1. Coping Strategies for Anxiety
Craig Page RGN. OHND.

2. Anxiety management
•This Presentation should help you to achieve this by covering the following topics:
•Physical and psychological response of anxiety
• Basic Techniques to cope with anxiety
• Anxiety and Avoidance
• More techniques to cope with anxiety
• Improving Sleep Patterns
• Caffeine, Exercise and Diet
• How to say “No!”
• Relapse prevention
• Maintaining Progress
• Act with Norman

3. Physical and psychological response of anxiety
THE FIGHT/FLIGHT RESPONSE: Useful in an acute situation but a disadvantage if chronic
Explanation of physical symptoms:
•HEART POUNDING:This happens because the heart is beating faster and stronger to pump more blood to and from the
muscles. This extra blood increases the efficiency of muscles should there be a need to run away or fight the danger.
• BREATHLESSNESS:This happens because the lungs are working harder to increase the level of oxygen in the blood. This can
help the person think more clearly and increase the efficiency of the muscles. However, if the muscles are not using this extra oxygen, physical
discomfort may result because the gases in the blood become unbalanced. Consequently, feelings of dizziness or light headedness or even
numbness may occur.
• TENSE MUSCLES:This happens because the hormone adrenaline is released into the blood. Adrenaline helps the body to
respond more effectively to a threat. If, however, the body remains sedentary, then the person may experience pain such as headache or
backache, it can also have the opposite effect and make him/her feel dizzy and weak.
•NAUSEA/BUTTERFLIES:The body is very clever ! When faced with a threat all the body’s energy is diverted to the
“fighting” muscles and the digestive system is shut down. Vomiting may also occur to clear the stomach of undigested food.
•URGE TO ELIMINATE: This happens because the body is attempting to “lighten itself”, once again to increase the
chances of “getting away” or “fighting” the danger.
•SWEATING/FLUSHING; As the blood flow to the muscles on the body surface increases, the feeling of being hot and
sweaty results.
•TURNING COLD AND PALE:Some people experience this faint/freeze reaction rather than the fight/flight reaction.
This also stems from our evolutionary history in terms of “feigning death”. It is another mechanism the body has to increase chances of survival.
•VISUAL DISTURBANCES;This can happen when the eyesight becomes more acute in order to increase the ability to spot
signs of danger. When this starts to wear off vision may seem blurred until the eyes readjust.

4. How you might feel when you are anxious
Everybody is Looking at
me
There’s Something
Wrong With Me
I’m Having a
Heart Attack
During anxiety, a person is experiencing a heightened level of arousal. That is to say, a different
part of the brain is being activated. The same part of the brain is activated in any form of high
arousal state. For example, you always say what you mean in an argument ? Just like this
example of anger, during an anxiety attack we may not think very clearly

5. Hyperventilation
•Sometimes people develop a habit of over-breathing especially when
they are anxious. Over-breathing can trigger an anxiety attack.
•Once the anxiety attack begins, breathing can become difficult or
irregular and the hyperventilation cycle can start

6. Techniques to manage anxiety effectively - AWARE
•A
Accept the anxiety. If you try to fight it you will further stimulate the nervous system and exacerbate the symptoms.
“It’s OK for the anxiety to be there”.
•W
Watch it and measure it. Look at the anxiety and observe it within yourself. On a
scale of 1 - 8 (8=most anxiety ever felt) How anxious are you now ?
•A
Act normal ! Rather than running away/doing anything bizarre continue with what you were doing prior to the onset of
the panic attack. If you are at a football match, stay there. You may have to slow down the activities but try and keep
your activities as normal as possible.
•R
Repeat: Back over the past three steps, remind yourself not to fight the anxiety just allow it to be there. What is it at
now ? It may have gone down. When you find that happening, you know it’s on its way out.
•E
Expect the best ! Start expecting positive to happen. People who get anxious continually jump to negative predictions
regarding what is going to happen to them. This anxiety attack is going to pass and you are going to become more
effective at managing your anxiety.

