on a bulletin board in your work station, on a
clipboard, phone, car dashboard, computer monitor, in your wallet or
pocket—anywhere it is readily accessible.
3. As soon as you stop the rumination with thought stopping, consult
the “Two P” list for a replacement to divert your attention.
4. Repeat this process daily until rumination is no longer a problem.
Calming rumination takes time, and this simple tool will help you
stay effective without generating new ruminative thoughts.

This very important but simple method positively affects the entire brain by
interrupting anxious thoughts. Remember:

• Negativity comes from the overactive limbic system.

• Rumination stems from the anterior cingulate gyrus (ACG) being
unable to move information to the prefrontal cortex (PFC) to be
resolved.
• Suppressing negative, obsessive thoughts is a function of the PFC
 activities of planning and conscious attention. By making and using
the list of replacement thoughts, you help the PFC deliberately shift
the ACG away from the anxious thought, thus helping suppress the
overactivity of the limbic system by allowing it to cool off (Schwartz,
1996).

NONVERBAL REMINDERS OF THOUGHT REPLACEMENT

FOR KIDS AND OTHERS
Not everyone is good at remembering what he or she was going to use as a
replacement thought when anxiety crops up, and not everyone does well with a
list. In these cases, nonverbal reminders are helpful. Here are a few ways to
create reminders for how you want to replace worry once you say, “Self! Stop
It!”:

• Flip chart. Use a three-ring binder or spiral notebook to make a

thought replacement reminder book. Every time you get a good idea,
draw a picture, write a symbol, put a sticker, or paste or tape a cutout
from a magazine or newspaper onto a page of the notebook. When you
need a thought replacement mental or physical activity, page through
the notebook until you find one that can work right at that moment.
This is great for kids as well as for people who respond better to visual
cues.
• Symbol card for the school or work desk. The idea of the reminder
notebook with symbols or visual cues can be done on a simple card
that is on or in your desk at school or work. For small children,
stickers or symbols can be used—for example, Dad’s phone number
on the card can be a symbol not to worry because Dad is just a phone
call away if things are rough, or a small picture of the family dog can
be a reminder of something pleasant to think about, or a sticker of a
book can be a reminder that the child could read a book for distraction.
An adult version of those same kinds of reminders about friends,
family, pets, and activities can work at workplace stations.
• Pictures that cue you to think happy thoughts (vacation spots, favorite
friends or pets) can go on a bulletin board or desk or be attached to the
refrigerator with a magnet.
These symbols and nonverbal reminder ideas can be planned in therapy, done in
consultation with teachers or parents, and so on.

THE SECOND-EASIEST METHOD IN THE BOOK: DO THE

WORST FIRST
This one little method can help a lot to stop the anxious mind from fretting. The
slogan “do the worst first” is a simple reminder to do what you do not want to
do, but must do, as soon as possible. If you are going to worry all day long about
what you have to do (like make a phone call you do not want to make or pay the
bills), just do it first and save yourself the worry. What a relief!
This is surprisingly beneficial to calming the anxious mind in an ongoing
way. When you have something on your mind, and it is a negative thought, the
thought is persistently agitating you. Constant agitation sets your brain up to
worry more and more. But when you get this task done, your brain can calm
down. The longer you can keep your brain calm, the easier it is for your brain to
stay calm.
This method applies well to day-to-day situations, such as calling a customer
who might be unhappy or taking a broken item back to the store when you don’t
want to deal with the process. It can also be used for tasks like cleaning or doing
homework or preparing a report for work.
Although this method is needed on a nearly daily basis for the small things
that crop up at work and home, it is also useful for the truly significant, big
issues. Most people will face issues of great importance over the course of their
lives. Real problems will certainly require attention to the appropriate solutions,
but people who are worriers are often quite good at handling real problems. It is
indecision and ambiguity that inflame the brain and make anxiety worse.
Weighty, worrying, dreadful things that need to be done, such as telling someone
you have seen for a while that you are going to end your relationship, telling a
friend you think he is drinking too much, confronting a spouse about lying to
you, talking to your child about finding drugs in her room, and other similar
problems drag us down. They preoccupy our anxious minds and distract us from
everything else.
Correcting your cognitions about doing the worst first helps to motivate
yourself to do it. Try this process:

1. Can you remember a time when you were faced with a similar task
 and how good you felt when it was done? Bring that sense of relief
clearly to mind. If you are dragging your feet about a chore, really
remember completing it—for example, how much you like it when
the bathroom is clean, how you felt lighter after you told your friend
you were not going to the concert you did not want to spend money
on, or even just how relaxing it felt to do something you wanted to do
with the work or the problem off your mind.
2. Figure out how many hours you have until you absolutely must do
the thing you don’t want to do. Seriously contemplate how much the
task is going to weigh on your mind during all those hours.
3. Ask yourself, “Do I want to worry about it for all those hours, or
have those hours be hours of relief?”
4. If you do the dreaded thing immediately, pay careful attention to the
benefits so you can recall them the next time you have to remember
why doing the worst first is a good idea. If you do not do what you
dread, or put it off until the last moment, pay careful attention to how
many hours you felt bad, worried, or anxious. Notice whether the
doing was as bad as you anticipated, and notice whether the relief of
getting it done was worth the hours of unpleasant waiting.

Although you might need time to think about it, getting the worst out of the
way as soon as possible makes it possible to move forward rather than sit on the
razor-sharp edge of anxiety, trying to be comfortable but hurting no matter how
you position yourself. As soon as you get off the edge and take the action you
have been dreading, the sooner that discomfort leaves and frees your anxious
mind.

MAKE A LIST WITH TIME FRAMES

Holly was sure she was having a panic attack. “I don’t know how I will ever get
it all done! It’s making me so anxious that I am having trouble breathing.” Holly
was finishing up grad school and getting ready to move to start her first full-time
job. She still had to finish the work for a few courses, as well as pack her
apartment. There were also many small things to get done, like turn in the
paperwork for her degree and get her robe before the ceremony. She was a self-
described wreck. When I asked how much time she had to do these things, she
exclaimed, as if it were only two hours, “A week!” I saw the need for a list.
List-making to calm anxiety goes beyond just writing down the items that
need to be accomplished, but it does start there. List-making involves an
accurate appraisal of how long each thing will take and what is most important.
When you can accurately know how much is possible to get done in a day, you
can have reasonable expectations of how it will get done. The decision of what
to do at what time resolves the ambiguity of what is going to get done and
resolves the anxious self-talk about not doing enough or not doing it perfectly.
I asked Holly to take a breath, handed her a pad of paper, and asked her to
write down every single thing she needed to do. We worked on this list out loud,
because I wanted to be sure that she was detailed enough. It turned out to be a
good idea. “Pack the apartment” became a longer list:

• Put out the clothes I need this week.

• Put the rest of my clothes into suitcases.
• Pack my dishes, pots, and pans.
• Put the bathroom stuff into a box.
• Put my bedding and linens into a box.

We decided that some of her list would be errands she needed to run, and
some would be things done at home, so she sorted her list into errands and home
tasks, which would be useful later when she decided when and how to do the
work. She then added the small and large tasks of finishing up the school-related
details of graduation. She even remembered several more small tasks, like
turning in keys, that would have come to her mind later—probably just as she
started to calm down from her panicky mode.
The next step was to go through every item on the list and write down how
long she estimated it would take her to complete each in minutes. “Turn in the
keys” looked like an item that was inconsequential but it would require 45
minutes to drive to her landlord and return home, unless she found a way to
combine it with another errand (which she subsequently did). She went on to
estimate a time frame for each and every task on the list.
She then created a hierarchy of all the tasks from most important to least
important. This is the anxiety-relieving step. If you have a limited amount of
time, knowing how much you can reasonably do in that amount of time
eliminates the pressure of the things that won’t get done. If your major and most
important task of the day is to finish your homework (or the work you brought
home) and you know you need about 90 minutes to do it, you can relax about
everything else. You can do something else without worrying about whether you
are going to get the homework done, because you know you have 90 minutes in
which to do it after dinner. Or you can relax your mind about other things
because you know you only have 90 minutes, which is not enough time to also
get another job done. Holly had more than one day, so once she made her list,
she decided what time she had available on each day and began to plug in the
tasks, from most important to least. She had some set appointments to work
around, and she remembered to put in time for taking lunch and other breaks.
When she realized that she had about 2 days worth of work and 7 days to get it
done, her panic disappeared. She had been so overwhelmed by the number of
tasks that she could not get past that. She would have been less efficient working
in that state of upset. Now she thought about how she was going to be able to
enjoy her last week before starting the new job.
Most of the time, when people do this for a day’s worth of work, they get a
very different outcome than Holly’s extra time. This was the case for John, who
made a list of what he needed to get done to leave for the family vacation. He
discovered he had 10½ hours of work, and about 8 hours in which to do it, so he
had to trim his expectations by 2½ hours. He then decided what tasks on his list
were absolutely necessary and what tasks could be left undone. So, instead of
anticipating a day full of pressure that would aggravate his mind, he felt calm,
knowing he had time to get things ready for his departure. If something did not
go as planned, he could make a new list, but unless that happened, he could
perform his tasks without that under-the-gun feeling that makes days like this
anxiety-provoking.
Making lists is also a great way of preventing the common anxiety-
producing problem of running late for an appointment, meeting, or social event.
The list can be done mentally in just a minute or two to figure out if you really
can, for example, stop at the grocery, the dry cleaner, and the pharmacy on your
way to pick up the kids after their baseball practice. Even if you realize that you
have to skip one of the tasks, you will be less agitated, and limited agitation is
good for calming the anxious mind.
To recap how to stop anxious thoughts by making a list:

1. List every single separate task you have to get done.

2. Estimate the time (including drive/walk/bus time for errands) each
 task will take.
3. Prioritize the list.
4. Eliminate tasks you cannot fit into your time frame.

MAKING THE THOUGHT-STOPPING TECHNIQUE WORK

The watchword for stopping thoughts is persistence. Symptoms are usually
persistent, and the technique only works when it is applied persistently.
Therapists working with clients who have generalized anxiety will cover this
ground over and over to pick up on all the subtleties of their thought process and
to reinforce the thought replacement methods. This does not work fast.
Improvement can be noticed almost immediately, but it can take many weeks or
even months before the anxious mind is persistently calm.
The key to making thought stopping work as quickly as possible is also to be
very consistent in trying to divert thoughts. Progress will be slow if the thought-
stopping methods are only occasionally applied. When you start to practice
thought-stopping, you may also see that the anxious thoughts increase very
briefly (this is more likely to happen when the thoughts are both persistent and
consistent), but this period will be followed by a rapid decrease in worrying.
There is a direct correlation between consistently applying this method and
decreasing the brain’s overactivity.
Janis, one of the hardest workers in therapy I have ever seen, is a good
example of the need for persistence. Beset by anxious thoughts, Janis practiced
every method I suggested over the course of therapy—quite an unusual client!
She was having persistent and extremely disturbing ruminations about whether
her cancer would recur. After learning to calm her body, she was ready to use
thought-stopping to interrupt these thoughts. After just a week, she reported
success at cutting the thoughts way back, and she told me the key to making it
work was that I warned her how hard it would be to stay persistent. She said, “I
thought you were kidding when you told me I would have to thought-stop every
time the cancer thought occurred, even if it was a thousand times a day. If you
hadn’t warned me, I would have given up in despair after about 100 times that
first day, thinking this method would never work for me. But you said 1,000
times a day, so I figured I had better keep at it.” What an example of persistently
stopping persistent anxiety!
CONCLUSION
Progress with calming mental anxiety begins before thought-stopping. It starts
with learning to calm the anxious body. The bad news is that unlike physical
calming, which can work immediately, calming the anxious mind and stopping
anxious thoughts takes time and practice. The good news is that the high energy
of the anxious brain can be tapped to effectively avert anxious thoughts and
replace them with positive ones.
 NINE

Technique #7: Contain Your Worry

Everybody worries, but people with generalized anxiety elevate worry to an art
form. They take normal worries and develop them into monstrous impediments
to clear thinking, enlarging them out of proportion to reality by excessive
rumination. The anxious mind can find odd things to get stuck on, too: breaking
laws, germs and contagion, poisoning, hurting others by accident. This
exaggeration of normal worry might even achieve a state of paranoia or
delusion, causing people to fear they are going crazy.
This kind of worry is hard to control; it becomes an anxiety disorder when a
person is so preoccupied by it that it robs life of joy and interferes with attention
to the details that enrich or inform life. When a person is no longer able to shrug
off worry, it is time to take charge and learn how to manage it. No one can avoid
worry altogether, but anyone can contain it. This technique acknowledges that at
times people cannot just “stop worrying about it,” as their family and friends tell
them to do. They instead have to learn strategies to contain their worries.
The strategies in this technique will not only provide immediate relief from
worrying, but also change the likelihood of future worry by calming down the
overactive limbic system that overreacts to indicators of trouble with excessive
worry. As with all of the other techniques, the goal is to eliminate the frequency,
intensity, and duration of anxiety symptoms to give the anxious brain a rest.
Freed of anxiety symptoms, the anxious mind will recuperate from its agitation
and generate less anxiety.

WHAT’S MAKING YOU SO WORRIED?

It’s that darned negative, limbic-generated worry getting stuck in the anterior
cingulate gyrus (ACG)! The prefrontal cortex (PFC) is too tired to take charge,
perhaps because of low serotonin levels that increase negativity, increase
agitation, and decrease the energy to contain worry. Even when the brain is
temporarily distracted, worry comes back to trouble you, like your tongue trying
desperately to get rid of a raspberry seed in your molar. The PFC needs to do a
manual override on that automatic process, which is what this technique is all
about.
Psychotherapy is very useful when people worry like this, because worry
seems so real to the people who are stuck. They lose sight of all the reasons why
it is safe not to worry. Needing help getting out of their rut is not unlike needing
a tow truck to get a perfectly running car out of a ditch. There is nothing wrong
with the car except that it cannot steer or move forward when its wheels are just
spinning. Once the car is freed from the rut, it can go back to handling the road
well. Containing worry allows the brain to do its work without spinning its
wheels.
Carrie was so good at worrying that she could take the slightest threat and
spend a whole day on it. A college senior, Carrie was applying for jobs and
needed to squeeze in interviews between work and classes. She scheduled one
interview that was a long drive from her campus, but she thought she could
make the trip and return in time for her senior seminar—a once-a-week class she
could not miss without affecting her final grade. When she overheard two
classmates discussing construction starting on the highway she would need to
drive, her amygdala signaled a warning, “What if the trip takes you too long?”
Then her brain got stuck on the fear that she would be late for the interview.
When she shook that off, it would switch to worrying about being late getting
back. Her logic never stepped in to consider what the actual consequences would
be because she just assumed they would be terrible. She finally mentioned to me
that she was stumped about what to do; she had been worrying for a week. She
was thoroughly agitated and becoming less able to control or correct her worries.
Part of her worry could be handled by planning, but part could not. It was
entirely possible that she would be late for the interview or class—even if there
was no construction, as highway slowdowns due to accidents or weather are
unpredictable. She needed to learn to contain her worry.

GET THE RIGHT REASSURANCE

People may try to cover up or get rid of ruminating worry without dealing with it
directly. One common way they attempt to do this is by seeking reassurance that
their worry is unfounded. If they can just hear the right information, they believe
that this reassurance will rid them of their worry. They endlessly ask other
people for reassurance that they have no reason to worry. They want to be
reassured once and for all, and sometimes they hear information that gives them
relief—for a moment.
Ultimately, however, the anxious mind will find a flaw in the reassurance
because there will always be something that makes the reassurance suspect or
ineffective. The anxious mind will then start off on another search for
reassurance. This is why Internet searching has become such a time-consuming
pastime for worriers. They can search and search without actually bothering their
families and friends for reassurance. Reassurance-seeking is a trap that makes
worry worse and does not teach you how not to worry in the future.
Worriers like this may also have odd thoughts that they know are bizarre but
cannot shake off. They cannot get reassurance unless they mention these
thoughts in some way, but they don’t want to actually tell anyone what the nature
of their (irrational) worry is. Let’s say that a worrier is afraid she has been
exposed to a virulent form of tuberculosis that was covered in the news when a
man traveled internationally knowing he had it. The worrier may try any of the
following ways to seek reassurance:

• She may joke: “I am going to put my boarding pass in my safe deposit

box, because when it comes out that I have that TB, I want to be sure I
can prove I was on his airplane and get in on the class action suit.”
• She may make a quip: “I bet I sat next to that guy—the passenger next
to me coughed all the way. That will teach me to wear a surgical mask
on the airplane!”
• She may ask a question: “There is no way the airline wouldn’t call to
tell me he was on my flight, is there?”

What the worrier hears back may provide some relief or start a cascade of
new worry. For example, a person searching the Internet for a possible
explanation for his persistent headaches might discover many terrifying possible
causes that generate a whole new set of worries for him.
The right reassurance is reassurance that the worrier is competent to handle
problems. The wrong reassurance suggests in some way that “everything will be
all right,” which the anxious mind will only believe for a moment before moving
on to new worries. Brandon is a good example of this. He had a fear that he had
an STD because he had some chafing marks at the juncture of his hip and leg
after a long bike ride. He knew he had not had the marks before the ride, but his
mind created all kinds of reasons why this could be a sign of STD trouble. He
thought if he just called the toll-free number for STD information, he would get
information that would let him stop worrying. Sure enough, when he called, he
was told that the symptoms he was worrying about had nothing to do with an
STD. His PFC sent the calming message down to his limbic system, “Wow!
Relief!” But, then the helpful person on the other end of the line told him that
sometimes STD symptoms do not always appear right away and might not be
visible in a sexual partner, so if he had sexual contact with someone who could
have possibly had an STD, he should see his doctor anyway. His amygdala then
screamed at him, “Red alert! I can have symptoms and not even know it!” It did
not matter what his actual risk was; what he got was the wrong reassurance. In
seeking reassurance about his chafed skin, he heard something that triggered
another unnecessary worry. This commonly occurs when worriers try to escape
anxiety by looking for reassurance for each and every worry.
What Brandon needed was the right reassurance. The right reassurance
involves:

1. Getting the worry out in the open to determine if you have a real
problem. Good worriers typically cannot tell the difference between
their worry and the real thing. Actually, they do know the real thing
when it is in front of them, and they usually respond very well. But
they cannot tell when a worry is not the real thing. The first part of
Brandon’s experience was not so bad. His worry stemmed from not
being able to ascertain if he had a genuine problem, so he called the
hotline to get his worry out in the open and ask if there was
something he should do about it.
2. Ascertaining that a person is competent to handle the consequences
of the possible problem. This is where things fell apart for Brandon.
Instead of being told that even if he did contract an STD he would be
competent enough to figure out what to do about it, he was told that
he was not even capable of knowing that he had a problem. He
needed to hear that he could determine a course of action that would
allow him to (a) identify an STD and (b) obtain treatment.
3. Most important is getting the reassurance that the worrier knows
how to stop and contain worry. If Brandon had managed his worry
 better, he would have contained it for a day or two to see the chafing
go away and not allow his anxiety to take over.

Right Reassurance for Panic and Social Anxiety

The right reassurance for panic and social anxiety—as opposed to generalized
anxiety—is a little different. When people are worried about whether they are
going to panic or blow it in a social scene, they do need to address the worry
directly, because it is almost always about whether they will show their
symptoms and how people will react. They will benefit if they can get that fear
right out on the table. It can help to hear their own acknowledgement that they
fear how they will look or what they will do if they have symptoms. This is a
worry that can be directly handled with reassurance about competence to cope
with the anxiety. The right reassurance for panic is to:

1. Acknowledge that the fear is a fear of experiencing panic.

2. Remind the person who is panicking (or remind yourself) of skills he
or she already has to cope with it.

The fear of having a panic attack can be intense. It is what leads people to avoid
situations in which they might panic. And it can help to hear the right
reassurance. Instead of saying, “Oh, you won’t panic,” try “Even if you panic,
you will get through it.” Or: “Even if you do panic, once it is over, you can go on
with what you were doing.” Or: “If you should panic, even if it is a lot of panic,
you have all the skills you need to cope with it.” Of course, if you are going to
use this last example, the person really does need the skills to stop panic, such as
diaphragmatic breathing and cued relaxation.
People with social anxiety are also inclined to fear the feelings of anxiety,
especially those that others might notice. The right reassurance for social anxiety
is to:

1. Get the worry out on the table. What exactly do you think will
happen?
2. Make sure they are competent to handle the anxiety for the things
they fear.
3. Make sure they have skills to handle the situations they fear. For
 instance, if the fear is about doing something new and looking afraid
while they are doing it, two levels of competency are needed—skills
and anxiety management. Make sure the person has the skills to
handle the situation. People with social anxiety often need to learn
social skills they missed growing up. They cannot believe they will
handle anxiety if the social situation is beyond their skill and practice
level.
4. Reassure them that they have the competence to handle their fear and
to handle the consequences of feeling afraid.

