Depression causes & symptoms

Most likely, depression is caused by a combination of genetic, biological, environmental, and psychological factors.
Depressive illnesses are disorders of the brain. Longstand-ing theories about depression suggest that important neurotransmitters—chemicals that brain cells use to communicate—are out of balance in depression. But it has been difficult to prove this.
Brain-imaging technologies, such as magnetic resonance imaging (MRI), have shown that the brains of people who have depression look different than those of people without depression. The parts of the brain involved in mood, think-ing, sleep, appetite, and behavior appear different. But these images do not reveal why the depression has occurred. They also cannot be used to diagnose depression.
Some types of depression tend to run in families. However, depression can occur in people without family histories of depression too.9 Scientists are studying certain genes that may make some people more prone to depression. Some genetics research indicates that risk for depression results from the influence of several genes acting together with envi-ronmental or other factors.10 In addition, trauma, loss of a loved one, a difficult relationship, or any stressful situation may trigger a depressive episode. Other depressive episodes may occur with or without an obvious trigger.

Chronic Anxiety

If individuals find it difficult to break the anxiety cycle, the problems can become chronic. It is
very likely that individuals with generalized anxiety disorder have had long-standing difficulties
with managing anxiety, sometimes for months or even years. Some of the results of feeling
anxious over a long time include:
· feeling restless or keyed up or on edge
· being easily tired
· difficulty concentrating or mind going blank
· irritability
· muscle tension
· trouble falling or staying asleep
· restless unsatisfying sleep
· feeling overwhelmed or unable to cope
· feeling depressed or demoralized
When you experience these problems, the anxiety has begun to interfere with your everyday
life. Because anxiety is a normal, in-built, and at times useful response, you will never banish it
completely from your life, but the good news is that you can learn to manage and control it.
Why Do the Symptoms of Tension and Anxiety Begin?
The reason why you have become anxious is probably due to a combination of causes. We will
briefly consider some possible causes.
The effect of personality
Personality refers to the usual way we react, feel, and behave year in and year out. Most people
who seek treatment for an anxiety disorder have come to regard themselves as nervous, not just
because of their high levels of anxiety, but because they consider themselves to be people who
are usually sensitive, emotional, and worry easily. There are advantages to being like this, for
the sensitivity means you can understand other people quickly and hence are often liked in
return. It also probably means that you like to do things properly and treat other people well.
But the emotionality and the proneness to worry are the seeds from which anxiety can grow.
The various strategies that we will teach you will aid you to control this aspect of your
personality. If you do become upset and worry easily, then you'll need to become particularly
expert in remaining alert, tense, but in control to prevent you becoming too anxious in the face
of difficulties.
The effect of life events and stressors
Anxiety may begin at a time when you are experiencing a high level of stress. Throughout our
lives, we are constantly adjusting to demands placed upon us by changing circumstances.
Making an important decision, meeting a deadline, changing jobs or routines, dealing with
others in our lives all require constant adjustments. However, at times you may experience asingle major problem, or several smaller problems, that may exceed your normal powers of
adaptation. When high levels of stress occur, anxiety can result if they produce in you a sense of
threat and lack of control.
The effect of your view of the world
Individuals with generalized anxiety disorder have an increased tendency - compared to
individuals without an anxiety disorder - to automatically interpret information in their lives as
threatening. For example, the ringing telephone is less likely to be considered with pleased
anticipation of a friend ringing for a chat, but more likely to be viewed with alarm as news of an
accident. Or a frown on the face of a supervisor at work is less likely to be viewed as the
supervisor’s personal problem, but more likely to viewed as a sign of disapproval. This view of
the world is thought to develop from previous life experiences, which might include the impact
of stressful life events, or the messages received from parents and other important people in
your life.
The Nature of Worry.
Worry is a central feature of generalized anxiety disorder. Most people can identify with the
idea of ‘worry’, but scientists have defined the following features in the worry of individuals
with generalized anxiety disorder:
· is usually a stream of thoughts or ideas;
· is accompanied by feelings of apprehension or anxiety;
· concerns future events and catastrophes;
· interferes with the ability to think clearly;
· is very difficult to control.
Research has shown that the typical person with generalized anxiety disorder can spend over
half of their waking hours worrying. In most instances, the individual can recognize, with
hindsight, that the worry was excessive and out of proportion to the actual event that triggered
the worry.
A large number of worries tend to focus on day-to-day concerns, most typically:
· family and home life
· relationships
· work and study
· illness or injury
· finances
Common themes of worry in generalized anxiety disorder can include:
· problems arising in the future
· perfectionism and a fear of failure
· fear of being negatively evaluated by others
It is clear that individuals with generalized anxiety disorder largely worry about events that are
remote (as opposed to in the immediate future) and which are unlikely to happen. This sort of
worry is rarely helpful as it is unlikely to promote effective problem solving. For example,

Anxiety Cycle

All of these changes in the body can be quickly reversed once vigorous physical activity has
been carried out. This explains why many people report the desire to run or in some other way
expend physical energy when placed in stressful situations. However, we are not often able to
immediately engage in physical activity and therefore are less able to reverse the changes. For
people who are prone to worry excessively, these changes can be quite disturbing and a new
source of threat. This, of course, leads to further activation of the ‘fight or flight’ response and
the whole cycle is continued.
Anxiety and Performance
Anxiety can become a problem if it occurs in situations where there is no real danger. The only
part of the ‘fight or flight’ response that is of use today when handling most stresses is the
increase in mental alertness that it provides. It is very important to understand that while
increased awareness can be helpful, anxiety in some situations can be unnecessary or
inappropriate.
Anxiety helps you perform any skilled activity. If you are totally relaxed when you take an
exam, play a sport, or discuss a problem with your colleagues, you will not give of your best. To
do anything really well you need to be alert, anxious to do well, or “psyched-up” in present day
terms. Anxiety in moderation is a drive that can work well to make you more efficient.
People with anxiety disorders often become afraid of the healthy anxiety that aids performance -
they fear it might become uncontrollable and hence avoid using anxiety in this healthy way.
Thus, they limit their ability to give of their best. This reaction is understandable, for if you
don't know how to control anxiety, it is probably better to have too little than too much. When
people do get too anxious, their skill at problem solving, managing the children, or meeting
deadlines at work declines rapidly. Extreme anxiety interferes with the ability to think clearly
and act sensibly. This, as everyone knows, is the sort of anxiety that robs us of our capacity to
do things as well as we are able. In fact, the more difficult the task, the more important it is to
manage anxiety carefully; ideally, one should be mildly anxious, alert, tense, and in control, for
maximum efficiency.
The relationship between anxiety and skill is shown in the diagram.
Very Good
Performance
Average
Very Poor
Very Calm Aroused Panic
Anxiety Level
It is, therefore, important to learn a strategies for remaining calm when appropriate, and alert,
tense, and in control in difficult situations

Generalized Anxiety Disorder

What is Generalized Anxiety Disorder?
Generalized anxiety disorder is a disorder that is characterized by persistent feelings of
anxiety and worry. The worry is typically out of proportion to the actual circumstances, it
exists through most areas of a person’s day-to-day life, and is experienced as difficult to
control. The anxiety and worry is described as generalized, as the content of the worry
can cover a number of different events or circumstances, and the physical symptoms of
anxiety are not specific and are part of a normal response to threat.
Individuals with generalized anxiety disorder describe themselves as sensitive by nature
and their tendency to worry has usually existed since childhood or early adolescence.
The symptoms of anxiety typically experienced by individuals with generalized anxiety
disorder are
· feeling restless, keyed up, or on edge
· being easily tired
· having difficulty concentrating, or having your mind going blank
· feeling irritable
· having tense, tight or sore muscles
· having difficulty sleeping; either difficulty falling or staying asleep, or restless
unsatisfying sleep.
Generalized anxiety disorder is one of the more common anxiety disorders in the
community. A recent Australian survey has suggested that, in a 12 month period, 3 in 100
people will have a generalized anxiety disorder.
Generalized anxiety disorder and everyday worry.
Everybody worries or gets anxious at some time in their lives. The worry in generalized
anxiety disorder is identical in nature to that experienced by anybody else, but it tends to
be out of proportion, pervasive, and difficult to control, unlike the worry most people
experience. Hence it significantly interferes with an individual’s functioning. The
constant anxiety-provoking thinking and the accompanying physical symptoms of
anxiety can be disabling, particularly if experienced over a long period of time.
Another feature of generalized anxiety disorder is that it has usually been present for
much of an individual’s life. From time to time, people may become unusually stressed,
because of a physical illness or a life event such as divorce, bereavement, or loss (or
threat of loss) of employment. During these times people may worry and become
significantly more anxious, but after the stress resolves, the person can usually return to
their usual functioning. This is not generalized anxiety disorder, but a temporary period
of difficulty adjusting to stress.
Medication
You may be taking medication to help you cope with anxiety. If you are taking
medication, you may need to talk about the issues discussed below with your therapist.
Antidepressant medication
Many of the medications that are useful to treat a depressive disorder are also useful to
help control anxiety. If your doctor has prescribed you this type of medication,
particularly if you have been depressed, it is important that you continue to take the
medication for several months, and only stop taking it in consultation with your doctor.
This medication typically has few side-effects, it is safe, and will not cause you to build
up tolerance or become dependent.
When you are ready to stop this medication (usually after you have been feeling calm and
in control for a number of months), it is very unlikely that you will experience a relapse
of your anxiety if you have been able to learn and put into practice the strategies taught
on this programme.
Sedatives, tranquilizers and sleeping pills.
This class of medication is the benzodiazepines. They dampen the feelings of anxiety
very effectively, but also produce the following problems:
· they can interfere with thinking and your ability to remember new information;
· they can make you feel drowsy and sleepy;
· they can interfere with your natural sleep cycle and rhythms;
· they can produce tolerance, so that you might need bigger and bigger doses for the
same effect;
· they can produce dependence, so that you come to rely on them and experience an
increase in anxiety without them;

