Do you experience sudden episodes of intense and overwhelming fear that seem to come on for no apparent reason? Read More

Clinical Disorders and Problem Areas

Extensive research on Cognitive Behavioural Psychotherapy (CBT) has been carried out. It has been shown to be an effective form of treatment, particularly for the following:

Obsessional OCD

Obsessional OCD

Here Jackie describes this distressing problem. Obsessional OCD is a form of OCD that people are often very frightened of or are too embarrassed to talk about.

Anxiety, Panic and Phobias

This section is divided into 4 parts. 

PART ONE contains general information about the CBT perspective on anxiety.This information is worth reading even if you think your problem is panic which is described in PART TWO or some form of phobia in PART THREE. Information regarding further reading based on cognitive behavioural psychotherapy and CBT based self-help resources are available in PART FOUR.


PART ONE: CBT AND ANXIETY


WHAT IS ANXIETY?


Anxiety is normal. It’s a normal reaction to help us deal with all sorts of difficult or dangerous situations. This same anxiety reaction occurs throughout the animal kingdom. We need it to survive. It alerts our body for action and enables us to react swiftly and efficiently.

Here are two examples:

a) If you are crossing a road and suddenly you see a car driving straight towards you, it is your anxiety response that helps you quickly jump out of the way. b) If you had to fight an enemy it is your anxiety that gets you prepared.

Obviously in either case it would be no good being all relaxed and half asleep as you would end up worse for wear.

Modern man has learned to use his anxiety. It has helped him to conquer the unknown and to survive. It drives us forward, giving us impetus to succeed and helps us to achieve our goals.

It is by making good use of the physical reaction of anxiety that man has become the dominant species on earth.

Everybody experiences anxious feelings at one time or another, for example when going to the dentist, sitting exams or attending an interview. At these times our anxiety is normal, appropriate and even useful. However, if anxiety becomes too intense or occurs in situations where there is no real danger, then it becomes very distressing and can cause major difficulties.

Approximately 1 in 10 adults seek professional help at some time in their life for anxiety. Many others suffer in silence. Problems with anxiety are common. Cognitive Behavioural Psychotherapy has been extensively researched and is widely recommended as the most effective form of psychotherapy for this area of difficulty.

The aim of this information is to help you understand what anxiety is and how it affects us. Re-read this several times, it contains a lot of information. Remember that anxiety affects us all in different ways, so there might be things mentioned that do not apply to you. Everybody is different and CBT involves assessment of every individual before an active treatment plan is agreed.

HOW DOES ANXIETY HAPPEN?

The physical sensations of anxiety are triggered by the brain interpreting a given situation as threatening. A message is then sent from the brain to the “adrenal glands” (these are situated on top of your kidneys), which in turn release  ADRENALIN into the blood stream.

The body is preparing for danger. It is in a state of readiness. Having sensed danger, we feel fearful and the body reacts with a primitive response to danger. It occurs very quickly, within seconds, without us having to think about it.

These reactions help us to respond to the danger. This response has become known as the “FIGHT OR FLIGHT” reaction – because the body is getting ready to stand and fight, or to run away.

The physical reaction is very similar to other emotions such as excitement or anger, though we often feel that it as very different, most of us like excitement but certainly don't like anxiety.  The major difference between these emotions is the interpretation that the brain places on it, i.e. the way that we look at the situation.

For example: Imagine two people on a roller coaster ride at a funfair. One of them might think that the experience was exciting and exhilarating (we like that!)whilst the other might think of it as fearful and anxiety provoking (do not like that!). They would both experience the same physiological reaction (the release of adrenalin) the only difference being their interpretation of the situation.


The “FIGHT OR FLIGHT” reaction.

