AnxietyPROFESSIONAL RESOURCESAlgorithm for the management of anxietydisorders in primary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Treatment notes for the management ofanxiety disorders in primary care . . . . . . . . . . . . . . . . . .4Anxiety checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Drug treatments for anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . .7Treatments for anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11PATIENT FACT SHEET1 Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .152 Distinguishing between a panic attackand a heart attack . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .243 Controlling over-breathing . . . . . . . . . . . . . . . . . . . . . . . .264 Learning to relax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .285 Overcoming particular fears (phobias) . . . . . . . .316 Helping someone else overcome a phobia . .347 What is Obsessive Compulsive Disorder . . . . . . .368 Useful organisations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .389 Post traumatic stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3910 Exam stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4211 Resources and organisations for anxiety,panic and phobias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

Treatment guideline forprimary care management ofindividuals with anxiety(2)Generalised Anxiety Disorder(GAD)Multiple symptoms of anxiety or tensioninclude; physical arousal (e.g. dizziness,dry mouth, chest pains), mental tension(e.g. worry, poor concentration, fear ofcatastrophe) physical tension (e.g.restlessness, inability to relax)Symptoms may last for months and recurregularly. Often, they are triggered bystressful events in those prone to worry.Prevalence = 5% (accounts for 30% of GPpsychiatric consultation)Cognitive and Behavioural Therapies areeffective. Failure of CBT or significant comorbidity, then use SSRI or SNRI at low dosegradually increasing to maximum tolerateddose. Physical activity may be beneficial.Generalised anxiety disorder that does notrespond to Buspirone or a benzodiazepine istreated with an antidepressant.Antidepressants licensed for this indicationinclude the SSRI Paroxetine and SNRIVenlafaxine XL. Doses should be adjusted asper BNF.Imipramine is likely to be beneficial in GADalthough this is an unlicensed indication.Panic Disorder (PD)Unexplained attacks of intense fearwithout obvious cause, often leading tofear of another attackCognitive Behavioural advice and support tohelp patient face fears. Applied relaxation mayalso be effective for panic. SSRI, Citalopramand Paroxetine are licensed (doses as perBNF).No trial data comparing the different SSRI’s.Treat for a minimum of 12 months. SSRI’s cancause initial increased anxiety, education aboutthis event is likely to improve adherence withmedication.In panic disorders (with or withoutagoraphobia) resistant to antidepressants, abenzodiazepine may be considered(unlicensed). A benzodiazepine may also beused as a short-term adjunctive therapy at thestart of antidepressant treatment to preventthe initial worsening of symptoms.Imipramine is likely to be beneficial in thosesuffering from panic disorder although this isan unlicensed indication.Phobic Disorders (incagoraphobia and social phobia)(Agoraphobia) unreasonably strong fear ofpeople, specific places or eventsFear/avoidance of specific situations.Exposure-based treatments and CBT haveshown efficacy in the treatment ofagoraphobia and simple phobias. Exposureand cognitive therapy are effective for thetreatment of social phobia. Failure of CBT orsignificant co morbidity, use an SSRI, graduallyincreasing the dose, after 2 to 4 weeks. SSRI’s,Paroxetine, Citalopram are licensed, the doesis built up gradually after 2–4 weeks. TheRIMA Moclobemide is also licensed for socialphobia, continued for 8–12 weeks to assess4Gloucestershire Mental Health Toolkit – Anxiety

efficacy (doses as per BNF). A beta-blockersuch as Propranolol at a dose of 40mg dailyincreased gradually to 40mg tds prn may behelpful in performance anxiety with symptomssuch as palpitations, sweating and tremor ornon-generalised social phobia. Oxprenolol isalso licensed. Clomipramine is licensed inphobic states. Benzodiazepines notrecommended in UK unless previoustreatments have failed.Obsessive Compulsive Disorder(OCD)Distressing recurrent and persistentthoughts or acts which person recognisesas their own, but has no apparentconscious control.Behaviour therapy (exposure with relapseprevention) and cognitive therapy appearseffective. Psychological treatments appear toproduce results similar to those achieved bydrug treatments. The SSRI’s Paroxetine,Fluoxetine, Fluvoxamine and Sertraline are alllicensed for this indication. No evidence of adifference in efficacy between the SSRI’stherefore choice is dependent on side effectprofile. The does should be increasedgradually to maximum licensed dose (as perBNF recommendations). Adequate trial is 12weeks at maximum licensed dose. Treat for atleast 12 months. Discontinuation should begradual. Clomipramine may also be effective,but has cholinergic and cardiac side effects.Blood level monitoring and ECGrecommended at high doses. There is limitedevidence to support combination ofantipsychotic and SSRI in patients notresponding to SSRI alone.Post Traumatic Stress Disorder(PTSD)Significant functional impairment, anxietyand depression, avoidance, autonomicarousal, intrusive memories, flashbacksand nightmares following exceptionallythreatening or catastrophic event orsituation.Psychological treatment may have an impacton PTSD; evidence suggests that this may belimited, and may reduce symptoms ofdepression and anxiety rather than primaryPTSD symptoms. Best evidence is available forexposure and CBT methods. Some evidencefor hypnotherapy and psychodynamic therapy.Failure of CBT or significant co morbidity.Treat with SSRI’s Paroxetine or Sertraline(licensed in females only).Additional notesAntidepressants: The licensing of SSRIs andrelated classes is varied dependant on theindication being treated. The 2 drugs licensedfor GAD are Paroxetine 20mg and VenlaxfaxineXL 75mg.Benzodiazepines: Longer acting compoundssuch as diazepam are preferred in short-termuse and for withdrawal regimes. They carry arisk of dependence, sedation andindustrial/road accidents. They should beavoided late in pregnancy and breastfeeding.May be useful as an adjunct to antidepressantsin first 1–2 weeks. They should not be used inpatients with suicidal ideation or a history ofalcohol or substance abuse. Benzodiazepinesare indicated for the short term relief (two tofour weeks only) of anxiety that is severe,disabling or subjecting the individual tounacceptable distress, occurring alone or inassociation with insomnia or short termpsychosomatic, organic or psychotic illness.The use of benzodiazepines to treat shortterm“mild” anxiety is inappropriate andunsuitable. Benzodiazepines should be usedto treat insomnia only when it is severe,disabling, or subjecting the individual toextreme distress. For information onwithdrawal of benzodiazepines see BNF.Gloucestershire Mental Health Toolkit – Anxiety 5

Anxiety checklistA. Feeling tense or anxious?B. Worrying a lot about things?If YES to any of the above, continue below1. Symptoms of arousal and anxiety?2. Experienced intense or sudden fearunexpectedly or for no apparent reason?Fear of dyingTrembling or shakingNumbness or tingling sensationsFear of losing controlChest pains or difficulty breathingFeelings of unrealityPounding heartFeeling dizzy, lighthearted or faintNauseaSweating3. Experiences fear/anxiety in specificsituations leaving familiar placestravelling alone, eg train, car, planecrowds confined places/public places4. Experiences fear/anxiety in socialsituationsspeaking in front of otherssocial eventseating in front of othersworry a lot about what others thinkor self-conscious?Summing upPositive to A, B and 1, recurring regularly,negative to 2, 3 and 4: Indication ofgeneralised anxietyNote:If there is more than one disorder present:best to treat an alcohol problem first ifpresentif low mood, treatment for depressiontakes priority over anxietyIf patient has an identified disorder:see relevant guideline to help determinetreatment planuse relevant handouts with the patient tohelp explain the disorderprovide self-help leaflets and explain howthis should be usedset up a follow up visit(s) to reviewtreatmentIf patient appears to have subthresholddisorder(s):(positive responses to many questions, butnot enough to fulfil the diagnostic criteria fora disorder):medication may not be necessaryuse the relevant advice and support topatient and family section of theguidelines and provide patient leafletsuse relevant handouts with the patient tohelp explain the disorderindicate that you are available forconsultation should the need arise.Positive to 1 and 2: indication of panicdisorderPositive to 2 and 3: indication ofagoraphobiaPositive to 3 and 4: indication ofsocial phobia6Gloucestershire Mental Health Toolkit – Anxiety

Drug treatments for anxietyDrugs known as ANXIOLYTICSDrug group: The beta-blockersDrugsavailableBrandname(s)OxprenololTrasicorSlow-TrasicorApsoloxPropranololLitarexInderal,Inderal-LAForms availableTablets ✔ ✔Capsules✔Liquid✔Injection✔Some other beta-blockers may have similareffects.What are beta-blockers usedfor?In lower dose, beta-blockers can be used tohelp treat the symptoms of anxiety e.g.palpitations, sweating, shakiness etc. They aremore usually used to help heart conditionssuch as hypertension (high blood pressure),angina, arrhythmias etc.How do beta-blockers work foranxiety?When you are anxious, your brain becomesmore active and alert. Your brain may thenmake more of the chemical messengers callednoradrenaline and adrenaline. These will thencause your body to have a faster heart rate,shake, sweat etc. and make you feel moreanxious. The beta-blockers reduce the effectof these transmitters and so reduce thephysical symptoms of anxiety. There are otherdrug treatments for anxiety e.g. thebenzodiazepines (diazepam etc.).How should I take them?Tablets and capsules:Tablets or capsules should be swallowed withat least half a glass of water whilst sitting orstanding. This is to make sure that they reachthe stomach and do not stick in the throat.The capsules are a ‘sustained-release’preparation and should not be sucked orchewed.Liquid:Your pharmacist should give you a medicinespoon. Use it carefully to make sure youmeasure the correct amount. Ask yourpharmacist for a medicine spoon if you do nothave one. Shake the bottle well before use.When should I take my betablocker?Take your medication as directed on themedicine label. Try to take them at regulartimes each day. Taking them at meal times maymake it easier to remember as there is noproblem about taking either of these drugswith or after food.How long will the beta-blockertake to work?They should start to work on your symptomsfairly soon after you start to take them e.g.within a few hours. After that your doctor mayneed to change the dose to suit you.How long will I need to keeptaking them for?This should be discussed with your doctor asdifferent people respond differently. The beta-Gloucestershire Mental Health Toolkit – Anxiety 7

