Episode 77 -- January 7, 2021

New Year, Deep Breath: Challenge Your Anxiety-Fueled Thoughts

Like a motor on a boat, a little anxiety can propel us through a happy, successful life. But too much anxiety is a bad thing—even if it's just a little too much. Being "almost" anxious limits our ability to pursue interests and risk new experiences. This, in turn, drags down our quality of life and well-being. In her book, Almost Anxious: Is My (or My Loved One's) Worry or Distress a Problem?, Dr. Luana Marques offers practical steps to reduce anxiety. Learning to monitor and challenge our negative thoughts can help us find more enjoyment in our days, experience a better family and work environment, and eliminate the emotional, mental, and even physical problems that anxiety often causes.

It has been edited for brevity.

Challenge Your Anxiety-Fueled Way of Thinking
When we begin to establish patterns of anxiety avoidance, our thinking can become distorted and make changing these avoidance behaviors more difficult.

Eduardo's Story
Eduardo was having a good time at a work-related party when a panic attack struck. He was sixty years old when it happened, and only now at sixty-five did he come to discuss it with me.

Eduardo had always been gregarious, and he'd built a large network of friends, colleagues, and acquaintances. He was married with two adult children and worked as a manager at a local restaurant, where he had first started as a waiter twenty years ago. Eduardo thrived in the social scene of the restaurant, telling me, "Working at the restaurant is like being home in Puerto Rico. People are always socializing. We are all familia." He knew the restaurant's regulars by name, always going the extra mile to make them feel like they were part of his extended family.

Given how outgoing Eduardo had always been and how much he enjoyed his job, it was completely surreal to him that he had a panic attack in the very place where he'd always felt at home. He was talking to the restaurant owner when it started. The first thing Eduardo noticed was his heart beating faster. He immediately thought, "That's strange; am I having a heart attack?" As the conversation continued, Eduardo began feeling panic-like symptoms: dizziness, numbness and tingling in his hands and legs, and finally a sense that he was leaving his own body. "You okay, hermano? You look white as a ghost," the owner said. In response, Eduardo excused himself to go to the restroom.

"That is when things got even worse. As I went into the restroom, the room began to spin, and I felt really dizzy and nauseated. I called my wife, who is a psychiatric nurse, to see if I was having a heart attack," he explained. By listening carefully to his symptoms, his wife, Maria, realized that Eduardo was probably having a panic attack.

Instead of feeling relieved, Eduardo got mad at his wife, accusing her of dismissing his symptoms. As he put it, "I thought only crazy people had anxiety attacks." Eduardo eventually rejoined the party for a few moments before excusing himself and taking a cab home; he refused to drive in case he was indeed having a heart attack.

The first thing he did the next day was to schedule a check-up with his primary care doctor. Maria was frustrated, since she was almost positive that Eduardo had had a panic attack, but she went along with his plan. After a battery of tests and a consultation with a cardiologist, Eduardo's doctors assured him that he did not have a heart condition and that his wife was likely correct with her suspicion of a panic attack. Eduardo felt relief over the test results for a few weeks, but his heart-related fears kept plaguing him.

At my first meeting with Eduardo and Maria, he told me that his life had never been the same since the panic attack. Although Eduardo did not avoid the restaurant or stop working, he felt as if he was always worried about the possibility of having another panic attack or, even worse, an actual heart attack. At work, Eduardo would notice that he was often more distracted by thoughts like "What if I lose control?... What if I go crazy?... What if I get sick and cannot get help?" These "what if" thoughts plagued Eduardo and robbed him of the joy he used to experience at the restaurant. The thoughts also got him stuck on his own almost anxious hamster wheel.

Eduardo also avoided some situations in response to the panic attack. He noticed that he would remember the attack when he was at parties. At first, he was reluctant to go to gatherings at all, but Maria insisted they continue their social life.

