A Resource Book for Good Mental Health

Taking Care

of Yourself and

Your Family

A Resource Book for Good Mental Health Supported by beyondblue: the national depression initiative

John Ashfield

You can order more copies of this book by visiting the beyondblue website http://www.beyondblue.org.au under Get Information

Parts of this book may be copied for personal or professional use. Any other use requires that the usual provisions of copyright, such as permission of the publisher and proper acknowledgement of source, author and publisher, be observed.

Please note: The information and self-help resources in this book are not intended as a substitute for mental health assessment, medical or psychiatric consultation, assessment or treatment.

Published for beyondblue: the national depression initiative by Peacock Publications
38 Sydenham Road, Norwood, South Australia 5067 Copyright © Mid North Health, 2004

11th edition published March, 2010 Reprinted July, 2010
Reprinted October, 2010
Reprinted March, 2011

National Library of Australia Card Number & ISBN 978-1-921601-09-5 Printed by Peacock Publications, Adelaide

Acknowledgements

Preparation, Layout and Design

Ruth Loechel (editions 1-9)
beyondblue: the national depression initiative (editions 10, 11)

Editing

Cynthia Collins (editions 1-10)
beyondblue: the national depression initiative and SA Country Health (edition 11)

Professional Advisory Reference Group

Ian Reid
Men’s Health Consultant

Shane Montgomerie
Drought Counsellor, Mid North Rural Counselling and Information Service

Mark Cuthbertson
Rural Counsellor,The Flinders and Pastoral Rural Counselling and Information Service

Jim Herbert
Youth Development Officer, Regional Health Services Program

Jim Cawthorne
Project Manager, Rural Solutions SA

Marcus Connelly
Mental Health Social Worker, Port Pirie Regional Health Service

Community Advisory Reference Group

Booleroo Centre

Brenton & Melissa Koch Mark Reichstein Graham Zanker

Peterborough

Peter & Jan Malycha

Orroroo

Peter Barrie
Jim & Gaye Kuerschner

Jamestown

Mary & Dennis Clark

beyondblue and SA Country Health wish to thank contributors to the 11th edition: Australian Centre for Posttraumatic Mental Health and the Australian Drug Foundation.

iii

Contents

Foreword from SA Government ……………………… vi Foreword by The Hon. Jeff Kennett …………………. viii Introduction…………………………………………………… ix Depression …………………………………………………… 1 Anxiety ………………………………………………………… 41 Disturbing Thoughts……………………………………. 87 Recovery from Trauma ……………………………….. 103 Insomnia…………………………………………………….. 119 Con ict ………………………………………………………. 149 Anger …………………………………………………………. 159 Stress …………………………………………………………. 177 Relationship Violence ………………………………….. 217 Alcohol ………………………………………………………. 225 Substances and Mental Health ……………………. 253 Grief…………………………………………………………… 267 Key Services and Resources ………………………… 301

Perinatal depression and anxiety ……….. 315 Chronic illness and mental health………. 316 Aboriginal and Torres Strait Islanders … 318 Young people…………………………………….. 319

Sources used in the preparation of this book …… 320

You can order more copies of this book by visiting the beyondblue website http://www.beyondblue.org.au under Get Information or by calling the beyondblue info line on 1300 22 4636.

Foreword

As Australian rural communities and families endeavour to cope with the impact of the recent debilitating drought, it is very important to have good, practical reference material that helps by giving tips on maintaining and protecting their health and well-being.

Australians are acknowledged as having great resilience in times of difficulty and uncertainty, but living and working on the land in the face of extended dryness, challenges even the most resilient.

More recently, for those who have experienced the impact of extensive flooding in Queensland and New South Wales, and the devastating fires in Victoria, the need for helpful information is essential as they face the process of rebuilding their properties and indeed, their lives.

Although disasters such as flood, fire and drought are an integral part of the Australian way of life, the physical and psychological burden that these cataclysmic events place on those affected is immense.

The South Australian Government is working with rural communities to build local capacity and to sustain personal resilience in these challenging times. Providing ways to help people care for their mental well-being is crucial. It is equally important that we also care for our families, neighbours and communities by recognising emerging signs of problems that may require professional support. Early assistance and intervention can help prevent unnecessary distress.

Taking Care of Yourself andYour Family was written in close consultation with people living and working in rural communities, some of whom can readily identify with the effects that drought

or other events can have.The book provides valuable advice and reflects the most current mental health issues that rural health services and rural people themselves have identified.

The book is one of a range of South Australian Government mental health initiatives which aim to provide people with practical and relevant information and self-help resources.

The 11th edition of Taking Care of Yourself andYour Family is
an important collaboration between Country Health SA and beyondblue: the national depression initiative.The content and the helpline information have been revised to make it nationally relevant, drawing on beyondblue’s experience in tackling depression and anxiety across Australia.

Taking Care of Yourself andYour Family is a valuable resource for the Australian community, to maintain good mental health and well-being. It is important to remember that if you don’t take care of yourself and your own well-being, it becomes harder to take care of your family and those you cherish.

I commend this book to you.

The Hon. John Hill MP
SA Minister for Mental Health and Substance Abuse

vii

Foreword

We know Australians are becoming more aware that depression is not a weakness, but a condition that needs treatment.

We also know that Australian men aren’t good at looking after themselves. So, I’d like to encourage men to read this book and then, if need be, talk to their doctor about their mental health as well as their physical health.

If you broke your arm or gashed your leg, you wouldn’t expect that it would get better all by itself. Depression is the same – it won’t go away if you ignore it – in fact it can get worse and untreated depression can not only be a risk factor for suicide, but can make you susceptible to physical illness as well.

beyondblue, with the support of funds raised by The Movember Foundation is making this book – Taking Care of Yourself andYour Family – available free to people throughout Australia.You’ll nd helpful information and self-care strategies that may assist you to get through the tough times and nd the right help.

To order additional copies of the book or for more information on depression, anxiety and related disorders, and where to get help visit http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636 (local call).

The Hon. Jeff Kennett AC
Chairman
beyondblue: the national depression initiative

viii

Introduction

Initially, this book was compiled for use by people in rural and remote areas of Australia who have little or no useful access to the kinds of counselling and psychotherapy support that people in urban centres can generally take for granted.While the book targets rural and remote Australians, it’s also helpful for other people as well. Some people may be unable to access local mental health services due to the location and cost of these services, or due to work commitments and a lack of time.This book provides useful information and practical strategies to help promote good mental health for everyone.

Given the vast area of rural Australia, and the limited resources of community mental health services, it has proven difficult to focus effectively on measures of preventative mental health, as well as responding to the demands of mental health crises and people with longstanding mental disorders.

General medical practitioners are often frustrated in responding to the mental health needs of their patients, because they sometimes have little choice but to prescribe medication to control symptoms for which they would prefer to recommend psychological therapy, if it were available. Likewise, where a combination of medication and psychological therapy is needed, the former is often all that can be provided.

This book is not intended as a substitute for psychological therapy (or psychotherapy), or formal mental health assessment. But it does aim to provide an additional resource for prevention, early detection, intervention, self-help, and education in relation to some common mental health issues and mental disorders. Its design takes account of the known resourcefulness, self-reliance and resilience of many people who live in our often harsh and isolating rural and remote areas.

The topics covered in the book were chosen because they have been found to be the most recurrent themes encountered by doctors and other human service providers.

The intended uses of the book include:

• A source of basic information about a range of mental health and related issues.

• A guide for helping others, or prompting them to seek assistance, in the event of a mental health issue.

• A resource of strategies and self-help therapies that have been adapted from some widely used and documented standard psychological therapies.

• A resource that can be photocopied and self-help therapies that doctors can use as handouts for their patients.

• A resource for use in basic community mental health education.

• A resource for health and human service workers.
The content of the book is organised so that readers are not required to read any more information than they need or interests them. Problem identi cation checklists are placed at the beginning of relevant sections so that, even if no other part of the section is read, the checklist may be.
A number of the self-help resources (such as Structured Problem-Solving) are provided in more than one section, to avoid readers having to refer to another part of the book in addition to the section they are reading.
Language, practical examples, and some of the diagrams used have been selected in order to be gender inclusive, or ‘user friendly’ for men as well as women.
It is hoped that the information and resources of this book
will not only stimulate interest and concern about mental health issues, but will contribute something to the capacity of Australians to take care of their own and each other’s mental health – often despite limited professional services and support.
x

Depression

For more information about depression, visit the beyondblue website at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

DEPRESSIon CHECK

For more than TWo WEEKS have you: Tick if Yes 1. Felt sad, down or miserable most of the time? m 2. Lost interest or pleasure in most of your usual activities? m

If you answered ‘YES’ to either of these questions, complete the symptom checklist below. If you did not answer ‘YES’ to either of these questions, it is unlikely that you have a depressive illness.

3. Lost or gained a lot of weight? OR Had a decrease or increase in appetite? m

4. Sleep disturbance? m

5. Felt slowed down, restless or excessively busy? m

6. Felt tired or had no energy? m

7. Felt worthless? OR Felt excessively guilty? OR Felt guilt
about things you should not have been feeling guilty about? m

8. Had poor concentration? OR Had dif culties thinking? OR Were very indecisive?

9. Had recurrent thoughts of death?

Add up the number of ticks for your total score:

What does your score mean?

m m

_____

(assuming you answered ‘YES’ to question 1 and/or question 2.) 4 or less: Unlikely to have a depressive illness
5 or more: Likely to have a depressive illness

If you have some of these symptoms and they are affecting your life –

.TAKE ACTIon. Arrange to speak to a doctor

DEPRESSION

Thoughts about suicide or self harm are serious. If you are having these thoughts –

.TAKE URGEnT ACTIon.

Arrange to speak to a doctor OR

Phone a 24-HoUR MEnTAL HEALTH EMERGEnCY LInE

national

Lifeline: 13 11 14
Suicide Call Back Service: 1300 659 467

State and Territory
ACT: Crisis Assessment and Treatment Team: 1800 629 354 nSW: Salvo Suicide Prevention & Crisis Line: Metro

02 9331 2000
Salvo Suicide Prevention & Crisis Line: Rural 1300 363 622 Suicide Prevention and Support: 1300 133 911

nT: Mental Health on Call Team:Top End (08) 8999 4988 Mental Health on Call Team: Central Australia
(08) 8951 7777

QLD: Salvo Crisis Counselling Service: Metro 07 3831 9016 Salvo Crisis Counselling Service: Rural 1300 363 622

SA: Mental Health Assessment and Crisis Intervention Service: 13 14 65

TAS: Mental Health Services Helpline: 1800 332 388 VIC: Mental Health Advice Line: 1300 280 737

SuicideLine: 1300 651 251
WA: Mental Health Emergency Response Line: Metro

1300 555 788
Rural Link: Rural 1800 552 002 Samaritans Crisis Line: 1800 198 313

nATIonAL HELP/InFoRMATIon LInES

beyondblue info line: 1300 22 4636
Lifeline: 13 11 14
MensLine Australia: 1300 78 9978
Kids Helpline: 1800 55 1800
Australian Psychological Society Referral Line: 1800 333 497 SANE Australia: 1800 18 7263

Relationships Australia: 1300 364 277 Carers Australia: 1800 242 636

DEPRESSION

About Depression

Depression is more than just a low mood – it’s a serious illness. While we all feel sad, moody or low from time to time, some people experience these feelings intensely, for long periods of time and often without reason. People with depression nd it hard to function every day and may be reluctant to participate in activities they once enjoyed.

Depression is one of the most common mental health problems. Over one million people in Australia experience depression each year.

Everyone has a bad day now and then. There is no shortage
of life events that can leave us feeling distressed, disappointed or just plain lousy. The problem is when these kinds of feelings persist; when long-lasting changes in mood, feelings and behaviours develop into depression. And yet, on occasions, depression just seems to come out of nowhere, at a time when everything appears to be ne.

Many factors may contribute to depression including:

• a family history of depression

• hormonal changes (in women and men)

• emotional stress (e.g. bereavement, job loss, relationship breakdown)

• medicines (e.g. some cancer and heart medicines)

• medical conditions – such as thyroid and other hormone problems, or battling a chronic or terminal illness (see page 316 for more information on co-morbid chronic illness and depression).

• personality – the type of person you are and how you respond to life events
4

DEPRESSION

• social support – whether you have suf cient supportive people around you. People isolated on farms or station properties may lack important social support.

• life changes – major life events such as the birth of a baby may increase the risk of developing depression. See page 315 for more information on perinatal depression and anxiety.
What if depression is left untreated?
Getting the right treatment early is crucial to a person’s recovery from depression. Left untreated, an episode of major depression may last from six to 12 months or longer. Half the people who recover from an untreated episode of depression will slip back into their former state of depression within two years of their rst episode.
Depression is a serious disorder. Even ‘minor’ depression can become very disruptive to people’s lives – more so than many physical disorders. However, when depression is properly treated, most people can expect a full recovery.
What are the treatments for depression?
Different types of depression require different types of treatment.This may include physical exercise for preventing
and treating mild depression, through to psychological and drug treatments for more severe levels of depression.The major types of treatment for depression include psychological treatments, antidepressant medication, and self-help strategies.
For more information on treatments see beyondblue Fact sheets 4, 10, 11 and 24 and A Guide to What Works for Depression – a comprehensive review of all known treatments for depression, including medical, psychological, complementary and lifestyle, available at http://www.beyondblue.org.au or by calling the beyondblue info line 1300 22 4636.

DEPRESSION

IMPoRTAnT

• Self-help measures are no substitute for medication if medication is needed.

• Thoughts about self-harm or suicide are serious. Speak to a doctor or call a 24 hour mental health crisis line immediately.

DEPRESSION

Psychological treatments

Psychological treatments deal with problems that particularly affect people with depression.These treatments help people to change negative patterns of thinking and/or sort out relationship dif culties.

Psychological treatments can help to:

• change negative thoughts and feelings

• encourage the person to get involved in activities

• speed the person’s recovery

• prevent depression from recurring

• identify ways to manage the illness and stay well.
Psychological treatments include Cognitive Behaviour Therapy (CBT), which is one of the most researched psychological therapies and has a lot of evidence to support
its effectiveness in treating people for depression and anxiety disorders. It teaches people to think realistically about common dif culties, helping them to change their thought patterns and the way they react to certain situations. Behavioural therapy approaches have been shown to be very helpful for many anxiety disorders.
Interpersonal Therapy (IPT) is another psychological treatment which has been researched and found to be effective for treatment of depression. It helps people nd new ways to get along with others and to resolve losses, changes and con ict in relationships.
6

Psychological treatments can be provided by GPs, psychologists, social workers, occupational therapists in mental health, and psychiatrists. In some regions, particularly in rural and remote Australia, this type of therapy is not always available. Online options such as MoodGym (www.moodgym.anu.edu.au) are good alternatives if people aren’t able to access a mental health professional.

The self-help strategies provided in this chapter are based on psychological treatments.

If a person is only mildly or moderately depressed, psychological treatment alone may be effective. However, if depression is severe or persists, medication may also be needed.

