Many patients first seek help in a crisis or for incidental reasons often after suffering symptoms for many years. Lack of basic information and irrational beliefs about anxiety are common problems and require education. Detailed explanation of general aspects such as links between physical and mental fitness is vital. More specific information such as the panic cycle, the learned association between panic attacks and agoraphobia and the link between social phobia and physical and cognitive symptoms is also required. Simple information needs to be provided verbally, while reference to useful texts for information and self-help techniques is also recommended (see references).
2. Relaxation Training
Relaxation can be an effective way for patients to demonstrate to themselves that they have control over their symptoms while also helping other cognitive behavioural techniques. One of the simplest ways of achieving some relaxation is through planning enjoyable and relaxing activities and planning breaks in busy routines. Formal training is useful for some and a range of relaxation techniques is available. One of the best approaches is the applied relaxation (AR) method of Ost (1983) which starts with progressive muscular relaxation involving alternating tension and relaxation phases. This method directly teaches discrimination between the two states in order to allow a patient to become more aware of tense body parts. The later stages of AR focus more on slow regular breathing and self instruction to relax, whilst generalising the technique to everyday activities and later anxiety provoking situations. Demonstration of the technique in the sessions (and taping of it) is more effective than provision of pre-recorded tapes. Alternative methods include self-hypnosis, yoga and meditation.
3. Slow Breathing Techniques
This simple technique is of great benefit for those suffering from both generalised anxiety and panic attacks. It is based on the principle that anxiety and hyperventilation are commonly associated both in generalised anxiety (chronic hyperventilation 16 to 20 rpm) and panic attacks (acute hyperventilation 20 to 30 rpm), with recognition that decreasing respiratory rate decreases expired carbon dioxide, returns acid base balance to normal, decreases anxiety symptoms and increases the threshold for panic attacks. The method can be applied both acutely or chronically although is best learned by regular practice over 2 to 3 weeks, 4 times each day. The aim is for 10 respirations per minute (or less) and is achieved by 5 minutes of breathing using a six-second cycle of inspiration and expiration (Page 1993). Breathing should be slow, steady and involve abdominal musculature.
Link to Breathing Workshop information.
4. Pleasurable Activities
It has been well demonstrated that patients with anxiety and depression are no longer active or enjoying life. A simple behavioural approach involves monitoring activities, pleasure and mastery (often with other indices of mood and anxiety) and thereafter actively scheduling pleasurable activities or planning graded task assignment to increase activities and level of enjoyment.
Similarly increased exercise is known to be associated with decreased anxiety levels, decreased depression and increased pleasure and enjoyment of life. Many patients who describe a recent increase in their anxiety have turned from their previously active lives to low levels of activity and exercise.
6. Supportive Psychotherapy
The standard support and counselling provided by psychiatrists, psychologists and other counsellors is an important adjunct to other CBT treatments.