It was at Maria's request that Eduardo ended up in my office. He'd regularly ask her to check his heart rate and to agree that he was "not crazy." Eduardo told me that in his mind only the "crazy people my wife works with" had anxiety attacks. He was ashamed and embarrassed by this thought. At first, Maria was happy to be supportive and reassure her husband that he was okay, but after a while, she grew frustrated. Five years later, she was fed up and told Eduardo to seek professional help, as her reassurance was not helping him.

The "what if" thoughts that Eduardo experienced are not limited to people with panic-like sensations. Most people, at some point in their lives, are bothered by catastrophic, distorted thoughts that cause them to momentarily lose focus on reality.

Errors in Thinking Can Fuel Anxiety
As you have learned, avoidance maintains your anxiety and makes it more difficult to face anxiety-provoking situations.

By avoiding, you start to see danger in situations that shouldn't be worrisome, such as a trip to the grocery store, simply because the last time you went to the store, you felt anxiety. As such, you pair grocery shopping with anxious feelings, and as a result you stop going to the store. By avoiding the supermarket, you start to believe that the store is indeed dangerous, which then leads to more distorted thinking and more avoidance. Eventually, you stop challenging the anxious thought of "Grocery shopping causes me to feel anxious," and you start to believe this thought as reality. This is the point—when you accept that anxious thoughts are reality, you get stuck.

In many ways, almost anxiety is like wearing prescription glasses that are either too strong or too weak. Your thoughts are filtered through these lenses, making your surroundings seem distorted and blurry. I am not saying you need to replace anxious thoughts with happy thoughts, as though you were wearing rose-colored glasses. But it is crucial to examine your thoughts, with the ultimate goal of finding a more balanced way of thinking that is not guided primarily by your almost anxiety.

Identify and Challenge Your Distorted Thoughts
All of us are thinking all the time. In fact, a chain of thoughts is always going through the average human's mind, often in a nonlinear fashion: "What do I have to do next? What will I do this weekend? How will I finish my work-related tasks by the deadline? Will I have enough time to cook dinner tonight? How will I find my perfect mate? Will I ever have kids? Will I be able to pay my bills this month?"

Thoughts are so free-flowing and continuous that most people don't really pay close attention to them, except when the thoughts start to interfere with their lives, either by creating negative feelings (anxiety, sadness, and so on) or by distorting their reality. We all, at one time or another, assume that a thought is the same thing as a fact.

For example, many people may say something like, "I feel anxious because I am sure my boss is not satisfied with my work." This sentence has two parts: feelings (I'm anxious) and a thought (my boss is dissatisfied with my work). But is that thought irrational or unreasonable? Is it distorted? How do you identify whether your thoughts are actually the root cause for your almost anxiety?

First, you'll need to broaden your reality by challenging your specific patterns of thinking. Here are four steps to identifying distorted thinking.

Step 1: Notice Your Mood and Physical Sensations
The first step in identifying a distorted, unbalanced thought is to examine how you are feeling (including mood and physical sensations). Often, it is much easier to assess your mood than your exact thoughts. Individuals who are more panic-sensitive might first notice a sudden change in their bodily sensations before they recognize a change in their thoughts.

For example, Eduardo often noticed his heart pounding a little faster, which would immediately trigger a feeling of anxiety or danger. As soon as you notice a change in either your mood or your bodily sensations, move on to step 2.

Step 2: Write Down Your Thoughts Related to the Anxiety
Identifying your thoughts that are related to a mood change is a skill that takes practice to develop. As soon as Eduardo's heart skipped a beat, he would think, "What if I am having a heart attack?"

At this stage, I encourage you to write down the most simple, naked version of your thought. Often, when I ask patients what they were thinking, they tend to give me a paragraph full of thoughts and feelings, which is helpful but will not aid in challenging a specific thought. Identifying the basic thought is particularly tricky since we don't generally have one single thought that exists on its own.