Reassurance should only happen one time for any situation. If a person
repeatedly raises the same concern, it is a disguised form of worrying. “One time
through” should be the rule for any specific worry or situation that a person
brings up. For example, if a woman has trouble responding to criticisms made by
her mother-in-law and keeps bringing up the issue over and over, she is probably
seeking reassurance. She may seek reassurance for how to handle her mother-in-
law’s criticism of her Thanksgiving dinner, and then the following week seek
reassurance that she can handle it if her mother-in-law criticizes her birthday
party hosting. This is the same worry, and it does not need reviewing again.
After a situation has been reviewed according to the steps offered earlier, it
should not be repeated. If the worry comes up again, reassurance is simple: “You
know what to do about anxiety and you can handle being worried or afraid.”

To sum up, below is a list of the right reassurance for the three types of anxiety:

For general worries:

1. Get the worry out in the open to see if it is a real problem or a worry.
2. If it is a real problem, make a plan, which reinforces a sense of
competence to handle the problem.
3. If it is a worry, stop and contain the worry (addressed later in this
chapter).
4. Reassure the worrier, “You are competent to manage your anxiety.”

For panic:
1. Acknowledge that the fear is a fear of having panic.
 2. Remind the person of their skills to cope with it.
3. Reassure the worrier, “You are competent to handle your panic and
the consequences of panic.”

For social anxiety:

1. Get the worry out on the table.
2. Make a plan to handle whatever realistic components there are,
including learning additional skills if necessary or practicing skills.
3. Review the methods to handle pre-situation anxiety and during-
situation anxiety to be sure all the management skills are in place.
4. Reassure the worrier of his or her competence to handle their fear and
to handle the consequences of feeling afraid.

For all forms of anxiety:

1. After a situation has been reviewed, it should not be repeated. If the
worry comes up again, reassurance is simple: “You know what to do
about anxiety and you can handle being worried or afraid.”

PLANNING IS AN ANTIDOTE TO WORRYING

Worry is defeated when people confidently take action to solve their problems. I
have found that people who worry about things going wrong are often competent
at handling things when they do go wrong. It is the ambiguity of potential
problems that is so hard on people with anxiety. Real problems have real
solutions, so they do not stimulate anxiety about what to do about them. A clear
plan of action is a godsend to an anxious mind.
Even though people with anxiety might do better facing real problems than
facing worries, they may not be very good at planning. They also may not see
how to use a plan to relieve worry. Planning is a simple but often overlooked
skill that can make a big difference to calming a ruminative mind. If you do not
have planning skills, you will be at a loss for how to get relief. If you are
worrying about an upcoming situation, examine whether you can make an action
plan for it. A typical situation would be a “what if” type of worry. “What if my
car breaks down on vacation?” “What if I fail the test?” “What if no one asks me
to the prom?” “What if I do not get this job I applied for?” All of these situations
have a common element—if they do happen, a response will be in order, and in
each case, a plan could be made. Worriers get confused between what might
require action and what is just a worry.
An excellent response to the “what if” syndrome is to make sure you know
how to make a plan, and then to see if the situation is something for which a plan
can be made. Lots of materials are available that teach problem-solving and
planning skills. (An Internet search for books on problem-solving and planning
skills quickly pulls up a long list of resources for different age groups and
different kinds of environments.) One of the first things a plan always addresses
is how to clarify the problem. If you cannot identify a specific problem that can
be solved, then it is probably just a worry, and thought-stopping and thought
replacement will be sufficient.
If you can identify a problem, going on to make a plan will be a relief to the
anxious mind. “What if” thinking is anxiety-provoking. The goal of thought-
stopping is to eliminate the arousal of constant anxiety and cool off the anxious
mind. Therefore, figuring out what to do if a problem comes up becomes a part
of the overall plan to stop thinking about it at all. Once the “what if” cognitions
are identified and resolved into action plans, the idea is to never think about
them again, unless they actually occur, in which case the anxious person has a
plan all laid out. If you do find yourself continuing to worry, control it by saying,
“Stop! I have a plan!” and then without reviewing the plan, replace the “what if”
with a planned-ahead thought replacement (Chapter 8).
The process of making a good plan includes:

1. Concretely identifying what the problem is, including at what point it

will be a problem and how you will know if it needs a solution.
2. Listing (brainstorming) the options to solve the problem.
3. Weighing the options (you may need a pro-con list here).
4. Selecting one option or plan.
5. Writing out the steps you will follow for this plan.
6. If the time comes to exercise the plan, starting the plan and carrying
it out.
7. Evaluating how the plan worked.

It is helpful to write out the plan on paper, because the anxious mind will
remember it better. Seeing the list in writing puts the information back into your
mind through a different pathway.
Let’s look at these steps more carefully.

Identify the Problem

Good plans start with a description of what the problem is. That may seem too
obvious to mention, but actually it is the most important step. “What ifs” can go
on endlessly in the mind because the problem shifts as you worry. For example,
“What if I do not get asked to the prom?” can transform into “What if I get asked
by someone I don’t like?” “What if I ask someone who says no?” “What if I say
yes to someone because I am afraid no one else will ask me and then I get asked
by someone I really like?” “What if I end up having no one to go with 2 weeks
before, a week before, 2 days before … when do I do something about it?” This
can go on endlessly. At this point, stop! Define the problem.
In this example, even though all the “what ifs” seem worthy of discussion,
they are only problems if you do get an invitation to the prom. The answer is to
handle “what if I don’t get asked?” with a plan. “What if I do get asked?” is a
question you can handle with, “I will stop and make a new plan.”

Brainstorm Options

After you know what the problem really is, it is time to brainstorm.
Brainstorming means quickly thinking of many things you could do if you face
the situation. Don’t censor yourself during this stage; write down everything you
think of, even if it seems silly or outlandish. This is the time to get your brain
busy and stimulate creativity. Remember how the anterior cingulate gyrus
(ACG) gets stuck? This part of problem-solving, finding as many solutions as
possible, is an intentional (PFC) way to get unstuck. You may even want to ask
someone to help you—that person’s point of view will be different and he or she
may be able to stimulate new ideas. After the list of options is as long as you can
get it, you can begin to weigh them each with a pro-con list.

Select One Option

In addition to helping the ACG get unstuck, listing every option, even the silly
and outrageous ones, helps make the process of selecting the best option easier.
Seeing the obviously wrong choices makes the right choice easier to identify and
accept. For example, suppose you are fed up with your job and have
brainstormed what to do. Even though you know it’s preposterous, you’ve listed
the option of “quitting today.” “Of course I can’t quit,” you say. “I need the
money I earn.” But in reality you can quit, and this is what putting everything
down shows—that you do have choices. Knowing that staying is an actual
choice somehow makes staying seem easier. And it clarifies what all of your
other options could reasonably be. A final reason for listing everything is that
sometimes the wild ideas sow seeds of solutions that can work.
It is usually fairly easy to see a few “best” options. Identifying the best of
that group, however, may require a pro-con list, or a cost-benefit analysis. Again,
putting this in writing helps to make the choices evident. Also, the anxious mind
has trouble concentrating, so putting something in writing will help focus
attention on what the most salient aspects of the solution are without wandering
off into the territory of more anxiety about what to choose.
At this point, you may get stuck for another, very common reason. The
anxious mind wants to believe in a perfect choice. If you can find the perfect
choice, then you won’t have to worry, right? (Remember how perfectionism is
an attempt to ward off anxiety? This is another version of it.) Remind yourself,
“There are many good choices. There are no perfect choices.” Then, pick one of
the good ones and carry it out.
A small but important point here is that once the plan is selected, and steps
are written down for following the plan, the process of planning is done on that
problem. The “what if” worrier can easily make a transition to “What if I did not
think of everything?” and go on worrying by replanning the plan she just made.
When this happens, you must immediately say, “Stop! I have a plan!” and then
divert your thoughts without reviewing the plan for any reason. Even reviewing
the plan to reassure yourself that you have one is a subtle version of “what if”
thinking, and must be avoided if you are going to calm your anxiety.

Evaluate How the Plan Worked

The amygdala, that part of the brain that is on the lookout for trouble, needs
opportunities to learn that some things do not need to be scary or are not like
other times that were anxiety-provoking. Setting up a plan provides an
opportunity for the amygdala to observe how a new situation is different from an
old one. Taking time to evaluate the outcome of a situation can help the process.
Bringing conscious attention to the outcome is a prefrontal cortex (PFC)
decision to analyze all of the information coming from the senses and the body
through the limbic system. This involves the processing function of the anterior
cingulate gyrus (ACG) and the integration of the orbito-frontal cortex to take
note of the motivational information from the basal ganglia. The whole brain
gets in on the act. The amygdala will have learned something whether you take
the time to analyze or not, but it learns much more when the process is
deliberate.
Recalling all the aspects of the situation is a way of reliving it. Reliving it
helps reinforce the memory of it, and focusing on positive outcome reinforces
the desensitization of fear that occurs when something goes as planned. Even
when the outcome is not 100% positive, noting which parts of the solution
worked and which did not provides the opportunity to really feel and analyze
what worked so it does not get lost in the anxiety of what was not perfect. Many
anxious people dismiss what was not perfect as no good at all. Evaluating
outcomes helps to avoid the notion of perfectionism to see that a lot of good can
exist among the few not-so-good aspects of a solution.
If a solution to a problem and its action plan went unused because the
problem never came up, that outcome ought to be noticed as well. This
reinforces the knowledge that most of what we worry about does not ever
happen. Those “what ifs” are just potentials, not realities.
To recap planning:

1. Look for the “what if” thinking that could be solved with a plan.
2. Identify the problem.
3. Generate a list of solutions and select one good one—there is no
perfect one.
4. Write out the action steps you will follow if necessary.
5. Stop “what if” thinking, telling yourself, “Stop! I have a plan!”
6. Immediately practice thought replacement.
7. Do not re-plan the plan.
8. Put the plan into action if the time comes to use it.
9. Evaluate the outcome whether or not you put the plan into action.

WORRY WELL AND ONLY ONCE

Noelle was seriously worried about losing her job. She was constantly alert to
her boss’s moods and reported to her sister on an almost daily basis about the
status of her job security. “Well,” she would say, “he looked at me funny when I
told him I wanted Wednesday night off, and I am sure he is just waiting to see if
I will be willing to work overtime to make up for that. If I can’t, I know I will be
in big trouble.” Sensing that Noelle was suffering from anxiety, her sister
recommended she seek therapy.
As Noelle described her problem to me, I began thinking about possible
causes for it. She could be having trouble with self-esteem, or with reading other
people’s emotions. She could be overreacting to small signals from her boss that
her request was causing him a problem. In the absence of a personality disorder,
Noelle might have been showing hypervigilance, perceiving her work situation
as “precarious” when she was the one who was unclear about what her boss’s
attitude was. She could have been worrying in the absence of evidence that
worry was called for. However, worrying about a job loss is not unreasonable if
there is a real threat. It was impossible for me to know for sure whether her boss
wanted to fire her, so any attempt to convince her to just stop worrying was not
going to be effective. Also, thought-stopping alone wouldn’t be enough because
every day could potentially bring a new threat. Noelle needed to learn how to
manage her worry about her job once and for all if she did not want to carry the
anxiety around with her and did not want to wear out her sister. This was the
time to teach her how to “worry well and only once.”
This is a strategy that takes worry seriously one time and one time only. It
sorts out what is a real problem from what is unfounded worry. It involves
examining what you can control versus what you cannot control and what you
can do something about versus what you can do nothing about. And it helps you
make arrangements for when it would be a good idea to worry again.
Worrying well and only once should have a time limit. Usually 10 to 15
minutes will do the trick.

1. Begin by making a list and outlining all the things that you could be
worried about. Brainstorm to make sure every worry is identified and
none is held back for you to reworry about later. Tease out every
aspect of each worry.
2. Do anything that must be done at this time and do not delay. Make
phone calls, talk to someone, write or make something, repair, clean,
or take any action that will improve the situation.
 3. In some cases, actions are only necessary if the problem should occur.
This is where planning skills can come in handy, because making a
plan is the intermediate process when you cannot just set a problem
aside. Review the problem and make a plan for what you’ll do if it
actually happens.
4. Ask yourself, “Is there anything I else I need to worry about
regarding this situation?” If the answer is yes, apply the steps of
whether it is a real problem that needs a plan and a date. If it doesn’t,
it goes into the category of worry without a plan. With these worries,
it is helpful to set a date to review the worry to see if it needs
worrying about later on. Continue with this step, “Is there anything
else I need to worry about?” until the answer is no. This is the only
way that the worried brain will be able to move on. This step prevents
later reworrying by ensuring that all the possibilities are covered.
Your brain has to believe it when you say you already worried, and it
will believe you more easily if you have asked this question
deliberately while you are worrying well.
5. Set a time when it will be necessary to think about the worry again,
and write it down somewhere: “If x happens, I will do y. If x does not
happen, the next time I will review this worry is on March 15.” (You
can also note this on your calendar: “Worry about X.”) This will
relieve the anxious mind of trying to remember when to worry, which
it would otherwise bring up frequently. When a “worry date” is
written into the calendar, you can say, “I know when to worry again,
and I don’t have to worry now.”
6. Whenever the worry pops up again, immediately declare, “Stop! I
already worried!” and divert your thoughts as quickly as possible
with thought replacement techniques.

With Noelle, the challenge was not to worry about how to change her boss. It
was to say, “Okay, let’s worry about what will happen if you do lose your job”—
to get it right out there as if it had happened.
We began by outlining all the things she could be worried about. At first, it
seemed that her only worry was “What if I lost my job?” but eventually she was
able to break down that worry into several components:

• How will I pay my rent if I lose my job?

 • Where would I look for another job?
• What if I never get another job?

We then moved onto step #2, do anything that must be done and do not
delay. Noelle decided to call her boss and tell him that she could work on
Wednesday night. She also decided to set up a firm schedule for future work, and
discussed this with her boss. But this only partly resolved her fears about being
fired. We then needed to move onto step #3, making a plan.
To address her worry about paying her rent if she lost her job, Noelle came
up with two ideas. First, she would ask to borrow money from her mother.
Second, she would apply for a job at the local convenience store while she
looked for another job. We continued to talk about all her worries until she had a
plan to resolve them.
I then asked Noelle, “Is there anything else you need to worry about?” She
thought for a few moments. “What am I going to do about losing my insurance if
I get fired? I can’t go around without health insurance!” Again, we discussed a
plan to resolve this. Noelle researched COBRA’s continuation health coverage
and figured out what she would need to do to apply for it.
Next, Noelle set a date to worry about this problem in the future, and wrote it
down on her calendar. She decided it was reasonable to review her worry about
keeping her job once a month in case her boss’s attitude shifted in a noticeable
way, and she wrote down that on the 15th of the month, she would worry about
whether she was going to be fired.
Finally, after all this planning, Noelle felt that she had worried sufficiently
about the problem, at least for now. When her anxiety cropped up again, she told
herself, “Stop! I’ve already worried!” and reminded herself that she’d set a date
to reevaluate the problem on the 15th. She then distracted herself with thought
replacement techniques.
The idea behind the “worry well and only once” method is to address the
tendency to come up with new thoughts that keep the worry in place. Taking the
time to uncover all the aspects of a situation so that they can be evaluated (“Do I
need a plan or not?”) and resolved (“When or under what circumstances do I
review my worry?”) is using the PFC functions of analysis and decision-making
to their best advantage. When doing thought-stopping on the problem later, the
whole brain will respond by settling down faster because the cortex has
deliberately modulated the worry and will remember doing it. Thought-stopping
and replacement will calm the rest of the brain activity about the problem over
time.
To recap:

1. Worry through all the issues involved in the situation.

2. Do anything that must be done at this time to alleviate the worry and
do not delay.
3. Make a plan that might be called for if certain aspects of the problem
crop up at a specific point.
4. Ask yourself, “Is there anything else I need to worry about?”
5. Set a time to think about the worry again.
6. Then, whenever the thought pops up again, say, “Stop! I already
worried!”

DITCH YOUR DREAD

The sensation of dread can precede any idea that there is actually something to
feel dreadful about. Sometimes this is referred to as “free floating” anxiety, but it
can be recognized by the pit-of-the-stomach unease that all people associate with
dread. High norepinephrine levels that affect many anxiety sufferers cause the
brain to go into a scanning search for what the problem could be. Like doing an
MRI on a person’s life, the brain scans every aspect of life to see if there are
identifiable problems to be solved. This is foolproof for worriers. If they look for
trouble, they will find it. Some problem or potential for a problem will present
itself as the reason for the dread, and with an explanation, a switch is made from
un-ease to worry. The circle of dread is shown in Figure 9.1.
However, when worriers learn that the sensation of dread can develop for no
good reason, often the result of brain activity, they can monitor this in
themselves. High levels of norepinephrine in particular affect the autonomic
nervous system and can create a sensation of arousal that feels just like dread.
Also, people who have trouble with falling blood-sugar levels may experience
feelings of dread from out of nowhere. But this is just a feeling. Reminding
yourself of this is essential.
At first, however, it may be hard to tell the difference between dread for no
reason and dread for a reason, because the mind is involved in explaining why
the sensation is there. Containing the anxious mind means using mental
strategies to identify the dread and ditch it. The method is fairly simple. The first
step is to come to believe that you will not fail to notice a real problem. Literally
ask yourself, “Have I ever had a real problem that I failed to notice?” This
applies to physical health (a common worry for people), problems at work,
problems with children, and so on. If you do feel that you have a tendency to
overlook or ignore problems, some therapy work on what that is about will be
necessary before you can use this method to contain your worry. Usually,
however, people know when a problem is real. If you are really sick, for
instance, you have a fever or a cough or you bleed or have obvious pain.
(Knowing you have a problem, by the way, is different than knowing your
diagnosis. This question about failing to notice problems is about the ability to
recognize a problem, not about the ability to solve or diagnose it.) Being full of
dread when there is really nothing to worry about, however, is common in
people with generalized anxiety, and this kind of dread needs to be eliminated.

Figure 9.1 The Circle of Dread

So next, it is necessary to notice that the dread occurs before your brain
comes up with a reason for it. Instead of asking what the reason for the dread is,
ask whether this is a sensation of dread for no obvious reason. It is common to
believe that if you have this feeling, there must be a reason for it, so some
education about how neurochemical changes can create the sensation in the body
without any real reason will help you believe that your body is creating this
without cause. Pay attention to how you know you feel dread. It will almost
always be noted as a sinking sensation in the stomach, plus various other, less
significant physical indicators. But again, a feeling is just a feeling. You will not
fail to notice a real problem that needs a solution.
One way to stop the physical feeling of dread is diaphragmatic breathing.
With just a minute to breathe and induce muscle relaxation, the body can relax
and begin to let go of the dread at the physical level. (See Chapters 2 and 4 for a
discussion of the breathing and muscle relaxation techniques.)
As the relaxation is initiated, the thought-stopping process allows you to
notice that the sensation is physical. After thought-stopping, it is helpful to
reiterate, “I will not fail to notice a real problem.” Then, immediately use a
distraction or other thought replacement method. But even as the sensation of
dread settles down, the niggling sense that you ought to be scanning for trouble
may stick around, and you may need to repeat this step. Do not be tempted to
scan if the niggling sensation does not disappear. This is not a sign of a real
problem. It is a sign that you have not eliminated dread. Don’t be tempted to go
back and review. If you have let it go, then let it stay gone.
Again, the steps for ditching your dread are:

1. Ask yourself, “Have I ever failed to notice a real problem that needed
to be solved?” Work on believing that you will notice real problems
and respond to them when necessary.
2. Notice whether the dread is present without an obvious cause; notice
that it has preceded a reason to have it.
3. Tell yourself that a feeling is just a feeling.
4. Immediately breathe for a minute and do muscle relaxation.
5. Practice thought-stopping and tell yourself, “I will notice if I have a
real problem”; then, immediately use thought replacement.
6. Ignore the temptation to go back and scan for a problem.