  • Adrenalin is released into the blood stream.
  •  
  • This increases the strength and speed of the heart to pump more blood around the body for exertion. This can cause a feeling of the heart pounding,    which may be frightening but not dangerous. 
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  • Blood circulating to the muscles increases and the muscles become more tense especially those of the shoulders, neck, arms and legs, and become ready for action – so we can move quickly or react with strength, if there is any danger. These tense muscles also form a shield which protects organs of the body, (e.g. the heart and lungs).
  •  
  • This can result in a feeling of general tension and may lead to shaking or trembling.
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  • Muscles that get most tense are the scalp, neck and shoulder muscles, causing headaches, neck ache, or a feeling of a tight band around the head. The muscles need energy so that they can respond quickly. This is provided by oxygen reacting with the sugar (glucose) that is in the blood stream. So for this reaction to happen more oxygen is needed in the blood stream. 
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  • To get more oxygen into the blood stream, the lungs have to work harder to take in more air. This is why breathing becomes faster and shallower. This is fine and indeed normal during heavy exercise, but can cause problems when we become anxious when not exerting ourselves. It can make us feel short of breath or as if we are suffocating. 
  •  
  • The chest muscles  becoming tense can result in a feeling of tightness or even chest pain.
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  • Overbreathing at rest can alter the mixture of gasses in the blood causing dizziness, tingling sensations in the limbs and light-headedness.
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  • In preparation for action the muscles become tense and subsequently heat up. To prevent overheating the body uses it’s cooling system and sweating occurs. Sometimes blood is sent to the skin, where the blood vessels are close to the surface, to help this cooling process. This can result in blushing or a feeling of hot or cold flushes.
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  • Some organs are not needed to protect the body so these are shut down and resources re-routed. Blood is diverted away from the digestive system, causing churning, butterflies and nausea and secretions may dry up causing a dry mouth.
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  • The lighter you are the faster you can move. The body attempts to lighten itself ready for action so there may be an urge to pass urine or empty the bowels.
  •  
  • The senses sharpen, this includes the field of vision increasing (sometimes causing blurring) and hearing becomes more acute (sometimes causing ringing or muffling).
As you can see a lot of different things happen to us when we are anxious to help us deal with situations, to help us “fight” or "run away". We do not always experience all of these symptoms, just some, and not everybody experiences them to the same degree.


This is a summary of the physical symptoms that we can experience:

HEART RATE INCREASES ……………………Palpitations

BLOOD PRESSURE INCREASES …………....Feelings of pressure in head
                                                                   Headaches

BREATHING RATE INCREASES ……....……. Overbreathing
                                                                    Dizziness
                                                                    Tingling sensations
                                                                    Light-headedness
                                                                    Tightness in chest
                                                                    Chest pain
                                                                    Feelings of shortness of breath

MUSCLE TENSION INCREASES …………….. Aches and pains
                                                                    Trembling
                                                                    Muscle cramps / spasms
                                                                    Tightness in chest
                                                                    Tightness in throat
                                                                    Headaches

SWEATING INCREASES ………………………Clamminess of hands / forehead
                                                                    Hot / cold flushes
                                                                    Blushing

DIGESTIVE DISTURBANCES ………………….Butterflies
                                                                    Nausea / vomiting
                                                                    Indigestion
                                                                    Poor appetite
                                                                    Dry mouth
                                                                    - difficulty swallowing

BODY LIGHTENS SELF ………………………..Urges to pass urine or open bowels
                                                                    Retching / Vomiting

SENSES SHARPEN ……………………………..Noises in ears
                                                                    Blurred vision
                                                                    Sensitivity to noise / light changes
                                                                    Heightened, threat enhanced, taste and smell

Some people report a feeling of strangeness, detachment or unreality. The reasons for this are not firmly established but a theory suggested is that this is a psychologically induced “shutdown” mechanism to help reduce anxiety.


Some physical or medical conditions can cause symptoms similar to panic attacks for example; thyroid problems, binge drinking, mixing medications, caffeine use, low blood sugar, vertigo etc. If you are concerned that your problem may have a physical cause and you have not yet had a check-up from your GP, then it may be a good idea to make an appointment. Most people initially believe that there is a physical or medical cause because of the intensity of the symptoms and they are often surprised when their doctor suggests that their problem may be psychological in origin. People often do not realise how powerful the physical symptoms of anxiety can be.

These then are the major bodily changes that occur when someone feels anxious. The purpose is to prepare the body for action. It is a primitive, natural, normal response that has aided human survival right from stone-age times up to today.

When we feel in danger or under threat these are the normal bodily responses. When the danger passes, the body settles down to normal. However, we may experience fatigue following this process as it uses up a lot of energy.

As the anxiety that leads to people seeking CBT is usually not the result of actual physical danger or threat it is clear that the brain is very capable of triggering many false alarms, which we physically respond to as if they are real. These include social or financial "threats."

If we continue to feel anxious over a long period of time, then the body remains in a state of tension and further problems can occur. We may feel irritable or frustrated and unable to concentrate. We may experience sleep problems and be more likely to become ill. These symptoms may lead to relationship problems, sexual difficulties or depression. So, it is important to seek Cognitive Behavioural Psychotherapy and deal with anxiety symptoms as soon as possible before further problems occur.

