Posted on May 26, 2008

The psychological demands of recovery and rehabilitation form a complicated learning curve most patients are not emotionally prepared to handle. Recovery involves working through physical pain and discomfort and adapting to the constant interplay between losses and gains. Patients cycle through a myriad of feelings: frustration, anger, sadness. But moving toward rebuilding a functional life requires the critical skill of learning how to tolerate and negotiate anxiety.

The demands, both emotional and physical, of managing a chronic condition can make patients prone to anxiety as well as depression. Clients may exhibit a wide range of recognized anxiety disorders: generalized anxiety (GAD), obsessive compulsive disorder (OCD), social anxiety, post-traumatic stress, panic and phobias. If your patients struggle with any of these, it is important to immediately bring in a mental health team, as these are complex conditions that must be treated by the appropriate professionals. The common treatment for anxiety disorders is a combination of counseling, medication and cognitive-behavioral skills training.

Use of basic principles of anxiety management training can be integrated into sessions as a supplement to a solid mental health treatment referral. I encourage OT practitioners to work in conjunction with mental health professionals as they incorporate these strategies. Remember, individual patients may vary greatly in learning ability and capacity to tolerate the emotional and physiological stress these strategies may require.

Anxiety and Recovery

Kathy Lepper, LCSW, a psychotherapist who specializes in counseling chronically ill patients and is a chronically ill patient herself battling with neurological Lyme disease, provides further insight into understanding the nature of patients' anxiety:

"My patients experience anxiety on three levels; first they feel anxious on a global level. How are they going to make it, survive, support themselves or go back to work? Second, on a practical level, my patients have a lot of fear of functioning successfully in the world. Thirdly, they also have fears of how to independently manage the demands of their condition. My patients often express grief about their anxiety not being validated. I want to emphasize to practitioners that anxiety is to be expected. It is important not to judge patients and to give them the time they deserve to listen, support and understand the anxiety."

When untreated, anxiety patterns can become habituated and form a repetitive groove in the mind and body of each patient. These patterns can inhibit patients from taking appropriate risks and re-establishing their lives.

While all people experience anxiety throughout life, for persons with chronic conditions and disabilities, anxiety is often connected to traumatic medical events. It is essential to integrate anxiety management training in rehabilitation sessions so patients can learn these skills, not only to understand their anxiety triggers, but also to work through and recover independently from anxiety-producing situations.

Fear/Avoidance Patterns

The core of an anxiety symptom is the interaction between fear and avoidance; people with disabilities and chronic illnesses often have painful, traumatic and emotionally stimulating memories, which fuel this vicious cycle. Falling, unexpected hospitalizations, relapses, setbacks and loss of functioning are all vivid emotional references.

Anxiety for individuals with disabilities often occurs in two aspects. First, the challenges of daily functional tasks may stimulate fear depending on the disability. In addition, patients may have anxiety about the tasks of re-building a life: dating, meeting people, job interviewing and keeping up a schedule.

Annie, age 82, talks about the role that anxiety played in her life:

"Winters are really difficult. Winters to me mean falls. I fractured my hip three years ago. I just get a vision in my head of falling and it makes me anxious. I get terrified and then I wind up being housebound. I realized the fear would always be there. Now that I faced my anxiety, I don't categorize every bad weather day as a dangerous day and I pick and choose when and how to get out safely. I still hate the winter, but now have more options than just staying home. I always thought of it as a weather problem, but now I can see it is also an anxiety problem."

Lisa, 32, a wheelchair user with cerebral palsy, shares how she used a variety of techniques to work through her anxiety symptoms:

"Most of all, I learned not be ashamed of expressing my anxiety and asking for help. When I get an invitation to a party, my friends get excited. I get anxious. My mind starts racing, my heart beats fast, I break out into a sweat. I start going to a billion questions: How am I going to get there? How late am I going to be? How am I going to get home? Is it accessible? Now I take a deep breath, ask these questions ahead of time and repeat to myself, ?It is ok to be anxious.'"

Techniques

There are a variety of techniques that can be helpful to implement with patients. First, it is important to identify the way anxiety manifests in particular patient:

• emotional-feelings of fear,
  
• cognitive-anxious thoughts/thinking, or
  
• behavioral-physiological sensations or behavioral outcomes.

In sum, anxiety does not feel good. It is common for patients to feel like they are "going crazy" or losing control. Depending on the way a client exhibits anxiety, it is important to provide that person with the corresponding strategies.

Remember that there is no particular formula for anxiety management. Different stressors trigger patients in different ways, in varying sequences. The goal is to educate about a wide range of available techniques to enable patients to problem solve on an ongoing basis.

Psycho-educational. Identifying and educating patients about anxiety disorders is essential. This can reduce feelings of shame and aid patients in accepting assistance and understanding the nature of the treatment they need. The goal is to help patients develop empathy for their symptoms of aniety as a cue to problem solve, a signal to ask for help or a signal of what they need.

Validation. Validating a patient's anxiety involves identifying triggers-what makes them anxious or causes anxiety-and then identifying the particular sensations by which they manifest their anxiety. This can include questions oriented to the different aspects of anxiety, such as the following:

• What makes you anxious? (triggers)
  
• What do you say or think to yourself? (cognitive)
  
• How do you feel when you get upset? (emotional)
  
• What do you do when you get anxious? (behavioral)
  
• What kinds of sensations occur in your body when you are anxious? (physiological)

Rating anxiety/mood diary. Ask patients to get into the habit of rating their anxiety on a scale of 1-10. Keeping a mood diary or anxiety diary can help your patients establish a baseline, identify triggers and provide objective data on what they perceive their anxiety to be versus what they experience.

For example, one client I worked with would constantly say global statements to herself like, "This is going to be hard, I am going to freak out, I can't handle this." When she started rating her anxiety, she learned that she had a wider range of tolerance for anxiety than she had perceived. "I always thought I was a 9 or a 10, but sometimes I see that I am a 5 or a 6."

Behavioral planning. Helping patients to plan ahead of time for anxiety-producing goals or challenges can be very helpful. Behavioral planning, breaking down goals into small steps or using behavioral rewards can help to alleviate or moderate anxiety (see "Integrating Behavioral Skills," March 31, 2008).

Cognitive coping statements. A hallmark of anxiety is irrational, negative, catastrophic thinking patterns. In cognitive behavioral therapy, patients are taught to counter these cognitions with supportive, factual cognitive statements (See Worksheet ).

Stress management techniques. Working through anxiety is stressful even for the most skillful patient, so basic stress management techniques are essential. Incorporating techniques such as breathing, distraction or meditation can ease the secondary stress of confronting anxiety (see "Stress Management," April 28, 2008).

Exposure techniques. Another hallmark of anxiety management training is helping patients to face fears of things they avoid. This can be accomplished by using exposure techniques. OTs can problem solve with patients on ways to work toward goals-for example: walking in bad weather, planning a trip to the mall, learning how to cook again safely-in graduated steps.

The goal is to help the patient plan to experience a feared situation in small steps, both to re-establish the activity and work through the anxiety. This technique is sensitive, depending on the nature of the disability and the trauma history, so it is important to consult with a mental health professional when implementing it.

The most important point to impress on patients is that while there is no such thing as an anxiety-free life, it is possible, with effort and commitment, to be skillful at anxiety management. When patients learn to predict, control, manage or overcome their anxiety, they can move forward, tackling all the curve balls that it takes to build a meaningful life.

Dr. Reji Mathew is a psychotherapist/clinical instructor at New York University. Her clinical expertise is in integrative psychotherapy, particularly cognitive behavioral skills training. Reach her via email at rqm3463@nyu.edu .