Causes and Treatment OCD

To date, no one is certain of the causes of OCD. Though there are a number of theories that
attempt to explain the development of the condition, there is little evidence to support them. We
know that for some the onset is during childhood, while for others, the onset may be during
adolescence or early adulthood. We also know that in some cases the onset is sudden, while
others have a slow, insidious onset. Some of the theories that have been proposed to explain the
development of OCD follow.
2.1 The Biochemical Theory
This theory was put forward after it was found that certain medications were of benefit in the
treatment of OCD. These drugs mainly affect one type of chemical in the brain called serotonin.
Consequently, it was hypothesized that a problem with serotonin could be the cause of OCD.
Although the drugs are indeed effective in the treatment of this condition, there is little hard
evidence to indicate that sufferers have a deficit of serotonin in their brain.
2.2 The Genetic Theory
This theory was put forward to explain the finding that OCD can sometimes occur in families.
Although a genetic predisposition may account for some sufferers developing the condition,
there is also the strong possibility that the OCD behavior was learned from the parents or siblings.
It is extremely difficult to differentiate between OCD behavior thay may be the result of genetics
or OCD behavior that may be the result of the environment.
2.3 Learning Theory
This model suggests that obsessive-compulsive behavior has been learned through a process of
conditioning. Put simply, this theory states that a neutral event becomes associated with fear by
being paired with something that provokes fear, anxiety, or discomfort. This fear then generalizes
so that objects as well as thoughts and images also produce discomfort. The individual then
engages in behaviors that reduce the anxiety and because the behavior is successful in reducing
anxiety even if only for short periods of time it is performed each time discomfort or anxiety is
felt. The problem with this theory is that it fails to explain why particular fears such as
contamination or of harm to oneself and others commonly occur in OCD. Another problem is
that many sufferers do not recall any significant precipitating event that can explain the onset of
their symptoms. However, this theory does explain how obsessive-compulsive symptoms are
maintained, and as a result, this issue will be dealt with in much greater detail in subsequent
sections.
2.4 Psychoanalytic Theory
This theory basically states that obsessive-compulsive symptoms are attempts to keep
unconscious conflicts and impulses from conscious awareness. Unfortunately, there is little
evidence to support this theory and psychoanalysis is of little value in the treatment of the
majority of OCD sufferers. As can be seen, no theory is able to adequately explain the
development of OCD but that does not mean that there are no effective treatments. In fact, the
cause, though of considerable interest, has little bearing on treatment outcome. It is important to
note, however, that in some cases symptoms that resemble OCD may be the result of other
illnesses such as depression and schizophrenia. Effective treatment of these conditions will
generally result in a decrease in the OCD-like symptoms. Other conditions that may result in
symptoms that resemble OCD are Tourette’s Syndrome, dementia, brain trauma, or other
neurological disorders.
2.5 The Treatment Obsessive-Compulsive Disorder
There are currently two effective treatments available for OCD that may be used separately or
together. One is drug treatment, with medication that increases the availability of serotonin in the
brain; the other involves the use of behavior therapy techniques. At present, it appears that they
are both effective and there is little in the scientific literature to suggest that combining the two
results in a better outcome than using them individually. However, some sufferers who find
behavior therapy too difficult initially may benefit from a course of medication so that effective
behavior therapy can be undertaken.
2.5.1 Medication
The medications that have been found to be particularly helpful in the treatment of OCD come
from the antidepressant family of drugs and include clomipramine, fluoxetine, fluvoxamine, and
sertraline. They have specific effects on serotonin levels in the brain. Serotonin is the biochemical
substance that some researchers believe is involved in OCD. In general, these medications have
been shown to be effective for some OCD sufferers and assist them in bringing their symptoms
under control. If one of these medications is prescribed for you, you should be made aware of
possible side effects and report their occurrence to your therapist. It is important to remember that
these medications are not a cure for OCD. In addition, research indicates that ceasing the
medication in the short term generally results in a return of symptoms. It could be that sufferers
need to remain on the medication for long periods of time or that behavior therapy should be used
in conjunction with the drug.
2.5.2. Behavior Therapy
The rationale for using behavioral techniques is briefly explained in the learning theory section
above but it is important enough to state again in greater detail. Typically, the OCD sufferer has
intrusive thoughts that generate anxiety, discomfort, or an urge to carry out a ritual. Performing
the ritual results in a decrease in anxiety or discomfort, so that performing the ritual is actually
reinforcing through its ability to reduce these negative feelings. For example, an individual has
the thought that his or her hands may have touched something dirty or contaminated. This thought
produces anxiety in that the person feels uncomfortable about the possibility of being
contaminated or contaminating someone else. This unpleasant anxiety or discomfort is relieved
by washing of the hands or other contaminated objects and it feels good to rid oneself of such
negative feelings, so it feels “good” to wash. In the same manner, an individual who must check
the stove and heaters prior to leaving home in order not to cause a disastrous fire will feel some
relief after checking these items many times to ensure they are off. Thus the anxiety-producing
thought is temporarily minimized by checking, and it feels “good” to check.
This anxiety- or discomfort-reducing quality that the rituals possess is shown in the following
graph. Patients were asked to rate their levels of discomfort and urge to ritualize (1) before being
exposed to an anxiety-evoking stimulus, (2) after being exposed, and (3) after performing their
rituals. As can be seen, exposure to the stimulus results in a marked increase in discomfort and
urge to ritualize. Engaging in the ritual brings about an immediate and dramatic decrease in both
these measures.

Obsessive‐Compulsive Disorder And Treatment

This manual is both a guide to treatment and a workbook for persons who suffer
from Obsessive‐Compulsive Disorder. During treatment, it is a workbook in which
individuals can record their own experience of their disorder, together with the
additional advice for their particular case given by their clinician. After treatment
has concluded, this manual will serve as a self‐help resource enabling those who
have recovered, but who encounter further stressors or difficulties, to read the
appropriate section and, by putting the content into action, stay well. 1. The Nature Obsessive-Compulsive Disorder
Obsessive-compulsive disorder (OCD) is an anxiety disorder that, until quite recently, was
regarded as a rare condition. Recent studies have shown that OCD is considerably more common
than previously thought and as many as two in every hundred people may suffer from the
condition.
OCD is characterized by persistent, intrusive, unwanted thoughts that the sufferer is unable to
control. Such thoughts are often very distressing and result in discomfort. Many OCD sufferers
also engage in rituals or compulsions that are persistent needs or urges to perform certain
behaviors in order to reduce their anxiety or discomfort. Often the rituals are associated with an
obsessional thought. For example, washing in order to avoid contamination follows thoughts
about possible contamination. For some, there is no apparent connection between the intrusive
thought and the behavior for example, not stepping on cracks in the sidewalk in order to avoid
harm befalling one’s family. Others still have no compulsive behaviors and suffer from
obsessional thoughts alone, while others do not experience obsessions but have compulsive
rituals alone.
The one common element to the various symptoms in OCD is anxiety or discomfort. For those
suffering both obsessional thoughts and compulsive rituals, it is the anxiety or discomfort
associated with the thought that drives the ritual. In other words, the ritual is performed to reduce
the anxiety produced by the thought. For those suffering from obsessional thoughts alone, anxiety
is often associated with the thought, and mental rituals, distraction, or avoidance may be used to
lessen the discomfort. It is much the same for those with compulsive rituals alone in that the
behavior is performed in order to lessen the urge to ritualize. The role of anxiety is important in
OCD and will be discussed in much greater detail in subsequent sections.
Most OCD sufferers can see the uselessness and absurdity of their actions but still feel compelled
to perform their various rituals. They know that their hands are not dirty or contaminated and they
know that their house will not burn down if they leave the electric kettle switched on at the wall.
Because they are aware of how irrational their behavior is, many sufferers are ashamed of their
actions and go to great lengths to hide their symptoms from family, friends, and, unfortunately,
even their doctors. It is extremely important that your therapist is aware of all of your symptoms
no matter how embarrassing or shameful they may be, as this is the only way that a suitable
treatment program can be designed for you. Rest assured that a therapist experienced in the
treatment of OCD will have heard of symptoms worse than yours many times over.
1.1 Symptoms Obsessive-Compulsive Disorder
Obsessional thoughts are usually concerned with contamination, harm to self or others, disasters,
blasphemy, violence, sex or other distressing topics. Although generally called thoughts they
can quite often be images or scenes that enter the sufferer’s mind and cause distress. For example,
one sufferer may have the thought “My hands are dirty” enter his head. This thought will trigger
washing rituals. Another sufferer will actually have enter his head the scene of his house burning
down. This scene will trigger checking rituals. Individuals who suffer obsessions alone may also
experience thoughts, images, or scenes. For example, someone who has obsessions about harming
his or her children may have the thought of harming them or have a frightening scene of hurting
them or an image of the children already hurt.
As was pointed out earlier, many obsessions produce anxiety or discomfort that is relieved by
performing rituals. The most common rituals are washing and checking, although there are many
others such as counting, arranging, or doing things such as dressing in a rigid, orderly fashion.
Although rituals are performed to alleviate the anxiety or discomfort that is produced by the
obsession, the anxiety relief is usually short-lived. An individual who washes in order to avoid or
overcome contamination will often find him- or herself washing repeatedly, because either they
were uncertain whether they did a thorough enough job or because the obsessional thought that
they are contaminated has recurred. Similarly, someone who checks light switches, stoves, and so
forth in order to avoid the house burning down, often has to repeat the behavior over and over,
because he may not have done it properly or the thought or image of his house being destroyed
has recurred. Even individuals who have obsessional thoughts alone may find that they have to
repeat the cognitive rituals such as counting or praying many times over as they may not have
done them perfectly in the first place.
An important point to keep in mind is that many sufferers have more than one type of symptom
so that individuals may engage in more than one type of ritual or have more than one type of
obsessional thought. Another point to note is that symptoms change over time and someone who
is predominately a washer may, over time, develop checking rituals that eventually supersede the
original complaint. In addition to changes in symptoms, the course of the disorder may also
fluctuate over time, with periods of worsening and periods of improvement. Other sufferers may
find that their symptoms remain static, while yet others may find a gradual worsening of
symptoms since the onset of the disorder.
For many sufferers of OCD, these symptoms take up a great deal of time, often resulting in their
being late for appointments and work and causing considerable disruption and interference with
their lives. Apart from disrupting their own lives, it also frequently interferes with the lives of
family members as the typical sufferer often asks the other members to do things a certain way or
not to engage in certain behaviors, as this may prompt the sufferer to engage in rituals. Thus, the
symptoms are not only controlling, frustrating, and irritating to the patients, but also to their
family, friends, and workmates.
Avoidance of certain situations or objects that may trigger discomfort and rituals is also quite
common among OCD sufferers. It seems logical to avoid contact with contaminants if you are a
person who washes compulsively, or to avoid going out of the house if you must check all the
electrical equipment, the doors, and windows. While this seems like a reasonable way of coping,
it actually adds to the problem, as the typical sufferer avoids more and more situations and
gradually the problem comes to rule their life. Second, avoidance does little to deal with the
problem as it only serves to reinforce the idea that such situations are dangerous. Because the
situation or object is constantly avoided, there is no opportunity for the individual to learn that
there is no danger.

