Here we're going to talk about stress management and anxiety reduction.
Most of us probably don't have to worry about this much, right? NOT!
We're all stressed to some degree; that has become part of our daily lives.
So everyone here can probably benefit from some of this material, whether
we have OCD or not. However, those of us with an anxiety disorder are more
likely to be bothered by acute or persistent anxiety than the rest of us,
and hopefully the material we present here will be especially helpful to
you.
Whole body health. First of all, we're going to address the concept of
something we call "whole body health." Stress is probably the worst thing
that can happen to your body, after disease. It wears down your
resistance, depletes your immune system, robs your body of energy, vitamins
and minerals, and tends to make everything that is functioning either
marginally or poorly function even worse. Managing anxiety means not only
learning how to reduce stress (and we'll get to this in a minute, so don't
get anxious), but also learning how to help the body operate at higher
efficiency all the time. That way, when the stress dragon rears it's ugly
head, your body will be in better shape to deal with it. You can think of
it as building up your body's savings account so that you'll be in a better
position to manage future bodily expenses. One of the very first things we
can do to start our body's savings plan is to learn good nutrition. An
article by Liana Beckett published in the OCF newsletter entitled "OCD and
Nutrition" is a brief introduction to this area, and it's something for you
to take home and read. Most of us don't even know what a healthy diet is
anymore. Isn't that something? When our ancestors were foraging for food,
eating nuts and berries and whatever they could kill, they probably ate
better than most of us do now. Some of you are very conscious of your
diet, and may even know how many grams of fat and protein you eat every
day. Great! The rest of us should do as well. Basically, the arithmetic
looks like this for fat: out of a 2500 calorie per day diet we should get
no more than 30% of those in fat, which means about 750 calories. But
every gram of fat has nine calories, so that means only about 83 grams of
fat. That really isn't very much when you consider all the places you get
fat (even bran muffins are about 60% fat by calories, mainly from the oil
or shortening used for baking).
Getting enough fruits and vegetables is probably equally hard for most of
us. How many of us really eat six servings of fruits and vegetables per
day? Most of us don't. All of these considerations make a difference when
it comes to managing anxiety. But one big factor that a lot of us overlook
is caffeine (see Figure 5). Does anyone notice that when they drink
caffeine the feel a little more nervous, jumpy or hyper? And if you're
already anxious, caffeine can make it much worse. Each cup of regular
coffee has about 100 mg of caffeine in it, while an equal volume of tea or
soda has about half that much. Decaf coffee has about 5 mg caffeine per
cup, depending on the brand. Chocolate is another source of a
caffeine-like drug called theobromine - fancy name, does the same. A
five-ounce piece of chocolate has the same caffeine-equivalent as a cup of
regular coffee. Drinking cocoa, however, has only about as much caffeine
as decaf. The bottom line is that caffeine makes anxiety worse; the more
caffeine you drink, the worse your anxiety will be. Sometimes people ask
what an optimal amount of caffeine is, and that is pretty hard to answer.
The real answer is somewhere between none and half a cup of decaf per day.
But don't go out and quit drinking caffeine cold-turkey, or you will be
setting yourself up for very bad withdrawal headaches. The best rule is
moderation: if you drink a lot of caffeine now, try to cut down, not cut
out.
Another item that's near and dear to many of us is sugar. What does sugar
have to do with anxiety? Well, as any of you that have ever seen kids eat
breakfast cereal know, sugar gives you a burst of energy. If you eat a
cookie or candy bar in the late afternoon, you get a lift. How come?
Sugar is immediately used by the body as energy; it doesn't even have to be
converted into anything else the way complex carbohydrates or proteins do.
That lift can be just enough to get you through the day; however, one
problem with eating lots of sugar (which is also a problem with caffeine,
by the way) is that when the lift is over, we crash. The crash from sugar
is similar to what we feel when we're hungry, commonly called "low blood
sugar." This is one of the feelings that is frequently mistaken for
anxiety. So it's best if you can moderate your sugar consumption if you're
eating lots of it now.