CLEAR YOUR WORRIED THOUGHTS

Sometimes you just need to get everything off your mind—to clear away the
tangled thoughts and focus on something else. Sometimes you need to empty
your mind to rest. You need to clear away all the thoughts, put them into a
container, and then pay attention to what is really important at the moment. All
the worried thoughts buzzing around in your anxious mind distract you from
thinking clearly about just one thing at a time.
This method of clearing worried thoughts can be done in several ways;
basically, the method is to list all the thoughts, worries, and concerns that occupy
the mind and clear the way for selected thoughts to take their place. This can be
done as follows:

1. Imagine a container sitting in front of you. The container can hold all
your concerns. It has a lid, but right now the lid is off.
2. Next, create an image of all that concerns you in your life on this day.
Without thinking them over, see, name, and set those concerns into
the container.
3. When everything has been named and put into the container, put the
lid on the container and set it aside.
4. Then, invite thoughts about what is most important at this time to
come to mind.

Some people are imaginative worriers but don’t appreciate using imagery
such as the container. There are many ways to use this method without the image
of a container. For example:

• Write down your worried thoughts in the form of a list. Be very brief
—this is not like journaling. Use one or two words to list what is going
on in your life that occupies your thoughts. Then put the list in a
drawer or briefcase or another place where it will literally be put out of
sight (and out of mind.)
• Another version of this method is Al-Anon’s idea of a “God Box” to
hold slips of paper, each of which have a thought that is to be turned
over to God.
• Children can write or draw a picture of their thoughts or worries and
put it into a backpack. With an adult, they can periodically open the
backpack and see what is in it. This allows them to see which of the
things that worried them actually happened and how they coped with
them. All the things that were unnecessary worries that never
happened can be thrown away. This is a practical and concrete way to
 show children that most things they worry about never happen, and
just waste thought and time.
• There are small dolls in a box or bag from Guatemala that can be
purchased from global marketers or import stores. The legend is that a
person can hand the concerns or worries of life over to the dolls and
the dolls will take the worries away. The lid is literally put on the box
so that the dolls can carry the worries away and ready themselves for
the next batch of worries.

These and other ways of putting worries away have positive effects on the
brain. They stop the rumination of the anterior cingulate gyrus (ACG), slow the
overactive limbic system, and make it easier for serotonin to help the prefrontal
cortex (PFC) focus attention on whatever is most important at the moment. This
method works to turn off the ruminative mind, giving it a chance to rest and
calm the hot activity in the brain. Done habitually, such calming of the anxious
mind makes it less likely that the brain will be preoccupied with worries.
Once the mind is cleared, attention is free to focus on the activity or thoughts
that are most important at the moment. A student might clear his mind before
taking a test; a manager might clear her mind before a conference call or staff
meeting; someone who wants to contemplate a solution to a problem might want
to think about it without the confusion of many other thoughts. Clearing your
mind of worries before going to bed can help you get a more restful sleep. If you
do this, invite a peaceful thought into your mind after clearing the worries away.
A similar method of clearing the mind prepares people to work in therapy
sessions or to focus on specific concerns, even if working alone to gain insight.
This psychotherapy method, called “focusing,” was created by Eugene Gendlin
(1981, 1996) and developed further by Ann Weiser-Cornell (1996). (See the
References for more information on these readings.) The complete process of
focusing is an excellent therapeutic method for becoming aware of all the
implications of an issue. It is especially powerful for people whose physical
symptoms cloud their thinking. People learn to listen nonjudgmentally to the
body’s message and do not misinterpret sensations as anxiety. Learning to read
the body relieves much anxiety on a permanent basis. Focusing uses information
from physical sensations to understand what aspects of situations cause reactions
and what those emotional reactions are. This information helps people make
good decisions about how to change thoughts or behavior. Because people with
anxiety overinterpret physical and emotional sensations as anxiety, they miss
information that would cause them to make different choices if they were aware
of what they were missing.

CONCLUSION
Control over the worried mind is won slowly, purposefully, and persistently.
Doing it requires a willingness to put in effort, but the payoff is changing the
overactive brain into a calmer, quieter, less anxiety-generating brain through
deliberate use of worry management. Using the prefrontal cortex to change the
brain is the basis of thought and worry management techniques.
 TEN

Technique #8: Talk Yourself Into Changing Behavior

This technique reflects how changing mind and changing behavior go hand-in-
glove. A great deal of the behavior of anxiety is avoidance behavior. People with
panic avoid situations in which they might panic, and if they can avoid them,
they may feel fairly comfortable. The most obvious avoidance is that of the
person with blushing, quaking anxious body symptoms who tries to avoid being
observed. These people talk themselves into feeling anxious when others are
observing them. And no surprise: It is brain function that leads people to
overestimate how anxious they will feel in these situations and how avoidance
will help. This avoidance can also manifest as mental avoidance, whereby
worriers try to avoid their worried thoughts. Self-talk sows the seeds of the
pattern of avoidance. Managing your anxious mind depends on changing self-
talk, which is how the anxious mind creates anxious behavior. Change your
anxious mind with more positive self-talk, and you’ll change your anxious
behavior.

DON’T DELAY SEEKING HELP

People with social anxiety suffer some of the worst problems with avoidance.
Children with this type of anxiety may hold themselves back from achieving in
social and academic ways, because they will not put themselves in positions
where others might observe them and they might fail (Eisen, Kearney,
Christopher, & Schaefer, 1995; Eisen & Schaefer, 2005). One client told me that
when he was a boy, he could not even go through the grocery store line with a
gallon of milk without suffering: he blushed, sweated, and trembled having to
speak to the cashier, give money, and take change. He would avoid every
situation in which people looked at him. As a small child he hid behind his
mother. As he got older, he stayed quiet in school, had one friend at a time, and
did not participate in any activity that required him to talk. His talent for and
love of sports eventually took him into the spotlight in the comfort of being part
of a team, and he gradually improved his ability to tolerate being looked at. He
believed that without the desensitizing impact of his sports activities, he never
would have developed the courage to go away to college and achieve the level of
success he did. There cannot be a better reason for people who suffer this anxiety
to get help as soon as possible, in order to achieve their full potential socially,
educationally, and financially.

CHANGE SELF-TALK
The problems of social anxiety are the most important ones to address with
changes in self-talk. Self-talk is not necessarily ruminative like worry, and it is
not much like the fear of being afraid, as in a panic attack; rather, it has the
quality of stating truth. People believe that what they say to themselves is true.
Because they have probably been shy as children (Eisen & Schaefer, 2005;
Siegel, 1996; Winston et al., 2002), their self-talk reflects beliefs that a social
situation is cause for fear (Gazzaniga, 2005; Grillon, 2002). This fear reinforces
the need to continue avoiding. “If people see that I look nervous, they will laugh
at me. Therefore, I will avoid having people see me.”

The Necessary Precursor to Change: Get Educated About Anxiety

Changing behavior starts with the conviction that behavior change is necessary
to accomplish being less afraid and more able to cope with social circumstances.
Even though it will be necessary to practice in real-life situations, there are some
mental changes that come first. To put that effort forth, people need to believe
their effort will pay off.
Education can be obtained by reading (like reading this book!) or by working
with others in a group setting, like a clinic or self-help group. It can also be
provided to individuals in psychotherapy or other kinds of settings. Education is
an essential component of therapy because it creates the willingness to practice
the self-talk strategies. People with panic symptoms benefit from knowing that
they are not alone, that they are not dying, going crazy, or losing control, and
that methods to calm the anxious body really work. People who worry too much
need to learn that persistence in stopping worry will lead to less worry. And
people with social fears must learn that their fear is caused by their imagination
about the outcome of an interaction with someone else.
Psychoeducation teaches people how changing behavior works to change the
way they feel. It will take some time to accept the idea that fear is unnecessary.
People trying to change their anxious behavior need to develop new self-talk that
will help them try something new. They need to believe that their anxious bodies
are unnecessarily trying to protect them. They will have to commit to ignoring
the body by changing the way they talk to themselves about their fear. And they
will also need to:

• Learn to tolerate uncomfortable sensations

• Take control of their negative self-talk
• Act in direct opposition to their false beliefs
• Practice repeatedly so that the amygdala can re-learn anxiety cues

Again, making an intellectual decision to try to overcome emotional

reactions uses the executive decision-making power of the left prefrontal cortex
(PFC) to override the emotional demand of the limbic system. If people with
social fears believe the explanation of how they became anxious and how they
can control it, they will be more likely to plan and carry out practice sessions
even though they may be uncomfortable. The practice sessions are the ultimate
goal, because they allow the amygdala to re-learn what to react to and get
comfortable doing it. By practicing in real life, the goal of calming the amygdala
and the limbic system is achieved.
Remember:

• Anxiety symptoms are usually not happening because of any real risk.
It is biochemistry.
• Panic, worry, and social fears can be changed by changing thoughts
and behaviors.
• Social anxiety is not specifically fear of danger, but rather fear of
exposure (the fear that others will observe you looking embarrassed).
It is the autonomic response to being exposed with a risk of
humiliation. All that is the result of negative self-talk.
• Changing self-talk and beliefs is a key component of changing
behavior. Beliefs drive action.
 • Practicing new behavior is the ultimate way to change the anxious
brain.

FIND THE SELF-TALK

Beliefs about the self, the world, and other people are reflected in the choices
people make, and their impact is revealed in self-talk—that internal dialogue of
which many are unaware. Every small thought that creates anxiety must be
identified and corrected.

Ask Your Yourself “So What?”

People can be unaware of how they talk to themselves in self-sabotaging ways.

To hear your own voice, start out by being a detective in your own life. As you
go through experiences, try to notice exactly what happens and what you are
saying to yourself. Then write those observations down. You will be more likely
to find your internal dialogue if you start by noticing times when you are
uncomfortable and then writing down what is making you uncomfortable. For
example, if you have to speak up at a work meeting, you might write, “I am
sitting in the meeting, knowing I have to read this short report. My heart is
pounding because I know I have to speak. I can feel the heat in my face, and I
am afraid of my voice shaking when I have to speak.” Then ask yourself, “So
what? So what if my heart pounds or my face reddens?” This question will
reveal your inner dialogue. The answer might be, “So what?! I could look
stupid! People will think I don’t know what I am doing because my voice is
shaky. Or they might look away and my nervousness could make them
uncomfortable so they won’t like me.” The answer to the “so what” question
reveals this sort of damaging self-talk.

Use the Three-Column Method

Sometimes people are aware of what they are saying to themselves, and they
know they keep up a negative inner dialogue that stops them from trying things.
The task here is to identify situations in which you are holding yourself back,
and to identify the entire list of negative thoughts you might produce about the
situation. This two-column list can then be expanded into three columns to
counter the negative self-talk.
First, start by making three columns on a piece of paper. In the first column,
put down the goals, actions, or intentions that raise anxiety. In the second
column, write down your first thought about the situation. If this thought is
negative, think about the impact of such negativity on achieving your goal or
intention. The third column will be completed as you plan the direction of
change for your self-talk.
Figure 10.1 shows how this worked for Guy, a 22-year-old who wanted to go
back to college after he had dropped out due to anxiety. He knew he had the
intelligence to go to school, and it bothered him that he was working in a gas
station when he could be in school. First, he listed his intentions:

• I want to start school again in 6 weeks.

• I want to talk to the admissions office about getting all my other credits
accepted.
• I want to be able to talk to other students about the classes.
• I want to attend every class and not leave at any time due to
nervousness.
• I want to finish school completely in 2½ years.

Figure 10.1 Finding Self-Talk With the Three-Column Method

Then he began to fill these intentions into the chart, and as he thought about
each, he wrote in his first reaction, planning to talk about his reactions in therapy
before he filled out the third column.
By writing down his reactions, Guy began to reveal his negative self-talk.
This was the first step in figuring out how to challenge this self-talk (discussed
later in this chapter).
 Use the “A” and “B” Parts of the ABCD Method

Another way of identifying your inner dialogue is to use the ABCD method,
created by psychologist Albert Ellis. The “A” and “B” parts of this method are
the ones pertinent to the discussion here. (To see the whole method, read The
Practice of Rational Emotive Therapy, by Dryden & Ellis, 1987, pp. 52–53). The
“A” and “B” parts of Ellis’s method stand for the activating event and the belief
that a person holds about himself, others, and the situation.
A: The activating event. Describe the situation that contributed to the anxiety.
(In Guy’s case, this was deciding to go back to school and asking the admissions
office about getting his credits from the junior college accepted.)
B: The belief a person holds about:

• himself (like Guy saying to himself, “I have never managed this

before, and I probably won’t be able to do it now.”)
• others (“The admissions people will see me as a failure and won’t be
interested in helping me.”)
• the situation (“I shouldn’t get my hopes up because college works out
better for other people than it does for me.”) Try to especially notice
beliefs that start with:
Should (“I/You should.... ”)
Must (“I/You must.... ”)
Have to (“I/You have to.... ”)
It would be awful if....
These are essentially demands that people make on themselves or others,
whether they realize it or not. People with social anxiety become more aware
than most people about the little rules they set for themselves to make situations
safe or to reassure themselves that they followed rules. Then they can feel less
perturbed about how they performed or how they met expectations.
To recap, the best way to identify your negative self-talk is to:

1. Ask yourself, “So What?” and then list the answers to that question.
2. Use the first two columns of the three-column list for identifying
negative thoughts about specific situations.
3. Use the ABCD approach.
4. Try not to reinforce the beliefs. Rather, go on to discuss and counter
the negative self-talk that you identify.
 CHALLENGE THE NEGATIVE SELF-TALK
It is logical to think that the minute you find a negative you can apply a positive
to counteract to it. However, this does not always work in practice. Finding the
negative self-talk can be harder than one would think; therefore, just getting as
far as finding the self-talk might be a reasonable goal for someone who is not
always able to self-appraise.
It is also important to note here that changing self-talk engages your negative
internal dialogue directly, rather than trying to stop or contain the resulting
behavior. (See Chapters 7–9 for techniques to address panic and worry.)
Changing self-talk is not about ignoring it, stopping it, or putting it aside. It is
about getting a very clear picture of the negative aspects of it and then
deliberately changing it whenever it shows up in your inner dialogue.
Challenging negative self-talk is a part of the process needed to change the
sensitivity of the amygdala. That sensitivity, which sets off anxiety in social
situations, can only be relaxed via new experiences that are well tolerated.
Without challenging negative self-talk, people will be reluctant to have new
experiences in which they can succeed and calm down the amygdala.

Plan the Counter-Cognitions for the Three-Column List

Using the three-column list you began earlier, evaluate your thoughts one at a
time and find their opposite. Write down this positive opposite in the third
column. Figure 10.2 shows how Guy filled out the third column in his chart.
The action of making a list of counter-thoughts directly confronts the
negative with a positive alternative. Talking about positive alternatives also
engages the prefrontal cortex, which helps those new thoughts to be more readily
remembered. With the stronger etching of the new thought into conscious
awareness, it is more likely that it will be able to replace the negative
consistently. Rereading the list frequently then strengthens the memory of what
to look for and what to change.
Figure 10.2 Identifying Counter-Cognitions with the Three-Column Method

Use the “C” and “D” Parts of the ABCD Method

Ellis’s ABCD method is one of the clearest ways to challenge negative self-talk.
Because it identifies a very specific event that activates anxiety and the
subsequent avoidance behavior, it requires specific self-talk to challenge as well.
After you have identified the beliefs regarding the activating event, you can
address and confront the reality of the behavior. This is done by using the “C”
and “D” parts of the method. “C” stands for the consequences of A and B. “D”
stands for the demands you place on yourself, others, or the situation.
Adrienne was a client in her thirties who felt she was heading for career
trouble. She had a boss who was moody, and she was sure he was mad at her and
about to fire her whenever he came through the office without greeting her
pleasantly. This was disturbing to her, and every time it happened, Adrienne
would spend the whole day using self-talk about how she was not good enough,
would never get promoted, and even might get fired. This was not like the
ruminative worry that a plan could settle. It was only triggered by days when the
boss did not sound pleasant enough. On other days, Adrienne was not at all
troubled by thoughts of being fired. However, a promotion opportunity was
coming up and she hesitated to put her name in for it because she would have to
ask her boss to give her a recommendation, and she was sure he would never
recommend her. She could not bring herself to talk with him for fear that he
would “look at her funny” or hesitate to offer the recommendation. Then she
would blush, stammer, and need to walk out.
I decided to use the ABCD method with Adrienne to identify and challenge
her negative self-talk. Naming the activating event was very easy for her: “I have
to ask my boss for a recommendation for a promotion.” Next, Adrienne
identified the beliefs she held about herself, others, and the situation, noting
especially those that started with should, must, have to, and it would be awful if.
“I must be completely calm when asking about the new job or he will not
recommend me,” she said. “He must be in a perfect mood or he will never listen
to me. I have to present every one of my reasons to apply in perfect order or he
won’t agree to recommend me. It will be awful if he is rude or impatient and
does not make me feel good about applying. I think I would just run out of his
office and never show my face again.”
We then moved onto the “C” and “D” parts of the method.
C: What are the consequences of A and B? What are you likely to do, or
what did you do if you are thinking about this activating event? (Adrienne
responded, “I guess I won’t ask him for the recommendation. I don’t know if he
will ever be in a perfect mood, but I sure know I will never manage to ask him
perfectly.”)
D: Look at the demands you place on yourself, others, or the situation.
Question them, and question the ratings you make for situations. For example,
ask yourself, “How do I know that ______?” “Why must she always____?”
“Who ever promised that ________?” “Why do I think this the worst _____?”
You get the most effect out of this if you write out the question and the answer as
well as talk them over.
Adrienne realized she was attempting to mind-read when she assumed she
knew what her boss would act like and why it was awful. “How do I know?”
was an important question for her. She realized that her only evidence that he
would be rejecting was that he was grumpy on some mornings, so we took it a
bit farther: “How do you know that he is grumpy?” “How do you know that you
are the cause of his grumpiness?” Maybe he was just tired; maybe he was being
cheerful in his own way; maybe his whole day will turn around when he sees
you.
 Adrienne wrote: “I place a demand on myself to be perfect because I think
that will make my boss listen. But actually, I have no idea what makes him
listen, because I have no idea what makes him grumpy on some days. I also
don’t know that I will run out of the office if he is impatient, and I don’t even
know that it will be awful. I won’t like it all, but I could stick it out, I guess.”
Adrienne then wrote counter-messages to herself to dispute the beliefs she
held and the demands she had made:

• “I must be completely calm when asking about the new job or he will
not recommend me” was countered with: “He knows my work.
Whether I am calm while asking will not change his assessment of my
work.”
• “He must be in a perfect mood or he will never listen to me, and I have
to present every one of my reasons to apply in perfect order or he
won’t agree to recommend me” was countered with:
“There is no need to be perfect, because there is no way to know what
perfect is in this situation. I can be prepared, and I will be.”
• “It will be awful if he is rude or impatient and does not make me feel
good about applying; I think I would just run out of his office and
never show my face again” was countered with: “Who said he should
make me feel good about applying for a promotion? His feelings do
not have to affect me. There is no need to run if he is rude or
impatient. I have talked to him many times when he is impatient, and I
can do it again.”

Once the challenge is set—countering negative self-talk—it is necessary to

review the results often. The new messages can be written down in a notebook,
on a card, placed on the refrigerator door—anyplace where they will be visible
and accessible on a daily basis to counter the negative self-talk.

