MANAGING WORRY & GENERALISED ANXIETY DISORDER (GAD)

Transcription

1 MANAGING WORRY & GENERALISED ANXIETY DISORDER (GAD)

2 Contents Understanding Worry and Generalised Anxiety Disorder Worry Management Meet Amelia Meet Jay My own vicious cycle My targets for treatment Building motivation to move forwards Progressive Muscle Relaxation (PGMR) My worry diary My types of worry Managing my hypothetical worries: Worry time My worry time list Managing my practical worries: Practical problem solving Problem solving - my practical worry Reviewing your progress Relapse prevention Keeping my Low-Intensity CBT skills fresh Where to get more help My worry diary spares About the authors We would like to thank the Students, Practitioners and Therapists who have provided feedback on this workbook and it s design. The readability sore is 11.7 and the Flesch reading ease is 81. Calculated independently with Readability Studio (c) The right of Marie Chellingsworth and The CBT Resource to be identified as the author of this work has been asserted by them in accordance with the Copyright, Designs and Patent Act, All rights reserved. The booklet has been produced on the condition that it shall not, by way of trade or otherwise, be lent, sold, hired out or otherwise circulated in any form binding or cover other than that in which it is published and without a similar condition including this condition being imposed on the subsequent reader. Providing the source is fully acknowledged, all materials in this work may be freely copied, but for clinical purposes only.

3 Understanding Worry and Generalised Anxiety Disorder We all worry from time to time. We can also feel anxious occasionally. If you find that you have been worrying excessively, more days than not each week, it can be a sign of an anxiety problem called Generalised Anxiety Disorder, or GAD for short. People with GAD worry about what may happen in the future. For example, about their work or university life, their health or their relationships. This worry causes physical symptoms of anxiety and impacts on many areas of the person s life. Often people who worry with GAD describe themselves as having been a worrier most of their life. The anxiety and worry can get worse when there is a big life event happening, such as coming away to University or having tests and exams. If you have symptoms of GAD you may avoid things that make you feel more anxious. You may take more time than usual to get things done, wanting them to be right. You may also over prepare for things or you might keep putting things off until later (procrastination). All the worrying can make you feel tense in your body. You can experience more aches and pains, headaches, or stomach problems. Worrying takes up lots of your time and energy and can lead you to feeling irritable and struggling to concentrate on other things. The good news is that there are treatments that can really help. The National Institute for Health and Care Excellence (NICE) suggests CBT as a treatment to help to manage worry and GAD as it has a large evidence base. This workbook helps you to use worry management CBT techniques to help to improve your anxiety in easy steps. There is no set way to use this booklet. You may want to read it all first and then come back to complete the tasks. Others prefer to begin section on by section. Sometimes, people like to read about the other people who have experienced GAD and worry and how they used the workbook first. Just go at a pace that suits you. The important thing is to put what you learn into action in your daily life. Worry Management When you have excessive worry it can affect how you feel physically and what you do as a result. It can feel like you are always on edge. These symptoms can form a vicious cycle of worry and anxiety. Worry management helps you to break into this vicious cycle and improves it. It will help you to feel more in control of your worrying, rather than feeling like it is controlling you. Worry management has a range of techniques proven to help with worry and GAD. You don t have to start doing all of the things at once. It s a gradual process. The techniques in this workbook help to manage the physical symptoms you experience, help you to manage your worrying thoughts and problem solve any practical difficulties you may be experiencing. After a few weeks of using worry management techniques, you should start to notice that your symptoms begin to lift. You may have less worries or physical symptoms of anxiety. Read through the diagram below which shows the common symptoms that people with GAD may experience. Physical symptoms Tension in your muscles. Feeling irritable or on edge. Feeling tired. Problems with your sleep. Trouble concentrating. Digestive upset. Nausea. There are two examples of university students Amelia and Jay. They used worry management techniques through this workbook to feel better. As well as their stories, throughout the workbook they also share their tips to help you with things they found useful or challenging. Behaviours Worrying excessively. Putting things off (procrastinating). Over preparing. Avoiding things that are uncertain, unpredictable or uncontrollable. Seeking reassurance from others. Altered thoughts Lots of what if type thoughts about things that may happen in the future and about worrying itself. For example, What if I get in trouble at university What if my partner is late home What if my worrying keeps getting worse. 1 Marie Chellingsworth ( ). The CBT Resource. Marie Chellingsworth ( ). The CBT Resource. 2