What else happens when we feel anxious? Not only do physical symptoms occur when we become anxious, but thoughts and actions can also change.

THOUGHTS

When we get anxious, our minds fill with all sorts of worrying thoughts and feelings. It’s often hard to concentrate and think straight. Sometimes the thoughts may be about various problems, but often they are about the anxiety itself, particularly the physical symptoms.

These are examples of the sort of thoughts that people experience:

“I can’t cope”
“I’ll make a fool of myself, others will notice”
“I’ll faint in front of them”
“I’m going mad”
“I’m going to lose control”
“I’m having a heart attack”
“I’m dying”
“I can’t breath”

These thoughts can be very distressing and make our original symptoms worse. This confirms our worst fears and we become even more frightened, which makes our symptoms worse.

A vicious circle develops that maintains our anxiety and which links the following four areas together

FRIGHTENING THOUGHTS

PHYSICAL SYMPTOMS 

ANXIOUS FEELINGS

SAFETY SEEKING BEHAVIOURS


These thoughts are often untrue, but are never the less easy to believe. They are very unhelpful because they often assume that once we have felt anxious in a situation, we always will. Unhelpful thoughts influence how we interpret situations and how we behave. These thoughts increase our anxiety.

Often symptoms can make us feel frustrated or even guilty, sometimes we become frightened that the symptoms will return. Unfortunately this causes further anxiety, making the original anxiety even worse. Once again we get into a vicious cycle.

PANIC ATTACKS

Sometimes the physical feelings that we experience can increase very rapidly or occur very suddenly. If this happens we tend to think what are referred to as "catastrophic", frightening thoughts about these feelings and what will happen to us, i.e. we feel threatened by the symptoms themselves.

Here are some examples of how this might work:

Palpitations / Chest pain ………………… “I’m having a heart attack”
Breathlessness / Tight chest ……………. “I’m going to stop breathing”
Trembling / Shakiness ………………....… “I’m having a stroke”

These thoughts will increase our anxiety, which will in turn increase the symptoms, which we think confirms our initial thoughts. Once again we get into a vicious circle.

Often these symptoms are the result of over-breathing (hyperventilation – shallow, rapid breathing). Because we breathe in this way, too much oxygen is taken in, which upsets the blood gases, and can either cause, or worsen, the symptoms. (More about panic in PART TWO)

Jack Mislearns


Jack is anxious. He has lost his job, has money worries and has recently been in a car accident. All this has increased his general stress levels. Jack goes to a football match to try and forget his problems but while he is there his anxiety about these problems increases. He notices that his heart is pounding, his mouth is dry and his chest feels tight. Mistakenly Jack attributes this anxiety to the crowd that he is in. He is misattributing his anxiety as being triggered by the crowd rather than by his other problems. Consequently, Jack begins to associate the crowd with anxiety, and leaves the match early. On leaving the grounds his anxiety reduces. Jack begins to mistakenly learn that the crowds make him anxious. He feels anxious in crowds and the anxiety reduces when he leaves. Apparently logical, but in fact, illogical.

Next time there is a match Jack begins to feel anxious as he is getting ready to go. He remembers that he became anxious on his last visit to the grounds so he decides not to go, and the anxiety is reduced. Now Jack has learned that all crowds make him anxious and avoiding them reduces his anxiety. Jack therefore, begins to avoid any crowd and the learning has generalised from football crowds to any crowds.

Were Jack dealing with a wild tiger then this course of action would be appropriate, but what specifically is threatening or stressful about a crowd? Only what Jack perceives to be threatening, nothing that is actually threatening.

This is maladaptive learning. Jack lives in a city where there are crowds everywhere and as Jack has learned to be anxious in crowds, anxiety is often triggered. Jack therefore spends a lot of time suddenly getting anxious and then escaping or avoiding these situations. In the short term this helps to reduce his anxiety but in the long term it actually increases the frequency and intensity of his anxiety attacks. The only way that Jack will learn that crowds are not threatening is to stay in them long enough to discover that his anxiety reduces with time. He then begins to learn that crowds do not make him anxious. He has to. He is in a crowd and he is not anxious, relearning begins to take place.

This type of relearning is one type of CBT approach to anxiety but there are others also. Some of these are based on the idea of living more effectively with the feelings as part of a more mindful, values based life so that they do not affect us in such a debilitating way and still enable us to live our lives with the quality we desire.

