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Understanding Anxiety, Treatment for it, and how to Support: A Resource for Family and Friends

If you're reading this it's probably because someone you know and care about has been struggling with some kind of disordered anxiety.  Perhaps they're in therapy - or are considering therapy - and you're wanting to better understand what's going on, how therapy can help, and how you can help.  Disordered anxiety goes above and beyond the "normal" anxiety we all experience from time to time and can be really challenging (in the most extreme cases, crippling) for people in the throes of it. 

I often hear from people I work with that one of the most difficult aspects of struggling with anxiety is that other people just don't "get it".  Although the physical symptoms of anxiety are VERY real, anxiety isn't something you can see. It often manifests itself in changes of behavior that just might not make sense to people not dealing with an anxiety disorder of their own. I hear about responses from family members that range from extremely supportive (but enabling) to downright dismissive.  Wherever you land on this spectrum, this resource is intended to provide some basic education not only on the anxiety itself, but ways in which you can be supportive and most helpful to the person you know who is working on getting better.  I'll answer some common questions and cover symptoms, types of anxiety disorders, what to expect, and how to help. 

What is an Anxiety Disorder?

An anxiety disorder is a mental health condition characterized by excessive fear or worry that interferes with a person's ability to function "normally".  People with anxiety disorders might experience intense discomfort (even panic attacks at times) in situations that trigger anxiety.  The threat detection system we all have is essentially "hijacked" and leads to a a fight/flight/freeze response even in situations where no true threat is present. In some cases these triggers are associated with isolated and specific situations or things.  Someone with specific phobias, for example, might be intensely afraid of heights, large crowds, wide-open spaces, water, flying, driving, enclosed spaces, or needles (to name a few).  A person with social anxiety might find themselves extremely uncomfortable in a broad range of social situations.  Other times, anxiety looks more like excessive worry about health, family members, or the uncertainty associated with the future. 

This resource is not all exhaustive and might not fully resonate as it relates to the person you know, so make sure to check out our All-Things-Anxiety resource for a more detailed look at what anxiety is, how it's caused, and different anxiety disorder classifications. You'll also find a link at the bottom of this post with additional links.  

What is a Panic Attack? 

Panic attacks vary in severity and might be obvious or not-so-obvious to others.  It's essentially a sudden episode of intense fear that triggers the fight/flight/freeze hormonal response and extremely uncomfortable and scary physical sensations.  Some common symptoms of a panic attack include: increased heart rate, an impending sense of doom, lightheadedness, chest pain, shortness of breath, dizziness, feelings of being detached from self or reality, tunnel vision, shaking, fear of losing control or dying, stomach pain, and more.  Although panic attacks themselves are not dangerous, to a person experiencing the panic attack the terror can be very real. 

What an Anxiety Disorder might Look like from the outside?

No two people experience anxiety quite the same, but below is a list of some of the subtle and not-so-subtle things you might see in someone who is struggling with anxiety.

  • Avoidance.  Anxiety often causes people to start avoiding things that might cause extreme levels of discomfort or panic.  They'll sometimes stop going certain places, stop doing certain things, or only be able to do things under certain conditions with certain controls in place.  For example, a person who has experienced a panic attack in public might start avoiding going anywhere in public out of fear of experiencing another panic attack.  With disordered anxiety, fear of fear is essentially the core contributor to avoidance.  "What ifs" start to take over. "What if it happens again?", "What if I really do lose control?", "What if I have a panic attack and embarrass myself in front of everyone?", "What if the doors on the airplane close, I'm no longer able to leave, and if I just can't handle it?". Anxious thoughts lead to avoidance, as avoiding things is the one surefire way to prevent any of those "what ifs" from coming true.   
  • Escaping situations.  A person who has started to notice signs of anxiety or panic might react to the fight/flight/freeze response by doing everything they can to leave the situation they are in.  This provides almost immediate relief, but also reinforces the anxious response as the person essentially communicates to the brain and nervous system that the situation they were in was actually dangerous and something to be avoided at all costs.  It also reinforces the escape response since the escape response is so effective at reducing the anxiety.  
  • Safety Behaviors.  These types of behaviors are developed over time and are maladaptive things that people might do to reduce discomfort associated with triggers.  They might include: over planning, preparing, only going certain places with a "safe person", seeking reassurance from others or from google, or using alcohol or drugs when in anxiety-provoking situations.  For example, a person who has social anxiety might feel they can only attend and engage in social functions if they've had a drink or 2.  Someone with health-centered anxiety might go to the doctor often or find themselves googling symptoms at the onset of even the slightest new physical sensation to attempt to find reassurance that everything will be okay.  
  • Obsessive/Compulsive Rituals. Someone with Obsessive Compulsive Disorder traits might engage in repetitive behaviors in order to feel a sense of control, such as excessive hand washing or checking locks frequently.  They might also need things to be certain way or "just right" or have scary unwanted and intrusive thoughts.  
  • Depression.  Because anxiety can sometimes be stubborn (often shrinking people's world and limiting the things they feel comfortable doing), it's not uncommon for people to feel defeated or discouraged when trying to overcome it all.  People with anxiety know better than anyone that their fears and behaviors are irrational, but just aren't able to shake it or think their way out of it. They usually remember a time when anxiety was not so debilitating and want nothing more than to have their "old self" back.  
  • Irritability, restlessness, pacing, or difficulty sitting still 