One other area that we need to discuss is the relationship between OCD and
alcohol (or many other drugs, for that matter). It's not uncommon for
people who are stressed or who suffer from anxiety to drink when they're
feeling anxious. We often rationalize that "it calms my nerves" or "it
helps me unwind." This may be true, but there are two problems with this
approach. First, alcohol "disinhibits" us, which means that is reduces the
effectiveness of the parts of the brain that put the brakes on our thoughts
and emotions. So the parts of your brain that are already poorly
controlled due to your OCD will be under that much less control - some
people experience a worsening of their obsessions when they drink. Second,
if alcohol reduces your anxiety, you may have a rebound of anxiety when it
starts to wear off. That means that either your anxiety could be worse
than before, or you will have to continue drinking to keep the anxiety at
bay. Here again, the best approach is moderation. We would never tell you
that you can't have beer with your pizza again - you all would probably
leave now! But if you can cut down, it will help.
Any questions about OCD and nutrition? Let's talk about anxiety itself
for a few minutes. First of all, what is anxiety? Well, besides being
uncomfortable and a pain in the, well, it's also a signal that your body
needs to react to something, usually a danger. It's really a good thing
that we have some anxiety, because some dangers need responding to. But
sometimes we get false alarms, feelings of anxiety when there is no real
danger. How do you know when you feel anxious? It can be a mixture of
dread, nervousness, impatience, irritability and a bunch of other feelings
that many of us are aware of. We may feel that we're breathing a little
fast, that we perspire more than normal or that our stomach feels odd. But
sometimes those feelings can result from other things as well. There is a
quick mnemonic to help find out if you might be mistaking something else
for true anxiety. The key word is HALTE, and the letters stand for the
first letters of the words Hungry, Angry, Lonely, Tired and Exercise (see
Figure 6). If you think you may be feeling anxious, do a quick check: is
it possible that I'm just hungry? When was the last time I ate anything
substantial? This is a big one for me - if it's around 4:00pm and I'm
getting grouchy, I can be pretty sure that it's because it's feeding time,
not because I'm anxious. Once I eat, I feel much better, much calmer and
less annoyed. You can also ask yourself other key questions using this
approach. Am I really angry? Am I really lonely? Do I need to rest? Or
do I need to burn off some extra energy, to exercise? You may be surprised
at how often one of these other feelings gets mistaken for anxiety.
OK, let's suppose you've done your HALTE check and none of that applies.
There's a good chance that you're experiencing real anxiety. Some anxiety
is real and for good reason; for instance, if you were in danger you would
want you body alarms to be activated. Sometimes anxiety is real but only
based on the perception of danger. For instance, public speaking is the
number one most feared activity in this country. As Jerry Seinfeld said,
"When going to a funeral, most people would rather be the guy in the box
than the one delivering the eulogy." For now, let's assume that there is
no real danger nor any perception of danger. You're dealing with an awful
feeling that may be acute or chronic. And very few things can stimulate
that anxiety more than stress. The more stress, the more anxiety. So one
thing we can do to alleviate anxiety is to manage stress. Stress can be
either internal or external. External stress is often defined by demands,
deadlines, requests and desires of your environment, your job, school,
families, mates and other people. It can leave us feeling tired or
overwhelmed. Managing external stress may include things like taking fewer
classes, asking for help with the kids, educating your family to be more
supportive and therefore less demanding. To some of us this may sound like
copping out, taking the easy way. And if our anxiety is mostly internal,
dealing with the causes of external stress will not reduce the internal
problems. But it may help us feel a little less tired, a little less
overwhelmed and a little more able to face the challenges of our internal
anxiety. Plus, this feeling of copping out reflects on the way we view
ourselves, and that is a big part of what internal stress is all about: we
are not often as disturbed by things as we are by the view we take of them.
This is what makes anxiety so subjective: you may think, "So I'll take
one less class this term, no big deal." On the other hand, I might think,
" Oh boy, that means I'm not competent, not successful and will probably
never succeed at anything." Of course this is an example of a distorted
form of thinking, and there are others listed in this handout called the
Ten Cognitive Distortions (see Figure 7). Managing internal stress is
partly learning non-distorted thinking, like not thinking that everything
is a catastrophe or that things are only black-and-white. Cognitive
distortions are involved in a lot of other problems, most notably
depression, and are part of the focus of Cognitive Therapy.
Another part of learning to manage internal stress is to lessen worry.