MEDICARE REBATES

A rebate can be claimed through Medicare for ‘Psychological Therapy’ or ‘Focused Psychological Strategies’ when a GP, psychiatrist or paediatrician refers a person to a clinical psychologist, registered psychologist, social worker or occupational therapist in mental health.A rebate can

be claimed for part of the cost of up to 12 individual consultations (more in exceptional circumstances) and
12 group sessions in a calendar year. If the mental health practitioner bulk-bills, there will be no upfront charge and therefore no reason to claim a rebate.

For more details, ask your referring medical practitioner
or see beyondblue Fact sheet 24 – Help for depression, anxiety and related diorders under Medicare.
For a list of health professionals with expertise in treating depression, go to the beyondblue website: http://www.beyondblue. org.au and click on Find a Doctor or other Mental Health Practitioner or call the beyondblue info line on 1300 22 4636.

DEPRESSION

Antidepressant medication

There is a great deal of misinformation about antidepressant medication.

Antidepressant medications:

• ARE NOT addictive

• DO NOT change your personality

• DO NOT make people more dangerous
Antidepressant medication can play a role when people become severely depressed or when other treatments are ineffective in the treatment of depression. Deciding which antidepressants are best for a person can be complex.There is a range of factors that should be discussed with a doctor before starting antidepressants.
It’s important that any current medication or over-the-counter medications including herbal or natural remedies are reviewed by a medical practitioner before a person starts taking antidepressants.
Antidepressant medication can take 14 to 21 days before beginning to work effectively.The prescribing health professional should discuss differences in effects and possible side-effects of medications. Stopping medication should only be done gradually, on a doctor’s recommendation and under supervision.
Most people taking medication will also bene t from psychological therapies, which will reduce the likelihood of relapse after the person has stopped taking the medication.
The Therapeutic Goods Administration (Australia’s regulatory agency for medical drugs) and manufacturers of antidepressants do not recommend antidepressant use for treating depression in young people under the age of 18. For more information see beyondblue Fact sheet 11 – Antidepressant medication.

DEPRESSION

Self-help strategies

Any doctor can prescribe antidepressant medication – however, it’s important that people try to help themselves to recover and work towards preventing a relapse – with or without medication.

Self-help includes:

• managing thoughts and self-talk

• structured problem-solving

• activity planning and exercise

• reducing alcohol consumption to a moderate level

• managing stress

• restoring a pattern of normal sleep.
The activities in the following pages provide a range of different self-help strategies for managing depression.
What can I do to help someone who is depressed?
People who are depressed are not always easy to help because often, they are disinterested, lack energy and motivation,
can be irritable, and may not see the point of doing anything. Some people are not used to talking much – especially about themselves, so even getting a conversation going can be dif cult.

For more information, see A Guide to What Works for Depression at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

DEPRESSION

Useful tips for helping someone who may be depressed

• Think about the best way to approach the person – given what you know about his/her personality and temperament.

• Discreetly let the person know you have noticed a change in his/her behaviour. Indicate that you are seriously concerned.

• Talk openly about depression and suggest the person visits a doctor, or speaks to a health professional recommended by a doctor.

• If appropriate help the person to make the appointment; perhaps consider going with him/her – and follow up after the appointment.

• If you think the person won’t listen to you, consider: Who does this person usually con de in, feel comfortable with, and/or trust? Maybe that person could make the approach and encourage him/her to seek assistance?

• Provide the person with information about depression; give him/her a copy of this book or this section on depression – or refer the person to http://www.beyondblue.org.au

• Try to nd ways of reducing the person’s isolation:
– Make an extra effort to stay in touch, preferably in person. – Encourage other close friends and family to do the same.

• Encourage the person to excercise, eat well and become involved in social activities.
It’s unhelpful to:

• Pressure people with depression to ‘snap out of it’, ‘get their act together’ or ‘cheer up’

• Stay away or avoid them

• Tell them they just need to stay busy or get out more

• Pressure them to party more, or to wipe out how they’re feeling with drugs or alcohol

• Assume the problem will just go away. 10

DEPRESSION

Ø Thoughts about self-harm or suicide are serious. Be as determined and resourceful as you can in nding a way to get a person having these thoughts to speak to a doctor or appropriate health professional.

..HoW To TALK To SoMEonE ABoUT DEPRESSIon..

It’s not always easy to know how to help someone who may be experiencing depression. It can be hard to know what to say or do. Here are some tips.

• Talk to the person about how he/she is feeling.

• Listen to what the person is saying – sometimes, when people want to talk, they’re not always seeking advice, but just need to talk about their concerns. Make it clear the person has your full attention and you are listening properly. You may like to save any suggestions for a later discussion.

• Maintain eye contact and sit in a relaxed position – positive body language will help you both feel more comfortable.

• Use open-ended questions such as ‘So tell me about…?’, which require more than a ‘yes’ or ‘no’ answer. This is often a good way of starting a conversation.

• If your conversation becomes dif cult or the person you’re talking to gets angry: stay calm; be rm, fair and consistent; admit if you are wrong and don’t lose control.

• Often, just spending time with the person lets him/her know you care and can help you understand what he/she is going through.

• Encourage the person to seek professional help from the family doctor or a mental health worker.

• Take care of yourself. Supporting someone with depression can be demanding, so make sure you take some time out to look after yourself.

DEPRESSION

.REMEMBER
Ø Go out of your way and don’t give up on them.

Ø Just being with them, being present – even without much talking, can be very supportive and helpful.

DEPRESSION

Managing thoughts and self-talk

When people become depressed, they often think negatively about themselves (“What have I ever achieved?”,“I’m no good at anything”), their circumstances (“There’s no way out of
this mess”,“It’s all pointless…everything I’ve tried has just made things worse”), and the future (“Things will never really change, they’ll only get harder”).

How we think and what we say to ourselves in our head (self- talk) can have a profound effect on our mood and mental state.
It can also cause paralysis in problem-solving and decision-making.

Depression

Paralysis in problem-solving and decision-making

Negative

thoughts and self-talk

Worsening Depression

Becoming aware of our thoughts and self-talk, and learning the skill and habit of managing them, is essential to recovery from depression and, later on, preventing relapse.

There are basically two kinds of thought patterns we can use in responding to the things life deals out to us: one that is Self- Defeating, because it launches into negative thoughts and self-talk, and one that is Constructive and helpful, because it launches into sensible and rational thoughts and self-talk.

DEPRESSION

Mental Health

Consequences

− Worsened depression

− Feel angry and powerless

Self-defeating thoughts and self-talk

“I can’t even get on with my wife anymore” “Even my marriage is a failure”
“I’m useless at this like everything else”

Situation

Argument with wife

Physical Consequences

− Feel ‘sick’

− Knot in the
stomach

− Feel very tense
and shaky

Behavioural Consequences
− Will give up and withdraw, perhaps even get angry and make things worse

Mental Health

Consequences

− Feel regretful but OK because things are in perspective

Physical Consequences

− Feel a bit ‘wound up’ but am becoming calm

Constructive thoughts and self-talk

“I don’t feel good about this,but we are both tense and on edge” “Our relationship is OK. We will need to work this through when we are both calm”

Situation

Argument with wife

Behavioural Consequences
− Will seek to resolve problems

and relationships

Here are some examples:

Self-Defeating Pattern

Constructive Pattern

DEPRESSION

People who tend to use a self-defeating thought pattern in interpreting events also develop (mostly unconsciously) errors in thinking which, like ‘jumping to conclusions’, may seem to save time and energy, but can actually have consequences that demand much time and energy.

Managing thoughts and self-talk, and adopting constructive thought patterns, are essential for achieving and maintaining good mental health. It can be achieved through:

• becoming aware of how we respond to events (and what we think and say to ourselves in our heads)

• censoring and modifying our thoughts (especially those that are automatic) and self-talk

• challenging and dismantling errors in thinking.
Becoming aware
We can simply decide to become aware of our thoughts and self- talk. This awareness provides us with the opportunity to change them; it gives us the power of censorship. With practice, it is even possible to exert in uence over our automatic thoughts (challenging and dismantling errors in thinking will help this too).
To get this awareness underway, it is helpful to do some initial documenting of situations/events to be examined, the feelings experienced, and the thoughts that occur. This is also a good way to identify errors in thinking.

DEPRESSION

Situation/Event

Feelings experienced

Automatic thoughts (and self-talk)

An unexpected bill arrives that ‘throws’ my budget out.

‘Sick’ feeling in the pit of my stomach. Fear about how to cope with another bill.

“Everything just has to go wrong.”
“Like everything else around this place.” “There is no way we can cope with this.”

EXAMPLE

Practise ‘taking snapshots’ of situations, and write things
down like this. It can be quite revealing and is a useful way of establishing awareness. After a while, this can be expanded into the skill of censoring and modifying thoughts and self-talk.

Censoring and modifying

The key to censoring and modifying (or managing) thoughts and self-talk is the speed with which we intervene and ask ourselves: is this thought/idea (or what I’ve begun saying to myself) self-defeating or constructive? If it’s self-defeating, how can I immediately modify it or replace it so that I am using a constructive thought pattern?

This is a skill to be practised and a new habit to be formed. As with becoming aware, it can be really helpful (at least initially), to write things down. When we can ‘see’ our thoughts and what we are saying to ourselves, we have more power to change them.

DEPRESSION

Situation/Event

My thoughts and self-talk

Are these self-defeating or constructive?

If self-defeating, what would be constructive?

A friend, who you had arranged to come over and help you with something important, has left a message to cancel.

“Why is it me that gets let down?”
“This is typical of the way things go for me.”

Self-defeating, because I have reacted negatively and feel more flat and depressed than before.

Considering:
How do I know why he had to cancel? It could have been an emergency.
I’ve cancelled things too. There are other things I can do; this can be put on hold. Everyone feels let down sometimes — that’s life.

Situation/Event

My thoughts and self-talk

Are these self-defeating or constructive?

If self-defeating, what would be constructive?

Situation/Event

My thoughts and self-talk

Are these self-defeating or constructive?

If self-defeating, what would be constructive?

“One of these days something might just go right.”

Challenging and dismantling errors in thinking

Errors in thinking consist of certain assumptions and ways of thinking that keep recurring, are habitual and allow us to ‘save’ time by not thinking constructively about events. They provide an easy response, but one that is neither time-saving nor helpful. Errors in thinking ‘save a penny and spend a pound,’ because their consequences heavily tax our energy reserves and contribute to depression.

Errors in thinking need to be challenged and revised if we are to establish a constructive and healthy thought pattern.

Common Errors in Thinking:

DEPRESSION

— Mind-reading: — Catastrophising:

— Labelling:

— over-generalising:

“She thinks I’m a failure;”
“They think I’m not as good as…”

“Everything always turns out bad for me;” “Things are always against me;”
“Now I will never be able to…;”
“No matter how hard I try everything always goes wrong”

“I’m an idiot;” “I’m a failure;” “I’m a lousy…” (Instead of:“I did poorly;” or “I did not achieve…;” or “I needed to…”)

Saying,“Always,” “Never,” “No-one,” or “Everyone”

— Fortune telling:

— ‘Rule saying’:

— Black and white thinking:

“Everyone is sure to…..;”
“I’m sure to mess it up;”
“It’s going to be a disaster;”
“I’m sure to feel dreadful when I…”

“Should,” “Must,” or “Have to” (setting sometimes unrealistic expectations)

“Everything she does she gets right;”
“I’ve completely ruined everything;”

“He succeeds in everything… I never get it right!”

Examples you can think of: —
—
—

—

DEPRESSION

Structured Problem-Solving

It’s common for people who are depressed to feel stressed and overwhelmed by problems. Adopting a new way of tackling problems can be very helpful.

Structured problem-solving is a method designed to help you feel in control of your problems, and to enable you to deal more effectively with future problems.

The key elements of this method include:

• Identifying and ‘pinning down’ the problems that have
contributed to you feeling overwhelmed

• Thinking clearly and constructively about problems

• ‘Taking stock’ of how you’ve coped in the past: your personal strengths, and the support and resources available to you

• Providing a sound basis for important decision-making. With this method, you can work on a single problem or follow
the process to tackle a number of problems.
Usually though, it’s best to deal with one problem that is speci c and potentially solvable – especially to begin with.

DEPRESSION

Structured Problem-Solving Involves 6 Steps

STEP 1

Write down the problem causing you worry or distress:

STEP 2

Think about your options for dealing with this problem (try to think broadly – including good and not so good options); write them down:

DEPRESSION

STEP 3

Write down the advantages and disadvantages of each option:

STEP 4

Identify the best option(s) to deal with the problem:

DEPRESSION

STEP 5

List the steps needed to carry out each option (bear in mind the resources needed and pitfalls to overcome):

1. a. b.

2. a.

3. a.

4. a.

5. a.

STEP 6

Review your progress in carrying out your option(s):

What have I achieved?_______________________________

____________________________________________________

What still needs to be done? _________________________ ____________________________________________________

For more information, see Fact sheet 10 − Changing your thinking at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

DEPRESSION

Depression

Decreased
− Physical
− Mental and
− Social activity

Loss of energy, motivation, interest and pleasure in things

Activity Planning

Many people who have depression experience a loss of energy, motivation, interest and pleasure in things previously meaningful or enjoyed.

As a result, they become less physically, mentally, and socially active – which tends to worsen depression. Becoming active again is an important step in breaking the cycle of depression.

Activity planning aims to break the cycle of depression by methodically and gradually restoring important daily activities.

DEPRESSION

Achievement Activities

Daily achievements, even if only small, can help restore the lost experience of meaning and satisfaction; they can also reverse the sense of paralysis that is so common with depression.

List the activities that previously gave you a sense of achievement: Number in order of importance

•o •o •o •o •o

List work tasks that need to be done, which will give you a sense of achievement or relief to complete:

Number in order of importance

•o •o •o •o •o

DEPRESSION

Social Activities

People who are depressed commonly withdraw from family, friends, and important social activities. Social isolation, which can quickly set in, only serves to worsen depression and make recovery more dif cult.

Doing things with other people, even if it doesn’t feel comfortable at rst (and even if you have to drive a long distance), can help motivate you, lift your mood, and improve your general state of mind. It is important to decide to accept social invitations and to pursue opportunities for social contact and activities.

List the social contact and activities that used to be important to you:

Number in order of importance

•o •o •o •o •o

DEPRESSION

List the family and friends you need to reconnect with or spend more time with:

Number in order of importance

•o

•o Pleasant Activities

People who are depressed often lose interest and pleasure in things they once liked doing.

It is vital to recovery from depression, to plan activities that can again be a source of enjoyment, pleasure and satisfaction.

List activities that you would normally nd enjoyable, interesting relaxing or satisfying:

Number in order of importance

•o •o •o •o •o

DEPRESSION

Physical Activities

Regular daily exercise can be a powerful antidote for depression. Ideally this should be done early in the day and in the sunlight. Certainly, manual work provides exercise; but the best kind of physical activity for depression is separate from work, and purely dedicated to improving physical and mental health.Walking, cycling, using weights or an exercise machine, for example, even if only for 15 minutes a day, can be quite bene cial.

