Introduction

Anxiety Overview
Anxiety is one of the most distressing emotions that people feel. It is sometimes called fear or nervousness and is an
emotion that everyone experiences at some point in time. It can be difficult to overcome anxiety without learning what
exactly anxiety is and without learning helpful coping strategies. This course is designed to provide you with those
types of learning opportunities with the goal being to decrease your anxious feelings. There are 5 lessons within this
course that have been adapted from Greenberger and Padesky (1995) and Barlow (2008), which are both based on
Cognitive Behavioral Therapy (CBT) principles. CBT is popular for treating many psychological problems, including
anxiety.

When

to

Seek

Professional

Anxiety

Help

If your symptoms persist and significantly interfere with your day to day life, it is important to seek professional help.

Understanding & Overcoming Anxiety

Goal
To be able to understand anxiety, how it is impacting you, and how it can be overcome

What is Anxiety? (Greenberger & Padesky, pp. 174-175)

The word anxiety describes a number of problems including phobias (fear of specific
things or situations, such as heights, elevators, insects, flying in airplanes), panic attacks (intense feelings of anxiety in
which people often feel like they are about to die or go crazy), posttraumatic stress disorder (repeated memories of
terrible traumas with high levels of distress), obsessive-compulsive disorder (thinking about or doing things over and
over again), and generalized anxiety disorder (a mixture of worries and anxiety symptoms experienced most of the
time). Anxiety also describes brief periods of nervousness or fear experienced when faced with difficult life
experiences. Numerous cognitive, behavioral, physical, and emotional symptoms are associated with anxiety. This
course is designed for general anxiety problems.

Cognitive Symptoms
Overestimation of danger
Underestimation of your ability to cope
Underestimation of help available
Worries and catastrophic thoughts

Behavioral Changes
Avoiding situations where anxiety might occur
Leaving situations when anxiety begins to occur
Trying to do things perfectly or trying to control events to prevent danger

Emotional Symptoms
Nervous
Irritable
Anxious
Panicky

Physical Symptoms
Sweaty palms
Muscle tension
Flushed cheeks
Light-headedness
All of the physical, behavioral, and thinking changes we experience when we are anxious are part of the anxiety
responses called fight, flight, or freeze. These three responses can be adaptive when we face danger. Unfortunately,
we also experience these reactions when danger is not present, when danger is not as serious as you might think, or
when too much anxiety interferes with good coping.

Identifying & Assessing Symptoms Exercise

(Greenberger & Padesky, pp.

177-179)

Instructions: To help identify the symptoms of anxiety you are experiencing, rate the symptoms listed in the anxiety
inventory table below. Circle one number for each item that best describes how much you have experienced each
symptom over the last week.
Fill out this anxiety inventory once or twice per week as you complete this course to assess how your anxiety is
changing and which interventions are most worthwhile. Score the inventory by adding up the numbers you circled for
all the items. For example, if you circled 3 for each item, your score would be 72 (3 X 24 items). If you couldnt decide

between two numbers for an item and circled both, add only the higher number. To chart change, record your anxiety
inventory scores in the tracking table on page 3. Mark each column with the date you completed the anxiety inventory.
Then put an X in the column across from your score.
Anxiety Inventory

