Online Therapy for Depression | Talking Therapies UK

Chapter 1: Understanding Anxiety - The Transdiagnostic Approach
Chapter 2: The CBT Model of Anxiety
Chapter 3: Health Anxiety - Breaking the Worry Cycle
Chapter 4: Social Anxiety - Reclaiming Your Confidence
Chapter 5: Obsessive-Compulsive Disorder - Understanding and Managing OCD
Chapter 6: Specific Phobias - Facing Your Fears
Chapter 7: Generalised Anxiety - Managing Chronic Worry
Chapter 8: Panic Disorder - Understanding and Managing Panic Attacks
Chapter 9: CBT Techniques - Your Practical Toolkit
Chapter 10: Building Your Recovery Plan

Chapter One

Understanding Anxiety: The Transdiagnostic Approach

What is Anxiety?

Anxiety is a normal human emotion that everyone experiences from time to time. It's our body's natural alarm system, designed to protect us from danger. When functioning properly, anxiety helps us stay alert, motivates us to solve problems, and keeps us safe. However, when anxiety becomes excessive, persistent, or disproportionate to the actual threat, it can develop into an anxiety disorder that significantly impacts daily life.

Anxiety disorders are amongst the most common mental health conditions in the United Kingdom, affecting approximately one in four people at some point in their lives. The good news is that anxiety disorders are highly treatable, and Cognitive Behavioural Therapy (CBT) has been proven through extensive research to be one of the most effective treatments available.

Key Understanding

Anxiety becomes problematic when it is excessive, persistent, and interferes with your ability to function in daily life. The difference between normal anxiety and an anxiety disorder lies in the intensity, duration, and impact on your wellbeing.

The Transdiagnostic Nature of Anxiety

One of the most important developments in understanding and treating anxiety has been the recognition of its transdiagnostic features. This means that whilst anxiety manifests in different forms—such as health anxiety, social anxiety, OCD, phobias, generalised anxiety, and panic disorder—they all share common underlying mechanisms and maintaining factors.

Understanding these shared features is crucial because it means that many of the same CBT techniques can be applied across different anxiety disorders. This is why this book takes an integrated approach, highlighting both the unique aspects of each anxiety disorder and the common threads that connect them.

The Transdiagnostic Features of Anxiety

Overestimation of Threat

→

Safety Behaviours

→

Avoidance

→

Increased Anxiety

Common Features Across All Anxiety Disorders

1. Overestimation of Threat: All anxiety disorders involve an overestimation of danger or threat. Whether it's the threat of physical illness in health anxiety, the threat of negative evaluation in social anxiety, or the threat of intrusive thoughts in OCD, the fundamental process is the same—perceiving something as more dangerous than it actually is.

2. Safety Behaviours: People with anxiety develop behaviours they believe keep them safe or prevent feared outcomes. These might include checking (health anxiety, OCD), avoiding eye contact (social anxiety), or carrying safety items (panic disorder). Whilst these behaviours provide short-term relief, they maintain anxiety in the long term.

3. Avoidance: Avoidance is perhaps the most universal maintaining factor across all anxiety disorders. Whether avoiding social situations, contaminated objects, specific places, or even internal sensations, avoidance prevents the person from learning that their fears are unfounded.

4. Attentional Bias: Anxiety creates a tendency to focus attention on threat-related information whilst ignoring neutral or positive information. Someone with health anxiety notices every bodily sensation; someone with social anxiety focuses on signs of negative evaluation.

5. Intolerance of Uncertainty: All anxiety disorders involve difficulty tolerating uncertainty. The need for certainty drives many anxious behaviours, from excessive checking to reassurance-seeking to avoidance of ambiguous situations.

6. Physical Symptoms: Anxiety manifests physically through the body's stress response system. Common physical symptoms include increased heart rate, rapid breathing, muscle tension, sweating, trembling, dizziness, and gastrointestinal symptoms. These symptoms are identical across different anxiety disorders, though people may interpret them differently.

Illustration: The Same Symptoms, Different Interpretations

The Symptom: Increased heart rate and chest tightness

Health Anxiety Interpretation: "I'm having a heart attack. Something is seriously wrong with me physically."

Panic Disorder Interpretation: "I'm going to have a panic attack and lose control or collapse."

Social Anxiety Interpretation: "Everyone can see how anxious I am. They'll think I'm weak or strange."

The physical sensation is the same, but the interpretation and resulting behaviour differ. CBT helps you recognise and challenge these interpretations.

How CBT Addresses Transdiagnostic Features

CBT is particularly effective for anxiety disorders because it directly targets these common maintaining factors. Throughout this book, you'll learn how to:

Identify and challenge threat overestimations through cognitive restructuring
Recognise and reduce safety behaviours that maintain anxiety
Gradually face feared situations through exposure therapy
Broaden attentional focus beyond threat
Develop tolerance for uncertainty
Understand and normalise physical symptoms of anxiety

Worksheet 1.1: Understanding Your Anxiety

What form does your anxiety take? (e.g., health anxiety, social anxiety, OCD, specific phobia, generalised anxiety, panic disorder) What situations, thoughts, or sensations trigger your anxiety? What do you do to try to manage or reduce your anxiety? (Think about safety behaviours and avoidance) How does your anxiety affect your daily life? (Consider work, relationships, leisure activities, physical health) What would you like to be able to do if anxiety wasn't holding you back?

Chapter Two

The CBT Model of Anxiety

The Cognitive Model: How Thoughts, Feelings, and Behaviours Interact

Cognitive Behavioural Therapy is based on a simple but powerful principle: it's not situations themselves that cause our emotional responses, but rather how we interpret and think about those situations. This doesn't mean that anxiety is "all in your head" or that you can simply "think positively" and feel better. Rather, it recognises that our thoughts, feelings, physical sensations, and behaviours are all interconnected, and by changing one element, we can influence the others.

The CBT Model: The Five Areas Approach

SITUATION/TRIGGER
The event or circumstance that activates the anxiety response

THOUGHTS
Interpretations, predictions, beliefs

EMOTIONS
Feelings (anxiety, fear, panic)

PHYSICAL SENSATIONS
Bodily symptoms and changes

BEHAVIOURS
Actions, avoidance, safety behaviours

These five areas are constantly influencing each other. A change in one area ripples through to affect the others. This is why CBT is so effective—by targeting thoughts and behaviours, we can create positive changes in emotions and physical sensations.

Detailed Example: Sarah's Social Anxiety

Situation: Sarah is invited to her colleague's birthday party at a local pub. She's been at her new job for three months and doesn't know people well yet.

Thoughts: "I won't know what to say. Everyone will notice how awkward I am. They'll think I'm boring and weird. I'll make a fool of myself. People are probably only being polite by inviting me."

Emotions: Intense anxiety, dread, feeling of impending humiliation, fear

Physical Sensations: Heart racing, sweating, stomach churning, feeling hot, trembling hands, tight chest, feeling lightheaded

Behaviours: Makes an excuse and declines the invitation, stays at home alone feeling relieved initially but then guilty and isolated, avoids talking to colleagues the following week for fear they'll bring up the party, checks social media repeatedly to see photos from the party and convinces herself everyone had a better time without her

The Consequence: Sarah's avoidance provides immediate relief from anxiety, but reinforces her belief that social situations are dangerous and that she can't cope with them. She misses the opportunity to discover that her fears were exaggerated and that people might actually enjoy her company. Her anxiety about future social situations increases.

Understanding Thinking Errors in Anxiety

When we're anxious, our thinking becomes biased in predictable ways. These are called cognitive distortions or thinking errors. Recognising these patterns in your own thinking is the first step to challenging them.

Thinking Error	Description	Anxiety Example
Catastrophising	Assuming the worst possible outcome will occur	"If I have a panic attack on the bus, I'll collapse and everyone will think I'm crazy and call an ambulance and I'll lose my job"
Overestimating Danger	Exaggerating the likelihood or severity of threat	"This headache is probably a brain tumour" (Health Anxiety)
Mind Reading	Assuming you know what others are thinking	"They can tell I'm anxious and they're judging me" (Social Anxiety)
Fortune Telling	Predicting negative future outcomes with certainty	"I know I'll fail this presentation and everyone will lose respect for me"
Emotional Reasoning	Believing something is true because you feel it	"I feel anxious, so something bad must be about to happen"
Black and White Thinking	Seeing things in extremes with no middle ground	"If I don't perform perfectly, I'm a complete failure"
Selective Attention	Focusing only on threat-related information	Noticing every bodily sensation and interpreting it as dangerous whilst ignoring signs of health
Discounting the Positive	Dismissing positive experiences or evidence	"The doctor said I'm fine, but they might have missed something"

The Vicious Cycle of Anxiety

Understanding how anxiety maintains itself is crucial to breaking free from it. Anxiety creates a self-perpetuating cycle where short-term relief strategies actually strengthen anxiety in the long term.

The Anxiety Maintenance Cycle

1. Trigger
Internal or external cue

↓

2. Anxious Thought
"Something bad will happen"

↓

3. Anxiety Response
Physical symptoms, emotion

↓

4. Safety Behaviour/Avoidance
"I must escape/prevent/check"

↓

5. Short-term Relief
Anxiety reduces temporarily

↓

6. Reinforcement
"That behaviour kept me safe"
Belief strengthened, anxiety maintained

This cycle explains why anxiety doesn't naturally improve over time without intervention. Each time you engage in safety behaviours or avoidance, you prevent yourself from learning that:

The feared outcome was unlikely to happen anyway
Even if something uncomfortable happened, you could cope with it
Anxiety naturally decreases on its own without needing to escape or prevent
Physical symptoms of anxiety, whilst unpleasant, are not dangerous

The CBT Breakthrough

CBT works by helping you break this cycle at multiple points. You'll learn to identify and challenge anxious thoughts, tolerate uncomfortable feelings and sensations, reduce safety behaviours, and gradually face feared situations. This allows you to gather new evidence that challenges your anxiety-driven beliefs.

The Role of Avoidance

Avoidance is perhaps the single most important factor that maintains anxiety disorders. It comes in many forms:

Situational Avoidance: Staying away from places, people, or situations that trigger anxiety (e.g., avoiding parties, public transport, hospitals, or specific locations).

Subtle Avoidance: Being physically present but mentally or emotionally withdrawn (e.g., attending a party but standing in the corner looking at your phone, going to the doctor but not mentioning your real concerns).

Cognitive Avoidance: Trying not to think about anxiety-provoking topics, distracting yourself, or suppressing unwanted thoughts (which paradoxically makes them more frequent and intrusive).

Experiential Avoidance: Attempting to avoid internal experiences like thoughts, emotions, or physical sensations through distraction, substance use, or compulsive behaviours.

Whilst avoidance provides immediate relief, it has devastating long-term consequences. Each act of avoidance sends a message to your brain: "This really is dangerous, and I can't cope with it." Your confidence decreases, your world shrinks, and anxiety grows stronger.

Illustration: The Avoidance Trap in Action

James's Health Anxiety Journey:

James notices an unusual sensation in his chest. He immediately thinks, "What if this is heart disease?" His anxiety spikes, and he decides to visit A&E. The doctors run tests and reassure him everything is fine. James feels relieved—for about two days.

Then he notices the sensation again. This time, his anxiety is even higher because he thinks, "What if the doctors missed something?" He books an urgent GP appointment. Again, reassurance provides temporary relief, but the anxiety returns more quickly this time.

