Articles

By Karen Hastings

Changing the way you think in order to improve the way you feel, forms the basis of cognitive approaches to mental-wellbeing. Cognitive therapies recognise that our thoughts can affect our understanding of the outside world. Depressed people (i.e. people that practice depressed thoughts!) experience the world in a different way to others. For example, they may perceive colours less vibrantly, food can seem bland and unpleasant, and safe everyday situations can seem threatening. They often predict bad outcomes from actions and events where others would expect positive consequences. A depressed persons world is likely to be experienced significantly differently to a happy person’s. However, to an observer their circumstances could appear the same.

Cognitive therapy is very effective at helping people recognise the thinking habits behind problems such as depression, anxiety, panic disorders and phobias. There are many cognitive techniques for testing negative thinking patterns and developing new more adaptive ways of thinking. If you are considering cognitive therapy, expect to commit to homework tasks and regular practise of these techniques.

Negative thoughts are usually fairly easily identifiable with the help of a therapist. In order to bring about a more global change, it’s often necessary to go beyond the thoughts we have to the deeper levels of our cognition – our beliefs.

Most people rarely think about their beliefs, how they developed, their role in guiding your life or whether they are helpful and supportive.

That’s because our beliefs have often been with us for a very long time. Very often we develop them in childhood. For example, a child may learn that ‘dogs are dangerous’ or ‘dogs are friendly’, depending on his experiences related to dogs. As that child grows up, it is likely that he will become more flexible in his belief about dogs, able to judge individual dogs for friendliness or dangerousness. This happens in most areas of our lives, as the more rigid beliefs from childhood, evolve and become more flexible as we develop.

However, this is not always the case. Sometimes negative beliefs develop due to trauma or consistent negative interactions or early life experiences. These beliefs often remain fixed in adulthood even though they hold the person back or negatively impact on their lives. Often they are taken as the absolute truth.

Beliefs form the core of your identity. Holding beliefs about yourself, your world and others that are unconstructive and not necessarily true, can be bad news for your self-esteem. Beliefs influence on your emotional experience and behaviour by colouring how you see the world.

Every belief you have is a generalisation or simplified way of viewing the world. Generalisations by their very nature are distortions. Often when I see clients for therapy it is possible to find a distorted belief behind the problem. For example ‘I am worthless’ is a belief, which promotes depression.

Your beliefs can actually determine outcomes. This is because your beliefs effect what you focus on or pay attention too. So for example, if you focus on being un-likeable, your unconscious mind will be on the lookout for examples of people not liking you and will find various ways to bring this to your attention. Whilst this is going on, you are of course ignoring evidence that shows you are in fact liked by all sorts of people.

I practice CBT based therapy in Dunfermline, Fife. People often come to see me with difficulties, which can be traced back to limiting beliefs e.g. “I am unattractive”, “I am a bad person”. Of course, it is not always obvious to them that they are holding onto damaging beliefs about themselves and their world, which prevent them from growing and developing or doing things they want too.
By Karen Hastings

One of the most common reasons that clients seek treatment is for anxiety and panic related problems, such as generalised anxiety disorder, panic attacks and agoraphobia. Often, panic attacks are associated with other conditions such as generalised anxiety, phobia or depression. In this case, the appropriate course of action is to address these underlying issues first – the panic attacks usually subside, as these other issues are resolved.

Having worked in the NHS as a senior mental Health Occupational Therapist, I tended to come into contact with people experiencing what is considered to be severe mental health problems. It is these people that the mental health system and services are geared towards supporting and rightly so. However, until entering private practice, I was unaware of the number of people living day to day with the often, debilitating effects of panic and anxiety disorders, with what appears to be, little or no support from overstretched NHS services.

NICE (National Institute for Clinical Excellence) recommends Cognitive Therapy for the treatment of anxiety, panic attacks and panic disorder. Their research has shown it to be more effective than any drug treatments. Therapies such as Cognitive Behavioural Therapy (CBT) and involve the person seeing a therapist on a one-to-one basis for hour-long sessions. The total treatment course is typically between 6 and 12 sessions, with one session a week.