Recite Affirmations

Saying affirmations is a way to form and engrain new thought habits and
establish new, positive self-talk. An affirmation is a positive statement about
yourself, said aloud as if it were already true. The idea behind affirmations is
that we create the reality we believe. If we believe we will fail, we will. Our
chances of success are much better if we imagine ourselves succeeding, see
ourselves doing something right. By affirming what we want to be true (about
our lives, our situations, our character, our attitudes, and so on) we create the
conditions for that truth and make it manifest, even as we speak. For example, if
I want to become more comfortable talking at meetings, an affirmation I might
say would be, “I am confident and competent when I express myself at staff
meetings.” I say the affirmation as if the attitude and action is true right now.
Affirmations do not differentiate past, present, and future (Evers, 1989). That
said, affirmations need to be grounded in reality. Star, a client who wanted to
design movie sets, although she had no training or experience, wanted to affirm a
potential job coming to her. This could be a set-up for disappointment. After
some work, she realized a more realistic affirmation was, “I can learn the skills I
will need to achieve my goals.”
To summarize, you can challenge negative self-talk by:

1. Filling out the third column on the three-column list.

2. Carrying the list with you, using the new self-talk thoughts to replace
the old, negative ones.
3. In a specific situation, analyzing the effects of your beliefs with the
ABCD method.
4. Reviewing your new, positive self-talk messages at least daily.
5. Reciting affirmations about being confident and competent in the
situation, even when you do not feel confident or competent.

CHANGE THE FILTERS ON

EXPERIENCE
People fulfill their own expectations. If they expect to panic when they get in a
car, they will panic. If they worry about whether a party will go as they planned,
it will not go as planned. If they expect to be rejected or expect to appear
nervous, they will look nervous and spot someone who appears to be rejecting.
People create what they fear. More importantly, they will notice things that fulfill
their preset expectations. They will note when things were less than perfect, and
they will filter new experiences for evidence that they are being rejected or
nervous. They especially notice bad experiences and do not notice positive ones.
They begin to make inaccurate generalizations about their experiences (“I will
obviously panic whenever I get into a car”) and do not draw good conclusions
about the experience (“I know I did not really panic, but I felt like I might at any
moment, so that is just as bad”). And they begin to see risk in situations where
none exists.
People with social fear have expectations of being socially humiliated, of
being unassertive, ignored, embarrassed, or flustered, and often those anticipated
fears will be fulfilled. They will stop seeing the moments when others responded
warmly to them or when they succeeded socially. Behavioral avoidance is when
individuals avoid these situations and rationalize their avoidance with self-talk.
But this self-talk is not necessarily accurate. It reflects specific kinds of mental
errors that are common to social anxiety, and these errors are not challenged
because the fearful person avoids the very new situations that could contradict
the error. These mental errors get reinforced by experiences that seem to prove
them true.
The following beliefs are common to all people with anxiety, and especially
to those with social anxiety or panic:

• Overestimation that what you fear will occur. If you have had panic,
you believe you will panic. If you are worried about something, you
believe it definitely will happen. If you fear others will notice you and
reject you, you are certain that will come true.
• Catastrophic expectations. You believe that no matter what happens, it
will be the worst.
• Underestimation of your capacity to tolerate negative experience. You
believe you cannot tolerate anxious feelings or any negative thing you
fear might happen.
• You believe that you do not have control over how you feel. You think
that the outcome of situations is in the hands of others and that you
cannot influence your own actions and feelings if you feel anxiety.

Giving control over to anxiety is debilitating. Of course, total control is not

realistic, but nor is it necessary. Control over one’s emotional reaction to
situations is, however, an achievable goal. A place to start is to search for
situations that disprove these false beliefs. This will help you change your filters
on experiences.
 1. If you have social anxiety, look for and write down situations in
which you did not experience rejection or humiliation. If you have
generalized anxiety, look for and write down times when the thing
you were worried about did not ever come to pass. If you suffer from
panic, note the situations in which you could have panicked but did
not panic.
2. Bring these notes into therapy for discussion or write about them to
enhance your awareness of positive situations. People with social
anxiety must pay special attention here: even though you might have
felt embarrassed, did others actually humiliate you? It does not count
to say that the other person probably was thinking negative thoughts
about you. You can only record actual spoken words and specific
actions, so if the person remained engaged in conversation and
pleasant, it must be noticed as a positive. (This is helping the
amygdala with new learning.)
3. Keep up this search for positives as a regular part of your life. It’s
like the line from that old Bing Crosby song—“Accentuate the
positive, eliminate the negative, latch on to the affirmative, and don’t
mess with Mr. In Between.” Unlearning a lifetime of negative
filtering takes some time.

CHANGING SELF-TALK IN CHILDREN

Children may develop negative self-talk at a young age, prompting them to
withdraw from social interactions or successes in school. They can become
solemn and overwhelmed by anxious thoughts, and engage in behavior that it
self-defeating unless corrected. It is highly effective for parents and children to
watch for and correct the negative self-talk that occurs as children tell stories
about their social experience (Rapee, 2002). Parents can talk with children to
help them identify and reinforce positive corrections for catastrophizing,
overestimating that the worst will occur, fearing that they cannot handle bad
experiences, or believing they cannot control their own feelings. These positive
corrections include:

• Things happen. Everyone has a bad experience once in a while.

• Even if you feel scared, you can go ahead and do things anyway.
 That’s what “brave” means.
• Bad things happen to good people. Lots of bad experiences are not
your fault.
• If you actually did something wrong, you can correct it.
• Focus on the positive things that happen to you. Rehashing memories
of bad experiences only teaches you how to do things wrong again.

CONCLUSION
Learning positive self-talk strategies is a crucial aspect of effectively managing
the anxious mind. Once you get the right self-talk down, behavioral change—the
next part of this book—is much easier to implement. A person who has not
exercised for years cannot get up and run a marathon tomorrow. No one would
expect them to. They would need to start with a short walk—practiced, repeated,
and extended to be longer and faster—before they could ever expect to make a
long run. Every small step of progress is necessary, even if it’s not sufficient for
the final goal to be met. This is true of changing anxious behavior by changing
self-talk. Changing self-talk is like taking walks before beginning the marathon
of behavior change.

PART IV

MANAGING ANXIOUS BEHAVIOR

Many skills must be learned and interwoven for the best success in recovering
from any anxiety problem. We have already covered calming the anxious body
and managing the anxious mind. Now, we turn our attention move fully to
changing anxious behavior, the final component in successful anxiety
management.
As you already know from earlier chapters, avoidance is the behavioral
hallmark of anxiety. People who panic do everything they can to avoid situations
that might provoke it. They develop the belief that they can avert panic with
careful avoidance of any panic trigger. So they avoid driving, airplanes, enclosed
spaces, crowds of people, and so on, and their lives are inevitably diminished as
a result.
Worriers, too, try to avoid anything that will make them worry. They hold
themselves back from situations that seem too stressful and avoid interactions
with new people or new activities. They may also try to avoid worry by doing
everything they can think of to prevent a problem. Worriers typically have high
drive, hence their tendency to avoid worrisome things with lots of activity.
Socially anxious people are perhaps affected most, avoiding being in the
limelight. They do not promote their own skills, they often do not fully develop
their talents, and they avoid new people or situations that would enlarge their
scope and help them make good connections. As a result, they miss out on the
richness of life that comes with experiences and interactions with other people.
Anxiety is sometimes more troubling for what it takes away from a person’s
life than for the trouble it adds. When avoiding thoughts, situations, or feelings,
a person is less engaged in life. Changing anxious behavior is the culmination of
learning all the techniques and putting them into practice. Sometimes behavior
changes in a quiet, almost un-remarkable way as a person worries less, panics
less, and feels less inclined to avoid a problem. Sometimes the change is
dramatic, as when a shy person asks someone for a date and feels thrilled about
it. Whether the change in behavior is quiet or dramatic, the person’s life is richer
for being able to connect with others and accomplish activities that previously
felt impossible. The feeling of accomplishment a person has after finally doing
something without fear is unparalleled. The techniques in this section for
changing behavior can offer relief, connection, and success—hopefully all will
be more apparent in your life.
 ELEVEN

Technique #9: Control TMA (Too Much Activity)

People who have anxiety typified by tension, worry, and high-drive activity
make their anxiety worse with too much activity (TMA), developing a nonstop
lifestyle that they then seem unable to change. Those with a sensitive
temperament who are easily overstimulated are more likely to avoid this
lifestyle, recognizing the exhausting impact of TMA on their energy and
attention. They quickly notice how much more anxious they become when they
try to do too much. However, the person with generalized anxiety—the worrier
—often thrives on activity and is less likely to see its negative effects. Although
people with panic disorder may also have TMA, it is the person with tension and
high drive who is most likely to have TMA-related problems.

THE BRAIN AND TMA

Being unable to shift gears and let something go is the result of that “stuck”
quality when the anterior cingulate gyrus (ACG) is short on serotonin. Once on a
track of getting something done, high-drive individuals do not seem able to
decide whether it can be let go. They cannot see alternate ways of doing things
well. This intensifies the likelihood that they escalate their busyness rather than
learn new skills such as delegation and prioritization.
The elevated norepinephrine (NE) so common to the tension and
hypervigilance of generalized anxiety can lead to perfectionism. The need to
avoid mistakes is a critical cause of TMA. In some cases, GABA, the brain’s
braking mechanism, may be insufficient or ineffective. This contributes to TMA
as well, making it hard for the person to put things away mentally and keep
things in perspective. This adds to a difficulty relaxing. When GABA is not
working effectively, worrying is hard to stop, and that makes perfectionism
worse.
 Overactivity in the basal ganglia (BG) often results in highly motivated,
goal-directed behavior, and people who have that drive typically get a lot of
work done in a day, no matter what the work is—washing windows, grading
papers, writing computer programs, or doing a home repair project. This high
activity is not just adult work-related activity. It is seen in the elementary school
child who never misses a homework assignment, the high school student with
extra classes and three extracurricular activities a day, or the homemaker running
a household with three busy kids and community activities that fill every spare
moment. People with TMA are responding to their high-drive energy level,
which can become a problem when it is not harnessed for the benefit of the
anxious mind. The high activity level is probably not going to change, and
people with TMA may not ever relax in the way a less driven person can, but
they can change the way they direct their energy to achieve more balance, more
fun, and much less anxiety.

WORK STYLE AND WORK VALUES

A high activity level is not perceived as a problem by people who are that active.
Others around them may wish they would be less busy, but they themselves do
not recognize a problem until something brings it home. The pressure from a
spouse or the children to be more available may intensify, especially if the
family member has a problem that requires the person’s time, as when someone
gets sick and needs attention. If something blocks these high-drive people from
working at their “normal” pace, they feel agitated, and if that interruption lasts
too long, their anxiety skyrockets.
Even though they may be go-getters who get a lot done, people with high
drive are easily thrown into anxiety when things do not go as planned. Harry was
a good example of this. He traveled frequently for work, and he nearly always
had a story about getting into trouble for loudly and rudely hounding the airline
personnel when flights were delayed or canceled. He had trouble reorganizing
emotionally in a way that would let him find a new solution or plan for his time.
This was good evidence of his stuck anterior cingulate gyrus (ACG), coupled
with impulse-control problems. He appeared on the outside to be in a rage, and
on the inside he was feeling out of control over not being able to follow a plan
he made. In that state, he could not soothe himself easily. It took nearly getting
arrested for Harry to finally take control of his anxiety.
 Being forced to hold still or stop their work, whether for a brief period or a
longer spell, can seriously intensify anxiety for people like Harry. Having an
unexpected few hours of free time when a meeting cancels can cause anxiety
about how to use the time to their best advantage, and that stuck ACG can cause
even more anxiety by preventing the person from finding a good alternative use
of the time. I received a phone call one morning from a client whose office had
unexpectedly closed because of a plumbing problem. My client was having a
panic attack about what the right thing to do for the day was. He had so many
ideas of what he ought to be doing that he could not even begin to choose the
“best” one, and if he did not use his time to his best advantage, he knew he
would just get more anxious.
Sometimes, being slowed down by injury or illness can cause anxiety to rise.
If illness interrupts the flow of work, people may try to get back to work too
soon and suffer relapse or even re-injure themselves, as I have seen with anxious
clients trying to recuperate from a surgery or a muscle or bone injury. Holding
still seems to build up pressure that is hard to release, and that pressure becomes
a serious problem for health and relationships. It can raise blood pressure or
blow up in bad temper, irritability, and outbursts of anger at inappropriate times
or at people who do not deserve it.

HOW TO CONTROL TMA

Why would someone with TMA from anxiety resist changing their behavior or
activity? Because high activity diminishes anxiety. People feel agitated when
they aren’t active, which is distressing to them both mentally and physically.
When they hold still, especially when they have not planned how to use their
down time, the feelings of anxiety crescendo to an overwhelming pitch. The
following strategies provide ideas for controlling TMA.

Plan for Dreaded, Unexpected “Free” Time

This is a brief strategy but genuinely helpful to the overdriven TMA person. Life
always produces unexpected times when people have to hold still in one way or
another. People who travel for work know they are going to face delays. They
just do not know when those delays will occur. Social plans may be canceled,
leaving an unexpected free afternoon or evening. People get sick and work
meetings are put off, leaving a space of unscheduled time. Although most people
long for a few extra hours in which to get things done, people with TMA cannot
think of what they would do if they ever had a free minute. Their anxiety spikes
so fast about what to do with the “free” time that they become stuck and cannot
choose what to do. Then they are not only anxious about what the best choice
would be (it would be a mistake to pick the wrong activity), but they become
anxious that the time will go by and not be well spent. Following is a good
homework assignment for this situation.

1. Every time you say to yourself, at home or at work, “If I ever have a
few hours (or a few minutes), I want to ___________,” make a note.
This activity can be anything at all—take a bath, plant a garden,
organize photos, clean the garage, organize your tools, reorganize
your files, clean out desk drawers, and so on.
2. Transfer your note to a running list that you keep. Divide this list
into:
• Things that take 30 minutes
• Things that take an hour
• Things that take 3 hours
• Things that take a day
3. Carry the list with you, and whenever you are faced with the dreaded
unexpected “free” time, select something from the list that fits the
available time. You will be certain that you wanted to do it, you will
be able to select something quickly, and that anxiety will be relieved.
4. As you complete tasks, cross them off and add more to the list from
your notes. This is very satisfying for people with TMA.

If you are not a TMA person yourself and are helping someone with TMA,
do not underestimate how often this kind of problem—having unexpected free
time—occurs and increases their anxiety. It is quite possible that the person with
TMA does not recognize these situations for what they are. Be on the alert for
hearing about them. This simple fix of planning is truly that: a simple fix for a
frequent and completely manageable exacerbation of anxiety in the highly active
person.

Identify and Counter Perfectionism

When people who are anxious seem like perfectionists, they often do not see
themselves as such. They do not feel wedded to everything being perfect, as if
order and correctness are goals in themselves. Rather, perfectionism for them is a
way to ward off anxiety, and they may not realize it. What others see from the
outside is not what is going on inside.
People with anxiety try to handle it by eliminating reasons to worry, and a
good way to eliminate reasons to worry is to make no mistakes. The fewer
mistakes they make, the less they will to have to worry. And that attempt to
control mistakes becomes perfectionism. It sets them up to review their work
repeatedly, double-check for errors, work extra hours, and do work themselves
rather than entrust it to others.
Perfectionism shows up in social ways, too. The perfectionist may
monopolize a committee he or she is on or refuse to let other people handle
obligations such as planning a party. Younger perfectionists may not trust others
on a school project to do their share. In all these cases, the underlying impulse is
to take control of a situation and get it “done right.” This affects relationships
with other people, who see the perfectionist as controlling.
What these perfectionists do not realize is that they are going to worry no
matter how hard they work. They just find other things to worry about, and their
heightened stress makes them more hypervigilant and uptight. They also
overlook the consequences of working that hard: No one helps them anymore,
they end up with more work, they start to believe they can do it all, and—wham!
—their anxiety level climbs even higher. It becomes a vicious circle of looking
for potential problems to avert, finding them, being convinced they handled
them, and continuing to look for more.
Jenny, an event planner (what a perfect job for her anxiety!), described it like
this: “When someone asks me to take on a project, I feel as if I can see the way it
will go, like dominos falling. I can see the whole outcome if it goes right, or, if
one thing or another goes wrong, which way the dominos will fall. And I can
plan to avoid every one of the places where trouble could occur. That means if I
am careful enough, nothing will go wrong. I like being able to anticipate trouble,
so that I can know things will go perfectly and everyone will be happy about it.”
When I asked why she was willing to put in this level of foresight and effort to
do all the planning herself, she replied, “If I do it, then I won’t have to worry
about it. If I were to let other people be responsible for parts of it, then I would
worry until it was done. I would know something was going to go wrong, but I
wouldn’t know what it would be, and I would not be able to plan how to fix it. It
is not worth the worry to let someone else do the work.”
One aspect in which this anticipatory worry and perfectionism is beneficial is
that perfectionists get strong positive reinforcement for being such good
workers. They get promotions and praise and awards and good grades,
alleviating their worry about whether they are acceptable to others. It is a part of
their lives they can feel good about. On the other hand, they develop a fear that if
they ever let down their perfectionistic guard, things will completely fall apart
and others will blame them entirely. (Note the extreme always/never language.
This is the way the thought process goes.) In other words, they come to believe
that everyone believes mistakes are intolerable and proof of their unworthiness.
What works to alleviate this perfectionism? Identifying it is the first step.
People who have this style of handling anxiety rarely see themselves as
perfectionists, so calling them “perfectionists” is not useful at first. They see
themselves as “careful” or “detail-oriented.” Working in therapy, it is essential to
make sure that the perfectionism is not serving another unconscious,
psychological function and is not the outcome of a personality disorder such as
obsessive-compulsive disorder. Those conditions require psychotherapeutic
interventions beyond the scope of this technique. A good psychotherapy
interview, such as with coherence therapy techniques, and a personality
inventory can help to determine whether or not the perfectionism has deeper
psychological roots. However, when it can be determined that the perfectionism
developed as a tool to ward off anxiety, it can be handled with anxiety
management techniques.

Identify Perfectionism

This is fairly straightforward. The clues to look for are in the person’s language
about work, family, and social responsibilities. Following are instructions for
identifying perfectionism, which is often used as a way for people to avoid
anxiety, but can really lead to greater anxiety if it isn’t controlled.

• Do you have a strong sense of personal responsibility for the outcome

of work, social, or family activities, especially when other people
could reasonably be expected to do some of the work? You will see
this most easily in your major areas of responsibility. For example, if
you are a student you might see it in the way you participate in a club
or committee, doing all the work for the people who are supposed to
 do part of the planning. If you are a homemaker you might not rely on
other family members to finish their part of the laundry or cleaning or
get the trash out on time. At work, there are many ways to see this—a
project manager might assume total responsibility for the outcome of
every aspect of a project.
• Is your language full of the extremes discussed earlier? This is a major
indicator that the need to be perfect is connected to managing anxiety.
Note self-talk such as, “This is terrible.” “This staff never does things
according to the manual.” “No one around here ever does what they
say they will.” “I always end up doing all the planning.” “If I don’t get
this done, the whole thing will be ruined.” These kinds of attitudes and
observations reinforce the importance of being watchful about your
anxiety and potential perfectionism.
• Do you have a sense of the difference between “good enough” and
“perfect,” and can you apply it in deciding how much to do?

Once these features are observed, go on to look for a pattern.

1. First, trace the history of this behavior. Is there a time you can
remember when you didn’t think so hard about outcomes?
2. Next, consider what happens to your anxiety level when something
goes wrong. If your perfectionism is a way to ward off anxiety, your
anxiety will go off the charts when a mistake is made.
3. Then review the consequences of your mistake/anxiety.
Perfectionism develops when you resolve anxiety by determining to
be more careful in the future or to take charge of more of the details
personally.
4. Is there an escalating pattern in which you feel less anxiety by taking
charge of situations and doing even more work, checking things
more, or spending more hours on a task? If so, you are probably
using perfectionism as a way to ward off anxiety.

Intervene on Perfectionism

Step 1. Find the negative consequences of perfectionism. This way of avoiding

anxiety can be helpful and can contribute to self-esteem, so before you eliminate
perfectionism completely as a defense against anxiety, you will want to be sure it
has very negative consequences. Look for consequences like:

• Being blamed (unfairly) for being controlling rather than being seen as
helpful or careful.
• Taking on extra work that no one asks you to do and feeling
overworked.
• Feeling the stress of doing the work; feeling the pressure of having no
time for anything else, including time to have fun, which you firmly
believe you would have if you could only find the time to stop
working.
• A lack of pleasure and fun, even at activities that should be fun, due to
feeling so responsible for the outcome of the activity.
• Feeling completely exhausted and not knowing how or when you will
recover.
• Failing to prevent your anxiety. This is an especially important point.
You would not be trying to control anxiety if your perfectionism was
actually working to manage your anxiety. Why not work less and
figure out another way to let go of anxiety?