4 Meet Amelia Meet Jay My worrying got a lot worse when I moved away to study at University when I was 18. I was worrying all the time about whether my assignments were good enough and if I would be able to complete my degree. When I felt anxious I would ask my housemates, friends and family for reassurance which helped me initially but the worries would always come back. I also worried whether my friends at University really liked me. I started to feel tense all the time. I couldn t get to sleep at night because I couldn t switch off all the worries that would run through my mind. I became concerned I was worrying so much I would never be able to complete my assignments. I thought my worrying had become out of control and that there was something wrong with me. My Personal Advisor recommended that I went to see the Student Support Service. With their help, I used worry management to help me to feel better. Physical symptoms Tension Difficulty sleeping Feeling sick Aches and pains I had always been a worrier, something my friends from school used to tease me about. When I moved to University my worrying became much more of a problem. I was worrying about my finances mainly. I worried if I would have enough money at University without having a part time job. I was always worried whether I was spending too much money on food and whether I would have enough money for the month or to pay my rent. I kept saying yes to shifts in my part time job as I didn t want to miss the chance to earn money but I was working so much it made me exhausted and then affected my studies. My sleep was really affected and I experienced bad headaches. I was also becoming irritable with my friends and family. I was having lots of what if thoughts about the future. I was worried about having to find accommodation for second year and whether this would be too expensive. I was also worrying who I would live with as I wasn t socialising with my friends because I was working so much, so I worried what they thought of me. Physical symptoms Headaches Sleep problems Restlessness Tension in my muscles This all resulted in me worrying so much that I was making myself ill and whether the headaches were a warning sign for this. My worrying had become a real problem. To help me learn how to manage my worrying I used the worry management techniques in this workbook. Behaviours Checking my assignments continuously. Seeking reassurance from my friends. Ringing my family for reassurance. Procrastinating. Altered thoughts What if I can t complete my course? What if I fail my exams? What if my friends think there is something wrong with me? What if my worrying has got out of control and I will never be able to stop? Behaviours Worrying excessively Checking my bank account Calculating my finances constantly Altered thoughts What if I won t have enough money for food? What if I spend too much money this month? What if accommodation is too expensive next year? What if no one wants to live with me? 3 Marie Chellingsworth ( ). The CBT Resource. Marie Chellingsworth ( ). The CBT Resource. 4

5 My own vicious cycle If this is something that fits with how you have been feeling, then you may be experiencing worry or GAD. This workbook is based on evidence based worry management techniques that can help you to help yourself to feel better. Physical symptoms Behaviours Altered thoughts Jay: It is important to plan your goals. This means whilst doing the treatment you clearly know what you want to work towards. This really helped me focus and stick to the treatment. I knew that this could help me slowly improve my worrying and work towards the goals I had planned. This is called a vicious cycle because the symptoms in one area have a knock-on effect on the other areas. These can keep you in a spiral of feeling anxious and worried. If you break into this vicious cycle in one area, you can have a positive impact on the other areas. The good news is that this cycle can be reversed. This workbook s techniques will help you to do this. You will learn more about how to do that next. 5 Marie Chellingsworth ( ). The CBT Resource. Marie Chellingsworth ( ). The CBT Resource. 6

6 My targets for treatment Imagine into the future and that the symptoms in your problem statement have improved and the vicious cycle of worry has been broken. What would life be like? What would you be doing? Answer the questions below and think how things would be different for you and what you would be doing: Where would you be going? (For example, I would be able to go on holiday. I would be able to focus on a task without losing focus, I would be able to go shopping by myself). If these are targets you would like to work towards in treatment you can make goals for them below: Goal 1: for example, see my friends every couple of weeks. Things I can do towards this goal in the next couple of weeks: Things that I can do towards this goal in the next month: Longer term things I can do to work towards this goal over the next six months or so: What would you be doing? (For example, I would be able to do the weekly shop for myself. I would be doing the weekly reading for my modules.) Goal 2: for example, make an appointment with my personal advisor. Things I can do towards this goal in the next couple of weeks: Things that I can do towards this goal in the next month: Longer term things I can do to work towards this goal over the next six months or so: Who would you be with? (For example, I would be spending more time with my flat mates.) Goal 3: for example, have regular meal times. Things I can do towards this goal in the next couple of weeks: Things that I can do towards this goal in the next month: Longer term things I can do to work towards this goal over the next six months or so: 7 Marie Chellingsworth ( ). The CBT Resource. Marie Chellingsworth ( ). The CBT Resource. 8