I work with people experiencing anxiety, panic attacks and agoraphobia, usually over an 8-15 week period, seeing them once a week. This is flexible, and more or less sessions are carried out depending on the unique need of the individual. Obviously reducing the cost of treatment for the client is to be aimed for, particularly as I often work with people who have stopped working due to their problem.

In between sessions the client is given homework to complete. Support and encouragement via email is provided, if required.
By Karen Hastings

If you are an anxiety sufferer, I am sure that you will have read plenty of literature, on and off the internet about what anxiety is, what causes anxiety, what anxiety symptoms are and also information about the current anxiety treatments available. Therefore, this article will not spend time talking about these issues.

Understanding about anxiety is the first step in you overcoming it. However, the next and perhaps not as easy step, is to begin to become good at techniques that will allow you to master your anxiety or panic. I say ‘not as easy step’, because this is the feedback that I often get from clients during my first consultation with them. They often report to me that they have read so much about their problem that they know all there is to know. The difficulty, they find, is putting into practice the techniques. This is where the support of a therapist can be invaluable.

One of the more challenging, yet most effective techniques that a person with anxiety should know, is how to be mindful. What this means is being aware of the types of thoughts you have and the internal dialogue you hold with yourself. Being mindful means thinking about your thinking!! This article will discuss one way in which you can manage your anxiety by managing your thinking.

We know that the way we think can affect the way we feel physically and emotionally. People suffering from anxiety for several years or more can develop unhelpful thinking habits. Negative thinking habits have been found to activate the flight or fight response.

The trouble with negative thoughts is that they are very persuasive. Some of the characteristics of negative thoughts, is that they just ‘appear’ in your mind, they are unhelpful and stop you mastering anxiety, they are seductive, so that its easy to fall into the trap of believing them and they can seem overwhelming and difficult to dismiss from your mind. Sometimes we are aware of these thoughts and sometimes we are not. They can take the form of fleeting images or pictures in our minds, occurring automatically and disappearing quickly.

One of the ways to deal with negative thoughts is to challenge them. First you have to identify them. This can be challenging itself! Particularly if they are automatic thoughts. Spend time noting your thoughts, the situation they occurred in and how you felt. Once you have begun to recognise when you are having negative or upsetting thoughts try the following one technique. It involves challenging your thoughts by asking yourself a series of questions. You will need to practice the process until it becomes a habit to not just accept your thoughts as truth.

Ask yourself the following questions:
  1. What is the evidence
    • • What evidence is there to support my thoughts?
    • • What evidence is there against them?
    • • Don’t just assume your thought is true, record the evidence for both sides of the argument.
  2. Objective perspective
    • • How would someone else view this situation?
    • • How would I have viewed this situation at times when I have been strong and calm?
  3. Where does this thinking get me?
    • • What is the effect of thinking the way I do? Does it help me or hold me back? How does it do this?
  4. What types of thinking error am I making?
    • • People with anxiety tend to display several common thinking bias, some of which are listed below. Try to identify the thinking distortions you may be making.
    • • All or nothing thinking: ignoring the middle ground
    • • Focusing on the negative: ignoring strengths or any positives
    • • Jumping to conclusions/mind reading: predicting the future
    • • Catastrophising: overestimating the chances of crises
    • • Personalising: blaming self for something, which is not your fault
    • • Living by rigid beliefs: fretting about how things ought/should/must be.
  5. What can be done change my situation?
    • • What solutions are being overlooked? Make a list of what you can do to change your situation.
  6. What is the worst possible outcome?
    • • What is the worst thing that would happen and how bad would that really be? Fantasy is usually much worse then reality!
Further information about depression, the treatment of depression and the role of CBT and NLP.
By Dr. Stephen Last

A panic attack is a sudden feeling of extreme anxiety accompanied by significant physical symptoms such as trembling, sweating and shortness of breath. They are usually accompanied by an overwhelming fear of catastrophe – the person may feel they are dying or suffering a heart attack, or they may fear they are going mad. They can occur in response to specific situations (such as crowded areas) or spontaneously and with no obvious cause. They are usually short-lived (lasting a few minutes) but are so unpleasant that a person may live in fear of it happening again – in many cases, this will lead to the person avoiding situations that they think will trigger an attack (“avoidance behaviour”).