The belief that getting rid of extreme perfectionism is going to help anxiety
levels in the long run has to be reinforced. Learning to handle anxiety symptoms
with other techniques will be reassuring and will reinforce your willingness to
change the pattern.
Step 2. Stop using all/never language. A slogan for anxious perfectionists
should be: “Perfection is impossible.” You can follow this with the reminder that
“If something is really impossible, then I have no obligation to try for it.”
Step 3. Plan for non-perfectionism. Actually, planning a non-perfect
performance of some responsibilities works better than noticing accidental
imperfection. It won’t be quite as anxiety-provoking because you will be doing it
on purpose, and you will have made sure you can tolerate the outcome.
Instructions for planning for non-perfectionism include:

• Decide not to take on a specific, one-time responsibility, and see

whether the work gets done without you. Ask yourself in all
seriousness, “How important is this?” Start small, but pick something
 you otherwise might have agreed to do, such as mowing the lawn for
someone who says he is too busy, babysitting the grandkids, writing a
report when someone else could do it, or covering someone else’s
shift. The goal here is to see whether the work gets done even if you
don’t do it, and to recognize that someone else’s urgency does not
necessarily constitute importance. You may well find that when you
hold back, someone else will step up. Or, if the work does not get
done, it does not seem to end the world.
• Observe and evaluate how people respond to the imperfect work of
others.
• Go ahead and assume some responsibility, but do not do what others
are supposed to be responsible for. Observe the outcome in the
attitudes of others and in you own anxiety level.
• Plan to not finish some work that you would otherwise have knocked
yourself out to do. Miss a deadline by a little bit, or just don’t do
something at all. You may have to get advice on what you can let go,
but when you identify that, do it. The kinds of situations that serve as
good practice are usually minor in the eyes of others—for example,
don’t go out to buy the right napkins for the party; use paper towels.
Or, ask if you can have a one-day extension on a project, and see what
the boss or the teacher says. Or, don’t prepare the agenda in writing
before the staff meeting. These kinds of detail-oriented items that you
formerly believed were major will turn out to be inconsequential most
of the time.
• Observe how little anyone cares whether or not you were perfect.
• Note that when something goes wrong unexpectedly, people (including
yourself) usually cope pretty well with it.
• Finally, take note of what makes the difference between important and
inconsequential things. This evaluative step will help you to make
future decisions about what you can drop and what is essential. Your
vision has become unclear about such distinctions and needs practice
to clear it up.

Again, the way to identify and counter perfectionism is to:

1. Look at the things you try to do perfectly and listen to the language
 you use.
2. Identify the language of extremes—the “always or never” language.
3. Find the pattern of perfectionism in your work style.
4. Identify the negative consequences of perfectionism.
5. Start to change the language of extremes.
6. Plan for imperfect performances.
7. Pay attention to the outcomes so you learn to distinguish importance
versus urgency and consequential versus inconsequential. This will
help you better evaluate your perfection tendencies.

ACHIEVE BALANCE
Balance in life is three-pronged: achieving emotional, physical, and mental
health. People with TMA may get out of balance unintentionally but be unable to
correct it. For example, someone might put all her effort into a hobby that
becomes obsessive, like creating crafts to sell at a spring fair. Another might
pour the effort into participating in his children’s activities, and still another
might become so focused on her career that she gives up all social activity to
spend more time at the office.
Getting out of balance can sneak up on a person. Often, one part of life
assumes significance over other parts for good reason. It could be reasonable to
work at your job 12 hours a day during a circumscribed period of time when, for
example, you are preparing to sell your company or get your agency ready for
inspection. It makes sense that someone could devote most evenings in a single
year to finishing his academic career in night school.
However, shifting back to balanced activity can be a problem for the TMA
person who gets used to the workload and keeps on doing it. These people easily
continue on the trajectory they set, while other aspects of their life fade from
awareness. How often have you heard someone say, “I know I should exercise
and take care of my health, but.… ” Or, “I know I should spend more time with
my kids, but.… ” Or, “I know it would be better if I took time for myself every
day, but.… ” These kinds of statements indicate the tension of being out of
balance—of behaving in contradiction to personal values. The TMA person
easily forgets that high activity is not a value in and of itself.
 Identify Your Time-Related Values

The discussion of the values by which a person lives is hard to initiate. In our
culture, there is not much conversation about this, but people do live by their
values even when they have not articulated those values to themselves. One way
to start examining balance in life and whether it reflects your values is just to
ask, “What do I do with my time?”
TMA people can be very, very good at thinking they are balanced enough,
even when the significant others in their lives disagree. Keeping an objective,
measurable record can end the debate by providing facts.

1. Keep track of what you are doing with your time for at least a week,
every day, and if the week is not representative of your life, for 2
weeks.
2. Make a chart. Divide your week into hours with 15-minute time slots
in each day. Fill in the chart each day—not at the end of the week—to
keep from fooling yourself. Figure 11.1 shows a partially filled out
example of this chart. It includes 16 hours, with the assumption of 8
hours of sleeping time.
• List every activity. Include everything from personal hygiene,
watching television, and eating, to a breakdown of activities at
work.
• Total up the amount of time spent on each activity in minutes or
hours and assign categories to each, like work, children, social life,
etc.
• Based on the time totals from the chart, create a pie chart like the
one in Figure 11.2.

Evaluate Whether Your Use of Time Fits Your Values

What proportion of time for each activity makes sense? Is it sensible to spend 8
hours at the office, 2 hours commuting, and 6 hours divided among the other
parts of your life? What portion of the 6 hours should each of those other
activities get? Making these decisions can be easy, but it can be confusing to
know where to begin making changes. The least anxiety-provoking way to begin
altering the balance of time is to increase time for something that you want very
much to do, and to take time away from something that matters very little.
Figure 11.1 Keep Track of Your Time
Figure 11.2 Is There Balance In Your Life?

How you spend your time reflects the choices you make, but it also may be
in direct contradiction to what you want to do with your time. The biggest TMA
problem is committing to activities that take away from other things that are
more important. The activities may be fine in themselves, but when you commit
to them without conscious intention you may end up doing things that you do not
want to do while missing what is best for you. If you say yes to 10 hours a week
of volunteer activity, that could be a wonderful thing, but what if it is half of
your available time to spend with your children? This is when looking at your
values can help.

Examine Your Values

Your values are the considerations most important to you when you make
decisions. Several methods exist for looking at values. Learning what is
important to you, or “values clarification” (Simon, 1974; Simon, Howe, &
Kirschenbaum, 1995), can be done by thinking about how you make choices in
specific situations. To understand how your values affect your decisions—in any
situation in which you have a choice to make—try the following exercise:

1. Identify the situation. It could be taking a new job, buying a house, or

going to school, for example.
2. Make a list of every important aspect of the situation that will affect
your decision. These may be things like commute, family time,
hobby time, spouse time, time to volunteer, money, and so on. Do not
forget less tangible aspects such as intellectual stimulation, pride, a
chance for making business connections, and using your skills.
3. Sort the list. Establish a hierarchy of which items are most
significant. Sometimes you can just number your list because it is
easy to see what is important, but sometimes it is not so clear. You
can clarify your values by comparing one value at a time to each of
the other values on your list and deciding if each of the others is more
or less important. You can do this very tangibly by writing down each
value on a separate piece of paper or index card. Then, select one
value—“money,” for example—and go through the cards for the
others. Whenever you come to a value that is less important than
money, put the card under the money card. You will be left with a
stack of cards with considerations more important than money. Then
compare again against a consideration from the “more important”
pile. That card goes on top of money.
Let’s say you selected “time with spouse” as more important than
money. You then compare, deciding which considerations are more or
less important than time with spouse. Repeat this process until all the
“more important” considerations have been compared and put in
order. Your stack of cards will now have shifted and will be in order
of importance from high to low.
4. Now you can review the decision you have to make by going through
your values and seeing how the decision will reflect what is
important to you.

The ideal outcome of reflecting on what is important is that you will be able
to answer these two questions:

• What qualities of life make it worth living?

 • What is the value of work, leisure, and family/social activity?

The person with TMA typically is out of balance with work or tasks, and spends
too little time on the things that make life worth living. Recognizing how you are
actually spending your time, and whether or not you are in balance with what is
most important to you, you might find the fight to spend less time at work less
anxiety-provoking.
Remember that high drive comes from high activity in the basal ganglia and
also from excess norepinephrine (NE). Being busy may just be the way your
brain is made. Even if you work a little less, you are likely to be just as active,
but the added activities should create some balance in your life. Remember, the
goal of balance is for overall well-being. You may even discover what efficiency
experts have proven—that taking breaks to relax can help you be even more
productive.
Again, to achieve balance in your life:

1. Make a record of what you do with your time.

2. Examine your actual use of time.
3. Examine your values and how your time use reflects your values.
4. Add time for the thing you most want/need/wish to do, and take some
time away from what you least enjoy or what is least important.
5. Evaluate how the change feels after a few weeks, and rebalance again
if necessary to achieve well-being.

REDIRECT TMA TO HAVE SOME FUN

All the focus on perfectionism and the tendency to get out of balance causes
people with TMA to be overworked and underrelaxed. When worriers are so
preoccupied with preventing bad things from happening, or making sure
everyone else is okay before they can relax, they do not enjoy the relaxation they
could get during their leisure time. They think they maybe could have fun if
there were a time when everything else was done and that fun would not mean
missing any work. They do not direct their high activity to their own benefit by
using it for balance, rejuvenation, or relaxation. Rather, they just use their energy
as a counterweight to worry.
One client of mine, Betty, described it well. Although she said she liked to
entertain, she also said she could never remember much about what happened at
a party because she was so busy checking food and beverages and being alert to
guests who needed to be drawn into a conversation or activity. She was a
nonstop perfect hostess, and her parties were a great success. She realized the
only part she really liked was the knowledge that people enjoyed her hospitality.
Her “fun” was hearing from guests about what they enjoyed as they thanked her
for the invitation. The rest of it was work. This was classic TMA—too much
work related to the activity blotted out the fun.

Laughter Is a Good Start

Laughing is a great way to increase good feelings while discharging physical

energy. Remember how you felt the last time you laughed hard and long? You
might have held your stomach and breathed, feeling tired yet energized from the
pleasant expenditure of energy. Fun and laughter are vital to building a life that
is worth living (Berk & Tan, 1989; Sobel & Ornstein, 1996). The problem for
people with TMA is that constantly being on the lookout for mistakes (NE-
driven activity) and their solutions causes them to gradually take everyday life so
seriously that they stop experiencing the humor in it. Their time is spent
watching for potential problems rather than for potential delight. They become
so accustomed to worrying that they can barely recall any other mental attitude.
They need to remember what life was like before they were consumed with
worry.
Recreating fun and getting relief from laughter is serious therapy for this
serious person. Ask, “What makes me laugh?” Time with friends playing board
games? Going to a slapstick movie? Hearing a comedian? Playing with a small
child? And then make a plan to do whatever it takes to get that laugh.

Find Relaxation and Fun in Small Things

The rebalancing that fun stimulates can start with small things that give pleasure.
But often those with TMA think too hard about whether there is time to do these
small things, or whether they will lead to trouble. Will it cost too much money?
Will it inconvenience someone? Could something productive be done instead?
(Hear the perfectionist-minded attempt to prevent anxiety in these questions?) At
times it can be as simple as following a wish to do something without first
considering who else needs to be taken care of.
A favorite story of mine about how a small thing can help someone get a
sense of balance—and how taking just a small time-out can provide relief—
came out of a homework assignment I gave to a client named Anna. Anna was a
perfectionist and hard-working woman. I instructed her to do one thing she
wanted to do over the weekend that involved no work whatsoever—she was to
do it just because she felt like it at the moment. In other words, something for
just for fun. She was not to turn it into a family outing or do anything that
required her to work first, like invite the neighbors for a barbeque. When she
came back the next week to report on the outcome of that activity, she was still
smiling. In the middle of her errands, she thought getting an ice cream cone
would really taste good. It was, after all, a homework assignment. She pulled her
car into the nearest ice cream store, did not call home to see if anyone there
wanted a cone, ordered her favorite flavor, and stayed there to eat it, tasting
every bite, before she continued with her errands.
Being immersed in eating the cone was delightful to her, and to her
amazement, no one got mad or hurt or felt upset because she did it. It was just
fun. Her good mood lasted and made other parts of her day better. She reflected
that balance for her was not necessarily about taking a lot of time, but about the
quality of the time. That gave her pause to think about how often she denied
herself the moments that would make life more worth living. She commented on
how often she wouldn’t take 10 minutes to watch the sun set, or enjoy her coffee
with a few minutes of reading because she felt pressure to keep moving. She
resolved to keep trying to take a few minutes for small fun, knowing the effect
on her mood for the rest of the day would be entirely worth it.

Busy Fun Is Still Fun

People with TMA will probably never embrace the lie-in-the-hammock version
of time off. For them, balance is usually better found in busy activity, as long as
doing the activity is not a way to avoid anxiety but a way to use some energy in
a fun way. Whether it is a day of gardening, a 40-mile bike ride, or hitting every
garage sale in town on a Saturday morning, high-energy people usually want
their fun time to be busy, not leisurely. Discharging energy is good for TMA
people. The high energy level needs to be discharged, and using it for active non-
work activities is beneficial for anxiety relief and for calming the stress
response. That said, the person with TMA needs to distinguish between the
pleasure of accomplishment and pleasure just for the sake of pleasure. The actual
doing of the activity—not just accomplishing it—should be pleasurable.

Pay Attention to Whether Fun Feels Like Fun

Preoccupation with worry causes people not to notice fun when they are having
it. Their minds are in the future or the past, but not in the moment. Not paying
attention to fun robs it of its usefulness. Over time, they can get totally out of
touch with what they enjoy. Their thoughts about doing something for fun go
something like, “Oh, I have to go out to dinner with my best friend,” or “Oh no,
Friday is the night I have to go to the ball-game.” Again, the emphasis should be
on figuring out what is pleasurable.
When you pick what side of the fence an activity falls on—pleasurable or
unpleasurable—don’t use all the caveats that rob activities of fun. For example,
if you played games with the family on a Friday night and have to choose
whether the experience was pleasurable or unpleasurable, you cannot say, “well,
it would have been pleasurable if I had done better.” If you are forced to pick,
the statement becomes, “It was pleasurable.” If you have to go on to modify the
pleasure, use the word “and”—for example, “It was pleasurable, and I wanted to
do better.” Then you can examine more readily how you are interrupting their
pleasure and how you can change that interrupting.
Noticing pleasure and positive experiences is a huge challenge for overactive
people who are vigilantly looking out for mistakes in what they do. Their
difficulty shifting their thoughts away from worry and their on-the-go-no-time-
to-stop-to-reflect activity level interfere with noticing pleasure. But you can
learn to pay attention to what pleasure feels like—first by exploring it in
retrospect and then by paying attention on purpose when it happens. This
requires some brain power—you must use the prefrontal cortex to make a
decision to turn off your vigilance and deliberately shift the gears of your ACG,
and then consciously block the resulting anxiety. It also requires energy from the
prefrontal cortex to hold attention. If those things are just too hard to
accomplish, you will first need to acquire mental tools to interfere with
preoccupation and then come back to exploring positive experience.
Pay attention to activities you do during the week that are not work-related
and should be fun. Right after doing them, decide if the activity was pleasurable
or unpleasurable. Then write, draw, or talk with someone about how the fun felt.
Talking about what was pleasurable will expand the experience of pleasure and
make it easier to find similar opportunities to have fun.
Positive psychology researchers have demonstrated that enhancing positive
experiences is a necessary part of recovering from anxiety. Barbara Fredrickson
(2001), a prolific researcher and valuable contributor to the field of positive
psychology, has researched the impact of fun and has devised a way to make it
more powerful for people who do not get enough relaxation. She has described a
method she calls “broaden and build.” This method helps people fully appreciate
what positive activity does for their entire self and teaches them how to bring
more balance into their life when they are short on fun and relaxation. In short,
the method entails recalling a positive situation, event, or interaction in full
detail, remembering the feeling from each of the senses. Next, you repeat the
experience or create a similar experience. Then you notice how the new
experience is similar or different from the previous positive experience. This can
build upon the positive experience and cause you to be on the lookout for other
positive experiences.
In sum:

1. Find opportunities to laugh. It is a great way to discharge tension.

2. Follow an impulse to do something small, just because it is fun.
3. Notice whether the quality of the fun activity affects how balanced
you feel or how much anxiety you feel about other parts of your day.
4. Look for fun activities that require physical energy output.
5. Identify what is pleasurable or unpleasurable and pay attention to
pleasurable experiences.
6. Expand your awareness of positive experiences with the intentional
recollecting and reexperiencing of a similar event.

TMA AT DIFFERENT AGES AND IN SPECIAL

CIRCUMSTANCES
These methods to counter TMA can be used at all ages and with good success.
Even though TMA seems to be more of a problem for adults in their working
years, a few comments about other ages are useful. We don’t often worry about
children being too busy, especially whether they are too busy to relax. Therefore,
it should be a warning sign when you encounter a child who is very tense and
who is constantly busy. First, look for whether the parents (or you, if you are the
parent) have set up too much activity from their own anxiety about not giving
their kids the advantage of doing every activity humanly possible during their
childhood. These are children who are going to become anxious, who will not
learn self-soothing because they do not sit still long enough to calm themselves,
and who are going to hardwire the need for constant stimulation. Later in life
they will have great difficulty finding balance.
We don’t often worry about children being able to have fun, but when you
encounter a child who is very tense, it is wise to look for reasons at home, such
as abuse in their household or some other family secret that keeps them vigilant.
Also, there might be other mental health reasons, such as obsessive-compulsive
disorder. However, children and adolescents may be troubled by specific anxiety
about their social skills. Children are not good reporters of how they are getting
along with others. They may do very well one-on-one with a peer but not be able
to handle the stimulation or pressure of a group activity. They may fear being
teased for poor performance and stay out of activities that would otherwise be
fun. Contact teachers about how they do when they are in class or free time to
assess their ability to have some fun.
Adolescents who are tense and not relaxing may have anxiety that keeps
them perfectionistic or guarded against mistakes. Also, any teen with social
anxiety is in rough territory when at school. Their peers are very hard on them
and they have very little power to control classroom demands for public
performance. With adolescents, looking for the causes of this tension is essential,
because there is no way to relax and have fun if they cannot escape peer or
authority situations that keep them tense. In these cases, anxiety management
involves specific problem solving geared to interactions with peers or classroom
demands.
Sometimes the teen with high drive from basal ganglia overactivity will be
busy every moment with optional activities but not really relaxing while
participating in sports or clubs or extracurricular activities. Examine whether
these teens ever have relaxation times that they are not organizing or if they have
fun that does not have a score attached to it. Help them get into activities they do
not direct—they tend to be team captains or club presidents—and help them find
the kinds of active activities that are pleasurable but not graded or scored, like
bike riding, to open the door to the stress relief of active fun.
Elderly adults usually have the fewest demands for performance, but as
people with TMA age, they may face problems managing anxiety when their
activity is limited by health and mobility. When their anxiety escalates, they may
need help to find the less obvious reasons they can no longer manage their
anxiety, and then plan to correct it. For example, a newfound problem with
vision could be an obstacle to playing cards or reading or driving to activities
they enjoy. Such a problem would cause anxiety to skyrocket, yet that person
may not recognize the connection between fewer activities and increased
anxiety. Without knowing the cause, finding the right plan to address the anxiety
will be difficult. Offering that person medication might dull the anxiety, but
devising a plan to reestablish activities would be much more effective.