7 Building motivation to move forwards Thinking about the problem and beginning to work on the goals you have set, on a scale rate: How much impact does the problem have on my life currently? not at all affects everything Amelia: I wrote myself these letters, and it was very powerful. It helped me to see there was a way forward to help improve my worrying. I knew if I didn t make time to do this, that my worrying would continue; and could get worse. If I set time aside, I could learn to help manage my worries and get back to the things I wanted to be doing instead. Comparing the two letters helped me to see how much better life could be again. It really hit home! How important is it for me to reach my goals? not at all totally important How willing am I to set aside time to get better? not at all totally willing How much of a priority is getting better for me at the moment? not at all complete priority Some people find it helpful to complete the following exercise. This is useful if you are struggling with your motivation because of how you are feeling. Also, if you are struggling because of what the treatment may involve. Write a letter to yourself. It s five years into the future and you haven t set aside the time to get better or improve your symptoms. What would life be like? What would you be doing? Where would you be going? Next, write another short letter to yourself. It s five years in the future and you have made the changes to break the vicious cycle and feel better. How pleased are you? What changes has it opened up in your life? What would you be doing? Where would you be going? 9 Marie Chellingsworth ( ). The CBT Resource. Marie Chellingsworth ( ). The CBT Resource. 10

8 Progressive Muscle Relaxation (PGMR) Jay: I made sure I set at least 15 minutes aside each day for PGMR. I was feeling extremely tense from all my worrying, causing my muscles to ache. At the start, I found it quite hard because I was so tense. Once I started practicing twice each day I found this became easier. Don t give up straight away. You will slowly learn how to relax your muscles like I did, which helped reduce my anxiety. PGMR is an effective technique that breaks into the vicious cycle of worry and anxiety in GAD. It targets the physical symptom of tension. You can start to use PGMR straight away whilst keeping your baseline worry diary in the next section. For the first two weeks, aim to do PGMR twice per day at a set time. You should set aside around 15 minutes a day for each PGMR practice. It isn t a technique to do at a time when you are anxious, it is a skill that needs practicing daily at a neutral time. You should do it at a planned time once or twice a day, like after brushing your teeth in the morning, to get into a routine with it. It is a technique that works on the tension in your muscles we hold. We all have an amount of tension in our bodies. The amount of tension we have differs from person to person. We carry that tension around with us during the day and it can make us more anxious when we worry. The more anxious we are, the more tension we keep hold of and the more we can worry. The goal of PGMR is to help to break this cycle by reducing the muscle tension you carry in your body and helping your body learn to let go of any tension. PGMR helps your body to learn the difference between holding muscles tense and how they feel when relaxed. Through regular practice, the body learns to notice early signs when you are becoming anxious and to let go of the tension. You too will become more aware of tension and learn to relax your muscles, having a helpful impact on your anxiety. PGMR has a 5/15 time limit. You hold each muscle really tense for no longer than 5 seconds. You focus your attention on what it feels like when it is tensed. You don t want to hold a muscle tense for more than 5 seconds as it could lead to stiffness or cramping. You then let go of the tension and relax the muscle for 15 seconds and focus your attention on how that muscle group feels with the tension released. Really focus on the difference between feeling tense and relaxed. PGMR takes regular practice and you should keep doing it at a set time for at least three months. You should also use the worry management techniques for the specific type of worry you may be having. For the first two weeks you should aim to do it up to twice a day. Then move to once per day. Only do your PGMR practice at your scheduled time each day and not at any other times. 11 Marie Chellingsworth ( ). The CBT Resource. Marie Chellingsworth ( ). The CBT Resource. 12

