Robert L Leahy American Institute for Cognitive Therapy

Robert L. Leahy American Institute for Cognitive Therapy New York City Email: Leahy@ Cognitive. Therapy. NYC. com

What do you worry about?

How big a problem is worry? n n n 38 % of people worry every day Some worriers “worry all their lives” Chronic worry leads to depression---that lasts for years for some people Worry is a core feature of all of the anxiety disorders Irritable bowel syndrome, fatigue, depression, digestive problems

Prevalence of anxiety n n n 19 million Americans have an anxiety disorder Women are twice as likely as men to have GAD Many anxiety disorders continue for decades if there is no treatment

Historical changes n n n Twenge’s meta-analysis: anxiety has been increasing since the 1950’s The average HS student today is as anxious as the average psychiatric patient in the 1950’s Increases in anxiety are associated with historical decreases in social connectedness

Treatment for anxiety n n n Most patients with anxiety are not accurately diagnosed (especially by primary care physicians) Pharmacotherapy is often not effectively administered (duration and dosage) Not enough well-trained cognitive therapists available

Worry Examples What You Avoid or Do Anxiety Disorder Being evaluated by others Humiliation Rejection They’ll see I’m nervous. My hands will tremble. My mind will go blank Speaking in public Meeting new people Social Anxiety Disorder Fear of a specific situation or thing I’ll fall over the edge I’ll drown I’ll get trapped The plane will crash It’s dangerous Heights Water Insects, snakes, rats Closed spaces Flying Specific Phobia Leaving something undone, of being contaminated, making mistakes, of having thoughts and feelings that you fear I didn’t lock the door I have germs on my hands If I have a violent thought, I might act on it What You Do: You repeat actions over and over You check You won’t touch certain things You avoid situations or people that trigger your unwanted thoughts and feelings Obsessive-Compulsive Disorder

Worry that your physical sensations will go out of control and cause you to go crazy or get sick My heart is beating rapidly—I will have a heart attack. I’m so dizzy I will fall. I’ll get so anxious I’ll start to scream Being in places— theatres, restaurants, airplanes—where your exit is blocked. Open spaces— streets, malls, fields. Panic Disorder Worry that intrusive images and thoughts mean that something terrible is going to happen to you. I had another image of a disaster—I have to get out of here. I had a nightmare—it’s dangerous. Situations associated with your initial trauma —people, places, movies, stories. Post-Traumatic Stress Disorder Nothing will work out. I’ll end up a failure. What’s wrong with me? Why do I have so many problems? Doing things to help yourself— meeting people, taking on new challenges, establishing goals and solving your problems Depression Worry that the future is hopeless and bleak. Repetitive thoughts and feelings about your own suffering

What is the nature of worry? n What if we thought of worry as a set of rules that are rigidly followed?

Seven Rules of Highly Worried People n If something bad could happen—if you can simply imagine it—then it’s your responsibility to worry about it n Don’t accept any uncertainty—you need to know for sure n Treat all of your negative thoughts as if they are really true n Anything bad that could happen is a reflection of who you are as a person n Failure is unacceptable n Get rid of any negative feelings immediately n Treat everything like an emergency

But, wait! n n Did you leave out something? Isn’t there something you overlooked? Can you really trust your memory? You forgot the most important thing. You forgot to worry about worrying.

n You forgot to say, “All of this worrying is going to drive you crazy, give you a heart attack, and ruin your life completely. ”

n How could you forget the eighth rule—the rule that says, “Now that you’re worried, you’ve got to stop worrying completely or you’ll go crazy and die? ”

Worry makes sense to you 1. 2. 3. 4. 5. You believe that worry helps you solve problems You believe the world is dangerous—and that you are unable to cope Worry helps you avoid thinking about the worst possible outcome Your worry is “abstract” thinking rather than powerful emotional images You are not anxious when you are worried

Worry makes “sense” to you 6. Worry gives you the illusion of control 7. You feel that worry means you are responsible 8. Worry is a way to reduce uncertainty 9. You worry to control your thoughts and feelings 10. Worry Motivates You 11. How your parents taught you to worry

1. If something bad could happen— if you can simply imagine it—then it’s your responsibility to worry about it n n Nature of intrusive thoughts worriers treat the “occurring thought” as something that must be attended to

Worry is a “strategy” n n I’ll be prepared I won’t be surprised I’ll solve the problem I will be motivated

Meta-cognitive model of worry (Wells, 1997) n n n Positive view of worry Uncontrollable and dangerous Cognitive incompetence Negative beliefs Cognitive self-consciousness How will my worry help me?

2. Don’t accept any uncertainty— you need to know for sure n n n Worry entails the intolerance of uncertainty Uncertainty is equated with negative/dangerous outcomes Sense of responsibility for eliminating uncertainty

Model of Worry

3. Treat all of your negative thoughts as if they are really true n n Thought-action fusion in OCD (Rachman) Thought-reality fusion in GAD/worry Also Thought-self fusion in worry (I am what I think vs. I am what I choose or what I do)

Common thinking distortions in worry n n n Jumping to conclusions Catastrophizing All-or-nothing thinking Personalizing Discounting the positive Double-standard

Biased information processing Focus on threat n Over-estimation of threat n Perception of chain-reactions (this will lead to x->y->z) n Slippery slope n Trap door n Perception of rapid change n

4. Anything bad that could happen is a reflection of who you are as a person n Intrusive thought--- “I could make a mistake” à“I have a responsibility to make sure it does not happen” n Worry is associated with fear of regret, blaming yourself for mistakes, overgeneralizing “failure”, risk-aversion

