Cognitive-Behavioural Therapy

Panic Disorder is a serious problem and a condition recognized by the American Psychiatric Association that affects millions of Americans. This condition takes a panic attack a step further. Not only must you have experienced two or more attacks, you must also have had those attacks followed by a prolonged period of excessive worry over the possibility of another attack occurring. 

Anxiety attacks don´t occur because you are obsessing over something but rather they happen spontaneously, out of the blue, in places and among people you wouldn´t ordinarily associate with extreme apprehension. That is what makes these episodes so scary, the sheer unpredictability can be very troubling and cause the worry that turns these isolated instances into a disorder. 

The loss of control and fear are major contributing factors in turning isolated attacks into a disorder. Once you have panic disorder, your worry over another anxiety attack becomes pronounced and helps to foster an environment and feeling where attacks may only increase. 

In addition, avoidance tactics to prevent episodes may cause extreme harm to the normal functioning of your life.  Some of the symptoms associated with this disorder include:

Racing heart

Feeling faint or dizzy

Numbness

Hot or Cold Flashes

Excessive fear of losing control, dying or losing your mind

Muscle pain and discomfort

Chest pain and discomfort

These are just some of the symptoms and certainly if you have this problem you could be experiencing some, all or different sets of problems than what are listed here. Many people with this problem consult doctors, which is a smart course of action.

These symptoms can be very scary and they may be an indication that you have a serious medical problem. Getting checked out by a doctor is important to rule out any physical problems and provide some small measure of peace of mind about your suffering.

While consulting a doctor may rule out the need for multiple bypasses, it does not solve your problem. Panic attacks are still ruining your life. You can pay big bucks for psychological treatment or prescription medications to treat your anxiety and depression.

However, these options are not appealing to many people. There are alternatives. There are relaxation techniques that can be utilized to calm the overactive nerves and release the tension.

Many people are able to achieve positive results through a consistent exercise program where they work off accumulated stress and fill the body with endorphins, creating a positive feeling for a body and mind so sorely in need of it.

Many people also find that mind exercises such as meditation work to channel the anxiety into more positive pathways and release the negative build up. Meditation is a great way to control your panic attacks because it is fully portable. It can be done anywhere, at anytime and it soothes a worried mind and releases a lot of angst.

Meditation is something that anyone can learn and it really just requires practice and focus to become proficient. Using alternative techniques to relieve your worry is a great way to avoid the side effects and expense of prescription medications and therapy.

Panic Disorder is a serious problem and a condition recognized by the American Psychiatric Association that affects millions of Americans. This condition takes a panic attack a step further. Not only must you have experienced two or more attacks, you must also have had those attacks followed by a prolonged period of excessive worry over the possibility of another attack occurring.Anxiety attacks don´t occur because you are obsessing over something but rather they happen spontaneously, out of the blue, in places and among people you wouldn´t ordinarily associate with extreme apprehension. That is what makes these episodes so scary, the sheer unpredictability can be very troubling and cause the worry that turns these isolated instances into a disorder.The loss of control and fear are major contributing factors in turning isolated attacks into a disorder. Once you have panic disorder, your worry over another anxiety attack becomes pronounced and helps to foster an environment and feeling where attacks may only increase.In addition, avoidance tactics to prevent episodes may cause extreme harm to the normal functioning of your life. Some of the symptoms associated with this disorder include:? Trouble breathing? Racing heart? Feeling faint or dizzy? Numbness? Hot or Cold Flashes? Excessive fear of losing control, dying or losing your mind? Muscle pain and discomfort? Chest pain and discomfort? Bowel TroublesThese are just some of the symptoms and certainly if you have this problem you could be experiencing some, all or different sets of problems than what are listed here. Many people with this problem consult doctors, which is a smart course of action.These symptoms can be very scary and they may be an indication that you have a serious medical problem. Getting checked out by a doctor is important to rule out any physical problems and provide some small measure of peace of mind about your suffering.While consulting a doctor may rule out the need for multiple bypasses, it does not solve your problem. Panic attacks are still ruining your life. You can pay big bucks for psychological treatment or prescription medications to treat your anxiety and depression.However, these options are not appealing to many people. There are alternatives. There are relaxation techniques that can be utilized to calm the overactive nerves and release the tension.Many people are able to achieve positive results through a consistent exercise program where they work off accumulated stress and fill the body with endorphins, creating a positive feeling for a body and mind so sorely in need of it.Many people also find that mind exercises such as meditation work to channel the anxiety into more positive pathways and release the negative build up. Meditation is a great way to control your panic attacks because it is fully portable. It can be done anywhere, at anytime and it soothes a worried mind and releases a lot of angst.Meditation is something that anyone can learn and it really just requires practice and focus to become proficient. Using alternative techniques to relieve your worry is a great way to avoid the side effects and expense of prescription medications and therapy.