9 My Progressive Muscle Relaxation (PGMR) Exercise Worksheet My PGMR daily plan My Progressive Muscle Relaxation (PGMR) Exercise Worksheet My forehead: lift my eyebrows as high as I can and hold them tense. I am going to practice my PGMR each day at: This is a time I can ensure I am free for 15 minutes and won t be disturbed. I am going to really tense a muscle group and hold it for 5 seconds, focusing my attention on how it feels. Then I am going to let go of the tension and relax the muscle and for 15 seconds really focus my attention on the difference and how it feels when that muscle group is relaxed. I can start from my feet working upwards, or down from my head. Before I start: Sit down comfortably in a chair and remember to take off my shoes. Remember: If you have an existing physical health condition, back pain, muscle spasms or injury (or develop one of these problems during the time you are using PGMR) then you must always check this out with your GP before using PGMR My face: tighten up the muscles in my face, around my cheeks and nose and hold it tense. My jaw: hold my jaw slightly open and tense it. My neck and shoulders: lift up my shoulders to my neck, put my head forward and tense. My right arm at the top: tighten my bicep muscle and tense it as if showing someone my muscles. My left arm at the top: repeat as above with my left bicep muscle. My right hand and forearm: make a fist and tense my lower arm and stretch it out, keeping it tense. My left hand and forearm: repeat the above with my left hand and forearm. My upper back and shoulder blades: stretch up my back and shoulder blades and hold them tense. Tensing my muscles Starting at my head or my feet, whichever I prefer, tense one muscle group at a time from my list. Hold the muscle really tense for 5 seconds. Focus my attention on what it feels like when tensed up. Don t hold for any more that 5 seconds. Remember the 5/15 time limit. Holding it too long can feel uncomfortable or lead to cramping. Relaxing my muscles When I have held the muscle group I am working on tensing for 5 seconds and paid attention to what it feels like, then it is time to relax that muscle group for 15 seconds. I need to focus my attention on what it feels like to release the tension and the difference in how the muscle group feels now it is relaxed. Once I have tensed and relaxed one muscle for 5/15, then it is time to tense and relax the next muscle group from my list in the same way. I should do this until I have worked through all the muscles on my list. Ending the exercise You may feel a little stiff after tensing and relaxing all your muscle groups using your PGMR practice. Stretch it out and then you can carry on with the rest of your day. My abdomen and lower back: pull in my tummy muscles and hold them tight and tense. My buttocks: tighten my buttocks and tense them up. My entire right leg: put my leg out and tense it all the way down. My entire left leg: repeat the above on my left side. My lower right leg and calf: tense my calf muscle in my lower leg. My lower left leg and calf: repeat the above with my left side. My right foot: curl up my toes and tense my foot. My left foot: repeat the above with my left foot. 13 Marie Chellingsworth ( ). The CBT Resource. Marie Chellingsworth ( ). The CBT Resource. 14

10 My worry diary We have two main types of worries. Practical ones and hypothetical ones. Jay: I found it useful to keep a pen and notepad at the side of my bed. I could then make a note of the worries I had when I was trying to get off to sleep and then refocus on the task at hand sleeping! It took practice though but it helped lots. The diary helped me to record down all my worries throughout the day. Keeping a baseline worry diary allows you to know the type of worries you are having. You can then make a plan for the best way to tackle them. How we tackle each type of worry differs. Hypothetical worries are worries that may also be about everyday things. However, there is no action you could take to solve the worry at the time you are having this. For example, if you are at university, in an important two-hour lecture about your assessments, you should be focused on what your lecturer is saying. That is where your attention should be. If you are worrying about your accommodation for the next term in that lecture, that worry has taken your attention away from the lecture room and what is being said at that present time. There is no action you can take at that moment, because you need to be in the lecture and hear what is being said. Therefore, at the time you had the worry, it is hypothetical. We deal with hypothetical worries using worry time. Practical worries are about practical external things in our life, that we could take action to solve, at the time that we are having the worry. For example, if you have a credit card and the interest free period is coming to an end and you are worrying about getting charged. You are at home and not engaged in another activity, so you can go onto a comparison site and switch the card. You may even be able to pay it off at that time. When we worry we tend to procrastinate and put off doing these things at the time, leading to us worrying about them more. The key to breaking the worry cycle is to take action you can take there and then. The problem solving technique can help you to do this. Keep the worksheet with you throughout the day. Each time you have a worry, fill in the diary. Try to be as specific as possible and record the real thought that went through your mind. For example, What if my Advisor is angry with me. Then, to find out if it is a practical or hypothetical worry, you can use the types of worry diagram. You can then tick to say if it is practical or hypothetical. You may find that you have worries when you try to get off to sleep. You may also find you wake up in the night with a worry on your mind. Keep your worry diary and a pen at the side of the bed and make a note of these too. There are some spare blank copies at the back of the workbook for you to use. My worry diary What type of worry am I having? Use the types of worry diagram to see if it is a hypothetical or practical worry. Tick the box to show what type it is: H P How anxious am I? (0=not at all anxious and 10=most anxious I have ever been) My worry (e.g. what if?...) Situation Where am I? What am I doing? Who am I with? What is going on around me? Date & time 15 Marie Chellingsworth ( ). The CBT Resource. Marie Chellingsworth ( ). The CBT Resource. 16

11 My types of worry Is my worry a practical problem that I can solve and should be taking action on right now, at the time I am having the worry? Yes this is practical worry No this is hypothetical worry Next steps: I need to take action on my practical worries when I have them, not put it off until later. If I need help to do this I can use practical problem solving Next steps: For my hypothetical worries I can use the worry time technique and shift my attention back onto the present 17 Marie Chellingsworth ( ). The CBT Resource. Marie Chellingsworth ( ). The CBT Resource. 18