Bearing in mind any medical condition or physical limitations you might have, list physical/exercise activities you have done in the past:

Select one of these to recommence

•o •o •o •o •o

Now that you have listed and prioritised all the activities that are important for your recovery from depression: Achievement, Social, Pleasant, and Physical Activities, put your number one selections into your diary (or Daily Activities Diary provided).

DEPRESSION

Tips for Successful Activities Planning

• Whenever possible put one of each of these activities into your diary each day.

• ‘Don’t bite off more than you can chew;’ better to achieve small goals than to feel a failure because of attempting too much.

• If you start an activity or task and ‘run out of steam,’ or for some other reason can’t commence it or complete it, that’s ne. Simply reschedule it for the next day or another suitable time.

• Try to be sure you have the day’s activity plan completed the evening before, or in advance, so that you have a plan of action to follow immediately when you get up.

DEPRESSION

DAILY ACTIVITIES DIARY

Physical

Time SUnDAY 8.00am
9.00am
10.00am

MonDAY

TUESDAY

WEDnESDAY

11.00am 12.00noon 1.00pm 2.00pm 3.00pm 4.00pm 5.00pm 6.00pm 7.00pm 8.00pm 9.00pm 10.00pm

Achievements Social Pleasant

DEPRESSION

DAILY ACTIVITIES DIARY continued.

Time THURSDAY 8.00am
9.00am
10.00am

FRIDAY

SATURDAY

11.00am 12.00noon 1.00pm 2.00pm 3.00pm 4.00pm 5.00pm 6.00pm 7.00pm 8.00pm 9.00pm 10.00pm

Reducing Alcohol Consumption to a Moderate Level

Many people ‘drown their sorrows’ and try to escape problems and feelings of depression through the use of alcohol.

The problem is that any relief alcohol does provide is short-lived. Alcohol is actually a depressant drug – it spoils the quality of sleep and interferes with the effects of antidepressant medication.

Strategies for moderating drinking

• Try to avoid drinking at home alone – especially when you are feeling down or anxious.

• Try limiting your drinking to the evening meal time.

• Drink low-alcohol beers and mixes.

• Drink slowly (limit yourself to 2 standard drinks each day).

• Think ahead (and creatively) about how to avoid drinking excessively in situations (like the pub or social gatherings) where there is pressure to do so.

• Use your Daily Activity Diary to plan two alcohol-free days each week. Try to choose days when it is easiest to do so; like when an activity is planned for the evening that can be a useful distraction.

• Decide beforehand how much alcohol you will permit yourself to drink; measure it out, and only allow yourself that amount.

• Always try to stay within the Australian Alcohol Guidelines.

DEPRESSION

For Men and Women

over a lifetime: If you drink no more than 2 standard drinks a day, you reduce the lifetime risk of harming yourself from alcohol-related disease or injury.

on a single occasion: Having no more than 4 standard drinks on a single occasion reduces the risk of alcohol-related injury arising from that occasion.

NUMBER OF STANDARD DRINKS – BEER

1.1

285ml
Full Strength 4.8% Alc. Vol

0.8

285ml Mid Strength 3.5% Alc. Vol

0.6

285ml Low Strength 2.7% Alc. Vol

1.6

425ml
Full Strength 4.8% Alc. Vol

1.2

425ml Mid Strength 3.5% Alc. Vol

24 x 375ml

Full Strength 4.8% Alc. Vol

0.9

425ml Low Strength 2.7% Alc. Vol

24 x 375ml Mid Strength 3.5% Alc. Vol

1.4

375ml
Full Strength 4.8% Alc. Vol

375ml Mid Strength 3.5% Alc. Vol

0.8

375ml Low Strength 2.7% Alc. Vol

1.4 1 0.8

24 x 375ml Low Strength 2.7% Alc. Vol

375ml
Full Strength 4.8% Alc. Vol

375ml Mid Strength 3.5% Alc. Vol

375ml Low Strength 2.7% Alc. Vol

NUMBER OF STANDARD DRINKS – WINE

1.6 1 0.9 1.4 1

150ml Average Restaurant Serving of Red Wine 13.5% Alc. Vol

100ml Standard Serve of Red Wine 13.5% Alc. Vol

60ml Standard Serve of Port 18% Alc. Vol

150ml Average Restaurant Serving of White Wine 11.5% Alc. Vol

100ml Standard Serve of White Wine 11.5% Alc. Vol

1.4

150ml Average Restaurant Serve of Champagne 12% Alc. Vol

7.5

750ml
Bottle of Champagne 12.5% Alc. Vol

8 43 21 7.5 39 19.5 28

750ml
Bottle of Red Wine 13.5% Alc. Vol

4 Litres Cask Red Wine 13.5% Alc. Vol

2 Litres Cask Red Wine 13.5% Alc. Vol

750ml
Bottle of White Wine 12.5% Alc. Vol

4 Litres Cask White Wine 12.5% Alc. Vol

2 Litres Cask White Wine 12.5% Alc. Vol

2 Litres Cask of Port 17.5% Alc. Vol

NUMBER OF STANDARD DRINKS – SPIRITS

DEPRESSION

NUMBER OF STANDARD DRINKS – SPIRITS

30ml High Strength Spirit Nip 40% Alc. Vol

250ml Full Strength Pre-mix Spirits 5% Alc. Vol

700ml High Strength Bottle of Spirits 40% Alc. Vol

1.2

300ml Full Strength Pre-mix Spirits 5% Alc. Vol

1.1

275ml Full Strength RTD* 5% Alc. Vol

1.2

330ml Full Strength RTD* 5% Alc. Vol

2.6

660ml Full Strength RTD* 5% Alc. Vol

1.5

275ml High Strength RTD* 7% Alc. Vol

1.8

330ml High Strength RTD* 7% Alc. Vol

3.6

660ml High Strength RTD* 7% Alc. Vol

australian guidelines to reduce health risks from dri

1.5

375ml Full Strength Pre-mix Spirits 5% Alc. Vol

1.7

440ml Full Strength Pre-mix Spirits 5% Alc. Vol

1.4 – 1.9

250ml
High Strength Pre-mix Spirits 7% – 10% Alc. Vol

1.6

2.1

Guideline 1: Reducing the risk of alcohol-

lated

300ml High Strength Pre-mix Spirits 7% Alc. Vol

375ml High Strength Pre-mix Spirits 7% Alc. Vol

440ml High Strength Pre-mix Spirits 7% Alc. Vol

Men Women

1 in 100

For more information, see Fact sheet 9 − Reducing alcohol and

other drugs at http://www.beyondblue.org.au or call the beyondblue info line lcohol-related injury 1300 22 4636

8 43 21 7.5 39 19.5 28

750ml
Bottle of Red Wine 13.5% Alc. Vol

4 Litres Cask Red Wine 13.5% Alc. Vol

2 Litres Cask Red Wine 13.5% Alc. Vol

750ml
Bottle of White Wine 12.5% Alc. Vol

4 Litres Cask White Wine 12.5% Alc. Vol

2 Litres Cask White Wine 12.5% Alc. Vol

2 Litres Cask of Port 17.5% Alc. Vol

* Ready-to-Drink

11 10 9 8 7 6 5 4 3 2 1 0

Lifetime risk of death from alcohol-related disease per 100 drinkers, by number of

nking alcoho

harm over a lifetim

1 2 3 4 5 6 7 8 9 10 Standard drinks

figure 5 lifetime risk of death from alcohol-related disease per 100 drinkers, by number

standard drinks per occasion, Australia 2002

of standard drinks per occasion, australia 2002

For people who regularly drink 2 standard drinks per day, the lifetime risk of

Source: Rehm et al (2008)

death from an alcohol-related disease is about 0.4 in 100 people with that

drinking pattern. Above that level, the risk increases with the number of drinks

per day, and is above 1 in 100 at 3 drinks per day. The risk increases more sharply

for people who regularly drink two standard drinks per day, the lifetime risk of death from

for women than for men.

an alcohol-related disease is about 0.4 in 100 people with that drinking pattern. above that

Source: National Health and Medical Research Council Australian Guidelines to Reduce Health Risks

level, the risk increases with the number of drinks per day, and is above 1 in 100 at three

from Drinking Alcohol, Canberra: Commonwealth of Australia, 2009.

drinks per day. the risk increases more sharply for women than for men.

Basis and quality of the evidence

Lifetime risk of death from alcohol-related injury

A modelled analysis (Rehm et al 2008) was used to determine the

Lifetime risk per 100 drinkers

DEPRESSION

Managing stress

Emotional stress and acute distress have been identi ed as signi cant contributing factors to depression. However, trying to create a stress-free life would be both unrealistic and undesirable, since stress is associated with work, family and personal relationships – in fact with nearly all the changes and challenges that enable us to develop, adapt, and make our way successfully through life.

The problem arises when we experience too much stress – particularly at one time. For people who are depressed, too many sources of stress (or stressors) can worsen and prolong their depression. Consequently, nding ways of reducing and managing stress may be very important.

Ways of reducing stress

• Postponing major life changes

Some major life changes may be unavoidable. But it is best to postpone changes that are likely to generate stress and upheaval, if possible.

• Learning to relax

Think of the things that help you relax, and set aside time in the day to do more of them. Also, be sure to get enough rest and sleep each day.

• Regular daily exercise

Find a form of gentle exercise (apart from work) that you enjoy and can keep doing on a regular basis.

• Learn to say no and set priorities

You may need to say “no” more often to new commitments, and instead concentrate on your activities plan.

DEPRESSION

For more information, see Fact sheet 6 − Reducing Stress at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

• Work on your relationship
One of the most common contributors to long-term depression is tension and con ict in personal relationships. You may need to devote more time to ‘greasing the gears’ and resolving issues in your relationships. If you have access to a skilled counsellor, that could help a lot. If not, there are useful self-help books available in book stores and libraries, and information on the internet.

• Use Financial Advisory Services or Rural Counselling
Financial dif culties can be hugely stressful and are one of the leading causes of relationship breakdown. Using the expertise and more objective view of a nancial advisor
or rural counsellor can make a very real difference to how people view and tackle nancial hardship or pressure. Even when there appear to be no easy solutions, getting things into perspective, being clear about options, and getting a chance (perhaps for the rst time) to speak about how dif cult things are, can signi cantly reduce feelings of powerlessness and stress.

• Use the other self-help ideas in this book
See chapter on Stress (page 177).

DEPRESSION

Restoring a Normal Pattern of Sleep

Sleep disturbance is common with depression, and frequently takes the form of early-morning wakening (usually around 3am) with dif culty returning to sleep. To restore a normal pattern of sleep, it’s important to practise sleep-promoting behaviour during the day, in the evening, at bedtime, and during the night.

Better Sleep Guidelines

During the Day

• Organise your day. Regular times for eating meals, taking medicines, performing chores and other activities, help keep our inner clocks running smoothly.

• Regular exercise during the day (or early evening) can improve sleeping patterns.

• Set aside time for problem-solving and decision-making during the day, to avoid worry or anxiety at night (see Structured Problem-Solving on page 20).

• Avoid napping during the day, go to bed and get up at regular times.
During the Evening

• Put the day to rest. If you still have things on your mind, write them down or put them in your Daily Activities Diary, to be dealt with tomorrow.

• Light exercise early in the evening may help sleep. Avoid exercise late in the evening, as this may make getting to sleep more dif cult.

• Get into a routine of ‘winding down’ during the course of the evening, allowing at least half an hour of quiet activity, such as reading or listening to music, prior to bedtime.

DEPRESSION

• Avoid drinking caffeinated drinks after about 4pm, and don’t drink more than 2 cups of caffeinated drinks each day (especially coffee, tea, cocoa, and cola).

• Avoid smoking for at least an hour (preferably an hour and a half) before going to bed.

• Don’t use alcohol to make you sleep, and keep your intake moderate (limit yourself to 2 standard drinks each day). Have 1 or 2 alcohol-free days each week.

• Make sure your bed and bedroom are comfortable – not too cold or too warm.

• Ensure that your bedroom is dark and that the morning light does not lter in. However, if you have a tendency to oversleep, it may be helpful to let the morning light into the room.

• Avoid a heavy meal close to bedtime. If you are hungry, a light snack may help you get to sleep.
At Bedtime

• Try to do the same things before you go to bed each night. Develop a calming bedtime routine, such as having a warm bath or shower, listening to relaxation music, or using a relaxation technique (see Progressive Muscle Relaxation included on page 53). This way your body will learn to know that (with these activities) you are getting ready to go to sleep.

• Go to bed when you feel ‘sleepy tired’ and not before.

• Don’t watch TV or have conversations or arguments in bed. Keep your bed and bedroom only for sleep (and sexual activity).

• Turn the light off when you get into bed.

• Relax and tell yourself that sleep will come when it is ready. Enjoy relaxing your mind and body, even if you don’t fall asleep at rst.

DEPRESSION

During the night

• If you wake up too early in the night, don’t lie awake
for more than 30 minutes. Instead of just being awake
or worrying, get out of bed and do something that is distracting yet relaxing. Return to bed only when you feel sleepy again.

• Get up at the same time each morning. Don’t sleep late in the morning trying to make up for ‘lost sleep.’

• If you live in a place or area where there are sounds or noises that might wake you from sleep, use earplugs to block out the noise.

• Avoid sleeping pills − they do not provide a long-term solution to sleep problems.
national Help/Information Lines

• beyondblue info line: 1300 22 4636 (local call cost)

• Lifeline: 13 11 14

• Kids Help Line: 1800 55 1800

• MensLine Australia: 1300 78 99 78

• Australian Psychological Society Referral Line: 1800 333 497

• SANE Australia: 1800 18 7263 (national)

• Suicide Call Back Service: 1300 659 467
See Key Services and Resources on pages 302 to 319 for state and territory contacts.

For more information, see Fact sheet 7 − Sleeping well at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

DEPRESSION

DAepnrxeisestiyon

For more information, see ‘Anxiety’ at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

Warning signs of ANXIETY

Tickþthe signs that are familiar:
q Feeling ‘on edge’ or ‘wound up’ much of the time qConstantly worried about a lot of things
qFeeling irritable frequently
qTense or nervous much of the time
qAvoiding people and social situations
q Trembling, tingling, light-headedness, dizzy spells, sweating,

urinary frequency, diarrhoea
qFeeling panicky in some situations
qSleeping poorly/having dif culty falling asleep
qHaving dif culty relaxing
q Fear of making a fool of yourself socially, or of other people

watching you or drawing attention to you
qUsing alcohol or sedatives to calm down or to get to sleep qFear of having a serious illness that the doctor can’t detect q Fear of experiencing again the feelings of a past traumatic event qWorrying a lot about your health
q Fear of dying, going mad, or having something bad happen qHaving thoughts that are hard to control
q Fear of being in a place that you can’t get out of, or that you

can’t get out of without embarrassment
qFear of germs or infection
q Compulsively checking, counting or cleaning things
q Headaches, neck aches, chest pain, joint pain, or nausea qTiredness or fatigue

If you have some of these symptoms and they are affecting your life –

.TAKE ACTIon. Arrange to speak to a doctor.