Symptom

Not at all

Sometimes

Frequently

Most of the time

1. Feeling nervous

2. Frequent worrying

3. Trembling, twitching, feeling shaky

4. Muscle tension, muscle aches, muscle soreness

5. Restlessness

6. Easily tired

7. Shortness of breath

Anxiety Inventory

Symptom

Not at all

Sometimes

Frequently

Most of the time

8. Rapid heartbeat

9. Sweating not due to the heat

10. Dry mouth

11. Dizziness or light-headedness

12. Nausea, diarrhea, or stomach problems

13. Frequent urination

14. Flushes (hot flashes) or chills

Anxiety Inventory

Symptom

Not at all

Sometimes

Frequently

Most of the time

15. Trouble swallowing or lump in throat

16. Feeling keyed up or on edge

17. Quick to startle

18. Difficulty concentrating

19. Trouble falling or staying asleep

20. Irritability

21. Avoiding places where I might be anxious

22. Frequent thoughts of danger

Anxiety Inventory

Symptom

Not at all

Sometimes

Frequently

Most of the time

23. Seeing myself as unable to cope

24. Frequent thoughts that something terrible will happen

Score (of total circled numbers) = _____

Anxiety Inventory Tracking

Score

72

69

Anxiety Inventory Tracking

Score

66

63

60

57

54

51

48

Anxiety Inventory Tracking

Score

45

42

39

36

33

30

27

24

Anxiety Inventory Tracking

Score

21

18

15

12

Anxiety Inventory Tracking

Score

Date:

Overcoming Anxiety

(Greenberger & Padesky, pp. 184-189)

Anxiety can almost always be helped. The treatment approaches that have been shown to be most effective in reducing
anxious feelings include cognitive restructuring, relaxation training, overcoming avoidance, and medication.

Cognitive Restructuring
Anxiety can be reduced by decreasing your perception of danger or by increasing your confidence in the ability to cope
with threat. Evaluating anxious thoughts is helpful in order to more quickly and accurately evaluate the danger and its
consequences. Anxiety may decrease if you examine the evidence and discover that the danger you face is not as bad as
you thought. When threats or dangers are present, it is helpful to figure out what strategies will best help cope with
them.

Relaxation Training

Relaxation can be accomplished through either physical relaxation or mental relaxation.

Both methods can be equally effective. When we are physically relaxed, mental relaxation follows and when we are
mentally relaxed, physical relaxation follows. Relaxation training can alleviate anxiety because it is difficult for the
body or mind to be simultaneously relaxed and anxious. If you develop the ability to relax before and during stressful
situations, then you can substantially reduce the frequency and severity of the anxiety you experience.

Overcoming Avoidance
Avoidance is a hallmark of anxiety. When we avoid a difficult situation, we initially experience a decrease in anxiety.
Ironically, the more we avoid a situation, the more anxious we become about facing it in the future. In this way,
avoidance in the long run actually feeds anxiety, even though it seems to help anxiety in the short run. To overcome
anxiety, we need to learn to approach the situations or people we avoid.

Medication
The use of medication to treat anxiety is controversial due to the addiction potential many anxiety medications possess.
They can also potentially interfere with developing coping skills to overcome avoidance and managing anxiety without

medication. Medication to treat anxiety is appealing, however, since it produces relaxed, calming sensations. Some
antidepressant medications are used to treat anxiety but they are not always effective.

Anxious Thinking
Goal
To be able to more readily identify anxious thoughts

Anxious Thinking (Greenberger & Padesky, p. 177, 180)

Anxiety is accompanied by the perception that we are in danger or that we are threatened or vulnerable in some way. A
threat or danger can be physical, mental, or social. A physical threat occurs when you believe you will be physically
hurt (e.g., a snake bite, a heart attack, being hit). A social threat occurs when you believe you will be rejected,
humiliated, embarrassed, or put down. A mental threat occurs when something makes you worry that you are going
crazy or losing your mind.
The perception of these threats varies from person to person. Some people, because of their life experiences, may feel
threatened very easily and will often feel anxious. Other people may feel a greater sense of safety and security.
Growing up in chaotic and volatile surroundings may lead a person to conclude that the world and other people are
continually and constantly dangerous.

Anxious thoughts are future oriented and often predict catastrophe. Anxious thoughts often begin with What if... and
end with a disastrous outcome. Anxious thoughts also frequently include images of danger. Here are some examples of
anxious thoughts:
What if I stumble over my words?
What if I have a traffic accident on the freeway?
What if I get hurt?
What if I am rejected?

