C.A.L.M. - Choices for Anxious Lifestyle Management Publication
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The Development of Your Anxiety Disorder

William C. Shearer, Ph.D., M.P.H., M.B.A.
Robin L. Shearer, M.F.T., M.A., M.P.H., R.N.


If you suffer from severe anxiety, like thirty million other Americans, you probably have a desperate desire to know why. You may think there is something terribly wrong with you physically. On the other hand, you may fear being seen as “mentally ill.” Many of our clients have kept quiet for years about their anxiety, experiencing increasing social isolation, self-doubt, and self-criticism. For all who struggle with anxiety problems, the two most pressing questions are: “Why Me?” and “How do I get better?”

This issue addresses the question of “Why Me?” and will help you understand how you might have developed an anxiety-prone personality and how you continue to be distressed as long as you remain influenced by earlier learning. Other issues of “CALM” deal with treatment topics.

To explain “Why Me?,” we will take you step-by-step through causes of an anxiety disorder as well as factors that result in ongoing and worsening distress.

First, a reminder that the initial step in understanding and overcoming your anxiety problem is ruling out possible medical causes. Your physician, during a complete medical examination can rule out a number of medical conditions that often cause anxiety symptoms, conditions such as asthma, cardiovascular problems, seizure disorders, diabetes, hyperthyroidism, and inner ear problems.

Medications, such as thyroid supplements, stimulants, cold medications, sleeping pills, tranquilizers, some blood pressure medications, and even antidepressants, have been know to trigger anxiety symptoms. In some cases, misuse or withdrawal from medication or use of alcohol or marijuana may produce anxiety. And let's not forget caffeine, often overlooked as a contributor to high levels of anxiety. See your doctor to rule out these problems. You will have less to worry about and more peace of mind.

Getting medical device is important and is essential whenever there are physical symptoms. At the same time, you should be aware that anxiety has been known to mimic almost every known medical condition. Most of our clients are quite apprehensive about symptoms that lead them to believe that something is wrong with their bodies. Even when medical conditions are ruled out, our clients tend to persist in worrying. Gradually they come to accept the idea that their problem is anxiety, that it can't hurt them, and that they can handle it.

Now, turn your attention to the chart The Development of Anxiety Disorder, focusing first on the box at the top of the page.


 Individual Characteristics

Text Box: Unique biological factors, such as heredity, intelligence, creativity, imagination, or stimulus reactivity, make an individual better able to resist stress and anxiety, or on the contrary, more prone to develop an anxiety disorder.  Individual characteristics also include basic needs for safety, security, love, and acceptance.

 Individual Characteristics are all those characteristics you started off with. These personal factors result in either an anxiety prone personality or an anxiety resistant personality.

We vary greatly in our response to stress. Some people are more reactive than others genetically. Some are more ready to react to a flickering light or a loud noise. You may love roller coaster rides; you may feel terrified on a Ferris wheel.

If you are anxiety prone, you may actually be more intelligent, more creative, and have more power of imagination than those people who might be less afflicted. Like all of us, you started off with the basic needs for safety, security, love, and acceptance. You were more or less prone to develop an anxiety disorder based on how well these basic needs were met or frustrated in your childhood.

Childhood Circumstances

 Move next to the cluster of boxes labeled Childhood Circumstances. Now that you have moved beyond childhood these factors are historical and unchangeable. Childhood circumstances often constitute the key ingredients for your adult anxiety.

For the remainder of this article, we recommend that you put a number by the boxes that apply to you as we take you step-by-step through “The Development of an Anxiety Disorder.” Read each statement and the accompanying description and example, and decide the degree to which you agree with the statement or believe that the statement typifies your experience. Your choice is to select one of five descriptors, each with different point value. The choices are virtually never true (0 points), rarely true (1 point), sometimes true (2 points), often true (3 points), or consistently true (4 points).

Check and rate a box even if it applies only to a small degree. If a box does not apply, do not worry about it. Simply move on to the next box.

When you've finished, and look back over how you've rated all boxes, you will not only have an understanding of how you arrived at an anxiety disorder, but also have clear goals for change efforts and skill development. You will have the foundation for an excellent treatment plan. If you're working with a therapist, the two of you will find this material invaluable in your recovery work.

Text Box: “Be careful” programming from overly cautious parents

The first box relates to you if your parents often seemed worried about you and communicated their anxiety to you in a variety of subtle or not-so-subtle ways. It may be that your parents were themselves anxious and constantly worrisome about events that might have happened, but probably never did.

If your parents were anxious and worrisome about their own lives, it would be quite natural for you to have learned to share their anxieties or be prone to develop an abundance of worries of your own. For example, mothers who get on and off the bathroom scale frequently, and with obvious distress, usually have daughters with fears and insecurities about food and weight.

Text Box: Excessive criticism

If you experienced excessive criticism, you may have learned to think far too much about what you did wrong and far too little about what you did right. The result might be that you learned to be pessimistic about your own abilities, expecting defeat and lack of success. You may have learned to be quite anxious about making mistakes or taking risks. You may also have developed deep resentment that you were unable to express. Such resentments, if kept deep inside, often contribute to the development of an anxiety disorder.

Text Box: Extremely high standards and expectations

Extremely high standards and expectations may have presented you with impossible hurdles and blocked the development of confidence and self-esteem. You may have come to believe that you had to meet parental expectations in order to be loved and accepted. Those perceived expectations may have been quite unrealistic, leaving you either very fearful of falling short or convinced that you simply could not measure up.