Mind RELAXATION TRAINING

1. What is relaxation training?
Relaxation is the voluntary letting go of tension. This tension can be physical tension in the
muscles or it can be mental, or psychological, tension. When we physically relax, the impulses
arising in the various nerves in the muscles change the nature of the signals that are sent to the
brain. This change brings about a general feeling of calm, both physically and mentally. Muscle
relaxation has psychological benefits as well as physical. Through relaxation training you will learn
how to recognise tension and achieve deep relaxation. You will need to be an active participant,
committed to daily practice for two months or longer.
2. Importance of Relaxation Training
Muscles are designed to remain in a relaxed state until needed to perform some activity. In usual
circumstances the muscles do not remain at a high level of tension all the time but become
activated and deactivated according to a person's needs. The fight-or-flight response also results in
muscle tension. When people have been under stress for long periods of time, they may maintain
high levels of muscle tension. They may experience muscle fatigue, pain and constant
apprehension. Eventually these people may be unable to recognise tension or relax. As a result of
high levels of tension, these people may feel jumpy, irritable, nervy, or apprehensive. Tension may
appear to be almost relaxed compared with panic attacks.
When someone is in a continual high state of tension, it’s easier for a panic attack to occur because
the body is already highly activated. A minor event, such as getting stuck in traffic, can trigger
further tension, which in turn can lead to hyperventilation and panic. Constant tension makes
people over-sensitive and they respond to smaller and smaller events as though they were
threatening. By learning to relax, you can reduce general levels of arousal and tension, and gain
control over these feelings of anxiety.
Note that these responses are opposite to the fight-or-flight response.
Since some tension may be good for you, it is important to learn to discriminate between useful and
unnecessary tension. Much everyday tension is unnecessary. Only a few muscles are involved in
maintaining normal posture, e.g. sitting, standing or walking. Occasionally, an increase in tension
is extremely beneficial, for example, when you are about to receive a serve in a tennis game.
Likewise, it is probably helpful to tense up a bit before a job interview. Do not become frightened
of this type of tension. The tension is unnecessary when (a) it performs no useful alerting function,
(b) when it is too high for the activity involved, or (c) when it remains high after the activating
situation has passed.
3. Components of Relaxation Training
In order to be more in control of your anxiety, emotions, and general physical well-being it is
important to learn to relax. To do this you need to:
1. Learn to recognise tension
2. Learn to relax your body in a general, total sense
3. Learn to let tension go in specific muscles.
4. Recognising tension
Consider the following:
1. Where do you feel tension?
2. Do your muscles show characteristics of tension, such as soreness, fatigue or feeling hard?
3. Which reactions within yourself lead to an increase in tension?
(e.g. frustration, surprise, anger)
4. Which external events lead to an increase in tension?
(e.g. queues, waiting at traffic lights, work pressure)
5. Progressive Muscle Relaxation
Progressive muscle relaxation involves the muscles being relaxed in a progressive manner
gradually working through different muscle groups in the body. Both sides of the tape you have
been given have instructions for progressive muscle relaxation. Side A is a 25-minute version. Side
B is an abbreviated 15-minute version. You will be starting with Side A for the first week of the
program; your therapist will tell you when to use Side B.
Relaxation exercises should be done at least once a day to begin with. Initially, do the exercises in a
quiet room, minimising interruption, so that you can give your entire concentration to relaxation.
Explaining the exercises to those you live with, and perhaps playing the tape to them, will generally
lessen any embarrassment and minimise interruptions. Select a comfortable chair with good support
for your head and shoulders. Or cushions against a wall. Some people prefer to do the exercises
lying down, but do not use this position if you are likely to fall asleep. You cannot learn to relax
while asleep. Sleep is not the same as relaxation - consider those times when you have woken up
tense. If you want a method to put you to sleep, go over the relaxation exercises in your mind or
keep a relaxation tape specifically for that purpose. As you master the relaxation exercises, try
various postures and situations. You may use the relaxation tape as preparation for some activity
over which you anticipate difficulty. Arrange your seating appropriately, finish all you need to do
and then start the tape.
Do not practise progressive muscle relaxation while performing activities that require a high degree
of alertness, e.g., driving a car or operating a machine.
6. Getting the most out of progressive muscle relaxation
v Avoiding tensing too tightly. A maximum of 60 – 70% tension is recommended.
v Don’t tense to the point of pain or discomfort.
v Don’t worry if your mind wanders during the tape – this is often a sign of relaxation. Gently try
to focus back on the tape.
v Some people feel anxious during relaxation exercises. This usually is because they are
unfamiliar with being physically relaxed.
7. Isometric Relaxation Exercises
Isometric relaxation exercises can be done in everyday situations. Most of the exercises below do
not involve any obvious change in posture or movement. Others involve some movement. The
majority of exercises can be done quite unobtrusively, even when in company. In the early stages of
training you may have to do these exercises several times a day to counteract tension and maintain
a relaxed state, particularly when under stress. As you improve, they will take less time and become
easier. Eventually, you will find that you are doing them without thinking - that is, they may well
become a habit that you will use automatically to counter tension.
There are some important points that need to be remembered when doing the isometric exercises.
You are asked to hold your breath for 7 seconds while you hold in tension, but some people
occasionally find this too long. Try to hold it for 7 seconds if you can but this is not crucial. The
most important thing is to concentrate on putting the tension in slowly over approximately 7
seconds and releasing the tension slowing over approximately 7 seconds. The most common
mistakes that people make with isometric exercises is putting the tension in too quickly, or putting
in too much tension. These are meant to be gentle and slow exercises. The aim of the exercise is to
relax you, not get you even more tense. If circumstances do not allow you to hold the tension for 7
seconds, you can still benefit from putting in the tension slowly over some period of time and
releasing it in the same manner.
When sitting down or lying in private:
· Take a small breath and hold it for up to 7 seconds.
· At the same time straighten and stiffen your arms and legs out in front of you.
· After 7 seconds breathe out and slowly say the word "relax" to yourself.
· Let all the tension go from your muscles.
· Repeat if necessary until you feel relaxed.