7. Techniques to manage anxiety effectively – Breathing
Techniques
It has often been said that the breath is the bridge between the body and the
mind. Therefore, if you can start to relax your breathing both your mind and
body may relax.
There are a number of other benefits of relaxed breathing:
•It can induce and deepen relaxation
•It can help still the mind
•It can help manage anxiety attacks and hyperventilation
•It decreases the body’s arousal level

8. Techniques to manage anxiety effectively –The Counting
Breathing
•Breathe in and our through your nose.
•As you breathe in try in your own mind to count up to three.
•Do not hold your breath.
•Then, as you breathe out try and count up to four or five.
•It is important that the pace of counting remains the same for both breathing in and breathing out.
IN - up to three OUT - up to five
•Do not try to force your breathing - it will develop naturally.
•Spend five to ten minutes breathing in this way.
•If your concentration wanders, do not worry - bring it back to the numbers.
* The numbers that you use here are somewhat arbitrary, as long as the ‘out
Breath’ is longer than the ‘in breath’. It is the out breath that induces our relaxation response.

9. Techniques to manage anxiety effectively – Diaphragmatic
Breathing
•Find a quiet room where you will be undisturbed for about ten to fifteen minutes. Lie down on the
bed or floor. Undo tight clothing and remove your shoes. Spend a few moments settling yourself
down.
•Close your eyes and focus your attention on your breathing. Do not try and change your breathing
for the moment.
•Now put one hand on your upper chest and one hand on your abdomen just below your rib cage.
Relax the shoulders and hands. As you exhale gently press the lower hand to flatten your
abdomen. As you inhale, allow the abdomen to rise and as your exhale, allow the abdomen to
flatten. There should be little or no movement in the chest.
•Allow yourself a little time to get into a regular rhythm. It may help to imagine that as you are
breathing in, your draw half a circle with your breath around your body and as you breathe out you
complete the other half of the circle. Allow your breath to become smooth, easy and regular.
•Now, slow down your exhalation, then be conscious of a comfortable pause before allowing your
inhalation to follow smoothly and easily. If any distractions, thoughts or worries come into your
mind, allow them to come then allow them to go and bring your attention back to your breathing.
•When you are ready to end this exercise, take a few deeper breaths in. Bring some feeling back
into your fingers and toes. Open your eyes slowly and turn over onto one side before gently sitting
up.

10. Techniques to manage anxiety effectively – Warm Breathing
•Lie on your back, knees slightly touching and the soles of your feet flat on the
floor.
• Place your hands on either side of your ribcage.
• Concentrate on the area contained between your hands and your spine.
• As you inhale, imagine you are drawing air from the back of your spine up to
your hands.
• As you exhale, imagine that the air flows from your hands and back, through
your body to the floor.
• Within a few minutes you will begin to feel a warmth within your body.
• Continue breathing in this way for five minutes.

11. Anxiety and avoidance
•Avoidance is natural when the anxiety is real. For example, if you are having a picnic in
a field and a raging bull comes towards you. However, difficulties emerge when we learn
to be anxious when there is no real threat to our being. This can be due to misinterpreting
events as stressful when they are not.
•When a person starts to get anxious negative thinking styles emerge and this negative
pattern creates the environment for frequent anxiety. Negative thought turns safe
situations into stressful situations and thus raises anxiety levels.
• Often a light change in life-style or a life event (e.g. marriage, promotion, death of a
loved one, illness etc.,) can cause a general rise in anxiety levels. The person will then be
feeling anxious in numerous situations.
• Sometimes associations will be made of the situation the person is in with the anxiety
and thus misinterpret that situation with anxiety (e.g. agoraphobia, fear of flying etc.,).
The person may have learned to feel anxious in that particular situation. To help describe
this concept let us look at the example of “Joe”.