Over the following months, James:

Checks his pulse dozens of times per day
Avoids exercise because it makes his heart race
Researches heart conditions online constantly
Seeks reassurance from family members
Attends multiple medical appointments

Each of these behaviours provides momentary relief but strengthens his belief that his heart is in danger and that he must remain vigilant. His quality of life deteriorates, and his anxiety intensifies. This is the avoidance trap—the more he tries to eliminate anxiety, the more powerful it becomes.

Worksheet 2.1: Mapping Your Anxiety Using the CBT Model

Choose a recent situation when you felt anxious. Use the five areas model to map out what happened:

SITUATION: What triggered your anxiety? (Be specific: where were you, what was happening, who was there?) THOUGHTS: What went through your mind? (What were you thinking about yourself, others, the situation, or the future?) EMOTIONS: What emotions did you experience? (Rate the intensity 0-100%) PHYSICAL SENSATIONS: What did you notice in your body? BEHAVIOURS: What did you do? (Include safety behaviours, avoidance, checking, reassurance-seeking, escape) CONSEQUENCES: What were the short-term and long-term effects of your behaviours?

Worksheet 2.2: Identifying Your Thinking Errors

Look back at the thoughts you identified in Worksheet 2.1. Can you identify any thinking errors? List them below and try to name the type of thinking error:

Thought 1: Thinking error(s) present: Thought 2: Thinking error(s) present:

Chapter Three

Health Anxiety: Breaking the Worry Cycle

Understanding Health Anxiety

Health anxiety, sometimes called hypochondriasis or illness anxiety disorder, involves persistent worry about having or developing a serious medical condition. People with health anxiety misinterpret normal bodily sensations and minor symptoms as evidence of severe illness. The anxiety persists despite medical reassurance and negative test results.

It's important to understand that health anxiety is not about "making up" symptoms or seeking attention. The physical sensations are real, the worry is genuine, and the distress is significant. What distinguishes health anxiety from appropriate health concern is the intensity, persistence, and impact on daily functioning.

Key Features of Health Anxiety

Preoccupation with having or acquiring a serious illness
High level of anxiety about health
Excessive health-related behaviours (checking, researching, reassurance-seeking) or avoidance (avoiding medical appointments, health information)
Persistent concern despite medical reassurance
Significant distress or impairment in daily life
Symptoms lasting at least six months (though the specific illness feared may change)

The Health Anxiety Cycle

Health anxiety is maintained by a specific pattern of thoughts and behaviours that keep the worry alive:

The Health Anxiety Maintenance Cycle

TRIGGER
Bodily sensation, symptom, health information, news about illness

↓

INTERPRETATION
"This could be a sign of serious illness"
"What if it's cancer/heart disease/MS?"

↓

ANXIETY & ATTENTION
Increased focus on body
More symptoms noticed
Physical anxiety symptoms (heart racing, tension)

↓

SAFETY BEHAVIOURS
Checking body/pulse
Researching online
Seeking reassurance
Doctor visits
Body scanning

↓

TEMPORARY RELIEF
"I'm okay... for now"
But worry returns quickly
Belief in illness threat maintained

Common Safety Behaviours in Health Anxiety

Safety behaviours in health anxiety are actions performed to reduce anxiety or prevent feared health outcomes. Whilst they provide temporary relief, they maintain the problem by preventing you from learning that the perceived danger doesn't exist.

Safety Behaviour	Intended Function	How It Maintains Anxiety
Body checking (feeling lumps, taking pulse, examining skin)	To detect illness early or ensure everything is normal	Increases attention to body, creates/aggravates sensations, prevents habituation, confirms that body requires monitoring
Internet research about symptoms and diseases	To understand symptoms and gain certainty	Exposes you to worst-case scenarios, increases anxiety, provides information that fuels worry, prevents acceptance of uncertainty
Seeking reassurance from doctors, family, or online	To hear that you're okay and reduce worry	Relief is temporary, increases doubt ("What if they're wrong?"), prevents developing confidence in own judgement
Frequent medical appointments and tests	To rule out serious illness	Suggests illness is likely, prevents learning that symptoms are benign, creates financial and time costs
Avoidance of health information, medical programmes, hospitals	To prevent triggering anxiety	Maintains belief that health information is dangerous, prevents desensitisation, increases fear
Comparing your body to others or to how you used to be	To detect changes or abnormalities	Heightens self-focus, creates appearance of problems, prevents acceptance of normal variation

Case Study: Emma's Health Anxiety Journey

Background: Emma, 34, developed health anxiety after her father was diagnosed with bowel cancer. She became hypervigilant about her own digestive symptoms.

The Problem: Emma experienced normal digestive sensations—occasional bloating, changes in bowel habits related to stress and diet—but interpreted these as signs of cancer. She checked her stools daily, researched symptoms online for hours, and visited her GP monthly requesting tests. She had three colonoscopies in two years, all normal.

The Impact: Emma's anxiety was constant. She couldn't enjoy meals, avoided social eating, and was exhausted from hypervigilance. Her relationship suffered as her partner grew frustrated with constant reassurance-seeking. She spent significant money on private tests.

CBT Approach: Emma worked with a therapist to understand the health anxiety cycle. She learned that:

Anxiety itself causes digestive symptoms (the gut-brain connection)
Checking increased her awareness of normal sensations
Internet research exposed her to rare conditions and maintained fear
Reassurance provided only temporary relief and prevented her developing confidence

Treatment: Emma gradually reduced checking behaviours, limited internet research, and worked on accepting uncertainty. She used cognitive techniques to challenge catastrophic thoughts and conducted behavioural experiments. Over three months, her anxiety reduced by 70%, and she regained her quality of life.

Cognitive Techniques for Health Anxiety

1. Identifying and Challenging Catastrophic Thoughts

Health anxiety is characterised by catastrophic misinterpretation of bodily sensations. The first step is recognising these thoughts, then evaluating them objectively.

Worksheet 3.1: Thought Record for Health Anxiety

SITUATION: What triggered your health anxiety? ANXIOUS THOUGHT: What went through your mind? What do you fear this means? EMOTION & INTENSITY (0-100%): How did this thought make you feel? EVIDENCE FOR: What makes you think this thought might be true? EVIDENCE AGAINST: What evidence contradicts this thought? ALTERNATIVE PERSPECTIVE: What's a more balanced way of looking at this? RE-RATE EMOTION (0-100%): How do you feel now?

2. Probability Pie

When anxious, we focus exclusively on the worst possible explanation for symptoms. The probability pie technique helps you consider all possible causes, not just the catastrophic one.

Probability Pie Example: Chest Pain

Symptom: Tightness in chest

Catastrophic thought: "I'm having a heart attack" (100% of focus)

All possible explanations (with realistic probabilities):

Muscle tension from stress and poor posture (40%)
Anxiety-related chest tightness (30%)
Indigestion or acid reflux (15%)
Normal sensations that everyone experiences (10%)
Mild costochondritis (inflammation of rib cartilage) (4%)
Heart-related issue requiring medical attention (1%)

This exercise doesn't eliminate the feared explanation entirely (which would be unrealistic), but it puts it in proper perspective alongside much more likely explanations.

Worksheet 3.2: Your Probability Pie

What symptom or bodily sensation are you worried about? What's your catastrophic explanation? (The illness you fear) Now list ALL other possible explanations (include benign ones): Assign realistic probability percentages to each explanation (total should equal 100%): Reflection: How does seeing all possibilities change your perspective?

Behavioural Experiments for Health Anxiety

Behavioural experiments are the most powerful tool for challenging health anxiety. They involve testing your anxious predictions against reality.

Behavioural Experiment: Testing the Effects of Body Checking

Belief: "I need to check my pulse regularly to make sure my heart is okay"

Prediction: "If I don't check my pulse, I'll miss warning signs of heart problems and something terrible will happen"

Experiment:

Week 1: Continue normal checking behaviour (e.g., checking pulse 20 times per day). Record anxiety levels throughout each day (0-100 scale) and note any actual heart problems.

Week 2: Gradually reduce checking (10 times per day). Record anxiety levels and note any actual heart problems.

Week 3: Further reduce checking (5 times per day or less). Continue recording.

Results: Typical findings show that:

Anxiety may initially increase when reducing checking, then decreases
No actual heart problems occur whether checking or not
Quality of life improves with less time spent checking
The act of checking itself can cause irregular heartbeat due to anxiety

Learning: "Checking doesn't keep me safe; it maintains my anxiety. My heart functions normally without my monitoring. I can trust my body."

Worksheet 3.3: Planning Your Behavioural Experiment

What belief about your health do you want to test? What do you predict will happen if you change your safety behaviour? What's an alternative prediction (based on the CBT model)? What will you do differently? (Be specific) How will you measure the outcome? After the experiment - What happened? What did you learn?

Reducing Reassurance-Seeking

Reassurance-seeking is one of the most common and problematic safety behaviours in health anxiety. Each time you seek reassurance—from doctors, loved ones, or the internet—you get temporary relief, but the relief becomes shorter-lived over time, and you need reassurance more frequently.

Why reassurance doesn't work:

It prevents you from learning to tolerate uncertainty
It suggests that your anxiety is valid and requires external validation
The relief is always temporary; doubt returns: "But what if they're wrong?"
It trains your brain that you can't trust your own judgement
It can damage relationships when family members become frustrated

Gradual Approach to Reducing Reassurance

Don't try to stop all reassurance-seeking immediately. Instead, gradually reduce it:

Monitor: Track how often you seek reassurance for one week
Delay: When you feel the urge, wait 30 minutes, then an hour, then longer
Reduce frequency: If you typically ask three times, reduce to twice, then once
Self-reassurance: Practice reassuring yourself using balanced thinking
Accept uncertainty: Practise the phrase "I can never be 100% certain, and that's okay"

🌟 Seeking Professional Support

If health anxiety is significantly impacting your life, professional support can make a tremendous difference. TalkingTherapies.co.uk (www.TalkingTherapies.co.uk) offers access to evidence-based psychological therapies, including CBT specifically for health anxiety.

Through Talking Therapies (formerly IAPT), you can access free NHS psychological therapy services. These services offer:

Assessment and tailored treatment plans
CBT delivered by trained therapists
Individual or group therapy options
Telephone, video, or face-to-face sessions

You can self-refer to Talking Therapies without needing a GP referral in most areas of England. Visit www.TalkingTherapies.co.uk to find your local service.

Chapter Four

Social Anxiety: Reclaiming Your Confidence

Understanding Social Anxiety

Social anxiety disorder, also known as social phobia, is characterised by intense fear of social situations where you might be judged, embarrassed, or humiliated. It's much more than shyness—it's a persistent fear that significantly interferes with daily life, relationships, education, and career.

People with social anxiety fear that they'll act in ways that will be negatively evaluated by others. They worry about appearing anxious, incompetent, boring, or strange. The fear often centres on visible signs of anxiety (blushing, sweating, trembling, voice shaking) and the belief that others will judge these signs harshly.

Key Features of Social Anxiety

Marked fear of one or more social situations where you're exposed to possible scrutiny by others
Fear that you'll act in a way that will be negatively evaluated
Social situations almost always provoke fear or anxiety
Social situations are avoided or endured with intense distress
The fear is out of proportion to the actual threat
The fear, anxiety, or avoidance causes significant distress or impairment
The fear lasts for six months or more

The Social Anxiety Cycle

The Vicious Cycle of Social Anxiety

TRIGGER
Social situation (actual or anticipated)

↓

NEGATIVE THOUGHTS
"I'll say something stupid"
"Everyone will think I'm boring/weird"
"They'll see how anxious I am"

↓

INCREASED SELF-FOCUS
Attention turns inward
Monitoring own performance
Awareness of anxiety symptoms

↓

PHYSICAL SYMPTOMS & SAFETY BEHAVIOURS
Blushing, sweating, shaking
Avoiding eye contact, rehearsing,
staying quiet, escaping

↓

PERCEIVED POOR PERFORMANCE
"That was awful, everyone noticed"
Belief confirmed
Future situations feared more

The Role of Self-Focused Attention

One of the most important maintaining factors in social anxiety is excessive self-focused attention. When socially anxious, your attention turns inward like a spotlight, constantly monitoring your own performance, appearance, and anxiety symptoms. This creates several problems:

1. You create a distorted impression of how you appear: Your internal experience (feeling hot, anxious, uncomfortable) becomes your evidence for how you look externally. You assume that because you feel awful, you must look awful too.

