Friday, February 24, 2012

CBT session #3: Anxiety triangle

Today’s session of cognitive behavior therapy was the best yet. I felt my mind figuratively expand, and lots of bells and lights of recognition went off.
My therapist reviewed the anxiety triangle with me, and it helped me tremendously in understanding my OCD and generalized anxiety disorder (GAD).
I won’t go into nearly the detail that my therapist did, but here’s an overview.

A copy of my therpist's notes. He illustrated his points as he explained the anxiety triangle. All the lines show the connections that the physical, thoughts and behavior have.

The three points of the triangle are the physical components of anxiety, thoughts and behavior.
A big message for me was that we cannot control what thoughts we have, but we can choose what thoughts to attend to and how we behave in response to our thoughts.
So we can control our attention and our behavior.
Another big message was this: the more we learn to tolerate and embrace our anxiety, the more we can appreciate and enjoy the time we have, the people we love and the small moments we live.
We’re going to work on this, my therapist said, a moment at a time.

The physical

As someone with OCD and GAD, I’m sympathetic dominant. I stay in the fight or flight mode a lot of the time.
That means tension, shakiness, fidgeting, difficulty relaxing, numbness, light-headedness and sometimes a feeling of floating.
Yeah, that’s me.
Interestingly, I revealed something about my level of anxiety without even recognizing it myself. I told my therapist about my writing exercise a couple of weeks ago, which I described here.
I told him that during the writing exercise, my anxiety level rose to a six or seven, but after the exercise was over, it quickly went down to a three or four.
“Like you hadn’t even done the exercise?” he asked.
“Yes,” I said.
Well, what I was saying was that I am nearly always at a level three or four of anxiety. As my therapist put it, I start out at about 5,000 feet on the mountain. My anxiety level rises to about 20,000 feet, and then returns to 5,000 feet. But I’m still at 5,000 feet.
Oh, my, I thought.


Someone like me, a worrier, tends to be biased towards danger. I pay attention to danger and ignore safety.
As an example, my therapist said someone with social anxiety might enter a room with a lot of people and wonder immediately, which ones don’t like me? That person would ignore the people with smiles on their faces and pay attention to the ones with frowns, even though the smiles and frowns had nothing to do with that person.
Along with the bias towards danger goes the tendency to underestimate one’s coping ability. A worrier like me would tend to think, I can’t handle it.
People with OCD also tend to experience meta-cognition, thinking about thinking. We tend to believe we should be able to control our thoughts. We tend to believe that if we think it, it’s as if we acted upon it. (He said you see this in scrupulosity sometimes, where people may have learned that thinking something bad was as sinful as doing it.)
The only things we can control about our thoughts are which ones we attend to and how we respond to them: our attention and our behavior.


My therapist said situation A might cause anxiety, but when we practiced a particular behavior that lowered the anxiety, that behavior was reinforced.
OCD offers lots of examples of this. We may be very anxious about our hands being contaminated. But after washing them for 30 minutes, the anxiety lessens. So our brain associates the behavior—washing the hands for 30 minutes—with less anxiety. And that is what the brain is going for—less anxiety. Avoidance can also lessen anxiety.
We get caught up in rituals and avoidances in order to lessen anxiety. But really, we’re perpetuating and reinforcing behavior that causes us much pain and suffering.

What comes next?

My next appointment is in a week. Until then, I’m to work on the writing exercises more. But I’ll also include timed editing sessions and then—the hardest part—I will show the writing to someone.
I also need to self-monitor. When I have the symptoms of anxiety, I need to note what I’m thinking and what I’m doing and share that information at next week’s session.
I am so excited and hopeful!
Does this anxiety triangle make sense to you? Would you agree that the physical symptoms of anxiety, your thoughts and your behavior can feed off each other?


  1. This is very interesting. I'll have to review the notes some more and think about this more. I do think all three things feed off each other. In the past, I would sometimes feel anxiety for no reason, then I would start to wonder, "what is wrong with me?" then I would do some sort of behavior to lessen the anxiety but in reality it would reinforce the anxiety and start the whole cycle again. I have learned now to (mostly) ignore free-floating anxiety and not give it any mental acknowledgement nor respond to it with any behavior. The more I do this, the easier it becomes.

    When I first started therapy, I had a very high base level of anxiety (like your 5000 feet). Because the base level was so high, it really didn't take very much to send my anxiety skyrocketing. I am very, very pleased to say that now, usually my base level of anxiety is often very low or even gone!

    Good stuff. Thanks for sharing.

  2. Thank you, Sunny. I'm glad that your base level of anxiety has gone down. That inspires hope in me that mine will go down too! I've been concerned about that because I didn't even recognize it--it seems so "normal" to feel this way.

    The scanned copy of my therapist's notes is difficult to read, but I wanted to show all the lines he drew to show connections. I hope to write more about what I learned.

  3. Excellent post, Tina. Thanks for sharing, and everything you say makes perfect sense to me. By the time you are done with therapy, you'll know enough to be a therapist yourself! The best part of your post was hearing how hopeful and excited you are about the wonderful to hear!

    1. Thank you, Janet! It's a new feeling for me, to feel this positive about getting better. I had "settled" for a long time on feeling "OK" with the OCD. Time to really get better!

  4. Rachel and I have always talked about how all of the aspects (physical, emotional, and behavioral) all feed off each other. Being sick can make me anxious. The stress from the anxiety makes the OCD thoughts worse. Dealing with the thoughts make me even more stressed and sometimes depressed. The stress and depression build up and effect my immune system which can make me even sicker. That's part of what's been going on with all the craziness, stressors, and triggers within the last few months. It is a vicious cycle how they can all feed off each other. How you feel physically effects how you feel emotionally which effects how you act and behave which can effect how you feel emotionally and physically. Everything is so interrelated. I've never seen it laid out as a triangle, but it all makes perfect sense to me.

    I also totally get the fight or flight thing. Rachel always tells me that there is a normal person's place on the fight or flight scale. Then above that is their place on the fight or flight scale when stressed or frightened. Then above that is my normal place on the fight or flight scale, so I'm always running at the top. Thus, when I'm triggered, I'm completely off the charts. That has a major effect on EVERYTHING, emotional health, mental health, physical health, EVERYTHING.

    We have worked hard to help me understand this all and bring my normal level down. Mindfulness helps. I've actually found a great yoga DVD that has helped immensely!

    It sounds like you have a wonderful therapist and a wonderful therapy plan. I'm so glad that you are gaining so much insight. It really helps you feel more peaceful just to understand what is happening and why. Then the how to deal with it, how to change the behavior, is much easier to understand. It's still difficult to put into practice. It takes a lot of hard work, but it's easier to understand, thus bring yourself back to center when the anxiety makes you spin out mentally and emotionally.

    1. Kat, You are so right. Understanding how the thoughts, behavior, and physical symptoms are inter-related does help. The causes of why I feel the way I do and think the things I do and behave the way I do aren't so mysterious now. There are reasons, and knowing those reasons helps me deal with them better.

      I have a lot of work ahead of me, but now I feel like it won't be in vain.

      Thank you for your insight. I am working on mindfulness too. What is the name of the yoga DVD that you use? I have done yoga off and on over the years, and it would probably help me to try again.

    2. This is the DVD I use. I know Elizabeth has it as well.

    3. I bought my copy at Target. I know it's also on Amazon and at Wal-Mart and such. It seems pretty readily available.

    4. Thank you, Kat! I'll be checking for it.


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