lockers are best taken in a fairly low a dose asa ‘first aid’ measure.Are the beta-blockersaddictive?The beta-blockers are not addictive. They onlyact on the physical symptoms of anxiety. It isnot a good idea to stop them suddenly though(see next question).Can I stop taking the betablockersuddenly?It is best not to stop taking a beta-blockersuddenly if you have been taking themregularly every day for more than about 4 to 6weeks, although there probably would be nogreat problem. A gradual reduction in yourdose is probably best.What should I do if I forget totake a dose?Start again as soon as you remember unless itis almost time for your next dose. Do not tryto catch up by taking two or more doses atonce as you may get more side-effects. If youmiss several doses start again when youremember. Tell your doctor about this nexttime you meet.What sort of side-effects mightoccur?CommonSide effect:FatigueWhat happens:You feel tired all the time. This may happenearly on in treatment and should go away.What to do about it:If you feel like this for more than a week afterstarting the beta-blocker, tell your doctor. Itmay be possible to adjust your dose slightly.Side effect:Cold extremitiesWhat happens:Your toes and fingers feel cold. This mayhappen early on in treatment and should goaway.What to do about it:If you feel like this for more than a week afterstarting the beta-blocker, tell your doctor. Itmay be possible to adjust your dose slightly.UncommonSide effect:Stomach upsetWhat happens:This includes feeling sick and gettingdiarrhoea (the runs).What to do about it:After starting the beta-blocker, If you feel likethis for more than a week tell your doctor.Side effect:Sleep disturbancesWhat happens:You can’t sleep very well and may havenightmares.What to do about it:If you feel like this for more than a week afterstarting the beta-blocker, tell your doctor.Side effect:DizzinessWhat happens:Feeling light-headed and faint, especially whenyou stand up.What to do about it:Don’t stand up too quickly. Try and lie downwhen you feel it coming on. Don’t drive. Letyour doctor know next time you meet.Side effect:WheezinessWhat happens:When you find it difficult to breathe, and yourchest feels tight.8Gloucestershire Mental Health Toolkit – Anxiety

What to do about it:This may happen if you have asthma. Contactyour doctor now.Side effect:BradycardiaWhat happens:A very slow pulse (under 50 beats perminute).What to do about it:Contact your doctor now.RareSide effect:Skin troubleWhat happens:For example, a rash or itching that you haven’thad before.What to do about it:Contact your doctor now.Side effect:Dry eyesWhat happens:Your eyes feel dry.What to do about it:Contact your doctor.Adapted from UK Psychiatric PharmacyGroup leaflets, with kind permission(www. ukpgg. org)Do not be worried by this list of side effects.You may get none at all. There are other rareside effects. If you develop any unusualsymptoms ask your doctor about them nexttime you meet.Will the beta-blocker make medrowsy?Some people do feel a little drowsy,particularly at the start of treatment, but thisshould wear off. If you do feel drowsy, youshould not drive (see over) or operatemachinery until you know how they affectyou. You should be careful as they may affectyour reaction times.Will the beta-blocker cause meto put on weight?It is not thought that the beta-blockers causeany great changes in weight although it hasbeen reported that a few people put on asmall amount of weight over several years. If,however, you do start to have problems withyour weight tell your doctor next time youmeet as he or she can arrange for you to see adietician for advice.Will the beta-blocker affect mysex life?Beta- blockers do not have any knownsignificant effects. Higher doses may reduceblood pressure in some people (which is oftenwhy they are prescribed), which may have adetrimental effect in some men’s ability toachieve an erection. In some people, reducedanxiety may be an advantage.Can I drink alcohol while I amtaking a beta-blocker?Alcohol may slightly reduce the effect of yourbeta-blocker, but this is unlikely to be aproblem.Are there any foods or drinksthat I should avoid?You should have no problems with any foodor drink other than alcohol (see above).Will the beta-blocker affect myother medication?You should have no problems if you takeother medications although a few problemscan occur. Make sure your doctor knowsabout any other medicines you are taking.Gloucestershire Mental Health Toolkit – Anxiety 9

Make sure your doctor knows about any heart,breathing, thyroid or diabetic problems youhave had in the past e.g. you should notnormally take a beta-blocker if you haveasthma.The beta-blockers can ‘interact’ with someother drugs e.g. for high blood pressure,glaucoma and some anti depressants. Thisdoes not necessarily mean the drugs can notbe used together, just that you may need tofollow your doctors instructions very carefully.You should tell your doctor before starting orstopping these or any other drugs.If I am taking a contraceptivepill, will this be affected?It is not thought that the contraceptive pill isaffected by either of these drugs.Will I need a blood test?You should not need to have a blood test tocheck on your beta-blocker, although yourdoctor may want to check your blood forother reasons.Can I drive while I am taking abeta-blocker?The beta-blockers can reduce your ability tocarry out skilled tasks such as driving oroperating machinery. You may also feel drowsywhen you start to take them. Until theseeffects wear off or you know how your drugaffects you do not drive or operate machinery.You should be careful as they may affect yourreaction times.It is against the law to drive or attempt todrive when unfit through drugs or to be incharge of a vehicle when unfit through drugs.It is a good idea to let your insurancecompany know if you are taking these drugs.If you do not, and you have an accident, itcould effect your insurance cover.Printed with permission© 2000 Stephen Bazire, Norfolk MentalHealth Care NHS Trust10Gloucestershire Mental Health Toolkit – Anxiety

Treatments for anxietyDrugs known as ANXIOLYTICS(often wrongly called the ‘minortranquillisers’)Drug group: The benzodiazepinesDrugsavailableBrandname(s)Forms availableTabletsCapsulesLiquidInjection*Alprazolam *Bromazepam Chlordiazepoxide *Clobazam *ClorazepatedipotassiumXanaxLexotanLibriumTropiumFrisiumTranxeneDiazepam Lorazepam OxazepamManybrands 1AtivanSerenid(* means that these products are notavailable on the UK NHS for anxiety)1. Diazepam is available as Atensine, Tensiumand Rimaprim, as well as the better knownValium. It is also available as suppositoriesand rectal tubules.2. Many related drugs are available worldwide(about 40 in total).What are they used for?The benzodiazepines are ‘calmers’. They helpto calm you down and can make you sleepy.They are therefore used to help to treat, butnot cure, the symptoms of anxiety, such astension, feeling shaky, sweating and difficultyin thinking straight. They also have musclerelaxing properties and some can be used tohelp epilepsy, particularly ‘status epilepticus’e.g. diazepamHow do they work?When you are anxious, your brain becomesmore active. Your brain may then make achemical messenger (or ‘neurotransmitter’)called GABA which makes you feel calmer.GABA is the brains naturally occurring‘calmer’. The benzodiazepines make theaction of GABA more powerful and this helpscalm the brain down.How should I take them?Tablets and capsule:Tablets and capsules should be swallowed withat least half a glass of water whilst sitting orstanding. This is to make sure that they reachthe stomach and do not stick in the throat.Liquids:Your pharmacist should give you a medicinespoon. Use it carefully to make sure youmeasure the correct amount. (Ask yourpharmacist for a medicine spoon if you do nothave one).Shake the bottle well before use as the drugcan settle to the bottom and cause you toreceive a lower dose at the start and too higha dose at the end of the bottle.Gloucestershire Mental Health Toolkit – Anxiety 11

When should I take them?Take your medication as directed on themedicine label. Try to take them at regulartimes each day. Taking them at meal times maymake it easier to remember as there is noproblem about taking any of these drugs withor after food. If the instructions say to takethem once a day this is usually best at bedtimeas they should make you drowsy and help youto sleep.How long will they take towork?They should start to work fairly soon after youstart to take them. After that your doctor mayneed to change the dose to suit you.How long will I need to keeptaking them for?This should be discussed with your doctor asdifferent people respond differently.Benzodiazepines are very safe drugs if usedsensibly. They are best taken in as low a doseas possible for a short time e.g. as a ‘first aid’measure. Usually this should be no longerthan about one month to help you get overyour problems and for other treatments tostart working. If you need to take them forlonger you should discuss this regularly withyour doctor. Some people with long-termproblems may need to take them for longer.Are they addictive?Due to the effects that benzodiazepines haveon the brain they can sometimes produce‘dependence’ or ‘addiction’ in people if takenregularly every day for more than about 4 to 6weeks. Dependence or addiction means thatyou cannot manage without them because ifyou stop them you get withdrawal symptoms.In the worst cases withdrawal symptoms fromthe benzodiazepines could include anxiety,tension, panic attacks, poor concentration,difficulty in sleeping, nausea, trembling,palpitations, sweating and pains and stiffnessin your face, head and neck. These withdrawalsymptoms could occur several days afterstopping your benzodiazepine. They may lastfrom one to three weeks but can go on formonths. If you have taken them for a longperiod of time your doctor will need to takeyou off your benzodiazepine gradually. Thiswill be by reducing your dose slowly over aperiod of time to reduce the chance ofwithdrawal effects.It is also true to say that many people sufferno withdrawal symptoms when they stopbenzodiazepines, even if they have beentaking them for many years. You should thusmake sure that you discuss your particulartreatment with your doctor.Can I stop taking themsuddenly?It is best not to stop taking them suddenly ifyou have been taking them regularly every dayfor more than about 4 to 6 weeks. If you do,you may get some of the withdrawal effectsmentioned above. If you take them only whenreally necessary (e.g. for 1 or 2 weeks during asevere attack of anxiety and then have severalweeks without them) this is better than takingthem all the time and can prevent youbecoming addicted. You should talk about thiswith your doctor.What should I do if I forget totake them?Start again as soon as you remember unless itis almost time for your next dose. Do not tryto catch up by taking two or more doses atonce as you may get more side effects e.g.sleepiness. If you miss several doses startagain when you remember. Tell your doctorabout this next time you meet.12Gloucestershire Mental Health Toolkit – Anxiety

