“The fear people are feeling about COVID can be paralyzing,” according to Craig Pressley, MSW, social worker at the BIDMC transplant section in Boston. “It’s ubiquitous,” he says.
While healthcare workers may be anxious about the risk of contagion at work, we all may share that anxiety when it comes to shopping at the grocery store, picking up prescriptions, or even leaving the house for a walk. In an environment so full of unknowns it is difficult not to feel anxious: are our kids safe? Do we have childcare? Are our parents and family OK? Can we pay the bills? Will we have a job when COVID ends?
It’s important to note that anxiety and fear are an important human adaptation to stress that is essential to our survival–when we are facing a tiger and need to run, for example. But, according to Pressley, “it’s a part of us that can get hijacked, especially in an environment so full of real threats.”
Many articles on decreasing anxiety center around listening to music and mindfulness, and certainly both can be helpful. But there are many other effective approaches available to patients that are worthy of mention.
The following strategies set forth by anxiety experts Dr. Lawrence Cohen and Dr. Claire Weeks offer steps that have helped patients I have advocated for decrease their stress levels in highly fraught situations–whether going through a transplant surgery or combating panic attacks.
Cohen says his chief goal for patients struggling with anxiety is to help them find the opposite of worry: connection, trust, playfulness, and joy. To this end, he recommends three important steps: “facing and feeling”; challenging the stressful thought; and finally, rehearsing success.
Facing and Feeling
The idea isn’t complicated: acknowledge your feelings and you will better be able to face your fears. An important part of the “facing and feeling” step is to talk about the stress you are feeling with someone else. Interestingly, both adults and kids with high anxiety levels often resist doing this and insist to others, “I don’t want to talk about it!” They feel that not giving voice to their worries is the only way for them to avoid being overwhelmed by their feelings of anxiety.
Why is it helpful to talk about the stress you are feeling?
Because researchers have found that “talking about it is one of the best ways to lower anxiety,” according to Cohen. He offers the example of a child who fell out of a tree and landed on his head. The boy was deeply traumatized by the experience and had constant nightmares about it, which interfered with his sleep–and yet, he refused to talk about it. But when the nightmares interfered with his life so much that his parents sought help for the boy and he finally did talk about the experience– the nightmares went away.
Cohen says it’s important to find the edge between avoidance (not talking at all) and being overwhelmed by the feelings (flooding).
According to Dr. Cohen, there are four possible responses that people characteristically show when confronted with anxiety.
He gives the example of a kid worried about jumping off a diving board at the pool. The child can do one of the following when he feels anxious at the prospect:
- Avoidance: the child leaves the pool and doesn’t jump off the board. Result: he misses out on that activity — and his anxiety gets worse;
- Flooding: the child is overwhelmed by his feelings; he doesn’t want to jump and may cry uncontrollably – leading to the same results as avoidance;
- “White knuckling”: the child forces himself to endure the situation but avoids the feelings; he “grits his teeth.” He gets through it–but then never learns that it was scary but safe. Fighting the feeling, according to Dr. Weekes, leaves people in these circumstances feeling exhausted; those who “white knuckle” will “agitatedly seek to occupy [their] time in order to avoid feeling and force forgetfulness.”
- “Facing and feeling”: the child acknowledges his feelings of fear and learns that it is scary but safe.
Obviously, the last strategy sounds like the best approach and it sounds easy–but how exactly do you do that?
The first step is to recognize when you are experiencing feelings of anxiety. According to Dr. Weekes, the signs and symptoms of stress may include:
- A hot–or cold– feeling in the hands and feet
- A churning in the stomach
- A weak feeling in the legs
- Yawning
- A feeling that the heart is racing; it might feel like it will burst
- A fear of being alone; or a fear of being with people / in public
- Worry about being sick in public
- A sensation of not being able to take a deep breath
- A sensation of not being able to swallow
- A feeling that one’s thinking is slowed
- A fear of dark places
- A fear of taking a shower or bathing
As these symptoms progress, they can lead to panic attacks or compulsive behaviors or even to depression. Overwhelming anxiety, Weekes says, can result in debilitating “indecision, suggestibility, loss of confidence, feelings of personality disintegration, feelings of unreality – and after a long time, sometimes depression or obsessions, which are unpleasant thoughts or behaviors that you can’t control and feel you must do.”
