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Breaking free from the anxiety trap

If worry and panic are familiar foes, you’re surely not alone. A new book by a lifelong sufferer, herself a medical professional, provides everyday ways to ease your mind.

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For the anxious-by-nature person, very little help is to be found in the catchcry “don’t worry”. Most have had a lifetime of hearing it and, says Alice Boyes, not only is it irritating, but it can end up making them feel as if there’s something fundamentally wrong with them.

Boyes is just such an anxiety-prone person, and she has also trained and practised as a clinical psychologist. She has combined these two perspectives in a new book, The Anxiety Toolkit, a practical guide to managing anxiety so it doesn’t affect every­day well-being, but not, she’s at pains to point out, “one of those saccharine, stick-a-smiley-face-on-it, positive-thinking books”.

Growing up in Greymouth, Boyes was an anxious child. “I was one of those kids who wouldn’t go to school camp because it was too anxiety provoking,” she says. “I was terrified the camp leaders would make me eat food I didn’t like or tell me off for something I hadn’t meant to do. And the idea of changing to a new teacher at school made me sick with anxiety.”

Almost every decision Boyes has made in her adult years has left her feeling physically sick. She suspects her way of thinking and reacting in stressful situations might have resulted in her leading a more limited life if she hadn’t studied psychology at the University of Canterbury. This gave her crucial insight into her own thought patterns and equipped her with the techniques to manage them and stay mentally healthy.

“As I got into my training, all the things I was learning were so useful to me and so life-changing. I don’t know where I’d be now without them,” she says.

FREEING HERSELF UP


HughNorris
Hugh Norris of the Mental Health Foundation


Where New Zealand-born Boyes is now is Las Vegas. No longer practising as a psychologist, she’s focused on being a writer and regularly blogs for Psychology Today. She continues to use the coping mechanisms she learnt in her profession to manage her ongoing anxiety.

“For example, I know I’m a person who automatically thinks about the worst thing that can happen, so I’ll try also to consider the best thing and the most realistic. I do that naturally now. It’s as if the negative thoughts are spelling mistakes that I autocorrect. I still have the tendencies I’ve always had, but the strategies feel like part of me and not a burden.”

Another technique Boyes has found works for her is one used by US President Barack Obama and Facebook founder Mark Zuckerberg: eliminating micro-decisions about things such as what to wear or eat by sticking to the same choices. “People call me Chairman Mao,” laughs Boyes. “I have a uniform I wear every day and two outfits I put on if I have to go out. I was like that even as a kid – I’d wear my school uniform on mufti day. I’ve been teased mercilessly for it, but now there’s actual research to back me up.”

Boyes also often eats the same foods over and over again and says creating this base level of consistency is a way of managing her psychological bank account wisely. “If I’m not dealing with change in those areas, I free myself up to cope with it in other parts of my life.”

At times she has also employed a technique known as exposure to deal with intrusive thoughts about specific and often irrational fears. “Exposure is the most potent technique in treating anxiety. It involves bringing the worst case scenario to mind and holding it there, keeping the vivid images until the anxiety level drops. You repeat it until you can bring it to mind with only low levels of anxiety … it’s a bit like an inoculation.

“I used to have crazy thought intrusions about losing control. I’d worry about ending up in jail because I’d lost concentration and killed someone while driving. I used the technique of exposure and it took about three or four times before I stopped having the thoughts.”

Physical symptoms of panic attacks can be dealt with in a similar way, using a technique called interoceptive exposure. “So if a patient is dizzy during a panic attack, you get them to spin on a chair so they can experience the sensation without the panic.”

MODERN MALAISE


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Alice Boyes of the Mental Health Foundation.


For people like Boyes, anxiety is a result of a complex interplay between genes and environment. Several parts of the brain are involved in the production of fear and worry and this is something scientists continue to grapple with.

Last year a report by researchers at the University of Wisconsin associated an elevated anxious temperament with deficits in one of the brain’s off-switches for anxiety, neuropeptide Y receptors. In 2009, psychologists at Stanford University identified a region of the brain, the anterior insula, which plays a key role in predicting harm and learning to avoid it. Researchers found excessive levels of insula activation put people at risk of psychological disorders such as anxiety and phobias.

