The art of keeping calm (curious about worry)

Everyone worries at times, but when thoughts of disaster get the upper hand, it might be a good idea to seek help. Researchers at Karolinska Institutet knows how we all can become a little calmer.

HOW WILL IT ALL END? Regardless of whether it’s global threats or everyday blunders, it can be a good idea to keep a watchful eye on the future. By identifying impending disasters, big or small, we can at best avoid them. But when anxiety becomes excessive, it turns into a source of suffering in its own right.

It’s good to be aware that we're falling ill, for example. But for people with health anxiety, fear of diseases has become catastrophically troublesome.

“People who are anxious about their health worry about serious disease so much that it prevents them from living their lives to the full. This has major consequences not only for themselves but also for their families and relatives,” says Erik Hedman, psychologist and researcher at the Department of Clinical Neuroscience, who specialises in understanding and helping this group.

For people with health anxiety, common symptoms such as stomach ache, headache or small muscle twitches easily lead to worry that they have contracted cancer or some other serious disease such as ALS or multiple sclerosis.

Portrait of Erik Hedman.

According to Erik Hedman, approximately 3-4 per cent of the population suffer from health anxiety and the group is strongly over-represented among those who seek care. Around 20 per cent of all those who seek care have a heightened anxiety about their health, he estimates.

Worries on other themes also torment people with anxiety diagnoses such as social phobia, panic disorder and obsessive compulsive disorder. People with generalised anxiety disorder, GAD, are instead suffering from more general anxiety and easily fall into brooding about such things as their choice of career, academic performance, financial problems or that something bad is going to happen to their children. In short, things that most people can worry about in everyday life – but much more.

Strong anxiety or fear

But according to Erik Andersson, also a psychologist and researcher at the Department of Clinical Neuroscience, many people suffer from exaggerated anxiety without it motivating a psychiatric diagnosis for its own sake. Common to all forms of excessive worrying is a strong anxiety or fear that is perceived as difficult to control.

“Worry is part of many anxiety diagnoses but it’s also universally human. If you feel that things are missing from your life, for example that you can’t be totally present with your children because you’re too busy worrying, it might be a good idea to seek help to feel better,” he reasons.

It is a fine balancing act between having normal worry, which can also be difficult, and what researchers mean by excessive worrying.

Erik Andersson says he personally has learned to use worry as a driving force. It makes him for example see flaws in his research before it is too late, that he is ultimately more satisfied with his work, and avoids unpleasant surprises.

“To a certain extent it is of course good to worry; seeing threats and risks and reacting accordingly helps us in life. But at some point worry changes from being a problem-solver into a problem in itself,” he says.

We are all to a greater or lesser degree inclined to worry but our anxiety level changes over the course of our lives. Generalised anxiety disorder, according to Erik Andersson, appears relatively late in life, while most sufferers say they have felt fairly worried since childhood. Certain situations in life – having children is a common example – can cause worry to escalate into a problem.

Närporträtt av Erik Andersson utanför Aula Medica.
Erik Andersson, credit: Andreas Andersson.

When Erik Andersson recruited 140 participants to ‘The Worry Study’, a treatment study for people who worry excessively, he had a full complement within a week.

“We asked for anyone who feels that they worry overly much, with or without a diagnosis. So there were a lot of people who felt that it applied to them,” he goes on.

The treatment under study is based on a form of cognitive behavioural therapy, CBT, and takes the self-help book ‘Sluta älta och grubbla’ [Stop fretting and brooding] by psychologist Olle Wadström as its starting-point. Over the ten weeks of treatment, which is given via the Internet, participants read the book and learn different techniques (see the box) to reduce their worry.

Future threats

Worries often concern future threats – which can be anything from fatal diseases to having a puncture on the way to an important meeting – and how these threats can be avoided. But the aim of the treatment is not a more positive view of the future. According to Erik Andersson, it is on the contrary searching too intensively for solutions and comfort that characterise excessive worrying.

“Worrying is a chain of behaviour that switches between thoughts of disaster and comforting thoughts. First a person starts to worry about something that can go wrong and then tries to think up a solution in order to feel better. This might bring relief for a while but the problem is that it is not long before the next disaster thought appears, ‘what if it doesn’t work anyway’, and so the spiral continues. The person becomes very preoccupied with worrying and that’s a very exhausting state to be in,” he continues.

A more fruitful strategy according to Erik Andersson is to learn to live with the idea that things actually can go wrong. Then the spiral of worrying never needs to start. It may seem contradictory but to reduce their anxiety, the person needs to think more, not less, about what he or she is worried about.

“As with other forms of cognitive behavioural therapy, it’s a matter of subjecting oneself to what one’s afraid of under controlled conditions. A person who is afraid of dogs will not overcome their fear if they constantly avoid dogs. In the case of exaggerated worrying, it is instead their own thoughts that the person must learn to confront,” says Erik Andersson.