So when you notice anxious feelings, you might have a sequence of many thoughts: "What if I have a heart attack? What is wrong with me? Why am I so anxious when my boss looks at me? If I die now, what would happen to my family?" Write all of these thoughts down, but as you move to step 3, be prepared to work with one thought at a time.

When most of my patients begin observing and writing down their thoughts, they notice that a handful of thoughts show up again and again. Much like Eduardo, many of my patients who are almost anxious have numerous "what if " thoughts.

Step 3: Label the Distortions in Your Thoughts
When you have identified a few distorted thoughts, label them by the specific way that they're distorted. Psychologists have created a list of "cognitive distortions" that apply to most unbalanced thoughts that someone with almost anxiety might experience. Labeling your thoughts as a distortion will help you challenge them. It also provides further evidence that these thoughts might be at the root of your almost anxiety.

Step 4: Take Your Thought to the Courtroom and Challenge It
Identifying and labeling your distorted, anxiety-driven thoughts are the first steps toward refocusing your anxiety lenses. However, those will not be enough. To be able to create alternative thoughts—thoughts based on reality and driven less by anxiety—you have to learn how to challenge your thinking.

Again, I am not suggesting that you replace an anxious thought with a happy thought, but rather that you collect evidence to help you discover which line of thinking is more accurate. By challenging your thoughts, your anxiety will eventually start to decrease, and you naturally will start to have more balanced thinking.

By evidence, I mean anything that could be used in a court of law (as opposed to what couldn't be considered evidence: anxiety). When in doubt, ask yourself how a judge would respond to this evidence. To learn more about how to inspect your thoughts for evidence, let's look to Eduardo's thought that he was having a heart attack. Anytime that Eduardo felt his pulse increase even slightly, he jumped to the conclusion that this time he was having a heart attack. Even though several doctors reassured Eduardo that nothing was wrong with his heart, he had trouble believing it. As such, I asked Eduardo to evaluate his thought by asking two basic questions:

1. Do I have any evidence for this thought?
2. If no evidence exists, is there an alternate way to consider this thought? Even if this thought is true, is it helpful right now?

Your goal is to broaden your thinking and arrive at more balanced, fact-based thinking with fewer anxiety-driven thoughts.

Eduardo's Outcome
Eduardo learned that most of his thoughts were driven by his almost anxiety rather than by facts. The responses that Eduardo came up with helped him to manage his almost anxiety and collect more balanced views of the world around him. In addition to working on changing his thoughts, Eduardo also agreed to stop seeking repeated reassurance from his wife and to start approaching social activities instead of avoiding them.

About the Author:
Luana Marques, PhD, is an assistant professor of psychology at Harvard Medical School, the director of psychotherapy research and training at Massachusetts General Hospital and Harvard Medical School, and the director of the Hispanic Clinical Research Program at Massachusetts General Hospital and Harvard Medical School. Her groundbreaking research focuses on the presentation and treatment of anxiety disorders, with a particular focus on cultural differences in the phenomenology of anxiety as well as the dissemination and implementation of empirically supported treatments for anxiety to minority populations. Her research has been funded by the National Institute of Mental Health and the Multicultural Affairs Office at the Massachusetts General Hospital. She has published more than thirty articles and chapters, has served as the program chair of the Anxiety and Depression Association of America (ADAA), and is a member of the American Psychological Association (APA) and the Association for Behavioral Cognitive Therapies (ABCT). She is also actively involved in training and supervising clinical psychology interns at Massachusetts General Hospital. Dr. Marques maintains a private psychotherapy practice in Boston, where she treats individuals with almost anxiety, clinical anxiety, and mood disorders. Connect with her online at www.luanamarquesphd.com or follow her on Twitter at @drluanamarques.

Eric Metcalf, MPH, is a writer and health communicator based in Indianapolis. He has coauthored or contributed to more than a dozen books on health and fitness and written widely for magazines and online publications. He's also a producer and contributor for the weekly Sound Medicine public radio program.

© 2013 by Harvard University
All rights reserved