CONCLUSION
A final caveat about handling TMA is to remember there are people whose time
off of work is also work. Some people work two jobs, so time without work is
minimal. People who work a job and then come home to work for 6 more hours
(doing cooking, cleaning, caring for children or elderly parents, etc.) are not
going to have time to relax or have fun to relieve TMA. That problem is not
going to be solved by these methods for handling TMA. They suffer burnout
from too much work. They need relief, but careful thought must precede changes
to get the most self-care and balance back into the person’s life. This may
involve finding connections to social services that could help them. It may
involve problem-solving to make their work hours more efficient or their
minimal relaxation time more useful. All of the options cannot be identified
here, but practical support can often be a great anxiety and worry reliever, and
help from mental health practitioners at this practical level can be very powerful.
Finding every practical and delightful measure to reduce the impact of TMA
and get some relief requires people to value their leisure as restorative and
productive. The mind and body that have had time to play will be more
productive and creative. Remember this as you begin to manage your anxious
behavior, and direct your energy to fun and relaxation.
 TWELVE

Technique #10: Implement a Plan and Practice

This technique is about acquiring competence and confidence—the major

behavioral goal for people with the social anxiety symptoms of appearing very
nervous in situations where they will be observed. The only possible way to
achieve competence and confidence is through experiences that expand or
strengthen knowledge and skill. Technique #10 shows how to develop
competence and confidence for managing anxiety in work and social settings. In
order to devise a plan and carry it out, you will need to build on other
techniques, because part of the confidence is the confidence that if anxiety
occurs, you will be able to manage it.

THE BRAIN LEARNS AND UNLEARNS FEAR

Expectations of being anxious will cause anxiety to happen. It is probable that an
enlarged amygdala (the part of the brain that warns of trouble) causes people to
be overly sensitive to faces. When they detect even the slightest shift on a face,
the amygdala interprets the shift as negative, causing people to believe they are
being judged as failures or will be rejected. They then develop expectations such
as, “I cannot speak in public without shaking and embarrassing myself,” or “If
anyone notices me eating, I will humiliate myself somehow by spilling food or
making a mistake,” or “I just know I will panic if I have to wait for a long time
to get seated at the restaurant.” The die is cast. If they go into those situations,
they will panic or feel humiliated. Their expectations create their future reality.
Fortunately, the amygdala that warns of danger also has a function to unlearn
fear. But it can only unlearn when it is in a situation that previously created fear
and now does not create fear. The cortex sends information back to the amygdala
that the new situation is safe, calming it so that in the future it won’t generate
fear of the situation. Once you unlearn the fear, you can behave competently and
confidently and can do it again in a similar situation.
Unless new learning is planned for, there is no chance for the amygdala to
unlearn fear. Without a plan, you will be filled with the same old intense fear—
the thinking brain will be busy noticing how scary the situation is. Change
requires a deliberate decision to behave as if the situation is not frightening. With
specific planning and preparation, the amygdala has a chance for new learning.

THREE DEEP BREATHS AND GOOD PREPARATION

When I was in high school, I was stricken with vicious stage fright, which I now
know was an outcome of having panic attacks that attached themselves to a
variety of situations as well as to my acting. Waiting in the wings to go onstage,
I would pray to God to make me fall over dead before I had to go out and sing.
Dying would not have been a particularly useful avoidance behavior, to be sure,
but it was about the only excuse the rest of the cast and crew would accept for
missing my cue. My drama coach taught me one of the best anxiety management
ideas I would ever learn: to breathe slowly and deeply. She also gave me a
mental framework for handling the anxiety. “All you need to go out there
without fear is three deep breaths and good preparation.” Her “three deep breaths
and good preparation” has become my model for getting rid of anxious behavior
in any anxiety-producing situation.
“Three deep breaths” stands for the ability to remain physiologically calm
while waiting for the practice to start. People who are going to go out into the
real world and do something new—order in a restaurant, speak at a staff
meeting, sit in the middle of a theater, drive on the tollway—need to stay as calm
as possible so that it is harder to trigger their anxious reactions. Keeping the
body calm with breathing and muscle relaxation is a choice a person can make, a
prefrontal cortex activity that has effects on physiology and on brain function.
Begin one-breath relaxation or your favorite breathing method the moment
you know a situation could stir anxiety. If you have planned your practice, you
will know ahead of time that you need it. For example, if you are going to speak
up at a staff meeting, deliberately breathe and loosen up throughout the day
before the meeting. Prevent getting tense and uptight. Once you are in the room
for the meeting, you will use one-breath relaxation to stay physically calm until
it is time for you to speak. In this way your body remains as quiet as possible—
your sympathetic nervous system and your peripheral nervous system are quieter
—so your symptoms will not be as easily triggered. Even if you feel somewhat
nervous, you won’t be as uptight when you start speaking and will manage
anxiety successfully, which is the desired outcome of practice. In every planned
practice, staying calm is part of the plan. Having learned that, it is time to move
on to the heart of technique #10—implementing a plan and practicing in real life.
“Good preparation” stands for all the stages of getting ready to practice in
real life and for the practice session itself. Preparation includes mental readiness
like technique #8 for changing self-talk, which establishes the mental bridge to
practice management of anxious behavior. Good preparation also includes
finding the right motivation.
Why in the world would someone who wanted to die rather than sing a solo
in front of an audience go out to sing more than one time? Motivation. Once I
got in front of the audience without dying, I enjoyed the act of singing. I had
practiced it and I could do it well. Serotonin gave my brain a sense of
satisfaction at a job well done. And then there was the applause. My brain liked
the dopamine flowing as people applauded the performance. With enough
motivation, a person will face fear. Once fear is faced, it is diminished. I went on
to major in speech and drama in college with anxiety for performing well in
control.

IMPLEMENT A PLAN
Knowing precisely what you want in life and going after it is harder than most
people realize. Take some time to figure out what you desire and then follow this
process.

Set Goals

The first part of making a plan is setting a goal. It is goal-setting that gets you in
touch with motivation to do what scares you. Keeping motivation in front of you
will help you face the things that cause fear and be able to relax about them.
Know exactly what you want to do. People want to achieve myriad goals, some
very specific and some more general:

• “Order in a restaurant without breaking into a sweat.”

• “Speak to my boss without a quavering voice.”
 • “Stay in class this semester.”
• “Start interviewing for jobs.”

The best plans start with getting very specific about what you want to
accomplish.

Assess What Makes You Anxious and What Skills You Need

After the goal is identified, it is time to assess what skills are needed to meet the
goal. If you are preparing to attend social functions for work, assess your ability
to comfortably greet people and initiate conversation. If the goal is to go on a job
interview, assess your ability to field interview questions. If you want to begin
dating again, assess what opportunities are available to meet people via email,
phone, and in person and what communication skills you need.
Accurately assessing what makes you anxious and what skills you might
need requires a careful review of your history. This is very hard for a person to
do on his or her own. Working with a therapist for this whole technique is not
only helpful but also probably necessary. Review your life experiences in the
following areas to assess what is needed.

Social Skills

Do you have the need or desire to go out socially with friends or to date? Pockets
of social uncertainty can crop up unexpectedly, and sometimes otherwise highly
functioning people will have surprising insecurities about social events.
Specifically assess whether social skills are developed for everything you want
to do. Do you need to learn assertiveness? Can you confidently introduce
yourself to new acquaintances? How about being able to enter a meeting room
and choose where to sit or how to greet a colleague? Can you talk to your child’s
teachers or the parents of your child’s friends in person and by phone? Can you
ask for a date or invite a new acquaintance to a social gathering?

Personal Business Skills

Do you have the ability and willingness to do the social aspects of personal
business, such as signing checks or credit slips in front of a clerk or talking with
retail personnel? Can you ask questions to purchase, return, or exchange goods?
Can you talk with medical personnel and clarify information about medical
conditions and treatments? Can you talk to your child’s coaches or tutors and
make appointments and financial arrangements for lessons with ease?

Work or Career Skills

This is not so much about actual work skills, but rather the more social
components of a job: asking questions of a supervisor, talking with a coworker at
break, talking with a coworker about a work situation, and so on. Are work-
related and presentation skills developed? Can you interview for a job? Do you
know how to make a presentation in a meeting? Do you know how to offer
comments during a committee meeting? Do you have skills to handle
discussions with managers or supervisors regarding work?
Assertiveness is a skill that may be needed for any of these areas of
functioning. Assertiveness means knowing and being willing to ask that your
needs are considered and met in any situation. This is usually a relevant concern
in situations that may involve a hint of conflict, such as returning retail items to a
store, objecting to inaccurate charges on a bill, asking a repairman to clarify
appointments or bills, asking for changes in a work schedule or requesting a
vacation date, and telling a manager that a work assignment is too much.

Build Skills

Once the assessment is done, creating the plan to build the skills and develop a
practice routine comes next. When a person is missing skills, even skills that are
very easy to learn, he or she probably does not know what skills are necessary or
where to get them. That must be specifically planned.
There are so many ways to learn skills. Consider using workbooks for social
skills and assertiveness training. You can learn skills in group therapy for
assertiveness, social skills, conflict management, anger management, and so on.
Adult education departments at community colleges often offer free or
inexpensive classes for topics like public speaking, flirting, interviewing,
etiquette, Internet communication, and the like. You can even consider acting
class!

Practice in Private

Trying out the skills is very important, and so is making the steps small enough
to be done successfully. The brain needs the successes to be able to go on to a
more difficult step with confidence. Your brain knows if you are not competent
and will generate anxiety if you move too fast. Breaking every goal into small
steps is the best approach. Finding the right teacher, usually a psychotherapist, is
critical to success. Trying new skills requires the right amount of encouragement
to get the practice done. If you are working from a workbook, you should review
that you have the right idea and are not working too fast, and a therapist can be
an asset to making sure you are on track. Mastering each level of skill will
increase your confidence that you can do what it takes. If the amygdala is to
unlearn fear, it is essential that you do not rush into trying something until you
are sure you can do it. For example, if you want to learn to interview for jobs
without looking nervous, you might break it down into smaller steps like these:

• Learning to shake hands with eye contact, and practicing this

• Making a list of questions and referring to it casually while practicing
asking the questions
• Constructing some information about your work history, your
strengths, and your job skills and practicing describing this verbally
• Learning to pause and think if a question requires it without appearing
nervous
• Conducting a practice job interview with a therapist, friend, or
colleague.

With a therapist, people can “act as if.” In other words, they can practice
skills as if they are in a real-life situation while still feeling safe. That practice
will help the amygdala to unlearn some of the fear before going into practice in
real life. In a therapy session, a person can try out skills that the therapist has
taught or skills that are being learned from workbooks. Being in skills classes are
another way to practice in private before getting ready to go out into real life.
Practicing in private is a method many people resist because they are
embarrassed. That is exactly why it is necessary. Not practicing before the real
event is akin to learning a part in a play and then saying you do not want to
rehearse it before going onstage for the first performance in front of an audience.
Practicing what you will say to a server in a restaurant, what you will say if you
run into your new boss in the hallway, what you will do if you must use the
restroom during the middle of a movie, what you will say to your teacher if you
are feeling you cannot join a study group, and so on are important practice
situations. Find someone to practice with—a parent, a therapist, a spouse, a
friend—or speak your part out loud on your own. Your lips will remember better
what to do if they have said the words before. When you practice your brain is
getting a workout directed by your prefrontal cortex, and all the parts of your
brain are involved—the amygdala, motor cortex, limbic system, anterior
cingulate gyrus, orbito-frontal cortex, and prefrontal cortex. The more often you
practice, the better you will remember. You literally form pathways of
connections in your brain that will make it easier to remember what you have
practiced when you are under pressure.
To summarize:

1. Set a clear goal.

2. Assess what makes you anxious.
3. Build skills by reading and using workbooks, attending classes, etc.
4. Break it into manageable steps and accomplish them one by one.
5. Practice in private.

DESENSITIZATION OF TRAUMA
Desensitization cannot be taught here, but must be mentioned on behalf of those
who have a history of trauma that blocks being able to go back to an experience.
When people have been traumatized, just imagining a similar situation may
activate their sympathetic or peripheral nervous system. In these cases,
psychotherapy is necessary to desensitize the memory of that trauma. Similarly,
panic causes a rapid association between panic and details of a situation. Panic
attacks cause people to make the mistake of believing the situation caused the
panic, and then their brains automatically assume panic will occur whenever
they are in the situation. People who have panicked in a social setting will need
help desensitizing before they can reenter a similar setting, just as those with
social anxiety symptoms need help to recover from shame trauma for situations
in which they were intensely nervous and were humiliated for it.
There are three primary methods of desensitization: systematic
desensitization, energy therapy, and EMDR. All of these methods require
working with a therapist who is specialized in them.
 • Systematic desensitization. In this method, the therapist begins by
teaching the client relaxation, and then creating a hierarchy of anxious
elements of a situation. Starting with the element that produces the
lowest level of anxiety, the client imagines the element until he can
relax fully. The therapist then guides the client up the hierarchy, one
step at a time, until all elements are desensitized.
• Energy therapy. With this method, the client identifies the thoughts
that stimulate negative feelings and identifies the exact nature of the
negative feeling (anxiety, embarrassment, phobia, etc.). She then
notices the level of negative physical arousal and rates it. Next, she
taps on acupressure points that correspond with the physical arousal,
and rates the feeling again until the negative feeling has dissipated.
• EMDR. Eye movement desensitization and reprocessing (EMDR) is
the most versatile, profound, and challenging method for a therapist,
but it often produces results that may be unattainable with any other
method for traumatic experience, especially shame trauma for people
with social anxiety. Therapists must be trained and qualified to use
EMDR.

IN VIVO (REAL-LIFE) PRACTICE

Practice in real life—as opposed to in private—is done in small steps that
gradually increase the length of time in the situation in order to allow a person to
leave the situation while still feeling calm. The steps should also move from
“low stakes” to “high stakes”—high stakes are for the final stages, not the
beginning. For instance, if someone who fears sitting in the middle of a theater is
practicing going to the movies, he should not start out in vivo practice by
arriving late, when most of the seats are occupied, and staying for the duration of
the entire movie. He should not go to the opening night of a blockbuster movie
when every seat will be taken. He should not ask a first date to go along on a
practice run when the consequence of bolting from the theater in embarrassment
would risk humiliation in the eyes of a new romantic partner. Instead, this person
should break the situation down into steps of increasing exposure, like this:

1. Decide if any skills are necessary, like buying tickets without

embarrassment.
 2. Plan how long the exposure should be, based on the level of fear and
prior experience. Should you allow yourself to leave when the lights
are dimmed and when people are still coming and taking seats, or can
you stay for the previews and then leave as if you need more popcorn
before the show starts? Can you sit through the entirety of a short
film if you are by the door?
3. Plan whether you need a support person, like a good friend or a
spouse, or if it is better (less embarrassing) to try this alone.
4. Make the steps as large as possible but reasonably achievable. Arrive
early to a show that has been out for several weeks. Sit on the aisle by
the door and stay as long as you planned and no longer. Leave while
feeling competent so that you will be more confident for the next
level of exposure.

The most difficult part of this technique is getting exactly the right degree of
exposure to build competence without risk of diminishing confidence.

Cooperation for In Vivo Exposure

Getting the cooperation of people who are in a position to make the exposure go
better is not just a good idea but also necessary. This is particularly true with
children who have school-related anxieties. Various staff, such as the principal,
the school nurse, teachers, and the counselor, all need to know what the goals of
exposure are so that accidental escape or, worse, accidental humiliation is
avoided.
Parents play a key role with younger children. Ten-year-old Madison had
been nervous about school and was a shy child but had friends and was liked by
her teacher. After she had a substitute teacher twice in a week, she started asking
to stay home, saying she felt sick in the mornings. (The stomach is a good
indicator of how nervous a person is!) Her parents allowed her to stay home
“just until her stomach settled down enough to go to school.” It only took about
3 days to notice that Madison’s upset stomach always seemed to get better
around 3 P.M., when school was over for the day and she wouldn’t have to go.
Her parents needed to get her back into the classroom despite knowing she
would cry, so they contacted the office to make a plan.
The plan was that Madison would go to school the next day, but she would
be able to leave early, right after the first two classes, which she enjoyed. The
next day she would stay longer, through lunch so she could sit with her best
friend, and then leave while she felt good about that. On the third day she would
stay all day. Madison’s parents told her the plan and made sure she understood it.
They also made sure she remembered what they had taught her about how to
breathe and stay calm.
The following day, the plan was begun. Madison’s parents brought her into
the classroom before other students started arriving and were met by the nurse
and the teacher. They explained that the nurse would not be calling her parents
even if she felt sick, and that she would stay in the classroom without going to
the nurse even if she cried. As they left the classroom, her parents reminded her
that they would be there to pick her up after her second class. Madison cried, but
as there were no other students around yet and her parents were not there, her
avoidance behavior was not reinforced. She found that after she was in the
classroom and distracted by the days’ activities, she did not feel sick. It was
easier for both the parents and Madison to return to school the next day.
Another example is that of Meagan, who was a freshman in high school.
Meagan had always been timid. Although she did well in most subjects, she felt
out of her league in geometry. After she developed a string of reasons to skip
class, go home before class, and get sick just before class, the teacher spoke to
her and her counselor about it. Meagan revealed that speaking in math class was
unbearably anxiety-provoking. She could not stand the fear that she might be
called on, get the answer wrong, and be humiliated. Together with her parents,
the counselor, and the teacher, a plan was hammered out:

1. Meagan was taught one-breath relaxation to stay calm in class.

2. Meagan’s parents continually reviewed the homework with her to
practice saying answers out loud.
3. The first in vivo practice would occur the next day in class. Meagan
would raise her hand if she knew the answer. Her task was to do that
at least once, preferably at the beginning of the class. (This was the
“do the worst first” method of worry management.)
4. The teacher would immediately call on her if her hand was up and
would not call on her if it was not.
5. As Meagan successfully accomplished each step, she would review
with her parents and the counselor her successes and then go into
class knowing the next step.
The next stages of practice would take place as soon as Meagan felt competent
to raise her hand and get called on immediately:

1. Meagan would raise her hand and the teacher might or might not call
on her so that she could get used to the “surprise” if she was called
on.
2. She would practice one-breath relaxation while she waited.
3. After she felt competent to wait without anxiety the next level would
be tried.
4. The teacher would call on her no more than one time in a class when
her hand was up.
5. After Meagan could do that without fear, the final stage would be to
solve a homework problem on the board. The teacher would tell her
ahead of time which problem he would call on her for.

Practice Without a Support Person

An adult may have social goals that will not necessarily require cooperation with
others, but when adults live with others, there is usually someone who is running
interference for them on things they need to avoid. If a spouse or parent is
involved, make sure that he or she knows the plan and doesn’t inadvertently foil
it.
Jerrold had just been appointed as project manager for a contract his firm
was beginning. He was now responsible for giving regular reports in meetings he
had not previously had to attend. Although he was not worried about talking
with his team—they knew him well and it felt more like a conversation—the
thought of participating in the meetings with the boss and other directors was
nerve-wracking. When Jerrold made his plan, the goal was obvious—to be able
to speak in the meetings with his superiors without turning red and sweating. His
skill set for regular conversation was good enough; however, he had avoided
speaking in front of a group so often that he had no idea what it would take to
handle the stress. He had been in more meetings than he could count, and he had
listened to lots of reports, but he had always been so focused on his own
discomfort and avoidance tactics that he never especially noticed how people
handled their own behavior when they interjected comments or gave reports. An
assessment was necessary of what went on in meetings and what he feared
would trigger his anxiety.

1. Jerrold’s first step was to observe the meetings—how people said

hello, got coffee, and settled into their places. He was to observe the
protocol for people responding to someone giving a report. How did
people get acknowledged, called on, or responded to? He planned to
get into the room before others arrived so that he could see how
people entered, how they greeted each other, and how the meetings
progressed. His assignment was to observe others speaking.
2. Jerrold’s second step was to list those observations and identify his
self-talk for each one. He found that he had a series of negative self-
statements, such as “I can never be as relaxed as Morgan,” “No one
will listen to me because I am not charismatic like Frank,” and “I will
turn red the minute anyone looks at me and my credibility will be
shot.”
3. He then made a list of counter-cognitions to help prepare himself
mentally.
4. Finally, he made a list of steps he wanted to practice before he gave
his first full report.

Jerrold followed the principles we had identified to increase the intensity of

exposure a little at a time. In this case, it was increasing exposure to being
looked at without feeling on the spot. He realized that his avoidance behavior
had been to always be the first one in the room before a meeting. Thus he had
avoided coping with being looked at when he entered a meeting.

