B r a Brain i n B “Solid, smart, and sound advice for conquering anxiety from one a of America’s premier therapists.” s e – Louis Cozolino, PhD., Professor of Psychology, Pepperdine University, author of d T The Neuroscience of Psychotherapy: Building and Rebuilding the Human Brain h e Based r a “You will understand your anxiety and learn how to overcome it. Dr. Arden p y will be your friend along the way to your recovery.” f o r – Elke Zuercher-White, PhD, ABPP, author of The End of Panic A n x Therapy i e t y : A W o The Brain Based Therapy for Anxiety: A Workbook for Clinicians and Clients r k is a practical workbook that provides the reader with a clear understanding b for Anxiety o of the underlying causes of their anxiety, the triggers, and gives practical o k solutions for healing. f o r C Through easy-to-complete exercises and accessible explanations, the l in clinician and the client explore who and what causes anxiety and how to ic better effectively cope. Worksheets, reflective questions, and meditations ia A Workbook for n s provide a complete guide that you will use time and time again. a n d • Learn how the two hemispheres of the brain process emotion differently Clinicians and Clients C and how to balance their activity lie n • Rewire the brain, tame the amygdala and create new brain habits t s • Learn how dietary changes can tune up the brain to reduce anxiety • Relearn calmness and change the way you feel John B. Arden, PhD John B. Arden, Ph.D., is the Director of Training for the A Northern California region in mental r Author of The Brain Bible, d health for the Kaiser Permanente Medical e the best-selling Rewire n Centers. He is the author or coauthor of 13 Your Brain and Brain other books, including Rewire Your Brain and Based Therapy for The Brain Bible. John lives in Northern California. OCD: A Workbook PUB082390 $29.99 for Clinicians PESI and Clients ISBN: 978-1-936-12800-6 52999 Publishing & Media PESI Publishing www.pesipublishing.com 9 781936 128006 & Media Brain Based Therapy for anxieTy A Workbook for Clinicians and Clients John B. Arden Ph.D. Author of The Brain Based Therapy for OCD: A workbook for Clinicians and Clients PESI Publishing & Media www.pesipublishing.com Copyright © 2014 by John B. Arden Ph.D. Published by PESI Publishing & Media PESI, Inc 3839 White Ave Eau Claire, WI 54703 Printed in the United States of America ISBN: 978-1-937661-81-6 All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photo copying, recording, or by any information storage and retrieval system without the written permission from the author (except for the inclusion of brief quotations in a review). PESI Publishing & Media www.pesipublishing.com Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii Chapter 1: What Is Anxiety and What Causes It? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Symptoms of Anxiety Disorders 2 Causes of Anxiety Disorders 2 Assessing Your Anxiety 5 What Sensations Interfere with Your Life? 7 Symptom Severity Worksheet 9 Chapter 2: Types of Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Determining Your Anxiety Type 10 What Are Your Symptom Clusters? 11 Generalized Anxiety Disorder (GAD) 14 Phobias 15 Phobia Self-Assessment Test 16 Identify Your Social Fears 17 Chapter 3: Rewiring Your Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Getting to Know Your Brain 20 Taming Your Amygdala 23 How Your Brain Creates New Habits 24 Chapter 4: Change Your Diet to Tune Up Your Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 Getting the Right Brain Food 26 Balanced Meal Worksheet 27 Substances that Negatively Affect Your Brain Chemistry 31 Sugar Awareness Worksheet 32 Sodium Awareness Worksheet 33 Chapter 5: Fine-tuning Your Body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 Breathing to Relax 40 Your Daily Breathing Goals 44 Stretch Away the Tension 44 Move Your Body to Relax 45 How Can You Include Exercise in Your Day? 47 Exercise Worksheet 48 Sleeping Once Again 48 Chapter 6: Relearning Calmness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 Learning to Let Go 57 Using Imagery to Achieve a Sense of Peace 58 Self-hypnosis 59 iii iv The Brain Based Anxiety Workbook Meditation and Prayer 60 Relaxation Monitoring Worksheet 61 Hybrid Yoga 63 Daily Relaxation Worksheet 65 Chapter 7: Change Your Thinking to Change the Way You Feel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66 Your Thinking Influences Your Feelings 67 Restructuring Your Beliefs 70 What Are Your Automatic Thoughts? 