See page 3 for National Help/Information Lines.

ANXIETY

About Anxiety The ‘Fight or Flight’ response

Most people experiencing problems with anxiety visit their doctor because of worrying physical symptoms. It is important to understand that the symptoms of anxiety, rather than suggesting evidence of an underlying physical problem, are actually the result of what has been termed the ‘ ght or ight’ response.

When we are threatened by something or are in danger, our bodies respond with a series of biochemical changes aimed at preparing us to ght or escape. This harks back to our more primitive past, when people frequently needed quick bursts
of energy, as their bodies prepared to ght off or ee from ferocious predators or enemies. This remains an important response when we are faced with a real threat or danger. The problem is, our brain (in activating the ‘ ght or ight’ response) does not distinguish between what is real or what is imagined.

Many novice public speakers would confess that giving a speech
– even to a sympathetic audience – can generate as much terror and anxiety as any real physical danger or threat.What we imagine or perceive as threatening, and the way we anticipate problems or challenges in the future, whether real or not, may be ‘real’ enough for our brain to activate a response.

ANXIETY

Changes that occur due to the ‘Fight or Flight’ response

• The mind becomes alert.

• Bloodclottingabilityincreases,preparingforpossibleinjury.

• Heart rate speeds up and blood pressure rises.

• Sweating increases to help cool the body.

• Bloodisdivertedtothemuscleswhichtensereadyforaction.

• Digestion slows down.

• Saliva production decreases causing a dry mouth.

• Breathing rate speeds up – nostrils and air passages in
lungs open wider to get in air more quickly.

• Liver releases sugar to provide quick energy.

• Sphincter muscles contract to close the openings of the
bowel and bladder.

• Immune responses decrease (which is useful in the short-
term to allow massive response to immediate threat, but
can become harmful over a long period).

• Fear and apprehension

• Trembling or shaking

• Restlessness

• Cold and clammy hands

• Hot ushes or chills

• Feeling sick or nauseous

• Butter ies in the stomach
Excerpt from: Management of Mental Disorders Third edition (Australia, World Health Organization Collaborating Centre For Mental Health And Substance Abuse, 2000) Volumes 1 & 2.

Mild to moderate levels of anxiety – of ‘ ght or ight’ arousal – are normal, and can energise us, improve our thinking, reactions, and general performance. Too much anxiety, especially if it is prolonged, has the opposite and negative effect of diminishing our ability to cope and interfering with our lives.

ANXIETY

Situation or event that is perceived as dangerous or threatening

Brain activates fight or flight response

A series of biochemical changes occur in the body to prepare for conflict or escape

Anxiety Disorders

There are many types of anxiety disorders, each with a range of symptoms. Common anxiety disorders are:

Generalised Anxiety Disorder (GAD)

People who have GAD feel anxious on most days for at least six months. Generally, they worry about real issues such as nances, illness or family problems − to the point where it interferes with functioning from day to day.

Phobia

When a person has a phobia, he/she feels very fearful about particular objects or situations. Common examples include fear of social situations such as parties and meetings (social phobia) or fear of open spaces such as parks and big shopping centres (agoraphobia).

obsessive Compulsive Disorder (oCD)

Obsessive Compulsive Disorder gets its name because people who experience it have ongoing unwanted/intrusive thoughts and fears that cause anxiety called obsessions.These obsessions make people feel they need to carry out certain rituals in order to feel less anxious and these rituals are known as compulsions. Common obsessions may include fear of forgetting to do things, fear of germs/contamination, whereas compulsions may include constant checking behaviour and constant washing of hands.

ANXIETY

For more information, see Recovery From Trauma chapter on page 104

Panic Attacks/Disorder

Panic Disorder is diagnosed when a person experiences panic attacks. A panic attack is an intense feeling of anxiety that is overwhelming and dif cult to manage. Panic attacks have been likened to the experience of having a heart attack and may include shortness of breath, feeling lightheaded and/or nauseous or having chest pains.

Acute Stress Disorder (ASD) and Post-Traumatic Stress Disorder (PTSD)
ASD and PTSD are a set of reactions that can develop in people who have experienced or witnessed a traumatic event. Traumatic events involve life-threatening situations or serious injury that lead to feelings of intense fear, helplessness or horror, e.g. assault, war, serious accident, natural disaster. It is estimated that around 5% of people experience PTSD in their lives.

The Anxiety pages on the beyondblue website http://www.beyondblue.org.au will take you step-by-step through:

• types of anxiety disorders

• how to recognise signs and symptoms

• how to get help and treatment for yourself or someone you know

• how to stay well.
Other beyondblue anxiety information material available: beyondblue Fact sheet 21 – Anxiety Disorders
beyondblue Fact sheet 31 – Post-Traumatic Stress Disorder beyondblue Fact sheet 35 – Generalised Anxiety Disorder beyondblue Fact sheet 36 – Panic Disorder
beyondblue Fact sheet 37 – Obsessive Compulsive Disorder beyondblue Fact sheet 38 – Speci c Phobias
beyondblue Fact sheet 39 – Social Phobia
beyondblue wallet-size information card – Anxiety Disorders beyondblue envelope-size information card – Anxiety Disorders

ANXIETY

Anxiety can be very disabling

In a recent Australian Bureau of Statistics survey, around
1 in 7 people indicated that they were experiencing symptoms consistent with an anxiety disorder. People with anxiety disorders reported being unable to carry out their usual roles and tasks.

People with anxiety problems are also at increased risk of developing depression (2-4 times higher than people without
a history of anxiety). Anxiety disorders pre-date depression in most cases and more often than not, anxiety and depression are found together when depression is diagnosed.

What if anxiety is left untreated?

Left untreated, a problem of anxiety is likely to continue and worsen with signi cant life-diminishing consequences. As already mentioned, people with moderate to severe anxiety problems are at increased risk of developing depression.

The outlook for people with anxiety who do receive treatment is generally very good. But, just as with depression, people with anxiety will need to be actively involved in their treatment, mastering new skills and adopting changes in lifestyle.

ANXIETY

You can find more information about anxiety medication at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

What are the treatments for anxiety?

For mild to severe anxiety disorders, psychological therapy is the basis of treatment. Medication can be useful, especially for severe anxiety, or when there are repeated episodes of panic or obsessional thinking.

Medication

One of the most common medications used to treat anxiety is also used to treat depression. Its technical name is Selective Serotonin Reuptake Inhibitor (SSRI). SSRIs are also frequently used when anxiety and depression appear together.

Psychological Therapy

Even when drugs are prescribed, psychological therapy is an indispensable part of treatment. The therapies and strategies widely used and found to be most helpful for treating anxiety disorders include:

• controlled breathing (because over-breathing is generally a problem with anxiety)

• relaxation

• adopting constructive thought patterns

• structured problem-solving

• restoring a pattern of normal sleep

• graded exposure

• reducing alcohol and caffeine consumption.
If a suitable health professional is unavailable in your area, you may access therapy online. Options for online support are found at http://www.beyondblue.org.au (click on Get help/Links/E-health). Your doctor may recommend the use of medication and the self-help version of these therapies (along with other strategies) mentioned in this resource book.
48

ANXIETY

Though these self-help ‘therapies’ do re ect (and are a simpli ed form of) the therapies used by trained psychotherapists, they
are not intended as a substitute for seeing a doctor, or for psychological therapy when that is what the doctor strongly recommends. In the case of a severe anxiety disorder (especially if it has particularly dif cult features), it may be recommended and necessary to travel to where psychological therapy is available.

MEDICARE REBATES

For more details, ask your referring medical practitioner
or see beyondblue Fact sheet 24 – Help for depression, anxiety and related disorders under Medicare.

For a list of health professionals with expertise in treating depression, go to the beyondblue website: http://www.beyondblue. org.au and click on Find a Doctor or other Mental Health Practitioner or call the beyondblue info line on 1300 22 4636.

ANXIETY

Some of the symptoms of over-breathing

• Light-headedness

• Blurred vision

• Feeling strange

• Increased heartbeat

• Stiffness, twitching, or cramps in muscles

• Breathlessness
• Confusion
• Irregular heartbeat • Cold, clammy hands

• Numbness and tingling in hands or feet

Because over-breathing is hard physical work, a person may feel:

• Hot, ushed and sweaty

• Tired and exhausted.
Over-breathing may over-use chest muscles resulting in:

• Chest tightness
• Severe chest pain.

Controlled Breathing

The ‘ ght or ight’ response associated with anxiety (see
page 43) creates an increase in the rate of breathing (called hyperventilation). This over-breathing gives rise to a whole range of symptoms:

Over-breathing is not always obvious to the observer or even to the anxious people themselves. It can be very subtle – especially if the individual has been slightly over-breathing for a long period of time. Mild over-breathing can cause a person to be in a constant state of fearfulness and anxiety.

Over-breathing is especially associated with the experience of panic and may act as the initial prompt causing an individual to panic.

ANXIETY

One proven way of managing and reducing the symptoms of over- breathing is by using a controlled or slow breathing technique.

Controlled Breathing Technique

1. Breathe in (without taking a deep breath) and hold your breath for a count of 5.

2. When you get to 5, gently breathe out saying to yourself “relax” or “calm”.

3. Then just breathe in and out slowly, through your nose, counting 3 with each breath in, and 3 with each breath out.

4. Breathe this way for about 10 breaths, and then start the cycle again by holding your breath and counting to 5 (step 1).

5. Continue this controlled breathing cycle until all the symptoms of over-breathing have gone.

Tips on the use of the Controlled Breathing Technique

• Use the technique immediately the rst signs of over- breathing, panic, or growing anxiety occur.

• Practise the technique at least 4 times each day.

• ‘Over-learn’ the technique (practise it until it becomes an automatic response), so that it can be used quickly to prevent anxiety escalating.

• Spend enough time practising the technique for it to feel comfortable.

• Practise the technique whenever you notice sensations of anxiety.

ASNTXRIESTSY

Relaxation

The same mechanism that turns on the anxiety response can also switch it off again. When we decide to let go of physical
and mental tension (and take steps to do so), the nerves in our muscles change the type of signals they transmit to the brain.The brain then stops sending panic messages to our nervous system, and a general feeling of calmness, both physical and mental, begins to prevail.The relaxation response can help switch off the ght or ight anxiety response.

For people who are often anxious, there is little opportunity for high levels of muscle tension to diminish. The consequence of living with a high level of tension is that a state of tension becomes ‘normal’ and is taken for granted – so that being tense isn’t noticed.

Becoming aware of tension in our body, and taking steps to release it through effective relaxation, is a vital strategy in the management of anxiety.

ANXIETY

Recognising Tension

Ask yourself these questions:

• Where do I feel tension?
– In which parts of my body? – In which muscles?

• What does the tension feel like? – Is there hardness?
– Is there fatigue?
– Is there an ache or pain?

• What is it that has led to this tension?

• Is this tension helpful or unhelpful?

• Do I need to make time to relax?

Progressive Muscle Relaxation*

A method of relaxation with proven effectiveness which relieves muscle tension, and can help switch off the ‘ ght or ight’ anxiety response, is progressive muscle relaxation. This involves tensing and then relaxing muscles in a step-by-step sequence.The two main principles of this technique include:

1. Tensing muscle groups (one at a time) to become aware of the feeling of tension.

2. Relaxing the muscles and feeling the tension in them subside – as if owing out of the body.

* Adapted from: Davis, M., et al. The Relaxation and Stress Reduction Workbook Fourth edition (U.S.A., New Harbinger Publications, 1995).

ANXIETY

Progressive Muscle Relaxation

• You will need about 15 minutes for this relaxation exercise.

• Find a quiet place where you won’t be interrupted.

• Sit in a comfortable straight-backed chair, with your feet at on the oor.

• Close your eyes and use the controlled breathing technique for about 5 minutes.

• Tense each of the following muscle groups for 5 seconds, then relax them completely for 15-20 seconds (pay particular attention to the different sensations of tension and relaxation):

1. Curl both your sts and tighten your biceps and forearms (as if lifting weights). Relax.

2. Wrinkle up your forehead; tighten the muscles in your face causing your face to wrinkle; purse your lips and press your tongue against the roof of your mouth; hunch your shoulders. Relax.

3. Arch your back as you take a deep breath into your chest. Relax.

4. Taking a deep breath, gently push out your stomach. Relax.

5. Pull your feet and toes backwards tightening your shins. Relax.

6. Curl your toes at the same time as tightening your calves, thighs and buttocks. Relax.

• Close your eyes and use the controlled breathing technique for about 5 minutes.

• Now resume normal activities in a calm and peaceful manner.

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Tips and cautions on the use of progressive muscle relaxation

• Be patient with yourself and this technique. You may only experience partial success at rst. In time, it should be possible for you to relax your whole body quickly and successfully. Practise is the key.

• Be careful when you are tensing your neck and back. Don’t tighten your muscles beyond what feels comfortable for you.

• To achieve the best results with this technique it’s important to let go of the tension in a group of muscles you have tensed instantly. Releasing tension slowly may seem to relax muscles, when in fact it may just sustain tension. When you release muscle tension, do it instantly and let the muscles suddenly become limp.
other relaxation techniques
There are many relaxation techniques that people nd helpful, such as meditation, yoga, self-hypnosis and relaxation music combined with guided imagery or visualisation.These and many other techniques and resources are available from book shops, music stores, the internet and local or mobile libraries.

For more information, see Fact sheet 6 − Reducing stress at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

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Adopting a Constructive Thought Pattern

What we perceive as dangerous or threatening activates the ‘ ght or ight’ response. When this perception changes – either because the danger or threat ceases, or because we alter the way we think about or interpret it (“this is not a threat or danger to me”), the ‘ ght or ight’ response is deactivated or turned off.

How we interpret life events (the things that happen to us, challenge us, make demands of us, or that we perceive may have consequences for us), has a huge bearing on how much stress or anxiety we experience.

Part of this interpreting is what we think, how we think and what we say to ourselves in our head (our self-talk).

The kind of thought pattern or way of interpreting events that we use is generally either self-defeating or, alternatively, constructive.

Self-defeating interpretations (thoughts and self-talk) can generate high and unhealthy levels of stress or anxiety – as well as causing paralysis in attempts at problem-solving and decision-making.

Constructive interpretations (thoughts and self-talk) help to maintain healthy and useful levels of stress or anxiety, which permit and promote coping.

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Self-Defeating Interpretation

Self-defeating thoughts and self-talk

“I can’t even get on with my wife any more” “Even my marriage is a failure”

“I’m useless at this like everything else”

Event

Argument with wife

Experience

High level of stress/anxiety, causing difficulty in coping

Behavioural Consequences
− Will give up and withdraw, perhaps even get angry and make things worse

Constructive Interpretation

Constructive thoughts and self-talk

“I don’t feel good about this, but we are both tense and on edge”
“Our relationship is OK. We will need to work this through when we are both calm”

Experience

Moderate level
of stress/anxiety, permitting and promoting coping

Event

Argument with wife

Behavioural Consequences
− Will seek to resolve problems

and relationships

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Self-defeating interpretations also tend to become more entrenched, and stress or anxiety levels more unhealthy and unhelpful, as a self-reinforcing vicious cycle develops.