Anxiety and Panic Disorder

Patient Treatment Manual

This manual is both a guide to treatment and a workbook for persons who suffer
from Anxiety and Panic Disorder. During treatment, it is a workbook in which
individuals can record their own experience of their disorder, together with the
additional advice for their particular case given by their clinician. After treatment
has concluded, this manual will serve as a self‐help resource enabling those who
have recovered, but who encounter further stressors or difficulties, to read the
appropriate section and, by putting the content into action, stay well.
1. Panic Attacks, Panic Disorder & Agoraphobia
A Panic Attack is a sudden spell or attack when you felt frightened, anxious or very uneasy in a
situation when most people would not feel afraid. During one of these attacks the following
symptoms may occur:
shortness of breath trembling or shaking
pounding heart hot or cold flushes
dizzy or light headed things around you feel unreal
tingling fingers or feet dry mouth
tightness or pain in the chest nausea or butterflies
a choking or smothering feeling "jelly legs"
feeling faint blurred vision
sweating muscle tension
feeling you can’t get your thoughts together or speak
fear you might die, lose control or act in a crazy way
Panic Disorder is the name given to the condition in which people have unexpected panic attacks,
worry about what panic attacks might do or mean, and change their behaviour as a result of having
panic attacks. Individuals with panic disorder will have experienced a number of these symptoms
during a panic attack. Different people will find different symptoms more frightening or unpleasant
than others.
When the panic becomes severe most people try to get out of the particular situation, hoping the
panic will stop. Alternatively, they get help because of fears they might collapse, have a heart
attack, or go crazy. Occasionally, some people want to be alone so that they don't embarrass
themselves in some way. When individuals start associating panic attacks with certain situations,
they often try to minimise the panic attacks by avoiding the same or similar situations. For
example, some people who have their first panic attack on a train may start to avoid trains and
buses in the future. When this avoidance is widespread and severe, the condition is called
Agoraphobia.
Situations that are avoided by people with agoraphobia (or endured with anxiety or discomfort) can
usually be understood as situations from which escape might be difficult (physically or socially) or
in which it might be difficult to obtain help if a panic attack occurs. An underground train is an
example of a situation from which it is physically difficult to escape, whereas a dinner party is an
example of a situation from which leaving might be socially awkward. Being alone at home or
alternatively, a long way from home, are examples of situations in which it might be difficult to
obtain help. There are, of course, situations that combine elements of these: being on a peak-hour
train could be seen to involve difficulty escaping as well as difficulty obtaining help.

Anxiety and Phobias

A phobia is a particular type of fear. Just as people fear many things, there is a large range of
things that can become a phobic concern. However, a phobia is different from a fear for three
reasons. The first of these is that the fear is intense and includes many of the following
sensations:
BODILY SENSATIONS
· Heart racing
· Sweating
· Trembling
· Rapid breathing
· Breathlessness or shortness of breath
· Muscular tension
· "Butterflies" in the stomach
· Nausea
· Weakness in muscles
· Tingling in hands and feet
· Hot and cold flushes
· Chest tight or sore
ACTIONS
· Feeling like fleeing or doing so
· Feeling frozen to the spot
· Crying or screaming
THOUGHTS
· Fear
· Worry "what if . . ."
· Embarrassed or irritated
· Shame
· Confused thinking
· "Something might happen"
· "This is dangerous" or "I might act in a dangerous way"
All of these actions, thoughts, and feelings are indications of fear and anxiety. It is important to
note that while they are unpleasant to experience, on their own they are not dangerous or lifethreatening.
We will discuss later why these experiences occur, but before we do, the second
feature of a phobia needs to be described.
Phobias involve avoidance of what is feared (or, at the very least, the object or situation is
endured with distress). Because anxiety is unpleasant and people worry what might happen when
they confront what they fear, people with phobias avoid the objects or
situations that make them afraid. This avoidance may take many different and subtle forms, such
as:
· Not going near the feared object or situation
· Escaping the situation
· Making excuses for not doing what scares you
· Imagining yourself somewhere else
· Thinking about something else
· Looking the other way
· Drinking alcohol or taking other drugs
· Taking antianxiety medications
· Seeking the presence of others
· Talking to the people you are with about anything
Many of the ways in which people with phobias avoid what they fear are subtle and this, in part,
may be due to the final important characteristic of a phobia, its "irrationality." As you may have
found, people who do not have phobias have difficulty understanding those who do; they may
say that the fears are silly, childish, and nonsensical. And while you also know that the situation
does not represent a real danger, at another level you may believe that it may do so. You may
even be able to agree with your family and friends and say that "I know that nothing will
happen" but it doesn't help. There is still this other part of you that is afraid a nagging doubt
that says "what if . . ."
To summarize what we have covered so far, phobias are characterized by three things. First,
there is an intense fear and anxiety about some object or situation. Second, there is an avoidance
of the feared object or it is endured with great difficulty. Finally, there is a conflict between
the knowledge that the situation is relatively safe and the belief that it may not be.
1.1 Rationale the Program
The program will focus on the three aspects of the phobia and you will be given skills that
specifically target each of them. As such, the treatment is like a tripod. It requires all three legs to
be present to stand firmly. This means that you will need to learn, practice, and keep using all of
the techniques to control your anxiety. The three strategies that this program covers are
techniques designed (1) to control your physical sensations, (2) to help you face more
comfortably the things that you currently fear and avoid, and (3) to modify what you say to
yourself. A further module will cover skills that have specific relevance to controlling
the fainting in the presence of blood and injury.
It is important to realize that achieving control of anxiety is a skill that has to be learned. To be
effective, these skills must be practiced regularly. The more you put in, the more you will get out
of the program. It is not the severity of your fear or avoidance, how long you have had your
phobia, or how old you are that predicts the success of the program. Rather, it is your motivation
to change your reactions. Using all three techniques, you will be able to master your fear.

Specific Anxieties in Social Phobia

The predominant emotion in social phobia is anxiety. As we have seen, anxiety occurs in response
to a perceived threat through activation of the flight or fight response. Whilst this response
developed in animals as an emergency response to physical danger, in humans it can also be
triggered by the threat of some type of loss. It may be that a fear of losing our social standing with
others may trigger the anxiety of social phobia. It may also relate to some deep seated need to be
accepted by others which could date from prehistoric times when an individual’s survival in a harsh
and dangerous environment depended on acceptance by the tribe. In any case, it is now clear that
the anxiety in social phobia is triggered by a fear of being negatively evaluated. Underlying this is
an excessive concern about the opinions of others.
You can compare your degree of concern about what others may think of you with the general
population by completing the following questionnaire, developed by Watson and Friend.
FNE SCALES
In each case indicate whether or not the statement applies to you by writing either T for true or F for false.
Please be sure to answer all the statements.
1. ___ I rarely worry about seeming foolish to others.
2. ___ I worry about what people will think of me even when I know it doesn't make any difference.
3. ___ I become tense and jittery if I know someone is sizing me up.
4. ___ I am unconcerned even if I know people are forming an unfavorable impression of me.
5. ___ I feel very upset when I commit some social error.
6. ___ The opinions that important people have of me cause me little concern.
7. ___ I am often afraid that I may look ridiculous or make a fool of myself.
8. ___ I react very little when other people disapprove of me.
9. ___ I am frequently afraid of other people noticing my shortcomings.
10. ___ The disapproval of others would have little effect on me.
11. ___ If someone is evaluating me, I tend to expect the worst.
12. ___ I rarely worry about what kind of impression I am making on someone.
13. ___ I am afraid that others will not approve of me.
14. ___ I am afraid that people will find fault with me.
15. ___ Other people's opinions of me do not bother me.
16. ___ I am not necessarily upset if I do not please someone.
17. ___ When I am talking to someone, I worry about what they may be thinking about me.
18. ___ I feel that you can't help making social errors sometimes, so why worry about it.
19. ___ I am usually worried about what kind of impression I make.
20. ___ I worry a lot about what my superiors think of me.
21. ___ If I know someone is judging me, it has little effect on me.
22. ___ I worry that others will think I am not worthwhile.
23. ___ I worry very little about what others may think of me.
24. ___ Sometimes I think I am too concerned with what other people think of me.
25. ___ I often worry that I will say or do the wrong things.
26. ___ I am often indifferent to the opinion others have of me.
27. ___ I am usually confident that others will have a favorable impression of me.
28. ___ I often worry that people who are important to me won't think very much of me.
29. ___ I brood about the opinions my friends have about me.
30. ___ I become tense and jittery if I know I am being judged by my superiors.
Score this questionnaire by giving yourself 1 point if you said “True” to numbers 2,3,5,7,9,11,
13,14,17,19,20,22,24,25,28,29,10. Score 1 point if you said “False” to
1,4,6,8,10,12,15,16,18,21,23,26,27. Your score gives an indication of how concerned you are to get
the approval of others in your life. Approximately 75% of people in the general population score
less than 19 on this scale. Scores higher than this indicate a level of over concern about others’
opinions of you that is likely to cause distress – and result in anxiety in social situations.
That’s not to say that others don’t get any social anxiety. They do. Everyone would like to think
that they are accepted and approved of by others they come in contact with. We all know the
feeling of embarrassment when we make a silly mistake, say something inappropriate or draw
attention to ourselves in an unflattering, and usually accidental, way. However, there are several
differences between normal social anxiety and social phobia.
Normal social anxiety Social phobia
Moderate desire for approval Strong desire for approval
Expectation of approval Expectation of disapproval
Reasonable tolerance for disapproval Extremely distressed by disapproval
Easily forgets about faux pas Dwells on faux pas, very upset by them
When in doubt interprets response as positive When in doubt interprets reaction as critical
So, it is the fear of negative evaluation that is the core of the problem, but it is compounded by
unrealistic beliefs about:
· How bad you think negative evaluation is, and what you believe the consequences will be for
you
· How likely you think it is that you will be evaluated negatively
This explains why some people that show the apparent signs of anxiety that worry you - who blush
or tremble, sweat or shake, appear lost for words or stumble over what they are saying – do not
appear to worry about it. Indeed, many of the people we have treated in the past have commented
that they have encountered people who did what they themselves feared without worrying about it,
for example, the person who shook when writing, yet seemed unconcerned,

