How Can We Help?
“I’ve been told that ‘relaxation training’ skills, or deliberate exposure to things that trigger anxiety can help my anxiety. I doubt it. Convince me!”
I’m assuming that you already know how to do relaxation training but maybe have felt it “didn’t help” with your anxiety. So, I think we now want to talk about how it is actually best used to build on other Anxiety management skills. I will also discuss how exposure procedures can help treat anxiety.
Anxiety-Related Insomnia and Sleep Disruption
As you already know, many cases of severe night-time insomnia are associated with anxiety and conflict patients have about falling asleep. That is, rationally, the person knows they need to get to slee,p and truly want to sleep. On the other hand, it is though aspects of their mind don’t want them to sleep, because they have worries or anxiety trains of thought they feel they have to resolve, but which keep them awake. For instance, they may feel the need to engage in problem-solving, planning the next day, or reviewing recent conversations they have had, trying to “re-do” them, etc. They report they, “can’t let that stuff go”; or, they say, “I can’t shut my brains off to fall asleep”. The key theme here is that anxiety is directly contributing to insomnia.
Relaxation training can be very helpful in interrupting anxious, insomnia-related thinking. As I’ve mentioned, the main challenge patients report is that they want to sleep, but that, “some part of my brain doesn’t want to let go of thinking and problem solving”. Therefore, when attempting a bedtime relaxation procedure, they invariably report that this powerful tendency to keep on thinking will draw their mind away from attempts to focus on their breathing or other relaxation procedures. They have to pull their mind back to the relaxation training content repeatedly. This effort takes “work” and is frustrating to many patients. I can pretty much guarantee patients however, that with practice and persistence, they can learn to gradually spend more time engaged with the relaxation training procedures that promote sleep and less time thinking, worrying, problem-solving etc. The most important point here is that focusing on breathing, relaxing different muscle groups etc., is incompatible with thinking, worrying, problems-solving; one cannot do both at the very same time. So, theprocedure is a very important tool in disrupting repetitive, night time anxiety thinking.
Relaxation Training and Coping: Physical Symptoms of Anxiety
I also try to help patients use relaxation training to combat their worst physical symptoms of anxiety i.e., those that they find most distressing and disruptive. For example, with general muscle tension during anxiety episodes, a common symptom, we focus on identifying specific muscle groups that are the biggest problem e.g, clenching jaws as reflected in having sore jaw muscles; or, painful throat or chest, due to sensations of tightness in these areas during anxiety. We may coach them to specifically focus on these areas during relaxation training, or practice deliberately tensing and then relaxing these areas to better experience the contrast between tension or discomfort, and the relaxation response.
Relaxation-Related Exposure: Fight or Flight Anxiety Symptoms
As you probably know, a primary intervention theme in all of the empirically-supported treatments for anxiety disorders is called “exposure” i.e., helping patients tolerate graduated re-exposure to anxiety-related cues or triggers, as commonly experience in trauma (PTSD), panic attack, etc. For the past 12 years, I have developed and tweaked an exposure procedure that helps patients better manage the “fight or flight” symptoms of anxiety or panic attacks. I can report to you that in every case in which patients have reliably practiced the technique at home daily, for 3-4 weeks, they report an improved sense of control over the onset or early symptoms of their anxiety reaction. The general therapy principle of “exposure” comes into play here, as you might guess. We want to have patients simulate or replicate a couple of the key “fight or flight symptoms” of high anxiety i.e., rapid heart rate and breathing.
A word of caution: If you have been cleared by your primary care provider to engage in exercise and especially, aerobic activity, you consult with them about doing the following activity (i.e., obtain their permission or endorsement). You may want to double-check with them about what your max heart rate should be during aerobic activity, etc.
In this fight or flight simulation procedure, we coach patients to take a very short walk, maybe only around the block to start with. If they can engage in running, so much the better of course. If walking is a problem due to joint pain or high body weight, the exercise can be done on stair-step machine, elliptical, or in a swimming pool as part of a water aerobics class. It is important to get warmed up through slow, gradual exercise (walking, swimming, water aerobics, treadmill etc.).
Now, the procedure: During the final minute of your exercise (e.g., last 100 yards of your walk), pick up the pace of the activity dramatically. At the point your heart rate and breathing are quite rapid, it is you would be entering the door of your home, or arriving at an exercise mat, a comfortable chair, or even sitting/lying at the edge of the swimming pool. If for example, you have done a walking or running exercise at home, you would walk through your front door and immediately lie down on a couch or your bed.