People who tend to use a self-defeating thought pattern in interpreting events also develop (mostly unconsciously) errors in thinking which, like ‘jumping to conclusions,’ may seem to save time and energy, but can actually have consequences that demand much time and energy.

Adopting a constructive thought pattern in interpreting events is essential for managing stress or anxiety, and for achieving and maintaining good mental health.

How can this be done? It can be achieved through:

• becoming aware of how we respond to events
(and what we think and say to ourselves in our heads)

• censoring and modifying our thoughts (especially those that are automatic) and self-talk

• challenging and dismantling errors in thinking.

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Becoming aware

We can simply decide to become aware of our thoughts and self-talk.This awareness provides us with the opportunity to change them; it gives us the power of censorship.With practise, it’s possible to even exert in uence over our automatic thoughts (challenging and dismantling errors in thinking will help this too).

To get this awareness underway, it’s helpful to do some initial documenting of situations/events to be examined, the feelings experienced and the thoughts that occur. This is also a good way of identifying errors in thinking.

Situation/Event

Feelings experienced

Automatic thoughts (and self-talk)

You discover one of your vehicle tyres is flat, and you were organised to go somewhere.

Immediate ‘welling up’ of stress and anxiety, then strong feelings of anger.

“No!” “Everything just has to go wrong;” “Like everything else around this place;” “I just don’t need this.”

Situation/Event

Feelings experienced

Automatic thoughts (and self-talk)

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Practising taking ‘snapshots’ of situations and writing things down like this, is a useful tool for establishing awareness. After a while this can be expanded into the skill of censoring and modifying thoughts and self-talk.

Censoring and modifying

The key to censoring and modifying (or managing) thoughts and self-talk is the speed with which we intervene and ask ourselves: Is this thought/idea (or what I’ve begun saying to myself) self-defeating or constructive? If it is self-defeating, how can I immediately modify it or replace it so that I am using a constructive thought pattern?

This is a skill to be practised and a new habit to be formed. As with becoming aware, it can be really helpful (at least initially), to write things down; when we can ‘see’ our thoughts and what we are saying to ourselves, we have more power to change them.

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Situation/Event

My thoughts and self-talk

Are these self-defeating or constructive?

If self-defeating, what would be constructive?

A friend, who you had arranged to come over and help you with something important, has left a message to cancel.

“Great;” “Thanks a lot;” “Why is it I always get let down?”

Self-defeating, because I can feel stress and anger building up.

How do I know why
he cancelled….it could
have been an emergency. Everyone feels let down sometimes, that’s life. I’ve cancelled things too.
There are other things I can do; this can be put on hold. It’s all right.

Situation/Event

My thoughts and self-talk

Are these self-defeating or constructive?

If self-defeating, what would be constructive?

Situation/Event

My thoughts and self-talk

Are these self-defeating or constructive?

If self-defeating, what would be constructive?

Examples of common errors in thinking

Challenging and dismantling errors in thinking

Errors in thinking consist of certain assumptions and ways of thinking that keep recurring, are habitual, and allow us to save time by not thinking constructively about events.They provide
an easy response, but one that is neither time saving nor helpful. Errors in thinking ‘save a penny and spend a pound,’ because their consequences heavily tax our energy reserves, and generate high and unhealthy levels of stress or anxiety.

Errors in thinking need to be challenged and revised if we are to establish a constructive and healthy thought pattern.

Assumptions

All things are equally important and urgent

Challenge

Many things are not crucial or urgent. But they generate anxiety because I interpret them that way.
Some things are crucial and/ or urgent and cannot be left. Many things are not, and they can be postponed.

If I’m stressed or anxious, what does a thing matter, unless it is truly crucial or urgent?
This is not inevitable or necessary, it is a habit. Lots of other people take these things pretty much in their stride. No, getting uptight often

is mostly because I often interpret events in a self- defeating way.

Getting uptight about unforeseen or unwanted events is inevitable

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Everything has to go wrong. Life is against me succeeding

Based on what evidence? What about people who, against all apparent odds, still succeed? Do I need to examine how

I go about things? How I make decisions, and for what reasons?
If I expect things to go wrong, isn’t it highly likely I will contribute to that happening? Has ‘life’ really singled me out to be a victim?

What real evidence supports this assumption?
Are other people let
down also? How does my experience compare with theirs?

Have I on occasions let others down?
Do I know anyone who always experiences other people as completely reliable?

Do I automatically believe the best or the worst when people appear to let me down? Are my expectations reasonable?

People always let me down

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If I could go back in time: If I had…
If only I did…

The benefit of hindsight is a fine thing. Of course I could be more knowledgeable, skilled and wise if I could have been then who I am now,or if I could go back as who I am now.
How is this kind of thinking helpful?
I was who I was. I made decisions and did things as the person I was, and was capable of being then. No amount
of lamenting will change that. The only valid questions are perhaps:What can I learn
from the past? What can I
do differently now and in the future?

No one could live up to that, without lying about the many occasions when they, quite rightly, didn’t bother to do some things either perfectly or properly. Taking pride in doing important things well is admirable. But trying to

do everything perfectly or properly is not necessary, important, reasonable, or admirable. It is plain unhealthy! Perhaps what is more needful is to be able to prioritise?

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Everything has to be done perfectly or properly

other thinking habits:

— Mind-reading: — Catastrophising:

— Labelling:

— over-generalising: — Fortune-telling:

— ‘Rule-saying’:

— Black and white — thinking:

“She thinks I’m a failure;”
“They think I’m not as good as….”

“Everything always turns out bad for me;”
“Things are always against me;”
“Now I will never be able to….;” “No matter how hard I try everything always goes wrong.”

“I’m an idiot;” “I’m a failure;” “I’m a lousy…..” (Instead of “I did….poorly;” or “I did not achieve…..;” or “I needed to….”)

Saying,“Always,” “Never,” “No-one,” or “Everyone.”

“Everyone is sure to…..;”
“I’m sure to mess it up;”
“It’s going to be a disaster;”
“I’m sure to feel dreadful when I…..”

“Should,” “Must,” or “Have to” (setting sometimes unrealistic expectations).

“Everything she does she gets right;” “I’ve completely ruined everything;” “He succeeds in everything…… I never get it right!”

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Examples you can think of: —
—
—

—

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Structured Problem-Solving

For people who are anxious, it is common to feel threatened and overwhelmed by problems, and the thought of having to deal with them. So it can be really helpful to have a step-by-step methodical way of dealing with problems and making decisions. Through the method of structured problem-solving, it is possible to feel more in control of problems and to signi cantly reduce the feeling of being threatened or overwhelmed by them.

The key elements of this method include:

• Identifying and ‘pinning down’ the problems that have
contributed to you feeling overwhelmed

• Thinking clearly and constructively about problems

• ‘Taking stock’ of how you’ve coped in the past: your personal strengths, and the support and resources available to you

• Providing a sound basis for important decision-making. With this method you can work on a single problem or follow
the process to tackle a number of problems.
Usually though – especially to begin with − it is best to deal with one problem that is speci c and potentially solvable.

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Structured Problem-Solving Involves 6 Steps

STEP 1

Write down the problem causing you worry or distress:

STEP 2

Think about your options for dealing with this problem (try to think broadly − including good and not so good options); write them down:

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STEP 3

Write down the advantages and disadvantages of each option:

STEP 4

Identify the best option(s) to deal with the problem:

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1. a.

2. a.

3. a.

4. a.

5. a.

For more information, see Fact sheet 10 − Changing your thinking at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

STEP 5

List the steps needed to carry out each option (bear in mind the resources needed and pitfalls to overcome):

STEP 6

Review your progress in carrying out your option(s):

What have I achieved?_______________________________

____________________________________________________

What still needs to be done? _________________________ ____________________________________________________

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Restoring a Pattern of Normal Sleep

Sleep disturbance is common with anxiety – particularly the problem of not being able to get off to sleep at night. To achieve a pattern of normal sleep, it is important to practise sleep-promoting behaviours during the day, in the evening, at bedtime, and during the night.

Better Sleep Guidelines

During the Day

• Organise your day. Regular times for eating meals, taking medicines, performing chores and other activities, help keep our inner clocks running smoothly.

• Regular exercise during the day (or early evening) can improve sleeping patterns.

• Set aside time for problem-solving and decision-making during the day to avoid worry or anxiety at night (see Structured Problem-Solving included on page 67).

• Avoid napping during the day – go to bed and get up at regular times.
During the Evening

• Put the day to rest. If you still have things on your mind, write them down or put them in your diary, to be dealt with tomorrow.

• Light exercise early in the evening may help sleep. Avoid exercise late in the evening, as this may make getting to sleep more dif cult.

• Get into a routine of ‘winding down’ during the course of the evening, allowing at least half an hour of quiet activity, such as reading or listening to music, prior to bedtime.

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• Avoid drinking caffeinated drinks after about 4pm, and don’t drink more than 2 cups of caffeinated drinks each day (especially coffee, tea, cocoa and cola).

• Avoid smoking for at least an hour (preferably an hour and a half) before going to bed.

• Don’t use alcohol to make you sleep and keep your intake moderate (limit yourself to 2 standard drinks each day). Have 1 or 2 alcohol-free days each week.

• Make sure your bed and bedroom are comfortable – not too cold or too warm.

• Ensure that your bedroom is dark and that the morning light does not lter in. However, if you have a tendency to oversleep, it may be helpful to let the morning light into the room.

• Avoid a heavy meal close to bedtime. If you are hungry, a light snack might help you get to sleep.
At Bedtime

• Try to do the same things before you go to bed each night. Develop a calming bedtime routine, such as having a warm bath or shower, listening to relaxation music, or using a relaxation technique (see Progressive Muscle Relaxation on page 53). This way your body will learn to know that (with these activities) you are getting ready to go to sleep.

• Go to bed when you feel ‘sleepy tired’ and not before.

• Don’t watch TV or have conversations or arguments in bed. Keep your bed and bedroom only for sleep (and sexual activity).

• Turn the light off when you get into bed.

• Relax and tell yourself that sleep will come when it is ready. Enjoy relaxing your mind and body, even if you don’t at rst fall asleep.

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During the night

• Get up at the same time each morning. Don’t sleep late in the morning trying to make up for ‘lost sleep.’

• If you live in a place or area where there are sounds or noises that might wake you from sleep, have earplugs handy to block out the noise.

• Avoid sleeping pills − they do not provide a long-term solution to sleep problems.

For more information, see Fact sheet − 7 Sleeping well at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

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Gradual (graded) Exposure Anxiety resulting in avoidance and leaving

For people who are anxious, feeling noticeably or uncomfortably anxious in a particular situation can become associated with that or similar situations. Before long, they may begin to avoid these situations (for fear of becoming anxious); or, nding themselves in such situations, they may quickly leave (again, for fear of becoming anxious, or because they expected to be anxious, and that is what happened).

Unfortunately, both avoidance and leaving behaviours can make the problem of anxiety worse, because despite providing a feeling of relief and a drop in anxiety, these behaviours make it more and more dif cult to face the situations that are feared. Two main problems arise with avoidance and leaving:

• Because it is not always possible to avoid feared situations, it can become very distressing when a person is forced to face them.

• Frequently avoiding feared situations, a person begins to tolerate less and less anxiety, avoiding an ever-widening number of potentially anxiety producing situations. This can become quite disabling, and signi cantly affect lifestyle and daily living.

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Confronting fears through Gradual (graded) Exposure

A way of overcoming a fear of objects or situations that has proven to be successful in psychological therapy is confronting and facing fears using a method of gradual or graded exposure.

When things that are feared are confronted for long enough, fear eventually subsides, and the fear experienced in that situation next time around will be less. An important way of breaking
the pattern of avoidance and leaving behaviour is by gradually confronting things that are feared, starting with easy situations and slowly building up the con dence and resilience to face the harder things. Part of, and essential to, this process of gradual exposure is remaining in the feared situation until there is a clearly experienced decrease in anxiety. It is also critical to success that the person experiencing anxiety use the controlled breathing technique and relaxation, prior to each occasion of gradual exposure, to limit their initial anxiety and to build their con dence in the achievability of each progressive step towards achieving their goal.

Controlled breathing can easily be practised while in the feared situation, as can relaxation, by noticing tension in particular muscles, and consciously tensing and relaxing them (as in the technique of Progressive Muscle Relaxation).

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2. List the situations that make you feel panicky or fearful:

Number each one in order, from least feared to most feared

Gradual (graded) Exposure

IMPORTANT

1. Use the controlled breathing and relaxation techniques to prepare for each step and to manage your anxiety in each feared situation.

…………………………………………………………………………………………… o …………………………………………………………………………………………… o …………………………………………………………………………………………… o …………………………………………………………………………………………… o

3. Choose one of these situations (preferably the least feared) that you think you can cope with:

…………………………………………………………………………………………….. 4.

Write down the specific fears you have about this situation:

If any of these fears are exaggerated, write down what you think is more likely to happen:

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5. Plan a series of gradual steps for confronting/facing the feared situation, starting with small, not too threatening steps, progressing to more difficult ones:

Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8

REMEMBER

• Just as anxiety rises initially when confronting a feared situation, it also subsides within a few minutes, but can last up to 75 minutes.

• When you put your first step into action, stay in the situation until your anxiety has lessened.

• Monitor your anxiety to see how it starts to decrease the longer you stay in the situation.

• Remain until you no longer feel anxious before ending the task.

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Practise this step until it no longer causes anxiety.Then (and only then) move on to the next step.

6. Put the first step into action.

7. Move through each step until you can manage the feared situation.

NOTE: You might keep a record of which steps work best for you in future use.

IMPORTANT

Exposure Therapy will not work if you are intoxicated or taking sedatives such as Valium or sleeping tablets.

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Tips for succeeding with Gradual (graded) Exposure

• Begin with an achievable step.

• Don’t make your steps too easy or they will probably be unrewarding. Don’t make your steps too hard or you will probably fail and become discouraged.Aim for regular and gradual progress.

• Move on to the next step only once the present step has been genuinely mastered. Since some steps are more dif cult, at times progress may seem slow. Be patient with yourself and the process. Better to go slowly, than lose con dence and motivation by being abruptly set back by attempting too much.

• If the increase in dif culty of your steps turns out to be too high, put in some intermediate steps to make progress more manageable.

• Be prepared for setbacks. If a setback does occur, simply return to a previous step, and assess whether or not an intermediate step needs to be inserted. Don’t be discouraged – setbacks do occur, because the whole process, no matter how well thought through, may need to be altered once actually ‘put to the test.’

• Try to become conscious of your thoughts in approaching each step (particularly what you say to yourself in your head).

– When you can identify exaggerated fears, try to replace them with more realistic thoughts about what is more likely to happen.