Text Box: Rules, rules, rules, & rules

Like many families, your family may have been quite good at generating rules for every situation, rules that may not have been particularly consistent or meaningful but were certainly plentiful. Your need, like that of all other children, was not for thousands of rules, but for a few rules or limits that were fair, consistently applied, sensible, and meaningful. If rules were too numerous and confusing, the result may have been a growing sense of insecurity and the need to always be vigilant so as not to incur the wrath of parents. Or perhaps you were one of those children who rebelliously refused to follow any rules. Either way, substantial anxiety was generated, as well as doubts about your own competence and worthiness.

Text Box: Family mythology;   “We don’t have problems

Family mythology refers to the need within some families for members to appear perfect to everyone , including themselves. It may not have been okay to talk about problems or have certain kinds of problems. You may have lived in dread of disappointing your family by having a difficulty that family members were not supposed to have. As a result, problems were not discussed, feelings were avoided, communication was quite superficial. The stage was set for adult difficulties and anxieties.

J anice* grew up thinking she could never please her father. No matter how hard she tried, it didn't seem to be enough and he pointed out so many of her flaws that she could never quite remember everything that he said. Father seemed obsessionally rule-bound and never happy with his own or anyone else’s efforts. He constantly instructed Janice on “the right way” to do everything. So many rules! Usually confused and feeling inadequate, Janice bought into each and every one of her father’s countless rules in a desperate but futile effort to win his approval. Adding to her pressure were expectations of how family members were supposed to conduct themselves, particularly when others were observing. As an adult, Janice is incessantly worrisome about doing the right thing, always fearful of making a mistake, never feeling safe.

 *Names are changed in this article to protect anonymity.

 Text Box: Suppression of  feelings

Suppression of feelings goes hand in hand with the previous box. Feelings such as anger may not have been allowed in your family. Women in particular have often been taught as young girls that anger is not a “nice” feeling and must be suppressed. “Good little girls” were not supposed to get angry.

For many of our adult clients suffering from severe anxiety, a key question we ask is, “What do you do with anger?” Sometimes the initial response is a question, "What does anger have to do with it?" Often the response is, “I don't get angry,” “I don't express anger,” “I was taught anger is wrong and dangerous,” or “I am wrong if I hurt others with my anger.”

Suppression of anger over time often leads to intense generalized anxiety and an extreme whole body response, such as an anxiety attack. If you learned to bottle up feelings early, you may have been an anxious child. It may come as a surprise to many but children also have intense anxiety and anxiety attacks and tend to become anxious adults if untreated. This is something that is only lately being recognized and addressed by mental health professionals.

Text Box: Suppression of assertiveness

Suppression of assertiveness is a related problem. You may have been taught that expressing your feelings too openly was dangerous and would be punished. Many children, especially girls, are taught that they should not be selfish, should not ask for what they want, and should instead focus on the needs of others.

You may have learned to confuse assertiveness with aggressiveness and feared that if you voiced your feelings, you would be perceived as aggressive and hurtful. Suppression of feelings goes hand in hand with a learned inability to assertively go for what you want. The result may have been a growing resentment and a reservoir of anger that was seldom expressed. Sometimes the anger may have bubbled up to the surface and caused an explosion.

We call this the “Mt. St. Helen Syndrome” where a nonassertive person finally explodes and then feels overwhelmed with guilt and remorse, convinced once again that anger is dangerous and hurtful, returning once again to anger avoidance and a continued buildup of anger. If this applies to you, you may recall that following an angry outburst you renewed your determination to keep everything “under control.” This took enormous energy and generated enormous stress. A pattern may have been set in childhood for adult nonassertiveness and adult anxiety.

J ill is typical of many of our anxiety disorder clients. She cannot recall ever having told anyone of her anger. Anger was not allowed in her family, at least not from children. Jill remembers being punished severely for any sign of disagreement or any resistance to her parents wishes. Still f earful years later that her anger will bubble to the surface and cause problems, she works hard at staying in control, outwardly appearing pleasant and cooperative. Sometimes it is easier to avoid others than to risk conflict. She can accept feeling bored and lonely for more easily than risking conflict and rejection. Filled with the resulting general anxiety, often to the point of panic attacks, Jill cannot see a connection between her distress and the absence of any overt sign of anger.

Text Box: Alcoholism in family, major dysfunctions, abuse, secrets

In many cases, only one of these boxes needs to be checked to reveal how seeds of adult anxiety were planted. Alcoholism in the family is often quite sufficient as a predisposing condition, as millions of members of ACA (Adult Children of Alcoholics) can attest. If not alcoholism, there are other family dysfunctions that can also distort a child’s development. Mental illness, drug abuse, family violence, or sexual abuse will so distress a child that a lifelong struggle with anxiety may follow.

“Secrets” refers to what everyone knows, yet no one is allowed to acknowledge. It could be alcoholism, drug abuse, mental illness, criminal behavior, or many other sources of family guilt and shame. It is like having an elephant in the living room with everyone expected to pretend it is not there.

Text Box: Neglect, rejection, abandonment, loss, or fear of loss

This is about a loss of connection with a parent and may have come about in a variety of ways. You may have felt neglected, rejected, abandoned by your family. You may have come from a large family where you felt lost in the crowd and invisible. Perhaps you were seen as the family problem and actively persecuted. In other cases, a parent may have been lost through death or divorce. Even when mother or father were physically present, you may have feared the loss of a parent. Perhaps you had already lost one emotionally or physically and feared the loss of the other. The threat of loss may have been real or imagined. In any event, it was the perception that counted. You may desperately have wanted to be close to a parent, validated, and acknowledged. You may have either not believed you could get close or were constantly in fear of losing contact.