What sort of side-effects mightoccur?CommonSide effect:DrowsinessWhat happens:It can last for a few hours after taking yourdose, or longer.What to do about it:Don’t drive or use machinery. Discuss withyour doctor if you can take yourbenzodiazepine at a different time of the day.Side effect:DizzinessWhat to do about it:Don’t stand up too quickly. Try and lie or sitdown if you feel it coming on. Don’t drive.Less commonSide effect:AtaxiaWhat happens:Being unsteady on your feet.What to do about it:Discuss with your doctor when you next seehim or her.RareSide effect:AggressionWhat to do about it:Discuss this with your doctor. He or she maywant to adjust your drug or dose.Side effect:HeadacheWhat to do about it:Try aspirin or paracetamol. Your pharmacistwill be able to advise if these are safe to takewith any other drugs you may be taking.Side effect:ConfusionWhat to do about it:Discuss with your doctor when you next seehim or her. He or she may want to adjust yourdrug or dose.Side effect:HypotensionWhat happens:Low blood pressure -this can make you feeldizzy, particularly when you stand up.What to do about it:It is not dangerous. Don’t stand up tooquickly. If you feel dizzy, don’t drive.Side effect:AmnesiaWhat happens:Loss of short-term memory or difficulty inremembering.What to do about it:It is not dangerous. Discuss with your doctorif you are worried.Side effect:RashesWhat to do about it:Stop taking the drug and see your doctor now.Adapted from UK Psychiatric PharmacyGroup leaflets, with kind permission(www. ukppg. com)Do not be worried by this list of side effects.You may get none at all. There are other rareside-effects. If you develop any unusualsymptoms ask your doctor about them nexttime you meet.Will they make me drowsy?Depending on the dose these drugs shouldhelp to calm you down but they can calm youdown too much and send you to sleep! At ausual dose they may make you feel a bitdrowsy anyway. If you are taking them at nightGloucestershire Mental Health Toolkit – Anxiety 13

you may feel drowsy the next morning so youshould not drive (see below) or operatemachinery until you know how they affectyou. You should be careful as they may affectyour reaction times.Will they cause me to put onweight?It is not thought that the benzodiazepinescause any changes in weight. If, however, youdo start to have problems with your weighttell your doctor next time you meet as he orshe can arrange for you to see a dietician foradvice.Will it affect my sex life?Benzodiazepines do not have any knownsignificant effects. Drowsiness may have someeffect. In some people, reduced anxiety maybe an advantage.Can I drink alcohol while I amtaking these?If you drink alcohol while taking these drugs itmay make you feel more sleepy. This isparticularly important if you need to drive oroperate machinery and you must seek adviceon this. They may effect your reflexes orreaction times. They can also increase theeffects of alcohol and so it is best to avoidalcohol.Are there any foods or drinksthat I should avoid?You should have no problems with any foodor drink other than alcohol (see previous).Will they affect my othermedication?can occur. Make sure your doctor knowsabout all the medicines you are taking. Thebenzodiazepines can ‘interact’ with othersleeping drugs and some antidepressants byincreasing their sedative effect, although yourdoctor should know about these. Some othermedicines e.g. the painkiller coproxamol(‘Distalgesic’) can make you drowsy.Combined with your benzodiazepine thiscould make you even drowsier. This does notnecessarily mean the drugs can not be usedtogether, just that you may need to followyour doctors instructions very carefully. Youshould tell your doctor before starting orstopping these or any other drugs.If I am taking a contraceptivepill, will this be affected?It is not thought that the contraceptive pill isaffected by any of these drugs.Will I need a blood test?You will not need to have a blood test tocheck on your benzodiazepine.Can I drive while I am takingthem?The benzodiazepines can reduce your abilityto carry out skilled tasks such as driving oroperating machinery. You may also feel drowsythe day after you take them. Until these effectswear off or you know how your drug affectsyou do not drive or operate machinery. Youshould be careful as they may affect yourreaction times. It is against the law to drive orattempt to drive when unfit through drugs orto be in charge of a vehicle when unfitthrough drugs. It is a good idea to let yourinsurance company know if you are takingthese drugs. If you do not, and you have anaccident, it could effect your insurance cover.You should have no problems if you takeother medications although a few problems14Gloucestershire Mental Health Toolkit – Anxiety

Patientfactsheets1 AnxietyAnxiety is common andtreatableAn anxiety problem does not mean that youare weak or that you are losing your mind orthat you have a personality problem. Severeanxiety is a problem that can be overcomewith treatment. Effective treatments areavailable.What is anxiety?The word ‘anxiety’ is used to describe themental and physical response to feared andthreatening situations. This reaction mayinclude trembling, choking, increased heartrate, sweating, feelings of unreality and so on.Anxiety is a normal response experienced byeveryone at times. Nearly being hit by a car,sitting for an exam or giving a public talk areall examples of situations in which mostpeople would experience some anxiety.You are likely to be suffering from an anxietydisorder if you have any of the following:The anxiety reaction occurs frequentlyYour fears are out of proportion to thesituationYou start to avoid places or situationswhere you experience anxietyIt interferes with your working, social orfamily life.Different forms of anxiety1 Panic disorder2 Agoraphobia3 Social phobia4 Generalised anxietyTry to work out which the followingdescriptions best fit your situation.1. Panic disorderPeople who suffer from ‘panic disorder’ arelikely to experience attacks of sudden andintense anxiety. These panics cannot beassociated with events occurring around theperson. The person is generally free fromanxiety in between panics.Common symptoms of panic disordersinclude:Psychological symptomsfear of dyingGloucestershire Mental Health Toolkit – Anxiety 15

fear of going crazyfeelings of unrealityPhysical symptomstightness or pain in the chestshortness of breathchoking sensationnauseapounding heartnumbness/tingling sensation in fingersand feetlight-headednesssweatinghot and cold flushestremblingdizzinessPanics are also common with the other anxietydisorders. However, those panics are easier topredict because they mostly occur in responseto the feared situation(s).2. Social phobiaThe main feature of ‘social phobia’ is the fearof being the focus of attention or subject ofcriticism. People with this disorder may worrythat they will do something silly orembarrassing in front of others. Often socialphobia is experienced in many different socialsituations. This leads to the avoidance of thesesituations.Commonly feared situations include:speaking in front of othersasking questionseating in front of otherswriting in front of othersbeing the centre of attention3. AgoraphobiaPeople who have agoraphobia experiencepsychological and physical anxiety and oftenpanics, in particular places or situations, inwhich:there is a sense of being trapped, or beingunable to escapethe environment is different andunfamiliarit would not be easy to get help, or beingunable to leave should the need arisethey have had a panic before.This leads to the avoidance of many situationsand can severely affect day-to-day life. Inextreme cases people who suffer fromagoraphobia find it difficult to leave thehouse.Examples of commonly feared or avoidedsituations are:leaving home, travelling alone, crowds,public places.For further information on phobias refer to‘Overcoming particular fears and phobias” onpage 00.4. Generalised anxiety disorderGeneralised anxiety is different from the otheranxiety disorders. The experience of anxiety isnot linked to specific situations or to a fear ofhaving panic attacks. It is ongoing generalanxiety, tension and excessive worrying aboutnormal events and the future. You may feelworried most of the time about things whichmight go wrong or find that you are tensewithout knowing exactly what you are worriedabout. But you are less likely to have all thefeelings that are listed under ‘panic’ and‘phobias’, such as fear of dying or fear of activities such as lunches, dinners,parties, marriages, religious gatherings/festivals etc.16Gloucestershire Mental Health Toolkit – Anxiety

What may trigger anxiety?There are many possible triggers for anxiety. Itoften starts during periods of psychological orphysical stress.Examples of psychological and physicalstress include:Psychologicalrelationship break-upssevere argumentsloss of someone closeloss of a joblack of sleepwork pressurefinancial problemsphysical, sexual and emotional abuse.Physicalphysical illnessexcessive use of alcoholdomestic violenceabuse of other drugstrauma.Breathing too quickly and deeplyWhen people experience stress they have anatural tendency to breathe more quickly anddeeply. It is surprising for people to learn thatbreathing too quickly and/or deeply (alsoknown as ‘over breathing’ or‘hyperventilation’) can itself bring on anxiety.Breathing too quickly lowers the amount ofcarbon dioxide in your lungs and by acomplicated series of processes this causesphysical symptoms of anxiety or panic.Other important things to note are:You can get physical anxiety by slightlyover breathing for a long time. So, overbreathing does not have to be obvious toyou or to others.If you slightly over breathe, even a yawnor sigh can trigger a panic attack orphysical symptoms of anxiety.Changing the way you breathe can beuseful for managing anxiety.Over breathing is a habit and it takes time tochange.Worry and negative thinkingWhen people experience stress, there is also atendency to worry more than usual. Worry andunrealistic or negative thinking can triggeranxiety or make it worse.For example, you can:concentrate entirely on unpleasant things,or dwell on them and ignore good thingsspend a lot of time worrying aboutsomething that may never happenthink everything is going wrong whenonly one thing has actually gone wrongmisinterpret what other people are doing– for example, assuming that other peopleare looking at you and thinking how sillyyou are.Often changing the way you think andreducing worry can be the key to managinganxiety.Worry and negative thinking is a habit and ittakes time to change.What is anxious thinking?Being anxious affects the way you think, aswell as in how you feel. Once you are feelinganxious, you tend to look on the black side ofeverything and imagine that unpleasant andfrightening things are going to happen. Thesethoughts then make you even more anxious.Everyone looks ahead and tries to forsee andavoid problems. But in anxious thinking, thebalance between expecting the worst andexpecting good things is disturbed.Gloucestershire Mental Health Toolkit – Anxiety 17

Can you relate to the example below?Disagreement with a colleague…Person APerson BShe doesn’t agree with me; She thinks what Isaid was stupidSo we have a different point of view. That isOK. I have a right to my opinionI am a fool, I should not talkIt was interesting to discuss our differentideasI can not handle it; I am getting out of hereIf she has a problem, then too badPerson A – anxiety/panicPerson B – interested/stimulatedIdentify anxious and negativethinkingNegative and frightening thoughts can bedifficult to spot because they become a habit,they can flash quickly into your mind andmost of us are not used to noticing ourthoughts.Learning to recognise unrealistic, frighteningthoughts and to balance them with morerealistic, reassuring ones can be veryhelpful. However, changing your way ofthinking is quite difficult at first and you willneed to keep working at it. It may help toenlist the help of someone you trust.When you are anxious, you tend to think inparticular ways that are distorted. These arecalled ‘thinking errors’. Here are somecommon examples. Try to spot the ones thatapply to you.Thinking the worst, e.g. ‘The pain in mychest means there is something wrongwith my heart’Predicting that the worst will happen, e.g.‘They won’t like me. They’ll think I’mstupid’Exaggerating negatives, e.g. ‘I made acomplete mess of it. It was an absolutedisaster’Overgeneralising – if something happensonce, you think it will always happen, e.g.if you feel anxious at the supermarketcheckout, thinking ‘I’m always anxiouswhen I go out’All or nothing thinking, e.g. ‘Unless I doit with no mistakes at all, I have failed’“Mind reading” or imagining that youknow what other people are thinking, e.g.‘I can tell they are thinking what a fool Iam’.You may also have beliefs about yourself andabout other people that are unrealistic.Anxious people often imagine that otherpeople are judging them harshly. Here aresome examples of beliefs that make peoplemore likely to be overly anxious. Mark theones that apply to you.When people look at me they areexamining what I do, or evaluating meharshly.If I get criticised it means that I am wrong.If I make a mistake that means that I ama failure.If I don’t agree with people they won’tlike me.To be a good person I have to be nice toeveryone.If someone is hurt or offended by what Isay or do, this means I am a bad person.If I show emotion it means that I amweak.People will think that there is somethingwrong with me if they see that I amanxious.The opinions of other people about meare very important.18Gloucestershire Mental Health Toolkit – Anxiety