There’s also a trickle-down effect. Parents with an anxiety disorder are more likely to behave in ways that put their children at risk of developing them, according to a 2012 study at Johns Hopkins University.

And there may be a higher price to pay for anxiety. It has been linked to everything from poor sleep patterns to high blood pressure and even accelerated ageing. Plus a biological link has been established between stress, anxiety and depression (mixed anxiety-depressive disorder is a diagnostic category).

As we discover more about the biology of anxiety, new drug treatments will be developed. In the meantime, the psychological methods of treating it have changed. “One of the big trends these days is to recognise these things we label as negative emotions – shame, guilt, anxiety – actually have a purpose,” says Boyes. “An important step is realising that anxiety is not a defect; it’s a useful system that has got miscalibrated.”

There are sound evolutionary reasons for worrying. It’s an extension of the fight-or-flight response that keeps us on the lookout for potential threats. The problem is this hyper-vigilance system hasn’t adapted to modern life. In New Zealand, for instance, life is safer for the vast majority of people than it has ever been. Yet as a nation, we’re becoming more anxious, not less, something we have in common with populations in other wealthy, developed countries, such as the UK and Australia.

“In my clinical practice in Christchurch, anxiety was by far the most common problem I saw,” says Boyes. “It was huge. And when I started blogging, the posts about anxiety were the ones that drew in the most people.”

Results of the 2013/14 update of the New Zealand Health Survey showed that 18% of adults have been diagnosed with a mood and/or anxiety disorder at some point. That’s up from 16% in 2012/13 and 13% in 2006/07. Rates are 40% higher in women than men. These statistics cover only those who have sought help; there’s no telling how many others are suffering in silence.

Hugh Norris, director of policy and development at the Mental Health Foundation, identifies three factors in this steady rise. “The first is that more people are accessing help who perhaps wouldn’t have before when there was a greater stigma about it. Second, I think we’re lowering our tolerance to psychological pain. Where previous generations might have said, ‘That’s life’, we expect it to be able to be fixed. And third, there are some genuine stressors that are increasing.

“It seems possible that we’re moving away from stoicism as a strong cultural aspect of our society. Many people came back from the war very damaged and it just wasn’t talked about. Today people want to do something about emotional pain instead of just soldiering on, which isn’t terribly effective as a psychological strategy. A bit of resilience is good, but ignoring the fact that we’re vulnerable isn’t.”

Norris points to the massive changes we’ve seen in the past 20 years – the greater financial uncertainties and inequalities, the electronic and digital distractions, the expectation that we should be constantly available, as well as the facets of modern life that play on our tendency to be sensitive to comparison with others. “There has been a rise in consumer advertising, and a lot of that is based on the subtle fear that if you don’t have this product or that service, you may be missing out. Studies suggest social media is also mildly anxiety-provoking for similar reasons.”

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KNOW YOUR NATURE


The Mental Health Foundation is talking a preventative approach. Its Five Ways to Wellbeing programme encourages people to look after their mental health in the same way they do their physical health. Exercising, connecting with others, continuing to learn, appreciating the little things and being generous are the key pillars. Meanwhile, the Anxiety New Zealand Trust has released a free mood diary app to help sufferers track their symptoms and triggers and monitor their mental health.

As Boyes explains, part of the problem is that we often don’t recognise our anxiety – we’ll notice we’re feeling irritable or unhappy but won’t see anxiety as the underlying cause. Her approach is to use the principles of cognitive behavioural therapy to help people gain greater self-knowledge, then adapt the principles into tools that can shift thinking and behaviour.

“Old-fashioned psychology was about getting rid of the thoughts,” she says. “People still talk about ‘beating’ anxiety, but I don’t like those metaphors. If you fight against anxiety, it will fight back harder. You’ve got to know your nature and work with that. It’s about creating an owner’s manual for your brain and understanding your cognitive style – not about changing your thoughts but changing your relationship with them. The good news is that anxiety is one of the more treatable problems, much more so than depression, for instance. We know how to wind it back.”