Text Box: Lack of safety, emotional insecurity

Like many children, you may have grown up feeling unsafe and emotionally insecure. This was particularly true if your home was characterized by alcoholism, dysfunction, or abuse. You may have learned that nothing was certain or predictable. Anything could happen and you always had to be on guard, hypervigilant. It was not okay to relax. You may not have fully trusted that your parents would be there for you, capably protecting, guiding, and nurturing.

Text Box: Frustrated need for love and acceptance

Nothing more powerfully sets you up for future bouts with anxiety than not feeling fully loved or accepted by your parents and other family members. Self-love and self-acceptance begin in a family setting. If you felt loved and accepted, consistently and convincingly, you were given a powerful antidote against being overwhelmed by future life stresses. If not, the result may be chronic self-doubt, relationship insecurities, and lack of resilience in the face of adversity.

Text Box: Excessive dependence fostered

You may have rarely gotten a chance to make a decision on your own. Your parents may have intervened in every potential decision, large or small, often out of the concern that you might make a costly mistake. The reality is that mistakes are valuable. Mistakes are how we learn. Mistakes teach us and help us grow. Mistakes are vital in the development of your “struggle muscle.”

If you were not allowed to make mistakes, you were deprived of a most valuable learning opportunity. You may have been robbed of the confidence that comes with knowing that problems can be confronted directly and overcome by your own resources. If you grew up without this valuable learning, the result may be often feeling paralyzed by problems or being chronically indecisive and worrisome.

Text Box: Kids raising parents

Many of our clients over the years have reported to us that they felt responsible for their parents from an early age. They worried about their parents’ well-being. They also worried that their actions might be hurtful to their parents. They often felt they had to foresee any possible harm to the parents and prevent that occurrence. This is particularly true of many of our anorexic and bulimic clients who tell us they have long been worried about their parents well-being and, in some instances, saw their parents as incapable of adequately caring for themselves and much in need of the child’s protection. This is a terrible position to put a child in. A child needs the security that comes with knowing that parents are on the job and fully capable. Thrusting a child into the position of caretaker to the parent imposes a burden that blocks development. How are you going to be adequately self-nurturing if you grew up being totally absorbed in taking care of other family members?

Text Box: “Human doings”

Finally, “Human doings” refers to a powerfully self-destructive idea you may have grown up with if you learned to think that your worth came totally from what you did or what you achieved. This is in contrast to being raised as a “human being,” where an individual learns to believe he/she is valuable just because he/she is here, just because he/she exists. If your parents, with the best of intentions, reinforced not your intrinsic worth, but rather your accomplishments, they may have unwittingly instilled the idea that accomplishments were what counted and not you as a person. A most unfortunate learning experience!

If you grew up thinking you had worth only as long as you were accomplishing something, then you probably came to expect that your accomplishments must be increasingly impressive. You may not have learned a basic life skill -- to pat yourself on the back and simply feel good about yourself as an okay person, resting when you needed to, nurturing yourself in healthy ways, and generally enjoying life. Instead, you might have learned to incessantly drive yourself to accomplish and excel. You may have come to feel guilty for relaxing, always feeling the pressure to be doing something more, forever worried that what you are doing is not enough. The lack of self nurturing skill opens the door not only to extreme anxiety but to countless excesses and addictions as a way of trying to find relief externally.

M olly is a professional in her mid thirties. Friends see her as an extraordinary woman with unusually impressive accomplishments. Her job involves supervising a score of other professionals, answering any and all technical questions, solving daily personnel problems, and serving on numerous advisory boards and committees. Already possessing two graduate degrees, she now feels driven to complete her doctorate. Those who know her would be shocked to discover that this “human dynamo” has a deep sense of inadequacy and is terrified of not measuring up. She is convinced that everyone will not long be fooled, that she may soon be revealed as a fraud, a phony who only pretends to be competent and secure. She has never been without the anxiety that daily threatens to overwhelm her, anxiety that grows out of a childhood where pushing harder and doing more was the only way that seemed to insure ongoing love and acceptance.

 Before we move on to contributing factors that are ongoing, changeable, and exist in adult years, take a moment to look over the boxes you have checked and rated under childhood circumstances. A we mentioned earlier, if only one box is checked, it could still indicate something that significantly predisposed you to anxiety in adult life. If many boxes are checked, it is a virtual certainty that you learned in childhood to be an anxious adult.

The good news is that if you learned to be anxious, you can also learn to be more relaxed and worry-free. It should be reassuring to see where your anxiety comes from and to know there is new learning that can help you overcome your anxiety problem. You can learn to be free of excess fear and worry. You can learn to relax and have fun.

Contributing Factors

 Text Box: Self-criticism, guilt & shame, self-doubts

Our anxiety groups are quite diverse. We have members who are suffering from generalized anxiety disorder, phobias, social anxiety, agoraphobia, panic disorder, post traumatic stress disorder, obsessive-compulsive disorder, and eating disorders. They have different backgrounds and vary in their symptoms. A common factor for many is a critical attitude toward self accompanied by guilt, shame, and self-doubt. Typically, our group members are very hard on themselves. In a constant inner dialogue, they remind themselves of mistakes they have made, consequences they will have to pay, ways in which they do not measure up. They compare themselves with others and feel they have somehow not been as well equipped to deal with life. For many, self-talk is consistently negative, as they put themselves down and “catastrophize” and “awfulize” about their lives.