2. You miss important social information: Whilst monitoring yourself, you can't fully attend to the conversation or notice positive responses from others. You might miss someone's friendly smile or interested body language.

3. You create the problems you fear: The more you focus on not appearing anxious, the more anxious you become. The more you try to control your symptoms, the worse they get. The more you rehearse what to say, the less natural and spontaneous you appear.

4. You prevent yourself from engaging naturally: Social interaction requires your full attention. When you're self-monitoring, you can't be fully present, which actually does affect your social performance—but not in the way you fear.

Case Study: David's Social Anxiety

Background: David, 28, has struggled with social anxiety since his teens. He works in IT and mostly communicates via email to avoid face-to-face interactions. He was recently promoted to a role requiring presentations and team meetings.

The Problem: Before meetings, David experiences intense anxiety. During meetings, he focuses entirely on his internal experience: monitoring his voice for shakiness, feeling his face for heat, checking if his hands are trembling. He interprets his racing heart as evidence that everyone can see his anxiety. He stays silent to avoid drawing attention, which he later interprets as confirmation that he has nothing valuable to contribute.

Safety Behaviours:

Avoids speaking unless directly asked
Rehearses comments extensively before speaking
Avoids eye contact
Positions himself away from the centre of attention
Wears layers to hide sweating
Holds papers to hide hand tremors
Leaves immediately when meetings end

The Impact: David is exhausted after work due to constant vigilance. His manager has noted he seems "disengaged" in meetings. He declined a team social event, missing an opportunity to build relationships. He's considering leaving a job he otherwise enjoys.

CBT Treatment: David learned that his self-focused attention and safety behaviours were maintaining his anxiety. He conducted experiments to test his beliefs:

Video feedback: Recorded himself in role-played meetings. Was surprised to see he appeared much more confident than he felt.
Attention training: Practised focusing outward on the speaker rather than monitoring himself. Found he could actually follow conversations better and felt less anxious.
Dropping safety behaviours: Gradually made eye contact, spoke without excessive rehearsal, and stayed for brief chats after meetings. Discovered people responded positively.
Behavioural experiments: Deliberately displayed subtle "imperfections" (pausing while speaking, admitting he didn't know something). Learned that these were not catastrophic and people remained engaged.

Outcome: After 12 weeks of CBT, David's anxiety in work situations reduced significantly. He successfully delivered his first presentation and received positive feedback. He attended a team lunch and enjoyed it. Most importantly, he learned that his internal experience doesn't match his external appearance, and that people respond to his engagement, not his anxiety.

Common Safety Behaviours in Social Anxiety

Safety Behaviour	Intended Function	Unintended Consequence
Avoiding eye contact	To hide anxiety; to avoid appearing confrontational	Appears disinterested or unfriendly; misses positive social cues; increases self-focus
Rehearsing extensively before speaking	To sound intelligent and avoid mistakes	Appears stilted and unnatural; increases pressure; prevents spontaneous connection
Speaking very little or only when directly asked	To avoid saying something foolish; to hide anxiety	Appears disengaged; prevents others from getting to know you; confirms belief you have nothing to offer
Gripping cups/glasses tightly, folding arms, or holding objects	To hide trembling hands	Creates tension that increases trembling; closed body language appears unfriendly
Wearing certain clothes to hide blushing/sweating	To conceal visible signs of anxiety	Can cause overheating which increases sweating; maintains belief that these signs are catastrophic
Consuming alcohol before social events	To reduce anxiety and appear more relaxed	Risk of dependence; prevents natural confidence development; attributes any success to alcohol
Escaping situations early	To end discomfort	Provides relief but strengthens belief that situations are unbearable; prevents anxiety naturally decreasing
Overpreparing (e.g., researching topics extensively)	To ensure you have something interesting to say	Increases pressure; conversations feel forced; prevents discovering you can cope unprepared
Post-event rumination and self-criticism	To learn from mistakes and do better next time	Reinforces negative beliefs; increases anxiety about future events; distorts memory of events

Cognitive Techniques for Social Anxiety

1. Identifying and Challenging Negative Predictions

Social anxiety involves making catastrophic predictions about social situations. These predictions rarely come true, but we don't test them because we avoid situations or use safety behaviours.

Worksheet 4.1: Testing Your Social Predictions

Social situation you're anxious about: What do you predict will happen? (Be specific) How likely is this prediction (0-100%)? What evidence supports this prediction? What evidence contradicts this prediction? What's a more realistic prediction? After the event: What actually happened? How accurate was your original prediction?

2. The Spotlight Effect

People with social anxiety experience the "spotlight effect"—the belief that others are paying much more attention to you than they actually are. In reality, most people are focused on themselves, not scrutinising you.

Experiment: Testing the Spotlight Effect

Task: Try to recall specific details about other people from a recent social situation.

Questions to ask yourself:

What exactly were three different people wearing?
Did anyone blush, stumble over words, or appear nervous?
What did each person say? Can you remember their exact words?
Did anyone do anything embarrassing?

Likely finding: You probably can't remember most of these details. This is because people are generally absorbed in their own experiences, not carefully monitoring others. If you can't remember details about others, they're unlikely to remember details about you.

Conclusion: The attention you think you're receiving is vastly overestimated. Most people are too busy thinking about themselves to scrutinise you.

3. Challenging Mind Reading

Social anxiety involves assuming you know what others are thinking (usually something negative). This mind reading is a cognitive distortion that needs to be challenged.

Worksheet 4.2: Challenging Mind Reading

Describe a recent social situation: What do you believe others were thinking about you? What evidence do you have that they were thinking this? (Actual evidence, not feelings) Are there any alternative explanations for their behaviour? If you asked them directly, what might they actually say? How does your interpretation of others' thoughts affect your behaviour?

Behavioural Experiments for Social Anxiety

Behavioural experiments are essential for overcoming social anxiety. They involve testing your fears in real situations to gather evidence about whether your predictions are accurate.

Survey Experiments

One powerful type of experiment involves asking others about their thoughts and experiences. This can reveal that:

Others don't notice the things you fear they notice
Others have similar anxieties and experiences
Others are more understanding and less judgmental than you expect
Your standards for yourself are much higher than what others expect

Sample Survey Questions

For testing assumptions about blushing:

"When you're talking to someone and they blush, what do you think? How does it affect your opinion of them?"

Common response: "I usually don't notice, or if I do, I think they might be a bit nervous but I don't think negatively of them."

For testing assumptions about pauses in conversation:

"If there's a pause in conversation when you're talking to someone, what do you think and feel?"

Common response: "I usually see it as natural, a time to think. I don't judge the other person."

For testing assumptions about making mistakes:

"Can you remember a time when someone you were talking to said something a bit awkward or made a small mistake? How did it affect your overall impression of them?"

Common response: "I can't really remember specific instances. If something small happened, it wouldn't change my opinion."

Worksheet 4.3: Planning a Behavioural Experiment

What belief do you want to test? What do you predict will happen if you test this belief? What safety behaviours will you drop during this experiment? How will you measure the outcome? (What will you look for?) Alternative prediction (what CBT theory suggests will happen): What actually happened? What did you learn? How does this affect your belief (re-rate 0-100%)?

Video Feedback

Video feedback is an incredibly powerful technique for social anxiety. It involves recording yourself in a social situation (or role-play) and then watching it back. This helps you see the discrepancy between how you feel you appear and how you actually appear to others.

Steps for video feedback:

Before recording, write down your predictions about how you'll appear (e.g., "I'll look terrified, my hands will shake visibly, I'll stumble over my words constantly")
Record yourself in a social situation or role-play (e.g., having a conversation, giving a short presentation)
Before watching, rate how badly you think you performed (0-100)
Watch the video with your therapist or a trusted person, using specific rating scales
Compare your predicted appearance with your actual appearance
Re-rate your performance based on what you observed

Common Discoveries from Video Feedback

Anxiety symptoms are much less visible than you thought
You appear more confident and natural than you felt
Minor imperfections (pauses, "um") don't detract from overall impression
Others can't see your internal experience
You're often more critical of yourself than any observer would be

Attention Training

Shifting attention from internal monitoring to external focus is a crucial skill for managing social anxiety.

Worksheet 4.4: External Focus Practice

Practice this exercise daily to develop your ability to focus externally:

During a conversation, focus completely on the other person. Describe what you notice: What did you notice about your anxiety when you focused externally? What did you notice about the quality of the conversation? Compare this to a conversation where you were self-focused. What differences did you notice?

Graded Exposure for Social Anxiety

Exposure therapy involves gradually facing feared social situations without using safety behaviours. This is how you learn that your fears are exaggerated and that you can cope.

Worksheet 4.5: Building Your Social Anxiety Hierarchy

List social situations from least to most anxiety-provoking (0-100 anxiety rating):

Low anxiety situations (20-40): Moderate anxiety situations (40-60): Higher anxiety situations (60-80): Highest anxiety situations (80-100):

Principles of Effective Exposure

Gradual: Start with lower anxiety situations and work up
Repeated: Repeat each step multiple times until anxiety reduces
Prolonged: Stay in situations long enough for anxiety to decrease naturally (usually 30-60 minutes)
No safety behaviours: Drop safety behaviours to learn you can cope without them
Focus on learning: Each exposure is an experiment to test predictions
Expect discomfort: Anxiety will initially increase—this is normal and means you're doing it right

🌟 Professional Support for Social Anxiety

Social anxiety can feel isolating, but effective treatment is available. CBT has excellent outcomes for social anxiety, with many people experiencing significant improvement within 12-16 sessions.

TalkingTherapies.co.uk (www.TalkingTherapies.co.uk) provides access to evidence-based CBT for social anxiety. Services include:

Individual CBT tailored to your specific social fears
Group CBT programmes where you can practise social skills in a supportive environment
Telephone or video sessions if face-to-face feels too difficult initially
Self-referral in most English regions—no GP referral needed

Working with a therapist can help you implement these techniques more effectively, provide accountability, and offer support during challenging exposures.

Chapter Five

Obsessive-Compulsive Disorder: Understanding and Managing OCD

Understanding OCD

Obsessive-Compulsive Disorder (OCD) is characterised by intrusive, unwanted thoughts (obsessions) and repetitive behaviours or mental acts (compulsions) performed to reduce the distress caused by these thoughts. OCD is not about being neat, organised, or a perfectionist—it's a serious anxiety disorder that can be debilitating.

The key feature of OCD is that the person recognises that their obsessions and compulsions are excessive or unreasonable, but feels unable to resist them. The compulsions provide temporary relief from anxiety, but this relief is short-lived, and the cycle continues.