12 Managing my hypothetical worries: Worry time Worry time is an effective technique to break into the vicious cycle of hypothetical worry. If you ticked lots of hypothetical worries on your worry diary, then this technique can teach you a way of managing them. Using worry time helps you to feel more in control of your worry. Over time, the amount of hypothetical worries that you have will reduce. You will find you are more focused on other things happening around you at the present moment, instead of your worrying. The technique means you plan a time each day where you can worry. In this time, you can worry as much as you want about the worries you had during the day. This becomes your worry time. You must make sure that the amount of time you set aside feels realistic. This is a time where you will not be disturbed and you can focus just on your worries. You need a time when you are not at work, busy with the children, cooking or watching TV. This time is just to worry. You should not use your worry time for problem solving practical worries. These should be dealt with as and when they arise. There are then three parts to follow to put the technique into action: Outside your planned worry time, you are going to write down any worries that come into your mind during the day. Just like you did on the baseline worry diary. If they are hypothetical worries, you write them down. You can then worry about them as much as you want in your worry time that day. If they are practical and there is action you can take there and then, you are going to do it. When you have had a hypothetical worry and written it down on your list, you then need to re-focus your attention on the present. If you have a truly practical worry (one that you can take action on right away at the time you are having the worry), then take action on it straight away and don t procrastinate. Practical worries do not need to wait until your worry time. You can use the problem solving technique in this workbook if you need help to do it. You don t need to save practical worries up. Remember, your worry time is just for those hypothetical worries. Keep your worry list by the side of the bed and write down any worries then too, then refocus using part two. When you worry, you are distracted off the present moment. When we are truly paying attention to what is going on around us, we don t worry. So refocusing helps to break into the cycle. The best way to do this is to pay attention to things going on around you. For example, get up and change room. Go outside and look at the view and notice what is going on around you. Really listen to the discussion on the TV or radio, or a piece of music. If you are worrying at night when you are trying to get off to sleep, refocus your attention on the sheets. Or onto any background noise that you can hear for example. It can be even more helpful when doing this to focus your attention on a task and pay selective attention to it. For example, if you are watching TV when you were worrying, listen in to a conversation, but add a task for even more effect. You could listen out for how often the people speaking use the word and or perhaps use a word that starts with your initial to refocus. Then, after a few minutes change the word or intial, then switch it back after a minute or so more and so on. If you are listening to music, focus your attention just on say the base line for a few minutes and try to zone out the other instruments, then switch and try to focus on the piano or guitar for example. This really helps you to learn to focus your attention. It is a skill that needs practice so you can also do this at other times to strengthen your ability to do it. The same worry may keep popping back in at first. That is ok and may happen for a while. Remember worry me takes practice as does learning to pay attention and refocus on the present. If a hypothetical worry comes back, just write it down again and refocus as often as you need to. The last part of worry time is to take out your list of hypothetical worries that you have written down since after your last scheduled worry time. Then for the full amount of time you set aside, you are going to do nothing but worry. Read through the worries on your list and worry as much as you want to about each one in turn. Keep your attention on the worry and worrying about it. Then, when you are ready to move onto the next worry. Ask yourself how you felt at the time when you wrote down the worry and how you feel about it now. Did what you were worrying about happen? If it did, how did you manage it? If it is no longer a worry for you, why is that? What would have happened differently if you had worried about them at the time instead of using worry time? At the end of your planned worry time, throw your worry list away. Then spend a few minutes reflecting upon how your worry time went. Did you need all the time you set aside? Was it enough time? Have you noticed anything with how you are managing your worries or how you feel able to deal with them? What other things have you done in your day as result that you may not have otherwise been able to do? Then get a new worry list out and ready. Always start again with a blank worry list after your worry time. Any worries you have afterwards or that night belong in the next day s worry time. This is then when you can worry about them as much as you want. As you practice your worry time each day, you will hopefully find the amount of worries you have goes down. After a week, if you find the amount of time you have set aside is too much, you can reduce this. 19 Marie Chellingsworth ( ). The CBT Resource. Marie Chellingsworth ( ). The CBT Resource. 20