The next step only takes about 3-4 minutes. Lie very quietly and focus all of your concentration on your breathing and heart rate. Do NOTHING, except allow your body to naturally breath in/out, due to the stress of your exercise. Do not try to control or regulate your breathing. Just “allow it”. The next part is quite important. We want you to pay close attention to the point in time when you notice things slowing down e.g., your breathing becoming just a bit less rapid, your heart rating starts to slow. You want to identify the moment this is starting to occur. At this point, we want you to engage in an internal dialogue (yes, we all talk to ourselves, don’t we?): Such as, “O.K., I can tell my heart rate has slowed just a bit”, “I’m breathing a tiny bit more comfortably”; “I can tell things are just now starting to ‘slow down’”. Next, add in a few self-assurance statements to yourself: “When my heart rate is going fast, it will eventually slow down on its own; my body will take care of itself if I just allow it” “If I just monitor my breathing, it will slow down on its own; I just need to calmly wait it out”. Or, “ I can trust my body to calm itself when my breathing and heart rate are going too fast”
Again, the goal here is graduated exposure. We want you to deliberately simulate a couple of the most noticeable symptoms of having an anxiety reaction, then engage in the above simple mental exercise wherein you “allow” the symptoms. You reassure yourself that you need do nothing but monitor them. You can tell yourself that every time you exercise your body will regulate itself if you simply allow it.
This procedure is certainly not a “cure” for anxiety reactions or anxiety attacks. However, were you to do this daily for 3-4 weeks, you would begin to develop the perception that whenever your heart rate and breathing become uncomfortably rapid, you have a technique for gaining a sense of control, by “doing nothing” but monitoring it and waiting for your body to take care of itself. It is a tool you can eventually begin to use at the earliest stages of an anxiety or panic attack, or when you know you are going to have to deal with anxiety triggers or cues. I have emphasized that this procedure takes practice, but if you do any form of aerobic activity or walk regularly, adding the procedure only takes 3-4 minutes at the very end of your activity.
I can tell you that some patients with severe anxiety attacks or panic agree to try out the exposure activity, but fail to do so because they are afraid that exercising to increase their heart rate or breathing will “cause” them to fall into a panic or anxiety attack. In these cases, we want to break the activity down into smaller, simpler steps. For example, we might have them simply walk around the block without speeding up during the final minute, and simply get them to practice the 3-4 minute period of lying down, focusing on breathing and heart rate right after they arrive back home. After becoming comfortable doing this for say, a week, we would have them pick up the pace of walking just a bit, during the final 30 seconds of their walk.
I want to reiterate how important it is to make sure that symptoms that you believe are “fight or flight” in nature are truly due to an anxiety attack or panic attack. Some health conditions produce symptoms that are similar to anxiety reactions and need to be ruled out or treated by appropriate medical procedures. Thus, having an accurate diagnosis is very important. In addition, it is important to be cleared by your doctor or primary care provider to engage in aerobic activity and that you know whether he or she has placed some constraints or limits on what you can do.
Relaxation-Related Exposure: Anxiety and Light-headedness
Patients can be helped to better tolerate or accept other physical symptoms of anxiety such as the sensation of becoming light-headed or dizzy. Like the rapid heart rate and breathing, it is important that your primary care doctor or specialist rule out physiological causes for this symptom and attribute them strictly to anxiety. For example, sometimes, outright dizziness symptoms is directly caused by a momentary physiological changes e.g., blood pressure, as in orthostatic hypotension. Some patients with anxiety will any report feeling vaguely “light-headed” or “mentally ‘out-of-it’”, “something like dizziness” or that they are experiencing a disconnection with the immediate passage of time.
With regard to exposure, we may coach them to duplicate some of the symptoms of becoming light headed by standing up and turning around in a few circles, taking extreme care of course, that they do not get truly dizzy and fall. Stand right next to a couch or soft chair so you can sit or lie down quickly and assess whether they have simulated the light-headed or dizzy condition they experience when having an anxiety event. They are then coached to simply go through the breathing and heart rate exercise and note the moment when the light-headedness or dizziness begins to subside on its own. Some patients can do a good job of literally imagining becoming light-headed when they are not actually having this symptom, immediately after taking rapid walk, coming home and are in the midst of completing the self-monitoring procedure (outlined in the section on simulating fight or flight symptoms).
Training and Exposure: Learning to Tolerate Exposure to Anxiety Cues and Triggers
Another set of cognitive-behavioral exercises involves prompting patients to tolerate graduated exposure to the very cues or triggers associated with their anxiety or anxiety attacks. You are probably familiar with stories others about military veterans experiencing severe anxiety reactions upon hearing unexpected firework explosions. Many people with severe anxiety have reactions when standing in crowded spaces, or sitting in the driver seat of a car some days or weeks after they have been in an automobile accident. Having anxiety reactions when seated on an airplane is also a fairly common problem I confront with patients seeking help for anxiety in primary care settings. Anxiety triggers are a universal complaint by people with PTSD.
Exposure procedures that can help include some of the following examples for anxiety associated with large crowds or driving on crowded freeways: 1) pushing oneself to shop in small crowds versus large crowds, which may be too debilitating (e.g., shopping late at night, weekend mornings); 2) practice driving on freeways on Saturday mornings when traffic is light, with goal of driving past two exits. An important point in these forced exposure procedures is that over time, anxiety decreases with continued experience in mildly anxiety-producing situations. Also, total escape and avoidance of your anxiety situations and “trigggers” usually makes your anxiety reactions worse in the long run.
Copyright 2019 David M. Stein, Ph.D. Readers are welcome to link to this article. Copying this article without the written permission of the author is not permitted. Copying the article and presenting it on another website without appropriately crediting the present author is considered plagiarism. This action will be reported to state or provincial licensing boards as an ethical violation.