Key Features of OCD

Obsessions: Recurrent, persistent, intrusive thoughts, urges, or images that cause marked anxiety or distress
Compulsions: Repetitive behaviours or mental acts performed to reduce anxiety or prevent a feared outcome
Time-consuming: Obsessions and compulsions take more than one hour per day or cause significant impairment
Not pleasurable: Compulsions are performed out of anxiety, not for enjoyment
Ego-dystonic: The thoughts feel inconsistent with the person's values and character

Common Types of OCD

OCD Type	Typical Obsessions	Typical Compulsions
Contamination OCD	Fear of germs, illness, dirt, bodily fluids, chemicals	Excessive hand washing, showering, cleaning, avoiding "contaminated" objects or places
Checking OCD	Fear of harm (fire, burglary, accident) due to own carelessness	Repeatedly checking locks, appliances, switches; retracing routes; seeking reassurance
Symmetry & Ordering	Things must be "just right" or something bad will happen; discomfort with asymmetry	Arranging objects, counting, repeating actions until they feel right
Intrusive Thoughts (Pure O)	Unwanted violent, sexual, or blasphemous thoughts; fear of acting on thoughts	Mental rituals (praying, counting), thought suppression, reassurance-seeking, avoidance
Harm OCD	Fear of harming self or others; fear of being responsible for accidents	Avoidance of knives or other objects; seeking reassurance; mental checking; reviewing past actions
Scrupulosity	Fear of sinning, offending God, being immoral or blasphemous	Excessive praying, confessing, seeking forgiveness, mental review of actions
Relationship OCD	Doubts about whether partner is "the one"; fears about attraction or compatibility	Comparing partner to others, seeking reassurance, testing feelings, mental checking

The OCD Cycle

The Vicious Cycle of OCD

TRIGGER
Internal (thought, image, urge, doubt) or
External (object, situation, person)

↓

INTRUSIVE THOUGHT/OBSESSION
"What if I'm contaminated?"
"Did I really lock the door?"
"What if I harm someone?"

↓

CATASTROPHIC MISINTERPRETATION
"This thought means something terrible"
"I must do something to prevent disaster"
"I'm responsible for preventing harm"

↓

ANXIETY & DISTRESS
Intense fear, guilt, disgust, or discomfort

↓

COMPULSION
Behavioural (washing, checking, arranging) or
Mental (counting, praying, reviewing)

↓

TEMPORARY RELIEF
Anxiety decreases briefly
But... belief strengthened:
"The compulsion prevented disaster"
"I must do this again next time"

The Role of Thought-Action Fusion

A key feature of OCD is "thought-action fusion"—the belief that having a thought is morally equivalent to performing an action, or that thinking something makes it more likely to happen. This is particularly relevant in harm OCD and scrupulosity.

Understanding Thought-Action Fusion

Moral Thought-Action Fusion:

Thought: "What if I pushed that person in front of the train?"

Interpretation: "Having this thought means I'm a dangerous, terrible person. Good people don't think such things."

Reality: Intrusive thoughts are universal and don't reflect character or intentions. Research shows that 90% of people experience unwanted intrusive thoughts.

Likelihood Thought-Action Fusion:

Thought: "What if my mother gets ill?"

Interpretation: "Thinking this makes it more likely to happen. I need to neutralise this thought by thinking something positive."

Reality: Thoughts cannot cause external events. Thinking about something doesn't make it more or less likely to occur.

Understanding Intrusive Thoughts

Everyone experiences intrusive thoughts—they're a normal part of human psychology. Research shows:

Over 90% of people experience unwanted intrusive thoughts
The content is often bizarre, violent, sexual, or blasphemous
Most people dismiss these thoughts without distress
In OCD, the difference is not the thoughts themselves but the meaning attached to them
The more you try to suppress a thought, the more frequent it becomes (the "pink elephant" effect)

Case Study: Maria's Contamination OCD

Background: Maria, 42, developed OCD after watching a documentary about bacteria. She became preoccupied with contamination and germs.

The Problem: Maria's day revolved around contamination fears. She washed her hands 40-50 times daily until they were raw and bleeding. She showered for two hours each morning using specific rituals. She avoided public transport, shops, and visiting friends. She required family members to shower immediately upon entering the house and banned certain "contaminated" items.

Compulsions included:

Hand washing (lasting 5 minutes each, following specific steps)
Showering (2 hours, washing each body part a set number of times)
Cleaning surfaces repeatedly
Avoiding touching door handles, railings, money
Wearing gloves indoors
Mental checking ("Did I touch that?", "Am I contaminated?")
Seeking reassurance from family

The Impact: Maria lost her job due to lateness (caused by rituals). Her skin was damaged from excessive washing. Her marriage was strained. She felt trapped and hopeless. She spent 6-8 hours daily on OCD rituals.

CBT Treatment with ERP (Exposure and Response Prevention):

Maria worked with a specialist OCD therapist using ERP, the gold-standard treatment for OCD:

1. Psychoeducation: Maria learned:

Exposure to normal germs strengthens the immune system
Compulsions maintain OCD by preventing disconfirmation of fears
Anxiety naturally decreases without compulsions (habituation)
Her fear was of contamination, not actual danger

2. Creating an exposure hierarchy: Maria listed feared situations from least to most anxiety-provoking.

3. Gradual exposure with response prevention:

Week 1-2: Touch door handle, wait 30 minutes before washing
Week 3-4: Touch bathroom tap, resist washing for 1 hour
Week 5-6: Use public toilet, wash hands only once (normally)
Week 7-8: Touch floor, resist washing for 2 hours
Weeks 9-12: Touch bins, sit on grass, use public transport

Key principle: Maria had to experience anxiety without performing compulsions, allowing her to learn that her fears didn't come true and that anxiety decreased naturally.

Outcome: After 16 weeks of intensive ERP, Maria's OCD symptoms reduced by 80%. She returned to work, resumed social activities, and her relationship improved. She still occasionally experiences intrusive thoughts, but can now dismiss them without compulsions. She washes her hands a normal amount and showers for 15 minutes.

Cognitive Techniques for OCD

1. Normalising Intrusive Thoughts

Understanding that intrusive thoughts are universal and meaningless is fundamental to recovery.

Worksheet 5.1: Understanding Your Intrusive Thoughts

What intrusive thoughts do you experience? What meaning do you attach to these thoughts? (What do they mean about you or what might happen?) What would it mean if these thoughts were just random mental noise with no special significance? Can you think of examples where you've had random thoughts that meant nothing? (e.g., a song stuck in your head, imagining a purple elephant) If a friend told you they had these exact same thoughts, what would you think about them?

2. Thought Records for OCD

Examining the evidence for catastrophic interpretations of thoughts helps reduce their power.

Worksheet 5.2: OCD Thought Record

TRIGGER: What triggered the obsession? OBSESSION: What intrusive thought/image/urge did you have? INTERPRETATION: What does this thought mean? What do you fear will happen? ANXIETY LEVEL (0-100%): EVIDENCE SUPPORTING YOUR INTERPRETATION: Why might your interpretation be true? EVIDENCE AGAINST YOUR INTERPRETATION: What suggests your interpretation might not be accurate? ALTERNATIVE INTERPRETATION: What's a more balanced, realistic way to view this thought? RE-RATE ANXIETY (0-100%):

3. Responsibility Pie

OCD often involves an inflated sense of responsibility. The responsibility pie helps distribute responsibility more realistically.

Responsibility Pie Example: Fire Safety

OCD Belief: "I am 100% responsible for preventing a house fire by checking the cooker is off."

Question: "If there were a fire, who or what else might bear some responsibility?"

Distributing Responsibility:

Cooker manufacturers (design safety features): 20%
Building regulations (require smoke alarms): 15%
Fire service (rapid response): 15%
Insurance companies (cover losses): 10%
Other household members (also use cooker): 15%
Modern safety features (auto-shutoff): 15%
Me (reasonable checking): 10%

Realisation: Even in the worst-case scenario, responsibility is distributed among many factors. My personal responsibility is much smaller than I believed, and reasonable (not excessive) checking is sufficient.

Exposure and Response Prevention (ERP)

ERP is the gold-standard behavioural treatment for OCD. It involves:

EXPOSURE: Deliberately facing feared situations, thoughts, or objects without performing compulsions.

RESPONSE PREVENTION: Resisting the urge to perform compulsions, allowing anxiety to decrease naturally through habituation.

How ERP Works

When you resist compulsions, two crucial things happen:

You learn that the feared outcome doesn't occur: By not washing after touching a door handle, you discover you don't get ill. By not checking the lock 10 times, you learn your home remains secure.
Anxiety naturally decreases through habituation: If you stay with the anxiety without performing compulsions, it will peak and then gradually reduce. This teaches your brain that the situation isn't actually dangerous.

Worksheet 5.3: Building Your ERP Hierarchy

List situations or triggers from least to most anxiety-provoking. Include what you would normally do (compulsion) and what you'll do instead (response prevention).

LOW ANXIETY (20-40): Situation, normal compulsion, and planned response prevention: MODERATE ANXIETY (40-60): MODERATELY HIGH ANXIETY (60-75): HIGH ANXIETY (75-85): VERY HIGH ANXIETY (85-100):

Worksheet 5.4: ERP Practice Record

Record each ERP practice to track your progress:

DATE & TIME: EXPOSURE TASK: What did you do? ANXIETY BEFORE (0-100%): PEAK ANXIETY (0-100%) and when it occurred: ANXIETY AFTER 30 MINUTES (0-100%): ANXIETY AFTER 60 MINUTES (0-100%): DID YOU RESIST COMPULSIONS? (Note any lapses) WHAT DID YOU LEARN?

Dealing with Mental Compulsions

Mental compulsions (also called "Pure O" when they're the primary symptom) can be harder to resist than behavioural compulsions because they're internal and less obvious.

Common mental compulsions include:

Mental reviewing (going over past actions repeatedly)
Mental checking (analysing whether you did something properly)
Neutralising thoughts (replacing "bad" thoughts with "good" ones)
Counting or repeating phrases
Seeking certainty through mental analysis
Thought suppression

Strategies for Mental Compulsions

Label it: "This is a compulsion, not a helpful thought process"
Catch and redirect: When you notice mental ritualising, gently redirect attention to the present moment
Delay and distract: Put off the mental ritual for increasing periods
Accept uncertainty: Practice saying "Maybe, maybe not" or "I'll never know for sure"
Mindfulness: Observe thoughts without engaging with them

Example: Resisting Mental Compulsions

Situation: Tom has harm OCD. He experiences an intrusive thought: "What if I harmed that child?"

Mental compulsions Tom typically performs:

Mentally reviewing his actions: "Did I get too close? What exactly did I do?"
Seeking certainty: "I would never do that. I'm a good person. I love children."
Neutralising: Thinking "I want children to be safe" repeatedly
Analysing: "Why did I have that thought? What does it mean?"

Response prevention approach:

Tom learns to respond: "I'm having an intrusive thought about harm. This is OCD. I don't need to figure it out, review it, or neutralise it. Thoughts are just thoughts. I can let it be there without doing anything about it."

He practices accepting uncertainty: "I can't be 100% certain about anything, and that's okay. I don't need absolute certainty to move forward with my life."

Result: Initially anxiety increases, but over time and repeated practice, the thoughts lose their power. Tom learns he can have these thoughts without acting on them or engaging in rituals.

🌟 Specialist Support for OCD

OCD is highly treatable with specialist CBT, particularly ERP. Many people experience significant improvement within 12-20 sessions of evidence-based treatment.

TalkingTherapies.co.uk (www.TalkingTherapies.co.uk) can connect you with therapists trained in ERP for OCD. Services include:

Assessment to understand your specific OCD presentation
Individual CBT with ERP tailored to your obsessions and compulsions
Support in creating and implementing exposure hierarchies
Guidance for family members on how to support recovery

Additional specialist resources:

OCD Action: UK charity providing support and information (www.ocdaction.org.uk)
OCD-UK: Charity offering resources and helpline (www.ocduk.org)

Self-referral to Talking Therapies is available in most English regions—you don't need a GP referral.

