The more symptoms you checked off, the greater the role anxiety plays in your life. The list above is not exhaustive. You might experience symptoms that are not on the list. Write them down in the space below.
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.
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.
Tom’s anxiety was maladaptive. In fact, he was having a panic attack. Tom’s anxiety was a problem, because he became paralyzed by it. Tom is an example of someone with an anxiety disorder.
If you suffer from an anxiety disorder, you’re probably already familiar with at least some of the symptoms: breathlessness, racing heartbeat, dizziness, and a fear of choking, in the case of panic disorder; irritability, difficulty concentrating, restlessness, and constant worry, in the case of generalized anxiety disorder; or intense fear of a particular situation, object, or environment, such as grocery stores, in the case of phobia. You might not experience all the symptoms common to a specific disorder, and you might find that some of your symptoms fall into more than one category. This is because anxiety affects people in different ways.
Following is a list of many of the most common symptoms experienced by those with anxiety disorders.
• numbness or tingling
• feeling hot
• wobbliness in legs
• inability to relax
• fear of the worst happening
• dizziness or lightheadedness
• pounding or racing heart
• unsteadiness
• feelings of terror
• nervousness
• feelings of choking
• trembling hands
• shakiness
• fear of losing control
• difficulty breathing
• fear of dying
• indigestion or nausea
• feeling faint
• flushed face
• cold sweat
• worrying much of the time
• muscle tension
• restlessness, feeling keyed up
• irritability
• difficulty concentrating
• mind going blank
• easily fatigued
• intense fear cued by the presence or anticipation of a specific object or situation (for example, heights, enclosed spaces, or flying)
• marked feelings of anxiety when encountering that object or situation
• extreme avoidance of that object or situation
• fear of failure
• fear of rejection
• fear of social ridicule
• intense fear of talking to strangers
• stage fright
There are actually many causes of excessive anxiety. And what causes your anxiety may not be the same as what causes another person’s anxiety, even if you both have the same type of anxiety disorder.
You can become vulnerable to developing anxiety disorders because of a variety of biological, psychological, and social factors. These factors make up your biopsychosocial experience. Biological factors include genetics and neurochemistry, such as a family history of anxiety disorders. Brain-based conditioning and psychological factors involve your early attachment relationship with your parents and the quality of your relationships with your family members. For example, if your parents made you feel anxious, rather than comforted, around them, you can be prone to anxiety. Psychological factors also include your cognitive skills. If you think in black-and-white terms or hold yourself to extreme perfectionist standards, you’re likely to experience anxiety. Social factors include how well you adjust to your culture, ethnicity, and social situations, such as work, social gatherings, and cultural expectations. These factors comprise who you are and how you adapt to the world. None of them acts independently.
Each dimension of your biopsychosocial experience overlaps the others. The biological aspect involves your physical sensations, such as when you experience a rapid heartbeat or sweating. If you misinterpret these physical sensations as cause for alarm, you tend to increase your anxiety and might even experience a panic attack, leading you to believe that you are having a heart attack. The result is that you become extremely fearful of those physical sensations, doing everything you can to avoid them in the future. Or perhaps your palms sweat and your voice quivers a little when you meet new people. Becoming extremely concerned that someone might notice stirs up more anxiety, which contributes to an increase in sweaty palms and your voice quivering.
The psychological part of your biopsychosocial experience involves what you say to yourself when you experience anxiety. If you are a pessimist, a black-and-white thinker, or tend to catastrophize if things don’t go perfectly, you’ll stir up more anxiety. For example, say you encounter an unanticipated snag in your effort to complete a project. You could be flexible and roll with the bumps on the road, or you could say to yourself, “Everything’s falling apart! Now what am I going to do?” Your pessimism and inflexibility set you up to see a bump as more than a bump—it’s an impassable boulder in the road, a catastrophe.
Your “mood state” also affects how you think about and interpret the events in your life. When you’re in particular mood, your thoughts can be colored by that mood. You make statements to yourself about what you are experiencing at any given moment, and if those statements are colored by an anxious state of mind, they can perpetuate anxiety.
The social aspect of the biopsychosocial experience involves a fear that other people will see that you have an anxiety disorder, which can affect your relationship with them. If you are with people you don’t know, for example, you might say to yourself, “What if he can tell that I’m nervous? He’ll think I’m an idiot.” Statements like these heighten your anxiety.
It’s important to understand that you can heal your anxiety without knowing what caused it. You don’t need to discover the initial cause of the anxiety before you can take steps to dissolve it.
Joanne came to see me because she had developed a phobia about dogs and wanted to find out what had caused it. She wondered whether dogs held some sort of symbolic significance. Perhaps she had experienced some kind of trauma while petting a dog or even a nightmare about dogs that she could not remember. She felt certain that if only she could find the key to unlock her fear, she could regain her freedom.
Joanne needed to deal with her phobia, because most of her neighbors owned dogs. That’s when she came to see me. She wanted me to hypnotize her, so that I “could dig into the deep recesses of (her) mind to discover what went wrong.”