In recent years people suffering from anxiety have increasingly sought a variety of alternative therapies, approaches other than the two mainstream treatments offered by most professionals: cognitive-behavioral therapy and medication.

The desire to explore alternative approaches reflects a general trend both in the mental health field as well as in medicine. Recent surveys have found that about 40 percent of the adult population in the United States seeks out the assistance of alternative health practitioners, often paying out of pocket, to address a variety of medical and health issues.

Reasons for the move to alternative therapies are varied. For people suffering from anxiety disorders, dissatisfaction with conventional treatments, particularly the side effects of prescription medications, often leads to an exploration of approaches such as herbs, acupuncture, yoga, or massage.

There seems to be a desire to try natural approaches first before becoming dependent on medication. In addition, many people wish to take responsibility for their own recovery rather than relying on professionals who are often high priced, inadequately covered by managed care health plans, and sometimes not particularly empathic or understanding of their clients’ needs.

A large segment of the population seems to have decided that the time has come to take personal responsibility for their health and well-being, entrusting their doctors only with care in emergencies or severe illness.

How well do alternative therapies work? Are they effective in helping people to overcome anxiety disorders? Some alternative approaches, certain herbs and acupuncture, for example, appear to have direct, demonstrable effects on reducing anxiety symptoms or the depression that accompanies anxiety disorders in about 50 percent of cases.

Such approaches are most helpful to persons whose anxiety and/or depression is in the mild to moderate range. “Mild to moderate” means your symptoms are a nuisance, probably an inconvenience, and may cause you a certain level of discomfort. However, they are not disabling.

They don’t prevent you from working, managing the routines of daily living, or maintaining relatively satisfying relationships with loved ones. And they do not cause you severe distress, a feeling of being frightened or overwhelmed, more than half of your waking hours.

When anxiety phobia interferes with your ability to function and causes you significant levels of distress, it may be said to fall in the moderate to severe range. Such anxiety may be helped by alternative approaches, but is best treated by a combination of well-administered cognitive-behavioral therapy and medication.

The primary value of alternative therapies is their ability to improve your overall level of health and well-being. Such approaches work to make you feel better as a whole, rather than relieving a specific problem such as panic attacks, obsessions or a fear of driving far from home.

Their effect on anxiety symptoms is thus beneficial but indirect. Certainly if you feel better overall, you’re less likely to be vulnerable to anxiety or depression symptoms. But you’re also less likely to be bothered by any other stress-related symptoms, whether migraines, ulcers, low back pain, insomnia, or irritability.

Wellness involves multiple levels of your total being. If you feel more healthy and well in general, you’re not as likely to harbor the negative, fearful thoughts that instigate anxiety. You’re also less likely to hold the bodily tension and breathing restriction that can aggravate anxiety. It’s possible that even your brain neurotransmitters come into a better balance, improving your mood.

In general, you feel more confident and content with yourself and your life. Alternative therapies work to help you feel better as a whole person. That’s why they are often referred to as “holistic.” As such, they can definitely have a beneficial effect on anxiety and depression, along with everything else.