Anxiety Management

The previous section discussed the nature of anxiety and panic, and the situational and lifestyle
factors which can contribute to generally heightened levels of stress and anxiety. By paying
attention to these factors you can help reduce your level of arousal - the degree of tension and
alertness you feel – when this is excessive for your needs and your health.
Specific anxiety management strategies include:
· Hyperventilation control - the slow breathing technique covered in Section 2
· Relaxation Training
Slow-Breathing Technique
It is known that even a slightly elevated rate of depth of breathing beyond what is required in the
circumstances can contribute to feelings of anxiety. Many individuals will not have obvious
hyperventilation, and currently it is not felt to play a major role in the anxiety experienced by most
people with social phobia. It is more likely to be of importance if you noted an elevated breathing
rate in the exercise above, or if you do actually suffer panic attacks.
The slow breathing technique can be used as the foundation of your anxiety management strategies,
helping to calm you down so that you can think more clearly and apply the “straight thinking’
strategies you will learn in the next part of the program. It can also be useful strategy to shift your
focus away from your anxious concerns, and many people over the years have found the technique
helpful for these reasons. The best approach is to use the technique at the first signs of anxiety.
The slow breathing technique will give you a breathing rate of 10 breaths per minute. It is best to
use a watch in practice sessions initially to make sure that you get the feel for the right timing –
when we feel anxious there is a tendency for us to feel a bit “speedy” and want to do everything too
fast! Concentrate on making your breaths smooth and light. Breathe through your nose to help limit
the amount of air you take in and thus prevent overbreathing. It should feel as though the air is just
drifting lightly past your nostrils. Relax your stomach muscles. The movement is so light that it is
unnoticeable from normal breathing to anyone who may be watching. Ready? Now do the
following:
SLOW BREATHING TECHNIQUE
1. Take a medium sized breath in, hold it and count to 6 (timing 6 seconds with your watch).
2. When you get to 6, think “relax” and breathe out. Try and feel as though you are releasing
tension as you breathe out.
3. Next breathe in for three seconds and out for three seconds, in a smooth and light way.
4. At the end of each minute (after 10 breaths) hold your breath again for 6 seconds, think “relax”,
breathe out, and then continue breathing in the six-second cycle for another minute.

What is a panic attack?

Panic means a sudden spell or attack of feeling frightened, anxious or very uneasy. Typically
symptoms come on suddenly and escalate in severity over the next 5-10 minutes. A panic attack is
essentially a severe flight or fight reaction.
During a panic attack the following symptoms may occur:
· feeling short of breath
· pounding heart
· sweating
· trembling or shaking
· blushing
· trembling or croaking voice
· nausea or a fear of vomiting
· dizziness or light-headedness
· tingling fingers or feet
· tightness or pain in the chest
· a choking or smothering feeling
· hot or cold flushes
· feelings of unreality
· a feeling that you cannot get your thoughts together or speak
· an urge to flee
· a fear that you might die
· a fear that you might act in a crazy way.
You can see from the list of changes that occur during the flight or fight response how at least some
of these symptoms arise. Any or all of these symptoms may occur. Not every one with social
phobia gets panic attacks. Each individual tends to have their own pattern of symptoms in response
to anxiety, and to find some symptoms more distressing or unpleasant than others. In social phobia,
blushing, sweating and shaking are often seen as the most troubling symptoms.
When anxiety becomes severe, most people try to escape the situation in order to prevent the feared
consequences (the “flight” aspect of the flight or fight response). In other words, if an individual
fears that their anxiety will cause them to look odd, or say something inappropriate they will try to
escape the situation before this can happen. Once out of the situation the anxiety usually settles
quickly.
Most people rapidly learn to predict the situations in which the anxiety or panic is likely to occur.
Some people quickly begin to avoid such situations altogether. Anticipatory anxiety can be a severe
problem. Sometimes an individual really intends to go through with a social outing or performance
situation but avoids it at the last minute because their anxiety has escalated to the point where they
feel totally unable to manage the situation. Avoiding situations that cause anxiety may seem the
only alternative to the negative evaluation that it is feared may result if social performance is
adversely affected by anxiety.
But what if your performance wasn’t as badly affected as you thought? You would lose the
opportunity to learn this. Your anxiety would probably start spreading to other types of social
situations. Meanwhile, your level of confidence and self esteem would drop as you found yourself
more and more restricted in what you felt you could cope with. Hence, you would become even
more anxious about the situations you feared. When social phobia has been present for a long time
the individual often structures his or her life around the need to avoid certain situations or expends
considerable effort and anxiety planning what to do in case a panic should occur.
This program will teach you how to control your anxiety and panic and how to cope with situations
in which anxiety is likely to occur.
EXERCISE: MAKE A LIST OF SITUATIONS IN WHICH YOU WOULD FEEL VERY ANXIOUS
1. __________________________________________________________________________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________
4. __________________________________________________________________________________
5. __________________________________________________________________________________
The Role of Hyperventilation
We now turn our attention to one particular aspect of the flight or fight response, namely, the
increase in rate of respiration, or overbreathing.
Efficient control of the body's energy reactions depends on the maintenance of a specific balance
between oxygen and carbon dioxide. This balance can be maintained through an appropriate rate
and depth of breathing. The flight or fight response triggers an increase in the rate of breathing in
preparation for taking flight. When this response is triggered by a social situation, you are unlikely
to respond by running away, at least, not literally! The increase in oxygen intake is not matched by
an increase in carbon dioxide production and an imbalance results.
Hyperventilation is defined as a rate and depth of breathing that is too much for the body's needs at
a particular point in time. The imbalance which results causes many physical symptoms, including:
· dizziness
· light-headedness
· confusion
· breathlessness
· blurred vision

How Does Social Phobia Differ from Shyness and Normal Social Anxiety?

Many people describe themselves as shy, although there is no clear definition of what this means!
Shyness with others, or increased self-consciousness, occurs in phases through childhood. It is
common in the teenage years as an individual starts to think about how others might see them. For
most people, this type of social anxiety decreases with age.
Some social situations continue to cause a degree of anxiety for most people. Good examples are
public speaking, or arriving alone at a social gathering of unfamiliar people. Normal social anxiety
is not disabling, it settles quickly during or after the event, and it does not begin weeks before the
event. There is no expectation of negative evaluation. Things are different for the person with
social phobia. They tend to start worrying a long way in advance, the discomfort may well get
worse as they stay in the situation, and next time they may be even more worried. Afterwards they
may go over and over aspects of their performance with which they were unhappy. The reasons for
this will be discussed in detail in a later section of the manual. Severe shyness that causes
significant avoidance of social interaction or distressing anxiety in social situations is probably
social phobia.
What is Avoidant Personality Disorder?
Individuals with avoidant personality disorder are anxious in almost all types of social interaction.
They fear, and expect, not only negative evaluation, but also rejection or humiliation. There is often
a sense of inferiority to others, low self esteem, and considerable avoidance of social interaction.
Interestingly, looking anxious is often not the greatest concern of those with the avoidant
personality style. These individuals may be far more anxious about how they are relating to others,
and fearful that in some way they will be found inadequate or worthless and be rejected. The
problem has usually been present since early childhood, and involves deeply ingrained patterns of
thinking. Estimates vary greatly as to how common this problem is, but at least a quarter of those
with social phobia will also have the avoidant personality style. Avoidant personality styles can be
helped by the social phobia program because there is so much overlap between the two disorders.
If you have an avoidant personality, you must be prepared for the fact that it will probably take
some time to overcome your problems to a satisfactory degree because they have been present for
so long, and to such an extent. In many cases, you will find it helpful to seek ongoing help with
your problems after this program finishes. You can discuss this matter further with your therapist.
How Common is Social Phobia?
Social phobia has been documented across a range of cultures. It is estimated that between 1.5-
4.5% of the population has social phobia at any time. Slightly more women are affected than men.
However, probably more men are affected by avoidant personality disorder. Social phobia usually
starts in the teenage years and tends to be a chronic disorder that does not go away spontaneously.
Studies consistently indicate that most people have suffered with social phobia for many years
before they seek or find appropriate treatment.
What Causes Social Phobia?
We still don’t know for sure what causes social phobia. It seems that the most important factor
related to the development of social phobia is a genetic vulnerability to anxiety in general. This is
probably largely due to greater sensitivity and reactivity of the nervous system. Some people tend
to react more, often with anxiety or nervousness, when faced with any type of external event. These
people seem to be more vulnerable to developing anxiety problems. There is also an increased risk
of developing social phobia if a close relative has the disorder. It is unusual for social phobia to
develop from a specific incident, although this may happen more often in “circumscribed” social
phobia (where only one or a few situations cause anxiety). Aspects of the family environment do
not appear to be very important causative factors.
The Effect of Personality
Personality refers to habitual ways of thinking about ourselves, our relationships with others and
our environment, and the coping strategies we use in these situations. Individuals with social
phobia tend to describe themselves as sensitive, emotional and prone to worry. As we have seen,
this does tend to run in families. People who are very sensitive to criticism, or overly concerned
about creating a good impression may be more susceptible to social phobia. Some of these attitudes
are learned in childhood, but genetic and temperamental factors also influence personality
development in ways we do not fully understand.
Hypersensitivity, emotionality, and proneness to worry can be a handicap. You can’t radically alter
your personality – but nor should you want to! There are advantages to being sensitive: Sensitive
individuals care about others and can empathise readily, which are valuable characteristics. We can
teach people to be less sensitive but it is very hard to teach someone to be more sensitive! Those
with social phobia are “people people”. What you can change about your personality is the degree
to which you show various traits. This course aims to help you to learn to be less sensitive and less
worried about what others think.
Treatment of Social Phobia
Cognitive behaviour therapy has been shown to result in long term improvement. Cognitive
behaviour therapy is based on the principle that how we feel about a situation is determined by
how we think about it. It is based on the work of Aaron Beck and Albert Ellis. These principles
will be discussed in detail later in the program. The components of a cognitive behavioural
program for social phobia include:
· Knowledge about anxiety and social phobia
· Control of anxiety and panic
· Changing unhelpful thinking patterns
· Involvement in social interaction
Drug treatments are also available in social phobia but many people will not need medication.
When medication is necessary, it is still important to learn cognitive behavioural techniques for
managing social phobia, since this appears to give the best long term result. Your doctor can give
you more information.
The Aims of this Program
What you can expect by the end of this program is for your symptoms to have shown a noticeable
degree of improvement. You should have a good understanding of what is required to treat social
phobia and be confident that you can continue to apply the principles you have learned with a good
expectation of further success. Your therapist can discuss this with you in more detail.