She writes that patients suffering from severe anxiety or panic “may think one way one minute, and another the next. Each point of view seems equally important, equally right, and yet, a moment later, equally wrong. Even a simple decision seems beyond you. Loss of confidence follows, then a feeling that one’s personality has disintegrated – the sufferer has no inner strength on which to depend, no inner self from which to seek direction.”
According to recent studies, there is a marked increase in anxiety worldwide in the wake of COVID-19. One of the symptoms of anxiety that people in this country are googling a lot is panic attacks.
So what are panic attacks–and how can you treat them?
Dr. Weekes explains panic attacks as the “first fear followed by second fear.”
The first fear is one you have no direct control over – it comes in response to some danger, either something that happened to you, or a thought, or a memory, or out of the blue; essentially, it sensitizes a person to feelings of fear.
The second fear is a fear of the first fear – “here it is again—I must avoid it!”
Dr. Cohen explains, it’s really due to a misfiring security system. Usually a security system works like this: “Alert/alarm/assessment/all-clear.” The person with anxiety may not get the “all clear” signal and sometimes can’t even manage the “assessment.” Their security system is “on” all the time, and they can’t seem to hit the “Reset” button.
Dr. Weeke’s strategy: Unmask the “second fear” by Challenging the Stressful Thought
Start this way, says Weekes: “Sit in your seat and relax your body – let it sag, flop, and let the panic flash, let it do its very worst, let it flash right through you without withdrawing tensely from it—then there would be no mounting tension, no mounting panic. Your body may continue to flash panic for a while, but the panic would not mount, and you would be able to sit there and see the feeling through.”
She continues, “By analyzing your fear and its symptoms and seeing that they conform to a set pattern and are of no great medical significance, you unmask the fear and with it your dilemma. Realize that you are being bluffed by a physical feeling, terrible indeed, but still a physical feeling.”
She continues: “If you pluck a guitar string, it responds by vibrating, whereas a slack string does not—so slacken those strings. Surrender, accept the feelings. Take a slow breath, let it out gently. You should discover something very important. Your stress was triggered by something real, but you can loosen the peg on the guitar strings.”
Dr. Cohen’s Strategy: Create a Scale for Your Anxiety
Dr. Cohen recommends making up something called a SUDS scale (SUDS = “subjective units of distress”), where, for example:
0 = piece of cake
8-10 = crisis, panic
10 = about to explode
Then, he says, you can practice lowering your stress level by testing out different ways to make the numbers on your scale go down. For example:
- If your number on the scale is 8-10, you can try the following:
- Shake on purpose
- Moan or groan
- Splash ice cold water on your face
- Make yourself a reminder message: write on a piece of paper, “I am having a panic attack. It’s not life threatening. It will pass.” Keep it in your pocket as a “panic attack counter-attack”
- If your number is 3-8: you can try relaxation techniques
- Counting down slowly from 100;
- Exercise
- Bounce on your feet, shake your hands
- Anything that uses a separate pathway from anxiety in the brain, so counting, math, anything sensory – massage your head/neck
- “Victory” stance or mountain pose
- You can practice trying to get to “3” on your scale. This is called deep relaxation. Cohen recommends a warm bath, music, massage, deep breathing or visualization to accomplish this. You can choose a calming image and focus on it (soaking in the sun, stretched out on a rock by the lake).
Rehearsing Success
Cohen says the most important thing is to practice. How do you do that? He suggests inducing anxiety (with mildly scary thoughts–you get to decide what those are, depending on your own scale of what seems scary); check your number; try to bring it down with the above strategies. See what works for you. For example, if you are afraid of mummies, trying to force yourself not to think of mummies won’t work very well, but try imagining the mummy with a tutu and a baseball cap. You still have the thought, but the thought is less scary. Then you can start to rehearse your strategies, and find out which ones work best for you to lower your level.