Chapter Six

Specific Phobias: Facing Your Fears

Understanding Specific Phobias

A specific phobia is an intense, irrational fear of a particular object or situation. The fear is excessive and out of proportion to the actual danger posed. People with specific phobias recognise that their fear is excessive, but feel unable to control it.

Specific phobias are extremely common, affecting about 10% of the population at some point in their lives. Common phobias include animals (dogs, spiders, snakes), natural environment (heights, storms, water), blood-injection-injury, and situational (flying, enclosed spaces, driving).

Key Features of Specific Phobias

Marked fear or anxiety about a specific object or situation
The phobic object or situation almost always provokes immediate fear
The fear is out of proportion to the actual danger
The phobic object or situation is actively avoided or endured with intense distress
The fear, anxiety, or avoidance causes significant distress or impairment
The fear typically lasts for six months or more

Common Types of Specific Phobias

Phobia Type	Examples	Typical Fears
Animal	Dogs, spiders, snakes, insects, birds	Being bitten, attacked, contaminated; losing control
Natural Environment	Heights, storms, water, darkness	Falling, drowning, being struck by lightning
Blood-Injection-Injury	Needles, blood, medical procedures	Fainting, pain, seeing blood, loss of control
Situational	Flying, enclosed spaces, driving, bridges, lifts	Crashing, being trapped, suffocating, losing control
Other	Vomiting, choking, loud noises, costumed characters	Varies by specific phobia

How Phobias Develop and Are Maintained

Phobias can develop through several pathways:

1. Direct Conditioning: A traumatic or frightening experience (e.g., being bitten by a dog, turbulence during a flight)

2. Vicarious Learning: Observing someone else's fearful reaction (e.g., a parent's fear of spiders)

3. Information/Instruction: Being told that something is dangerous (e.g., "Be careful, that dog might bite")

4. Evolutionary Preparedness: Some phobias (snakes, heights, enclosed spaces) may have evolutionary roots, as these were genuine threats to our ancestors

However, how a phobia started is less important than understanding how it's maintained. The key maintaining factor is avoidance.

The Phobia Maintenance Cycle

ENCOUNTER (or anticipate) PHOBIC STIMULUS
Spider, height, needle, enclosed space, etc.

↓

CATASTROPHIC THOUGHT
"It will attack me / I'll fall / I'll be trapped"

↓

FEAR RESPONSE
Panic, anxiety, physical symptoms

↓

AVOIDANCE OR ESCAPE
Leave situation, avoid completely, use safety behaviours

↓

SHORT-TERM RELIEF
Anxiety decreases immediately
BUT phobia is strengthened
"I escaped just in time!"

Each time you avoid the phobic stimulus, you prevent yourself from learning that:

The feared outcome is unlikely to occur
Even if something uncomfortable happens, you can cope
Anxiety naturally decreases over time without escape
The stimulus is not as dangerous as you believe

Case Study: Sophie's Flying Phobia

Background: Sophie, 35, developed a fear of flying after experiencing severe turbulence five years ago. She'd previously flown without problems, but now the phobia was affecting her career and personal life.

The Problem: Sophie was offered a promotion requiring international travel, which she had to decline. She couldn't visit her sister who'd moved to Spain. She felt embarrassed and limited by her phobia.

Beliefs and fears:

"The plane will crash"
"Turbulence means something is wrong with the plane"
"I'll panic and embarrass myself"
"I won't be able to cope with the anxiety"

Avoidance behaviours:

Avoided all air travel for five years
Researched plane crashes online (which increased anxiety)
Avoided airports, flight-related TV programmes
Took 12-hour drives instead of 2-hour flights

CBT Treatment:

1. Psychoeducation about flying: Sophie learned:

Flying is statistically one of the safest forms of transport
Turbulence is uncomfortable but not dangerous—planes are designed to withstand far worse
Pilots are extensively trained and follow rigorous safety protocols
Modern aircraft have multiple redundant safety systems

2. Cognitive restructuring: Sophie challenged catastrophic thoughts by examining evidence and developing balanced alternatives.

3. Graded exposure hierarchy:

Week 1-2: Watch videos of planes taking off and landing (anxiety: 30/100)
Week 3: Visit airport observation area, watch planes (anxiety: 45/100)
Week 4: Visit airport departure lounge, no flight booked (anxiety: 55/100)
Week 5-6: Book short domestic flight (30 minutes), practice coping strategies
Week 7: Take short flight with therapist's support (anxiety: 75/100 before, 40/100 during)
Week 8-10: Take progressively longer flights independently

Coping strategies during flights:

Controlled breathing exercises
Challenging catastrophic thoughts with evidence
Staying present rather than anticipating worst outcomes
Accepting anxiety as uncomfortable but not dangerous

Outcome: After three months, Sophie successfully flew to Spain to visit her sister. She accepted the promotion at work. She still experiences some anxiety when flying, but it's manageable and doesn't prevent her from travelling. She learned that avoiding the fear kept it alive, whilst facing it gradually made it shrink.

Graded Exposure: The Core Treatment for Phobias

Graded exposure is the most effective treatment for specific phobias, with success rates of 80-90%. It involves gradually and systematically facing your fear in a controlled way.

Principles of Effective Exposure

Gradual: Start with situations that provoke moderate anxiety, not overwhelming fear
Repeated: Practise each step multiple times until anxiety reduces significantly
Prolonged: Stay in the situation long enough for anxiety to decrease naturally (usually 30-60 minutes)
Predictable: You control the exposure—no surprises
No escape: Resist the urge to leave when anxiety peaks
Drop safety behaviours: Face the fear without protective actions
Systematic: Follow your hierarchy, don't skip steps

Worksheet 6.1: Creating Your Fear Hierarchy

List 10-15 situations related to your phobia, from least to most anxiety-provoking:

My phobia is: STEP 1 (Anxiety: 20-30/100): STEP 2 (Anxiety: 30-40/100): STEP 3 (Anxiety: 40-50/100): STEP 4 (Anxiety: 50-60/100): STEP 5 (Anxiety: 60-70/100): STEP 6 (Anxiety: 70-80/100): STEP 7 (Anxiety: 80-90/100): STEP 8 (Anxiety: 90-100/100):

Worksheet 6.2: Exposure Practice Record

DATE & TIME: EXPOSURE TASK (from hierarchy): PREDICTED ANXIETY (0-100%): ACTUAL INITIAL ANXIETY (0-100%): PEAK ANXIETY (0-100%) and when: ANXIETY after 15 minutes (0-100%): ANXIETY after 30 minutes (0-100%): ANXIETY after 45 minutes (0-100%): FINAL ANXIETY at end of exposure (0-100%): DID THE FEARED OUTCOME OCCUR? What actually happened? WHAT DID YOU LEARN?

Cognitive Techniques for Phobias

1. Examining the Evidence

Phobias involve overestimating danger. Examining realistic evidence helps correct these distortions.

Worksheet 6.3: Examining Phobic Beliefs

My core phobic belief is: How strongly do I believe this (0-100%)? What evidence supports this belief? What evidence contradicts this belief? Am I overestimating the danger? What's the realistic level of danger? What's a more balanced belief? How strongly do I believe the balanced belief (0-100%)?

2. Probability Overestimation

People with phobias dramatically overestimate the likelihood of feared outcomes.

Reality Checking Example: Height Phobia

Feared belief: "If I stand near the edge of this viewing platform, I'll fall"

Estimated probability (initial anxiety-driven estimate): 80-90%

Reality check:

How many people visit this platform annually? (Let's say 100,000)
How many fall off? (Actual statistic: 0)
Are there safety barriers? (Yes, 1.5 metre high barriers)
Do I have any motor condition that would make me lose balance? (No)
Have I ever randomly fallen when standing still? (No)

Realistic probability: Less than 0.001% (virtually impossible with safety measures in place)

Conclusion: My anxiety-driven estimate was dramatically inflated. The actual danger is negligible.

Special Considerations: Blood-Injection-Injury Phobia

Blood-injection-injury (BII) phobia is unique among phobias because it can cause fainting. This occurs due to a vasovagal response—a sudden drop in heart rate and blood pressure.

Applied Tension Technique:

This technique, developed specifically for BII phobia, prevents fainting by maintaining blood pressure.

How to Practise Applied Tension

Tense the muscles in your arms, legs, and torso (not your face or neck)
Hold the tension for 15-20 seconds until you feel warmth rising to your face
Release the tension but don't relax completely
Wait 30 seconds, then repeat
Continue this cycle for 5 cycles
Practise this technique 5 times daily for a week before beginning exposure
During exposure to blood/needles, use applied tension to maintain blood pressure

🌟 Professional Support for Phobias

Whilst many people can overcome phobias using self-help strategies, working with a therapist can be particularly helpful if:

Your phobia significantly impacts your quality of life
You need support and accountability during exposures
Your phobia is complex or involves multiple fears
You've tried self-help without success

TalkingTherapies.co.uk (www.TalkingTherapies.co.uk) offers evidence-based treatment for specific phobias. Services include:

Individual CBT with graded exposure
Therapist-supported exposure sessions
Short-term, focused treatment (often 6-8 sessions)
Excellent success rates for specific phobias

You can self-refer in most English regions without needing a GP referral.

Chapter Seven

Generalised Anxiety Disorder: Managing Chronic Worry

Understanding Generalised Anxiety Disorder (GAD)

Generalised Anxiety Disorder is characterised by excessive, uncontrollable worry about a variety of topics. Unlike other anxiety disorders that focus on specific triggers, GAD involves persistent worry about multiple areas of life—health, finances, work, relationships, daily responsibilities, and even minor matters.

People with GAD often describe themselves as "worriers" and may have worried excessively for as long as they can remember. The worry feels uncontrollable and is accompanied by physical symptoms such as muscle tension, fatigue, difficulty concentrating, irritability, and sleep disturbance.

Key Features of GAD

Excessive anxiety and worry about multiple events or activities
Difficulty controlling the worry
Worry is associated with restlessness, fatigue, difficulty concentrating, irritability, muscle tension, or sleep disturbance
The anxiety causes significant distress or impairment
Symptoms persist for at least six months
Worry shifts from topic to topic

The Nature of Worry in GAD

Worry in GAD has several distinctive characteristics:

1. Chain of "What If" Questions: Worry typically follows a pattern of escalating "what if" questions, each more catastrophic than the last.

A Typical Worry Chain

Initial trigger: Slight headache

Worry chain:

"What if this headache gets worse?" → "What if I can't finish my work?" → "What if my boss thinks I'm unreliable?" → "What if I lose my job?" → "What if I can't pay my mortgage?" → "What if I lose my house?" → "What if I end up homeless?"

Within minutes, a mild headache has escalated to homelessness in the person's mind, generating significant anxiety.

2. Intolerance of Uncertainty: People with GAD struggle with uncertainty and ambiguity. They believe that worrying helps them prepare for or prevent negative outcomes, but in reality, worry increases distress without solving problems.

3. Positive Beliefs About Worry: Despite finding worry distressing, many people with GAD hold beliefs that worry is helpful or necessary:

"Worry helps me solve problems"
"Worry shows I'm a responsible person"
"If I worry, I'll be prepared if something bad happens"
"Worry motivates me to take action"
"If I don't worry, something bad will happen"

4. Meta-Worry (Worry About Worry): People with GAD often develop worry about worrying itself: "Will all this worry damage my health?" "What if I can't stop worrying?" "There must be something wrong with me."