Text Box: Distorted thinking, anxious self-talk, “scare-talk”

If you have an anxiety disorder, it is certain that you have Distorted thinking, although this is something that is not unique to those with anxiety. All of us deny, falsify, and distort reality. That is because we are all human. None of us is a pure rational “Mr. Spock” (not the pediatrician, but the Star Trek officer).

Because you are human, you tend to put your own particular slant on things. You perceive and process information in accordance with your own set of beliefs. Many of these beliefs are “taught” beliefs learned in your childhood from those closest to you in helping you meet your needs. At times, these beliefs are destructive to your self-esteem and to your relationships. You may be quite unaware of these beliefs, yet, all too frequently feel overwhelmed by the unpleasant emotions that stem from them. It may come as a surprise that external events are not nearly so much of the problem as the fact that you disturb yourself with ongoing and automatic self-talk and false beliefs learned early in life.

Having only one of these beliefs might be sufficient to generate extreme anxiety. Suppose you are one of those people who tell yourself (and absolutely believe it is true) “I must please everyone in all I do all of the time. If I do not please them, it is terrible; I failed and I cannot stand it.” This is an impossible expectation. No one can please everyone. There is bound to be someone you disappoint in some way. In fact, there are many situations where a healthy person is bound to disappoint those around them if only to assert their boundaries and rights in a psychologically healthy way. You simply cannot be a person of good self-esteem, have a good sense of your own identity and boundaries, and be a people pleaser believing that you “must” perfectly and consistently please those around you.

If you have such a belief and you are having a week in which everyone seems to be pleased, you are not off the hook. You are going to be preoccupied with the worry that someone might be displeased, that you might have failed to meet the needs of a family member, friend, or coworker. Talk about pressure! It's like having to take a thousand tests a day and needing a perfect score at each one.

And then if you do find yourself displeasing someone, it will be grounds for depression and a sense of failure. Either way, you cannot win. By virtue of only this one belief, you are destined to be anxious or depressed all the time. There are no other options

It gets worse. Others are quick to pick up on the fact that you are a people pleaser who is prone to guilt and therefore quite vulnerable to their manipulations. Because a corollary of the belief that you must please everyone is that you cannot express anger, for that would displease others for sure, you are going to be someone who tends to stuff and stack anger while incongruently wearing a smile on the outside.

You might find yourself saying “yes” when you would like to say “no.” Others are often quick to take advantage. You will find yourself resenting other people and seeing relationships with others as problematic and a source of anxiety. In the extreme, others will be perceived as so threatening that the only solution is to avoid then, leaving you isolated and alone. Having just this one belief can leave you feeling powerless, with lowered self-esteem, and full of anxiety.

In reality, we do not have only one irrational belief. We have many and these beliefs overlap and occur in teams. People with anxiety disorders tend to have a particular set of harsh, perfectionistic, and otherwise self-defeating beliefs, which serve to keep then stuck in their disorder. These thoughts are automatic, acting like a high speed computer. We are scarcely aware of them at all.

Much of our therapy is aimed at helping clients slow down their thinking and become mindful of their distortions. Once this new skill is formed, they can begin to participate in their reality in a different way, challenging anxiety producing beliefs, and plugging in more realistic ways of viewing themselves and the world around them. These skills of mindfulness and corrective self talk are vital to recovery from an anxiety disorder.

It would be impossible to have an anxiety disorder without having frightening self-talk, or “scare-talk.” An anxiety disorder is by definition a set of obsessive thoughts and compulsive behaviors centered on fear and worry. Those with an anxiety disorder are constantly caught up in “what if” thinking as well as “awful zing” and “catastrophizing.” Distorted thinking and anxiety provoking self-talk are at the core of anxiety disorders.

C arol sat in one of our eating disorder groups listening to a discussion about negative self-talk. Finally, she joined in, saying, “That may be true for the rest of you, but I do not have any self-talk.” Unaware of self-talk, she had never realized she had been disturbing herself with a steady stream of automatic messages. Upon further discussion, she began to see the childhood messages that influenced the course of her life. She had learned to see mistakes as unpardonable and a guarantee of rejection by others. Always vigilant, she had dedicated her life to making sure no one was disappointed and no one saw her make a mistake. By the end of the group session, Carol was a believer. If she was to recover from her anxiety disorder, it meant learned negative self-talk had to be replaced by more rational and compassionate inner dialogue.

Text Box: Extremely high self-expectation, perfectionism, “shoulds” and “musts,”   always dependable and competent

Many of our clients tell us they cannot be satisfied with what they have already accomplished. There is always more that needs to be done and with better results. Often they tell us they cannot possibly be perfectionists, as they make far too many mistakes. We point out to them that a perfectionist is not someone who does a perfect job, but rather someone who thinks he or she must perform perfectly in order to be acceptable. You are a perfectionist if you are someone who constantly places higher and higher hurdles in front of yourself, never able to rest on your laurels, never feeling like you quite measure up.

We ask our clients if they can comfortably and confidently say, “I am not perfect, but I am enough.” Those who can say it and believe it are on the right track. Those who cannot or will not are already stress casualties.