There is no precise formula for determining which of the many alternative therapies might be helpful for you. In reading through this article, listen to your intuition in deciding which particular approaches you feel drawn to try. Some trial and error is probably inevitable in the process of exploring those methods that ultimately turn out to be most effective for your particular situation.

Herbs and Supplements:

Herbs plant-based medicines have been an integral part of health care for thousands of years. In fact, about 25 percent of present-day prescription medications are still based on herbs. Pharmaceutical companies, however, are not very interested in herbs, because the plants from which they are derived cannot be patented and sold exclusively by any one company for profit.

Herbal treatments have been very popular in Europe and recently have gained increasing public interest in the United States. Most drug stores now offer an assortment of herbs that can treat conditions ranging from colds to poor memory.

Herbs tend to work more slowly and gently than prescription drugs. If you’re used to the rapid and intense effects of a drug like Xanax, you need to be patient with the milder effect of a relaxing herb such as valerian or kava.

The principal advantage of herbs is that they work naturally, in harmony with your body, rather than imposing a specific biochemical change, as in the case of drugs. Unlike medications, herbs generally have few or no side effects. Nor are they physically addictive, although you could become psychologically dependent on one that brings you consistent benefit.

Panic attacks are frightening! They are worse than being chased by Mike Meyers or pursued by Freddy Krueger. These acute episodes are particularly frightening because they can strike so unexpectedly. 

The symptoms and effects of severe anxiety can mirror actual medical problems, leading you to fear for your very life. Moreover, you lose control during an attack and can easily become the source of ridicule. The humiliation that people who contend with this problem feel is one of the main reasons that their lifestyles are so dramatically affected by this condition.

Stop avoiding activities, people and opportunities because you are afraid of having a panic attack. You can retrain your body and mind to confront difficult or disturbing stimuli with a calm demeanor instead of massive apprehension. 

While this certainly sounds good, actually achieving these results takes work, determination and practice. If you are willing to work at it, you can avoid prescription medication and deal with your anxiety through relaxation techniques.  While prescription medication and therapy can help with severe worry, they also have drawbacks. Prescription medications are addictive and have side effects. Both medications and therapy can be expensive and many people don´t like the idea of spilling their cuts on someone´s couch. 

There are tools, methods and activities that can be used to assist you in coping with panic attacks. You need to redirect the negative, worrisome thoughts that are plaguing your mind and manifesting in your physical body, with more positive attitudes. 

It´s a simple premise, but it takes work to achieve. You can conquer your fears; you have the power as long as you have the willpower. 

The secret to dealing with panicked thoughts is to retrain your mind to focus on the positive aspects of a situation rather than heighten the negative aspects. Panic attack sufferers tend to blow everything out of proportion. Their mind fills with one thought after another, each more disturbing than the last to the point where their mind and body become overwhelmed. The body goes into survival mode because the mind is telling it there is real danger. The sensations that course through our body cause even more worry and fear, heightening the possibility for subsequent attacks. 

There are alternatives to prescription medications, especially for mild and moderate anxiety sufferers. The key is releasing the tension in the body and trying to initiate the relaxation response in the body.

By initiating the relaxation response, you are taking the body out of survival mode. This allows sensation to return to your extremities, allows blood to flow more evenly and slowly throughout the body and enables your breathing to return to normal. 

Panic attacks affect and interfere with every facet of a person´s life. They make you afraid to try new things, take advantage of new opportunities and experience life to its fullest. Don´t let panic attacks beat you down and affect your life. Find outlets for your worry and start your recovery by finding ways to trigger the relaxation response.

Panic attacks leave a terrible impact on a person´s life. There are several symptoms that tend to disturb a person in many ways. An individual with panic attack disorder also lives in constant worry that he may have to soon suffer an attack and feel embarrassed in front of other people.

