Saturday, September 24, 2016

7 Questions That Will Help You Overcome Anxiety, Fear and Panic

Anxiety, fear and panic are associated with irrational thoughts involving themes of threat or danger. These irrational thoughts take the form of “if” or “what if” beliefs. For example, a person who is afraid of heights may think, “If I am on the elevator alone and it gets stuck, no one will be able to save me,” or a person with panic disorder may believe, “If my heart beats too fast, it means that I am probably having a heart attack.” The “if” and “what if” thinking in anxiety disorders is a byproduct of your irrational thought patterns, including magnification, catastrophizing, overgeneralizing, and “should” and “must statements.” Sometimes anxiety is a result of genuine problems or situations that have no solutions. The seven questions that you ask yourself to overcome anxiety are as below:

  1. What is the likelihood of this happening?
  2. What is the evidence supporting my prediction?
  3. What are some other ways to look at this based on facts?
  4. Based on facts, what can happen most realistically?
  5. Can I cope with the most realistic outcome?
  6. If this is a genuine problem, can I problem-solve?
  7. Is it time to accept?
What is the likelihood of this happening?
Individuals with anxiety or panic overestimate the probability of a threat or a bad outcome in a particular situation. Overestimating the probability involves irrational thought patterns of overgeneralizing (e.g., if it has happened one time over past several hundreds of times, it can happen again), jumping to conclusion (e.g., it will happen despite no evidence to support it or evidence to the contrary), or “should”/“must” statements (e.g., it will happen because you have a rigid rule about it). For example, a person with panic disorder may feel that they will faint, if they feel dizzy. However, they may have never fainted before during a panic attack, but their irrational thinking makes them overestimate the probability of fainting. Another common irrational thought in people with panic disorder is that they will have a heart attack if their heart is beating quickly, even though they may not have any history or risk factors of heart disease and their faster heart rate could be explained by several alternative explanations such as doing physical work, drinking coffee, or just being excited.

Other questions you can ask yourself to challenge this faulty overestimation are as below:

  • “What are the odds of this happening?”
  • “Realistically, how likely is this situation going to happen?”
  • “How often has this happened to me in the past?”
  • “How often have I seen this happen to others?”
  • “Am I overestimating the likelihood of this situation to happen?”
What is the evidence supporting my prediction?
This question is particularly helpful to quell your catastrophic thinking about the severity of consequences of a situation. In catastrophic thinking, you believe that a particular outcome will be unmanageable and at the same time underestimate your ability to manage the outcome. Related irrational thought processes are “awfulizing” and “I-can’t-stand-it-it is.” Examples of catastrophic statements include the following:
  • “If I have a panic attack in a movie theater, it would be a disaster.”
  • “It would be absolutely terrible to faint.”
  • “I couldn’t manage if I were to panic on an airplane.”
  • “If I lose my job, it would be a complete disaster.”
  • “I must do everything I can to avoid experiencing a panic attack or else something horrible will happen.”
  • “I would not be able to manage if I were to have a panic attack at work.”
  • “If I have a panic attack, I would not be able to cope.”
One of the most important ways to challenge your catastrophic thinking is to look for evidence to support your worst-case scenario prediction. It is easier to identify irrational thoughts if you change the “what if” statement to a definite statement. For example, “What if the elevator runs out of air?” would be reframed as, “The elevator is going to run out of air.” Then ask yourself, “What is the evidence supporting my prediction?” 

Other questions that you can ask yourself are as below:

  • “Am I predicting that a particular situation will be more catastrophic or unmanageable than it actually is?”
  • “Do I know for sure if my prediction will come true?”
  • “If I have made similar predictions in the past, how often have they come true?”
  • “Do I have any proof that this situation is as dangerous as it appears?”
  • “Will I still think about this situation a month, 6 months, year, or five years from now?”
  • “When I think that I would not be able to cope, what does ‘not be able to cope’ mean?”
  • “Have I ever actually lost control before?”
  • “Based on my past experience, what is the worst thing that will happen?”
  • “What does my past experience tell me about the likelihood of this happening? 
  • “Am I underestimating my ability to cope with this situation?”