Interpretation of Problems (Greenberger & Padesky, p. 4)

How we understand our problems has an effect on how we cope. Our

interpretation of the problems is influenced by thoughts (beliefs, images, memories), moods, behaviors, physical
reactions, and environment (past and present). Notice that the five areas are interconnected as shown in the image
below. The connecting lines convey that each different aspect of a persons life influences all the others. For example,

changes in our behavior influence how we think and also how we feel (both physically and emotionally). Behavior
changes can also change our environment. Likewise, changes in our thinking affect our behavior, mood, physical
reactions, and can lead to changes in our social environment. Some thoughts are automaticmaking it difficult to
understand the influence it is having on the other areas. With practice, however, even automatic thoughts can be
improved.

Understanding Automatic Thoughts

Watch this video to better understand automatic thoughts:
http://www.youtube.com/watch?v=m2zRA5zCA6M

Identifying Anxious Thoughts Exercise (Greenberger & Padesky, pp. 180-181)

Instructions: To identify the thoughts that are associated with anxiety or fear in your own life, complete the table
below. Think about a recent time when you were anxious, fearful, or nervous. Recall the thoughts you had (in words, in
images). If you had a visual image, describe it. If your thoughts were in words, notice if the thoughts began with What
if....
Situation
Who?
What?
When?
Where?

Moods

a. What did you feel?

b. Rate each mood (0-100%)

Automatic Thoughts/Images

a. What was going through your mind just before you started to
feel this way? Any other thoughts? Images?

Situation

Moods

Automatic Thoughts/Images

b. Circle thoughts implying danger, vulnerability, or a prediction

of catastrophe.

Cognitive Restructuring Part I

Goal
To be able to challenge faulty thinking

Faulty Thinking
Thoughts are not always accurate. What we tell ourselves may or may not be correct. Anxious thoughts create ruts in
our brains, which can automatically lead us down a path toward feelings of fear or nervousness. It is time to get out of

the rut and be on a new path with more realistic, accurate, and truthful thoughts and beliefs. One of the ways you can
do this is by challenging your existing thoughts.

Challenging Faulty Thinking Exercise (Barlow, p. 101)

Instructions: Identify a single faulty thought or belief and answer the following questions on a separate piece of paper:
1. What is the evidence for and against this idea?
2. Is your belief a habit or based on facts?
3. Are your interpretations of the situation too far removed from reality to be accurate?
4. Are you thinking in all-or-nothing terms?
5. Are you using words or phrases that are extreme or exaggerated? (i.e., always, forever, never, need, should,
must, cant, and every time)
6. Are you taking the situation out of context and only focusing on one aspect of the event?
7. Is the source of information reliable?
8. Are you confusing a low probability with a high probability?
9. Are your judgments based on feelings rather than facts?
10.Are you focused on irrelevant factors?

Example: You may believe that others will reject you. Consider the evidence for and against this belief. Yes, people
may have rejected you in the past, but that does not mean that everyone will reject you.

Thinking Mistakes Exercise

Instructions: Read through the table on the next page of 12 common thinking mistakes. Put a check mark next to the
mistakes that you frequently experience. For the checked items, write an example of when you have made the thinking
mistake.

Thinking Mistake

Description

Example

All-or-nothing thinking

You see things in only

two categories when it is
really on a continuum.

Either Im perfect or Ive

completely failed.

Jumping to conclusions

You take one observation

and are sure it has only
one implication.

Since I didnt meet the deadline,

trying to improve my performance
is impossible.

Negative fortune-telling

You make a negative

prediction without
recognizing it is not the
only possible outcome.

I wont go to the party since no

one will talk to me anyway.

Your Example

Thinking Mistake

Description

Example

Positive fortune-telling

You are overly optimistic

about the most likely
outcome.

I will be able to complete my 10

page paper in an hour.

Discounting the positive

You unreasonably
discount your positive
actions or qualities.

It doesnt matter if Ive lost a few

pounds. I deserve credit only after
Ive lost all of the weight I need to
lose.

Emotional reasoning

You think your thoughts

must be true because they
feel true, even if there is
conflicting evidence.

Since I feel so hopeless about my

marriage improving, it really must
be hopeless.

Labeling

You label yourself (or

someone else) in a
globally negative way
without really considering
the whole person.