I pointed out that the initial cause of her anxiety about dogs was far less important than what she increasingly did to compensate for it. And what she increasingly did was avoid walking in the neighborhood. Like the famous chaos theory analogy about a butterfly flapping its wings in the Maldives and creating a typhoon in the Indian Ocean, one day Joanne had had to walk on the other side of the street to avoid a large, aggressive dog running loose in the neighbor’s yard. Although the dog frightened her, she didn’t find the experience traumatizing at the time. However, she began to feel anxious when she walked in the neighborhood and started to avoid walking outside, taking the car instead. Over time, she stopped going outside altogether.
Joanne didn’t need to know what had sparked her phobia; it was more important that she focus on changing the way she was dealing with her anxiety about dogs. She needed to stop avoiding her fear and return to walking on her neighborhood sidewalks.
If you suffer from a major health problem, some of the symptoms of your condition can resemble the symptoms of anxiety. Being unaware of the origins of these symptoms can cause you to believe that you suffer from an anxiety disorder. The symptoms of mitral valve prolapse (see below), for example, are similar to those experienced during a panic attack. Overreacting to these physical sensations without understanding their origin can actually spur on a real panic attack. If you have a medical condition that is associated with anxiety symptoms, seek treatment.
Following are some common conditions that can cause anxiety-like symptoms.
Mitral Valve Prolapse (MVP) A heart disorder that occurs when the valve between your heart’s left upper chamber (left atrium) and your left lower chamber (left ventricle) doesn’t close properly, MVP occurs in 2 percent of the general population. Approximately 50 percent of people with MVP experience chest pains, breathlessness, and palpitation, the same symptoms of a panic attack.
Exposure to Toxins The metabolic and toxic effects of either consuming or being exposed to chemicals and environmental toxins, such as hydrocarbons, mercury, and carbon dioxide, can cause or worsen anxiety symptoms. For example, many pesticides containing DDT, chlordane, lindane, and dieldrin can cause nervousness, insomnia, and nausea. Usually, the anxiety-like symptoms of exposure from the toxic chemicals fade once you get away from them. However, if you experienced major exposure to toxins, the severity of impairment will be greater.
• Genetics: inheriting an anxious or shy temperament
• Growing up with anxious parents who model their anxiety and worry about everything
• Poor attachment relationships with your parents or caregivers, making it hard for you to feel connected and comforted by other people
• Being criticized consistently while growing up, causing you to be overcritical of yourself
• Experiencing physical, sexual, or emotional abuse, which can cause you to feel undeserving of the good things in life
• Traumatic experiences that have a lingering effect by making you hypervigilant for similar trauma
• Side effects of medical problems and medications (see the following section)
• Embracing thinking styles, such as perfectionism and black-and-white thinking, that decrease your flexibility and adaptability
• Creating a biochemistry that stirs anxiety through poor eating habits
• Trying to avoid feeling any kind of stress
Medication Side Effects The side effects of many medications—monoamine oxidase inhibitors, calcium channel blockers, and theophylline, for example—can cause anxiety-like symptoms, which your primary care physician might not have warned you about. Over-the-counter medications, such as antihistamines, can also mimic anxiety symptoms. Talk to the pharmacist when you pick up your medication. Pharmacists usually know the side effects of various medications. Always read the medication information sheet that comes with the bottle.
Following is a list of other medical, health, and drug-related conditions that can produce anxiety-like symptoms:
• Endocrinological: hyperthyroidism, hypoglycemia, Cushing’s syndrome, menopause, premenstrual syndrome, and pheochromocytoma
• Neurological: complex partial seizures, vestibular dysfunctions, head injuries
• Pulmonary: asthma, hyperventilation
• Cardiological: high blood pressure, chronic obstructive pulmonary disease (COPD), lung cancer
• Alcohol and benzodiazepine withdrawal
• Use of cocaine and marijuana
• Excessive caffeine consumption
• Deficiencies in magnesium, vitamin B12, potassium, and calcium
If you have any of these medical conditions, work with your doctor to get comprehensive treatment. If you still suffer from anxiety, then the rest of this book can be helpful.
To determine to what degree you’re troubled by anxiety, it will be helpful to identify your symptoms. You will be referring back to this list when you perform some of the exercises in this book. From the following list, check off the symptoms that apply to you.
• numbness or tingling
• feeling hot
• wobbliness in legs
• inability to relax
• fear of the worst happening
• dizziness or lightheadedness
• pounding or racing heart
• unsteadiness
• feeling terrified
• nervousness
• feelings of choking
• trembling hands
• shakiness
• fear of losing control
• difficulty breathing
• fear of dying
• indigestion or nausea
• feeling faint
• flushed face
• cold sweat
• worrying much of the time
• muscle tension
• restlessness, feeling keyed up
• irritability
• difficulty concentrating
• mind going blank
• easily fatigued
• fear of failure
• fear of rejection
• fear of social ridicule
The more symptoms you checked off, the greater the role anxiety plays in your life. The list above is not exhaustive. You might experience symptoms that are not on the list. Write them down in the space below.