I am afraid that I look or sound silly toother people.Approval is very important to me.When people see me behave like this theywill talk badly of me to others.Now if you have other unrealistic beliefswrite them below or use separate sheet ofpaper eg if someone is late, I assume therehas been an accident.ask yourself if the belief is true in everysituationexamine the other similar situationsexamine other explanations for the eventoccurringask yourself if you could be making amistake in the way you are thinkingThird, counter each unrealistic/negativethought with more realistic, reassuring onesthese should be positive and helpfulinclude thoughts which give you a positiveaffirmationtry and produce as many useful alternativeviews as possible.How do you change the way youthink?You may have been thinking in an unrealisticor a negative way for some time now, so youmay find it quite difficult to change negativethoughts, such as ‘I’m useless. I can’t doanything right’. You may need help from afriend or from your health worker. Rememberyou can learn to think more realistically andthis will make a huge difference in your life,just give yourself time.Here are some suggestions:First, write down any negative or frighteningthoughts as soon as possible after the event. Ifit’s difficult to spot any thoughts, try noticingwhen you feel down and ask ‘what wentthrough my mind just before I started feelinganxious’Second, ask yourself, is this thought realisticand true? In order to do this, it may help to…consult someone outside the situation fortheir opinionask yourself whether everyone would havethe same thought or belief in the samesituationExamplesPlease read the following example and thentry to create your own examples. Try to findsolutions to them using the same method.SITUATION: Anxious eating in a restaurantUnreasonable frightening or negativethoughts might be:I am sure they know that I am anxiousbecause my fork is shakingThey will think that I am crazyThey will think that I am a foolI hope they will not tell anyone I am oddI wish I could get out of hereResulting Feelings: PanicBalancing reassuring or positive thoughts:It is unlikely that they have noticed myanxietyIt is more noticeable to me than to themIf they were to think anything they wouldprobably only think that I was shyEven if they did think that I was anxiousthey would not think badly of meGloucestershire Mental Health Toolkit – Anxiety 19

I will try to stay focused on the meal andour conversationResulting feelings: Manageable anxietyIt is important that you make these statementseven when you don’t really believe them. Ifyou make reassuring or positive statementsoften, you will find that the frightening or selfcriticalthoughts that used to occur graduallydisappear.Now you can work through your ownexamples. Write down a situation that hasmade you anxious and any thoughts you mayhave had and the resulting feelings. Next,opposite each frightening thought, write downa more balanced thought and any newfeelings. You will find that after practising thistechnique for a while, you get much better atbalancing your thoughts.Remember it will take time to change theway you think and feel.How is anxiety treated?Feeling anxious does not necessarily mean youhave a problem. Anxiety is a normal responsethat everyone has to certain situations. Butanxiety can get out of hand; sometimes itreaches disabling proportions.The aim is not to get rid of all anxiety butrather to reduce it to manageableproportions.The best way to manage anxiety is throughpsychological help (counselling) and socialsupport. With different psychologicalmethods, it is possible to:control and stop panic attacksconfront feared situations previouslyavoidedchange negative and unrealistic thinkingand reduce worryPsychological methods include:breathing controlrelaxationproblem solvingbalancing anxious thinking with reassuringthoughts (cognitive therapy)gradually facing the things that you fear(graded exposure).These psychological methods are often taughtin Stress Management Courses.Tablets are sometimes prescribed for anxiety.Tranquillisers can make people feel calmer.They also help with difficulties sleeping. Theywork quite quickly but can be addictive.Because of this they are recommended forshort term use and only when the anxietyexperienced is very severe and psychologicalmethods are also being used. Anti-depressantsare sometimes also prescribed, especially forsomeone who feels depressed as well asanxious. These tablets work quite slowly atfirst and may take two weeks to work properly.They sometimes have side-effects – such as adry mouth. They are not addictive and areusually given over quite a long time. Betablockers slow down the activity of the heartand they are sometimes prescribed to controla fast or irregular heartbeat and other bodilysymptoms of anxiety. They may be useful inthe short term treatment of ‘stage fright’ orpanic symptoms, though they do not helppeople to stop avoiding the things they fear.Your doctor will explain what he or she isprescribing for you and why. You can also askthe pharmacist who gives you the tablets.Tablets do not solve problems or cure anxietyin the long term. Tablets are an important helpbut, in the long run we all have to solve ourproblems ourselves. It is still important to tryto do other things as well to overcome youranxiety.How to reduce anxietyThe first thing to do is to be clear about whatthe problem is. The next two exercises will20Gloucestershire Mental Health Toolkit – Anxiety

help you describe and understand theproblem.1 Identify your symptoms of anxietyMark on the scale how much you experienceeach symptom. If you have other symptoms,write them on another piece of paper and alsorate them.Symptom severitySymptom Not Mild Moderate Severeat allPsychologicalworryfear of loss ofcontrolfear of dyingfear of going crazyfeelings of unrealityPhysicaltremblingtightness/pain inthe chestshortness of breath/choking sweatingpounding hearthot and cold flushesdizziness/lightheadedness2 Identify situations or places thatyou fear or avoidIt is common for people to experience anxietyin certain situations or places but not inothers. It is also common for people to avoidthose situations so that they can avoid thefeeling of anxiety.Do you fear or avoid anything? Use the listbelow to identify any situations you avoid orfear. Add any that are not listed. Discuss themwith your doctor and/or counsellor orsomeone else you trust.Fear or avoidance Symptom severitySymptom Not Mild Moderate Severeat allPlaces/situationsEating or drinkingwith other peopleBeing watched orstared atTalking to people inauthoritySpeaking in publicBeing criticisedAsking for directionsin the streetOrdering in arestaurantAsking for help ina shopTravelling alone orby busWalking alone onbusy streetsGoing into crowdedshopsGoing to the moviesTaking elevatorsYou can repeat this exercise every week, sothat you can see the progress you aremaking.Some methods of reducing anxiety areappropriate for certain types of anxietyproblems. For example, learning controlledbreathing is particularly useful for controllingpanics and gradually facing the situations andthings that you fear (exposure) is particularlyuseful for phobias. Discuss what is mostappropriate for you with your health worker.Remember: Most people have ups and downsas they get over their problems, andoccasional set-backs are normal. They do notmean that you are not making progressoverall.Gloucestershire Mental Health Toolkit – Anxiety 21

As you start to tackle the problems you usedto avoid, your anxiety will probably increase.This is only to be expected. By confrontingyour difficulties you will improve yourconfidence and self-esteem which will make itmuch easier to deal with anxiety.3 Try physical exerciseSpecifically, aerobic exercise is the form ofexercise most consistently shown to reduceanxiety, and the duration should be of morethan twenty minutes. Anxiety reductionachieved through aerobic exercise is similar tothe reduction achieved through meditation orrelaxation.4 Check your caffeine intakeTry to avoid drinking too much tea and coffeeas caffeine can increase anxiety levels.5 Check your alcohol intakePeople who are anxious may try to cope withthe anxiety by drinking more alcohol. Thismakes things worse. Guidelines for what is‘low-risk’ drinking are presented below.Individuals will differ in terms of what levelwill cause harm.Because alcohol is a drug it can lower yourmood leaving some people feeling depressed.for menup to 3 units of alcohol per day, with amaximum of 21 units per week spreadthroughout the week (including at least 2alcohol free days per week)for womenup to 2 units of alcohol per day, with amaximum of 14 units per week spreadthroughout the week (including at least 2alcohol free days per week)As a rough guide, there’s ONE unit ofalcohol in:half a pint of ordinary strength (3.5 or 4%ABV) beer, lager or cidera small glass (125ml) of lower strengthwine (8 or 9% ABV)a single 25 ml pub measure of spirits(40% ABV)In a typical day how many units of alcohol doyou have?On how many days in a typical week do youdrink?Is this above the safe limits for your gender?If you would like help to reduce yourdrinking, ask your health worker for moreinformation.6 Dealing with worries andproblemsIf you find that you are worrying, endlesslyturning over your different problems in yourhead, try putting your worry to a usefulpurpose. Pick out one or two problems thatseem really important and make a decision toresolve them. You may like to ask a friend tohelp you.Sit down and list any problems you want todeal with. Go through the following steps foreach problem:1. Say exactly what the problem is. You mayfind it consists of several problems.2. List 5 or 6 possible solutions for eachproblem – write down any ideas that occurto you, not merely the ‘good’ ideas.3. Evaluate the good and bad points of eachidea in turn.4. Choose the solution(s) that best fits yourneeds.22Gloucestershire Mental Health Toolkit – Anxiety

5. Plan exactly the steps you will take to putthe solution into action, and try them out.6. Review your efforts after carry out theplan. Praise all efforts. If unsuccessful, usethe experience to plan a better strategyand try again.Your health worker can give you moreinformation about problem solvingtechniques..Gloucestershire Mental Health Toolkit – Anxiety 23