Im bad for not taking my dog for

a walk today.

Mind reading

You are sure you know

what others are thinking,

Everyone will think I am stupid if I

ask a question.

Your Example

Thinking Mistake

Description

Example

even in the absence of

compelling data.
Self-deluding thinking

You tell yourself things

that you really do not
believe at other times.

I dont deserve a speeding ticket

for going 20 mph over the speed
limit since I was in a hurry.

Dysfunctional
(unhelpful) rules

You mandate what

you/others must/must not
do without considering
circumstances.

I can only express happy, positive

feelings.

Irrelevance

You link two unrelated

concepts.

Its okay to go shopping because

Im so stressed out.

Exaggeration

You make a sweeping

statement on the basis of
a small set of data.

My kids are totally out of control.

(Adapted from Beck, 2007, pp. 146-147)

Your Example

Next Step
Identify additional faulty thoughts or beliefs and evaluate them using the questions from the challenging faulty thinking
exercise.
Learn more about thinking mistakes by watching the following video:

Cognitive Restructuring Part II

Goal
To be able construct alternative thoughts and beliefs

Alternative Thoughts & Beliefs

Once the faulty thoughts or beliefs are challenged, new truths need to be identified. By practicing the new and more
realistic way of looking at life experiences, over time your feelings will positively respond to your new way of
thinking.

Thought Record Exercise (Barlow, p. 105)

Instructions: Use the table on the next page to construct alternative thoughts to various situations. Complete the
exercise once per day for the next 7 days. Identify and rate your thought(s)/belief(s) and emotion(s) about a situation
and challenge your thought(s) just like you did in prior lessons. Next, determine if you are making a thinking mistake.

Then, ask yourself what else you could say instead of your original thought(s). Lastly, rerate your original thought(s)
and reexamine your feeling(s) about the situation. Keep in mind that if you do not make a thinking mistake, you likely
will not experience a change in your feeling(s).

Thought Record

Situation

Thought(s) & Emotion(s)

Describe
what led to

List your primary thought(s)

about the situation and specify

Challenge

Thinking
Mistake

Alternative Thought(s)

Use the questions in

lesson 4 to examine

Use the thinking

mistakes table

What else can I say instead of my

initial thought(s)? How else can I

Thought Record

Situation

Thought(s) & Emotion(s)

the
unpleasant
emotion(s).

your emotion(s). Rate how

strongly you feel the emotion(s)
from 0-100%.

Challenge
your initial
thought(s).

Thinking
Mistake
in lesson 4 to
determine if this
is a particular
pattern of
thinking.

Alternative Thought(s)
interpret the event? Rate your
belief in the alternative thought(s)
from 0-100%.
Rerate how much you now
believe your initial thought(s)
from 0-100%.
List the emotion(s) you are
experiencing about the situation
now and specify how strong it is
from 0-100%.

Overcoming Avoidance (Greenberger & Padesky, p. 187)

Learning to approach and cope with situations in which we feel anxious is a lasting and powerful way of eliminating
anxiety. Use the various relaxation strategies that you will learn in lesson 5 to reduce your anxiety about situations you
tend to avoid. By gradually approaching what you fear, you can gather evidence about the accuracy of your catastrophic
expectations and replace avoidance with engagement.

Overcoming Avoidance Exercise (adapted from http://www.anxietybc.com/resources/anxiety.php)

Instructions: To help you identify situations that you avoid, try to come up with as many answers as possible to the
following questions:
If you woke up tomorrow morning and all your anxiety had magically disappeared, what would you do?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

How would you act?

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

How would someone close to you know you werent anxious?