However, what most people are not aware of is that panic attack disorders are treatable, no matter how serious or intense the case. Experts in the field of medical science tend to recommend different types of techniques and therapies to facilitate the sufferer to lead a normal life. They believe that the disorder is a result of a combination of several environmental as well as biological factors just as other serious disorders like diabetes and heart disease.

People can be relieved of the scary symptoms via professional care. Success of the treatment depends and varies from one individual to the other. Some people may respond to a therapy within a few months while others may require about a year. The treatment method may also be made complex keeping in mind the exact state of the individual and intensity of the disorder.

The professional needs to understand whether the individual is suffering from depression or substance abuse. Sometimes, people may also suffer from more than one anxiety disorder. This also makes the treatment procedure, a little complicated.

There are certain steps recommended by the experts to people with panic attack disorder. Following these steps will help overcoming disturbing symptoms and even over-come avoidance of panic attacks.

Before following the steps given below, it is important to remember that avoiding places and situation that leads to occurrence of panic is not recommended. Avoidance tends to stimulate panic development.

Steps to follow:

a) Step one: Prepare a list: You must prepare a list of all types of safety behaviors you can imagine as well as exact reasons for adopting these. Also make a note of what you fear in case, you don’t follow these safety behaviors. 

b) Step two: Rate Behaviors:  You need to rate each of these behaviors on a scale of 1 to 10.

c) Step three: Prepare a list: Now, make a new list again and write down all the items in order of severity. The lowest severe should appear on top.

d) Step four: Rational alternatives: You need to have a look at all your reasons one by one. Now write down alternatives that are more rational. For instance, my heart seems to be fine hence, I can walk a little faster.

e) Step five: Decision to change: You must take the first behavior appearing on your list and try as hard as possible to resist it. Doing this will provide you an opportunity to understand that things are fine around you.

Please, visit my blog for related articles: www.PanicGoodbye.com/blog

The last two decades of the twentieth century saw an explosion of knowledge about different types of problems with anxiety and how to treat them. Seven major types of anxiety disorders were described:

A. Panic Disorder: Sudden episodes of acute, intense anxiety that appear to come out of the blue.

B. Agoraphobia: A fear of panic attacks in situations that are perceived to be far from safety or a safe place such as home, or from which escape might be difficult, such as driving on a freeway or waiting in line at the grocery store. This fear can lead to avoidance of a wide range of situations.

C. Social Phobia: A fear of embarrassment or humiliation in situations where you are exposed to the scrutiny of others or must perform.

D. Specific Phobia: A strong fear and avoidance of one particular object or situation, such as spiders, water, thunderstorms, elevators, or flying.

E. Generalized Anxiety Disorder: A chronic anxiety and worry for at least six months about two or more issues or activities, such as work or health.

F. Obsessive-Compulsive Disorder: Recurring obsessions, repetitive thoughts, and/or compulsions, rituals performed to dispel anxiety, that are severe enough to be time-consuming or cause marked distress.

G. Post-traumatic Stress Disorder: Development of anxiety and other symptoms following an acute and intense trauma such as a natural disaster, assault, rape, or accident or after witnessing an event that involves death or injury to another person.

Researchers and clinicians in both the United States and Britain have developed effective methods for treating these difficulties. Cognitive-behavioral therapy (CBT), the marriage of Aaron Beck’s cognitive therapy and Joseph Wolpe’s systematic desensitization, became and remains to this day the dominant and most helpful psychological treatment for all of the anxiety disorders.

Research and clinical experience has consistently demonstrated the efficacy of CBT. In its present form, cognitive-behavioral therapy consists of a combination of approximately six strategies, including:

1. Abdominal Breathing Training: Learning to breathe more slowly from your abdomen.

2. Muscle Relaxation Training: Learning to deeply relax all the muscles of your body.

3. Cognitive Therapy: Replacing catastrophic, fearful thoughts with more realistic, constructive thoughts.

4. Interoceptive Exposure: Desensitizing to internal sensations of anxiety.

5. In Vivo Exposure: Gradually facing phobic situations that have been avoided, often with a support person.

6. Exposure and Response Prevention: Refraining from compulsive behaviors when exposed to situations that would ordinarily provoke them.