Social Phobia

Introduction
Social phobia is a treatable condition. This manual takes you step by step through a cognitive
behavioural program. By working through it you will learn about the nature of social phobia,
anxiety, and panic. Not only will you learn skills that will enable you to develop more control over
your anxiety, you will also learn to worry less about appearing anxious and about being evaluated.
To learn these skills will require time and effort. To be effective, they will need to be practiced
regularly. The more you put in, the more you will get out of the program. However, you are
unlikely to be completely cured by the time you get to the last page, or even to the last session of
your treatment program. To get lasting improvement you need to be prepared to go on working.
Research around the world has demonstrated the possibility of long-term achievements, as well as
continued improvement.
What Is Social Phobia?
Social phobia is a fear of being scrutinized, evaluated, or the center of attention. However, the real
underlying fear is of being evaluated negatively. People with social phobia commonly fear that
others will find fault with them or think that they are incompetent or strange. They may worry that
this will occur during social interaction with one or more other people, when they are doing
something under observation or even in situations where there is just the chance that they may
attract attention. Sometimes, this may involve just being with others.
The person with social phobia believes that being judged negatively may result from being seen to
be anxious (for example, blushing, sweating, trembling, or shaking), from saying or doing
something embarrassing, appearing awkward or making a mistake. Some also believe that there is
some aspect of their appearance or behavior that may attract criticism.
Feared situations include public speaking (including tutorials and presentations), parties, writing or
signing one's name under scrutiny, standing in a line, using the phone with others around, eating or
drinking in public, using public toilets, and public transportation. Some individuals fear that
embarrassing bodily functions will occur inappropriately, for example, losing control of bowel or
bladder, passing flatus, vomiting, stomach noises.
The main fears in social phobia may relate more to performance situations or more to social
interaction. There may be great anxiety about looking anxious or even having a panic attack in
these situations. The individual may believe that this anxiety will be obvious and will lead others to
evaluate them negatively. When social interaction is the main fear, the individual often worries
about having nothing to say, being boring, saying something inappropriate or being judged as
inadequate in some way. In any case, social situations are either endured with intense anxiety and
discomfort (during which, panic attacks may occur) or are avoided. Anxiety and avoidance may be
linked to only one situation, (circumscribed social phobia) but commonly occur in many situations
(generalized social phobia).
The fears in social phobia are excessive and unreasonable. While in the situation, feeling acutely
anxious and convinced that things are going badly, it may not seem that the fear is unreasonable.
However, most individuals with social phobia realize that their anxiety in social situations is much
greater than for those who do not suffer from the disorder. Thinking about things more calmly once
out of the situation it is usually possible to accept that the anxiety triggered by the actual
circumstances was excessive. More about this later.

Depression Testimony

This is my testimony (in a nutshell) in dealing with and
eventually overcoming severe depression.
For me, 1989 had been a productive and hope
filled year. After graduating from Bible College in 1988, I
had joined a church planting team as the assistant pastor. I
expected 1990 to be one of best years of my life as I
planned to further my theological training and join another
church planting venture in pursuit of my goal of becoming
a missionary in Thailand.
However, throughout that year a number of factors
combined to cause the gradual decline of my mental and
physical health. I had neglected physical exercise, eaten
poorly and devoted little time to rest and recreation. I
worked full time as well as serving part time in the church.
The sleeplessness which had troubled me in recent years
had developed into chronic insomnia. As I became ever
more fatigued, panic attacks and obsessive fearful thoughts
afflicted me in increasing frequency and severity, even
though I had no idea what they were at that time.
Undiagnosed complex partial epilepsy churning
away in the background was another contributing factor. On
the other hand, throughout that year I remained positive and
full of zeal for life, excitedly pursuing my goal to be a
pastor and missionary.
In late November 1989 I went to Thailand for a
hectic ten-day missionary orientation course, where I barely
slept at all. When I returned to Melbourne, I fell apart
emotionally, physically, mentally, and spiritually. Although
178cm tall, my weight had fallen to 55kg. The final straw
came a few days later - I suffered a shock so powerful that
for almost 24 hours I was unable to complete a single
thought in my mind.
After eight nightmarish days that defied all reason,
I suddenly bounced back to some semblance of normality.
Unfortunately, I collapsed again two weeks later, where my
mind unravelled to the extent that for the next several days,
I did little else but lay on my bed, rocking from side to side
as I tried in vain to pull myself out of terrifying panic
attacks that would not cease.
This time, instead of bouncing back, I remained
stuck in the hellish nightmare, which continued without
respite into the New Year. I felt disturbed and ill at ease all
day and could barely sleep at night. My mind became
sluggish, stuck in a rut of thinking fearful, anxious thoughts
all the time. Many physical complaints assailed me, missed,
palpitating and racing heart beats, very painful aches in the
shoulders and jaw, nausea and chest pains, difficulty
breathing, and more. Emotional symptoms included anger,
confusion, irritability, loss of interest in life, fear that I
would never escape the nightmare, and I withdrew from
almost all relationships. My spiritual life was equally a
shambles, I struggled with anger and bitterness towards
God, could no longer feel His presence, and felt guilty all of
the time. Although I continued to languish in this miry pit of
bleak hopelessness for the next seven months, there were a
number of things that slowly helped me cope with the
ordeal.

Shattered Dreams

It can be very difficult to cope with the destruction of our
plans and dreams for the future, especially if we believed
those plans had come from God in the first place. Shock,
denial, confusion, anger, and even descent into depression
are common reactions.
On the other hand, the onset of depression can also
destroy our plans for the future, which in turn makes
depression worse.
Some Christians blame God for allowing those
plans and dreams to be shattered. Others, doubting God’s
goodness, accuse Him of destroying those plans
deliberately.
I stand amongst those whose plans for the future were
destroyed by depression. When I was nineteen, I felt a
strong burden for the Asian peoples and spent the next five
years preparing to go to Thailand as a pastor and
missionary. I went to Bible College, helped plant a local
church, and went to Thailand on a missionary orientation
course. The plan for 1990 was additional Bible college
studies and more church planting experience.
It was at that point in my life that depression
overwhelmed me. As the days turned to weeks and then
months, with no sign of the unbelievably intense suffering
abating, I had no choice but to quit the ministry and
abandon my plans for the future.
Yet having been convinced that God had called me
to be a missionary in Asia, forsaking that dream left me
terribly confused and wracked with guilt. I remember
wondering during those dark months how Jesus viewed me,
was He displeased and disappointed in me for making that
decision? As I pondered this and my horrific condition, I
began to get angry with Him, as you can see from this diary
entry.
38
8th February 1990 – ‘Jesus cannot blame me for throwing
in all thoughts of the ministry. He would have known that I
would give up after going through all this - so He can’t
blame me for pulling out. Also, I would have been heading
for Thailand, doing Bible college etc right now, if all this
stuff had not happened. So if Jesus wanted me to be a
missionary, then He would not have or (should not have) let
all this happen to me. But the truth is, all this has happened
to me, but why? Where has it come from?’
Due to counselling and prayer, I eventually realised that I
had made the mistake of placing my faith and trust in
obediently following the path that I believed God had set
for me. In fact, I became terrified of making a wrong step in
the erroneous belief that this would destroy His plans for
my life.
Such faulty thought processes had placed me in a
fearful bondage. We are not to place our faith in the path we
believe God has called us to follow - we are to place our
faith and trust in God Himself. As to fearing I could destroy
God’s plans for my life, God tells us to follow His precepts
as presented in His word, and that He will never leave or
forsake us. "And surely I am with you always, to the very
end of the age.” Matthew 28:20.
Let us have a look at Proverbs 3:5. ‘Trust in the LORD with
all your heart and lean not on your own understanding.’
I learnt that we must not place our hope in our
understanding of how our future will turn out. For if we do,
when things do not turn out as we expect them to, this may
shake our life’s foundations. We are to build our lives upon
Christ, the Cornerstone, the sure foundation – we must not
build our lives upon our own understandings of what the
future will be.
In his heart a man plans his course, but the LORD
determines his steps. Proverbs 16:9
There is a saying in the military. “No battle plan survives
contact with the enemy.” There is a great lesson to learn
here – not only do plans encounter resistance, but
calculated or random events alter their course too. We must
expect this and be flexible. When things do not turn out as
we were expecting, trust in God instead of fearing,
doubting, or blaming Him. God is in control, and uses all
things for good for those who love Him.
Romans 8:28 says, ‘And we know that in all things God
works for the good of those who love him, who have been
called according to his purpose.’
Now it turns out that God did indeed give me a burden for
the Asian peoples. But His plan for my life was not to be a
missionary in Thailand planting churches. Instead, He led
me to marry a Japanese girl and serve Him in a Japanese
Christian church in my city. I had made plans, but God
determined my steps. Letting go of the fears that depression
had destroyed God’s plan for my life, I acknowledged Him
with each step I took and He led me down a straight path.