ACTIONS

Due to the physical symptoms and unhelpful thoughts that occur, we may adopt certain safety seeking  behaviours. We may “avoid” the situation or “escape” from the situation once we are there.

Avoiding situations is natural but in the long run makes the fear worse. Often we become anxious when there is no real danger, i.e. in crowds, shops, public transport, etc. If we continually avoid these situations we fail to learn that we can cope and that we have no need to be anxious. Unfortunately the fear then spreads to other situations and we gradually avoid more and more situations.

Escaping from danger is natural, but again if there is no real danger it makes the situation worse. Each time we escape a situation it becomes much harder to enter that situation. We fail to learn that nothing bad will happen to us.

WHAT GOES WRONG?

Sometimes we think we are threatened when there is nothing to fight or run away from. Basically we learn to become anxious when there is no real threat to our being, by misinterpreting events as stressful when they are not. The body has no way of knowing if a stressful situation is real or imagined unless the brain tells it. When we start to get anxious we tend to think in a biased way and it is this unhelpful thinking that creates the environment for frequent anxiety. Unhelpful thoughts turn safe situations into stressful situations and thus raises anxiety levels.

Often a slight change in lifestyle or a life event (e.g. marriage, promotion, the death of a close relative, etc) will cause a general rise in anxiety levels. We will then start to feel anxious in numerous situations.

Sometimes we will associate the situation that we are in with the anxiety that we experience. We will have learned to feel anxious in that situation.

Sometimes the physical sensations of anxiety will be associated with ill-health, concern regarding this imagined ill-health will lead to further stress and further anxiety symptoms.

Sometimes the anxiety just simmers along in the background, causing generalised tension, headaches, irritability and a general feeling of not being able to cope.


SO WHAT DO WE KNOW SO FAR?
 
  • Anxiety reactions play an important role in our survival. It helps us to react to danger. Also research suggests that an increase in our anxiety levels can help us to perform better. It gives us the desire to succeed. However, too much anxiety can have the opposite effect, when we become over anxious we may be unable to concentrate, think straight or perform tasks that we normally perform well.
  •  
  • When we become anxious we experience a wide range of physical symptoms. Although these can be very distressing they are NOT DANGEROUS.
  •  
  • Often when we become anxious our thoughts become very negative and tend to make the whole situation much worse. If we think that we are under threat or in danger then we will become anxious. The more we think in this manner the more anxious we become.
  •  
  • Sometimes the physical symptoms of anxiety can appear out of the blue or suddenly get much worse. In this situation we tend to believe that something physically, socially or mentally terrible is going to happen to us. This is called a “panic attack”. Despite how we feel these panic attacks are NOT DANGEROUS. The physical symptoms occur suddenly because we are already quite anxious, even if we are unaware of it, and our anxiety reaction is easily triggered.
  •  
  • Escaping and avoiding situations where there is real danger is both natural and appropriate. However, in situations where there is no real danger it is unhelpful. In the short term it reduces our anxiety, but in the long term it makes it much worse. It results in more and more situations becoming harder and harder to deal with. Most importantly it prevents us from learning that we can cope with our anxious feelings.
  •  
  • Very often we misattribute the anxiety that we experience to the situation that we are in. In this way we learn to become afraid of situations that do not represent any real danger to us. Remember Jack!

DON’T FORGET: IT IS NOT SITUATIONS OR EVENTS THAT MAKE US ANXIOUS, IT IS THE WAY THAT WE VIEW THEM.

ANXIETY IS NORMAL AND DOES NOT MEAN THAT WE ARE OUT OF CONTROL, EVEN IF IT FEELS THAT WAY.

IT IS UP TO US TO DO SOMETHING CONSTRUCTIVE ABOUT IT. SEEK EFFECTIVE HELP FROM A CBT THERPIST


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PART TWO: PANIC ATTACKS AND PANIC DISORDER

The following information might help you to decide if panic is likely to be the explanation for your experience and will point you in the right direction in terms of getting the appropriate help or treatment.

AM I HAVING PANIC ATTACKS?

Everyone knows what it is like to feel anxious or panicky. Panic is a normal experience from time to time and very much part of human life. Here are some examples:

• Your car breaks down in an unfamiliar part of town, the very night you left your mobile phone at home.
• Exams and interviews.
• You can’t find your purse/wallet and are unsure as to whether is has been mislaid or stolen and it contains your credit and debit cards.
• The car in front of you brakes sharply and you manage to pull up just in time to prevent a collision.
• Redundancies have been announced at work and you receive a message that your boss would like to speak with you.