Relapse, or What to Do When Panic Returns: Coping with “The Old Forgotten Feelings”
Dr. Weekes writes: “When I review the difficulties of recovery, I would say that the most alarming of them all is the way panic can flash so intensely, so quickly and unexpectedly – weeks, months, even years – after a person thinks he has completely recovered. This unexpected return of panic causes more concern than any other aspect of this illness; it shocks, frightens, and it reminds—that is why it is so shocking. It reminds of so much one would rather forget forever, of so much one thought one had forgotten. And the fear that is immediately added, together with the physical disturbance caused by the flash of panic, re-sensitizes the person slightly and brings back some of the old, almost forgotten sensations of nervousness, so that the unwary sufferer is often bluffed into thinking “it” has returned or that “it will return if he doesn’t watch out.”
Almost invariably he makes the old mistake of capitulating before the feeling and trying to run away from it– “retreating from fear in fear.”
“Never do this. Never let the unexpected return of panic, whenever it may strike—even if it comes years after you think it has gone forever—never let it shock you into running away from it. Halt. Go slowly. See the panic through and then quietly go on with what you are doing. Let the panic come again and again if it should.”
A Circular Process
Cognitive behavioral therapists talk about the “CBT triangle” where an anxious thought can lead to an anxious action, and point out that another way of short-cutting anxiety is to intervene early — to recognize the anxious thought, and redirect it, or question the anxious action. According to Pressley, “The brain is a story telling machine. The trick is understanding that we can influence the story that is being told.” I think of this process as more circular than triangular. And like other medical conditions, from heart disease to cystic fibrosis--success breeds success: the earlier you treat signs and symptoms, the better you will feel. And so it goes for anxiety — notice the early symptoms and signs (cold or hot hands; pounding heart) and put into place whichever of these strategies you have learned works best for you — and likewise, the better you will feel.
In Sum
I hope these strategies may offer you somewhere to start. These ARE difficult times–but responding to them with anxiety and panic can make them even more challenging. To summarize the three strategies, recommended by Drs. Cohen and Weekes:
- Facing and Feeling: acknowledge your feelings and face your fear. Weekes says, “Let go of self pity and regretting and sighing “what ifs”; “let there be few regrets and fewer ‘if onlys.’ There are no ‘shoulds’ about feelings. Focus on what IS, not what IF.”
- Challenge the anxious thought: ask yourself, what is the worst thing that could happen? What’s the scariest thing about this? Acknowledge the problem and work toward a solution: “Yes, it is challenging; how will I handle it? What will happen?”
- Rehearse success: remember the past times when you coped well; imagine yourself coping well in the future; practice stress reduction strategies by activating more of the brain centers—”get physical, get mathematical, get sensory,” says Dr. Cohen. “You can change how you think about things, not necessarily what you think about,” he says.
Photo credit: photo by Umit Bulut from Unsplash.
Medical Disclaimer: The suggestions given here are not intended as a substitute for the medical advice of your physician. The reader should regularly consult a physician in matters relating to his/her health and particularly with respect to any symptoms that may require diagnosis or medical attention.
References:
Dr. Lawrence J. Cohen, The Opposite of Worry; Ballantine Books: 2013.
Dr. Claire Weekes, Hope and Help for Your Nerves; Signet; 1962. An Australian physician who pioneered the treatment of anxiety used by cognitive behavioral therapists today.
I highly recommend both of these books: Dr. Lawrence Cohen’s The Opposite of Worry was written in 2013 and is primarily written to address childhood anxiety, though many of the principles and strategies he suggests apply equally to adults; Dr. Claire Weekes, a physician who wrote Hope and Help for your Nerves in 1962, was one of the first to brilliantly describe anxiety and panic attacks and advocate for effective cognitive therapy for them