The GAD Maintenance Cycle

How GAD Maintains Itself

TRIGGER
Uncertainty, ambiguous situation, reminder of responsibilities

↓

"WHAT IF?" WORRY
Generating catastrophic scenarios
Mental problem-solving without resolution

↓

INCREASED ANXIETY
Physical tension, restlessness
Difficulty concentrating
More things to worry about noticed

↓

WORRY BEHAVIOURS
Seeking reassurance
Overpreparing
Procrastinating (to avoid worry)
Trying to control everything

↓

TEMPORARY RELIEF OR EXHAUSTION
Brief sense of control or preparedness
OR mental exhaustion from constant worry

↓

BELIEFS REINFORCED
"Worry helps me cope"
"I need to stay vigilant"
Cycle continues

Case Study: Rachel's Generalised Anxiety

Background: Rachel, 46, has worried "about everything" for as long as she can remember. She describes herself as a born worrier. Her mother was the same way.

Current worries include:

Her teenage children (their safety, friendships, academic performance, future)
Her husband's health (he's slightly overweight)
Her own health (various aches and pains)
Finances (despite having adequate savings)
Work performance (despite positive reviews)
Her ageing parents
World events (climate change, economy, politics)
Small daily matters (being late, forgetting things, making mistakes)

The Impact: Rachel is exhausted. She wakes at 3am with her mind racing. She struggles to concentrate at work because she's preoccupied with worries. Her shoulders and neck are constantly tense. She's irritable with her family. She checks on her children excessively, which they find suffocating. She researches health symptoms online for hours. She makes excessive lists and plans trying to feel prepared.

Rachel's beliefs about worry:

"Worry shows I care about my family"
"If I worry, I'll be prepared for problems"
"Worry helps me think through solutions"
"If I stop worrying, something bad will happen"
"I'm a responsible person because I worry"

CBT Treatment:

1. Distinguishing productive from unproductive worry:

Rachel learned to differentiate between:

Practical problems (have specific solutions, are current, actionable): "My car needs servicing" → Solution: Book appointment
Hypothetical worries (what-if scenarios, future, uncontrollable): "What if my child gets bullied?" → No current problem to solve

2. Challenging beliefs about worry:

Rachel examined evidence for and against her positive beliefs about worry:

"Does worry actually help me solve problems, or does it just make me anxious?"
"Am I more prepared than people who worry less?"
"Has worry ever prevented something bad from happening?"
"What's the cost of constant worry to my health, relationships, and quality of life?"

3. Worry postponement:

Rachel designated a 20-minute "worry time" each day at 6pm. When worries arose during the day, she noted them down and postponed them to worry time. During worry time, she reviewed her worry list. Often, worries seemed less urgent or had resolved. This taught her that worries don't require immediate attention.

4. Acceptance of uncertainty:

Rachel practised accepting uncertainty rather than trying to eliminate it through worry. She used phrases like:

"I can never be 100% certain, and that's okay"
"I can handle uncertainty"
"Not knowing is uncomfortable but not dangerous"

5. Mindfulness and present-moment focus:

Rachel learned to notice when her mind drifted to worry and gently bring attention back to the present moment.

Outcome: After 16 weeks of CBT, Rachel's worry reduced significantly. She still worries sometimes, but she can now recognise unproductive worry and let it go. She sleeps better, feels less tense, and is more present with her family. She learned that worry doesn't protect her loved ones—being present and engaged does.

CBT Techniques for GAD

1. Worry Awareness Training

The first step is becoming aware of your worry patterns.

Worksheet 7.1: Worry Diary

Keep a worry diary for one week to understand your patterns:

Day/Time: What am I worrying about? Is this a practical problem (current, specific, solvable) or hypothetical worry (what-if, future, uncontrollable)? Anxiety level (0-100%): How long did I worry? What was I doing when the worry started? Patterns noticed after one week:

2. Challenging Beliefs About Worry

Worksheet 7.2: Is Worry Helpful?

What positive beliefs do I hold about worry? (Why do I think worry is helpful?) What evidence supports this belief? (Has worry actually helped in these ways?) What evidence contradicts this belief? What are the costs of worry? (How does worry affect my health, relationships, work, enjoyment of life?) Do the benefits of worry outweigh the costs? What would be a more helpful belief about worry?

3. Worry Postponement Technique

How to Practise Worry Postponement

Choose a specific 15-20 minute "worry time" each day (same time, same place)
Keep a worry list throughout the day
When a worry arises, write it down and say "I'll think about this during worry time"
Return attention to what you're doing
During worry time, review your list:
- For practical problems: Make an action plan
- For hypothetical worries: Accept uncertainty and let them go
When worry time ends, close your notebook and stop worrying

What this teaches: Worries don't require immediate attention. Many worries resolve on their own or seem less important later. You can control when and how much you worry.

4. Problem-Solving for Practical Worries

Worksheet 7.3: Structured Problem-Solving

Use this for practical problems (current, specific, solvable):

STEP 1 - Define the problem specifically: STEP 2 - Generate possible solutions (brainstorm without judging): STEP 3 - Evaluate each solution (pros and cons): STEP 4 - Choose the best solution: STEP 5 - Make an action plan (specific steps, timeline): STEP 6 - Implement and review (after taking action, evaluate how it went):

5. Decatastrophising Technique

This technique helps you see that even if your worries came true, you could cope.

Worksheet 7.4: Decatastrophising

What am I worried about? What's the worst that could happen? How likely is this worst-case scenario (realistically, 0-100%)? What's the best that could happen? What's the most realistic/likely outcome? If the worst did happen, how would I cope? What resources or support do I have? Have I coped with difficult situations in the past? What strengths did I show? Would this matter in 5 years?

Building Tolerance for Uncertainty

Intolerance of uncertainty is a core feature of GAD. Learning to accept uncertainty is essential for recovery.

Uncertainty Tolerance Strategies

Recognise certainty-seeking: Notice when you're trying to eliminate uncertainty through worry, reassurance-seeking, or excessive planning
Challenge certainty beliefs: "Do I need 100% certainty?" "Can anyone ever be completely certain?" "What's the cost of pursuing certainty?"
Practise uncertainty exposure: Deliberately engage in activities with uncertain outcomes (try a new restaurant, watch a film without reading reviews, make small decisions without extensive research)
Use uncertainty-acceptance statements: "I can never be completely certain, and that's part of life" "Uncertainty is uncomfortable but not dangerous" "I can handle not knowing"
Notice the impossibility of certainty: Even things we consider "certain" aren't 100% guaranteed. We function daily accepting uncertainty

Worksheet 7.5: Uncertainty Exposure Practice

Situation where I'm seeking certainty: What am I trying to make certain? How do I typically try to gain certainty? (checking, researching, asking, planning) Uncertainty exposure challenge: What will I do differently? Predicted anxiety (0-100%): Actual anxiety (0-100%) - rate at different time points: What happened? Could I tolerate the uncertainty? What did I learn?

🌟 Professional Support for GAD

GAD is highly treatable with CBT. Research shows that CBT produces significant, lasting improvements in worry and anxiety.

TalkingTherapies.co.uk (www.TalkingTherapies.co.uk) provides evidence-based CBT for GAD. Services include:

Individual CBT tailored to your worry patterns
Teaching practical techniques for managing worry
Support in building uncertainty tolerance
Typically 12-16 sessions with significant improvement

You can self-refer in most English regions without a GP referral. Don't let worry control your life—effective help is available.

Chapter Eight

Panic Disorder: Understanding and Managing Panic Attacks

Understanding Panic Attacks and Panic Disorder

A panic attack is a sudden surge of intense fear or discomfort that reaches a peak within minutes. During a panic attack, physical symptoms are so intense that people often believe they're having a heart attack, dying, or losing control. Panic attacks are frightening but not dangerous.

Panic disorder develops when someone experiences recurrent unexpected panic attacks and develops persistent concern about having another attack or changes their behaviour to avoid attacks (such as avoiding places where attacks have occurred).

Common Panic Attack Symptoms

A panic attack involves at least four of the following symptoms:

Palpitations, pounding heart, or accelerated heart rate
Sweating
Trembling or shaking
Sensations of shortness of breath or smothering
Feelings of choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, light-headed, or faint
Chills or heat sensations
Paraesthesia (numbness or tingling sensations)
Derealisation (feelings of unreality) or depersonalisation (being detached from oneself)
Fear of losing control or "going crazy"
Fear of dying

The Panic Cycle: How Panic Maintains Itself

The Vicious Cycle of Panic

TRIGGER
Internal (bodily sensation, thought) or
External (situation, place)

↓

PERCEIVED THREAT
"Something is seriously wrong"
"I'm having a heart attack"
"I'm going to lose control"

↓

ANXIETY/FEAR RESPONSE
Body's alarm system activates
(Fight-or-flight response)

↓

PHYSICAL SYMPTOMS
Heart racing, breathing changes,
dizziness, chest tightness, etc.

↓

CATASTROPHIC MISINTERPRETATION
"These symptoms prove something is
seriously wrong—I must escape!"

↑ ← FEEDBACK LOOP

The misinterpretation intensifies the fear response, which increases symptoms, which increases misinterpretation... creating a rapidly escalating panic attack.

Understanding the Physiology of Panic

Understanding what happens in your body during a panic attack is crucial. All panic symptoms are caused by the activation of your body's fight-or-flight response—an evolutionary survival mechanism.

Symptom	Physiological Cause	Purpose (Fight-or-Flight)
Rapid heartbeat	Heart pumps faster to send blood to muscles	Prepares body to run or fight
Rapid breathing	Breathing rate increases to take in more oxygen	Provides oxygen for physical exertion
Chest tightness	Chest muscles tense; hyperventilation changes blood chemistry	Preparing for action
Dizziness/lightheadedness	Hyperventilation causes changes in blood CO2 levels	Side effect of overbreathing (not dangerous)
Tingling/numbness	Blood flow redirected from extremities to major muscles	Prioritises vital organs and large muscles
Sweating	Body cools itself in preparation for exertion	Temperature regulation
Nausea	Digestion slows/stops; blood redirected from stomach	Energy conserved for immediate action
Derealisation	Heightened alertness makes surroundings seem different	Enhanced perception of threat
Trembling	Muscles tense and prepare for action	Ready for fight or flight

Crucial Understanding

Every panic symptom is produced by the fight-or-flight response—your body's alarm system. This system is designed to protect you from danger. The symptoms feel awful, but they are NOT dangerous. They are the OPPOSITE of dangerous—they're your body's way of keeping you safe.

You cannot die from a panic attack. You cannot have a heart attack from a panic attack (if your heart is healthy). You cannot go crazy or lose control. These are common fears, but they never happen.

Case Study: Michael's Panic Disorder

Background: Michael, 32, experienced his first panic attack whilst driving on a motorway. He felt his heart racing, couldn't breathe properly, and was convinced he was having a heart attack. He pulled over, called an ambulance, and was taken to A&E.

Medical tests: ECG, blood tests, and examination were all normal. The doctor told him it was "just a panic attack" and to "try to relax." Michael didn't believe this—the symptoms had felt too severe to be "just anxiety."

The Development of Panic Disorder:

Following this first attack, Michael became hypervigilant about his body. He constantly monitored his heart rate. When he noticed his heart beating faster (which happens naturally many times per day), he thought "It's happening again!" This thought triggered anxiety, which made his heart beat even faster, which confirmed his fear, creating a panic attack.