Panic attacks quite commonly accompany other anxiety conditions such as generalised anxiety and specific phobias (particularly Agoraphobia – the fear of open spaces). However they can occur outwith these other conditions – a study in 1994 found that 3 people in every 100 had experienced panic attacks alone.

Panic Disorder is the term used by Psychiatrists for those psychological conditions in which panic attacks predominate.

Psychological Symptoms of Panic Attacks
  • • Intense anxiety
  • • Fear of dying
  • • Fear of losing control or going mad
  • • Depersonalisation (the unpleasant feeling that you are not “real” or are detached from yourself)
  • • Derealisation (the unpleasant feeling that your environment is “fake” or you are an “actor in a play”)
  • • Physical Symptoms of Panic Attacks
  • • Shortness of breath or feeling “smothered”
  • • Choking
  • • Palpitations (feeling the heart racing or beating irregularly)
  • • Chest pain
  • • Sweating
  • • Dizziness or feeling faint
  • • Nausea or abdominal discomfort
  • • Flushing of the skin or feeling chilled
  • • Trembling or shaking
The feeling of being unable to breath can lead to a compensatory increase in breathing rate (hyperventilation) by the person. This in turn can affect the body adversely, leading to both a worsening of the physical symptoms above and additional symptoms:

Physical Symptoms of Hyperventilation
  • • Tinnitus (ringing in the ears)
  • • Numbness or tingling sensations in the hands, feet and face
  • • Headache
  • • Weakness
  • • Spasms of the hand and foot muscles
  • • In a panic attack, people will usually experience at least 4 of the above symptoms, although most experience many more than this. For a diagnosis of Panic Disorder, the person will experience at least 4 panic attacks in a 4-week period, or experience significant fear of a further attack (and exhibit avoidance behaviour) for 4 weeks following a single episode.


Treatment
If the panic attacks are associated with other conditions such as generalised anxiety, phobia or depression, then the appropriate course of action is to address these underlying issues first – the panic attacks should subside as these other issues are resolved.

If the panic attacks are the main problem, then (as with most psychological problems) two courses of action are available – drug treatment and psychological therapies.

The drug treatment of panic attacks limited. Sedative drugs such as the Benzodiazepines (e.g. Diazepam (Valium)) are very effective in the short term, but are highly addictive and can lead to dependence. Further, when these drugs are withdrawn, a resurgence of the panic is likely. Antidepressants, particularly the Selective Serotonin Reuptake Inhibitors (SSRIs) such as Citalopram (Cipramil) and Paroxetine (Seroxat), are licensed for use in panic disorder. They can cause an initial worsening of symptoms when first taken, and can cause other side effects such as gastro-intestinal disturbance and sexual dysfunction. Drug treatments are not as effective as psychological therapies in these conditions.

NICE (National Institute for Clinical Excellence) recommends Cognitive Therapy for the treatment of panic attacks and panic disorder. Their research has shown it to be more effective than any drug treatments. Therapies such as Cognitive Behavioural Therapy (CBT) and Neuro-Linguistic Programming (NLP) involve the patient seeing a therapist on a one-to-one basis for hour-long sessions. The total treatment course is typically between 6 and 12 sessions, with one session a week. The therapies involve an explanation of the psychological and physical symptoms of panic attacks, and may involve the deliberate precipitation of a panic attack during a session. The aim is to reduce the fear associated with the physical symptoms – this fear is often a cause of the attacks itself and the associated avoidance behaviours. Once the fear of the panic attacks is reduced, the attacks themselves will lessen in frequency and severity and, hopefully, disappear altogether.