2 Distinguishing between apanic attack and a heart attackBefore we distinguish between a panic attackand a heart attack it is important to definewhat a panic attack is. A panic attack usuallyhas three important features:It consists of intense fear and anxietyIt usually comes on fairly suddenlyIt usually lasts a relatively brief timePanic is usually accompanied by a sense thatsomething awful is about to happen. You maythink that you will die, or go mad, or make acomplete fool of yourself, or something else…there are as many different fears as there arepeople that panic. For some people, paniccomes ‘out of the blue’. In other words, thepanic attack is completely unexpected anddoes not appear to be triggered by anything.Other people can recognise particularsituations which are likely to trigger an attack.Panic attacks are very common and they arenot a sign of serious mental illness. We knowthat as many as one in ten of the generalpublic have at least one panic attack in theirlife. Many people have panics for a while, butthen the panics go away. For others, they maybe a problem for a long time. Many peoplewait years before they tell anyone or seekprofessional help, and some people neverseek help at all.People who have panic attacks commonly fearthat they are having a heart attack. This fearmakes the panic worse. As some of thesymptoms of a panic attack are alsoexperienced during a heart attack (eg chestpain), it is understandable that people maymix them up. If chest pain is recurrent orlong-lasting, it is wise to have a thoroughmedical investigation. However, if your doctorhas ruled out heart disease, then it is veryunlikely that subsequent chest pain is causedby a heart attack. The information below maybe helpful in telling the symptoms of panicand a heart attack apart.Ischaemic heart disease is very rare in youngwomen. Young women are the group mostlikely to experience panic disorder. Heartdisease does NOT cause panic attacks andpanic attacks do NOT cause heart disease.Generally, if you are prone to panic attacksand you experience another similar attack, it isprobably best for you to sit quietly and use theslow breathing exercise for about five to tenminutes. It may also be helpful to ask yourself‘Did I die or have a heart attack the last time Iexperienced these symptoms?’However, if the pain is still present after tenminutes of slow breathing, you are advised toseek medical advice.Distinguishing between a panicattack and a heart attackSymptom: PainHeart attack:May or may not be present. If present, thepain is often described as a crushing feeling(like someone standing on the chest).Pain, if present, is not usually made worse bybreathing or by pressing on the chest, isusually persistent and lasts longer than 5–10minutesPanic attack:Any pain is usually described as ‘sharp’. Thepain tends to be localised over the heart andis usually made worse by breathing in and outand pressing on the centre of the chest. Painusually disappears within about 5–10 minutes.24Gloucestershire Mental Health Toolkit – Anxiety

Symptom: TinglingHeart attack:Tingling, if present, is usually in the left armPanic attack:Tingling is usually present all over the body.Symptom: VomitingHeart attack:CommonPanic attack:Nausea may be present but vomiting is lesscommon.Panic attack:Breathing too quickly or too deeply(hyperventilation) is an extremely commonpanic response which precedes most panicattacks.Adapted with permission from World HealthOrganisation Collaborating Centre forResearch & Training for Mental Health, eds.WHO Guide to Mental Health in PrimaryCare. London: Royal Society of MedicinePress, 2000.Symptom: Breathing too quickly or deeplyHeart attack:A heart attack does not cause you to breathetoo quickly or too deeply (hyperventilation) –panic does. With a heart attack you may feel alittle short of breath. It is possible however, tohave a heart attack and then start panicking.In this case, hyperventilation is a symptom ofpanic not of the heart attackGloucestershire Mental Health Toolkit – Anxiety 25

3 Controlling over-breathingYou may find yourself breathing faster forseveral reasons such as during strenuousexercise or if you’ve experienced a suddenshock. In these situations an increased rate ofrespiration is a perfectly normal response.Some people can, however, develop a habit ofover-breathing, especially when they arestressed or worried.It is surprising for people to learn thatbreathing too quickly and/or deeply (alsoknown as over-breathing or hyperventilation)can itself bring on anxiety. Breathing tooquickly lowers the amount of carbon dioxideand increases in your lungs. This upsets thechemical balance in your blood which theoxygen causes physical symptoms of anxiety.Other important things to note are:You can get physical anxiety by slightlyover breathing for a long time. So, overbreathing does not have to be obvious toyou or to others.If you slightly over breathe, even a yawnor sigh can trigger a panic attack orphysical symptoms of anxiety.Changing the way you breathe can beuseful for managing anxiety.By controlling over-breathing you are lesslikely to experience symptoms o anxietyand panic.Getting to know your breathinghabitsThe following exercises will help you learnmore about your breathing habits. First checkto see if you have any of the followingsymptoms of over-breathing.Symptom Yes No Not sureShallow frequent breathingmore than 10–12 breathsa minute at restYour chest sometimesfeels over-expanded ortightYou or others have noticedthat you sigh or yawnquite a bitYou often gasp or takedeep breaths particularlyin situations that makeyou anxiousSlow breathing to reduceanxiety/panicWhen you get physical symptoms of anxiety,for example breathlessness, it feels like youare not breathing enough. The naturalresponse is to breathe in more. However, ifyou do try to get more air by breathing inmore, it just makes the problem worse. Thebest solution is to slow down your breathingeven though you may feel that you shouldspeed it up. Now we suggest a slow breathingtechnique to stop the unpleasant feelings ofanxiety.The aim of this exercise is to slow yourbreathing rate to 8–10 breaths per minute.Remember to breathe in using your abdomen(not your chest) and through your nose.Begin by focusing your attention on yourbreathing.Practice pragmatic breathing. This meansbreathing by using your diaghphragm todraw out into your lungs.Place your hand on your stomach abovethe waist and you will notice with26Gloucestershire Mental Health Toolkit – Anxiety

diaphragmatic breathing you stomach willrise and fall with each breath. Try toreduce any movement in your upper chestand shoulders.Now breathe in slowly to the count of 3and pause for 3 seconds.Then slowly breathe out to the count of 3seconds.Pause for 3 seconds before breathing inagain.Continue this exercise for 5 minutes or so.Practice this exercise regularly 5–6 times aday and you will find you can control yourbreathing.Try to check and slow down yourbreathing during the day.Use the slow breathing techniquewhenever you get anxious.This technique can be used anywhere andonly takes a few minutes. Remember thetechnique of slow breathing sounds verysimple and it is very effective, but it will takepractice to master the technique.The paper-bag techniqueThis method of controlling over-breathingincreases the amount of CO 2 in the bloodstreamsimply by restricting the amount of O 2that enters your lungs and increasing yourintake of CO 2 . This takes place as you breatheback in the air you have already exhaled –(don’t worry, you are still absorbing ampleamounts of oxygen). This method does notinvolve as much practice as the slow breathingtechnique, but obviously is less easily used inpublic.When you feel panicky place a small paperbag over your mouth and nose. Keep thebag firmly in place by holding it close toyour face with your hands. Try not to allowany gaps where the air can escape.Now breathe slowly and regularly into thebag. Keep breathing in and out into thebag keep breathing in and out into thebag until the panic attack begins tosubside and your breathing becomes easy.A similar affect can be achieved bycupping your hands around your nose andmouth and breathing slowly.To use this technique, you will need to carry apaper-bag with you in your hand or pocket. Inpublic, the hand-cupping technique is moreconvenient. If you find a private place whereyou can use the paper-bag, however, thetechnique will help restore the balance ofgases in your blood quickly and so help tocontrol your anxiety.Distraction techniquesIt is useful to find some thing to take yourmind of your symptoms. Focusing yourattention on your symptoms usually makesthem worse.Here are a few suggestions:The rubber band techniqueWear a rubber band loosely around yourwrist. When you feel a panic attackstarting, stretch the rubber band and let itsnap back. Often this short, sharpsensation of pain will be enough toredirect your attention away from yoursymptoms. This can give you the chance tostart controlling your breathing.CountingSome people find it helpful to countobjects in their environment, such aswindow panes or railings etc divertthemselves from an imminent panic.Recite a poem or nursery rhyme in yourhead.It is important for you to find a techniquewhich works for you when you feel you areover-breathing or panicky, so that you can facedifficult situations with the confidence thatyou can be in control.Gloucestershire Mental Health Toolkit – Anxiety 27

4 Learning to relaxMany people find that learning to relax helpsthem reduce worry and anxiety. It can alsohelp improve sleep and relieve physicalsymptoms caused by stress, such as headachesor stomach pains. Learning to relax is a skilland takes practice before it can be doneproperly.You may already have learned a relaxationexercise or you may want to try a relaxation oryoga class at an adult education class or othercentre near you. If not, here is a guide on howto relax. This exercise should take about 15–20minutes. However, if you have only 5 minutesto spare, 5 minutes is better than nothing.1. Find a quiet and relaxing placeChoose a comfortable chair where you won’tbe disturbed. Make sure you take the phoneoff the hook. You may need to explain to yourfamily or friends what you are doing so thatthey do not disturb you. Telling them may alsoreduce any embarrassment you may feel.2. Clear your mindTry to clear your mind of all worries ordisturbing thoughts. If these worries orthoughts drift back into your mind while youare relaxing, do not try to stop them, just letthem float gently across and out of your mindwithout reacting to them. Let your mind beclear and calm.3. Practice the slow breathingmethodBreathe in for 3 seconds and breath out for 3seconds, thinking the word ‘relax’ every timeyou breathe out. Let your breathing flowsmoothly. Imagine the tension flowing out ofyour body each time you breathe out.4. Relax your musclesFor each of the muscle groups in your body,tense the muscles for 7–10 seconds, then relaxfor 10 seconds. Only tense your musclesmoderately (not to the point of inducingpain). Don’t try to force relaxation. Simply letgo of the tension in your muscles and allowthem to become relaxed. Relax your musclesin the following order:Hands – clench one fist tightly, then relax. Dothe same with the other handLower arms – bend your hand down at thewrist, as though you were trying to touch theunderside of your arm, then relaxUpper arms – bend your elbows and tenseyour arms. Feel the tension in your upperarm, then relaxShoulders – hunch your shoulders up as iftrying to touch your ears with them, thenrelaxNeck – stretch your neck gently to the left,then forward, then to the right, then to theback in a slow rolling motion, then relaxForehead and scalp – raise your eyebrows,then relaxEyes – screw up your eyes, then relaxJaw – clench your teeth (just to tighten themuscles), then relaxTongue – press your tongue against the roofof your mouth, then relaxChest – breathe in deeply to inflate yourlungs, then breath out and relaxStomach – pull your tummy in to tighten themuscle, then relaxUpper back – pull your shoulders forwardwith your arms at your side, then relax28Gloucestershire Mental Health Toolkit – Anxiety