12. Case study - Anxiety and avoidance
Joe is anxious. He has lost his job; he has money worries and has recently been in a car
accident. All this has increased his general anxiety. Joe goes to a football match to forget
his problems. Whilst there his anxiety about his problems increases. Joe feels his heart
thumping and legs feeling weak. Joe attributes this anxiety to the crowd he is in. He is
attributing his anxiety as being triggered by a crowd rather than by his problems.
Consequently Joe beings to associate the crowd with anxiety. Joe leaves the match early,
on leaving the ground his anxiety is reduced. In this way Joe begins to learn that crowds
make him anxious. He feels anxious in crowds; the anxiety is reduced when he leaves.
Next time there is a match on Joe feels anxious, as he is getting ready to go. He recalls
that he became anxious on his last visit to the ground. He decides not to go and the
anxiety is reduced. Now Joe has learned that all crowds make him anxious and avoiding
crowds reduces the anxiety. Joe therefore begins to avoid crowds. The learning has
generalised from football crowds, to any crowds.

13. Case Study continued
The anxiety system is following its normal course:
STRESS … ANXIETY … NEGATIVE THOUGHTS … AVOIDANCE …
REDUCED ANXIETY
If Joe was dealing with a wild tiger this could be appropriate but what is specifically
threatening or stressful about a crowd? Only what Joe perceives as threatening, nothing
that is really threatening.
Joe lives in a city, there are crowds everywhere. As Joe has learned to be anxious in
crowds, anxiety is often triggered. Joe therefore spends a lot of time suddenly getting
anxious then escaping or avoiding anxiety. In the short term this is the obvious thing to
do, in the long term it actually increases the number of intensity of anxiety attacks. The
only way that Joe will learn that crowds are not threatening is to stay in them long enough
to discover that his anxiety reduces with time.
Like Joe you may have begun avoiding situations, which you know may cause you
anxiety. The symptoms of anxiety can be uncomfortable and you may prefer not to face
up to them. However,
“each time we avoid the situation and our anxiety successfully we make it more likely that
the next time the feared situation crops up, we will avoid it again”
What would happen if you remained in the situation you fear?
-

14. Techniques to manage anxiety effectively - The Five Question
Approach
•Are there reasons for me having this worrying thought?
Firstly, consider the evidence to suggest why you may be having this thought. This may help you understand
why you have the worry and make you feel less embarrassed about it.
•Are there reasons against me holding this thought?
Now you are beginning to look for evidence against your worry. It might be helpful to ask a friend or partner to
help you find statements to challenge your worry.
•What is the worst thing that could happen?
Be brave and consider the worst outcome of the situation, which bothers you.
•How could I cope with this?
Try and work out a plan for coping in the worst situation. If you can cope with the worst thing that could happen,
then you can rest assured that anything else will be a lot easier. Look back at how you have coped in the past
when things have gone well.
•What is a more constructive way of viewing the situation?
Having looked at the above four questions and using the skills you have acquired over the last three weeks,
what is a more balanced and constructive way of viewing the situation? Spend the most time on this question!

15. Techniques to manage anxiety effectively – Anxiety and Sleep
•ALL PEOPLE SOMETIMES HAVE TROUBLE SLEEPING.
• Establish a bedtime routine - go to bed at a regular time and wind down slowly.
•Avoid catnapping during the day.
•Avoid stimulants such as coffee/tea from mid afternoon.
•Try to relax. Make time to relax an hour or two before you go to bed. For example, take a
gentle stroll, warm bath or listen to soothing music.
•Use breathing/relaxation exercises to keep your anxiety level at a minimum when you are in
bed.
•If you must remember something, which must be done, have a pen and pad/tape recorder by
the bed. Writing it down there and then will lift the burden of consciously needing to
remember.
•Take exercise each day - physical exertion is conducive to restful sleep - but avoid stressful
activity for at least one hour before bedtime.
•For some people, deprivation is a result of a hectic lifestyle. By not listening carefully to
our body’s needs, we ignore tiredness and stay up late even if we need to rise early the next
day. Some people work at night and do not allow themselves sufficient time to rest during
the day.