– It can be helpful to write down your thoughts and ‘self- talk’ (preferably as soon as they occur), to challenge how rational they are.

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Thoughts and self-talk

How exaggerated are these? How rational?

What would be a more rational and helpful way of thinking about the situation?

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Reducing Alcohol and Caffeine Consumption

The problem with alcohol and anxiety

It is common for anxious people to ‘settle the nerves’ or to cover over their fears using alcohol. There are several problems with this:

• Alcohol becomes a substitute for developing con dence.

• Dependence can quickly (but often unknowingly) occur, with alcohol being used for anxiety control in more and
more situations.

• Usual coping strategies (even if only partially effective)
become neglected and even less effective when alcohol is
used as a substitute.

• Alcohol can negatively affect the quality of sleep, and
interferes with the effects of medication prescribed for anxiety.
Strategies for moderating alcohol consumption

• Try to avoid drinking at home alone – especially when you are feeling down or anxious.

• Try limiting your drinking to the evening meal time.

• Drink low-alcohol beers and mixes.

• Drink slowly (limit yourself to 2 standard drinks each day).

• Think ahead (and creatively) about how to avoid drinking
excessively in situations (like the pub or social gatherings)
where there is pressure to do so.

• Plan to have 2 alcohol-free days each week. Try to choose
days when it is easiest to do so, like when an activity is planned for the evening that may be a useful distraction.

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NUMBER OF STANDARD DRINKS – BEER

1.1

285ml
Full Strength 4.8% Alc. Vol

0.8

285ml Mid Strength 3.5% Alc. Vol

0.6

285ml Low Strength 2.7% Alc. Vol

1.6

425ml
Full Strength 4.8% Alc. Vol

1.2

425ml Mid Strength 3.5% Alc. Vol

24 x 375ml

Full Strength 4.8% Alc. Vol

0.9

425ml Low Strength 2.7% Alc. Vol

24 x 375ml Mid Strength 3.5% Alc. Vol

1.4

375ml
Full Strength 4.8% Alc. Vol

375ml Mid Strength 3.5% Alc. Vol

0.8

375ml Low Strength 2.7% Alc. Vol

1.4 1 0.8

24 x 375ml Low Strength 2.7% Alc. Vol

375ml
Full Strength 4.8% Alc. Vol

375ml Mid Strength 3.5% Alc. Vol

375ml Low Strength 2.7% Alc. Vol

• Decide how much alcohol you will permit yourself to drink; measure it out, and only allow yourself that amount.

• Always try to stay within the Australian Alcohol Guidelines.
For Men and Women
over a lifetime: If you drink no more than 2 standard drinks a day, you reduce the lifetime risk of harming yourself from alcohol-related disease or injury.
on a single occasion: Having no more than 4 standard drinks on a single occasion reduces the risk of alcohol-related injury arising from that occasion.

NUMBER OF STANDARD DRINKS – WINE

1.6 1 0.9 1.4 1

150ml Average Restaurant Serving of Red Wine 13.5% Alc. Vol

100ml Standard Serve of Red Wine 13.5% Alc. Vol

60ml Standard Serve of Port 18% Alc. Vol

150ml Average Restaurant Serving of White Wine 11.5% Alc. Vol

100ml Standard Serve of White Wine 11.5% Alc. Vol

1.4

150ml Average Restaurant Serve of Champagne 12% Alc. Vol

7.5

750ml
Bottle of Champagne 12.5% Alc. Vol

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1.4 1 0.8 34 24 19

375ml
Full Strength 4.8% Alc. Vol

375ml Mid Strength 3.5% Alc. Vol

375ml Low Strength 2.7% Alc. Vol

24 x 375ml

Full Strength 4.8% Alc. Vol

24 x 375ml Mid Strength 3.5% Alc. Vol

24 x 375ml Low Strength 2.7% Alc. Vol

NUMBER OF STANDARD DRINKS – WINE

1.6 1 0.9 1.4 1

150ml Average Restaurant Serving of Red Wine 13.5% Alc. Vol

100ml Standard Serve of Red Wine 13.5% Alc. Vol

60ml Standard Serve of Port 18% Alc. Vol

150ml Average Restaurant Serving of White Wine 11.5% Alc. Vol

100ml Standard Serve of White Wine 11.5% Alc. Vol

1.4

150ml Average Restaurant Serve of Champagne 12% Alc. Vol

7.5

750ml
Bottle of Champagne 12.5% Alc. Vol

8 43 21 7.5 39 19.5 28

750ml
Bottle of Red Wine 13.5% Alc. Vol

4 Litres Cask Red Wine 13.5% Alc. Vol

2 Litres Cask Red Wine 13.5% Alc. Vol

750ml
Bottle of White Wine 12.5% Alc. Vol

4 Litres Cask White Wine 12.5% Alc. Vol

2 Litres Cask White Wine 12.5% Alc. Vol

2 Litres Cask of Port 17.5% Alc. Vol

NUMBER OF STANDARD DRINKS – SPIRITS

30ml High Strength Spirit Nip 40% Alc. Vol

250ml Full Strength Pre-mix Spirits 5% Alc. Vol

700ml High Strength Bottle of Spirits 40% Alc. Vol

1.2

300ml Full Strength Pre-mix Spirits 5% Alc. Vol

1.1

275ml Full Strength RTD* 5% Alc. Vol

1.5

375ml Full Strength Pre-mix Spirits 5% Alc. Vol

1.2

330ml Full Strength RTD* 5% Alc. Vol

1.7

440ml Full Strength Pre-mix Spirits 5% Alc. Vol

2.6

660ml Full Strength RTD* 5% Alc. Vol

1.4 – 1.9

250ml High Strength Pre-mix Spirits

1.5

275ml High Strength RTD* 7% Alc. Vol

1.6

300ml High Strength Pre-mix Spirits

1.8

330ml High Strength RTD* 7% Alc. Vol

2.1

375ml High Strength Pre-mix Spirits 7% Alc. Vol

3.6

660ml High Strength RTD* 7% Alc. Vol

2.4

440ml High Strength Pre-mix Spirits 7% Alc. Vol

7% – 10% Alc. Vol 7% Alc. Vol

* Ready-to-Drink

For more information see chapter on Alcohol, page 225

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Men Women

1 in 100

11 10 9 8 7 6 5 4 3 2 1 0

1 2 3 4 5 6 7 8 9 10 Standard drinks

lifetime risk of death from alcohol-related disease per 100 drinkers, by number

figure 5

Lifetime risk of death from alcohol-related disease per 100 drinkers, by number of

of standard drinks per occasion, australia 2002

standard drinks per occasion, Australia 2002

Source: Rehm et al (2008)

For people who regularly drink 2 standard drinks per day, the lifetime risk of

death from an alcohol-related disease is about 0.4 in 100 people with that

drinking pattern. Above that level, the risk increases with the number of drinks

for people who regularly drink two standard drinks per day, the lifetime risk of death from

per day, and is above 1 in 100 at 3 drinks per day. The risk increases more sharply

an alcohol-related disease is about 0.4 in 100 people with that drinking pattern. above that

for women than for men.

level, the risk increases with the number of drinks per day, and is above 1 in 100 at three

Source: National Health and Medical Research Council Australian Guidelines to Reduce Health Risks

drinks per day. the risk increases more sharply for women than for men.

from Drinking Alcohol, Canberra: Commonwealth of Australia, 2009.

The problem with caffeine and anxiety

alcohol-related injury

Caffeine is a substance that is derived from plants or is produced

sByanstihseatincdallqyu, anlidtyisoaf nthaeddeivtidvenincea number of food products and

over-the-counter medications such as pain relievers, appetite

Lifetime risk of death from alcohol-related injury

suppressants, and cold medicines. Most commonly, it is known

A modelled analysis (Rehm et al 2008) was used to determine the

to be an ingredient in tea, coffee, chocolate, cocoa, colas, and so

accumulated lifetime risk of death from injury categories for which alcohol

called ‘energy-boosting’ beverages.

has an accepted causal effect (based on established epidemiological data:

English et al 1995; Rothman & Greenland 1998). Lifetime risk was calculated

Tea and coffee are seen by most people merely as beverages,

for an increasing number of drinks per occasion and for various numbers of

drinking occasions over a lifetime. Alcohol-attributable injury deaths per

however they do contain caffeine.

drinking occasion, and lifetime risk, were calculated using four main steps:7

• calculation of overall gender- and age-speci c risk of fatal injury per day

Because caffeine is a central nervous system stimulant, in

for each category of injury without the impact of alcohol (ie baseline risk)

anxious people it can worsen symptoms of anxiety considerably.

Consequently, it has been named in diagnoses such as caffeine-

related anxiety, and caffeine-related sleep disorder (because of its 7 Details of the modelling are given in Appendix A5.

association with insomnia).

national health and medical research council |

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Lifetime risk per 100 drinkers

People with an anxiety problem would do well to eliminate caffeine from their diet – or at least reduce intake to a nominal amount. For tea and coffee drinkers, it is now possible to purchase these products in caffeine-reduced and decaffeinated forms. For people accustomed to a high caffeine intake, it is advisable to reduce consumption gradually to minimise potential withdrawal effects.

national Help/Information Lines

• beyondblue info line: 1300 22 4636 ( local call cost)

• Lifeline: 13 11 14

• Kids Help Line: 1800 55 1800

• MensLine Australia: 1300 78 99 78

• Australian Psychological Society Referral Line: 1800 333 497

• SANE Australia: 1800 18 7263 (national)

• Suicide Call Back Service: 1300 659 467
See Key Services and Resources on pages 302 to 319 for state and territory contacts.

For more information, see Fact sheet 9 − Reducing alcohol and other drugs at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

ANXIETY

DistuDrbepinrgeTsshionughts

Disturbing Thoughts

Disturbing thoughts are danger signs that should not be ignored.

Tickþthe signs that are familiar:

rThinking things are hopeless and won’t change in the future rThinking or saying to yourself:

− life isn’t worth living, or
− people would be better off without me, or
− nothing is ever going to get better, what’s the point of going on, or
− there will be no end to the mental/emotional pain I’m feeling, or
− my relationship/marriage is in such trouble I just can’t bear it; I don’t want to go on….what’s the point?

r Thoughts about death and dying, and how people would cope without you

rYou have had thoughts about:
− what you might do to yourself to end your life
− when and where you would do it
− what you might use to end your life
− who you would put in your will, and the instructions you would leave for people, or the note you would write, for after your death.

rThoughts about hurting others
rThoughts about harming or mutilating yourself
rBeing very suspicious about other people’s intentions towards

you
r Thoughts that you are being persecuted, taken advantage of or

wronged in some way
rBeing preoccupied with intrusive thoughts or perceptions that

are important to you, but which others don’t understand or accept the importance of.

DISTURBING THOUGHTS

Feelings that often accompany disturbing thoughts:

rFeeling an overwhelming sense of failure in life
rFeelings of emotional/mental pain that are almost unbearable

and seem to get no better
rFeeling hopeless and helpless much of the time
r Feeling sad, miserable and/or depressed for days at a time rFeeling unsafe

Behaviours that sometimes accompany disturbing thoughts:

r Becoming withdrawn, avoiding people and social events rIncreasing use of alcohol or other drugs to try to cover

feelings of mental pain and hopelessness
rBecoming secretive about your thoughts and feelings of

hopelessness and helplessness
r Being careless, taking needless risks, acting dangerously, or

putting yourself in harm’s way
Thoughts, feelings and behaviours of this kind need to be taken

very seriously. Do not ignore them.
.TAKE URGEnT ACTIon.

Arrange to speak to a doctor OR

Phone a 24-HoUR MEnTAL HEALTH EMERGEnCY LInE

national

Lifeline: 13 11 14
Suicide Call Back Service: 1300 659 467

State and Territory
ACT: Crisis Assessment and Treatment Team: 1800 629 354 nSW: Salvo Suicide Prevention & Crisis Line: Metro

02 9331 2000
Salvo Suicide Prevention & Crisis Line: Rural 1300 363 622 Suicide Prevention and Support: 1300 133 911

DISTURBING THOUGHTS

nT: Mental Health on Call Team:Top End (08) 8999 4988 Mental Health on Call Team: Central Australia
(08) 8951 7777

QLD: Salvo Crisis Counselling Service: Metro 07 3831 9016 Salvo Crisis Counselling Service: Rural 1300 363 622

SA: Mental Health Assessment and Crisis Intervention Service: 13 14 65

TAS: Mental Health Services Helpline: 1800 332 388 VIC: Mental Health Advice Line: 1300 280 737

SuicideLine: 1300 651 251

WA: Mental Health Emergency Response Line: Metro 1300 555 788

Rural Link: Rural 1800 552 002 Samaritans Crisis Line: 1800 198 313

nATIonAL HELP/InFoRMATIon LInES

DISTURBING THOUGHTS

Some things to consider if you are experiencing suicidal thoughts

• No matter how bad your situation, no matter how overwhelming your mental/emotional pain, there is always a better option than considering suicide or self-harm – but it may not have occurred to you. Speak to a doctor (and other help can follow). Or phone a 24 hour Mental Health Crisis line.

• When people kill themselves, it seriously affects their family and friends. Feeling “They’d be better off without me” doesn’t cancel out the fact that they would be greatly damaged – perhaps for life.

• Promise yourself (and someone else) that you will get help, that you will do it now, and you will not give up until you get it.

I promise, for my sake and for the sake of others, that I will get help NOW

Signed………………………………………………………………………………………

• Suicidal thinking is often driven by depression. 90% of older people who attempt suicide have a mental illness – usually undiagnosed depression. Remember, depression is an illness, not a chosen state of mind. Risk of actual suicide increases without treatment.

• Break your silence and isolation: get help NOW.

• Feelings of hopelessness, helplessness, and overwhelming mental/emotional pain can be turned around with appropriate treatment.

DISTURBING THOUGHTS

More powerful than all problems is the courage to deal with them.

• If you think a particular problem has brought you to this point, try using Structured Problem-Solving (included in this section).This may ‘take some pressure off’. However, still speak to a doctor about your mental state.

• Who are the people who really matter to you? Think about why they do care, and the good things that have happened between you.
REMEMBER
Things can feel very different and look very different; energy, motivation, problem-solving ability, and hope for the future can be restored if you act with courage and speak to a doctor or phone a Mental Health Crisis Line.

DISTURBING THOUGHTS

To help someone else

IMPORTANT

• First and foremost recognise that you are not responsible for someone else’s suicidal behaviour. You have no control over the person’s will. If the person chooses to act in a self-harming or destructive way, he/she has chosen to do so; he/she is responsible.

• Asking a person if he/she has suicidal thoughts will not encourage the person to act on these thoughts, but will signal genuine concern and an avenue of hope.

• People who are experiencing suicidal thoughts, whether depressed or not, may not be easy to help.They may have become secretive and evasive, or may be so depressed or troubled that they view everything as pointless except ending how they feel. Persevere anyway.
Useful tips for helping someone who may be suicidal

• Think about the best way to approach the person – given what you know about his/her personality and temperament.