Exaggerated sense of self needing to control outcomes n n n It’s up to me to make sure it doesn’t happen Seeing the self as the center of things— “What will people think of me? ” “How can I make sure it doesn’t go wrong? ”

5. Failure is unacceptable n n n “Failure” is identified with “value of self” Failure is “who I am” Failure is catastrophized Worriers discount their positives Worriers see a small negative change as the start of things unraveling Worriers don’t take credit for positives

Perfectionism and worry n n n Worry is a strategy to avoid failure Worry must “assure” a perfect outcome Reject solutions that are less than perfect

How worry works

6. Get rid of any negative feelings immediately n n n Worriers are alexithymic Hard to identify their emotions Negative view of their emotions Worry is a form of emotional avoidance Worry suppresses arousal temporarily Arousal incubates and bounces back

Negative view of emotion n n Worriers think: My emotions don’t make sense, they will last indefinitely, overwhelm me, they feel ashamed, they can’t stand having “mixed feelings”, their emotions are “different” from others They think they cannot express emotion or get validation

7. Solve every problem immediately n n n Sense of urgency No time to get “out of the way” Inability to live in the moment

How can we change worry?

The Seven Steps to Stop Worry 1) 2) 3) 4) 5) 6) 7) Identify Productive and Unproductive Worry Accept Reality and Commit to Change Challenge Your Worried Thinking Focus On The Deeper Threat Turn “Failure” Into Opportunity Use Your Emotions Rather Than Worry About Them Take Control of Time

The Seven Steps to Stop Worry Step One n 1) Identify Productive and Unproductive Worry

What are the costs and benefits to worrying about this? Costs Benefits

The Signs of Productive Worry n n n There is a question that has an answer You are focused on a single event—not a chain reaction You are willing to accept imperfect solutions You do not use your anxiety as a guide You recognize what you can control and what you cannot control

The Signs of Unproductive Worry n n n You worry about unanswerable questions You worry about a chain reaction of events You reject a solution because it is not a perfect solution You think you should worry until you feel less anxious You think you should worry until you control everything

Once you categorize this as unproductive worry, then what?

Step Two Accept Reality and Commit to Change n n n n Mindfulness Become an observer Gain Distance Describe What is in Front of You Suspend Judgment Take Yourself Out of It Disappear to see reality

Step Two Why You Don’t Accept Reality n n You Don’t Like What You See You want THE ANSWER You Won’t Settle For Less You have to control everything

Step Two n Accept Limitation n Accept unsolvable problems n Know what you can never know

Step Two n Uncertainty training - tolerate uncertainty and experience emotion n Learn how to tolerate uncertainty 1. Examine the costs and benefits of accepting uncertainty 2. Practice the emotional image 3. Flood yourself with uncertainty

Step Two Committing to change The Power of Doing What You Don’t Want To Do 1. The power of choice 2. Successful Imperfectionism 3. Constructive Discomfort 4. Take Your Discomfort History 5. Discomfort Diary

Step Three 3. Challenge Your Worried Thinking Keep Track Of Your Worries Your Worry Record Set Aside “Worry-Time” Test Your Predictions

Step Three Ten Ways to Defeat Your Worries 1. What thinking distortion are you using? 2. How likely (0– 100%) is it that this will actually happen? 3. What is the worst outcome? The most likely outcome? The best outcome? 4. Tell yourself a story about better outcomes 5. What is the evidence that something really bad is going to happen?

Defeat your worries 6. How many times have you been wrong in the past about your worries? 7. Put predictions in perspective Turn catastrophes into detours Use realistic probabilities Get off the Slippery slope Don’t fall through your Trap Door 8. How could you cope if the bad outcome actually happens? 9. What advice would you give a friend who had your worries? 10. Show yourself why this is not really a problem

The Seven Steps to Stop Worry 7. Take Control of Time n n I need it right now What’s Your Sense of Time? Turn the urgency off Step away from time

Step Seven 1. Do you often feel pressured for time? 2. Are you often thinking about things that might happen in the future? 3. Do you have a hard time staying in the moment? 4. Do you find yourself frustrated with how slowly things are going? 5. Do you feel like rushing people through their conversation? 6. Are you often worried about deadlines?

Step Seven 7. Are you often over-scheduled? 8. Do you show up a lot earlier—or a lot later—than other people? 9. Do you keep checking your watch or the clock? 10. Do you get frustrated when you are “behind” someone in traffic or walking down the street? 11. Do you feel you just can’t stand waiting? 12. If you think that something bad could happen, do you feel you need the answer right now?

Step Seven n n Use Mindful Detachment Improve the moment Stretch time Plan time

Stretch Time n How will I feel about this in a month? n A year? Five years? n What will you do five hours from now? The next day? The day after? n What are all the positives that could happen between now and then? n What are all the positives that could happen this moment? In a month, a year, in ten years?

To take control of time Turn the urgency off Accept Impermanence Appreciate the moment Improve the moment Stretch time Plan time

Summary 1) Identify Productive and Unproductive Worry 2) Accept Reality and Commit to Change 3) Challenge Your Worried Thinking 4) Focus On The Deeper Threat 5) Turn “Failure” Into Opportunity 6) Use Your Emotions Rather Than Worry About Them 7) Take Control of Time

Thank you Robert L. Leahy American Institute for Cognitive Therapy New York City Email: Leahy@ Cognitive. Therapy. NYC. com