Shoulds” and “musts” involve inflexible rules about how you and other people “should” act. These rules become sacred commandments, guiding every aspect of your behavior. They are seen as right and indisputable with no deviation allowed. Any departure from strict adherence to the rules is accompanied with extreme guilt and anxiety.

One of our groups brainstormed a list of “shoulds” and “musts” they believed applied to them. Their group generated list follows:

1. I should always put others first.
2. I should never express anger.
3. I should not have conspicuous needs or wants.
4. I should not make waves.
5. I should not take time for myself.
6. I should not waste time relaxing.
7. I should not have fun.
8. I should not have expectations from others.
9. I should not get too close to others or they will discover my flaws.
10. I should not be a burden to others.
11. I should not trust.
12. I should not ask for help.
13. I should not make mistakes or fail in any way.
14. I should be perfect.
15. I should stay in control, always be on guard.
16. I should not say no. I should always be there for others.
17. I should please everyone.
18. I should be what others want me to be.
19. I should not be too visible.
20. I should not be comfortable with compliments.
21. I should accept criticism.
22. I should not be overly optimistic or hopeful.
23. I should not be assertive.
24. I should not have strong opinions.
25. I should not love myself or even like myself.
26. I should not act as though I have rights.

Years ago, the famous psychiatrist Karen Horney called this kind of thinking the “tyranny of the shoulds.” Anxious people tend to have extremely high stress levels generated by many such unreasonable demands on self. For the most part, the anxiety and stress is generated by such self talk or at least amplified by your own perfectionistic messages to self.

Some of these “shoulds” have especially destructive and far reaching results. For example, if you believe you should not express anger, the result will be much free floating anxiety, lowered self-esteem, and relationship problems. Other shoulds have similar widely extending negative consequences.

Text Box: Either-or thinking, catastrophizing

The central theme of Either-or thinking is the belief that the world consists of black or white choices. Things have to be either one way or the other. There is very little room for middle ground. People and things are good or bad, wonderful or horrible, successful or miserable failures. This polarized thinking leads to an either/or world where reactions to events swing from one emotional extreme to its opposite. Perhaps the worst problem with polarized thinking is the effect upon self-image and self-esteem. If you are not perfect or wonderful in every respect, then you are surely the worst kind of reject, a “worm” of a person beneath contempt. There is no room for mistakes. Each new day brings with it a thousand more tests. Anything other than a perfect score is ultimate failure.

Catastrophizing means that wherever bad things can possibly happen, surely they will occur. We are reminded of a Woody Allen movie in which his headache is certain evidence he has brain cancer. For anxious people, catastrophizing means that if bad things are possible, then they are not only likely to happen but need to be endlessly worried over. This "anticipatory anxiety" is a hallmark feature of an anxiety disorder.

Catastrophizing self-talk often starts with the words “what if.” What if this happened or that happened? If it can happen, then it probably will. The list of possible calamities is endless. Many anxious individuals tend to be chronic worriers. In particular, they may worry about being out of control with fear itself, as is often the case with anxiety attacks. Fearing a panic attack is often the way to generate one.

P hyllis thinks she learned to worry from her mother. Like mom, she is on guard against anything that could potentially cause distress, pain, or illness. “What if” thinking keeps her stirred up and robs her of any life enjoyment. She is not much fun to be around. Anxiety attacks are frequently fueled by the fear of another attack and the constant scanning of her body for signs of something wrong. As physical symptoms are found, Phyllis goes into a full body reaction. Rising anxiety combines with panic filled thoughts, leading rapidly to a full blown panic attack.

Text Box: Anxiety provoking “core beliefs”

Self-talk is the main way we distress ourselves, but that self-talk stems in turn from underlying core beliefs. Some beliefs are more important than others and more central to our thinking, emotions, and behaviors. These “core beliefs” influence everything we do and can generate enormous anxiety.

The most basic and distress “core belief” is the belief that “there is something really wrong with me” or “I am basically a bad, unworthy person.” You may have concluded from your family experiences that you are not good enough or worthy enough. As a result, feelings of inadequacy and failure predominate. You may be working hard to create a façade to hide a deep sense of inadequacy.

Text Box: Fear of not pleasing others, fear of rejection

The second “core belief” is “No one would love me as I am.” You may believe everyone would abandon you if the truth were known. You may have a fear of being too visible or getting too close to others. Surely, others will discover serious flaws if they get close enough. Outwardly, you may be projecting an image of being in charge of life, not needing help, of being unaffected by problems.

A third “core belief” is that “My needs for love and acceptance are never going to be met if I am truly myself, if I do not transform myself into a more acceptable version. I must be what others expect me to be if I am to get their love and acceptance.” This belief erodes away self-esteem and generates much hidden resentment, which in turn damages relationships. Of course, true intimacy is unattainable as long as your true self is kept hidden.

L arry feels hopeless. He cannot remember ever feeling adequate. As a teen, he avoided others, choosing loneliness and boredom over risking rejection. He was always positive that rejection would follow if others got close. Sure enough, Larry finished high school with only one friend, another social outcast like himself. Larry took this as evidence of his unacceptability, unaware of the existence of a self-fulfilling prophecy, the tendency to find evidence to support a dysfunctional belief. As a young adult, Larry alternates between withdrawing from social risks out of fear and trying too hard to please others. This strategy almost always backfires. Either way, he is unfulfilled, lonely, and convinced that life cannot be any different for him.