Despite the clear recommendations by NICE, the availability of Cognitive Therapy remains limited in the NHS. If your GP or local Mental Health Trust is unable to provide the appropriate treatment for your condition, they may be able to recommend a therapist in the private sector.
Dr. Stephen Last

Anxiety is common and usually normal – all of us have experienced the sensation at some point in our lives. It is usually precipitated by the situations we find ourselves in, situations that possess an element of fear for us – exam time, interviews, public speaking and so on. In such situations, the anxiety response is normal and can work in our favour. The heightened awareness and rush of adrenaline can improve our performance. Of course, if the degree of anxiety is excessive, the effect can be the opposite, and our performance suffers.

The point at which anxiety stops being an appropriate response and becomes a hindrance to us can be considered the point at which it becomes a problem, a condition. This inappropriateness is the fundamental aspect of anxiety when viewed as a psychological condition. Typically the anxiety response will be prolonged (i.e. not restricted to the precipitating situation) or severe (i.e. excessive anxiety given the situation) or a combination of both. Clearly, these judgements are arbitrary – one person’s excessive anxiety may be considered by another as appropriate or normal. This is a situation in which “the customer is always right” – if an individual feels their anxiety is excessive or prolonged, then that is, in fact, the case. Anxiety becomes a problem when it adversely affects the individual to the point that they recognise it as such.

The common symptoms of anxiety are well known to all of us. They can be divided into two categories – the psychological response (mediated by the brains neurotransmitters) and the physical response (mediated by the hormone adrenaline in the bloodstream).

Psychological features of anxiety response:
  • • Heightened response to stimuli (“jumpiness”)
  • • Racing thoughts
  • • Excessive worry or “tension”
  • • Fear of losing control/dying/going mad (in severe cases)
  • • Physical features of the anxiety response:
  • • Palpitations (the sensation of the heart beating excessively or irregularly)
  • • Shortness of breath
  • • Faintness/dizziness
  • • Shakiness/tremulousness
  • • Sweating
  • • Urge to urinate/defecate
  • • Numbness of fingers (in severe cases)
  • • Vomiting (in severe cases)


Many of us have experienced these features at various times in our lives. It is a matter of personal judgement if one feels they are excessive or prolonged. Some people will expect to feel breathless and nauseous prior to speaking publicly – others will find this intolerable. Some people may expect to be anxious for several weeks before an exam or interview – others will see this as a problem. Psychiatrists will diagnose anxiety as a mental condition if the individual’s symptoms cause them significant distress.

The anxiety response in humans is akin to the “flight or fight” response in animals. It is a survival mechanism precipitated by perceived threat – a surge of adrenaline is released into the blood by the adrenal cortex (just above the kidneys), which then acts on the body to provide the ability to fight or flee the threat (i.e. the heart pumps faster, breathing is increased). The mental correlate is a “speeding up” of thoughts (to allow quick decision making) and an increased sensitivity to the environment (to allow accurate and fast assessment of the situation). It is a very useful response – in animals.

Modern human beings (in the industrialised societies at least) no longer face the sort of threat that the flight or fight response is designed to meet. We aren’t likely to be eaten by predators or attacked by other humans. Our threats today are usually less life threatening – but they are still important to us. And an inappropriate anxiety response can hinder our ability to cope.

The treatment of anxiety can be divided into two categories – drug treatments and talking treatments (or therapies). The choice of treatment offered by the GP will depend on the nature and severity of the condition, on the availability of treatments and (hopefully) on the wishes of the patient.