13 My worry time list Write down all the worries that come into your mind during the day (or at night) until your next planned worry time. Remember to re-focus your attention onto the present moment once you have written a worry down. The same hypothetical worries may come back into your mind. That s ok, just re-write them on your list and re-focus your attention again. At your planned worry time sit and worry about the things you have written here as much as you want to. Then at the end of your worry time, throw this list away and start with a fresh worksheet. Managing my practical worries: Practical problem solving Problem solving is an effective way to break into the vicious cycle of practical worries. Practical worries are worries that we can and should act on when we are having them. They are worries that we should focus on dealing with when we experience them, rather than worrying about them. It allows a step by step approach to be taken. This helps to create ideas that will help solve the problem. The pros and cons of each solution can be weighed up before deciding which action to take. When we worry, your ability to problem solve can be affected. This can lead to not taking the action you need to. This can undermine your confidence when the next practical problem comes along. To use problem solving, you pick out what the practical problem is and when it needs to be done by. You then think through as many solutions as possible. These many even be ideas or things you would never do, as these help to create your ideas. Then put these into the order you would feel able to carry them out. Finally, make a plan to put your solution into action. Jay: Worry time is a very useful exercise. I recorded all the worries I had throughout the day and what came to mind at night. However, I knew I wasn t allowed to worry about them until my planned worried time. When my worry time came around I could then worry about all of the things I had written down and then throw the list away. Have you made sure you recorded all your worries throughout the day? Are you worrying too much outside off your planned worry time? Amelia: If you are having lots of practical worries then this is a good exercise to complete. It will help you deal with the worries you are having and find a solution to them. Writing the pros and cons of each solution is a great way for you to find the one most suitable. You can then carry this out and hopefully solve your problem, easing your worrying. Use the worksheet below to help you do this! 21 Marie Chellingsworth ( ). The CBT Resource. Marie Chellingsworth ( ). The CBT Resource. 22

14 Problem solving - My practical worry 1 Turn my worry into a practical problem What do I need to do and when do I need to do it by? 4 Make a plan to carry out the solution I have chosen What am I going to do? When am I going to do it? Will anything get in my way? How can I overcome that? Now put it into action - time to carry out my plan! 2 3 List as many solutions as I can on the table Don t rule out any yet, even ones that seem impossible or not sensible help to generate my ideas List the pros and cons on every solution I have come up with Then number them: with 1 being the one I feel most able to try out that is likely to solve the problem I have Potential solution Pros Cons Number 5 How did my plan go? Reflect here how it went, what do I need to do next? If it went to plan, what has it taught me? If I didn t solve the problem I should choose solution 2 and put that into action Amelia: If you are having lots of practical worries then this is a good exercise to complete. It will help you deal with the worries you are having and find a solution to them. Writing the pros and cons of each solution is a great way for you to find the one most suitable. You can then carry this out and hopefully solve your problem, easing your worrying. Use the worksheet below to help you do this! 23 Marie Chellingsworth ( ). The CBT Resource. Marie Chellingsworth ( ). The CBT Resource. Jay: If your first solution didn t work out, don t let this get you down. Go straight to solution 2 and try this. Put this into action and see if this works out better for you. 24

15 Reviewing your progress What is a relapse? It will take time to break the vicious cycle of worry, but these evidence based techniques will help you to do just that. Once you have used the worry management techniques for a couple of weeks it is a good time to review your progress Keep up your PGMR practice, this is something that you may want to continue even after you feel better. For best results PGMR should be practiced for at least three months. At first you may not notice any difference from the practice, but it will be working in the background to help you feel less tense. It will also break that vicious cycle of tension and worry. It is individual how long you may want to carry on with Worry Time. People often find the time they first thought they needed is too long! This means that they can reduce this down to minutes after the first week or so. Remember the time should be spent just for worrying about the worrying thoughts that you have collected throughout the day. Don t forget to refocus your attention on a task in the present when you write down your worries. Can I really go it alone or will I become unwell again? I would like to keep working on feeling better. Am I ready? I feel so much better! But will it come back? I don t want to look back.i want to look forwards, how can this help me? When you find that you no longer have many hypothetical worries to worry about in your worry time and that you can manage them by refocusing your attention in the moment, then you have broken the cycle. Practical Problem Solving is a technique that you only need to use for practical worries and so you may find you use this less often, or that you are able to solve the problems that arise without it. You can use this as much as you need, whenever you need it. It is great you have got this far! Now it is time to look at some techniques for staying well in the future. It is great news that you have completed your worry management treatment and feel better! Now it is time to think about staying well in the future. Next, we will learn more about everyday mood fluctuations. It is also important to know when you may be having a lapse or a relapse. You should know what the differences are between them. Using this relapse section will help you to manage your mood in the future. You can put your worry management skills back into action at any time you need them. Everyday mood changes It is normal for our mood to change day to day. Often more than once a day, depending on what happens to us! We all have times when we feel anxious for a few hours or even a few days at a time. We also have worries, a level of worrying is normal!. We just don t pay so much attention to them as they pop back out of our minds again. What do you do when you have a day like this? Try not to let how you are feeling, or any worries affect what you do. That s when that vicious cycle can take hold again. It is part of everyday life to feel this way from time to time. Be kind to yourself. Don t put yourself under too much pressure that your mood has always got to be positive and you won t worry you will. This is ok, we all worry! They key is not to let it form a cycle again and affect what you do. You have the skills to manage it. Amelia: I kept doing PGMR, I still do it now! It has really reduced my tension and I seem to sleep better and have less aches and pains. What is a lapse? Sometimes, you can lapse back into old ways for a few days. For example, you may avoid things because of worrying. A lapse does not mean that you have relapsed. Spotting it means you can act to break the cycle before it takes hold. Recognise a lapse for what it is. Try not to worry that it is a sign that you have gone back to square one. It isn t! If you spot this happening, it s a sign to put your skills into action again. What is a relapse? A relapse is when you start to feel the way you did before. Your physical symptoms and worries may return for several days in a row. If this should happen, you have the worry management skills to put back into action again. That should mean that the problem doesn t get as bad or last as long. Completing this guide can help you to spot early warning signs before that vicious cycle has a chance to take hold again. 25 Marie Chellingsworth ( ). The CBT Resource. Marie Chellingsworth ( ). The CBT Resource. 26