 Text Box: Feelings   stuffed & stacked

Are you able to express your feelings honestly and directly, without guilt? Do you believe you have a perfect right to tell others what you are thinking and feeling? If you are uncomfortable expressing anger or other feelings, you may be transforming buried anger into surface tension and anxiety. If you fear conflict or hurting others to the point that you carry hidden resentment, you may instead feel stressed and unable to enjoy life. As mentioned previously, the key ingredient in anxiety states and attacks is often suppressed anger.

Text Box: Reactive to perceived criticism

At the same time, you may find yourself very reactive to perceived criticism (with emphasis on “perceived”). If you are already self-critical and fearful of not measuring up, you are probably alert to any sign of disapproval from others. You may be so sensitive to this possibility that you perceive criticism even when none is intended. As a result, others may seem to be a constant source of anxiety.

Text Box: Need to appear calm, cannot relax

Many of our clients, particularly those whose anxiety is manifested as an eating disorder, feel a need to project a calm, unruffled image. Inwardly, a threatening storm is gathering strength and there is no relief in the forecast. If this description applies to you, recognize that you are a perpetual anxiety machine. You exert a lot of energy looking as though you are in control, while actually doing nothing to calm the inner storm. You are operating like a pressure cooker without a valve to vent the steam.

Text Box: Need to be in control at all times

If at the same time, you need always to be in control, you are probably already a stress casualty. Being in control means always being on duty, always hypervigilant. Everything is important. Everything must get your full attention. Besides, you can imagine someone watching, waiting for you to mess up. Can you conceive of anyone needing this kind of control and not being highly anxious? As we often tell our clients, “Over control is out of control.”

J ack prides himself on being invaluable to his organization. He arrives early, leaves late, and always brings work home. He believes he must fulfill all requests and keep everyone happy. Beneath his professional image he is fearful of falling short. He does not know how to relax and cannot recall relaxing in the past. He often feels he cannot keep up the pace. Others must not see his distress. He must keep going. He must maintain his image. Lately, he has begun to have anxiety attacks.

Text Box: Learned avoidance behavior

A word used repeatedly in our anxiety groups is “avoidance.” Ongoing anxiety generally means a lot of energy is being used to avoid whatever is perceived as scary, dangerous, or uncomfortable. At the top of the list of things to be avoided is conflict and angry feelings. Sometimes people are avoided out of fear of rejection or abuse. Perhaps the most consequential avoidance is avoiding finding out who you truly are. All forms of avoidance leave you stuck in your anxiety. If you don't deal with it, you can't heal it.

Text Box: Fear of failure

Fear of failure lies behind much avoidance behavior, particularly avoidance of taking risks. You might be so concerned about possible failure that you resist making the effort or even attempting something new. You may be so preoccupied with the fear of failure that there is no enjoyment of day-to-day life and family. Past successes count for nothing, as the possibility of a humiliating failure always seems to loom on your horizon, if not just outside your door. Think for a moment. How many of the things you worried about last year actually came true?

Fear of failure breeds paralysis, lack of fun, inability to relax, and severely limits success in life. Real satisfaction and real growth come to those who worry little about possible failures, and instead courageously take calculated risks that may get them much of what they want.

Text Box: Lack of self-nurturing , denial of needs and feelings

If we talk to you about your anxiety, we will ask you questions such as “What do you do for fun? How do you nurture you? Can you tell those closest to you what you need, what you feel?” If you are typical of our anxiety clients, your answers reveal someone who rarely takes time to relax and enjoy life, someone who does not act on needs and feelings directly. You might be someone who places everyone else’s needs first, feeling selfish if you focus on your own agenda. You may not take time to do things for you, often claiming you do not have the time or that other things are more important. In short, you may not be very good at taking care of you, or even believing you deserve it. You might be getting a low grade in carrying out your most basic mission in life, to simply take good care of yourself.

Text Box: Relationship problems

If you checked several of the previous boxes, it is very likely that you have relationship problems. Holding feelings in or denying your own needs and feelings is sure to get in the way of intimacy. Lack of assertiveness or fear of conflict results in hidden resentments and withholding of your complete emotional truth. If you cannot be fully honest with others out of fear of conflict, fear of hurting them, fear of their anger, or simply fear of being wrong, your relationship is blocked. It cannot grow. If you do not believe in your rights as a person and fear being seen as aggressive or selfish, you are likely to be manipulated by others, dislike yourself, and be full of anxiety.

Text Box: Stress of unmet needs

Stress of unmet needs is also a predictable result if you found yourself checking several boxes. This is particularly true if, for a long time, you have felt unsatisfied in your need for love and acceptance. You may feel perpetually lonely, tense, and worrisome, fearful of not being good enough for others to be there for you.

If you checked still other boxes, you may be someone who holds back from direct action aimed at getting you what you want. You may be paralyzed by the possibility of failure, or by a deep sense of not deserving to have your needs met. You may spend so much time focusing on the needs of others that you are out of touch with your own needs. This is the meaning of the much used (and misused) term “codependency.” In short, if you are not feeling fully empowered to guiltlessly and fearlessly take care of yourself, you are no doubt feeling the constant stress and anxiety of unmet needs.

J ane has had a series of failed relationships. Eager to please and fearful of rejection, she has given up herself in an attempt to get love and acceptance. Afraid to complain or say no, always focused on the needs of others, she has often felt victimized. Inwardly angry and resentful, she has not believed she could ever express such feelings and still be accepted. Increasingly, she has either avoided relationships or found ways to sabotage them before they got going. Now she finds herself dreading new encounters while feeling alone and unfulfilled.