Lower back – while sitting, lean your headand upper back forward, rolling your back intoa smooth arc thus tensing the lower back,then relaxButtocks – tighten your buttocks, then relaxThighs – while sitting, push your feet firmlyinto the floor, then relaxCalves – lift your toes off the ground towardsyour shins, then relaxFeet – gently curl your toes down so that theyare pressing into the floor, then relax.5. Enjoy the feeling of relaxationTake some slow breaths while you sit still for afew minutes enjoying the feeling of relaxation.Some people find that playing calming musichelps them to relax. However, it is importantto choose music that you find particularlyrestful and does not evoke stormy feelings.Practice once or twice a day for at least eightweeks. During the day, try relaxing specificmuscles whenever you notice that they aretense.Recognising tensionMany people find learning to relax difficult.This is because being tense has become ahabit.Use the chart below to help you see whereand when you get tense. Write in thesituations when you’ve noticed differentmuscles becoming tense. You might have beendoing something (such as shopping). Orwaiting to do something (such as a test). Writein what it was. Write it in next to the muscleswhich became tense. As you become moreaware of when you get tense, add thesituations to your chart. In those situations,practise parts of your relaxation routine toovercome the tensionBreathingHandsArmsShouldersNeckForeheadJawChestStomachBackLegsAutogenic relaxationAutogenic relaxation simply means focusingon two aspects of the relaxation response –increased blood flow and decreased musculartension. It does this by concentrating on threethings that we feel when relaxing: warmth –which is a sensation we experience whenmore blood reaches the extremities, such asthe arms, legs, hands and feet and heavinesswhich is what we feel when the muscles arerelaxed and easy natural breathing.Autogenic relaxation does not require you toforce anything. Just let yourself go. Becomeaware of how, when and where you are tenseand allow the tension to melt away. Let anydistracting thoughts go through and out ofyour mind.Autogenic relaxation can be done lying downor sitting in a supportive armchair.What to doWhen you are comfortable, lying or sitting,take a deep, diaphragmatic breath. Exhalegently and notice that first pleasant feeling ofrelaxation. There is no need to move duringautogenics unless you want to make yourselfmore comfortable. Simply unwind, allowingyourself to focus on the sensations ofGloucestershire Mental Health Toolkit – Anxiety 29

elaxation. The following phrases help you todo this. Say them to yourself 3 times, pausingafter each repetition. Take your time, keepingyour breathing regular, calm and relaxed.I am at peace with myself and fully relaxedMy right arm is heavy (if left handed you maywant to start with your left hand)My left arm is heavyMy right leg is heavyMy left leg is heavyMy neck and shoulders are heavyTake a deep, full breath and unwindeven furtherMy right arm is warmMy left arm is warmMy right leg is warmMy left leg is warmMy neck and shoulders are warmMy heartbeat is calm and regularMy breathing is calm and regularMy stomach is warm and calmMy forehead is cool and calmTake some time to enjoy the sensations ofrelaxation; when you are ready say toyourself – I am refreshed and completelyalert.Adapted with permission from World HealthOrganization Collaborating Centre forResearch and Training for Mental Health,eds. Who Guide to Mental Health in PrimaryCare. London: Royal Society of MedicinePress, 2000.VisualisationWe use visual imagery all the time, althoughmost of the time we are not aware of it. Weuse our “mind’s eye” to reconstgruct thingsfrom the past and to predict what mighthappen in the future.Our imagination is a powerful force which canhelp or hinder us. Without imagination it isdifficult to solve problems, as for this we needto think of different ways of doing things andthat requires the use of our imagination.Unfortunately anxious people often use visualimagery in negative or unhelpful ways, such asimagining the worst possible outcomes. If,however you can train your imagination to beyour “good friend” you will have a powerfultool constantly at your disposal.You can use visualisation to help you tosucceed. Before you go into a stressfulsituation, visualise the situation one step at atime. Visualise yourself doing well and copingwith your anxious feelings and the situation.Visualise yourself using your coping strategiesto good effect, controlling your breathing andcalming and encouraging yourself withpositive “self talk”. Visualise a positiveoutcome and you feeling good about yourselfand your achievements.Or you might like to visualise a peaceful placewhere you can relax and feel calm; perhaps abeautiful garden or a sunny beach.30Gloucestershire Mental Health Toolkit – Anxiety

5 Overcoming particular fears(phobias)It is not known for sure why some peoplehave fears that seem, even to them, to beirrational – such as a fear of eating in front ofpeople, fear of being away from a safe place orfear of dogs. However, we do know whatmaintains the fears and keeps them going:avoidance. Avoiding the thing that you feargives an immediate sense of relief in the shortterm. But in the long term, the avoidanceleads to embarrassment, lack of confidenceand an increase in the fear. This can cause avicious cycle. To break the cycle and overcomethe fear, it is essential that you face the thingthat you are afraid of. This is easier to do ifyou do it early on, when you first notice thatthere is a problem. If the fear you want totackle is long-standing, it can still beovercome, but will take longer and requiremore persistence and help from others.The key strategy for overcoming your fearinvolves constructing a plan to graduallyexpose yourself to what you fear, in smallsteps, so that you tackle what you fear withoutbecoming too frightened. Make a list of thesituations you avoid and that make youanxious, even if only mildly so. Then arrangethese situations in order of difficulty.Here are some examples of how a fearedsituation might be tackled:Example 1: fear of using publictransportWith a friend:walk to local bus stop to study thetimetable.wait at the bus stop. Allow bus to arrive.But do not get on.wait at bus stop. Allow bus to arrive. Geton and off again.catch the bus, go one stop and walkhome.catch bus, go two stops and walk home.catch bus to local shops. Walk home.catch bus to local shops. Catch bus home.Repeat the activities on your own.Example 2: fear of eating in publicWith a friend:go to a coffee shop with a friend. Ordercoffee but do not drink it.go to coffee shop with a friend. Ordercoffee and drink it.have a sandwich in a coffee shop with afriend.have dinner in restaurant with a friend.– vary the time of day that you go– go into quiet and then busy shops/cafes– go to informal and formal placesRepeat the activities on your own.Example 3: feeling uncomfortablewith groups of peopleorganise and go to a social event with agroup of friendsorganise and go to a social event with agroup of friends and some acquaintancesorganise and go to a social event withacquaintances onlyGloucestershire Mental Health Toolkit – Anxiety 31

organise and go to a social event withwork colleagues- vary the social events– vary the time of the day– vary the formality of the events.Example 4: fear of leaving thehousewalk alone to front gate.walk alone along street to first lamp post.walk alone along street and stand outsidethe local store.go into shop with friend.walk alone and go into shop withoutbuying anything.go into supermarket with friend.go alone and buy something from thelocal store.go alone to the supermarket and buysomething.Here are some general guidelines tohelp you make your own plan:Build up slowly: start with easy tasks andbuild up to harder tasks. The first stepshould make you slightly anxious but notfrighten you so much you can hardlytackle it.Only move on to a harder task when youfeel comfortable with the task you areworking onPractise tasks regularly, once a day isbetter than twice a weekPlan things you enjoy so that you havesomething to look forward to each timeyou move on a step.Expect set-backs and do not give upbecause of them. Everyone’s confidencevaries. If something is too hard, find waysof breaking it down into smaler steps orgo more slowlyDiscuss your problems with your doctorand/or your counselor or a friend youtrust.Get someone to help and encourage you.Give them a copy of the leaflet ‘Helpingsomeone else overcome a phobia’Do not use alcohol or drugs to cope withthe feared situationLearn and practise the breathing, rationalthinking and relaxation exercises beforeyou start, so that you can use them tohelp you reduce anxiety while yougradually face the fears.Specific guidelines:Always stay in the situation until youranxiety level drops. If you leave thesituation while your anxiety is high orwhen you are in a panic you willexperience relief. But this will make youranxiety worse the next time you areconfronted with a similar situation.Use slow breathing strategies to controlphysical anxietyUse ‘rational thinking’ strategies to replaceunrealistic/negative thinkingUse relaxation before you expose yourselfto the feared situationYour health worker can give you moreinformation about slow breathing, dealingwith anxious thinking and relaxation. Ask forthe leaflets on these topics.Remember: The rate of progress is differentfor different people. It does not matter howslowly you go. As long as you are practising,you will keep progressing and will get there inthe end.32Gloucestershire Mental Health Toolkit – Anxiety

Keeping track of your progressExposure form and overall rating of howyou feelWe recommend that you use this form everyweek to monitor your symptoms of anxiety forsituations in which you have carried outexposure exercises.SITUATION:Example: getting used to speaking andasking for assistanceFear or avoidance scoreWeek specific task not at all mild moderate severe________________________________________________________________________________Most people have ups and downs as they getover their problems. Occasional setbacks arenormal. They do not mean that you are notmaking progress overall.Gloucestershire Mental Health Toolkit – Anxiety 33

6 Helping someone elseovercome a phobiaWhen someone is working to overcome aphobia, it can be enormously helpful to themto have the support of a relative, partner orfriend. The leaflet has been written to helpyou to provide this support. It should be readin conjunction with the leaflets: How toOvercome a Phobia and Anxiety and How ToReduce It.What is a phobia?Phobias are fears of particular things orsituations, such as a fear of eating in front ofpeople, fear of being away from a safe place orfear of dogs. While it is not known for surewhy people develop these fears, we do knowwhat maintains the fears and keeps themgoing: avoidance. Avoiding the thing that isfeared gives an immediate sense of relief inthe short term. But in the long term, theavoidance leads to embarrassment, lack ofconfidence and an increase in the fear. Thiscan cause a vicious cycle. To break the cycleand overcome the fear, it is essential for theperson to gradually face the thing that theyare afraid of. This takes real courage –especially if the fear is a long-standing one –and is easier for most people to do with helpfrom others.Deciding if this is the rightthing for you to doTo help your friend, you will need to be surethat:Your friend wants your help and you arehappy to give it. It is best if both of youread all the information you have beengiven on anxiety and phobias and thendiscuss it together.You are able to appreciate that yourfriend’s feelings are real, even if thedanger is not. Your friend needs realcourage to face the fear and it is importantnot to belittle his or her feelings. If youare having trouble understanding thefeeling, think about a time when you havebeen really scared.You have the time to support your friendwithout feeling put-upon or resentful. Theamount of time needed will varyaccording to the role you take. Forexample, if your friend is afraid oftravelling on a bus and you decide toaccompany your friend on some bus trips,that will take more time than if you decidethat your role is simply to help plan thetrips and listen to how they went. Theimportant thing is that you don’t take onmore than you can do. Your friend needsto be able to rely on you to do what youpromise with good will.You can support your friend withoutdoing things for them that they need todo for themselves. For example, if yourfriend is afraid to go into shops, you maygo with them as part of the plan, butshould not take over and do the shoppingfor them. Think of going with a friend to ahospital appointment when you know thatthey are expecting bad news. You cannotturn the news into good news or face itfor them, but you can be there with them.You can support and encourage yourfriend while also leaving them in controlof the decisions. They must becomfortable with the plan to overcometheir fear. They must go at the pace atwhich they are comfortable, however slowthis might seem to you.34Gloucestershire Mental Health Toolkit – Anxiety