Within three months, Michael had experienced 15 panic attacks. He:

Stopped driving on motorways (site of first attack)
Avoided exercise (made his heart race)
Stopped drinking coffee (stimulant)
Avoided crowded places (harder to escape)
Kept medication with him at all times
Sat near exits
Required his partner to accompany him places

The Impact: Michael's world had shrunk dramatically. He'd stopped going to the gym, declined social invitations, and was considering leaving his job due to panic attacks during meetings. His relationship was strained. He felt trapped and hopeless.

CBT Treatment:

1. Psychoeducation about panic:

Michael learned:

What panic attacks are and what causes the symptoms
Why symptoms feel dangerous but aren't
How catastrophic misinterpretation creates and maintains panic
That avoidance keeps panic alive

2. Identifying catastrophic misinterpretations:

Michael learned to recognise his panic-inducing thoughts:

Heart racing → "I'm having a heart attack"
Breathing difficulty → "I'm suffocating"
Dizziness → "I'm going to collapse"
Derealisation → "I'm going crazy"

3. Challenging catastrophic thoughts with evidence:

Michael examined evidence against his fears:

"I've had 15 panic attacks. Have I ever had a heart attack, collapsed, or gone crazy? No."
"Medical tests showed my heart is healthy"
"My symptoms match the description of fight-or-flight, not a medical emergency"
"Panic attacks always pass, usually within 10 minutes"

4. Interoceptive exposure (deliberately inducing physical sensations):

Michael practised exercises that created panic-like sensations in a controlled way:

Hyperventilation for 60 seconds (creates dizziness, tingling)
Running on spot for 60 seconds (increases heart rate)
Spinning in chair (creates dizziness)
Breathing through straw (creates breathlessness feeling)

This taught him that:

He could tolerate these sensations
The sensations were uncomfortable but not dangerous
Sensations passed naturally without catastrophe
His body sensations were normal responses, not signs of danger

5. Situational exposure (gradually facing avoided situations):

Michael created a hierarchy and gradually faced:

Drinking coffee
Light exercise
Sitting in middle of cinema (not near exit)
Attending meetings without escape plan
Shopping in crowded supermarket
Driving on dual carriageways
Driving on motorways

6. Dropping safety behaviours:

Michael gradually stopped carrying medication, checking his pulse, requiring accompaniment, and sitting near exits.

Outcome: After 12 weeks of CBT, Michael was panic-free. He'd resumed all activities, including motorway driving and exercise. When he occasionally noticed his heart racing, he could recognise it as normal variation and didn't catastrophise. He'd learned that panic attacks, whilst unpleasant, were not dangerous, and that facing feared situations was the key to freedom.

Cognitive Techniques for Panic

1. Identifying Catastrophic Misinterpretations

Worksheet 8.1: What Do My Panic Symptoms Mean?

Physical sensation I fear during panic: My catastrophic interpretation (what I fear this means): How strongly do I believe this interpretation during a panic attack (0-100%)? What evidence supports this catastrophic interpretation? What evidence contradicts this interpretation? What's an alternative, non-catastrophic explanation for this sensation? How strongly do I believe the alternative explanation (0-100%)?

2. The Panic Diary

Worksheet 8.2: Panic Attack Record

Recording panic attacks helps you understand patterns and challenge catastrophic beliefs:

Date, time, and location: What was I doing just before the panic started? What was the first sensation I noticed? What did I think this sensation meant? What physical symptoms did I experience? (List all) Peak anxiety (0-100%) and when it occurred: What did I do during the panic? (safety behaviours, escape, avoidance) How long did the panic last? What was I afraid would happen? Did the feared outcome occur? What actually happened? What did I learn from this experience?

Interoceptive Exposure: Facing Feared Sensations

Interoceptive exposure involves deliberately inducing the physical sensations you fear during panic attacks. This is one of the most powerful techniques for overcoming panic disorder.

Why Interoceptive Exposure Works

When you deliberately create panic-like sensations, you learn that:

You can tolerate these sensations
The sensations are not dangerous (nothing bad happens when you experience them)
The sensations pass naturally without needing to escape
You can control when these sensations occur (reducing the fear of unexpected panic)
The sensations are just sensations—your interpretation creates the panic

Exercise	How to Do It	Sensations Created
Hyperventilation	Breathe rapidly and deeply for 60 seconds	Dizziness, lightheadedness, tingling, breathlessness, derealisation
Running on Spot	Run vigorously for 60 seconds	Increased heart rate, breathlessness, sweating, heat
Straw Breathing	Breathe only through a narrow straw for 2 minutes (pinch nose closed)	Breathlessness, air hunger, chest tightness
Head Rolling	Roll head in circles for 30 seconds	Dizziness, disorientation
Spinning	Spin in a swivel chair or spin body in circles for 60 seconds	Dizziness, nausea, disorientation
Staring at Spot	Stare at a spot on wall without blinking for 90 seconds	Derealisation, visual distortions
Muscle Tension	Tense all body muscles as hard as possible for 60 seconds	Shaking, trembling, muscle aches, warmth
Holding Breath	Take a deep breath and hold as long as comfortable	Breathlessness, chest tightness, air hunger

Worksheet 8.3: Interoceptive Exposure Practice

Exercise chosen: Predicted anxiety (0-100%): What do I fear will happen? Actual anxiety during exercise (0-100%): What sensations did I experience? Did my feared outcome occur? What actually happened? How long did sensations last after stopping the exercise? What did I learn? Anxiety rating after completing exercise (0-100%):

Controlled Breathing

Whilst interoceptive exposure teaches you that panic symptoms aren't dangerous, controlled breathing can help you feel calmer during high anxiety.

How to Practise Controlled Breathing

Sit or stand comfortably
Place one hand on your chest, one on your abdomen
Breathe in slowly through your nose for 4 counts (your abdomen should expand, not your chest)
Hold for 1 count
Breathe out slowly through your mouth for 6 counts
Pause for 1 count
Repeat for 3-5 minutes

Important: The goal isn't to prevent panic (that would be a safety behaviour) but to demonstrate that you can influence your body's anxiety response and stay calmer overall.

Situational Exposure for Panic Disorder

Many people with panic disorder develop agoraphobia—avoidance of situations where escape might be difficult or help unavailable if a panic attack occurs.

Worksheet 8.4: Situational Exposure Hierarchy

List situations you avoid due to fear of panic, from least to most anxiety-provoking:

Situation 1 (Anxiety: 20-30/100): Situation 2 (Anxiety: 30-40/100): Situation 3 (Anxiety: 40-50/100): Situation 4 (Anxiety: 50-60/100): Situation 5 (Anxiety: 60-70/100): Situation 6 (Anxiety: 70-80/100): Situation 7 (Anxiety: 80-90/100): Situation 8 (Anxiety: 90-100/100):

🌟 Professional Support for Panic Disorder

Panic disorder is highly treatable with CBT. Most people experience significant improvement within 8-12 sessions of focused treatment.

TalkingTherapies.co.uk (www.TalkingTherapies.co.uk) provides specialist CBT for panic disorder. Services include:

Education about panic and anxiety physiology
Cognitive restructuring to challenge catastrophic thoughts
Guided interoceptive exposure exercises
Support with situational exposure
Techniques to manage anticipatory anxiety

Self-referral available in most English regions. Don't let panic control your life—effective treatment is available.

Chapter Nine

CBT Techniques: Your Practical Toolkit

Core CBT Skills Across All Anxiety Disorders

Whilst each anxiety disorder has specific features, certain CBT skills are universally helpful. This chapter consolidates the most powerful techniques you can use regardless of your specific anxiety presentation.

1. Thought Records: The Foundation of Cognitive Change

Thought records help you identify, examine, and challenge anxiety-driven thinking patterns.

Worksheet 9.1: Comprehensive Thought Record

SITUATION: Describe the event or situation objectively (who, what, when, where) EMOTIONS: What emotions did you feel? Rate intensity (0-100%) AUTOMATIC THOUGHTS: What went through your mind? What were you thinking about yourself, others, the situation, the future? THINKING ERRORS: Identify any cognitive distortions present EVIDENCE FOR: What evidence supports your automatic thoughts? EVIDENCE AGAINST: What evidence contradicts your automatic thoughts? ALTERNATIVE BALANCED THOUGHT: Based on the evidence, what's a more realistic, balanced way of thinking about this situation? RE-RATE EMOTIONS: How do you feel now? Rate intensity (0-100%) ACTION PLAN: What will you do differently next time based on this new perspective?

2. Behavioural Activation: Taking Action Despite Anxiety

Anxiety often leads to avoidance and withdrawal, which maintains low mood and anxiety. Behavioural activation involves gradually resuming activities you've been avoiding.

Worksheet 9.2: Activity Scheduling

Plan activities for the week ahead, including things you've been avoiding:

Activities I'm currently avoiding due to anxiety: Activities that used to give me pleasure or achievement: MONDAY - Planned activities: TUESDAY - Planned activities: WEDNESDAY - Planned activities: THURSDAY - Planned activities: FRIDAY - Planned activities: WEEKEND - Planned activities: After completing: What did I actually do? How did it feel? What did I learn?

3. Mindfulness and Present-Moment Awareness

Anxiety pulls your attention to future threats or past mistakes. Mindfulness anchors you in the present moment, where anxiety has less power.

Simple Mindfulness Exercises

5-4-3-2-1 Grounding Technique:

Name 5 things you can see
Name 4 things you can touch
Name 3 things you can hear
Name 2 things you can smell
Name 1 thing you can taste

Mindful Breathing (3 minutes):

Focus attention on your breath
Notice the sensation of air entering and leaving
When your mind wanders (it will), gently bring attention back to breath
Don't try to change your breathing, just observe it

Body Scan (10 minutes):

Lie or sit comfortably
Systematically focus attention on each body part, from toes to head
Notice sensations without judging them
Breathe into areas of tension, allowing them to soften

4. Relaxation Training

Regular relaxation practice reduces baseline anxiety and provides a coping tool for managing acute anxiety.

Progressive Muscle Relaxation (PMR)

Find a quiet, comfortable place
Tense each muscle group for 5 seconds, then release for 10 seconds
Notice the difference between tension and relaxation
Work through: hands/arms, shoulders, neck, face, chest, stomach, legs, feet
Practice daily for 15-20 minutes

Benefits: Reduces physical tension, improves sleep, increases body awareness, provides a calming routine

5. Problem-Solving vs. Worry

Effective problem-solving addresses practical concerns, whilst worry is unproductive mental spinning.

Problem-Solving	Worry
Specific, concrete problem	Vague, hypothetical "what ifs"
Present or near-future focused	Distant future focused
Actionable—you can do something	Uncontrollable—outside your influence
Leads to action plan	Leads to more worry
Increases sense of control	Increases anxiety and helplessness
Example: "I need to prepare for tomorrow's presentation"	Example: "What if I embarrass myself? What if everyone thinks I'm incompetent? What if this ruins my career?"

6. Self-Compassion

Anxiety is often accompanied by harsh self-criticism. Self-compassion involves treating yourself with the same kindness you'd offer a good friend.

Worksheet 9.3: Developing Self-Compassion

What critical things do I say to myself when I'm anxious? If a good friend was experiencing the same anxiety, what would I say to them? Why is it easier to be compassionate to others than to myself? Write a compassionate letter to yourself about your anxiety struggles:

7. Lifestyle Factors That Support Anxiety Management

Building Your Foundation

Sleep: Aim for 7-9 hours. Poor sleep increases anxiety significantly. Establish a regular sleep schedule, avoid screens before bed, create a relaxing bedtime routine.