16 My early warning signs My regular review Make a note of the things that you noticed first when you were becoming unwell. How did it affect you physically? What where you doing or not doing because of this? How did it affect your thoughts? Sometimes others around us noticed these things before we do. Ask those close to you what they noticed first. These are things to look out for as early warning signs in the future. Remember though, that you may have some of these symptoms as part of a normal mood pattern. If they are affecting how you are feeling and what you are doing more days than not, it is time to act. Both Jay and Amelia suggest reflecting on how you feel now your worry has improved. This is useful in staying well. Write yourself a letter about how far you have come, how you are feeling and how you made that happen. Then, pop it into an envelope and address it to yourself. Put a reminder on your calendar or on your phone. This can remind you to open it and enjoy reading it again in 3, 6 and 9 months from today s date. Once opened, reflect on how you are feeling. Also reflect on the impact that making the changes you have put into place has had on your life since. Then re-seal it and put it somewhere safe you will remember for next time! You should take out your letter and read this again if you notice any early warning signs. This will motivate you to put your CBT skills back into action. This will help prevent your early warning signs from getting worse. Remember, you have helped yourself before. You can do it again! Amelia: I found it useful to write a letter to myself. It enabled me to see how my worries had improved and how far I had come. I knew I would be able to put my skills back into practice if I experienced any early warning signs. 27 Marie Chellingsworth ( ). The CBT Resource. Marie Chellingsworth ( ). The CBT Resource. 28

17 My regular review Keeping my low-intensity CBT skills fresh How has my mood been this month? Keeping check on my mood What do I remember are the key points of the worry management techniques that I learnt? Take a few moments to read through your intervention booklet again and practice the technique. Even if you are feeling well, this is a great way to make sure you know what you need to do if you need the skill again in the future. Do I feel confident enough to be able to use the techniques again if I needed to? Date of my next review day. Put this in your calendar or somewhere you will see it as a reminder. DATE: YES Have I had any of my early warning signs? For how many days? NO Reflect on the progress you have made since your last review and take a moment to think about what you would like to do in the next month to keep moving forwards Am I avoiding things because of how I am feeling, having negative thoughts that are affecting what I am doing, or have I been doing things to feel better, that only work in the short term? YES If yes: Do I need to put my BA skills back into action? If so what am I going to do and when am I going to do it? Use the questions below and the worksheet to keep your BA skills fresh NO Move to the next question and use the worksheet to keep your BA skills fresh Jay: Remember to keep your skills fresh. Make sure you feel confident enough to be able to use the techniques again. This is important in case any of your early warning signs appear again. When I found I was starting to worry again I knew I could apply the techniques I had learnt in this booklet. 29 Marie Chellingsworth ( ). The CBT Resource. Marie Chellingsworth ( ). The CBT Resource. 30