With the advent of short-acting, high-potency tranquilizers in the 80s and selective serotonin reuptake inhibitor (SSRI) medications in the 90s, psychiatry has also developed effective psychopharmacological treatments for all of the anxiety disorders.

Current clinical practice often combines cognitive-behavioral therapy and medication, especially in the case of panic disorder, social phobia, and obsessive-compulsive disorder. Medications appear particularly helpful when anxiety symptoms are in the moderate to severe range of intensity.

If fear of rejection has led you to distance yourself from people, especially groups, there are several specific things you can do. First and foremost, you need to build a sense of your own self-worth. In addition to this, cognitive-behavioral therapy offers three specific types of interventions:

• Social skills training

• Graded exposure to social situations

• Cognitive-behavioral group therapy

Social skills training may be appropriate if you feel at a loss about how to converse with people in small or large groups. You can gain proficiency in starting and maintaining conversations, drawing other people out, listening, maintaining good eye contact, and achieving self-disclosure through role-playing these skills with a family member or a therapist.

You can also role-play more specific activities such as interviewing for a job, using small talk at a party, or asking someone out on a date. Once you gain confidence in such skills with a supportive friend or therapist, you can begin to try them out in real life.

Graded exposure to social situations involves setting up a series of specific activities that you commit to doing, either with the help of a therapist or on your own. The series of activities are arranged in a “hierarchy” from easiest to most difficult. A typical hierarchy might look like this:

INITIATING CONVERSATIONS:

1. Call two stores to ask if something is in stock.

2. Call a counseling hotline and talk about yourself.

3. Attend a small meeting and say your name.

4. Attend a small meeting and make two comments.

5. Repeat 3 and 4 with a small group of friends.

6. Attend a social gathering and stay for twenty minutes.

7. Same as 6, but stay for an hour, responding when other people talk to you.

8. Same as 7, but you initiate at least two conversations.

9. Initiate conversations while waiting in line with people you don’t know.

10. Walk up to someone in a shopping mall and make conversation.

You might also construct a hierarchy for one specific type of behavior, breaking it down into a series of steps. For example, in learning to ask someone out for a date, you might practice with people listed through a dating service before you try walking up to someone at a party.

Cognitive-behavioral group therapy, if available in your area, is perhaps the optimal way to overcome social anxiety and a fear of participating in groups. In such a group you work on challenging and countering socially phobic thinking i.e. self-statements such as “I´ll humiliate myself,” “People will think I´m weird because I don´t know what to say,” or “What if they see me blush?”

In addition, you practice speaking up, expressing your ideas, sustaining conversations, asking for what you want, responding to criticism, and engaging in other types of activities relevant to participating in groups. By continually practicing activities you previously avoided in a supportive group setting, you can learn to desensitize to them and gain confidence in yourself.

If cognitive-behavioral group therapy is not available in your area, you can still do the work with a therapist experienced in working with social anxiety or social phobia. Then you can try out what you´ve learned in various group settings, beginning with situations you deem “easy” and progressing to more difficult ones.

Learning to speak up or express your ideas, for example, can be practiced first in a class or workshop and ultimately at a toastmaster´s meeting or a similar training in public speaking.

Overcoming long-standing shyness or social anxiety takes work and sustained commitment on your part. You may find it somewhat easier under the guidance of a skilled cognitive-behavioral therapist who is familiar with social anxiety and social phobia. In some cases, medication can also be helpful.

Current treatment strategies for more severe social anxiety combine therapy with an SSRI medication such as Paxil (or a benzodiazepine such as Klonopin). This combination of therapy and medication seems to be very effective for many people.

In my blog I discuss in a series of 6 articles the personality issues on anxiety. Each article begins with a list of five questions to help you assess whether the particular trait applies to you. The remainder of the section describes the characteristic in more detail and then suggests strategies to help you overcome it.

