Real versus hypothetical worry

Anxiety comes from worrying about things and focusing on what could go wrong. There is a big difference however between the types of worry that we engage in. This post is about real versus hypothetical worry. Real worry needs to be actioned and hypothetical worry needs to be ignored and dismissed. Everyone worries but excessive worry will lead to exhaustion.

Real worries need to be dealt with now. An example of a real worry might be that your car has broken down and you need to contact a mechanic. An example of a hypothetical worry would be a “what if?” type worry, for example: What if I have nothing to say at the party and end up looking stupid?

Treatment of worry

1. In order to begin to overcome worry the first step is to learn how to recognise when we worry: is it real or hypothetical? Simply labelling these thoughts as “oh there’s all my hypothetical worries again, off I go!” will help interrupt the stream of thoughts and allow you distance yourself from the anxiety a little. Once you can do this, you will learn how to rationalise things a little better. We tend to go into worst case scenario often these scenarios never happen. A good question to ask yourself then is;

Whats the most likely thing to happen?

2. The second key thing to do is to recognise all the unhelpful attempts you use when you are worried, all the approach vs avoidance strategies. These may feel like they are helping in the moment however this actually makes us more exhausted. In addition it keeps the problem going because we gradually reduce our tolerance of anxiety, so smaller and smaller things will cause us an extreme anxiety response.

To reduce your worry therefore it’s a good idea to start recognising “what is it that I want to do to feel better” and try to slowly reduce the amount of excessive behaviours you carry out. For instance, if you ask others for reassurance, try reassure yourself rather than relying on other people.

Make a list of all the things you tend to do and see what things you can start to reduce a little. See it as an experiment over the next few weeks to keep it more fun and engaging. For instance “I will deliberately not check and re-check my emails before sending”

“I will deliberately not ask my partner if I’ve made the right decision”

The way this will help is it will start to build your tolerance of uncertainty; a key maintaining factor involved in excessive worry.

Allergy metaphor – if you were allergic to pollen and suffered hay fever it would take the smallest amount of pollen to set off a bad reaction – sneezing, stinging eyes etc. The same is true for GAD sufferers, that it only takes a small amount of uncertainty in our lives to set off our worry allergy. So for example, someone with GAD will worry a great deal about their plane crashing as there is a small possibility that it “may” happen.

To help stop worry and anxiety then we could either a) increase our certainty of situations i.e know 100% all the time what will happen, or b) increase our ability to tolerate uncertainty. All the behaviours you do when you are anxious is an attempt to increase certainty, by reducing this down you will allow yourself to build your tolerance of uncertainty. Of course, we cannot be 100% certain, life just doesn’t work that way so we need to focus on increasing our tolerance of uncertainty.

3) The final part of treatment involves looking at another maintaining factor which is your beliefs about worry. People who worry tend to have a belief about worry for instance “worry helps me prepare for the worst” or “worry helps me to get things done”. For this we just need to spend some time questioning the usefulness of worry and whether we can learn to live a life where we can have a more acceptable level of worry rather than excessive worry. See table below about questioning some of your beliefs about worry.

Examples of intolerance of uncertainty

Wanting to do everything yourself and not delegating.

Looking for a lot of information before proceeding.

Questioning a decision you have already made because you are no longer sure it was the right decision.

Looking for reassurance regularly.

Rechecking and doing things over because you aren’t sure you did it right the first time.

Overprotecting others, doing things for them.

The above strategies are known as “approach strategies” where we actively do something to try feel more certain. Below are avoidant type strategies to deal with uncertainty:

Avoid fully committing to certain things.

Finding ‘imaginary’ reasons for not doing things.

Procrastinating.

Think about which behaviours you engage in to avoid uncertainty. Are they more approach or avoidance type behaviours or both? Write them down.

Set up a behavioural experiment where you decrease one of your unhelpful behaviours. Think about how stressed you might be if you aren;t able to ask for reassurance for a day. Predict what you think might happen and then try out your new behaviour (eg. don’t procrastinate or make a quick decision)…then have a look at how it went. Did your prediction come true? You will probably find that the reality wasn’t as bad as what your imagination conjured up!

What is the link between intolerance of uncertainty and worry?