The drug treatment of anxiety symptoms can be very effective – it can also be very unhelpful and lead to other problems. The drug treatment of anxiety is at it’s best in those cases where the anxiety is limited to a discrete time or situation. Examples might include a trip to the dentist or a plane journey for a nervous flyer. Drugs are commonly used to reduce anxiety prior to operations (the “pre-med”). The drugs used in these situations are usually tranquillizers such as the Benzodiazepines (e.g. temazepam, lorazepam, diazepam). They are effective and act quickly. Unfortunately they are both sedative (therefore best not used before a speech or interview!) and highly addictive if taken regularly for more than a few weeks, the body becomes used to them and they no longer work unless the dose is constantly increased. Furthermore, if one tries to come off them after this period, one is likely to experience withdrawal symptoms – a return of the anxiety symptoms (but worse than before) or even convulsions. Once habituated to sedatives it is a long hard road to come off them. But this is not an issue with limited, short-term use.

Another drug that is frequently used to treat anxiety is a Beta-blocker (a medication used in cardiology to lower blood pressure and slow an abnormally fast heart rate) such as Atenolol. This is certainly less sedative than the benzodiazepines and is not addictive. It does have other side effects such as faintness/giddiness, lethargy, erectile dysfunction, and is very dangerous in overdose. Further, it is effective only on the physical symptoms of anxiety – the psychological symptoms are usually unaffected.

The final class of drugs available for the treatment of anxiety are the antidepressants. Some of these medications appear to have some efficacy in relieving anxiety symptoms as well as depression. They are typically the modern drugs and have fewer side effects than the older antidepressants, and are not considered to be addictive. They take longer to work than the benzodiazepines or a beta-blocker (e.g. weeks rather than hours).

Thus, drug treatments for anxiety are available and can be effective but they do have their down side. So what is available for those who whom such treatment is not appropriate or is ineffective, or those who prefer not to take tablets? There is the option of “talking therapies”.

There is a wide range of such therapies available, each with it’s own theory, method and applications. Therapies such as counselling and the traditional psychotherapies (e.g. psychoanalytic psychotherapy) are probably less suited to the treatment of anxiety than the more modern cognitive therapies such as Cognitive Behavioural Therapy (CBT) and Neuro-Linguistic Programming (NLP). These latter treatments focus less on the individuals past (and issues arising from it) and more on the “here and now”. They encourage the individual to become aware of how he or she thinks and feels, both in the anxiety-provoking situation(s) and in the normal course of life. It is usually possible to identify unhelpful patterns of thinking and reacting in people suffering from anxiety. These patterns serve to increase the anxiety response and thus increase the individual’s anxiety symptoms. Once such patterns have been recognised (individuals are usually unaware of them initially) it becomes possible to examine them and develop more useful and adaptive methods of thinking and reacting. This in turn will lessen the anxiety symptoms experienced.

Both CBT and NLP involve the client and therapist meeting on a one-to-one basis, typically for one-hour sessions. A course of therapy can last anything up to twenty or more sessions, though six to twelve sessions on a once – weekly basis is more typical. Such therapy involves a commitment by both parties. The therapist commits to regular sessions and will use their expertise to hep the client. The client commits to an intensive therapy that will challenge them mentally and frequently require work outside of the sessions e.g. the reading of literature recommended by the therapist, the monitoring and recording of their thoughts, feelings and behaviours in varying situations etc. An important aspect of the therapy is that the more the effort the client makes, the better the results.

Cognitive therapies are undoubtedly effective in the treatment of anxiety. Many psychiatrists consider such therapies as the “gold standard” in anxiety conditions – they are frequently more effective than drug treatments and do not have side effects. Furthermore, a course of cognitive therapy has the potential to help an individual for the remainder of their life. Once the techniques have been mastered, and the individual is aware of “problem” thinking and it’s solution, the techniques can be applied to any situation at any time in the future. A persons distressing anxiety may be a thing of the past.

Unfortunately, such therapies are not widely available on the NHS – a familiar story! If your GP is unable to refer you for the therapy on the NHS, he or she may be able to recommend a suitable private therapist.