71 New Automatic Thoughts 72 Changing Your Assumptions 73 Correct Your Assumptions 75 New Assumptions 76 Restructuring Your Core Beliefs 77 Refute Your Stressful Core Beliefs 78 New Core Beliefs 79 Setting Goals to Boost Your Self-Esteem 80 Chapter 8: Facing Your Fears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83 Forms of Avoidance 84 Identifying Your Avoidant Behaviors 87 Escape Behavior Identifier Worksheet 87 Avoidance Behavior Identifier Worksheet 87 Procrastination Identifier Worksheet 88 Safety Behavior Identifier Worksheet 88 Avoidance Timeline 89 Fear Hierarchy Worksheet 89 Learning to Recondition Yourself 90 Steps to Exposure 92 Imagined Exposure Worksheet 1 93 Imagined Exposure Worksheet 2 94 In Vivo Exposure Worksheet 96 SUDS Exposure Worksheet 97 Chapter 9: Accepting Your Bodily Sensations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98 Anxiety Sensitivity 98 What Are Your Anxiety Symptoms? 99 Acknowledging Your Bodily Sensations 100 Learning Interoceptive Exposure 101 Assess Your Physical Sensations 102 Identify Your Coping Skills 103 Overbreathing Worksheet 105 Running in Place Worksheet 106 Breath-holding Worksheet 107 Spinning Worksheet 107 Swallowing Worksheet 108 Body Tension Worksheet 109 Standing Up Worksheet 109 Staring Worksheet 110 Shaking Your Head Worksheet 111 Head Between Your Legs Worksheet 111 Contents v Chapter 10: Preventing Relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113 Minimizing Your Vulnerability 113 What Are Your Stressors? 114 Recognizing Your Anxiety Triggers 116 Cues Planning Worksheet 117 Managing Setbacks 118 How Do You Deal with Setbacks? 120 Integrating Relapse-Prevention Skills into Your Everyday Life 120 Skills Checkup Worksheet 122 Relapse-prevention Monitoring Worksheet 126 About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127 introduction If you are plagued by anxiety, you are not alone. Anxiety disorders are more common in the United States than any other psychological problem, including depression. Some estimates indicate that one-fifth of all adults have experienced an anxiety disorder at some point in their lives. We live in a stress-filled world. Terrorism, financial and job pressures, and the wars in Iraq and Afghanistan have all contributed to an underlying sense of anxiety in our day-to-day lives. Although most of us find ways to deal with that anxiety, some people experience it in the extreme and can, as a result, develop anxiety disorders. Living with an anxiety disorder can be a challenge. It can make getting through the day and enjoying your life difficult. An anxiety disorder can put your life in disorder. The good news is that you can bring your anxiety disorder under control. Just as your body has the ability to heal wounds, so can your brain. Your brain has the capacity to change through a process known as neuroplasticity, which means rewiring your brain. This workbook will help you discover how to do just that. It contains the step-by-step lessons that I teach in my Mastering Anxiety class. You’ll learn: • how anxiety develops • the types of anxiety • how your brain works and how to rewire it • what you can do to make your brain more capable of rewiring • which foods and nutritional supplements create the right biochemistry to help your brain make you calmer • how to restructure your thinking, so that you can make your anxiety work for you, instead of against you • how to avoid avoidance and maximize exposure (you’ll find out more about these in chapter 8) • how to keep from overreacting to the physical sensations associated with anxiety • how to prevent relapse In the following chapters, you’ll discover the practices that can help you overcome panic disorder, phobia, and generalized anxiety. These practices are what I call “brain-based” and “evidence-based.” Brain-based practices help you change how you think. Because your brain is central to everything you do and feel, when you rewire your brain, you can put anxiety behind you. Evidence-based practices are techniques that are known to help overcome anxiety. After performing hundreds of studies on treating anxiety disorders, psychologists have found that some techniques work and some do not. You are going to learn the ones that work. These vii viii The Brain Based Anxiety Workbook evidence-based practices form the basis of two books I have written for professional therapists on brain-based therapy. In this book, you’ll discover how to heal your anxiety from a biopsychosocial perspective—that is, biologically, psychologically, and socially. A biopsychosocial approach is comprehensive because anxiety encompasses biological (your brain and the rest of your body), psychological (thinking and feeling), and social (social and cultural contexts) aspects. By following the practices in this book, you can physically change your brain and body, change the way you think to help you change the way you feel, and change the way you approach social situations. You’ll learn how to rewire your brain and alter the way your body functions. You’ll learn to restructure your thoughts, so