Treating agoraphobia is difficult because you have to face your fears and who wants to do that?

The best way to confront it is a two-part program called cognitive behavior therapy. Cognitive behavior therapy seeks to help you understand the origins of your fear and face that fear head on.

By learning the factors that trigger your particular panic attacks and how to control them you can work with breathing exercises and relaxation techniques to help you battle through the symptoms or prevent them altogether.

Another part of therapy is facing your fears head on. If you are afraid to go to the supermarket, then you need to go but go with a safe person. The person you go with will be there for reassurance and to help you if you experience panic symptoms. Simply knowing that you have assistance if something were to happen is often enough to prevent a panic attack.

As time goes by you go to more and more places and realize that panic attacks are either not as severe or not occurring at all. You can then wean yourself from the safe person that has been accompanying you. Your mind and body have been trained and have learned that fears don´t come true and that anxiety can be diminished or go away entirely over time.

Addressing your panic attacks is the key to either preventing agoraphobia or managing and eliminating it if it has already developed. Good ways to cope and care for yourself while dealing with this disorder include:

1.  Don´t avoid fearful situations. The more you avoid fearful situations, the more you enforce that fear. Try to go to places that cause anxiety or fear because by confronting that fear your mind realizes, that the place or situation that seemed so fearful really isn´t. 

2.  Learn calming skills. Taking yoga, participating in meditating, learning relaxation or deep breathing techniques can all be helpful in terms of getting your mind and body in a place where it is not responding as forcefully to anxiety producing situations. 

3.  Practice relaxation techniques. Relaxation techniques include yoga, meditation and breathing but also include imagery techniques and positive thought redirection. 4.  Find Support. Talk to people about what you´re going through, you may realize that there are more people than you thought struggling with fear, anxiety, panic attacks and agoraphobia. Support groups are also a great help.

5.  Avoid alcohol and illegal drugs. A lot of people who suffer from agoraphobia turn to excessive alcohol or illegal drug use to ease the disturbing feelings that they have to cope with every day. You need to change your lifestyle, your habits and even some of your thought processes to make an impact and change your life. 

Agoraphobia treatment can include both medications and therapy or it can be treated with just therapy alone. If you´re on prescription medication, follow the instructions and take them as directed. The drugs that you might have been prescribed include Prozac, Paxil or Zoloft. 

Even if you have a prescription, more likely than not, it will not be the cure all you were looking for. The problem with drugs is that they have side effects and can eventually trigger dependency issues. However, for some people with acute problems, they may be the only answer to get short term relief. 

Relief over the long-term comes from changing your lifestyle and your thinking to better enable you to confront the situations that inspire such fear and anxiety and walk through the anxiety, realizing that you can handle it and come out the other side. 

Once both your body and mind realize that you can survive and manage the panic, the fear of them lessens, the need for avoidance decreases, the stresses and anxiety naturally diminish and you will find yourself able to go places and do things you weren´t able to before without having an attack or even worrying that you are going to have one. 

Exposure therapy as treatment for Social Phobia is exactly what it sounds like, exposing your mind and body to that which you fear. By gradually exposing and training your mind that the feared event is not as horrible as you think it is, you are working to desensitize yourself to the stimulus. 

A). During exposure therapy, you expose yourself to small doses of the feared event and increase the duration of exposure over time. If you are afraid of talking in groups, start by imagining yourself in front of groups, then speak in front of a couple of family members or close friends, then a couple of acquaintances and build up to a room full of strangers. 

You don´t need to pay someone to help you; you can work on this at home.

1. Start off imagining an event that causes severe anxiety, talking to your boss, asking a girl out, talking in front of your class, whatever it may be. Feel the anxiety, nervousness and agitation wash over you. After a minute or two, withdraw your mind from that situation. You have endured it and you are still here to tell about it. 