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

 Finish this sentence: My anxiety stops me from

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Finish this sentence: When I am not anxious, I will be able to

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Next Step
It takes time for a new thought to replace the original, problematic thought. Once you have completed this exercise, you
may find it helpful to re-read what you wrote down to help solidify your shift in thinking.
Learn how to complete a thought record by watching the following video. We apologize for the visual quality of the
video:

Relaxation Training

Goal
To be able to feel relaxed after completing a relaxation exercise

Diaphragmatic Breathing
Diaphragmatic breathing can be a highly effective relaxation strategy. In order to do it properly, it is important to
breathe from your diaphragm (abdomen) rather than from your chest muscles. It takes practice to learn how to breathe
properly. The following video introduces diaphragmatic breathing and begins a three part training on how to do it
properly.
Video 1: http://www.youtube.com/watch?v=8-_NNCrrdus

Deep Muscle Relaxation (adapted from Martin & Pear, 2002, pp. 382-383)
Deep muscle relaxation is an additional form of relaxation and consists of relaxing all of your muscles completely and
to recognize when they are relaxed. This is done by alternately tensing and relaxing your muscles while attending
closely to the internal activities and sensations you are feeling at the time.
In order to learn how to do deep muscle relaxation effectively, it is helpful to have someone with a soothing voice read
a muscle relaxation script to you. Record them reading the script so you will always have it. Alternatively, use a prerecorded script that can be found online, such as http://www.youtube.com/watch?v=HFwCKKa--18.

Script: Listen closely to these instructions. They will help you to increase
your ability to relax. Each time I pause, continue doing what you were doing before the pause. Now, close your eyes
and take 3 deep breaths (pause for 10 seconds). Make a tight fist with your left hand. Squeeze it tightly. Note how it
feels (pause for 5 seconds). Now relax (pause for 5 seconds). Once again, squeeze your left hand tightly and study the
tension that you feel (pause for 5 seconds). And once again, just relax and think of the tension disappearing from our
fingers (pause for 10 seconds). Make a tight fist with your right hand. Squeeze it as tightly as you can and note the
tension in your fingers and your hand, and your forearm (pause for 5 seconds). Now relax (pause for 5 seconds). Once
again, squeeze your right fist tightly (pause for 5 seconds). And again, just relax (pause for 10 seconds).
Make a tight fist with your left hand and bend your arm to make your left biceps hard. Hold it tense (pause for 5
seconds). Now relax totally. Feel the warmth escape down your biceps through your forearm, and out of your fingers
(pause for 10 seconds). Now make a tight fist with the other hand and raise your hand to make your right biceps hard.
Hold it tightly, and feel 16 the tension (pause for 5 seconds). Now relax. Concentrate on the feelings flowing through
your arm (pause for 10 seconds). Now, squeeze both fists at once and bend both arms to make them totally tense
throughout. Hold it, and think about the tension you feel (pause for 5 seconds). Now relax, and feel the total warmth
and relaxation flowing through your muscles. All the tension is flowing out of your fingertips (pause for 10 seconds).
Now, wrinkle your forehead and squint your eyes very tight and hard. Squeeze them tight and hard. Feel the tension
across your forehead and through your eyes. Now relax. Note the sensations running through your eyes. Just relax
(pause for 10 seconds). Okay, squeeze your jaws tight together and raise your chin to make your neck muscles hard.

Hold it, bite down hard, tense your neck, and squeeze your lips really tight (pause for 5 seconds). Now relax (pause for
10 seconds). Now, all together, wrinkle up your forehead and squeeze your eyes tight, bite down hard with your jaws,
raise your chin and tighten up your neck, and make your lips tight. Hold them all and feel the tension throughout your
forehead, and eyes, and jaw, and neck, and lips. Hold it. Now relax. Just totally relax and enjoy the tingling sensations
(pause for 15 seconds).
Now, squeeze both your shoulders forward as hard as you can until you feel your muscles pulling tightly right across
your back, especially in the area between your shoulder blades. Squeeze them. Hold them tight. Now relax (pause for
10 seconds). Now squeeze your shoulders forward again and, at the same time, suck your stomach in as far as you can
and tense your stomach muscles. Feel the tension throughout your stomach. Hold it (pause for 5 seconds). Now relax
(pause for 10 seconds). Once more, squeeze your shoulder blades forward again, suck in your stomach as far as you
can, tense your stomach muscles, and feel the tension throughout your upper body. Now relax (pause for 10 seconds).