• Let the person know that you are seriously concerned. Suggest that he/she might see a doctor immediately or speak to a health professional recommended by a doctor − or ring a 24 hour Mental Health Crisis Line. Help the person to make the appointment or phone call. Offer to take or go with him/her to receive assistance.

• If you think the person won’t listen to you, then consider who he/she usually con des in, feels comfortable with and/ or trusts. Maybe this nominated person could make the approach and encourage the person who may be depressed to seek assistance.

The most important aim is to keep the person safe.

DISTURBING THOUGHTS

• Provide the person with a 24 hour crisis line number (see page 89 and 90).Try to get the person to put it where it won’t be lost and will be accessible.

• Enlist the help of relatives or friends to keep a watchful eye on the person, to break his/her isolation, and to provide extra safety.

• Maybe you can help the person to work through a major problem rationally, resolve a relationship con ict, or get a new perspective on things (see Structured Problem-Solving on page 96).

• Encourage the person to think about what is valuable, worthwhile and precious in his/her life. As well, encourage the person to recognise who depends on and values him/ her.

• Be as determined and resourceful as you can in nding a way to get the person to a doctor or appropriate health professional (or to seek help by phoning a Mental Health Crisis Line).

• Emphasise that mental/emotional pain, depression, low energy, and feelings of hopelessness and helplessness can be quickly turned around with appropriate treatment from a doctor. Left untreated, the person’s mental state may deteriorate. The risk of acting on suicidal thoughts and feelings increases without treatment.

• Try to get agreement on a no Harm/Seek Help promise (an example is included on page 95).

• Be determined, but respectful.

• Listen to the person carefully.

• Think safety.

• Avoid being overdramatic; be calm and thoughtful.

• Remind yourself that you are not responsible for someone else’s suicidal behaviour.

DISTURBING THOUGHTS

no Harm – Seek Help PRoMISE

I give my word that I will not harm myself or put myself in danger and that I will seek help until I get help to deal with what is happening to me.

Signed: ………………………………………………………………….. Witnessed: ……………………………………………………………. Dated:……………………………………………………………………

DISTURBING THOUGHTS

Structured Problem-Solving

Some problems can feel absolutely overwhelming, and impossible to deal with.

Structured problem-solving is a method designed to help you feel in control of a problem, and to nd a way through it.

The key elements of this method include:

• identifying and ‘pinning down’ the problems that have contributed to you feeling overwhelmed

• thinking clearly and constructively about problems

• ‘taking stock’ of how you’ve coped in the past: your
personal strengths and the support and resources available
to you

• providing a sound basis for important decision-making.

DISTURBING THOUGHTS

Structured Problem-Solving Involves 6 Steps

STEP 1

Write down the problem causing you worry or distress:

STEP 2

Think about your options for dealing with this problem (try to think broadly − including good and not so good options); write them down:

STEP 3

Write down the advantages and disadvantages of each option:

STEP 4

Identify the best option(s) to deal with the problem:

DISTURBING THOUGHTS

a. b.

c. d.

STEP 5

List the steps needed to carry out each option (bear in mind the resources needed and pitfalls to overcome):

STEP 6

Review your progress in carrying out your option(s):

What have I achieved?_______________________________

____________________________________________________

What still needs to be done? _________________________ ____________________________________________________ ____________________________________________________

DISTURBING THOUGHTS

Some Facts about Suicide

Most people who die by suicide are affected by a mental disorder. Ninety per cent of older people who attempt or die by suicide have a mental disorder that is often undiagnosed and untreated. In most cases, these people have been experiencing depression.

Though depression is the most common mental disorder associated with suicide, some suicides are impulsive; many who attempt to end their lives are not so much motivated by a desire for death, but to escape the mental/emotional pain and anguish they are experiencing. This is important to understand, because when someone is on a path to suicide, it is often possible to intervene in a way that gives them the resources to cope with or overcome their pain and dif culties without resorting to self- harm.

The of cial number of recorded suicides in Australia has decreased in recent years following peaks in 1997 and 1998. Despite these decreases, suicide remains a major cause of death. For example, in each of the years from 1994 to 2004 the total number of deaths from suicide was greater than the number of deaths from road accidents.

Research shows that more women deliberately self-harm and attempt suicide than men, however men in Australia are almost four times more likely than women to die from a suicide attempt.

There were 1,881 deaths from suicide registered in 2007, representing 1.4% of all deaths that year. Men of all age groups in Australia are far more likely than women to die from suicide. In 2007, the rate of suicide deaths was 13.9 per 100,000 men compared to 4 per 100,000 women.

DISTURBING THOUGHTS

Suicide rates for men have been consistently higher than for women throughout the time Australian data has been collected.

In 2007:
77% of suicide deaths were men
21% of all male deaths under the age of 35 were by suicide.

Suicides in 2007 occurred at a rate of:

• 8.3 per 100,000 in the 15-24 age group

• 12.8 per 100,000 in the 25-34 age group

• 13.1 per 100,000 in the 35-44 age group

• 12.2 per 100,000 in the 45-54 age group

• 10.6 per 100,000 in the 55-64 age group

• 8.0 per 100,000 in the 65-74 age group

• 9.6 per 100,000 in the 75-84 age group

• 10.2 per 100,000 in the over 85 age group
Source: Australian Bureau of Statistics. (2009).
Causes of Death, Australia, Suicides 2007. ABS Catalogue No. 3303.0.
Factors that contribute to suicide risk

• Marital breakdown/relationship problems

• Bereavement

• Depression (or other mental disorders)

• Unemployment

• Financial problems – including a sudden change in nancial circumstances

• Previous suicide attempt

• High levels of stress, distress and depleted (‘run down’)
emotional and personal coping resources

• Ready access to a rearm, pills, or other means of
committing suicide

• Alcohol dependence and/or abuse

• Deliberate self-harm

• Isolation

DISTURBING THOUGHTS

100

Factors believed to diminish suicide risk

• Family connectedness

• Responsibility for children and others

• Close relationships/friendships

• A sense of meaning and purpose in life

• Personal resilience and problem-solving skills

• Being connected to a community and social activities

• Good mental health

• A preparedness to seek out early help for mental health
dif culties

• A belief that suicide is wrong

• Lack of access to guns
Major issues for men
Some of the most telling issues linked with male suicide in Australia include:

• alcohol use, marijuana or other drug dependence

• a sense of failure in life, towards family, and nancially

• family/relationship problems

• loneliness, isolation

• physical or mental illness

• unemployment and/or nancial problems

• unaddressed depression.

Most telling issues relative to age:

• A sense of failure appears most signi cant to men under 45 years of age.

• Family/relationship problems and a sense of failure appear to be signi cant factors for men aged 45-49 years.

• Physical and/or mental illness and family problems appear to be signi cant factors for men aged 60-69 years.

• Loneliness or physical illness appear to be signi cant for men aged 70 years (Hassan, 1995).

SSee section on DEPRESSIon (Page 2)

101

DISTURBING THOUGHTS

102

ReDceopverersysiforonm Trauma

Information in this chapter provided in association with the Australian Centre for Posttraumatic Mental Health

103

Recovery from Trauma

Warning signs of a problem with traumatic stress

Tickþthe signs that are familiar:

r You have been through an event during which you experienced intense distressing emotions such as fear, helplessness or horror

r Intense memories/thoughts of the event keep re-occurring and are highly distressing

r You get emotionally upset when something reminds you of the event

r You have unpleasant dreams or nightmares about the event r When you think about the event, you feel sweaty, tense, your

heart races and your breathing increases

r You try to avoid activities, places, or people that remind you of the traumatic event

r You avoid thoughts, feelings or conversations that are associated with the trauma

r You are having dif culty sleeping, concentrating and/or you feel highly irritable since the event

r You feel depressed or have low motivation
r You have high levels of irritability or anger that is interfering

with your relationships
r You feel intense guilt about the event

If it has been over four weeks since the traumatic event and some or all of the above symptoms are interfering with your ability to carry out the things you usually do, such as work or study −

.TAKE ACTIon. Arrange to speak to a doctor.

RECOVERY FROM TRAUMA

104

What is a traumatic event?

A traumatic event is often de ned as an event which involves an encounter with death, or the experience of severe injury. Some traumatic events only have the potential of death or injury – that is, the event doesn’t actually result in death or severe injury, but the individual believed that it could have done.When someone says,“I thought I was going to die,” that is more important than whether or not the person was actually in danger of being killed.

Traumatic events usually result in intense emotional responses such as fear, helplessness or horror. In Australia, common traumatic experiences include disasters (such as bush res), being threatened with a weapon, being physically assaulted, being involved in a life threatening accident, sexual assault, and child abuse or neglect. Other traumatic events include things like war, kidnapping and being tortured.Witnessing these types of events happening to others, or learning about these kinds of events occurring to loved ones, may also be a traumatic experience for some people. Unfortunately, traumatic experiences are common. Around 65 per cent of Australians have experienced at least one traumatic event and many will experience more than one event.

Common reactions to trauma

Individuals who have gone through a traumatic event often experience many different emotional reactions.This is referred
to as traumatic stress and, in its milder forms, is part of a normal reaction to very frightening events. Common experiences include:

• Distressing memories of the event – Distressing memories or thoughts of the event may enter your mind even when you don’t want them to.This may include images or thoughts about the event, or sensory experiences like sounds or smells. Nightmares are also common. Although memories and nightmares are distressing, they are part of the body’s natural way of coming to terms with, or getting used to, very frightening events. Re-experiencing provides you

105

RECOVERY FROM TRAUMA

with the opportunity to try to make sense of the experience and understand what it means to you. For the majority of people, these memories usually fade over time.

• Physical symptoms – When a person is anxious, his/ her body will respond with a ‘ ght or ight’ response.This response can include shortness of breath, increased heart rate, sweating, shaking, feeling restless, muscle tension and nausea. Read the Anxiety chapter in this book (page 41) for more information on anxiety disorders.

• Avoidance – You may nd yourself avoiding activities, situations or people that remind you of your traumatic experience.

• Depression and grief – It is usual to experience sadness and grief following a traumatic experience. It is normal to feel upset and confused when you think or talk about your experience. Grieving is a process of healing − it is part of the process of coming to terms with the things you have lost.This sadness usually lifts as you start to adjust to your experience.

• Guilt – Guilt is a strong emotion that people often feel following a traumatic experience.You may feel guilty if you think you were responsible for the event or for not avoiding it. Some people feel guilt because they survived while others did not.They may feel guilty because others experienced more of the trauma than they did.

• Anger – At some stage, people usually experience anger about the traumatic experience.Anger may be directed toward yourself or toward others. It may be about the injustice of the situation, the carelessness of others or your stupidity for getting into the situation.

• Sleeping dif culties – Following a traumatic event, you might nd it dif cult to fall asleep and/or stay asleep. Nightmares and bad dreams can make sleeping dif cult. One reason sleeping is dif cult following a traumatic experience is because of increased stress levels. When we are stressed, our bodies release adrenaline and we become alert, making it almost impossible to sleep.

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106

• Concentration and memory dif culties – Following a traumatic experience, you may notice that you are easily distracted and that your concentration is very poor.This is because your mind is preoccupied with going over and over the traumatic event, so that you have little space for anything else.

When to seek professional help

The above reactions to trauma are common and – as long as they are not too severe and they do not last too long – they
are a normal part of adjusting to a traumatic event.They can be distressing, but for most people, the reactions gradually decrease over time. These symptoms are part of the natural healing process of adjusting to a very powerful event, making sense out of what happened, and putting it into perspective.

Sometimes traumatic events can be dif cult to overcome and professional help may be required. If you tick any of the boxes below, talk to your GP:

r Continue to experience high levels of distress four or more weeks after the traumatic event

r Feel very distressed, frightened, irritable or on edge much of the time

r Find yourself avoiding situations because they remind you of the traumatic event, and this is causing you dif culties

r Are unable to carry out your normal role at home, work, or school

r Find that your distress is interfering with your important relationships such as with friends or family

r Feel hopeless, despairing and think that you can’t go on r Are thinking of harming yourself or someone else

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RECOVERY FROM TRAUMA

Signs and symptoms of Post-Traumatic Stress Disorder (PTSD)

People with PTSD often experience feelings of panic or extreme fear, which may resemble those sensations that were felt during the traumatic event. A person with PTSD has four main types of dif culties:

1. Re-living the traumatic event – through unwanted and recurring memories, often in the form of vivid images and nightmares.There may be intense emotional or physical reactions, such as sweating, heart palpitations or panic when reminded of the event.

2. Being overly alert or wound up – sleeping dif culties, irritability, lack of concentration, becoming easily startled and constantly being on the look out for signs of danger.

3. Avoiding reminders of the event – deliberately avoiding activities, places, people, thoughts or feelings associated with the event because they bring back painful memories.

4. Feeling emotionally numb – losing interest in day-to-day activities, feeling cut off and detached from friends and family, or feeling emotionally at and numb.

These symptoms usually lead to signi cant distress and interfere with the person’s ability to work and study, as well as his/her social relationships. It’s not unusual for people with PTSD to experience other mental health problems at the same time. These additional problems, most commonly depression, anxiety and alcohol or drug use, are more likely to occur if PTSD has persisted for a long time.

RECOVERY FROM TRAUMA

108

Signs and symptoms of Acute Stress Disorder (ASD)

ASD is very similar to PTSD. The main difference is the length of time that problems remain after the traumatic event. ASD
is diagnosed when serious problems occur in the rst month after a traumatic incident. If problems continue to impact on a person’s life for longer than one month, PTSD may be diagnosed. People with ASD are at high risk of developing PTSD. For more information on ASD visit http://www.acpmh.edu.au

How to help yourself

Adjusting to, and recovering from a traumatic experience takes time.You will have good days where you feel like you are moving forward to recovery and other days when you will feel like you are going backwards.While the process of recovery may be long and painful, many people are able to use the experience to grow. People often feel that they come out of the traumatic experience with a stronger belief in themselves, with improved social relationships and bene ts in personal growth and life priorities. You may not feel like this at the moment, but it is worth remembering this as you progress down the road of recovery.

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RECOVERY FROM TRAUMA

Helpful Strategies to Recover from a Traumatic Event

Talking about the event

Although you might want to just forget about what you’ve been through, talking about it is very important. Many people avoid talking about their experience in depth because they feel they will be overwhelmed with distress. However, talking about your experience is the way to begin your recovery process.

Talking (or writing) about the trauma helps your recovery in a number of different ways. Firstly, it helps you make sense of the experience.You can ll in bits of information that are missing. It helps you to see your experience clearly and may help you see
it from different perspectives. Other people’s opinions can also be useful to help you take a different perspective. Secondly, the more you tell your story, the more you get used to it and the less distressing it becomes. Like when you rst learn to drive, you may feel anxious, but the more you do it, the less anxious you feel.This will happen with telling your story – it is very dif cult at rst, but it will get easier.