Worry is concern about things over which you have no control, interest paid
on a debt before it comes due. The difference between worry and obsession
is partly a matter of degree, but also that worry is more often a rational
concern, while an obsession is by definition irrational. Lessening worry
is not easy, but there are two simple rules (from a book title) to remember
about worry. Rule 1: Don't sweat the small stuff. Rule 2: It's all
small stuff. Actually this is pretty true: usually the "worst that can
happen" is not only not very bad, but also pretty unlikely. It often helps
to lessen worry if you share your worries with someone you trust.
Sometimes just listening as they come out of your mouth can make them seem
not quite so overwhelming, and the brain actually processes information
that you hear or speak differently from information that stays in your head
or that you read. It seems that reaching out, or even speaking out, makes
the obsession more "out there someplace," and less part of us.
There are a couple of other things that fit into the "whole body
management" concept of anxiety. One is exercise. How many people exercise
regularly, meaning at least 20 minutes a day three times a week? Not many
of us. There's nothing like exercising to get the blood flowing, to get
your lungs working and increase the exchange rate of carbon dioxide for
oxygen in your bloodstream. Even walking up the stairs instead of taking
the elevator, going for a 15-20 minute walk at lunchtime or running in
place at home for just a few minutes is helpful. After exercise it's usual
to feel tired, but it's not that exhaustion you feel after being anxious
all day. It's the kind of feeling that says "I'm ready to rest now."
Great - that feeling means that you are relaxed enough to rest. There are
a couple of other activities that can make you feel this way as well, and
they include anything that sends the brain primarily into alpha rhythms.
These include daydreaming, watching TV, yoga and meditation. There are
nearly an infinite number of ways to do meditation, which is simply
learning to focus your mental energies on one thing, like a chant or on
your breathing. All of these things send the message to your brain: "I'm
relaxed enough to rest."
We'll some simple techniques for getting to this feeling, but first I want
to mention one more thing about anxiety. I mentioned that anxiety is
subjective, and your attitude about things really determines your reactions
to them. We can demonstrate this by using what we call a "stress-gauge
diagram" (see Figure 8). This triangle is our stress gauge, and this wavy
line near the bottom is our baseline level of stress. We all have some
stress in our daily life, and it can be so constant that we don't even
recognize it until it moves up from the baseline. The rest of the triangle
above the baseline represents our reserve, our capacity to deal with
stress. You can see that under "normal conditions," we have a large
reserve. Now let's assume that some stressful event happens, like it's
your turn to teach the OCD group here. Now the wavy line representing our
stress goes up. What does that do to our reserve? It gets smaller, so
that we will have less reserve to deal with any other stress going on in
our lives. Now let's look at someone who is suffering from an anxiety
disorder, say OCD for example. We have the same triangle, but the wavy
line that represents the background stress level is already way up. They
don't have much reserve, even under "normal conditions." And if a similar
stressful event occurs and their stress level goes way up here, well, you
can see that this person may be feeling that they just can't take much
more. In fact, this is a pretty common feeling for OCD sufferers. "I just
don't know how I can handle any more." "I'm at the end of my rope." For
those of us who have never had an anxiety problem to call our own, this may
be a little difficult to comprehend. But let me give you an example of the
kind of feeling that OCD sufferers may have when they're having a
particularly bad day. Close your eyes, and imagine that you're in a sky
diving plane, the kind with a big open cargo bay and one big square door in
the side. Now you're 5000 feet above the ground, and the houses look like
dots and the highways look like string. Now imagine that you're at the
mouth of the door with both hands holding on very tightly to the edges of
the door. The instructor is trying to push you out the door, into ...
empty space. But there's one problem - you have a parachute that can't be
guaranteed to open. And the instructor is saying, "Just let go!" Even
though you have never actually fallen from this height without a parachute,
you probably feel that you know this: if you don't hold on, you might die.
Now open your eyes. That is often what people with OCD say about their
rituals or their obsessions: "if I don't do it (think it), I might die."
Or sometimes, "someone else might die." This is the level of anxiety that
we are talking about here, a level at which it may really be impossible to
"just" do something.
Anxiety management. Now that we know what we've got, what can we do about
it? Not to worry, we won't leave you hanging. The first and easiest thing
to do about anxiety is to change the way you breathe. Yes, change the way
you breathe. I bet you didn't know that all of us learned the wrong way to
breathe. We breathe like this, with our chests expanded. You know,
"breathe like a man," "suck in that gut," "you won't look good in a bikini
with your tummy sticking out." What happens when we breathe this way?