1. Jerrold decided to practice entering the room later and later until he
could enter just before it started without discomfort. He was able to
do that over the course of a couple of weeks.
2. When he reviewed his progress, he noted that he had overestimated
how much people were noticing him. That made him feel safer.
3. Next, he wanted to practice volunteering some comments when he
would otherwise have kept quiet. He decided to start with short
comments that indicated he agreed with a statement, so there would
be no complication of feeling nervous that he was starting a conflict.
 4. When he evaluated how he did, he was able to notice that people
were polite to him and accepted his comments.
5. His next and final practice was to find a topic that was being debated
and make a comment supporting one side of the debate. To his
surprise, he had no trouble finding an opportunity because in every
meeting there was back and forth conversation.
6. In evaluating his success, Jerrold realized that he was expecting
others to jump on him if he stated an opinion, but that in reality
everyone else was expressing opinions and no one appeared to be
shocked when he did.
7. He was ready to prepare and give his first report, which he practiced
out loud a couple of times to make sure he knew what he wanted to
say.
Jerrold followed the principles of good real-life practice:

• Make a list of small, achievable steps.

• Increase the intensity of the steps and the duration of exposure. That
means increasing the length of time you stay in a situation, how long
you speak, how many people you interact with, and so on.

What If I Fail a Step?

The point of breaking a plan down into small steps is to maximize your chances
of success. However, there may be times when you fail in trying to achieve a
step. Don’t despair or give up when this happens! Remember:

• The in vivo process reveals what else you need to know. If something
goes wrong, the good news is that you now know what you have to
plan for.
• Everyone makes mistakes. No one is exempt. You are human.
• Failing to achieve what you wanted in the step is no big deal—you
have been scared or embarrassed before and you lived through it. Your
brain is accustomed to it. It will be possible to try again with a better
plan.
 Help from Medication

Although all these techniques are intended to be done without medication, a

brief word is necessary here. This situation—real-life practice—is the only one
in which using medication to stay calm can be a definite aid to learning. When
people are overwhelmed by fear, they are not going to learn anything new. It is
important to keep the degree of nervousness or fear in manageable proportions
while they are practicing. Because panic and flushing, sweating, and shaking are
so hard to completely prevent, it can be very useful to have medication as a
back-up to reduce the level of fear during practice.
When trying to do something new, many of my clients make a plan with their
M.D. to use their anti-anxiety medications on an as-needed basis. They still feel
nervousness but it is much less, and they are much more likely to succeed at
managing the nervousness and performing their step successfully. This helps the
amygdala unlearn fear in that situation and confidence is built that the next step
will also work. Before moving to the next step, one trial without medication is a
good idea. You can then use it again for the first trial of the subsequent small
step.
To recap the steps of in vivo exposure:

1. Remember the “three deep breaths and good preparation” guideline.

This helps you calm the mind and body, set goals, and get skills.
2. Make a list of all the possible small steps, and pick the largest small
step that can be done successfully.
3. Enlist the assistance of everyone who can help or inadvertently hinder
the steps to be sure they understand the plan and will do their part to
help you succeed and not rescue you.
4. Decide whether to use medication and plan to use it for the first trials
of the graduated steps.
5. Begin planned, graduated real-life practice steps—specific small steps
that can be prepared for and for which the success is assured by
practice in private and confidence in skills to stay calm.
6. Review success and select the next step, increasing the duration of
exposure but making sure the step can be achieved so new learning can
occur.
7. Evaluate any failures to achieve the steps and make course corrections
 for practice.
8. Continue each step with preparation until the whole goal is met. At
every stage, the new learning (or unlearning of fear) lays groundwork
for the next step to occur safely. It is not until the whole goal is met
that the safe experience will completely turn off the warning signal for
that specific situation in the future.

CONCLUSION
Practice means exactly that—making trial runs to do things you have not been
able to do before. And no one goes out on a practice run without preparation. If
you are preparing for an athletic event, you learn skills, you try them out, you
see what works and what doesn’t, you get advice about how to do those skills,
and then you try them out again before the competition. If you are running a
marathon, you go through months of preparing, starting with short runs and
working up gradually to the long run. If you are going to act in a play, you
practice by using a script and staying within marks on the floor of a room to
show where the stage is. Then you practice on the stage without the script, and
finally you have a dress rehearsal with all the parts in place before an audience
sees you. The same is true for in vivo practice. Become able to take those three
deep breaths, prepare well, and get ready to go out into real life. Practice makes
possible.
Recommended Reading & Resources THE BRAIN AND
METHODS TO WORK WITH IT
Amen, D., & Routh, L. (2004). Healing anxiety and depression. New York: Penguin.
Walsh, D., & Bennett, N. (2004). Why do they act that way? A survival guide to the adolescent brain for
you and your teen. New York: Free Press.
Wehrenberg, M., & Prinz, S. (2007). The anxious brain. New York: Norton.

WORKBOOKS AND ACTIVITIES FOR SOCIAL SKILLS,

ASSERTIVENESS, AND ANGER MANAGEMENT
Carter, L., & Minirth, F. (1993). The anger workbook. Nashville, TN: Thomas Nelson.
Eifert, G., McKay, M., & Forsyth, J. (2006). Act on life, not on anger. Oakland, CA: New Harbinger.
Eifert, G., McKay, M., & Forsyth, J. (2005). Acceptance and commitment therapy for anxiety disorders.
Oakland, CA: New Harbinger.
Khalsa, S. (1996). Group exercise for enhancing social skills and self-esteem. Sarasota, FL: Professional
Resource Press.
Madson, P. R. (2005). Improv wisdom. New York: Crown.
Nay, W. R. (1995). Anger and aggression: Cognitive-behavioral and short-term interventions. In L.
Vandercreek, S. Knap, & T. Jackson (Eds.), Innovations in clinical practice. Sarasota, FL:
Professional Resource Press.
Novotni, M. (1999). What does everybody else know that I don’t know? Plantation, FL: Specialty Press.
O’Hanlon, B. (1999). Do one thing different. New York: William Morrow.
Robbins, J. M. (2002). Acting techniques in everyday life. New York: Marlowe.
Seigel, D., & Hartzell, M. (2003). Parenting from the inside out. New York: Putnam.
Wagner, A. (2005). Worried no more: Help and hope for anxious children. Rochester, NY: Lighthouse
Press.
Wilson, R. (1996). Don’t panic: Taking control of anxiety attacks. New York: Harper Collins.
Zeff, T., & Aron, E. (2004). The highly sensitive person’s survival guide: Essential skills for living well
in an overstimulating world. Oakland, CA: New Harbinger.

LISTENING TO YOUR BODY

Childre, D., & Martin, H. (1999). The heartmath solution. San Francisco: Harper Collins.
Cornell, A. W. (1996). The power of focusing. Oakland, CA: New Harbinger.
Gendlin, E. (1998). Focusing-oriented psychotherapy. New York: Guilford.

RELAXATION, MEDITATION
Davis, M., McKay, M., & Eshelman, E. R. (1980). The relaxation and stress reduction workbook.
Oakland, CA: New Harbinger.
Ensley, E. (2007). Prayer that relieves stress and worry. Fortson, GA: Contemplative Press.
Nhat Hanh, T. (1975). The miracle of mindfulness. Boston: Beacon.

ADDITIONAL ANXIETY MANAGEMENT TECHNIQUES AND

RESOURCES
Baker, D. (2004). What happy people know. New York: St. Martin’s-Griffin.
Burns, D. (1999). The feeling good handbook. New York: Plume.
Ecker, B., & Hully, L. (2007). Coherence therapy manual. Available on their website
www.coherencetherapy.org.
Gallo, F., & Vincenzi, H. (2000). Energy tapping. Oakland, CA: New Harbinger.
McMullin, R. (2005). Taking out your mental trash. New York: Norton.
Pratt, G., & Lambrou, P. (2000). Instant emotional healing. New York: Broadway Books.
Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and
procedures (2nd ed.). New York: Guilford.

Emotional Freedom Technique

PO Box 269
Coulterville, CA 95311
www.emofree.com

Energy Tapping
www.energypsych.com

Instant Emotional Healing

www.instantemotionalhealing.com

GUIDED IMAGERY AND RELAXATION AUDIO CDs Margaret

Wehrenberg (for breathing and relaxation techniques described in this
book) 1555 Naperville/Wheaton Road
Naperville, IL 60563
630-961-2854
www.margaretwehrenberg.com

Belleruth Naperstak (selection of audio tapes for anxiety) HealthJourneys

891 Moe Drive, Suite C
Akron, OH 44310
1-800-800-8661
www.healthjourneys.com

NUTRITION AND SUPPLEMENTS

Des Maisons, K. (1998). Potatoes, not Prozac. New York: Simon & Schuster.
Hendler, S., & Rovik, M. S. (Eds.). (2001). Physician’s desk reference for nutritional supplements. Des
Moines, IA: Thompson Healthcare.
Weil, A. (2000). Eating well for optimal health. New York: Knopf.

University of Pittsburgh (resources, websites, and groups who study and promote herbal remedies)
www.pitt.edu/~cbw/herb.html

Medline
www.medlineplus.gov/

The American Botanical Council

PO Box 144345
Austin, TX 78714-4345
1-800-373-7105
512-926-2345 (f)
www.abc.herbalgram.org

MEDICATION ASSISTANCE
National Alliance on Mental Illness (resources for people who cannot afford medication) Colonial Place
Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201-3042
1-800-950-NAMI (6264)
www.nami.org

IRRITABLE BOWEL SYNDROME

www.webmd.com/ibs/guide/stress-anxiety-IBS

SLEEP
www.sleepeducation.com

ADDICTIONS
National Institute of Drug Addiction
www.nida.nih.gov

National Clearinghouse on Drug and Alcohol Addiction 1-800-729-6686

Addiction self-help:
• www.alcoholics-anonymous.org
• www.rational.org
• www.smartrecovery.org
 • www.ca.org (Cocaine Anonymous) Family help with addiction:
• www.al-anon.alateen.org
• www.familiesanonymous.org

TRAUMA
International Society for Traumatic Stress Studies 60 Revere Drive, Suite 500
Northbrook, IL 60062
847-480-9028
847-480-9282 (f)
www.istss.org

Sidran Traumatic Stress Foundation

200 East Joppa Road, Suite 207
Baltimore, MD 21286
410-825-8888
www.sidran.org

International Critical Incident Stress Foundation 10176 Baltimore National Pike, Unit 201
Ellicott City, MD 21042
410-750-9600
410-750-9601 (f)
www.icisf.org

MENTAL HEALTH ORGANIZATIONS

Anxiety Disorder Association of America 8730 Georgia Avenue, Suite 600
Silver Spring, MD 20910
240-485-1001
240-485-1035 (f)
www.adaa.org