16. Techniques to manage anxiety effectively – Anxiety and
Exercise
“ If you’re not exercising regularly, you may be missing out on an easy, inexpensive way to
improve your overall mood as well as your ability to cope with stress and anxiety. While
exercise is not a cure for anxiety disorders, it can be an important tool in your recovery”.
Henning (2002
•Physical activity need not be strenuous to achieve health benefits
•There is research to suggest that participating in physical activities may help minimise anxiety related
symptoms by providing a “time out” period. That is to say, it can provide distraction.
•Exercise can be viewed as time for YOU, no ‘phones, no children, no bosses!!
•Theories may vary on why exercise improves mood. A number of factors appear to be at work e.g.
reduced muscle tension and increased endorphins.
•Endorphins are chemicals, which are found within the body and naturally relieve pain and induce
feelings of relaxation and well being
•It can be helpful to exercise with a friend or group. Knowing someone is waiting for you can make a
difference. Companionship can also add to the enjoyment.

17. Techniques to manage anxiety effectively – Anxiety and Diet
“A balanced diet can lift your mood, improve fitness, give you more energy, feed
muscles, improve circulation, prevent illness, strengthen your immune system and
make you feel better able to cope with life’s stresses”.
(Powell 2000)
•Reduce fats especially saturated fats such as butter and untrimmed red meat
•Reduce cholesterol consumption
•Increase consumption of fish, poultry, lean meats and low fat dairy products
•Reduce total calorie intake, balance caloric intake with energy expenditure
•Increase consumption of foods containing complex carbohydrates and fibre such as whole
grains, cereals, leafy vegetables, dried fruit and peas and fruit
•Choose foods low in sodium and minimise addition of table salt.
•Try to consume no more than two alcoholic drinks per day.

18. Techniques to manage anxiety effectively – Anxiety and
Caffeine
As well as trying to achieve a balanced diet, it is also important when learning to manage
your anxiety to be aware of your caffeine intake.
Coffee, tea, cola, cocoa and other foods all contain caffeine. Caffeine is a stimulant, which if
consumed in large amounts can mimic the anxiety response.
•Identify all current means of caffeine intake and patterns of use
•Ensure one form of caffeine intake is not swapped for another
•Do not stop caffeine abruptly
•Drink tea or coffee which is gradually weaker
•Substitute caffeinated drinks with decaffeinated varieties, again this should be done gradually
DRINK WATER
•Non-caffeine containing analgesics may be helpful to treat withdrawal headache
•Use herbal teas (check they do not contain caffeine) to keep social rituals alive
•You do not have to stop caffeine completely, you may find it helpful to limit consumption to certain
fixed times of the day, e.g. one coffee with breakfast and one after lunch

19. Techniques to manage anxiety effectively – Saying NO!
•Sometimes people can experience increased anxiety levels when they are faced
with situations in which they want to say “No”. As a consequence, the person
may agree to the request despite not necessarily having the resources
(time/effort/money) to carry it out.
•There are six techniques, which can be used to help with saying “No”. It may be
useful to practice these with a trusted friend/family member to get used to these
approaches:

20. Techniques to manage anxiety effectively – Saying NO!
•Simple, Direct “No”
The aim here is to say “No” without necessarily apologising. The other person may have a difficulty, but try not to allow
him/her to pass it on to you -
“No, no, I prefer not to”
A direct “No” is forceful and can be effective with aggressive sales people.
• Reflecting “No”
This technique involves reflecting back the content and feeling of the request and adding your assertive refusal at the end.
“I know the letters are urgent, but I can’t go to the Post Office tonight”
This is a firm and final way of saying “No” that allows any room for further negotiation.
• Reasoned No”
This method gives very briefly the genuine reason for the refusal.
“I can’t post the letters tonight because I’m meeting a friend”
You might use this method of refusal if you do not want to offend, but have a genuine reason for refusing. It does not open
up further negotiation.