What you can do to helpHelping devise the plan of actionThe key strategy for overcoming the fearinvolves devising a plan of gradual exposure tothe thing or situation that is feared, but insmall steps, so that the person tackles thingswhich are a little bit frightening but notoverwhelmingly frightening. It can beenormously helpful to have someone to helpwith this, to ensure that the plan is clear andrealistic. You can help in choosing the steps tobe taken and help your friend to avoid thecommon pitfalls, such as making the steps inthe plan too large or too vague. See theexamples in the leaflet on facing specific fears.Provide companionship for somesteps in the planFor some phobias, it can be tremendouslyhelpful for the person to face some of themost feared situations with the support andcompanionship of a trusted friend. This can bea step on the way to facing the fearedsituation alone.Listening to reports of how thesteps in the plan have goneYour friend can report back to you the resultsof his or her steps in the plan. You can listen,understand the courage that your friend isshowing in facing things that cause him or herfear. You can celebrate successes and helpyour friends to deal with setbacks. Setbacksare to be expected and are not a sign offailure. They are often a sign that the step hasbeen too big or that one step has not beenpractised enough before going on to the next.If a step is too big, help your friend to break itdown into more manageable achievement. However, some people withphobias (and other forms of anxiety) feel thatthey are stupid to have the fear in the firstplace and that they do not deserve rewards fortheir efforts in overcoming the fear. You canhelp your friend to choose something thatthey will enjoy and encourage them to indulgethemselves a little after each step in the plan.The list of pleasant things to do may give yousome ideas. Your friend needs to choosesomething that works for them. It is betterthat the reward is not alcohol, cigarettes orcaffeine as these are unhelpful ways of dealingwith anxiety. It helps if the reward comesquickly after the goal is reached.A special situationSometimes a person, especially a familymember, takes over doing things for someonein order to help them. For example, a womanbecame gradually frightened of going awayfrom home. Her husband tried to help her bydoing all the shopping for her so that she didnot have to leave home alone. If you are inthis situation, the step by step plan will meanthat you gradually reduce the things that youdo for your partner or friend. In this case, itmay be useful for you and your partner todiscuss your plan with a third party who is lessinvolved, such as your doctor or counsellor.Help to plan rewardsIt takes a great deal of courage to overcome aphobia and every step should be celebrated asGloucestershire Mental Health Toolkit – Anxiety 35

7 What is ObessiveCompulsive Disorder (OCD)OCD is an anxiety disorder in which peoplefeel they have no control over certainthoughts or ideas which seem to forcethemselves into consciousness. Theserepeated thoughts – obsessions – are oftenfrightening and distressing or seem sounacceptable that they cannot be shared withothers. They often include a belief inimpending death or disaster involvingthemselves or others.The obsessions, even if they seem unrealistic,cannot be dismissed or reasoned away. Theycreate unbearable anxiety, which often makespeople feel quite helpless. The anxiety canonly be relieved by performing the particularritual that neutralizes the devastatingthoughts. But the relief from the anxiety isalways temporary.This could be something like repeatedlyopening and closing doors, washing hands,counting, checking locks, cleaning; in otherwords, exaggerated elements of everydayactions and routines.For example, Peggy was a teacher, but she hadacquired an obsession: protecting herself fromAIDS and cancer germs. When she came tosee a therapist she was at the point of whereshe had not been able to bring food into herapartment for six months. She spent fivehours a day washing her hands andshowering. If a checkout supermarketassistant looked poorly, she switched toanother. Her laundry required many rewashingsdue to her fears. She tried not toshake hands or brush against people, and shesegregated her ‘clean’ clothes – those she hadworn in her apartment – from her ‘dirty’clothes – those she had worn outside theapartment. Peggy wasn’t quite sure thattouching contaminated objects would causeher to contract cancer or AIDS. But she alsocouldn’t be sure that it wouldn’t. So she kepton performing the rituals, just in case.This irresistible urge to carry out such ritualsis known as compulsion.What are the signs of OCDOCD is similar to a phobia. In both cases, fearbrings anxiety and panic and may cause:Rapid heartbeatChurning stomachDizzinessShortness of breathSweating and tremblingWe all occasionally worry about whether thegas is turned off or the door is locked, and weall talk about being obsessed with work,football, etc. Many of us indulge in ritualswithout thinking or engage in compulsivebehaviour such as straightening objects,cleaning more than is necessary, etc.Obsessive-compulsive disorder, however,involves extreme, of this kind of behaviour.Someone would be described as having OCDif they experience obsessions or compulsions,or both, to a degree that affects their daily lifeor causes them distress. For some, this mightmean spending five hours a day washing likePeggy or repeating the same action (going upand down stairs) over and over again. Theyare compelled to do so by the fear that it wasnot done right or that something awful willhappen if they do not do it.It has been estimated that between one andthree per cent of the population experiences36Gloucestershire Mental Health Toolkit – Anxiety

symptoms of OCD, although only thoseseverely affected may seek help.What sort of help can I get?The symptoms for OCD can be quitedistressing. While there is no immediate cure,there are a number of different treatmentsavailable.MedicationMedication is the first choice of treatment;and can be helpful, either on its own or inconjunction with psychological therapy.Psychological therapyThere are several kinds of talking treatmentsavailable. The most evidence-based treatmentfor OCD is cognitive-behavioural therapy. Thistype of therapy aims to identify connectionsbetween thoughts, feelings and behaviour, andto help develop practical skills to manage yourthoughts and behaviours. Behaviour therapyhas also been shown to be effective,psychologists in particular, may employ thispractical approach to help some people facefears and reduce their rituals. It is also knownas exposure therapy or desensitisation.Your GP surgery may be able to advise you ofcounsellors trained in the above techniqueswho may be able to help. Therapy is alsoavailable through the NHS however strictcriteria for accessment is applied due to thelarge demand for treatment. Private therapistsare available but do charge a fee.What can I do to help myself?Self-help groupsIt can be useful to share experiences andmethods of coping with others. Triumph OverPhobia (TOPS) UK hold weekly self-helpgroups in both Gloucester and Cheltenham.You can call their national number 01225 330353 for more details of groups in your area.They also have information booklets andbooks on a range of anxiety disordersincluding OCD.Relaxation techniquesSome people have found relaxationtechniques useful in teaching them how toreduce tension by improving their breathing.Physical exercise can also help to relaxmuscles.ReadingThere are many good self-help books availableto buy or to borrow from your local library.A few are listed below:Getting Control: Overcoming YourObsessions and Compulsions, 1991 by LeeBaer Plume Books. Available from TOPS UK.Obsessive Compulsive Disorder: New Helpfor the Family, by Gravitz & Broatch 1998Partners Publishing Group.The OCD Workbook: Your Guide to BreakingFree From Obsessive Compulsive Disorder byHyman & Pedrick 2000 New HarbingerPublishers.Tormenting Thoughts & Secret Rituals: TheHidden Epidemic of Obsessive CompulsiveDisorder, by Ian Osborn 1999Understanding Obsession & Compulsions: ASelf-help Manual, by Frank Tallis 1992 SheldonPressUnderstanding Obsessions and Compulsionsby Frank Tallis 1992 SheldonAll books listed above are also available topurchase off the internet Mental Health Toolkit – Anxiety 37

8 Useful organisationsTriumph Over Phobia (TOPS) UKPO Box 1831, Bath BA2 4YWTel: 08456 009601Email: Triumphoverphobia.comObsessive Action Aberdeen Centre22-24 Highbury Grove London N5 2EATel: 0207 2264000National Phobics Society Zion Centre339 Stretford Road, Hulme,Manchester M15 4ZYTel: 0161 227 9898Email: Nationalphobic@btconnect.comHelpline and reccommendations for localprivate therapistsFirst Steps to Freedom7 Avon Court, School Lane,Kenilworth CV8 2GXTel: 0845 1202916Telephone helpline and tele conference selfhelpgroup.British Association for Cognitive-Behavioural TherapistsPO Box 9, Accrington BB5 2GDTel: 01254 875277Can provide a list of therapists in your area.Please note most therapists may charge a feeranging from £30 – £45 per session.www.babcp.com38Gloucestershire Mental Health Toolkit – Anxiety

9 Post traumatic stressIn recent years, much has been learned abouthow people are affected by the experience ofevents which seriously threaten their safety orthe safety of their family or friends. It is notonly the survivors of such traumatic eventswho are affected, but also people who arebereaved, helpers, rescuers and others whohave worked with the survivors or thebereaved.Common reactions during thetraumaWhen we experience a threatening event ourbodies automatically respond in a way thatallows us to protect ourselves or escape fromthe situation. This ‘fight-or-flight’ responseinvolves an increase in heart rate, bloodpressure, muscle tension and breathing rate.All these changes help us to physically dealwith danger or to leave the situation veryquickly if necessary.During an extremely traumatic event thisreaction will be very strong. The commonreactions experienced may include:shocknumbnessangerpounding heartfast breathingexcitementdisbeliefintense fearconfusiontrembling or shakingsweatingnauseaRemember, however, that while theseresponses are to be expected, it is usuallyhelpful to discuss the responses and feelingswith somebody when they occur.Common reactions during thedays following the traumaIt is also common for individuals to continueto experience a number of thoughts, imagesand feelings for some days, or even weeks,following the trauma. Again, these reactionsare common and are a sign that the body isrecovering from a severe stress.The most commonly reported reactionsinclude:Anxiety or fear of danger to self or lovedones, being alone, being in otherfrightening situations, and having a similarevent happen againAvoidance of situations or thoughts thatremind you of the traumatic eventBeing easily startled by loud noises orsudden movementsFlashbacks where images of the traumaticevent come into your mind suddenly forno apparent reason, or where you mentalyre-experience the eventPhysical symptoms such as tense muscles,trembling or shaking, diarrhoea orconstipation, nausea, headaches, sweating,tirednessLack of interest in usual activities,including loss of appetite or interest in sexSadness or feelings of loss or alonenessShock or disbelief at what has happened;feeling numb, unreal, isolated, ordetached from other people.Gloucestershire Mental Health Toolkit – Anxiety 39