National Institute of Mental Health

www.nimh.nih.gov

Obsessive-Compulsive Foundation

676 State Street

New Haven, CT 06511
203-401-2070
www.ocfoundation.org

American Psychological Association

750 First Street Northeast
Washington, DC 20002-4242
1-800-374-2721
www.apa.org

American Psychiatric Association

1000 Wilson Boulevard, Suite 1825
Arlington, VA 22209-3901
703-907-7300
www.psych.org

EMDR International Association

5806 Mesa Drive, Suite 360
Austin, TX 78731
1-866-451-5200
512-451-5256 (f)
www.emdria.org
 References

Alsene, K., Deckert, J., Sand, P., & de Wit, H. (2003). Association between A2a receptor gene
polymorphisms and caffeine-induced anxiety. Neuropsychopharmacology, 28(9), 1694–1702.
Amen, D. (2003). Healing anxiety and depression. New York: Penguin.
Amen, D. (2000). Change your brain, change your life. New York: Three Rivers Press.
Aron, E. (1996). The highly sensitive person. New York: Birch Lane Press.
Bartholomew, J. B. (2005). Brief aerobic exercise may improve mood, well-being in major depression.
Medicine and Science in Sports and Exercise, 37, 2032–2037.
Benson, H. (1996). Timeless healing: The power and biology of belief. New York: Fireside.
Benson, H. (1975). The relaxation response. New York: Avon.
Berk, L., & Tan, S. (1989). Neuroendocrine influences of mirthful laughter. The American Journal of the
Medical Sciences, 298(6), 390–396.
Berretta, S. (2005). Cortico-amygdala circuits: Role in the conditioned stress response. Stress, 8(4), 221–
232.
Blackburn, I. M., & Moore, R. G. (1997). Controlled acute and follow-up trial of cognitive therapy and
pharmacotherapy in out-patients with recurrent depression. The British Journal of Psychiatry,
171, 328–334.
Blaylock, R. (2004). Connection between MS and aspartame. [On-line]. Available:
www.wnho.net/ms_and_aspartame.html.
Bouton, M. E. (2002). Context, ambiguity and unlearning: Sources of relapse after behavioral extinction.
Biological Psychiatry, 52(10), 976–986.
Bush, G., Luu, P., & Posner, M. I. (2000). Cognitive and emotional influences in anterior cingulate
cortex. Trends in Cognitive Science, 4, 214–222.
Childre, D., & Martin, H. (1999). The heartmath solution. San Francisco: Harper.
Clark, D. M., Ehlers, A., McManus, F., Hackmann, A., Fennell, M., Campbell, H., Flower, T.,
Davenport, C., & Louis, B. (2003). Cognitive therapy versus fluoxetine in generalized social
phobia: A randomized placebo-controlled trial. Journal of Consulting and Clinical Psychology,
71, 1058–1067.
Cottraux, J. (2005). Recent developments, research and treatment for social phobia (social anxiety
disorder). Current Opinion in Psychiatry, 18(1), 51–54.
Craft, L. (2005). Exercise and clinical depression: Examining two psychological mechanisms.
Psychology of Sport and Exercise, 6(2), 151–171.
Cynkar, A. (2007). A prescription for exercise. Monitor on Psychology, 42–43.
Davidson, J. R. T., Stein, D. J., Shalev, A. Y., & Yehuda, R. (2004). Posttraumatic stress disorder.
Journal of Neuropsychiatry and Clinical Neurosciences, 16(2), 35–51.
Delgado, P. L., Price, L. H., Miller, H. L., Salomon, R. M., Aghajanian, G. K., Heninger, G. R., &
Charney, D. S. (1994). Serotonin and the neurobiology of depression: Effects of tryptophan
depletion in drug-free depressed patients. Archives of General Psychiatry, 51, 865–874.
Demos, J. (2004). Getting started with neurofeedback. New York: Norton.
DesMaisons, K. (1998). Potatoes not prozac. New York: Simon & Schuster.
Dunn, A., Trivedi, M., Kampert, J., Clark, C., & Chambliss, H. (2005). Exercise treatment for
depression: Efficacy and dose response. American Journal of Preventive Medicine, 28(1), 1–8.
Eisen, A. R., Kearney, C. A., & Schaefer, C. E. (1995). Clinical handbook of anxiety disorders in
children and adolescents. New York: Aronson.
Eisen, A. R., & Schaefer, C. E. (2005). Separation anxiety in children and adolescents: An
individualized approach to assessment and treatment. New York: Guilford.
Evans, G. W., & Johnson, D. (2000). Stress and open-office noise. Journal of Applied Psychology, 85(5),
779–783.
Evers, A. (1989). Affirmations: Your passport to happiness. North Vancouver, BC, Canada:
Affirmations-International Publishing Company.
Fava, G. A., Rafanelli, C., Grandi, S., Conti, S., & Belluardo, P. (1998). Prevention of recurrent
depression with cognitive behavioral therapy. Archives of General Psychiatry, 55, 816–820.
Field, T. (2002). Massage for fibromyalgia. Journal of Clinical Rheumatology, 8(2), 72–76.
Fisone G. G., Borgkvist, A., & Usiello, A. (2004). Caffeine as a psychomotor stimulant: Mechanism of
action. Cell and Molecular Life Science, 61(7–8), 857–872.
Frank, E. (1991). Interpersonal psychotherapy as a maintenance treatment for patients with recurrent
depression. Psychotherapy, 28, 259–266.
Fredholm, B., Bättig, K., Holmén, J., Nehlig, A., & Zvartau, E. (1999). Actions of caffeine in the brain
with special reference to factors that contribute to its widespread use. Pharmacology Review,
51(1), 83–133.
Fredrickson, B. L. (2001). The role of positive emotions in positive psychology: The broaden-and-build
theory of positive emotions. American Psychologist, 56, 218–226.
Gallo, F. (2000). Energy diagnostic and treatment methods. New York: Norton.
Gazzaniga, M. (2005). The ethical brain. Chicago: University of Chicago Press.
Gendlin, E. T. (1981). Focusing. New York: Bantam.
Gendlin, E. (1996). Focusing-oriented psychotherapy: A manual of the experiential method. New York:
Guilford.
Goldberg, J. (1997). Can we boost neurotransmitter precursors? [On-line]. Medscape Psychiatry &
Mental Health eJournal 2(1). Available: www.medscape.com/viewarticle/431512.
Gould, R., Otto, M. W., & Pollack, M. H. (1995). A meta-analysis of treatment outcome for panic
disorder. Clinical Psychology Review, 15, 819–844.
Grillon, C. (2002). Startle reactivity and anxiety disorders: Aversive conditioning, context and
neurobiology. Biological Psychiatry, 52, 958–975.
Hafen, B., Karren, K., Frandsen, K., & Smith, N. (1996). Mind/body health: The effects of attitudes,
emotions, and relationships. Needham Heights, MA: Allyn and Bacon.
Haskell, W. L., Lee, I. M., Pate, R. R., Powell, K. E., Blair, S. N., Franklin, B. A., Macera, C. A., Heath,
G. W., Thompson, P. D., & Bauman, A. (2007). Physical activity and public health: Updated
recommendation for adults from the American College of Sports Medicine and the American
Heart Association. [On-line]. Circulation, 116. Available:
www.circ.ahajournals.org/cgi/content/abstract/circulationaha.107.185649.
Kabat-Zinn, J. (2005). Coming to our senses: Healing ourselves and the world through mindfulness.
New York: Hyperion.
Kaplan, G., & Hammer, R. P. (Eds.). (2002). Brain circuitry and signaling in psychiatry: Basic science
and clinical implications. Washington, DC: American Psychiatric Publishing.
Kent, J., Mathew, S. J., & Gorman, J. M. (2002). Molecular targets in the treatment of anxiety.
Biological Psychiatry, 52, 1008–1030.
Kiive, E., Maaroos, J., Shlik, J., Toru, I., & Harro, J. (2004). Growth hormone, cortisol and prolactin
responses to physical exercise: Higher prolactin response in depressed patients. Progress in
Neuro-Psychopharmacology & Biological Psychiatry, 28(6), 1007–1013.
Kosfeld, M., Heinrichs, M., Zak, P., Fischbacher, V., Fehr, E. (2005). Oxytocin increases trust in humans.
Nature, 435(2), 673–676.
Kroenke, K. (2007). Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and
detection. Annals of Internal Medicine, 146, 317–325.
Labar, K. S., & Cabeza, R. (2006). Cognitive neuroscience of emotional memory. Nature Review of
Neuroscience, 7(1), 54–64.
Lancer, R. (2005). The effect of aerobic exercise on obsessive compulsive disorder, anxiety, and
 depression. Dissertation Abstracts International: Section B: The Sciences and Engineering, 66(1-
B), 599.
Larson, E. (2006). Moderate amounts of regular exercise might delay Alzheimer’s disease in older
adults. Annals of Internal Medicine, 144, 73–81.
Lobaugh, N. J., Gibson, E., & Taylor, M. J. (2006). Children recruit distinct neural systems for implicit
emotional face processing. Neuroreport, 17(2), 215–219.
Lonigan, C., & Phillips, B. (2001). Temperamental influence on the development of anxiety disorders. In
M. W. Vasey & M. R. Dadds, Mark R. (Eds.), The developmental psychopathology of anxiety
(pp. 60–91). New York: Oxford.
Manger, T. A., & Motta, R. W. (2005). The impact of an exercise program on posttraumatic stress
disorder, anxiety, and depression. International Journal of Emergency Mental Health, 7(1), 49–
57.
Maron, E., Kuikka, J., Ulst, K., Tiihonen, J., Vasar, V., & Shilk, J. (2004). SPECT-imaging of serotonin
transporter binding in patients with generalized anxiety disorder. World Journal of Biological
Psychiatry (suppl 1), 137.
McNally, R. J. (2002). Anxiety sensitivity and panic disorder. Biological Psychiatry, 52, 938–946.
Milham, M. P., Nugent, A. C., Drevets, W. C., Dickstein, D. P., Leibenluft, E., Ernst, M., Charney, D., &
Pine, D. (2005). Selective reduction in amygdala volume in pediatric anxiety disorders: A voxel-
based morphometry investigation. Biological Psychiatry, 57(9), 961–966.
McDonald, G., & Leary, M. (2005). Why does social exclusion hurt? The relationship between social
and physical pain. Psychological Bulletin, 131(2), 202–223.
Muller, T., Peterson, S., Sonnewald, U., & Unsgard, G. (1995). Effects of aspartame on Ca+ influx and
LDH leakage from nerve cells in culture. Neuropharmacology and Neurotoxicology Rapid
Communications of Oxford Ltd., 6, 318–320.
Nardi, A., Valença, A., Lopes, F., de-Melo-Neto, V., Freire, R., Veras, A., et al. (2007). Caffeine and
35% carbon dioxide challenge tests in panic disorder. Human Psychopharmacology: Clinical and
Experimental, 22(4), 231–240.
Nelson, M. E., Rejeski, W. J., Blair, S. N., Duncan, P. W., Judge, J. O., King, A. C., Macera, C. A., &
Castaneda-Sceppa, C. (2007). Physical activity and public health in older adults. [On-line].
Circulation, 116. Available:
www.circ.ahajournals.org/cgi/content/abstract/circulationaha.107.185650.
Nhat Hanh, T. (1999). The miracle of mindfulness. Boston: Beacon.
O’Riordan, M. (2007). ACSM/AHA updates physical activity recommendations, including guidelines for
older adults. [On-line]. Available: www.medscape.com/viewarticle/561102.
Penedo, F. J., & Dahn, J. R. (2005). Exercise and well-being: A review of mental and physical health
benefits associated with physical activity. Current Opinion in Psychiatry, 18(2), 189–193.
Phan, K. L., Fitzgerald, D. A., Nathan, P. J., & Tancer, M. E. (2006). Association between amygdala
hyperactivity to harsh faces and severity of social anxiety in generalized social phobia. Biological
Psychiatry, 59, 424–429.
Pliszka, S. R. (2003). Neuroscience for the mental health clinician. New York: Guilford.
Rapee, R. (2002). The development and modification of temperamental risk for anxiety disorders:
Prevention of a lifetime of anxiety. Biological Psychiatry, 52, 947–957.
Rothschild, B. (2000). The body remembers: The psychophysiology of trauma and trauma treatment.
New York: Norton.
Schaubroeck, J., & Ganster, D. (1993). Chronic demands and responsivity to challenge. Journal of
Applied Psychology, 78(1), 73–85.
Schwartz, J. (1996). Brainlock: Freeing yourself from obsessive-compulsive disorder. New York: Harper
Collins.
Schwartz, J. M., Gulliford, E. Z., Stier, J., & Thienemann, M. (2005). Mindful awareness and self-
directed neuroplasticity: Integrating psychospiritual and biological approaches to mental health
with a focus on obsessive-compulsive disorder. In S. G. Mijares & G. S. Khalsa (Eds.), The
psychospiritual clinician’s handbook: Alternative methods for understanding and treating mental
 disorders (pp. 281–300). New York: Haworth.
Schwartz, T., Azhar, N., Husain, J., Nihalani, N., Simionescu, M., Coovert, D., Jindal, S., & Tirmazi, S.
(2005). An open-label study of Tiagabine as augmentation therapy for anxiety. Annals of Clinical
Psychiatry, 17(3), 167–172.
Shekhar, A., Truitt, W., Rainnie, D., & Sajdyk, T. (2005). Role of stress, corticotrophin releasing factor
(CRF), and amygdala plasticity in chronic anxiety. Stress, 8(4), 209–19.
Siegel, D. (2007). The mindful brain: Reflection and attunement in the cultivation of well-being. New
York: Norton.
Siegel, D. (1999). The developing mind: Toward a neurobiology of interpersonal experience. New York:
Guilford.
Simon, S. (1974). Meeting yourself halfway: 31 values and clarification strategies for daily living. Niles,
IL: Argus.
Simon, S., Howe, L., & Kirschenbaum, H. (1995). Values clarification: A practical, action directed
workbook. New York: Time Warner Books.
Sobel, D., & Ornstein, R. (1996a). Good humor good health. Mind/body Newsletter, 6(1), 3–6.
Sobel, D. & Ornstein, R. (1996b). The healthy mind, healthy body workbook. New York: Time Life
Medical.
Sofuoglu, M., & Kosten, T. R. (2004). Pharmacologic management of relapse prevention in addictive
disorders. Psychiatric Clinics of North America, 27(4), 627–48.
Stahl, S. (2000). Essential psychopharmacology. New York: Cambridge University Press.
Tafet, G. E., Feder, D. J., Abulafia, D. P., & Roffman, S. S. (2005). Regulation of hypothalamic-
pituitary-adrenal activity in response to cognitive therapy in patients with generalized anxiety
disorder. Cognitive, Affective & Behavioral Neuroscience, 5(1), 37–40.
Talbott, S. (2002). The cortisol connection: Why stress makes you fat and ruins your health—and what
you can do about it. Alameda, CA: Hunter House.
Walton, R. (1998). The possible role of aspartame in seizure induction. Presented at “Dietary
Phenylalanine and Brain Function.” Proceedings of the First International Meeting on Dietary
Phenylalanine and Brain Function, Washington, DC, May 8–10, 1987. Reprinted in Dietary
phenylalanine and brain function, 159–162. Boston: Birkhauser.
Weil, A. (1998). Natural health, natural medicine: A comprehensive manual for wellness and self care.
Boston: Houghton-Mifflin.
Weiser-Cornell, A. (1996). The power of focusing: A practical guide to emotional self-healing. Oakland,
CA: New Harbinger.
Williams, M., Teasdale, J., Segal, Z., & Kabat-Zinn, J. (2007). The mindful way through depression:
Freeing yourself from chronic unhappiness. New York: Guilford.
Winston, J. S., Strange, B. A., O’Doherty, J., & Dolan, R. J. (2002). Automatic and intentional brain
responses during evaluation of trustworthiness of faces. Nature Neuroscience, 5(3), 277–83.
Wolfersdorf, M., Maier, V., Froscher, W., Laage, M., & Straub, R. (1993). Folic acid deficiency in
patients hospitalized with depression. A pilot study of clinical relevance. Nervenharzt, 64, 269–
272.
Yehuda, R., & McFarlane, A. C. (Eds.). (1997). Psychobiology of posttraumatic stress disorder. Annals
of the New York Academy of Sciences, 821, 57–75.
 Index ABCD method
using “A” and “B” parts of
using “C” and “D” parts of
ACG. see anterior cingulate gyrus (ACG) ACSM. see American College of
Sports Medicine (ACSM) activating event
naming
self-talk and
activities, making time between adolescents
movement and
sleep needs of
too much activity and
adult education, skill-building through aerobic exercise
affirmations, reciting
AHA. see American Heart Association (AHA) Al-Anon
alcohol
benzodiazepines and
limiting intake of
all/never language, perfectionism and alone time, balance wheel and American
College of Sports Medicine (ACSM) American Heart Association (AHA)
amygdala
calming
catastrophizing and
over-sensitization to
planning and
skill-building and
sleep and
unlearning fear and
anger
anger management
anterior cingulate gyrus (ACG) clearing worried thoughts and exercise and
planning and
ruminating worry and
serotonin deficiency and
skill-building and
 too much activity and
worry and
anti-convulsants
anxiety
alcohol and
assessing, and gaining skills breathing and
caffeine, limiting intake and educating self about
pervasiveness of
right assurance for
symptoms of
too much activity and
types of
anxiety cues, amygdala and re-learning about Anxiety Disorder Association of
America anxiety disorders, diagnosis of anxiety management, breathing and
anxious behavior
managing
anxious body
managing
anxious mind
managing
symptoms of
anxious thoughts competing with
distracting from
stopping
arm stretch
aromatherapy
aspartame
assertiveness
asthma, breathing difficulties with ativan (lorazepam)
avoidance
awareness, shifting, mindfulness with back stretch
balance
achieving
healthy functioning and
time-related values and
wheel of
basal ganglia (BG)
 breathing and calming of
sleep and
tension and
too much activity and overactivity in behavioral avoidance
Benson, H.
benzodiazepines
beta-blockers
BG. see basal ganglia (BG) binge drinking
biochemistry, anxiety symptoms and biofeedback
blood-sugar levels
blushing
body, using to change the mind brain
anxiety and structures of
anxiety and workings of
anxiety symptoms and parts of calming the body and calming of
communication within
exercise and
lateral (side) view of
learning/unlearning fear and nutritious food and
planning and
skill-building and
sleep and
too much activity and
understanding
using to change brain
brainstorming
breakfast
breaks, taking
breathe technique (technique #2) breathing. see also diaphragmatic breathing
exercises
for minimal arousal
muscle relaxation paired with observing
relaxation with
“breathing minutes,” creating breathing observations checklist burnout
business skills
buspirone (BuSpar)
caffeine
limiting intake of
sleep and reducing intake of caffeine, alcohol, tobacco, sugar. See C.A.T.S.
calf stretch
calm brain
calming anxious mind
calming rumination
career skills
catastrophic thinking, prefrontal cortex and catastrophizing, stopping
C.A.T.S., limiting
celexa (citalopram)
cell phones, turning off
change your intake (technique #1) children
with anxiety, seeking help for changing self-talk in
exercise and
movement and
muscle relaxation and
reducing dread and
sleep needs for
social phobia in
too much activity and
in vivo exposure and
circadian rhythms
classroom, in vivo exposure and coherence therapy techniques communication-
related technology, demands related to communication skills
commuting, balance wheel and competence, acquiring
confidence, acquiring
consequential vs. inconsequential contain your worry (technique #7) control
debunking thoughts about loss of over one’s emotional reactions cooperation,
for in vivo exposure cortex
counter-cognitions identifying for three-column method workplace and use of
counter-messages
“crackberry” users
creating demand delays
Crosby, B.
“cued” relaxation cymbalta (duloxetine) DA. see dopamine (DA) dating
decatastrophizing
 of anger
remembering real experience
searching for exact image or thought deep breathing, progressive muscle
relaxation and delays, planning for
delegation
demand delays
creating
grid
desensitization
methods of
systematic
of trauma
diaphragmatic breathing
changing intake of tobacco and effect of
last word about
muscle relaxation and
obstacles to
practicing
reducing dread and
distractions
from anxious thoughts
breathing and
doom
dopamine (DA)
function of
low levels of, impact on brain structures and
“do worst first” method
dread
circle of
ditching feelings of
driving
avoidance and
mindfulness and
dying, debunking thoughts about education, about anxiety
effexor (venlafaxine)
elderly adults
muscle relaxation and
 sleep needs for
too much activity, and health/mobility issues for Ellis, A.
email
embarrassment, as just a feeling EMDR. see eye movement desensitization and
reprocessing (EMDR) emotional health, balance in life and energy therapy
essential oils
estrogen
exercise
balance wheel and
getting started with
as prime stress reliever
record
relaxation and
expectations, changing filters on experience, changing filters on exposure, social
anxiety and fear of exposure therapy, steps in, example eye movement
desensitization and reprocessing (EMDR) faces, anxiety and over-
sensitization to expressions on family relationships
balance wheel and
too much activity and
fear
brain and learning/unlearning of facing
of having panic attacks
feelings, as just feelings

5-Count Energizing Breath

flip charts, for nonverbal reminders fluorescent lighting
focusing process
folic acid
free floating anxiety
free time, unexpected, planning for fun
busy fun and
finding in small things
opportunities for
redirecting too much activity and allowing time for GABA
benzodiazepines and
 function of
ineffective, impact on brain structures and too much activity and
Gendlin, E.
generalized anxiety
physical symptoms of
progressive muscle relaxation and symptoms of
worry and
glutamate
goal setting
“God Box,”
“going crazy,” debunking thoughts about Guitar Heroes

heart health, aerobic exercise and heartmath help, seeking

herbal teas
high drive
Hill, F.
hippocampus
hobbies, balance wheel and
hypervigilance
elevated norepinephrine and
perfectionism and
hypoglycemia
hypothalamus

IBS. see irritable bowel syndrome (IBS) illness, anxiety and work interrupted by
implement a plan and practice (technique #10) importance vs. urgency
impulse-control problems
inconsequential vs. consequential inhaling, restrictions to
injuries, anxiety and work interrupted by instant messages, demand delays and
Internet searching, reassurance-seeking and interviewing skills
in vivo (real-life) practice cooperation for
failing a step during
practicing without a support person irritable bowel syndrome (IBS) jobs,
multiple, too much activity and job security, worrying well and Kabat-
Zinn, J.
klonopin (clonazepam)

laughter
left-brain activity
leg lunges
leisure
lexapro (escitalopram)
limbic system
calming
parts and functions of
serotonin deficiency and
skill-building and
list-making, with time frames losing control, debunking thoughts about L-
tryptophan
lung diseases, breathing difficulties with luvox (fluvoxamine)

martial arts
massages
Mcdonald, G.
medical checkup
medications
benzodiazepines
brain management with
buspirone (BuSpar)
complicated situations and
decision-making about
impact of, on brain
“off-label”
selective serotonin reuptake inhibitors before starting therapy
understanding benefits/limits with in vivo exposure and as-needed use of
meditation
meetings at work, in vivo exposure techniques and melatonin, sleep and
mental errors
mental health, balance in life and mental management methods
mental tension
mental vacations
mindfulness
flushing, sweating, or embarrassed anxiety and panic attacks and
mindfulness with shifting awareness(technique #3) mistakes, in vivo exposure
and motivation
motor cortex, skill-building and muscle relaxation
breathing and promotion of
reducing dread and
music, as positive distraction NE. see norepinephrine (NE) negative self-talk
challenging
identifying
negative thoughts, thought replacing and negativity, overactive limbic system
and nervous system
neurofeedback
neurons
neurotransmitters
activities of
balance of
nutritious food and
receiving messages and
no calls zone, at meal times noisy offices, stress related to non-perfectionism,
planning for nonverbal reminders, thought replacement and norepinephrine
(NE)
dread and high levels of
excessive, high drive and
function of
hypervigilance and
physical tension and
sleep and
nutritious food, increasing intake of obsessive-compulsive disorder in children
obsessive thoughts, thought replacing and OFC. see orbito-frontal cortex (OFC)
“off-label” medications
one-breath muscle relaxation options, allowing for
orbito-frontal cortex (OFC) exercise and
planning and
serotonin deficiency and
skill-building and
overhead stretch
overstimulation

pager calls, demand delays and pain, circular nature of

panic attacks
 avoidance and
breathing and stopping
caffeine consumption and
fear of
medication and
mindfulness and
over-awareness of physical sensations and planning on
right assurance for
searching for exact image or thought and serotonin deficiency and
stage fright and
unpleasant, but not lethal
panic disorder
beliefs related to
physical symptoms with
relaxation and
stopping catastrophizing and too much activity and
parasympathetic nervous system (PSNS) Parkinson’s disease
paxil (paroxetine)
peer relationships, social anxiety and perfectionism
countering
identifying
intervention for
peripheral nervous system (PNS) persistence
personal business skills
PFC. see prefrontal cortex (PFC) phone calls, demand delays and physical
health, balance in life and physical limitations, to breathing physical
sensations, focusing attention away from physiology, breathing and change
in pictures, for nonverbal reminders planning
as antidote to worrying
for dreaded, unexpected “free” time effective
evaluating
implementing
for non-perfectionism
pleasant, productive thoughts, cultivating pleasure
overcoming anxiety and
PNS. see peripheral nervous system (PNS) practice
Practice of Rational Emotive Therapy, The (Dryden & Ellis) prefrontal cortex
 (PFC)
breathing and
calming breathing and
catastrophic thinking and
learing worried thoughts and decision-making power of
planning and
skill-building and
“two P” list for the day and preparation, breathing and presentation skills
prioritization
problem identification
productive, pleasant thoughts, cultivating progesterone
progressive muscle relaxation deep breathing and
process of
protein, importance of
prozac (fluoxetine)
PSNS. see parasympathetic nervous system (PSNS) psychoeducation
psychotherapy
medical checkups and
panic triggers and
worry and perspective gained through quick breathing relaxers, changing
tobacco intake and rapid eye movement (REM)
readiness
real-life practice
reassurance-seeking, ruminating worry and refocus on tasks at hand
rejuvenation
relaxation
exercise and
finding in small things
progressive muscle relaxation sleep and
slowing down and
sphere of light imagery for
stretching and
relaxation (technique #4)
REM. see rapid eye movement (REM) response demand stress, reducing right
assurance
for all forms of anxiety
for general worries
 for panic
for social anxiety
right-brain activity
rumination
anterior cingulate gyrus and “two P” list for the day and school
social anxiety in teens at
in vivo exposure and
SE. see serotonin (SE) seated-at-your-desk arm stretch seated-at-your-desk head
tilt seated posture change
selective serotonin reuptake inhibitors (SSRIs) function of
self-esteem, perfectionism and self-observation, prefrontal cortex and self-talk
changing
children and
finding
stopping panic with
three-column method and
serotonin and norepinephrine reuptake inhibitors (SNRIs) serotonin (SE)
folic acid and
function of
low levels of, impact on brain and worry and
shaking
shame trauma, social anxiety and Siegel, D.
skills
assessing
building
interviewing
personal business
practicing in private
social
work or career
sleep
anxious brain and readiness for clearing the mind and
environments conducive to
importance of
planning on getting back to
sufficient, patterns for
slowing down to relax
smoking
limiting or eliminating
record
SNRIs. see serotonin and norepinephrine reuptake inhibitors (SNRIs) SNS. see
sympathetic nervous system (SNS) social anxiety
avoidance and
beliefs related to
relaxation and
right assurance for
school setting and
shame trauma and
symptoms of
social drinking
socializing, balance wheel and social phobia
social skills sphere of light imagery, for relaxation spiritual life, balance wheel
and spouse, balance wheel and
SSRIs. see selective serotonin reuptake inhibitors (SSRIs) stage fright
stimulation intake, lowering stop anxious thoughts (technique #6) stop
catastrophizing (technique #5) stress
circular nature of
exercise and reduction in
mindfulness and reduction in sleep and
stress response system
stretching
relaxation and
students, in vivo exposure and sugar, limiting intake of
sun protection
support person, practicing without sweating
sweeteners, limiting intake of symbol cards, for nonverbal reminders
sympathetic nervous system (SNS) synapse
systematic desensitization

talk yourself into changing behavior (technique # 8) techniques

breathe (technique #2)
change your intake (technique #1) contain your worry (technique #7) control
TMA (technique #9)
implement a plan and practice (technique#10) mindfulness with shifting
 awareness (technique #3) relax (technique #4)
stop anxious thoughts (technique #6) stop catastrophizing (technique #5)
talking yourself into changing behavior (technique #8) technology-free
time, creating temporomandibular joint pain (TMJ) generalized anxiety
and
tension
elevated norepinephrine and
muscle relaxation and release of too much activity and
thalamus
therapists, working with
therapy, taking medication before start of Thich Nhat Hanh
thought replacement
nonverbal reminders of, for kids and others “two P” list for the day and
thought-stopping
maximizing technique of
reducing dread and
worry well and only once method three-column method
finding self-talk with
planning counter-cognitions for “three deep breaths and good preparation,”
thyroid function
time frames, list-making with time-related values, identifying time tracking chart
TMA. see too much activity (TMA) TMJ. see temporomandibular joint pain
(TMJ) tobacco, limiting or eliminating intake of too much activity (TMA)
achieving balance in life and brain and
controlling
at different ages and in special circumstances for dreaded, unexpected “free”
time examining your values
fun, rebalancing and
fun and redirecting of
time-related values and
time use and consistency with values trauma
catastrophic fears rooted in desensitization of

urgency vs. importance values, use of time consistent with values clarification
vigilance
vitamins
voicemail management
volunteering, balance wheel and warm baths
sleep and
water, walking or running near Weil, A.
Weiser-Cornell, A.
well-being, balance and “what if” syndrome, planning skills and withdrawal
effects
work, balance wheel and
working memory
workplace
communication-related technology and de-stressing techniques for
taking regular breaks at
work skills
work style, work values and worried thoughts, clearing
worriers, avoidance and
worry
containing
“do the worst first” and defusing of exercise and
general, right assurance for hypervigilance and
perfectionism and
planning as antidote to
serotonin deficiency and
too much activity and
“worry dreams”
worry well and only once method worst first, doing, defusing worry and xanax
(alprazolam)

yoga

zoloft (sertraline)