What are some other ways to look at this based on facts?
Another strategy that complements the previous approaches to challenge your underlying irrational anxious thoughts is to find more plausible explanations for the situation, thought, body sensations, or image that is causing you to feel anxious or fearful. For example, increase in heart rate may be due to several other factors such as climbing up a flight of stairs. A person who is anxious about making a presentation may arrive at another way to look at this if they tell themselves that people don’t care about how one appears during a presentation. Similarly, a person worrying about their spouse being half-hour late coming home from work can alternatively interpret this as their spouse either leaving work late or being stuck in traffic. It is not unusual for individuals with anxiety to jump to conclusions and arrive at the most fearful scenarios to explain an uncomfortable situation while ignoring the most common possibilities that may explain that situation.  

Based on facts, what can happen most realistically?
The next step in your effort to change your irrational anxious thinking is to pause, assimilate all the information you have gathered so far, and come up with the most realistic outcome for the situation that you predicted as dangerous or awful. Ask yourself, “Given the information I have now, what is the most realistic outcome in this situation?” If you are still convinced that the worst-case scenario is the only plausible outcome, then either you may have to dig deeper to challenge the anxious thoughts or you may have some underlying rigid assumptions or negative core beliefs (e.g., all dogs are dangerous or no one likes me). In addition, it takes practice and repetition to be able to successfully identify, challenge, and change irrational thoughts. You have had these thoughts for years and they are not going to change overnight. 

Can I cope with the most realistic outcome?
Once you have arrived at the most realistic outcome, ask yourself if you are able to cope with it. Most people with anxiety disorders underestimate their ability to manage an anxiety-provoking situation. Coping not only involves your internal resources, but also external resources such as getting help from friends, family, or support group members, and seeking advice from healthcare professionals. Ask yourself:
  • “How have I coped with this before?” 
  • "What other resources are available to me to cope with this situation?" 

If this a genuine problem, can I problem-solve?

Genuine problems such as not being able to pay your bills on time or not knowing how to go about furthering your education can also lead to anxiety and are best addressed by problem-solving and not by cognitive techniques such as challenging your irrational thoughts. The problem-solving steps are described next:

  • Define the problem in clear and specific behavioral terms, i.e., what specific behavior needs to be addressed or changed. You will be able to generate better solutions for a specific problem such as, “I have been postponing paying my bills for last two weeks and feel overwhelmed whenever I try to do that” versus the vague problem, “I can’t get anything done.” To get the specifics of a problem, describe it in terms of: Who? What? When? Where? Why? and How?
  • Define your goals in addressing the problem – what is your desired outcome? Goals are often stated beginning with the phrase, “How can I …?”
  • Brainstorm possible solutions to the problem. When brainstorming solutions, generate as many solutions as possible, don’t analyze or judge the possible solutions at this stage.
  • Weigh pros and cons for each solution.
  • Pick one solution and implement it. Sometimes a combination of solutions may work better as they complement each other.
  • Evaluate the effectiveness and make changes to your approach, if needed.

Is it time to accept?

At other times, there may not be a solution to your problem that is contributing to your anxiety and you may have to switch to an acceptance mode. For example, a person who finds out that their loved one has a terminal illness. Mindfulness-based strategies offer a way of acceptance to manage anxiety related to such unfortunate situations.  

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.


Saturday, September 3, 2016

Internet-Based Psychotherapy for Depression: Does it Work and What to Look For?

There are several internet-based psychological treatments available for treating depression. Most of the commercially available treatments are based on the principles of cognitive-behavioral therapy (Titov et al., 2014). Studies comparing internet-based therapy with face-to-face therapy demonstrate that internet-based treatments are as effective as face-to-face therapy (Andrews et al., 2010).
Similar to other evidence-based therapies for depression, internet-based cognitive-behavioral therapy is a structured program divided into modules with assigned reading, worksheets, self-assessments, and homework. This may not be suitable for individuals who prefer a less structured therapy. In addition, like traditional face-to-face therapy, internet-based approaches may take time to be effective. If you don’t see any effect within 3 to 4 weeks after starting an internet-based depression intervention, it may be time to discuss potential barriers to using the program or other treatment options with the therapist or clinician assigned to you through the program. Internet-based self-guided programs are not geared for crisis situations and shouldn’t be undertaken if one is at risk for harming self or others.