It would be normal in any of these situations to feel a sense of heightened anxiety or panic. The feelings are understandable and would be experienced by many other people in the same situation. They pass quite quickly and are often forgotten about. You tend to focus on the situation or circumstances rather than on the bad feelings themselves.

A panic attack is a bit like 'normal' anxiety or panic, but differs in a number of ways that make it a very frightening and distressing experience:

• The feelings are very intense and strong and seem out of proportion to the situation.
• They are unexpected in relation to the situations in which they occur.
• They come 'out of the blue', for no apparent reason in situations where other people would not usually have similar reactions.

As the feelings are INTENSE and UNEXPECTED they can be extremely frightening. Common physical feelings experienced by people having a panic attack include:

• Tightness or pain in the chest, pounding heart, palpitations, rapid heartbeat or skipping beats.
• Changes in breathing, either over-breathing or gulping air, breathing fast or feeling short of breath
• Pressure/ pounding in your head, headaches.
• Numbness or tingling in fingers or toes.
• Dry mouth, tightness in your throat and feeling as though you can’t swallow.
• Butterflies in the stomach, nausea, feeling sick. indigestion, poor appetite.
• Dizziness, lightheadedness, wobbly legs, feeling as though you’re going to faint,
• General muscular aches and pains, trembling, cramps/spasms
• Sweating, hot and cold flushes, blushing.
• Urges to pass urine or open bowels.
• Noises in ears, blurred vision, sensitivity to noise / light changes
• A feeling of strangeness or unreality.
Some people have most or all of the symptoms, others just a few.

Some physical or medical conditions can cause symptoms similar to panic attacks for example; thyroid problems, binge drinking, mixing medications, caffeine use, low blood sugar, vertigo etc. If you are concerned that your problem may have a physical cause and you have not yet had a check-up from your GP, then it may be a good idea to make an appointment. Most people initially believe that there is a physical or medical cause because of the intensity of the symptoms and they are often surprised when their doctor suggests that their problem may be psychological in origin. People often do not realise how powerful the physical symptoms of anxiety can be.

Panic attacks affect people in many different ways, but what makes it distinct from normal anxiety and panic is that there is usually a feeling that something really awful or “catastrophic” is about to happen for example:

• That they will have a heart attack, stroke, brain haemorrhage, faint/collapse or even die.
• That they will humiliate themselves in front of others.
• That they will lose their mind, “go mad” or lose control in an irreversible way.
The good news is that although the experience is horrible and sometimes terrifying, nothing really awful is actually going to happen and panic attacks themselves are not dangerous.

Sometimes the panic attacks become “predictable” or associated with particular situations, for others they continue to be “out of the blue”. Some people have a “one off” panic attack, occasional or “one off” panic attacks are quite common. For others they occur on a repeated basis and if not addressed can continue for many years.

Unfortunately, the understandable ways in which people try to deal with or “cope” with their panic ultimately maintain or exacerbate the problem. Examples of this include:

• Avoiding situations in which panic has previously occurred.
• Escaping, rushing to get away or leaving situations as soon as you can
• Taking measures that you think will beat or resolve the symptoms for example, taking deep breaths if you think you are going to suffocate, sitting down if you think you are going to faint, lying down if you think you are having a heart attack or scanning your body for evidence of something being wrong.
• Seeking help like calling an ambulance, going to accident and emergency, or calling out the doctor.
• Distraction.
• Unprescribed drug use, alcohol misuse.
• Repeated reassurance seeking.

The good news is that these difficulties respond well to Cognitive Behavioural Therapy (CBT).


PART THREE: PHOBIA'S (To be added, sorry for the delay)


PART FOUR: CBT BASED SELF HELP AND READING MATERIALS


Overcoming Panic by Derrick Silove and Vijaya Manicavasagar.

Overcoming Anxiety by Helen Kennerley

Overcoming Anxiety - A Five Areas Approach - Chris WIlliams

Overcoming Worry by Kevin Meares and Mark Freeston

The Worry Cure by Robert Leahy

Mastering your Fears and Phobia's by Mark Antony, Michelle Craske and David Barlow

Manage Your Mood by David Veale and Rob WiIlson



 

Contact Information

If you want any further information or would like to arrange an appointment, please contact me.

Jackie O’Kelly,
Heather Edge,
Lullymore,
Rathangan,
Co.Kildare.

Phone: 045 870 423
Mobile: 086 0530445
Email: jackie@cbt-ireland.ie