Preventing worry from escalating like this is easier said than done because it runs contrary to what comes naturally to an anxious person and initially leads to increased anxiety. But a recent study where the method was compared with relaxation exercises and a control group showed that the method was more effective than the alternatives and that anxiety was till lower a year later.

Erik Hedman has made three treatment studies using a similar method specifically designed for patients with health anxiety, also with good results. The treatment will be implemented in regular care during 2017.

He explains that a person with health anxiety, who begins to worry that they for example have contracted cancer, usually reacts by for example googling on their own initiative or getting in touch with the healthcare services in the hope of having their fear disproved. But this is something that Erik Hedman strongly advises against.

“More information doesn’t help against health anxiety because it’s not a lack of information that’s the problem,” says Erik Hedman.

Illustration showing a worry pill.

A reassuring answer only gives temporary relief from their health anxiety. It won’t be long before new symptoms appear and the anxiety spiral continues.

Nor is it exaggerated thoughts about falling ill that are the real problem according to the researchers but rather how the person reacts to such thoughts when they appear.

“Anxious people dare not have certain thoughts that they nonetheless have and that they will continue to have whether they like it or not,” says Erik Hedman.

Useless to try to escape

That it is useless to try to escape from ones anxieties has to do with the fact that life actually is uncertain. We can’t get away from the fact that we actually can contract diseases and that other terrible things can happen to us that we have no control over. So there’s no point to try to use our minds to guard against such things. Instead of explaining away our anxieties’ dire scenarios we should get to know them better.

Since the anxiety can intrude like an uninvited guest at any time – for example during a dinner party – it is easy to begin avoiding such situations. But according to Erik Hedman it is important not to limit one’s life too much but despite one’s anxieties try to live the way you actually want to.

He gives a few tips:

“When a worrying thought comes into your head, don’t dispel it but focus on it and think it all the way through, even if you’re at a dinner party for example. If you’re afraid of contracting a disease, imagine that you’ve actually fallen ill and that it might even result in you dying. Imagine what that feels like. Then try to shift focus and join in the conversation as usual, even though you know the troublesome thought is there,” he says.

A person who practises doing this will find that the thoughts in themselves are not disastrous but that life can go on in spite of them. Then the intense anxiety can begin to dissipate. The disaster thoughts may remain but the fear and the need to escape from them subside.

“The aim is to train one’s tolerance towards uncertainty and make it less frightening. Then you can function normally despite the negative thoughts,” says Erik Hedman.

Erik Andersson has not investigated whether the treatment of anxiety can also help against the psychiatric problem where worry is a component, such as obsessive compulsive disorder, panic disorder, social anxiety disorder or severe sleep disorders. But it’s not inconceivable.

Mentally very occupied

“These diagnoses differ from each other in different ways but something they all have in common is that one is mentally very occupied, some kind of worrying is going on. Breaking this spiral might have other effects than just reducing the worrying but we need to research that more,” he says.

When it comes to health anxiety, we know today that treatment not only has an effect against disease-related anxiety but also on the degree of anxiety in general.

“It’s thus not true that people who lose their health anxiety begin to worry about some other area of their lives instead, but on the contrary they become less worried in general,” Erik Hedman goes on.

But isn’t anxiety in some cases part of our personality that we have to live with?

“Heredity probably explains some of the variation in individuals’ propensity for anxiety and a certain degree of anxiety is of value to the individual. But it's not of any particularly great clinical help to explain anxiety by saying that one has an anxious personality,” Erik Hedman says.

But he has nonetheless investigated the link between personality and anxiety in his research. He showed in one study that the degree of neuroticism – a person’s tendency to experience negative emotions – is permanently decreased in people who have received treatment for health anxiety. Since neuroticism is considered to be one of the factors that make up our personality, the findings can be interpreted as an indication that the anxious participants in the study actually underwent a personality change.

The most important thing to take away from the research, irrespective of whether you have only a mild bout of superficial anxiety or are the deeply anxious type, is that it is possible to learn to be less anxious.

“It works, the effects are stable over a long period of time and do not cause any other problems. Help is quite simply available,” says Erik Hedman.

Text: Ola Danielsson, first published in Medicinsk Vetenskap nr 2 2017

Three routes to reduce anxiety

Here are a few techniques that participants in the CBT treatment for anxiety practise:

Conscious presence. Practise being more attentive to your worrying thoughts, describe them to yourself and keep them in your head. They will over time become less frightening.

Worst thought. Learn to dare to imagine the absolutely worst case scenario you can think of without trying to calm yourself.

Acceptance and exposure. Practise thinking ‘what happens happens’ and deliberately expose yourself to situations in which you are anxious.

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