21. Techniques to manage anxiety effectively – Saying NO!
Rain check “No”
This is the way to say “No” to the present request, without refusing it.
“I can’t post the letters tonight, but I can go in the morning”
This is not a definite “No” and could be a prelude for negotiation. Use this technique only if you can genuinely fulfil the
request later
Enquiring “No”
This is not a definite “No” and is a genuine invitation to open up negotiation.
“Is there any other time you would like me to go?”
You could use this technique if you want to do what is being asked of you, but the timing does not suit you.
Broken Record “No”
This method involves repeating a simple statement of refusal over and over again.
“No. I can’t go to the Post Office”
“Oh, please, the letters have to go this evening”
“No, I can’t go to the Post office”
This is a good method to use with someone who is persistent

22. Techniques to manage anxiety effectively – Relapse
Prevention
“At first I thought anxiety management was like taking antibiotics: take
the course and feel better. Well, I did feel better, but anxiety management
is a long-term commitment, rather like exercise: the more you practice, the
better you feel. I’ve learned how to make anxiety management part of my
life and how to predict and handle the occasional setback. This isn’t a
chore! It’s enjoyable and wise investment of my time and effort”.

23. Techniques to manage anxiety effectively – Maintaining
Progress
•Continue to practice your new skills regularly – Remember you are never too
busy to relax and relaxing will actually increase your efficiency.
•Try and use your skills as soon as possible!
•It is ok to feel anxious at times. Don’t get frightened or alarmed when you feel
anxious; just apply your coping skills and the sensations will soon pass.
Remember to reward yourself for handling the situation.
•Try not to put too much pressure on yourself. Any essential drains on your
energy must be worked through/deferred.
•Try to arrange things so that you don’t have more than one major life event
occurring at a time. We know this isn’t always easy or possible, but it will help in
keeping your baseline level of anxiety low.

24. Techniques to manage anxiety effectively – Maintaining
Progress
Remember to keep a check on your workload. Try and talk to your manager – have regular face-to-face
meetings. If needed, remember to be assertive – ask for help if you need it – say no when your workload
gets too heavy. If you are unsure, getting clear guidelines can help – ask your manager to define your job
responsibilities.
MANAGING
•Variety – plan each day/week to give you a variety of tasks you enjoy and tasks you find less rewarding.
•Satisfaction – make the best of your own and other peoples skills – check what work you could delegate.
•Skills – learn to use practical coping skills, like time management, setting priorities and being assertive.
TIME OUT
•Make full use of coffee and lunch breaks – away from your immediate workplace.
•Have a clear ‘Cut-off Point’ at the end of each working day to help you shake off your work role –
exercise class? long bath?
•Keep healthy – eat well, sleep well, enjoy yourself, get some exercise and get some fresh air!

25. Techniques to manage anxiety effectively – Maintaining
Progress
ORGANISE YOUR DAY
•Make sure you plan to eat properly and in a more leisurely way.
• Planning the day also allows you to face life more smoothly with less rush and uncertainty
- less anxiety.
•There is little worse than having nothing to think about other than work and worries. Your
mind needs a rest as much as your body.
• Why not join an evening class/health club. It could improve your social life too.
•A change can be as good as a rest and even small changes can keep your mind from
becoming stuck in one track. A different route to work, a different meal, a new hairstyle or
even a different television programme or type of book can all help.

26. Techniques to manage anxiety effectively – Act with
NORMAN
N =NOTICE yourself becoming uptight and
discomforted as early as possible
O =OPT out of the tension circle … make a
conscious decision to do something
positive about it
R =RELAX use your training to ease away
some of the body reaction
M =MENTALLY sum up the situation, is it
real or a paper tiger – are you frightening
yourself by thinking negatively? Change it.
A =ACT in a more positive manner, don’t
slide into escape or avoidance
N =NOTICE the difference and NOTICE your
gains

27. QUESTIONS?