Well, we have to expand a lot of chest muscles and rib bones, and in
reality they don't move very far. There is an easier way, and we call this
diaphragmatic breathing. Try this: put one hand on your chest, and the
other on your tummy. Now when you breathe the usual way, your chest hand
moves and your tummy hand doesn't. Try to reverse that, so your tummy hand
moves and your chest hand doesn't. First, stick your tummy out all the way
without breathing. Now take a breath. Do you notice how all of the air
automatically goes into your stomach? The thin muscle called the diaphragm
just below the bottom of your ribs offers almost no resistance to
breathing, so breathing in and out through your tummy takes much less
energy. Also there's more room to expand your lungs this way, so you get
more air with each breath. And you can't do this kind of breathing very
fast, so you naturally slow down your inhalation. This limits the tendency
to hyperventilate, and actually makes the exchange of oxygen in your lungs
more efficient. Try this five or six times. This is the type of breathing
that your body automatically does when you are about to fall asleep. So
what you are doing is fooling your body into thinking that you are relaxed
enough to go to sleep. Try doing this just before dealing with a stressful
situation. Better still, try doing this several times during the day when
you're not particularly stressed, with the idea that eventually you will
change over to breathing this way as a matter of habit. But at the very
least, take 5-6 breaths like this when you're feeling stressed - you'll
feel better fast. By the way, after you get this down, you don't need to
use your hands anymore. We'd look pretty funny up here in front of you
with our hands on our tummies for 90 minutes.
Now stand up. If you're holding anything, please put it on the floor.
Reach up toward the ceiling, standing on your toes, stretching your back
muscles back and forth, wiggling your fingers as you really try to touch
the ceiling. Now in one smooth slow movement, bend back down and point
toward the floor. If you can touch the floor fine, but you don't have to
get all the way there to get the benefit of this stretch. As you're down
here, rock slowly at your hips, and remember not to lock your knees. One
more time, reach up toward the ceiling, on your toes and wiggling your back
muscles. Now, slowly back down toward the floor, keeping your knees
slightly bent and all your other joints as loose as possible. OK, let's
stand up straight again just for a minute to check that no one feels dizzy
from this exercise, and then let's sit down.
What you did just now was exercise. How about that! It wasn't so painful
after all, huh? Stretching is a great way to loosen up those stiff muscles
and joints where most of us keep our stress locked up. It's much harder to
feel stressed when you're limber and loose. Think for a minute: where do
you hold your stress? In your neck, or maybe your lower back? Some of us
may hold it in our stomach muscles, or in our facial muscles. We'll
discuss an exercise in a minute that will get at all your muscular-stress
hiding places. But if you know where you keep your stress and can develop
a stretching exercise to loosen those muscles, that might be enough. Many
of us don't know right away where our stress is, so this kind of overall
stretching is better to start out with. You can develop other overall
stretches, some standing up, some sitting, and some lying down, depending
on your specific needs. Try this a couple of times a day; you may even be
able to develop stretches that no one else can see (if you started doing
our toes-to-ceiling stretch in the supermarket, you run the risk of having
the stock person asking you "do you need some help reaching something?").
But especially, if you are planning to do some exercise like running,
walking or something else, always include at least 5 minutes of stretching
both before and after your exercise. You don't want to start out working
cold muscles too hard, and stretching afterward is a good way to "cool
down;" both things help prevent injury to muscles. Remember: stretching
is to muscles as Slick 50 is to your car's engine.
Progressive muscle relaxation. We want to demonstrate one more
stress/anxiety reduction technique for you; this one is called progressive
muscle relaxation. We'll show you how to concentrate on one muscle group
after another, first tightening and then relaxing them, until you've done
this with all your major muscle groups. When we do this here, we will
actually combine the muscle relaxation with two other things: the first is
the diaphragmatic breathing that we talked about already, and the second is
mental imagery. As we do this exercise, I'll describe a scene for you, and
I'd like you to try to imagine the scene as you see it, not necessarily as
I describe it. This should take us about 20 minutes; you can turn out some
of the lights for this if you wish.