RECOVERY FROM TRAUMA

110

Talking about the event − Strategies

• Choose someone you trust and whom you think can cope with your story. Some trauma experiences are
so horri c and distressing that it is better to tell a professional person such as a psychologist, psychiatrist or other trained mental health professional.Your GP can help you nd someone suitable.

• Start gradually by just outlining what happened.

• As this becomes easier, ll in some more detail.

• Finally, tell your story with as much detail as you can. This will include what happened (including what you saw, heard, smelt, etc.) as well as how you reacted (what you did as well as what you were thinking, feeling, etc). Remember, each time you tell your story, the easier it becomes.

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RECOVERY FROM TRAUMA

Writing your story − Strategies

• Writing can also be useful in assisting your recovery, especially if you do not have someone with whom you feel comfortable talking about what happened.

• Start at the beginning; write down what happened, how you were feeling at the time, what things were going through your head during the experience. Include as much detail as you can.

• Read through it to make sure you haven’t missed anything.You will probably feel quite sad and/or anxious when writing – these feelings are normal and helpful.

• Over the next couple of days, read through your story and add in bits you may have missed out. Reading the story helps you adjust to what you’ve been though. If it is painful to read through your story, remember that each time you read through it, it will be become easier.

• Sometimes during this process you might nd yourself getting ‘stuck’ by a particular thought (like “It was all my fault” or “I’ll never be safe again”). Usually these thoughts will change as you repeat the writing and come to see what happened from a different perspective. If they don’t, it is worth considering some professional help to get you over that hurdle.

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112

Dealing with reactions to a traumatic event

Dealing with anxiety

• Take up relaxation or meditation classes (see page 52).

• Schedule in quiet time, where you take time out for yourself to do something enjoyable like taking a bath, reading a book, listening to music.

• Do other things to look after yourself such as eat well, exercise regularly, rest regularly, and decrease your use of alcohol and cigarettes.

Dealing with avoidance (See Gradual Exposure section on page 74).

• Talking or writing about what happened is a good way to stop avoiding the memories and start your recovery.

• When you feel ready, try
to visit the place where the traumatic event happened or look at photos taken of the event if relevant.

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RECOVERY FROM TRAUMA

Dealing with grief and depression

• Think about all that you have lost as a consequence of
this event. It may be friends, family or possessions; it may be something about your physical body, or it may be something else about you like your independence, health, or a sense of safety.

• Talk or write about what you have lost, and how it feels to have lost these things.

• Think about how you can rebuild these things. For example, to rebuild your sense of control – try to make as many day-to-day decisions
as possible for yourself.This will increase your feeling of control over your life.

• Think about whether any good things have come out of this experience; the things you have learnt about yourself and others, about new directions, or new priorities.

• Read the Depression chapter of this book, especially the section Activity Planning on page 24.The Grief chapter of this book deals with normal grieving and complicated grief (see page 267).

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114

Dealing with anger

• Read the chapter on Anger in this book (page 159) for some helpful advice.

Dealing with guilt

• Often guilt arises when we take on too much responsibility for the traumatic event.

• Think about how responsible you were for the situation.

• Make a list of all the people and aspects of the situation that contributed to the event.Think about what percentage each contributed to the situation. For example, you may feel very responsible for your car accident, however when you do this exercise, you’ll realise that lots of other things (such as weather, road and traf c conditions, other drivers) also contributed to the accident. This exercise helps you put your behaviour in perspective, and helps you make sense of the situation.

Dealing with sleep disturbance

• The Insomnia chapter of this book (page 118) has some helpful hints about dealing with sleeping problems.

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RECOVERY FROM TRAUMA

Dealing with concentration and memory problems

• Help your memory by carrying around a small note pad and writing down things you want to remember.

• To remind yourself of appointments or other things, place notes in strategic places (like stuck to your mirror).

• Make allowances for your poor concentration − give yourself more time than usual to carry out a task.Try not
to give yourself a hard time about forgetting things or not concentrating.

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116

Referral information

There are services that can help you adjust to your trauma.

Speak to your local doctor and tell him/her of your dif culties. The doctor can refer you to a psychologist, psychiatrist or other mental health practitioner.

Your Community Health Service or Community Mental Health Clinic may also offer some counselling services – check your local phone book for contact details.

The Australian Psychological Society Referral Line –
1800 333 497 – can give you the names of psychologists who deal with traumatic stress in your area.We recommend you ask for a clinical psychologist who uses Cognitive Behaviour Therapy (CBT) (see page 6).

And nally, remember, things will get better. After a traumatic experience, it is sometimes hard to see any light at the end of the tunnel. However, don’t lose sight of the fact that it will get easier – even if that’s hard to believe at the moment. Having this knowledge is important in pushing on with your recovery.

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RECOVERY FROM TRAUMA

Insomnia

119

Warning Signs of a problem with INSOMNIA

Tickþthe signs that are familiar

qDif culty falling asleep
qDif culty staying asleep
qWaking up too early at the end of the sleep period qDif culty getting back to sleep after waking
q Feeling worried, annoyed, frustrated, anxious, or angry at

bedtime or while lying in bed trying to go to sleep
qRacing thoughts when trying to go to sleep or when waking in

the night
qFeeling physically or mentally tired during the day
qYour sleep has been disturbed for 3 or more days per week

for at least a month
qSleep disturbance is causing you signi cant personal distress

or interferes with your social life or ability to work qPoor quality of sleep (not waking feeling refreshed despite

having been asleep for a reasonable period of time) qYou’re very concerned about your lack of sleep (most of the

time), and the consequences of this lack of sleep
qSpending excessive time in bed and experiencing sleep broken

by frequent awakenings
q Falling asleep early each evening (before 9pm), waking very

early and being unable to return to sleep

If some of these signs are familiar and poor sleep is affecting your life –

.TAKE ACTIon. Arrange to speak to a doctor

INSOMNIA

120

Why speak to a doctor?

Restoring a normal pattern of sleep usually requires little more than the use of some simple guidelines and strategies. But because there are many factors that can cause or contribute to insomnia, requiring medical diagnosis, treatment, or referral, it is important to speak to a doctor. These include:

• medical disorders associated with insomnia

• mental disorders associated with insomnia

• prescription medications

• use of non-prescription drugs and alcohol

• sleep disorders associated with malfunctioning body organs.

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INSOMNIA

About Insomnia

Sleep problems are one of the most common complaints people make when presenting to doctors in general practice.

Twenty to twenty- ve per cent of Australians report suffering from some form of lasting insomnia at some time in their lives. Up to 12% have long-term (chronic) dif culty either going to sleep or maintaining sleep.

Common complaints of people with insomnia are:

• dif culty falling asleep

• dif culty staying asleep

• waking up early at the end of the sleep period

• feeling anxious, irritable, worried or depressed – especially at bedtime

• racing thoughts when waiting to go to sleep or when waking up in the night

• feeling physically or mentally tired during the day. What are the effects of insomnia?
Sleep is a natural process that allows the body and brain time to recover from daily activity. During sleep, the body makes chemicals which help it grow and repair, and the immune system becomes more active to ght infection and illness.
Sleep is also important for emotional balance and a healthy mood state. It is also thought that sleep is a time when memories, experiences, and skills are sorted and stored. But what about when sleep is disturbed, when people fail to get enough sleep, or their quality of sleep is poor?
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INSOMNIA

Some of the consequences of insomnia

• Fatigue (due to tiredness) is involved in approximately 1 in 6 fatal road accidents in Australia.

• An older person with insomnia has 4 times the risk of having a fall and suffering a major injury.

• Tiredness and fatigue are responsible for 52.5% of work- related accidents and almost 29% of accidents around the home. Nearly 10% of people with chronic insomnia experience serious accident or injury.

• Staying awake for 17 hours decreases performance, the same as a blood alcohol level of 0.05%.

• After 5 nights of poor sleep, 3 drinks have the same effect on the body as 6 would when the person is well rested.

• People experiencing insomnia are 25% more likely to miss work.

• Studies of people with insomnia show the disorder impairs concentration, memory, and the ability to accomplish daily tasks, and affects interpersonal relationships.
What causes insomnia?
Insomnia commonly begins during times of increased life
stress. Most people at some stage in their lives experience sleeplessness due to lying awake at night thinking about personal problems, work, or their nances.This sleep dif culty is only
a temporary problem that will likely resolve within a few days
or weeks. Sometimes though, especially if the stressful issue is major and a person’s ability to function is signi cantly affected
by sleeplessness, he/she will also become preoccupied with the inability to get to sleep.The effect is a vicious cycle of anxiety and worry about not sleeping, feeding into and worsening the problem of sleeplessness itself. In this way, a temporary problem of sleeplessness can develop into insomnia.

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Sleeplessness

Anxiety about inability to sleep

Insomnia

Though times of increased stress are a common beginning for insomnia, there are actually many factors that can cause or contribute to it such as:

• ageing

• lifestyle commitments

• physical disorders

• mental disorders

• prescription medication

• non-prescription drugs and alcohol.

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What about using medication?

Medication may be prescribed for a short period of time (3 to 5 days). However, the preferred approach to overcome sleep dif culties is NOT to use medication.

The use of sleeping pills (sedative hypnotics) for any length
of time can cause more problems than it solves: dependence, addiction, returning symptoms, side-effects and for older people in particular, an increased risk of falls.

Problems associated with Sleep Medication

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Self-help Sleep Guidelines and Therapies

Individual differences in the need for sleep

People differ in the amount of sleep they need. Some people appear to need 9 to 10 hours sleep each night, whereas others can wake refreshed and function well during the day on 4 to
5 hours sleep each night. As people get older, they generally require less sleep. Few people in their sixties need as much sleep as when they were in their thirties. Teenagers tend to need as much sleep as small children – around 10 hours per night.

You are the best person to judge whether you have a problem with sleep. You may feel ne and function well even though you don’t get a lot of sleep. However, if this is not the case, and your life is being adversely affected by insomnia, there are some very effective measures you can take to establish a better pattern of sleep.

Better Sleep Guidelines

To establish a better pattern of sleep, often all that is necessary is to practise sleep promoting behaviours during the day, in the evening, at bedtime, and during the night.

During the day

• Organise your day. Regular times for eating meals, taking medicines, performing chores and other activities, help keep our inner clocks running smoothly.

• Regular exercise during the day (or early evening) can improve sleeping patterns. Avoid exercise late in the evening as this may make getting to sleep more dif cult.

• Set aside time for problem-solving and decision-making during the day to avoid worry or anxiety at night. (See Structured Problem-Solving included in this section.)

• Avoid napping during the day – go to bed and get up at regular times.
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During the Evening

• Put the day to rest. If you still have things on your mind, write them down or put them in your diary to be dealt with tomorrow.

• Light exercise early in the evening may help sleep; exercise late in the evening may make getting to sleep more dif cult.

• Get into a routine of ‘winding down’ during the course of the evening, allowing at least half an hour of quiet activity, such as reading or listening to music, prior to bedtime.

• Avoid drinking caffeinated drinks after about 4pm, and don’t drink more than 2 cups of caffeinated drinks each day (especially coffee, tea, cocoa and cola).

• Avoid smoking for at least an hour (preferably an hour and a half) before going to bed.

• Don’t use alcohol to make you sleep, and keep your intake moderate (2 standard drinks each day). Have 1 or 2 alcohol- free days each week.

• Make sure your bed and bedroom are comfortable – not too cold or warm.

• Ensure that your bedroom is dark and that the morning light does not lter in (except if you have a tendency to oversleep, in which case it may be helpful to let the morning light into the room).

• Avoid a heavy meal close to bedtime. If you are hungry, a light snack might help you get to sleep.
At Bedtime

• Try to do the same things before you go to bed each night. Develop a calming bedtime routine, such as having a warm bath or shower, listening to relaxation music, or using a relaxation technique (see Progressive Muscle Relaxation on page 134). This way your body will learn to know that (with these activities) you are getting ready to go to sleep.

• Go to bed when you feel ‘sleepy tired’ and not before.

• Don’t read, watch TV, or have conversations or arguments in bed. Keep your bed and bedroom only for sleep (and sexual
activity).

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For more information, see Fact sheet 7 − Sleeping well at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

• Turn the light off when you get into bed.

• Relax and tell yourself that sleep will come when it is ready.
Enjoy relaxing your mind and body, even if you don’t at rst fall asleep.
During the night

• If you wake up too early in the night don’t lie awake for more than 30 minutes. Instead of just being awake or worrying, get out of bed and do something that is distracting yet relaxing. Return to bed only when you feel sleepy again.

• Get up at the same time each morning. Don’t sleep late in the morning trying to make up for ‘lost sleep.’

• If you live in a place or area where there are sounds or noises that might wake you from sleep, have earplugs handy to block out the noise.

• Avoid sleeping pills − they do not provide a long-term solution to sleep problems.
Taking note of your sleep pattern
Before looking at the role or relevance of self-help sleep therapies, it is best to be clear about the factors or patterns evident in your sleep over a 2 week period. There may be some features of your sleep dif culty of which you are unaware.
You may be able to simply recall enough of this information to complete a sleep diary. If not, then monitor what happens for the next 2 weeks. A solution cannot be matched to a problem until the problem is clearly de ned.

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DAY

Time of getting to bed

Time taken to fall asleep

no. times woke up

Time spent awake during night

Sleep Diary

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Time of waking up in morning

Time of getting up

Daytime naps

Exercise (type and duration)

Alcohol, caffeine, drugs

Significant events today

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Insomnia is affecting your ability to enjoy life.
You worry about not sleeping or how you’ll cope the next day.

Better Sleep Guidelines should suffice

You don’t seem to be able to relax in bed. Your mind races, you feel tense, you toss and turn a lot.

Relaxation Therapy

Going to bed has become associated with not sleeping.
You get worried, anxious and frustrated.

You feel less sleepy after turning out the lights than before you went to bed.

Stimulus Control Therapy

Choosing a self-help therapy

Sleep pattern Sleep Therapy

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Sleep pattern Sleep Therapy

You have been spending an excessive amount of time in bed (9 or more hours).

You do this in the hope of trying to catch up on lost sleep

Bedtime Restriction Therapy

You don’t get to sleep until the early hours of the morning.
You have difficulty getting up early each morning even with an alarm.

Bright Light Therapy (Morning)

You tend to fall asleep before 9pm each night. You wake too early and can’t get back to sleep.

Bright Light Therapy (Evening)

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Relaxation Therapy

There are many different relaxation methods including: meditation, self-hypnosis, mental imagery, yoga, special relaxation music. These (and many others) are readily available from book stores, libraries, and on the internet.

Progressive Muscle Relaxation

A method of relaxation with proven effectiveness which relieves muscle tension and anxiety is progressive muscle relaxation. This involves tensing and then relaxing muscles in a step-by-step sequence. The two main principles of this technique include:

1. Tensing muscle groups (one at a time) to become aware of the feeling of tension.

2. Relaxing the muscles and feeling the tension in them subside – as if owing out of the body.

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Progressive Muscle Relaxation

• You will need about 15 minutes for this relaxation exercise.

• Find a quiet place where you won’t be interrupted.

• Sit in a comfortable straight backed chair, with your feet
at on the oor.