18 Where to get more help If you feel you are experiencing low mood, there is lots of help available to you. Do not be afraid to get help! Here is some information provided on the UEA wellbeing service, emergency contacts and some useful web links. These provide good information on student mental health. UEA Wellbeing Service: Contact Support Non- Emergency Mental Health and Disability Support: There is lots of self-help materials online on Wellbeing, Mental Health and Disability. The UEA Wellbeing Service website focuses on a few areas of selfhelp. These sources which are both useful and reliable. These can be found on The Wellbeing Service also offer highly effective group therapy workshops on themes including Stress and Anxiety. These provide very practical ways of managing issues you may have at times during your studies at UEA. You can find more about these workshops on the Wellbeing Service website: uea.ac.uk/student-support-service/wellbeing/ To book an Initial Wellbeing Consultation appointment contact the Student Support Service on You can also studentsupport@uea. ac.uk. This appointment will signpost you to the most suitable support. It may not be possible to have an appointment straight away at times of peak demand. UEA Student Support Services also provide other services including: Learning Enhancement UEA Accommodation Office UEA Dental Practice International Students Advisory Team Financial Advice General Personal Support Student Conduct and Harassment For more information on these can be found on the UEA Student Support Services website: You can also contact Student Support Services Reception on You can studentsupport@uea.ac.uk also. Emergency Contacts The University Wellbeing Service is not an emergency service. If you, or someone you are worried about, need support in an emergency situation, do not put off getting help. The following can be used in an emergency: Emergencies: 999 Fast medical advice in a non-life threatening situation: 111 UEA Security: UEA Nightline: (8pm-8am every night during term time). Samaritans: (8:00am to 9:00pm local call charges apply) or Freephone (24-hour service). The University Medical Service: (This is not a UEA telephone number so needs to be dialed in full). When the Medical Service is closed calls will be transferred to the NHS out of hours emergency service. Further web links Below are some useful web links with good information for student mental health. These also provide support and advice to help student s when they feel they are struggling. Mind also offer an app called Emoodji and guide to help students cope with the challenges of University life. If you are struggling with your mental health at University you can contact Mind s Infoline or your local Mind to get support. Remember, do not be afraid to get help. It is there to help you get better! 31 Marie Chellingsworth ( ). The CBT Resource. Marie Chellingsworth ( ). The CBT Resource. 32

19 My worry diary Date & time Situation Where am I? What am I doing? Who am I with? What is going on around me? My worry diary Date & time Situation Where am I? What am I doing? Who am I with? What is going on around me? My worry (e.g. what if?...) My worry (e.g. what if?...) How anxious am I? (0=not at all anxious and 10=most anxious I have ever been) How anxious am I? (0=not at all anxious and 10=most anxious I have ever been) What type of worry am I having? Use the types of worry diagram to see if it is a hypothetical or practical worry. Tick the box to show what type it is: H P What type of worry am I having? Use the types of worry diagram to see if it is a hypothetical or practical worry. Tick the box to show what type it is: H P 33 Marie Chellingsworth ( ). The CBT Resource. Marie Chellingsworth ( ). The CBT Resource. 34

20 What type of worry am I having? Use the types of worry diagram to see if it is a hypothetical or practical worry. Tick the box to show what type it is: H P How anxious am I? (0=not at all anxious and 10=most anxious I have ever been) About the authors Marie Chellingsworth I am Executive Director of CBT & Evidence Based Programmes in Norwich Medical School, UEA. I am also the Founder of The CBT Resource My clinical background is in mental health and Psychological Therapies. I have written many CBT Self Help books and workbooks for people with anxiety and depression and training for Practitioners supporting people with these difficulties. I have been involved at national level in training others in CBT for many years having worked at the Universities of Nottingham and Exeter prior to UEA and with the national IAPT programme. My own interest in mental health came from hearing a song called Howard Hughes (a B side of a band I love called Ride back in 1992!). Outside of work I love good music and spending time walking with my three Irish Setters Alfie, Monty and Perdy. My worry diary My worry (e.g. what if?...) Situation Where am I? What am I doing? Who am I with? What is going on around me? Date & time Shannon Bartram I have just recently graduated from UEA, after studying for my Psychology degree. During my time as a student at UEA I got a research internship with Marie evaluating self help materials readability and engagement factors within the England IAPT programme. I carried this on for my third-year dissertation. As part of my time at UEA as a student, I worked on an Alumni funded project with Marie and colleagues to write two booklets on being resilient for students at UEA on Health courses, and was then asked to help with these adaptation of Marie s published self help materials for students to give a student perspective. I am now an Associate Tutor at UEA, working on the IAPT programmes and updating course materials. I hope to go on to study further within the field of mental health and CBT in my career. 35 Marie Chellingsworth ( ). The CBT Resource. Marie Chellingsworth ( ). The CBT Resource. 36

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