Text Box: Shallow breathing and muscle tension

We really like the term “uptight.” It is very graphic and very accurate. If you are like most anxious people, you carry your tension in your upper chest, shoulders, neck, and head. You may be breathing shallowly and tensing upper body muscles when feeling stressed. In the extreme, you may have what is know as “hyperventilation syndrome,” breathing shallowly and rapidly, getting rid of too much carbon dioxide and upsetting your body chemistry. The result may be nerves and muscles feeling overly stimulated along with lightheadedness and an “unreal feeling.” These symptoms are so close to the feeling of an anxiety attack or panic attack that they may trigger an actual attack.

Anxious people breathe from their upper chest and often feel as though there is not enough air. If you imagine the shape of your lungs you'll quickly see that the least room is at the top. This is the area of lungs anxious people perpetually struggle to breathe from. Learning to breathe diaphragmatically is a key skill. Ongoing awareness of breathing that comes from breathing retraining puts you in touch with your level of anxiety and also presents you with the cues necessary to plug-in a learned relaxation response, effectively short-circuiting your anxiety reaction.

Muscle tension often results in chest pain, neck pain, and headaches. Worry over all these bodily sensations may lead to concerns over having a heart attack or losing control. As a result, more stress is experienced and an ever escalating cycle of anxiety takes over.

Text Box: Disregard of/or overreaction to emotional and physical signs

Some disregard emotional and physical signs when they should not. Physical signs can help alert you to take care of business. You may be someone who pushes on no matter what you feel. If you are physically worn down, you redouble your efforts instead of resting. Your favorite motto may be, “When the going gets tough, the tough get going,” or, “If at first you do not succeed, try, try, and try again.” For the first motto, we would like to add, “When the tough keep going, and going, and going, and going without listening to their bodies, they begin to break down.” As to the second motto, perseverance is a great quality if balanced by knowing when to reassess the situation, when to rest, and when its is healthier to quit.

Perhaps you are someone who overreacts or misinterprets emotional and physical signals. Typically, those with panic attacks fear they are going to die, go crazy, or do something embarrassing. These things don't happen.

Chest pain, although commonly stemming from anxiety, does need to be taken seriously. See your physician and rule out a medical problem. Most likely, it's a stress symptom and you'll get good news -- and one less thing to worry about. Once you know you are not dying, start using your symptoms to help guide you to deal with real issues.

L inda is terrified. She is convinced that her panic arracks are going to kill her. Surely, the next one will be worse and will probably be “the big one.” Other body sensations are equally scary. “There must be something terribly wrong.” When asked to demonstrate deep slow breathing, she complies with a mighty breath, but one that is quick and shallow. Like many others, Linda needs to be instructed in the use of abdominal breathing for self-calming and she needs practice. She will also benefit from relaxation training and learning how to relax tense muscles. She is literally “up tight,” carrying all her tension in her upper torso, neck, shoulders, and head, unaware that tense muscles and shallow breathing generate frightening sensations and more anxiety.

Text Box: Substance abuse, stimulant, high stress lifestyle

 We have been involved with drug and alcohol intervention and counseling for many years. For many, getting “clean and sober” is only the beginning. Often, they were anxious as teens, worried about fitting in or being good enough. Life may have seemed unpredictable and stressful until the discovery of alcohol and drugs. Finally, there was something that worked every time, bringing control and predictability. After years of using such a crutch to cope and feel in control, facing old anxieties cold sober can be overwhelming.

Using drugs and alcohol often generates more troubles and results in increased anxiety and depression. Many come to hate their drug of choice, but they hate facing life without it even more. They feel trapped and hopeless. Many feel suicidal.

We have been struck by how many of our clients with panic attacks report having had their first attack while using a drug such as marijuana or speed. They got more than they bargained for. Instead of a better feeling, they felt out of control and terrified. A new cycle of anxiety was created.

Stimulants include not only amphetamines and cocaine, but also caffeine. You may be someone who cannot seem to get going without jump starting your heart with several cups of coffee. One of the first things we ask anxiety clients is “Do you drink coffee?” and, “How much?” We frequently encounter high anxiety people with enough caffeine intake to wake up Minneapolis. Seem like an obvious connection? Cutting down on or eliminating caffeine may not entirely solve your anxiety problem, but it is a step in the right direction.

A high stress lifestyle speaks for itself. Are you able to relax and recharge your batteries? Do you have freedom from fear and worry? Can you calm down, rest, relax, and have fun? Are you able to rest on your laurels, put ambition on the back burner for a while, and believe you are “enough?” If the answer is “no” to any of the above questions, you may have become a perpetual anxiety machine. That's right, you’re doing it to yourself.

Type A behavior fits in here. That's the pattern where you feel intense competition with others, there is never enough time, and you must do better (the pack might be gaining on you). That description has long applied to many men and now increasingly applies to many women who often add the quality of having to be everything to everybody.

Text Box: Impact of significant personal loss, life changes, trauma

We all suffer losses. Change is inevitable. Your losses may be overwhelming or so numerous that you feel unbalanced. Changes, even positive changes, like getting a promotion or getting married, are stressful. If change has been very frequent, you are likely to feel stressed and very anxious.

Some changes require major adjustments: taking a job far from your support system or marrying someone with teenage children when you have never been a parent. Many of our clients come to us, not for a lifelong pattern of anxiety, but because they have found themselves caught in a very difficult situation.