that your emotions can follow their lead. You’ll also learn to use the social world around you to enhance your comfort level. You live in a social world with culturally defined methods of dealing with problems, including anxiety. Some of these are unhelpful and lead to misunderstandings. You’ll learn which socially sanctioned methods to discard and which ones to embrace. What this book will not cover is the use of medications to treat anxiety disorders. My position with respect to medication is that less is more. Although I am not fundamentally against the use of medications, I find that most people can heal their anxiety without them. Antianxiety medications, such as Ativan and Valium, can impede your ability to heal your anxiety in the long term and can contribute to a wide range of negative side effects, such as depression, sleep problems, and addiction. Selective Serotonin Reuptake Inhibitors (SSRIs), such as Paxil and Prozac, have been found to have anti-anxiety effects, but they also come with side effects. If you want your gains to be permanent, don’t rely on medications. They are only useful when you use them. Try the methods described in this book before considering medications. This book will also not cover post-traumatic stress disorder (PTSD) or obsessive-compulsive disorder (OCD). If you have PTSD or OCD, you’ll want to refer to one of my other books: Conquering Post-Traumatic Stress Disorder (with Dr. Victoria Beckner) and The Heal-Your-OCD Workbook (with Dr. Daniel Dal Corso). Finally, this is not just a book about anxiety. It is a book on how to heal your anxiety. As you read through it, you’ll not only learn how to overcome excessive anxiety, but you’ll also be practicing methods to overcome it, through a series of exercises. With practice and the techniques you learn in the book, you, too, can live a life free of anxiety disorders. Chapter 1 What is anxiety and What Causes it? Everyone experiences anxiety once in a while—when the car breaks down on the way to a job interview, for example, or when you’re standing on the high-diving board and the water looks a long way down. Anxiety is a fact of life. In fact, some anxiety is necessary. You need a little anxiety to get to work on time or to get to the grocery store before it closes. If you didn’t have anxiety, you wouldn’t know to get out of the way when you see a truck bearing down on you in the street. Anxiety can be a bad thing, however, if you worry that your boss doesn’t like you, even though you have no realistic evidence that he does not, or if you feel panic when there are “too many” people in the grocery store, or if you avoid crossing streets, because you never know when a truck is going to come out of nowhere. Anxiety becomes a problem when it gets turned on too high. Feeling constant tension and worry makes each day trying at best and a walking nightmare at worst. And when you’re extremely fearful about a situation—meeting new people, for instance— your life becomes severely limited. You can feel like you’re walking through a minefield when you’re plagued by panic attacks, because you never know when one might occur. When anxiety becomes extreme, it’s considered an anxiety disorder. But an anxiety disorder doesn’t have to be permanent. How Jake and Tom Experience Anxiety Jake and Tom were both scheduled to take a seminar on a new computer program. Jake was excited about the opportunity to get out of the office and meet new people. Although he was a little anxious about whether he was going to be able to learn the entire system, he was eager to give it a try. Tom was reluctant to go to the seminar. He tried to get out of it by saying he had too much work to do at the office. Secretly, he feared having to meet new people and was particularly afraid of being asked to speak. He even thought of quitting his job, so that he would not have to go to the seminar, but decided against it because it would mean going to job interviews, which he feared more than the seminar. As Tom drove to the building in which the seminar was being held, his heart began to pound, his breathing became shallow, and he started sweating profusely. As he stepped out of the car, his thoughts raced by so fast, he couldn’t decide what to do. Should he go to the hospital, or should he sit back down in his car and hope this nightmare didn’t kill him? When Jake arrived, he anxiously looked Tom over and asked, “Are you okay? Should I call the paramedics?” Tom nodded yes. Jake dialed 911, then anxiously turned to Tom. “Is it your heart?” Tom looked horrified and again nodded yes. Jake paced nervously, hoping that the ambulance would arrive before Tom died. Which of these two men had anxiety? Both did. But Jake’s anxiety was adaptive. It helped him spring into action to help a man in distress. 1