2. Increase your exposure time gradually and then work your way up to real life exposure to the situation.

B). Image desensitization is a great way and process to implement exposure therapy on your own or in a group setting. 

A great place to find support while you are working to desensitize yourself to the social phobia inducing situations is to work in a group with other sufferers. By rehearsing stressful situations within a group, not only do you know you are in a safe place where you will not be judged but you might learn from other sufferer´s coping strategies. 

The second part of the cognitive behavior approach involves retraining the thought process in your mind. For many anxiety sufferers, the immediate and instinctive thought reaction to stressful situations is negativity. Social phobic don´t see the glass as half full but rather half empty and dirty. 

It is important to substitute positive thoughts for the negative ones and not to overestimate the dangers, reactions and thoughts in any given social situation. You have a surprising ability to cope with what the world throws at you; you just need to uncover those resources. 

Cognitive restructuring is used to help social phobia sufferers uncover the thoughts that automatically flood their minds whenever they are in stressful situations.  The thoughts flooding in the head probably involve fears of messing up a story, sounding stupid, having people think you are an idiot or maybe they´ll just turn their backs and walk away, completely uninterested in anything that comes out of your mouth. 

Are these fears realistic? You need to test these notions to see if they compare with what will happen in the real world. You have told funny stories before, so you can probably do it again. Even if the story is stupid or uninteresting, the listeners would surely never be so rude as to turn their backs and walk away and most if not all will at the very least pretend to be interested. 

However, you could also tell an interesting and engaging story that starts you down the road towards new friendships and better interaction with colleagues. If you constantly look at and examine your beliefs and rationalize them it can chip away at the long-held, negative beliefs that are holding you back. You can train your mind not to react negatively in every circumstance and certainly not to overestimate or over exaggerate the negative.  

Approximately 30-40 percent of people who receive state-of-the-art treatment for their anxiety problems have limited recovery. They do not experience the relief they were hoping to find.

Of those people who do initially derive benefit from treatment, a significant percentage has a relapse after a period of time. In some cases the relapse is a temporary response to increased stress and may be overcome; in other, less fortunate cases, it seems to be enduring.

Why do some persons not get better in spite of good treatment? Why do others relapse? If you´ve not gotten better because you´ve not received appropriate treatment i.e., your therapist sat and just talked with you or tried some other form of treatment instead of cognitive-behavioral therapy, you need to keep looking until you find effective help.

So keep in mind that the reasons that follow assume you’ve already had proper treatment but have not improved as much as you would like.

1. YOU SHOULD CONTINUE TO PRACTICE THE BASIC TECHNIQUES AND STRATEGIES OF COGNITIVE BEHAVIORAL THERAPY.

Recovery from panic, phobias, obsessions and compulsions, or general anxiety requires consistent effort over a period of time. You need to make time each day to practice deep muscle relaxation, engage in aerobic exercise, challenge and counter anxiety-provoking self-talk, and incrementally face internal anxiety sensations or avoided external situations.

If you’re unable or unwilling to make such an effort during a course of cognitive-behavioral therapy, you will probably not benefit much from it. And if you don’t keep up with the basic practices of relaxation, exercise, and exposure following the completion of therapy, you increase your risk of relapse.

Recovery from an anxiety disorder requires a permanent change in lifestyle, with time allocated each day for practicing skills that keep anxiety and phobias from recurring.

If you find you’re having difficulty maintaining a commitment to the daily practices that can ensure your long-term recovery, there are a couple of things you might do.

First, you might arrange with your therapist to have periodic “booster sessions”, after you’ve finished therapy, to help you stay on track with your recovery program.

Second, if you live in a large metropolitan area, you can attend an anxiety disorders support group. Such a group needs to be a place where the focus is on what everybody is doing to maintain or enhance recovery, not just venting about their problems. If you don’t have a support group in your area, you can find support through message boards and chat rooms online.