Trauma is usually from something that forces a sudden and abrupt change, shocking and life altering. You find that you or someone close to you has a major illness. You are involved in a carjacking or lose your life savings. Some of our clients are Vietnam veterans whose trauma occurred many years ago. For them, change was the abrupt transition from high school and dating to the unrelenting horrors or war. The sheer magnitude of what they endured was so outside the normal experience that it can be fully understood only if you've been there. For many, the result has been a life of constant and extreme anxiety.

Text Box: Lack of meaning or purpose in life

Other questions we ask are, “What are your goals?” “What really matters?” These questions refer to a dimension of life know as “existential.” Often a major source of anxiety is the feeling that your life is empty and without meaning. Is there something in your life that gives you a real sense of purpose? Are you feeling involved with life and looking forward to what life may offer? Do you continuously create new and interesting goals for yourself, goals that give your life zest and meaning? Perhaps the most important questions are: “What is it that is really important to you anyway?” and “Is that what your life is about?” Existential anxiety is often at the core of long-term anxious and uneasy feelings.

Again, look back at the boxes checked and rated. If several were checked, you have a clear picture of what keeps your anxiety going and what needs to be worked on. If you checked only one box, it is likely to be a very important box. If no boxes were checked, you have either exceptionally good mental health (in which case, your problem with anxiety is likely to be physiological) or you are in denial.


Deepening Distress

 Many of our clients erroneously conclude that being anxious is their lot in life. They tell us that this is the way it has always been, so this is surely the way it will always be. Besides, they tell us, their family was an anxious family. That is just the way it is with the Johnsons, the Smiths, or (fill in your family name). Many delay seeking treatment for years, thinking there is nothing that can be done.

This thinking is most unfortunate. Anxiety disorders are highly treatable. You learned to be anxious. Learned behavior keeps it going, generating more anxiety. That’s good news! If you learned it, you can learn how to free yourself from excess fear and worry. You can learn to be free, to relax, and have fun.

We get satisfaction from working with our anxiety groups. It is a pleasure to see so much growth, often in a short period of time. It is the proof of everything we are saying.

Text Box: Stress overload

If you have a stress overload, you want relief. You feel intensely uncomfortable. There does not seem to be much pleasure in life. Physical and psychological symptoms have put a damper on quality of life. You have become a stress casualty headed for burnout, breakdown, or major illness.

Text Box: Drugs and alcohol may be used to self-medicate for stress and anxiety.  Other addictions and compulsions as well as eating disorders may develop.  More anxiety is created.

Many seek a quick fix through drugs or alcohol, but this kind of help is an illusion. Not only is your life still a mess when you are not using, but using complicates things and creates more stress, anxiety and depression. Other addictions and compulsions, such as gambling, sex, or excessive spending, only distract you from your worries and fears temporarily. In reality, all addictions are deepening your distress.

For years we have specialized in the treatment of eating disorders. In working with these very difficult problems, we have found it most useful to think of them as anxiety disorders. Anorexia nervosa, bulimia, and compulsive eating are not about food and weight. They exist as ways of mindlessly coping with extreme psychological distress through a numbing and distracting avoidance and a shift to obsessing about substitute problems. Food and weight are merely smokescreen issues. The real underlying issues are identity, self-esteem, relationships, rage, and raw fear. Perhaps the biggest anxiety these clients have is the anxiety that comes with avoiding a relationship with self. As is the case with other addictions and compulsions, a defense against anxiety turns out sooner or later to be the main source of anxiety.

If you are willing to work at it, and with the right help, you are going to get better. However, for many who may not believe they can change or are unwilling to seek help, there is deepening distress. Your stress load accumulates over time.

Text Box: Possible biological imbalances

As stress accumulates over time, there is more and more wear and tear on your body and emotions. Changes take place that weaken your immune system, exhaust your body’s coping resources, and even change your brain chemistry. These changes in turn make it harder for you to resist subsequent stressors. You may feel run down, unable to effectively meet new challenges. You may feel depressed, even hopeless, and your anxiety is increased.

Text Box: Push harder, cannot relax

As stress accumulates over time, you have essentially three choices: develop an addictive lifestyle, become a stress casualty, or find better ways to deal with life. You are most at risk if you are someone who meets pressure and stress with still greater effort, someone who cannot waste time relaxing, an “adrenaline junkie.”

Text Box: Ignore needs and feelings, ignore bodily signals, cannot have a problem, cannot ask for help

You may know you are in trouble, but cannot ask for help. You may have headaches, backaches, G.I. tract distress, sleep disturbance, anxiety, and depression, yet see no alternative other than looking in control and pushing on. Be aware that you are living a pressure cooker life. It is self-destructive. If you do not already have a full blown anxiety disorder, addiction, or other mental or physical illness, it is on the way.

Now the good news. From the preceding material, you probably have a good idea how you developed an anxiety disorder. You can probably see how you keep your anxiety disorder going. Congratulations! You have just taken your first step in treatment, understanding “Why me.”

Rather than believing your essence as a person is fatally flawed or that it is in your genes, you can now see how you were programmed by family, environment, and events. Using a computer analogy, the “program” is the problem, not you. It is time to write a new program, delete some files, update some, and creates some new files altogether. Helping you rewrite your program systematically, step-by-step, is our mission and the purpose of CALM. The end result? Freedom from fear and worry, freedom to be truly you.

© 2005 William Carey Shearer Ph.D., M.B.A., M.P.H

© 2006 Alternative Group, Inc. All Rights Reserved.
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