The techniques she outlines in The Anxiety Toolkit are particularly useful for those who are anxious by nature but not necessarily suffering from a full-blown disorder. Rather than the common method of identifying the various conditions – generalised anxiety disorder, obsessive compulsive disorder, panic disorder, post-traumatic stress disorder and social anxiety – Boyes takes a more practical approach and pinpoints what she refers to as the common “anxiety traps”, the things we do that make the problem worse.

“Almost everything people do to try to relieve anxiety – from avoidance coping to compensatory things like over-checking your work – cause anxiety to snowball.”

THE ANXIETY TRAPS


Rumination is the trap people most commonly fall into, says Boyes. Mentally replaying past events and worrying about the future is what she refers to as “unhelpful over-thinking”. To illustrate how people can get stuck in it, she refers to a study from Yale University and the University of California that found women who were prone to rumination took an average of 39 days longer to seek help after noticing a breast lump.

“When I was assessing clients, rumination was the first or second highest score for everyone,” says Boyes, who admits to being prone to it herself. “I might have an awkward interaction and then ruminate. I’ll be slightly off and it might take a day and a half to feel better, but I know myself well enough now to understand that it takes time to pass – it doesn’t impede my day.”

An obvious trigger for rumination is email, a form of communication stripped of all nonverbal and many context cues, and often prone to slow responses or perhaps no response at all. As a result, it’s easy to jump to negative conclusions and take the whole thing personally. “Short distraction is helpful for rumination. Just two minutes can help disrupt it. So perhaps spend the time doing a Sudoku puzzle, although I prefer doing things that are practical, like washing some dishes.”

Self-compassion is a newer tool to help break the rumination habit. “It’s been practised in therapy for the past few years and can be a hard one for clients to get. But for me, self-compassion has been the missing piece in psychology.”

Kristin Neff is one of the leading experts on self-compassion and was among the first to conduct research on the topic. She defines it as giving ourselves the same kindness and care we’d give to a good friend, accepting our failings rather than criticising ourselves for them, and not becoming wrapped up in a situation or emotional drama. On her website, self-compassion.org, she includes a quiz so people can test their own tendencies, plus exercises and guided meditations to help us develop more self-compassion.

Anxiety-related perfectionism is a trap that can be as paralysing as rumination. “There is more and more research coming out that [shows] perfectionism is a risk factor for other problems,” says Boyes. “It can even increase mortality. But it can be hard to distinguish between perfectionism and conscientiousness, particularly for high achievers.”

Anxious perfectionists believe they must perform flawlessly at all times. If they manage to meet their ultra-high standards, they may conclude those standards weren’t high enough and revise them upwards. Perfectionists tend to overdo things, persist too long on certain tasks, or avoid them completely when self-doubt creeps in.

But there is a way to keep your standards high without the problems that come from perfectionism, says Boyes. “If you can shift your thinking from a performance focus to a mastery focus, you’ll become less fearful, more resilient and more open to new ideas. A mastery focus means learning to tolerate that you’re not going to be perfect right out of the gate, so you can cope with a less than excellent performance and become less upset about failures.”

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HERE’S THE PLAN


Avoidance is the technique most of us tend to naturally fall back on to control panic and worry. We may avoid situations or courses of action that make us anxious. This isn’t just a bad idea, it’s a terrible one, says Boyes, since avoidance has been shown to be one of the main factors that fuel anxiety. “It’ll eat you alive psychologically if you don’t work on it. Why in a war do only a small proportion of people get post-traumatic stress? They’re the ones using avoidance mechanisms – staying away from crowded places, not talking about their experiences.”

Exposure hierarchy is a common tool used to treat avoidance issues in cognitive behavioural therapy. It’s a simple concept. You make a list of all the situations and behaviours you avoid and assign a number to each based on how anxiety-provoking you expect it to be. You then make a plan for working through the list, starting by tackling the things with the lowest scores and repeating them several times before moving on to the next. Boyes also suggests a 30-day project to overcome avoidance coping. “The goal is to start unravelling your habits bit by bit. If you sometimes fall back into the trap, that’s to be expected.”

She hopes that working through the quizzes, thought experiments and action plans included in The Anxiety Toolkit will help people become more resilient to future stress, less stuck in unhelpful behaviours and not necessarily less anxious by nature but less adversely affected by it.