Insomnia, and Frustration

Insomnia, or being unable to sleep at night, is one of the
most frustrating things I have had to deal with.
Overwhelmed by fatigue and so sleepy that I could
barely keep my eyes open, I would crawl into bed at a good
hour, looking forward to a good night’s sleep. My mind
was at peace, content, even empty of thought - yet I would
lie there, awake, hour after hour. Sleep simply would not
come.
As this continued, I began to crawl into bed in an
anxious state of mind. I knew I desperately needed sleep
but was worried it would not come. This tension made sleep
even more evasive. My heart raced, my mind developed a
habit of glancing about fearfully, which often trigged panic
attacks.
As insomnia became more frequent, I tried to wait
patiently for sleep to come. Yet as the hours continued to
tick by I became more and more frustrated. My body was
telling me that I needed sleep. I was so tired that I could not
keep my eyes open, so why was I lying awake hour after
hour? I would pray, beg, and plead with the Lord to give
me sleep, quoting scriptures at Him, trying to convince Him
to stretch out His hand or speak a word over me to put me
to sleep. Then, after lying awake for five or six hours,
frustration would blossom into rage. I lost count of how
many times I shook my fist at the ceiling and said, “Jesus,
why do you just sit there! Can’t you see that I need sleep?
Why don’t you act? Don’t you care?”
As well as getting angry with God, I became
enraged with my mind and body. What was wrong with
them, couldn’t they see what they were doing to me? I was
so tired and sleepy yet my useless, stupid mind simply
would not shut off! It was as though my body conspired
against me, and I hated it, I wrote in my diary.
Following these sessions of rage against God and
myself, came anguish, repentence and guilt. I knew I should
not react like this, but I needed sleep!
Eventually the insomnia became so bad that for
five days I would fall asleep when the sun came up, and on
the sixth, sleep would not come at all. On those days I felt
robbed, cheated, betrayed. When I rose, I felt dirty and
unclean. Then the cycle started again.
Finally, due to a number of factors, I fell into
strong depression towards the end of 1989. Panic attacks
afflicted me 24 hours a day, my mind never ceased to churn
through terrifying fearful thoughts, and insomnia continued
to afflict me.
Attitudes We Cannot Afford to Have Towards Insomnia
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As you can see from what I have shared above, the ways I
reacted to insomnia made it worse. These negative reactions
of fearing or fighting it released negative adrenalin into my
system, elevated my anxiety levels and made it harder to
sleep. What a vicious cycle – insomnia begets tension and
fatigue, which in turn make insomnia worse, which causes
further tension and fatigue.
Here are some reactions we cannot afford to have towards
insomnia:
1. going to bed fearful that we may not sleep
2. becoming frustrated when we cannot sleep
3. worrying how this lack of sleep will affect us tomorrow
4. letting the frustration boil over into rage
Helpful Attitudes Towards Insomnia
Here is a list of what reactions we need to have towards
insomnia.
1. when we go to bed, be prepared to stay awake all night
2. be content to stay awake all night instead of getting
frustrated or angry
3. recognize that resting contentedly all night in bed, even
without sleeping, is still beneficial
4. if we don’t sleep tonight, there is always tomorrow night.
Some Things that May Help with Mild Insomnia
In my dealings with insomnia over the decades, I have
learned a few tricks that can help alleviate mild insomnia.
1. a glass of hot milk, or a bowl of hot cereal, taken
immediately before bed, can be helpful
2. if still awake two to three hours later, have another glass
of hot milk or cereal
3. regular exercise is crucial. This may be going on brisk
30-45 minute walks three times a week, or doing aerobics,
swimming, jogging, etc. Working out with light handweights
several days a week also helps. (Small note - avoid
the above types of exercise near bedtime!)
4. eat a good, balanced diet, with lots of fruit. Drink plenty
of water
5. if you must have a nap during the day, make it a 15
minute power nap, no longer. Set an alarm.
6. listening to soothing or relaxing music immediately
before going to bed can also be helpful.
Another point I would like to make is that we humans have
a tendency to take on too many responsibilities and get
involved with too many activities. Sometimes it is good to
take a step back, sit at Christ’s feet and wait on Him, and
then prayfully examine our life. Are we doing too much?
Are there some aspects of our life that are placing us under
pressure unnecessarily? Are there some things that we can
quit or that can be put off until next year? Frantic, stressful
lifestyles can cause insomnia or make it worse. I learned
this lesson the hard way. (Twice…)
Severe Insomnia
If insomnia has become so bad that we cannot sleep night
after night, (this is typical for those suffering from
depression), seek medical assistance - we must not struggle
through it by ourselves. A doctor can help determine
insomnia’s causes (there are many different causes) and
recommend medical treatment. For someone suffering from
strong depression, sleep is a necessary part of the healing
process. I am so glad that after three to four months of
trying to cope with depression and insomnia on my own, I
finally saw a doctor and went onto anti-depressant
medication that included a mild tranquilizer. The
combination of the medication and being able to sleep again
were important factors in dulling depression’s effects,
which helped me to concentrate on the task of recovery.
It was not until seventeen years after insomnia
began to plague me that I discovered that I was suffering
from complex partial epilepsy. This typically begins to
become apparent in one’s late teens, and I believe this was
the primary cause of the insomnia. (However, the way I
reacted to it during the first few years made it much worse.)
I no longer take anti-depressant medication, only
epilepsy anti-seizure meds. On most nights, I fall asleep
easily, but several times a year I still have those sleepless
nights. Instead of getting frustrated or angry, this is what I
say to myself when it happens, “If I stay awake all night -
that’s fine. I’ll make myself comfortable and snuggle up in
the blankets. If I fall asleep eventually - great! If not, that’s
fine too. Resting all night in bed is still beneficial.” I submit
my mind to Christ, dwell in His peace and take refuge in
His presence. I have learned to be content, whatever my
circumstances, including those sleepless nights.
Philippians 4:12-13 ‘I know what it is to be in need, and I
know what it is to have plenty. I have learned the secret of
being content in any and every situation, whether well fed
or hungry, whether living in plenty or in want. I can do
everything through him who gives me strength.’
Colossians 3:15 ‘Let the peace of Christ rule in your hearts,
since as members of one body you were called to peace.
And be thankful.’
Philippians 4:6-7 Do not be anxious about anything, but in
everything, by prayer and petition, with thanksgiving,
present your requests to God. And the peace of God, which
transcends all understanding, will guard your hearts and
your minds in Christ Jesus. (Special thanks to a reader for
reminding where to find this verse!)

Panic Attacks and Christians

Unfortunately, for some Christians, a panic attack caused
by the fear of making the wrong life choice has another
insidious dimension to it. Since they cannot control it or
make it stop, and because it is accompanied by a distinct
lack of peace, they erroneously misinterpret the panic attack
as God guiding them. A common expression not found in
the Bible is, “Let the peace of God guide you.” It
embarrasses me to admit that for many years I thought
panic attacks were God guiding me.
Mistaking panic attacks as being God’s guidance
actually makes the panic attacks worse, as such Christians
in their eagerness to obey God are (unnecessarily) terrified
of disobeying Him. A verse which used to torment me
when I resisted and fought against a panic attack was 1
Samuel 15:22 “Does the LORD delight in burnt offerings
and sacrifices as much as in obeying the voice of the
LORD. To obey is better than sacrifice.” As I drew closer
to depression as 1989 wore on, I had an attack and lost my
peace every time I was faced with a major decision. Every
time I tried to take a step forward, an attack (which I
misinterpreted as God’s guidance) would send me reeling
two steps backwards. In the end, I was too scared to make
decisions any more. 18/2/1990 – 'I’m scared to commit to
anything, such as joining a new church, getting a girlfriend,
buying a computer, etc, in case He says no. It’s got to the
point that I won’t do anything in case God says no.'
Can you imagine the relief I felt when I discovered
that panic attacks were not God’s guidance, and that
ignoring them was not disobeying Him?
The most bewildering aspect of mistaking panic
attacks as God guiding us is trying to work out exactly what
God is trying to say (since He is not actually saying
anything). When severely depressed I was frequently
afflicted by cyclic panic attacks over a period of months.
These were associated with a large range of fears, most
telling me that I was supposed to be doing this or that. Here
is a diary entry showing the exasperation I felt at that time.
15/3/1990 – I feel like saying, “What sort of God are You to
do this to someone, and why don’t You speak clearly? All
You have to do is speak to me or give me a vision, etc, and
I’ll obey, but what is this ‘Guess what I’m saying with the
hit and miss affair [when I take away your peace to guide
you.]’ ”
Before I became depressed, one thing that reinforced my
belief that losing my peace due to a panic attack was God’s
voice, was that every time I gave into the panic attack fear,
the attack ended and my peace returned immediately. For
example, once I was about to leave my job, enter part time
ministry and look for a part time job. The massive panic
attack which followed ceased as soon as I decided to turn
down the offer for part time ministry and remain at my job.
However, when I became clinically depressed,
giving into a panic attack and doing what it appeared to be
'saying' no longer stopped the attack. The attack just kept
coming back, normally by switching immediately to
another fearful thought, or topic. This was because while
suffering from depression, we are in a state of constant
anxiety. This was when I got my first real clue that the
attacks and the lack of peace were not God’s attempt to
guide me, but something else. Being convinced of this was
another matter entirely.
“Then you will know the truth, and the truth will set you
free." John 8:32
Finally in April 1990 I saw a Christian counsellor. She told
me that I was suffering from depression, and assured me
that the panic attacks and lack of peace were NOT God
attempting to guide me. She said that I had been placing my
trust in following a lack of peace as guidance – “It’s always
worked before” – instead of in Him. Through her
counselling, prayer and Bible study, the Lord taught me the
following truths, which set me free from the erroneous
belief that panic attacks were God guiding me.
Isaiah 9:6 ‘For to us a child is born, to us a son is given,
and the government will be on his shoulders. And he will be
called Wonderful Counselor, Mighty God, Everlasting
Father, Prince of Peace.’ Jesus is the Prince of Peace, not
the Prince of a lack of peace.
John 14:27 “Peace I leave with you; my peace I give you. I
do not give to you as the world gives. Do not let your hearts
be troubled and do not be afraid.” It does not say “My lack
of peace I give to guide you.”