Sleep problems including getting tosleep, waking in the middle of the night,dreams or nightmaresProblems with thinking, concentration, orremembering things (especially aspects ofthe traumatic event)Preoccupation with thinking about thetraumaGuilt and self-doubt for not having actedin some other way during the trauma, orfor being better off than others, or feeling‘responsible’ for another person’s deathor injuryAnger or irritability at what hashappened; at the senselessness of it all; atwhat caused the event to happen, oftenasking ‘Why me?’Not everyone will experience all of thesereactions, or experience these reactions to thesame extent. There may also be otherreactions to add to the list. However, in mostcases, these symptoms will disappear after ashort period of time (i.e., a few hours, days, orweeks).Psychological responses totraumatic stress – what to do:Immediately after the eventMake sure you are with people. Do not gohome to an empty house – ask a friend orrelative to stay with you.Talk about the incident with others.Talking will help you get over thereactions.Remind yourself that the event is over andthat you are now safe.If possible get some physical exercise. Thiswill help to ‘burn off ’ some of yourtension and anxiety.Avoid alcohol, sedatives, or sleeping pills(they will only dull the experience and notallow you to deal with your feelingsproperly).Restrict stimulants (such as tea, coffee,chocolate, cola, or cigarettes) because youdo not want to make your body evenmore agitated than it already is at present.Try to eat something even if you do notfeel like eating.If you cannot sleep, do not lie in bedtossing and turning – get up and dosomething until you feel tired.How to handle the next few daysRemind yourself that your reactions are anormal result of trauma and will pass intime.Try to get back into your normal routineas soon as possible. You may need togradually introduce yourself to tasks thatseem difficult.If you feel uncomfortable, scared oranxious, take some long, slow breaths andremind yourself that you are safe and thatthe trauma is over.Make sure that you are doing things thatare relaxing and enjoyable – be kind toyourself.Continue to talk to your family, friendsand colleagues about the trauma. This willhelp you to get over your feelings. Even ifyou feel a bit distant from other people,do not reject their support. Do not beafraid of your feelings.Work on your general stress levels byensuring that you have adequate sleep, agood diet and regular exercise. Practicerelaxation to help reduce nervous tension.Drive more carefuly and be more carefularound the home and with machinery.Accidents are more common after severestress.40Gloucestershire Mental Health Toolkit – Anxiety

Allow yourself time to deal with thememories. You will need commitment andpatience. There may be some aspects ofthe experience that will be difficult toforget.If your reaction continues to seriouslydisrupt your life, please talk to your healthworker.Adapted with permission from World HealthOrganization Collaborating Centre forResearch and Training for Mental Health,eds. Who Guide to Mental Health in PrimaryCare. London: Royal Society of MedicinePress, 2000.Gloucestershire Mental Health Toolkit – Anxiety 41

10 Exam stressAn exam creates some stress, but there’s anever-increasing load of stress on pupilsstudying for big exams. Pressure comes fromfamily, teachers and yourself to do well andsecure a place at university. Anxiety can reachsuch a level that concentration is impaired,making studying all but impossible.Having a positive attitude towards the exam isa good start towards passing it. Believe you’llpass! Visualise your exam paper marked ‘A’.Eliminate any thoughts of failure. But ofcourse – Study!Tips for passingBesides keeping up-to-date on class workand homework, occasionally through theyear (or term) go back and do a littlereview.As the dreaded day approaches, start yourintensive study in plenty of time to avoidcramming at the end.Discipline yourself to do the requiredamount of study each day, rememberingto take breaks every 30–60 minutes. Walkaround, stretch, do a little exercise,breathe some fresh air, think aboutsomething entirely different for 10minutes. This clears the brain and relaxesthe muscles before the next stretch.Buy a pack of file cards (index cards). Onone side write down the question and onthe other side write the answer. Use thesefor whatever you find hardest toremember – events in history, dates, etc.Keep a few with you so you can flipthrough them when you have a sparemoment.It may be a useful trick to make up arhyme such as ‘A pint is a pound the worldaround’. OR remember a formula or quoteby memorising the first letter in eachword and forming those letters into aword, however silly that nonsense wordsturns out to be.Find one or more friends who arestudying for the same test. Each onewrites out the 20 questions he/she feelsare most likely to be asked. Get together.Each one reads out his/her questions andthe others try to answer. Be prepared tostick to the exercise rather than goofingoff and watching TV. If you feeldiscouraged at the end of the session, takecourage. It pointed out where you need toconcentrate your study.In the weeks just before the exam, makesure you get adequate sleep and eatproperly.The night before the exam, lay outeverything you’re going to need for thenext day.Make sure you get your quota of sleep –8–9 hours. Since your study has been wellplanned, you won’t need to burn themidnight oil and walk into the exam like azombie.The big day is here! You couldn’t dobetter than start with a few minutes ofyoga and meditation.Breakfast is essential. The brain needssome fuel.Face to face with the examRead the whole exam through first. Thistells you which parts will require the mosttime. Make a rough assessment of time tobe allowed for each section, then eachquestion. Be a clock-watcher, so you don’tcut yourself short of time toward the end.42Gloucestershire Mental Health Toolkit – Anxiety

Read directions carefully! You may be told‘Answer two of the following questions’.Some students barge ahead and answer allfour. They’ve only wasted valuable time,and the usual way of marking such apaper is to accept the two first answers,which may not be the ones the studentdid best at.When you begin to feel tired, take a minbreak.Look up and relax your eyes bylooking into the distance. Do some fingerstretches and even a few neck andshoulder exercises. Relax your body andregulate your breathing. Picture this examgraded ‘A’. Put yourself ahead in time andfocus on your favourite things to. All ofthis should only take between 2–3minutes. Then back to work, feelingrenewed.When you’ve finished, put all scrap paperin one pile, all exam papers in another, inorder. Check your paper carefully.Read all instructions again and check tosee that you have answered the requirednumber of questions.Starting with question one, read thequestion – then your answer. Make sureyou haven’t omitted a part. Have youanswered what was asked? No matter howmuch information you give, it counts forlittle if you didn’t answer what was asked.Is your writing easy to read?Just before handing in your paper, makeone final check that all parts of your examare there in correct order, the pagesnumbered and your name on each one.Then – go and celebrate!GOOD LUCK WITH YOUR EXAMS!Taken from: Bad Hair Day? A Guide toDealing with Everyday Stress by Nancy ScottCameron, Element Children’s Books, 2000.Gloucestershire Mental Health Toolkit – Anxiety 43

11 Resources andorganisations for anxiety, panicand phobiasNational organisationsAssociation for Post-natal Stress145 Pawers Road25 Jerdan Place, London SW6 7EBTel: 0207 386 0868Mon–Wed–Fri 10am–2pm. Tue–Thu10am–5pm. Network of volunteers (recoveredsufferers) to support UK sufferers. Freeservice: offer reassurance and advice. Factsheets – contact with other recovered mothersby phone, post or emailFirst Steps to Freedom7 Avon Court, School Lane KenilworthWarwickshire CV8 2GXHelpline: 0845 1202916Also run telephone self-help group byconference call.National Phobics Society339 Stretford Road, Hulme,Manchester M15 4ZYTel: 0161 227 9898Email:£16 annual subscriptio.offer helpline and canrecommend local private therapists.No Panic (local groups)93 Brands Farm Way, Telford TF3 2JQInformation line: 0800 783 1531For further information pack, helpline andadvice also run telephone conference recoverycourses. £10 joining fee and quarterlynewsletters.Obsessive Action22–24 Highbury Grove, London N5 2EATel: 020 7226 4000Volunteer helpline. Tue, Wed and Thurs9.30am–5.00pmSaneline – National Mental HealthHelplineTel: 0845 6678000Open 12 noon–2am – midnight and offerstelephone counselling for a range of mentalillnesses.SamaritansTel: 08457 90909024 hour crisis counselling helplineThe Council for InvoluntaryTranquilliser AddictionCavendish House, Brighton Road, Waterloo,Liverpool L22 5NG.Helpline: 0151 932 0102 (10am–1pmMon–Fri).Helpline: 01952 590545 10am–10pm;Head Office: 01952 590005;44Gloucestershire Mental Health Toolkit – Anxiety

Local organisationAgoraphobic Support GroupGloucester Association for Mental HealthBelsize House, Brunswick Square, GloucesterGL1 1UGTel: 01452 416575Listening service and give advice aboutappropriate services.Gloucestershire Counselling ServiceTel: 01453 766 310Personal, relationship and family counsellingthroughout county.Triumph Over Phobia (TOP UK)(local groups Gloucester & Cheltenham)PO Box 1831, Bath BA2 4YWTel: 08456 009601 (office)Email: triumphoverphobia.comPrimary Mental Health TeamLocal Stress management Workshops acrossGloucestershire, Daytime, Evening andSaturdays.Tel: 01452 383242 (office hours 9am–5pm) readingUnderstanding Stress by Professor GregWilkinson. (Published in Family Doctor seriesin association with BMA, available from LloydsChemists and some Tesco stores)Managing Your Mind: The Mental FitnessGuide by Gilian Butler and Tony Hope.(Oxford University Press, 1996)Self-help for Your Nerves by Claire WeeksOvercoming Panic by Derrick Silove andVijaya Manicavasagar (Robinson, 1997)Coping Successfully with Panic Attacks byShirley Tickett (Sheldon Press)Anxiety, Phobias and Panic Attacks by ElainSheehan (Element Guide Series)Living with Fear – Understanding and Copingwith Anxiety by Isaac Marks M.D. (McGrawHil). Available from TOPS UK (address below)The Panic Book Suitable for Children &Adults by Neil Phillips. Available from TOPSUK – PO Box 1831 Bath BA2 4YWPanic Attacks by Christian Ingkam (Thorsons1997)Overcoming Social Anxiety & Shyness byGillian Butler (Robinson 1999)The Relaxation & Stress Reduction WorkbookDavis, Robbins, Eshelman & McKay (NewHarbinger 1995)Teach Yourself: Managing Stress Looker, Terry& Gregson, Olga (Teach yourself books 1997)Audiotapes Coping with exam nerves, Copingwith depression, Coping with sleep problems,Feeling good (self-esteem/assertiveness),Coping with pain, The relaxation kit & Copingwith stress at work. Available from Relaxationfor Living, 29 Burwood Park Rd, Walton-on-Thames, Surrey KT12 5LH. SAE only. TalkingLife, PO Box 1, Wirral L47 7DD. Tel: 0151 6320662. Fax: 0151 632 1206.Classes and activitiesAdult classes in yoga, medication, relaxationand assertiveness are commonly held in localschools or in Colleges of Further Education,during the day and evening. These are not justfor people with anxiety problems, but canhelp you relax and perhaps have some fun atthe same time. Leisure Centres run differentkinds of exercise classes, which may also help.Ask your doctor, nurse or counsellor if theythink any of these are appropriate for you.Gloucestershire Mental Health Toolkit – Anxiety 45

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