The next question to ask yourself is whether your symptoms have been increasing in severity. In general, the more severe your anxiety symptoms, the more they negatively impact your life. However, the severity of the symptoms also increases over time. This alarming tendency occurs if you make efforts to avoid the situations that make you anxious. Not surprisingly, the higher the severity of your symptoms, the greater the potential for avoidance. If your anxiety is severe, it can start to impinge on your life. Take a look at what happened to Cynthia.
Cynthia, a graduate student in history, came to my anxiety class because she feared driving on the freeway. Whenever she was in a car on the freeway, she started to panic, so she started to avoid them. Sometimes she added hours to her commute to avoid the freeways. Soon, she was feeling anxious about driving in general. Even driving on the city streets made her anxious.
Cynthia decided that she would retreat to her comfort level, so that she could regroup to gather her strength. Once she “felt ready again,” she would drive again, not only on the city streets but also on the freeways.
As time went on, however, Cynthia grew to feel more, not less, anxious about driving. She felt like she was falling into quicksand, sinking day by day into feeling anxious all the time. One day, she told her husband, who was becoming frustrated because he had become her taxi service, that she felt she was “having a mental breakdown.”
Cynthia’s anxiety about driving on the freeways was interfering with her life. In the space below, write down the sensations that interfere with your life and keep you from doing the things you want and need to do. By identifying these sensations, you will be in a better position to confront and neutralize them in the exercises that follow. The end result will be that they won’t stand in the way of you enjoying your life.
The following chart is a measure of severity. It is called the Subjective Units of Distress Scale, or SUDS for short. The SUDS method of measuring the severity of anxiety will help you target the anxiety situations that need to be addressed and to gauge your progress. You’ll be referring to this chart throughout the rest of the workbook.
| RATING | SEVERITY | DESCRIPTION |
| 0 | none | You feel no distress or anxiety. You are absolutely calm and relaxed. |
| 10 | minimal | You feel mostly calm, but have a twinge of tension or alertness that isn’t very noticeable. |
| 20 | mild | You feel slightly tense or nervous, but are still able to focus on your work or social activities. |
| 30 | mild | You feel mildly stressed, tense, or nervous. You can work or socialize, but you have to actively manage the anxiety in some way, and you might be irritable. Your body may be tense or “keyed up.” |
| 40 | moderate | You feel mild-to-moderate anxiety, and are somewhat distracted or irritable. You have mild physical symptoms, such as muscle tension, shakiness, or feeling weak. |
| 50 | moderate | You are moderately anxious or stressed, and it is interfering somewhat with your ability to focus or work. You are distracted, hyperalert, and on your guard. Physical symptoms can include increased heart rate, lightheadedness, butterflies, and irregular breathing. |
| 60 | moderate | You are very anxious, distracted, and hypervigilant. You might feel dizzy, lightheaded, or shaky, with rapid heart rate, tightness in the chest, and nausea. |
| 70 | severe | You are intensely anxious or stressed, with strong physical symptoms. You are having difficulty concentrating on anything but the anxiety. |
| 80 | severe | Your anxiety is very intense and overwhelming, with significant physical symptoms (pounding heart, rapid breathing, sweating, dizziness, nausea). You are focused on wanting to get out of the situation. |
| 90 | extreme | You are in a state of extreme fear and distress and are having difficulty coping. Physical sensations are intense, and you are entirely focused on escaping the situation. |
| 100 | extreme | You are in full panic mode and fear you may die, faint, or lose your mind. Your fear is so intense that you are overwhelmed and can only think of escape. |
Paula came to my anxiety class after experiencing increasing anxiety for two months. She described the following symptoms: shortness of breath, sweating, trembling, rapid heartbeat, dizziness, and chest pain. These periodic and overwhelming physical sensations came in bursts lasting about ten minutes. When she experienced these “attacks,” she couldn’t think of anything else. She said, “It felt like my world was falling apart!”
For the next exercise, use the SUDS chart to determine the degree of anxiety that you are experiencing. Apply a SUDS score to each symptom in the blank worksheet below. To give you an example, I have shown how Paula filled out her SUDS worksheet.
PAULA’S SUDS SCORES
| SYMPTOMS | SUDS |
| shortness of breath | 90 |
| rapid heartbeat | 87 |
| sweating | 80 |
| trembling | 71 |
| dizziness | 68 |
| chest pain | 55 |
Based on her responses, Paula was suffering from a fear of her physical sensations. She described how they came out of the blue and overwhelmed her. This symptom constellation indicates that Paula was suffering from panic disorder.
In the chart below, write your symptoms and their SUDS, starting with the most severe.
| SYMPTOMS | SUDS |
You will be referring back to these exercises throughout the later chapters of the book. The information about your symptoms and your SUDS will be useful to give you an idea of whether you are suffering from an anxiety disorder and, if so, what type of disorder you have. In the next chapter, you’ll learn about the various types of anxiety disorders. You’ll be able to diagnose yourself and learn how to treat your particular anxiety through the exercises in the rest of the book.