Now, we are going to review all of the muscle systems that we have covered
so far. First, take three deep breaths (pause for 10 seconds). Ready? Tighten up both fists and bend both of your arms to
squeeze your biceps tight. Wrinkle your forehead and squeeze your eyes tight. Bite down hard with your jaws, raise
your chin, and hold your lips tight. Squeeze your shoulders forward and suck in your stomach and push your stomach
muscles against it. Hold them all. Feel the tremendous tension throughout. Now relax. Take a deep breath. Just feel the

tension disappearing. Think about the total relaxation throughout all of your muscles-in your arms, in your head, in
your shoulders, in your stomach. Just relax (pause for 10 seconds).
Now, lets go to your legs. Bring your left heel in tight toward your chair, push it down hard, and raise your toes so that
your calf and your thigh are extremely tense. Squeeze your toes up and push your heel down hard (pause for 5
seconds). Now relax (pause for 10 seconds). One more time, bring your left heel in tight toward your chair, push it
down hard, and raise your toes so that your calf and your thigh are extremely tense. Push down on the heel and raise
your toes. Now relax (pause for 10 seconds). Now, bring your right heel in tight toward your chair and push it down
and raise your toes so that your calf and your thigh are extremely tense. Push your heel down, squeeze your toes up,
and squeeze your leg in tight (pause for 5 seconds). Now relax (pause for 10 seconds).
Now, lets do both legs together. Squeeze your heels in tight toward your chair, push down on your heels, and raise your
toes as high and as tight as you can. Hold it (pause for 5 seconds). Now relax (pause for 10 seconds). Now, take 3 deep
breaths (pause for 5 seconds). Now, tense all the muscles as they are named, exactly as you have practiced: left fist and
biceps, right fist and biceps, forehead, eyes, jaw, neck, lips, shoulders, stomach, left leg, right leg. Hold it (pause for 5
seconds). Now relax (pause for 10 seconds). Breathe in deeply 3 times and then repeat the total tensing and then the
total relaxing, and while you are breathing in deeply and then tensing and then relaxing, notice how relaxed all of your
muscles feel. Now tense (pause for 5 seconds) and relax (pause for 5 seconds). Now, breathe normally and enjoy the
completely tension-free state of your body and muscles (pause for 5 seconds). Now turn the recording off.

Deep Muscle Relaxation Exercise

Practice deep muscle relaxation by either playing the recording of the muscle relaxation script or watching the video.
Make sure you are in a quiet, dimly lit setting with as few of distractions as possible.

Imagery (Greenberger & Padesky, pp. 185-186)

Imagery involves visualizing scenes that are tranquil and relaxing to you. Scenes may be actual places you know that
feel safe and relaxing, or they may be scenes you create to be tranquil, safe, and relaxing. The specific scene is less
important than how the image makes you feel. The more senses you can incorporate into your image, the more relaxing
imagery is likely to be. If you can imagine the smells, sounds, and tactile sensations as well as the visual aspects of the
scene, you will improve your ability to relax.

Imagery Exercise
Instructions: Watch this guided imagery video and reflect on the experience by thinking about your answers to the
following questions:
How did you feel before, during, and after the exercise?
What thoughts did you have during the exercise?

 Did your feelings of anxiety decrease after completing the exercise?

Distraction (Greenberger & Padesky, p. 186)

When anxious, we tend to focus on physical sensations or thoughts connected to our anxiety. Distraction works because
our attention is focused away from the thoughts or physical sensations that contribute to our anxiety. To the degree that
you can become absorbed in other activities or thoughts you will shut off the cognitive fuel for your anxiety, thereby
decreasing or eliminating your anxiety symptoms. Practice distraction for at least 4 minutes before expecting a decrease
in anxiety.

Next Step
To determine which relaxation methods work best for you, rate your level of anxiety or tension on a 0-100 scale before
and after completing them. Practice the one or two methods that work best for you regularly to make them fully
effective.