What Causes Anxiety Disorders

Although the cause is not always entirely clear, we can usually point to one or more contributing factors. Here are a few:

  • Extended periods of stress
  • An activating incident or adverse triggering experience 
  • Genetics.  Anxiety disorders often run in families.  
  • Brain chemistry
  • Some medical issues, such as thyroid conditions
  • Trauma
  • Patterns of avoiding things that cause anxiety over time
  • Alcohol or Drug use

Key Components in Therapy and How it Can Help

One of the great things about disordered anxiety is that it's a very treatable condition with the right kind of help.  Cognitive Behavioral Therapy combined with Exposure Therapy principles are "gold-standard" approaches for treating anxiety.  Here are some of the steps and key components involved.

  • Psychoeducation: Learning about anxiety, what caused it, and how it can be treated
  • Identifying anxiety triggers
  • Identifying avoidance and safety behaviors that may be contributing to anxiety
  • Addressing the role of thinking and any irrational thinking patterns that may be contributing to anxiety
  • Developing new coping skills for dealing with anxiety and associated triggers.  
  • Creating an exposure hierarchy.  An exposure hierarchy outlines the steps that will allow an individual to slowly and gradually expose themselves to things and situations that bring on anxiety.  Through the use of new coping skills and new ways of thinking, the person engaging in exposure therapy will become desensitized to the things that trigger anxiety the most.  This is often the hardest part of the work because it feels counterintuitive and is designed to bring on the anxious response.  

Here are some Dos and Don'ts as it relates to Supporting the Person in your Life Struggling with Anxiety

Do:

  • Be supportive.  Be there to talk, but more importantly to listen.
  • Learn about their anxiety.  If you're reading this through, you're already ahead of the game and clearly have some interest in understanding.  Since there are different types of anxiety disorders, ask them if they have received a diagnosis from their therapist, doctor, or psychiatrist.  Seek resources and learn about what's going on.  
  • Recognize that even though you might not get it or understand what's going on, that this thing is very real to the person experiencing anxiety.  Nobody wants to experience disordered anxiety and anyone dealing with it would return back to "normal" if they could. With anxiety, it's not as simple as mind-over-matter.
  • Encourage them to see therapy through with a therapist who is specialized in treating anxiety.  Therapy should not be a permanent thing and should not be something that anyone becomes dependent on, but resolving anxiety can take some time.  If you're skeptical about therapy or if therapy isn't your thing, know that it has helped many people - and that all therapists should be working from evidence-based models that are proven to be effective and that are time-limited in nature.  
  • Check in with them on their progress.  Improvement can be drastically quick for some people, but slower for others.  Progress might not always be obvious.  Ask them how they're doing and how they're progressing every so often.
  • Ask them how you can help, but not before reading the "don'ts" below as sometimes what you think might be helpful, is only enabling.  You might be recruited for help with some exposure exercises.  
  • Ask them what's involved in their "treatment plan. Discuss therapy sessions and encourage them to follow-through on any "homework" they might have.
  • Show lots of praise when you see any progress or signs of improvement.  Working to overcome anxiety and/or any specific fears can be exhausting work, even if the things they're doing seem rather ordinary in nature.  Recognizing progress and showing praise will help to reinforce their efforts and keep them motivated to continue.

Don't

  • Don't minimize their experience or invalidate it even though you might not fully understand it.
  • Don't enable or become a crutch.  Anxiety often causes people to avoid the things that make them uncomfortable and to overly rely on others.  In therapy, they'll be learning how to stop avoiding the things that cause them discomfort and how to start facing those things in a new way in order to slowly/gradually decrease the threat response (fight/flight/freeze).  They'll also be learning that they don't actually need anyone, any thing, or any ritual to help them recover from anxiety. They ultimately have all of the internal resources to cope with anxiety on their own.  They just need to learn some tools and how to trust themselves. Again, maintain a supportive presence...but do not enable or allow them to become overly reliant on you.  This may be difficult (or impossible) in the earlier stages of recovery, but will become more and more important as they make progress towards getting out of therapy.  
  • Don't force them to confront things that they are not ready for. The exposure hierarchy developed in therapy will allow them to slowly/gradually confront anxiety-provoking situations in order to desensitize the system to stimuli and to build confidence over time.  Encourage, but do not push too hard.
  • Don't discourage, criticize, or show disappointment if they aren't making progress as quickly as you would like.

Joel Schmidt, MA, Licensed Mental Health Counselor & Anxiety Specialist

Additional Resources:

All-things-anxiety resource: Another one of our resources on all-things anxiety

The Anxious Truth - This is a great podcast for learning about anxiety and strategies for recovering

Anxiety Basics - A supplemental article with education on anxiety 

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