Exercise: Regular physical activity (30 minutes most days) reduces anxiety as effectively as some medications. Find activities you enjoy—walking, swimming, dancing, cycling.

Nutrition: Eat regular meals to stabilise blood sugar. Limit caffeine and alcohol, which can increase anxiety. Stay hydrated.

Social Connection: Maintain relationships even when anxiety makes you want to withdraw. Social support is protective against anxiety.

Routine: Establish regular daily routines. Structure and predictability help manage anxiety.

Worksheet 9.4: Lifestyle Assessment and Goals

SLEEP - Current habits and concerns: SLEEP - Changes I'll make: EXERCISE - Current activity level: EXERCISE - Goals: NUTRITION - Current eating patterns: NUTRITION - Changes I'll make: SOCIAL CONNECTION - Current social activities: SOCIAL CONNECTION - Goals:

Chapter Ten

Building Your Recovery Plan

Creating Your Personal CBT Programme

Recovery from anxiety disorders requires a structured, consistent approach. This chapter helps you consolidate what you've learned and create a personalised plan for overcoming your anxiety.

Step 1: Understanding Your Anxiety

Worksheet 10.1: My Anxiety Formulation

My primary anxiety disorder(s): How my anxiety developed (what I understand about how it started): What maintains my anxiety (the vicious cycles I've identified): My main triggers: My catastrophic thoughts and beliefs: My safety behaviours and avoidance patterns: Physical symptoms I experience: How my anxiety impacts my life:

Step 2: Setting SMART Goals

Effective goals are Specific, Measurable, Achievable, Relevant, and Time-bound.

Worksheet 10.2: My Recovery Goals

SHORT-TERM GOAL 1 (achievable in 1-4 weeks): How will I measure success? SHORT-TERM GOAL 2: How will I measure success? MEDIUM-TERM GOAL 1 (achievable in 1-3 months): Steps needed to achieve this: MEDIUM-TERM GOAL 2: Steps needed to achieve this: LONG-TERM GOAL (achievable in 3-6 months): How will my life be different when I achieve this goal?

Step 3: Your Weekly CBT Schedule

Consistency is crucial. Dedicate regular time to CBT practice each week.

Worksheet 10.3: Weekly CBT Practice Schedule

DAILY PRACTICES (10-15 minutes): SCHEDULED EXPOSURE PRACTICE (30-60 minutes, 3-4 times per week): WEEKLY REVIEW SESSION (30 minutes, once per week): OTHER CBT ACTIVITIES:

Step 4: Tracking Your Progress

Regular monitoring helps you see improvements and stay motivated.

Worksheet 10.4: Weekly Progress Tracker

Week beginning (date): Overall anxiety level this week (average, 0-100%): Exposures completed this week: Safety behaviours I successfully reduced or dropped: Thought records completed: Situations I faced that I would previously have avoided: Challenges I encountered: Successes and positive changes I noticed: What I learned this week: Goals for next week:

Step 5: Overcoming Obstacles

Recovery isn't linear. You'll encounter setbacks and challenges. Planning for these helps you stay on track.

Common Obstacles and Solutions

Obstacle: "I'm too anxious to start exposure exercises"

Solution: Start with very small steps. If your lowest hierarchy item feels too difficult, break it down further. Any step forward counts.

Obstacle: "I completed an exposure but still felt anxious"

Solution: The goal isn't to eliminate anxiety immediately, but to learn you can tolerate it. Anxiety reduction happens gradually over repeated practice.

Obstacle: "I had a setback and feel discouraged"

Solution: Setbacks are normal and expected. They're opportunities to practice coping skills. One difficult day doesn't undo your progress.

Obstacle: "I don't have time for CBT practice"

Solution: Anxiety already takes up significant time through worry, safety behaviours, and avoidance. CBT practice is time invested in reclaiming your life. Start with 15 minutes daily.

Obstacle: "I'm not seeing progress fast enough"

Solution: Change is gradual. Review your progress tracker—you've likely made more progress than you realise. Anxiety recovery typically takes 12-16 weeks of consistent practice.

Step 6: Maintaining Your Gains

Once you've made significant progress, the focus shifts to maintaining your improvements and preventing relapse.

Worksheet 10.5: Relapse Prevention Plan

Early warning signs that my anxiety might be increasing: High-risk situations (when I'm more vulnerable to anxiety): CBT skills I found most helpful: Action plan if I notice warning signs: Ongoing maintenance practices I'll continue: Support people I can contact if struggling: What I'll tell myself if I experience a setback:

Step 7: Celebrating Your Progress

Acknowledging your achievements, no matter how small, is crucial for maintaining motivation.

Worksheet 10.6: My Recovery Journey

Things I can do now that I couldn't do before: Situations I now face without excessive anxiety: Safety behaviours I've successfully dropped: Changes others have noticed in me: Skills I'm most proud of developing: What I've learned about myself through this process: How my life has improved: My message to my past self who was struggling with anxiety:

When to Seek Professional Help

Self-help CBT is powerful, but professional support can be invaluable, especially if:

Your anxiety is severe and significantly impacts daily functioning
You've tried self-help consistently for 8-12 weeks without significant improvement
You're experiencing depression alongside anxiety
You're struggling with suicidal thoughts
Your anxiety involves complex trauma
You need accountability and support to implement CBT techniques
You're unsure which techniques to prioritise for your specific situation

🌟 Accessing Professional CBT

TalkingTherapies.co.uk (www.TalkingTherapies.co.uk) is your gateway to free NHS psychological therapy services in England. Services include:

How to access:

Visit www.TalkingTherapies.co.uk
Find your local service using the postcode finder
Self-refer online or by phone (no GP referral needed in most areas)
Complete a brief assessment
Receive a tailored treatment plan

What's available:

Individual CBT (typically 6-20 sessions depending on severity)
Group CBT programmes for specific anxiety disorders
Telephone, video, or face-to-face appointments
Guided self-help with therapist support
Evidence-based treatments delivered by qualified therapists

Additional resources:

Anxiety UK: Support, information, and helpline (03444 775 774) - www.anxietyuk.org.uk
Mind: Mental health information and local support services (0300 123 3393) - www.mind.org.uk
Samaritans: 24/7 emotional support (116 123) - www.samaritans.org
NHS 111: For urgent mental health support - dial 111

Emergency: If you're in crisis or have thoughts of harming yourself, call 999 or go to A&E immediately.

Final Thoughts

Recovery from anxiety is possible. Thousands of people have used CBT to overcome anxiety disorders and reclaim their lives. The techniques in this book are evidence-based and effective—but they require consistent practice and patience.

Remember these key principles:

Anxiety is maintained by avoidance and safety behaviours. Facing fears gradually is essential for recovery.
Your thoughts aren't facts. Learning to identify and challenge anxious thinking patterns reduces anxiety.
Anxiety symptoms are uncomfortable but not dangerous. Your body's fight-or-flight response is a false alarm, not a real emergency.
Recovery isn't linear. Setbacks are normal and don't mean you've failed. Each challenge is an opportunity to practise coping skills.
You're stronger than your anxiety. You've already survived every anxious moment you've experienced. You have the capacity to face and overcome your fears.
Small steps count. Every exposure exercise, every challenged thought, every moment of facing discomfort is progress.
You deserve support. Whether through self-help, professional therapy, or both, help is available and effective.

Your Journey Forward

Anxiety may be part of your story, but it doesn't have to be the ending. With the CBT skills you've learned in this book, you have the tools to write a different narrative—one where anxiety no longer controls your choices, limits your experiences, or defines who you are.

The path forward requires courage, consistency, and self-compassion. There will be difficult days, but there will also be moments of pride, relief, and freedom. Each step you take towards facing your fears is an act of bravery.

You've already taken the first step by reading this book and engaging with these techniques. Continue forward. Your anxiety-free life is waiting.

Final Reflection: My Commitment to Recovery

I'm committed to working on my anxiety because: The life I want to live (free from anxiety's constraints): Three CBT techniques I'll prioritise: My first step (what I'll do this week): How I'll support myself through this journey: My commitment statement: Date of commitment:

You Are Not Alone

Millions of people have overcome anxiety using CBT. You can too.

For professional support: www.TalkingTherapies.co.uk

Your courage in facing anxiety deserves recognition. Be proud of every step forward, no matter how small.

The Complete CBT Guide to Overcoming Anxiety

A Comprehensive Self-Help Handbook with Practical Worksheets and Evidence-Based Strategies

Contents

Understanding Anxiety: The Transdiagnostic Approach

What is Anxiety?

Key Understanding

The Transdiagnostic Nature of Anxiety

The Transdiagnostic Features of Anxiety

Common Features Across All Anxiety Disorders

Illustration: The Same Symptoms, Different Interpretations

How CBT Addresses Transdiagnostic Features

Worksheet 1.1: Understanding Your Anxiety

The CBT Model of Anxiety

The Cognitive Model: How Thoughts, Feelings, and Behaviours Interact

The CBT Model: The Five Areas Approach

Detailed Example: Sarah's Social Anxiety

Understanding Thinking Errors in Anxiety

The Vicious Cycle of Anxiety

The Anxiety Maintenance Cycle

The CBT Breakthrough

The Role of Avoidance

Illustration: The Avoidance Trap in Action

Worksheet 2.1: Mapping Your Anxiety Using the CBT Model

Worksheet 2.2: Identifying Your Thinking Errors

Health Anxiety: Breaking the Worry Cycle

Understanding Health Anxiety

Key Features of Health Anxiety

The Health Anxiety Cycle

The Health Anxiety Maintenance Cycle

Common Safety Behaviours in Health Anxiety

Case Study: Emma's Health Anxiety Journey

Cognitive Techniques for Health Anxiety

Worksheet 3.1: Thought Record for Health Anxiety

Probability Pie Example: Chest Pain

Worksheet 3.2: Your Probability Pie

Behavioural Experiments for Health Anxiety

Behavioural Experiment: Testing the Effects of Body Checking

Worksheet 3.3: Planning Your Behavioural Experiment

Reducing Reassurance-Seeking

Gradual Approach to Reducing Reassurance

🌟 Seeking Professional Support

Social Anxiety: Reclaiming Your Confidence

Understanding Social Anxiety

Key Features of Social Anxiety

The Social Anxiety Cycle

The Vicious Cycle of Social Anxiety

The Role of Self-Focused Attention

Case Study: David's Social Anxiety

Common Safety Behaviours in Social Anxiety

Cognitive Techniques for Social Anxiety

Worksheet 4.1: Testing Your Social Predictions

Experiment: Testing the Spotlight Effect

Worksheet 4.2: Challenging Mind Reading

Behavioural Experiments for Social Anxiety

Survey Experiments

Sample Survey Questions

Worksheet 4.3: Planning a Behavioural Experiment

Video Feedback

Common Discoveries from Video Feedback

Attention Training

Worksheet 4.4: External Focus Practice

Graded Exposure for Social Anxiety

Worksheet 4.5: Building Your Social Anxiety Hierarchy

Principles of Effective Exposure

🌟 Professional Support for Social Anxiety

Obsessive-Compulsive Disorder: Understanding and Managing OCD

Understanding OCD

Key Features of OCD

Common Types of OCD

The OCD Cycle

The Vicious Cycle of OCD

The Role of Thought-Action Fusion

Understanding Thought-Action Fusion

Understanding Intrusive Thoughts

Case Study: Maria's Contamination OCD

Cognitive Techniques for OCD

Worksheet 5.1: Understanding Your Intrusive Thoughts

Worksheet 5.2: OCD Thought Record

Responsibility Pie Example: Fire Safety

Exposure and Response Prevention (ERP)