Panic Attacks

What is a Panic Attack?
A panic attack (also known as an anxiety attack) is
relatively brief episode of intense fear that comes on
suddenly, where the person is both terrified of the physical
symptoms that are afflicting them as well as by the
associated fears that either triggered or accompanied the
attack.
A panic attack typically lasts for at least ten
minutes but can stretch on for much longer, even hours or
days if cyclic in nature. Cyclic panic attacks are where a
person is subject to a continuous cycle of attack after attack,
with a new attack triggering even as the previous one is
fading away.
The fears associated with a panic attack are
strongest when the attack begins. These fears demand our
attention, yet the more attention we give them – the more
we fear them - the greater they become. Fighting, arguing
with, fearing or trying to flee the panic attack and its
disturbing symptoms causes negative adrenalin to flood our
being. This in turn causes even greater anxiety and even
more disturbing sensations to afflict us during the attack.

In my case, a typical panic attack included an
increased heart rate, flushed face, increased temperature,
shortness of breath, chest feeling constricted, a complete
lack of peace, and an intense churning/discomfort in the
stomach. These physical symptoms were accompanied by a
terrifying fear that was so vivid and threatening that I
would often ‘scream’ in my mind. (Many sufferers wail or
scream quite loudly during an attack.)
What triggers panic attacks?
A panic attack can be triggered by an extremely stressful or
fearful situation, or even by an exceptionally terrifying
fearful thought. Subsequent exposure to the same situation
or fearful thought could trigger further attacks. Being afraid
that another attack may come increases the likelihood of
them striking again.
The stress of trying to making an important life
decision can also trigger a panic attack. (See below for how
this can affect Christians in particular.)
Panic attacks can even trigger without a cause,
however, in these cases, the mind typically searches for a
reason for the attack, and may latch onto a fear which then
becomes the associated fear for that attack. It is typical for
the mind to latch onto a fear that has terrified the person in
the past.
A mind prone to anxiety is the perfect seedbed in
which a panic attack can take root and flourish. Some
people by nature have a sensitive nervous system, which
can be due to past or recent traumas or even due to genetic
inheritance. However, those suffering from depression are
especially susceptible to panic attacks as their minds are
locked in a state of constant anxiety.
1 Peter 5:8 is a perfect description of how panic
attacks operate. 'Be self-controlled and alert. Your enemy
the devil prowls around like a roaring lion looking for
someone to devour.’ Although Satan has been defeated by
Christ’s victory on the cross, he masquerades as a roaring
lion and tricks people into believing that panic attacks have
real power and can devour them, when in fact they have no
power at all.
Dealing with Panic Attacks
In late July, 1990, I read ‘Self Help for Your Nerves,’ by Dr
Claire Weekes, which taught me all about the ‘fearadrenalin-
fear cycle,’ (1) and how the more we fear, flee or
fight panic attacks, the worse we become as the additional
adrenalin produced prolongs symptoms and produces more
disturbing physical, mental, emotional and spiritual
sensations. It is a very vicious cycle.
To recover from panic attacks we need to break this cycle.
This is how I learnt to break the panic attack cycle:
1. do not fear panic attacks – let them come,
2. when an attack comes, do not fight or fear it, nor debate
or argue with its associated fears, instead, just accept it for
the time being,
3. let time pass while reminding ourselves that the panic
attack’s intensity will fade as we do so. (2) (3)
30
After I read ‘Self Help for Your Nerves,’ whenever a panic
attack hit me, I said to myself: “Peter, you're having a panic
attack. Don't fight it or fear it, just accept it, and learn to
live with it, don't debate it and argue with it, and let time
pass, and it will fade.”
To my amazement, the above technique worked,
as it broke the fear-adrenalin-fear cycle. First the intensity
of the attacks reduced, then their frequency grew less, and
finally I found that in most cases, I was able to nip the
attack in the bud before it could take off.
Another thing that can help when afflicted by an
annoying re-occurring panic attack is to share the panic
attack topic or fear with a wise Christian friend, so that we
can get a fresh, healthier perspective on the issue. Although
a fearful thought may seem larger than life to us, our friend
will see right through it. In this case, trust their perspective,
not our own fearful one. (A word of caution, it is not wise
to continually run these fears past our friends, as this will
not only drive them crazy, but in time we need to learn how
to find a fresh perspective ourselves from prayer and Bible
study.)
Another small note: if you suffer from panic
attacks and you simply cannot put into practice the steps I
have outlined above, I recommend seeing a doctor. If the
doctor recommends anti-depressants and professional
counselling, consider the advice carefully. Anti-depressants
dull the effects of depression and panic attacks and this is a
huge help in overcoming them. (See my entry, Depression,
Christians, and Anti-Depressant Medication.)
2 Timothy 1:7 ‘For God did not give us a spirit of timidity
(of cowardice, of craven and cringing and fawning fear),
but [He has given us a spirit] of power and of love and of
calm and well-balanced mind and discipline and selfcontrol.’
(Amplified Bible)

Perspective on Depression’s Fearful Thoughts

If suffering from depression, it is common to be troubled by
persistent irrational fearful thoughts that come back time
and again until they become a mental obsession. When
these obsessive fears confront us, a mental battle of epic
proportions ensues as we examine, debate and work
through them in a vain attempt to find relief and release.
This process can take hours, days, or longer.
This is not surprising, as our mind is so exhausted
that it has lost the flexibility of a healthy mind, which
would have dismissed such irrational fears out of hand.
Try as we might, we cannot shake free of these
fears and in the end, we can no longer see them from any
other perspective. We lose the ability to differentiate
between what we fear, and what is real, and come to believe
that the fearful perspective is the only perspective.
I finally found the courage to share some of my
irrational fears with the Christian lady who was counselling
24
me, and she gently helped me to see such fearful thoughts
from another perspective – the true perspective.
At first, I could not feel the truth of a new
perspective, but I accepted it, and kept it in my mind. And
when those fears returned, instead of going through the
exhausting process of trying to work through them again, I
recalled the new perspective given me by my counsellor,
and accepted it and believed it. I then learned to live with
the fearful thoughts simmering away at the back of my
mind, without fearing or fighting them, while continually
reminding myself of the new perspective. And as I let time
pass, the new perspective, the truth, finally won out.
Sometimes we can embrace the new perspective
quickly, but if severely depressed, it can be some time
before the truth sinks in, and when it does, we receive relief
and freedom. “Then you will know the truth, and the truth
will set you free." John 8:32
In the book “Self Help for your Nerves,” Dr
Weekes explains the importance of finding someone
suitable to help us find 'the other point of view.' “Let it be
your wisest and not just your nearest friend…If you have no
such friend, find a suitable minister, priest or doctor.” p68.
A Christian professional therapist/health care worker is of
course another possibility. The lady who counselled me had
experienced and overcome depression, and understood what
I was going through.
To help me with this process of learning to see and
embrace new perspectives, I wrote each new perspective on
the back of a business card or scrap of paper, which I kept
in my pocket or wallet. And when that fear reared its ugly
head again, I pulled out the card and read it.
As I continued to recover from depression, I was
able to work through such fears and find the new
perspective myself, with the assistance of prayer and God's
Word. In many of these cases, I continued to write the new
perspectives on flashcards. This saved me a lot of mental
anguish of trying to work through things again that I had
already worked through in the past.
Here is an example of finding a new perspective
regarding a very powerful fear. I had the misfortune of
having a car crash while recovering from depression. My
exhausted mind, already struggling with anxiety, was
swamped by fears that assured me I was going to have
heaps of car crashes, starting with the loan car, and then in
every car I got in for the next two weeks, regardless of
whose car it was. These fears were so fresh and powerful
that they felt real.
Remembering what I had learned, I sought the
new, correct perspective to have towards this irrational fear,
and this was:
1. These thoughts that say I am going to have lots of car
crashes are not real.
2. These thoughts are not what is going to happen, they are
only what I am afraid is going to happen.
3. Jesus said to let not my heart be troubled, but trust in
God and in Him. John 14:1
4. Therefore I will get in these cars and trust Him to keep
me safe. Psalm 18:2
And regarding the fears that I was going to suffer many car
crashes over those two weeks, this is what I wrote in my
diary afterwards: "Nothing happened."