[Speaking gently, but not in a monotone] First, close your eyes, put your
feet on the floor and your hands either in your lap or on the armrests of
the chair. Imagine that you're at the beach, sitting in an empty hot tub,
looking out at the ocean. You feel both the sun and the breeze on your
skin, and you can see the sky above the ocean. You can hear my voice and
the ocean. As you follow my voice, imagine that the hot tub starts to fill
with swirling water, just slightly warmer than you are and pleasantly
scented. Now take your right foot and press down on the floor with your
toes. You should feel tension in your right calf. As you hold this
tension, breathe in and out through your stomach. As you relax your foot,
breathe again. Now repeat that: press down with your right foot, and
breathe in and out. Hold the tension for just a moment. Now relax. Now
do the same thing with the left foot: press down with your toes, and hold
the tension. While you're holding it, you may be able to look out over the
ocean, at the line that separates the sea from the sky, and breathe. Now
relax your foot as you notice that the water is beginning to cover your
feet and legs, swirling around your skin. Now press down a second time
with your left foot, and breathe. Relax your foot. You might notice some
warmth coming into your leg muscles. This could be blood flowing into
those muscles, or it could be the warm water surrounding them. Now press
down with your right heel, and feel the tension in your right thigh. Hold
this for a minute, and breathe in and out. The breeze may feel quite
pleasant as you now relax your heel. Now press again with the same heel,
feeling tension in your right thigh. And breathe. Relax your heel, and
notice the warmth in that leg as the water is now rising to the level of
your knees. Now press down with your left heel, and breathe. Hold that
for a moment, and then relax your heel. The water is still swirling up,
over your thighs. Now press down with your left heel again, and hold the
tension there. And breathe, in and out. Now relax your heel, and notice
that the water has covered your thighs and you may feel very heavy from
there down.
Now tighten your buttocks, holding the tension and breathing, in and out
through your stomach. You may feel yourself rising up out of your chair a
bit; just hold that for a moment. Now relax, as the water continues to
swirl around you with it's warmth and sweetness. Now tighten again, and
breathe in and out. The ocean sounds are gentle at the shore, and you can
hear them as the waves wash the sand. Now relax. The water is rising up
around your waist now, as you breathe, in and out. Now tighten your
stomach muscles, and hold this for a moment. Now relax them, and breathe
again. The water in the hot tub is warm, just the right temperature.
Tighten your stomach again, and hold it. Now relax, and breathe. The water
is up around your tummy now, and from your waist down your body feels very
heavy. As you arch your back slightly, until you can feel tension in your
lower back. The warmth of the water or the sun or the air on your back may
help to warm and relax those muscles. Breathe through your stomach, and
then relax. Now arch your back again, and hold it for a moment. You may
feel yourself sitting up a little taller again. Now relax, as you breathe,
in and out. The water in the hot tub is now up around your chest, and the
scent from the steaming surface pleasantly fills your nostrils.
Now make a fist with your right hand, and feel the tension in your hand,
lower arm and upper arm. You might feel your whole arm start to shake a
bit; remember to breathe through your stomach. Now relax your hand and
arm, as you drop them back down to where they were before. You might need
to stretch your fingers a little. Now make a fist again, feeling the
tension in your hand, lower arm and upper arm. Hold it just for a moment,
and breathe. Now relax, drop your arm again, flexing your fingers if you
need to. Now do the same with your left hand, making a fist and feeling
the tension in your lower and upper arms. Let them shake a bit from the
tension, as you breathe, in and out. Now relax, and drop your left hand.
Stretch your left fingers a bit. You might feel warmth in these muscles as
the blood flows into them, and as the water swirls around them. Now one
more time, tighten your left fist, lower arm and upper arm. Breathe, in
and out. As you watch sky drifting slowly and lazily by, relax that hand
and arm, stretching your fingers. The water is near the top of your arms
now, and has just a few more inches to rise. Now rotate your shoulders in
a circle, ending up with them up as close to your ears as possible. Hold
them up there as you breathe, in and out. Now relax your shoulders,
pushing your arms down as low as they will go, dropping them lower than
normal. As the water comes up, the vapor from the surface may create a
little steam that makes the whole world look a little softer than usual.
Now rotate your shoulders again, and hold them up around your ears for just
a moment, as you breathe, in and out. Now relax, pushing both arms down as
far as they will go. The water is up at the top of the hot tub now, and
you are covered up to your neck in warm, sweet, bubbling water. From your
neck down, you may be aware that you hardly feel your body because it is so
heavy, as you breathe, in and out.