2. YOU SHOULD TAKE MEDICATION WHEN IT’S NEEDED OR STOP TAKING IT BEFORE IT HAS OFFERED ITS FULL BENEFIT.

Often prescription medication is unnecessary. However, if your problem is relatively severe, you may well need to combine medication with cognitive-behavioral therapy to get the best results. By “severe,” I mean that your problem meets at least one of the following criteria:

• Your anxiety is disruptive enough that it’s difficult for you to get to work and/or function on your job, or it has caused you to stop working.

• Your anxiety interferes with your ability to maintain fulfilling and close relationships with family members and/or significant others, or it prevents you from establishing a relationship with any significant other.

• Your anxiety causes you significant distress 50 percent of the time you’re awake. It’s not just a major nuisance or irritation; you often feel overwhelmed and find it hard to get through the day.

If you believe your anxiety problem meets any one or more of these criteria, it’s likely you may benefit from a trial of medication subscribed by your doctor. Not to try medications because you’re afraid or philosophically opposed to them may hamper your recovery if your situation is severe.

3. YOU SHOULD MODIFY YOUR LIFESTYLE IN A WAY THAT SUPPORTS GREATER PEACE AND EASE IN YOUR LIFE.

Even if you’ve received cognitive-behavioral therapy and have taken the proper medication(s), your recovery may still be limited if your lifestyle is so complicated and busy that you continually keep yourself at a high level of stress.

Anxiety disorders are caused by three factors: heredity, personality based on childhood experience, and cumulative stress. You can’t do much about your genetic makeup or your early childhood, but you can do a lot to mitigate stress in your life.

If you reduce and manage your stress, you will reduce your vulnerability to anxiety. It’s that simple. Stress arises from both external and internal factors. External stress factors include things like work demands, rush-hour commuters, smog, food additives, negative relatives, and noise pollution.

These types of stressors usually require external solutions. Internal stress factors have to do with your own attitudes, such as overemphasizing success at the cost of everything else, or a tendency to cram too many things into too short a time. They require internal solutions, basically shifting your attitudes and priorities.

Many persons do not recover from panic or anxiety until they are willing to place as much importance on their peace of mind and health as they do on career success and material accomplishment.

4. YOU SHOULD NOT FAIL TO ADDRESS PERSONALITY AND INTERPERSONAL ISSUES THAT PERPETUATE ANXIETY.

Cognitive therapy and exposure may help you to change panic-provoking thoughts and face your fears. However, they may not modify core personality traits that predispose you to be anxious in the first place.

If you grew up with perfectionistic, overly controlling parents, for example, you’re likely to be perfectionistic yourself. Nothing in yourself or your life ever quite meets your overdrawn standards, and so you set yourself up for continuous stress.

Or if your parents were highly critical of you, you may have grown up with an excessive need to please and win approval. If you spend your life trying to please others at the expense of your own personal needs, you’re likely to harbor a lot of unexpressed resentment and thus be more prone to anxiety.

Insecurity, over-dependency, over-cautiousness, and the excessive need for control are additional personality issues common to people with anxiety disorders. Such core personality traits are often associated with interpersonal problems, i.e., perhaps you expect too much of your spouse (perfectionism) or you don’t ask enough (excessive need to please). Or you may resent your parents’ attempts to control you, but you don’t assert your needs with them.

5. EXISTENTIAL ISSUES

The problem at the root of your anxiety may lie still deeper than personality. Anxiety may persist in spite of therapy and medication because you experience a sense of emptiness or meaninglessness about your life.

In present times, with so many conflicting values and a loss of traditional authorities such as the church or social mores, it’s easy to feel adrift and confused. The very pace of modern life can lead to feelings of confusion, if not outright chaos.

What has been called “existential anxiety” does not respond to cognitive-behavioral therapy and demands a different kind of approach.

If your life feels meaningless or without direction, perhaps you need to discover your own unique gifts and creativity, and then find a way to meaningfully express them in the world. I believe each of us has a unique gift to offer, a unique contribution to make.