“People are sick of being told to eat better, sleep better, do your meditation. This is about finding techniques that feel like reflections of your natural self. Of course there is some trial and error. People themselves don’t know what’s going to work and one of the traps is negative predictions, so there is a balance between choosing strategies that naturally appeal and trying some that sound kooky or seem too simple to work, as often they’re the ones that are most effective.”

One thing’s for sure – it has to be better than having people constantly tell you: “Don’t worry.”

The Anxiety Toolkit, by Alice Boyes (Hachette, $39.99), is also available as an e-book.

Toolkit techniques


•  Slow your breathing. This is the best way to instantly feel calmer. Drop your shoulders and focus on breathing slowly rather than deeply.

•  Decelerate. If you’re feeling overwhelmed or your thoughts are scattered, do a task 25% slower than your usual speed.

•  Suit yourself. Set up your life to accommodate your temperament. Aim to be only as busy as you can handle and to maintain the right level of social contact for you.

•  Act. Any small action you take to address what you’ve been avoiding or worrying about will help alleviate anxiety. Even something as simple as making a shortlist of options or solutions will help shift over-thinking to problem solving.

•  Reduce excess sensory stimulation. Try wearing noise-reducing headphones, for example.

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Anxiety sufferer Sarah Townsend: careful not to overload herself.

‘Lucky thing to have anxiety’


The Aromatherapy Company founder Sarah Townsend considers greater self-awareness an unexpected benefit of her anxiety disorder.

Sarah Townsend has come to realise her anxiety-prone nature isn’t such a bad thing. The Auckland businesswoman first started suffering serious symptoms of panic in her early twenties when she was living in London, working and playing too hard.

“I started feeling absolutely terrible,” she recalls. “I was exhausted, short of breath, my heart was beating too hard. It would come in waves. I’d think I had different illnesses all the time and kept going back to my GP.”

On her seventh visit, the doctor asked her to take a medical textbook from the shelves, open it at random and read from a page. Townsend doesn’t recall what condition was on it but does remember saying to her GP, “That’s it, I’ve got that.”

He told her, actually, she didn’t. “There was nothing wrong with me physically – I was perfectly healthy,” says Townsend. “I was manifesting these things because I had an anxiety disorder.”

Although it’s something she has continued to experience in different forms, anxiety hasn’t held her back. Twenty-five years ago she founded her business The Aromatherapy Company and has since gone from working alone in her garage to employing 60 people and exporting a large product range around the world.

She’s learnt to recognise her triggers. “It’s when I’ve been too stressed, pushing myself, possibly having too many late nights. My work uses up a lot of emotional energy because I’m a creative and it also involves a lot of travelling, so I have to make sure I keep myself in check. There are signs: I’ll start getting a bit breathless, my sleep will be affected, I may start to be a little too chatty and overexcited.”

Sometimes the symptoms do still take her by surprise. On one particularly frantic work trip to Shanghai, she became aware of an uncomfortable lump in her throat. “I couldn’t swallow and because of that I couldn’t sleep. I was really worried. I thought I had throat cancer.”

Back in New Zealand, it didn’t take her GP long to diagnose the problem. As Townsend described her symptoms, she was taking big anxious, gasping breaths. That’s what was causing her muscles to spasm. She was referred to Auckland’s Breathing Works clinic and still uses the techniques she was taught along with regular yoga, meditation and mindfulness.

“Exercise is also a key thing for me and it’s good to do things that are a challenge. Recently I took a sailing course, which wasn’t something I ever thought I’d do. And it was a really good feeling. I wasn’t in control, I had no idea what I was doing and I had to focus.”

Townsend still has to be careful not to overload herself. She’s now stepping back from her position as chief executive and has hired someone else to fill the role so she can reduce her work hours and focus on the more creative side of the business, which she sees as her real strength. She credits her anxious nature with helping her understand how to manage her life and work better.

“I’d describe it as like a train going along a track. You’ll have a little derailment and while you’re off the track you can take a moment to check in with yourself and consider why it happened, and if it might be because you’re doing too much. So it’s actually a wonderful, lucky thing to have anxiety.”

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