What to look for in an internet-based psychological treatment?

Internet-based psychological treatments come in various formats and some are freely accessible while others require a fee or an activation code. Some programs are self-guided while others are therapist-guided. Below are few questions that may help you evaluate these programs (Renton et al., 2014):

  • Is there a fee or physician referral required to access the program?

  • Has the program been evaluated for efficacy with at least one randomized controlled trial? Go to the research section of the program and look for the words “randomized” and “controlled” in the cited research as randomized controlled trials afford the highest level of evidence to support the effectiveness of an intervention.

  • What therapies/treatment approach(es) does the program offer? Research mostly supports cognitive-behavioral therapy approaches as being effective for depression with some evidence to support the efficacy of behavioral activation, interpersonal psychotherapy, and acceptance-based treatment (Carlbring et al., 2013; Titov et al., 2014).  

  • Who is the program designed for? The program should be designed for individuals with depression with or without anxiety.

  • Is the program interactive or only provides education about depression? Although education about depression may increase your knowledge about this condition, it is not a substitute for therapy-based interventions that interactive programs offer.

  • Does the program allow users to monitor their progress/modules completion and mood over time? A key ingredient for self-management of depression is monitoring your symptoms to gauge if the treatment is effective.

  • Does the program offer linking with a clinician or therapist (either your own clinician or a program-specific clinician)? What is the type of linkage (e.g., telephone, secure email, text message, etc.)? Research shows that clinician-guided programs have better outcomes and retention.

  • Does the program offer worksheets, either printable for offline use or integrated throughout the program? Are these worksheets mandatory or optional?

  • Does the program offer crisis or emergency contacts?

  • Does the program offer an assessment at the beginning?

  • Does the program offer additional features such as e-mail or text reminders?

  • Does the program offer peer-support (e.g., forum, personal story sharing, or blogs)?

  • Is the program available in the language of your choice?

  • How is the content delivered: size of text, audio or video inputs, use of character examples, and case scenarios?

  • What kind of personal or mental health information is required by the program and how is it kept confidential?

These questions will help you find a program that tailors to your needs in terms of accessibility, affordability, type of intervention being sought, and the extent of support desired. You may find answers to majority of these questions in the “Frequently Asked Questions” section on the program website. Besides affordability and accessibility, the other key factor in choosing the right program for yourself is that it needs to be evidence-based and documents the research supporting its beneficial effects. Don’t waste your time on programs that don’t cite any research to support their effectiveness.

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.



Andrews, G., Cuijpers, P., Craske, M. G., McEvoy, P., & Titov, N. (2010). Computer therapy for anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis. PLoS ONE, 5(10), e13196. doi:10.1371/journal.pone.0013196

Carlbring, P., Hägglund, M., Luthström, A., Dahlin, M., Kadowaki, A., Vernmark, K., & Andersson, G. (2013). Internet-based behavioral activation and acceptance-based treatment for depression: a randomized controlled trial. Journal of Affective Disorders, 148, 331-337.

Renton, T., Tang, H., Ennis, N., Cusimano, M. D., Bhalerao, S., Schweizer, T. A., & Topolovec-Vranic, J. (2014). Web-based intervention programs for depression: a scoping review and evaluation. Journal of Medical Internet Research, 16(9), e209. Doi:10.2196/jmir.3147.

Titov, N., Dear, B. F., & Andersson, G. (2014). Internet-delivered psychotherapy for anxiety disorders and depression. FOCUS, XII(3), 299-308.

Written by a board-certified psychiatrist and an international expert on self-management of depression, this blog focuses on proven scientific methods of treating depression that go beyond medications and traditional therapy. It discusses elements of healthy lifestyle, positive psychology, relationships, values, strengths, communication, and wellness. The content of the blog is not to be construed as treatment advice.

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