Intolerance of uncertainty can be described as the difficulty of accepting the fact that it is not completely impossible that a negative event might happen despite its low probability. Here is an example: “Allison and Brenda are both referred for an abdominal ultrasound because of recurring abdominal pain. Allison asks her doctor about the possible cause of her pain and the medical procedure and then makes an appointment. During the next few days, she thinks about the procedure and starts to feel anxious. She tells herself, however, that the procedure will help determine the cause of her pain. She continues with her daily activities and doesn’t think too much about the procedure. Brenda, on the other hand, asks her doctor plenty of questions. She wants to be reassured and told that she does not have cancer. Over the next few days, she thinks often about the procedure, imagining that she will be told she has cancer, that she will have to undergo difficult treatments, that she might die, and that her children will grow up without a mother. To calm herself, she looks for information on the Internet and asks her husband for reassurance about her condition. Despite everything she is told, she continues to feel anxious and has difficulty sleeping.” This example shows how two people can react quite differently to an uncertain situation. Allison is more tolerant of uncertainty—she doesn’t dramatize the situation and waits calmly for the procedure. Brenda, however, is quite intolerant of uncertainty—she immediately imagines the worst case scenario, looks in vain for reassurance, and experiences many anxious symptoms. How do you react when you encounter uncertain situations that seem unclear or ambiguous? Do you identify with Brenda? Perhaps you are intolerant of uncertainty in regard to your health, but have a greater tolerance of uncertainty in other areas such as finances or your career. Perhaps you are more tolerant of uncertainty regarding your health, but react more strongly when it comes to the safety of your loved ones or interpersonal relationships. In short, intolerance of uncertainty does not always impact every aspect of a person’s life.

Faced with an uncertain situation, someone who worries excessively will ask more “what if…” type questions (It’s possible that…, if only…, perhaps if…). This kind of questioning makes it easier to see the negative aspects of the situation (thus leading to worry). Consider the example of Brenda. For her, the medical procedure was synonymous with a serious problem (“what if I have cancer?”, “what if I need to undergo chemotherapy?”, “am I going to die?”). People intolerant of uncertainty misjudge the probability of a negative event occurring. They have a tendency to overestimate the risk and negative consequences that may result from the situation. The case of Brenda who readily imagines having cancer illustrates this tendency. Allison, on the other hand, could also have imagined having cancer, but instead entertained several other more 2 realistic possibilities. In short, the more you are intolerant of uncertainty, the more you ask “what if…” type questions, and the more you overestimate the risks and negative consequences, opening the door to worry. How do we cope with uncertainty? For people who are intolerant of uncertainty, the initial response when faced with uncertainty might be to try and eliminate or avoid it. For example: searching for reassurance, making lists, avoiding certain activities, or over-informing oneself. Does increasing your level of certainty turn out to be an effective way to worry less? The answer to this question is no. First, it is important to note that you continue to worry despite your efforts to increase your degree of certainty. Any relief is short-lived as illustrated by Brenda’s example. She felt relieved when her husband told her she probably didn’t have cancer, but her worries quickly returned and she had to find another way to reassure herself (i.e. searching for information on the Internet). It is well known that engaging in checking behaviours leads to the belief that there may be serious consequences to not checking. The search for certainty quickly decreases tolerance of uncertainty and contributes to the maintenance of worry. In addition, the search for certainty is futile as uncertainty is a part of life. Since it is impossible to be 100% certain of anything, the search for certainty will lead you to worry. For example, it makes sense to invest financially in preparation for retirement, however, checking the weekly fluctuations in stock prices to reassure yourself that you haven’t lost any money does not guarantee that you won’t ever experience financial hardship. Similarly, it is a good idea to visit your doctor for regular check-ups, but visiting often to try and detect any future problems does not guarantee that you will be healthy all your life. Indeed, a variety of factors beyond our control can influence the course of events. In short, trying to increase certainty decreases tolerance of uncertainty and only serves to increase worry. On the contrary, increasing tolerance of uncertainty helps to decrease worry.

What to do: increase certainty or increase tolerance of uncertainty?

If you are intolerant of uncertainty and you now know that the search for certainty maintains this intolerance and leads you to worry, are you wondering what you can do to feel less worried? You will need to reverse your usual way of responding: rather than try to increase your certainty, you should increase your tolerance of uncertainty. Some of our patients sometimes confuse tolerance of uncertainty with “letting go” or negligence. Rest assured, you do not become negligent by tolerating uncertainty; this only serves to decrease the number of opportunities to worry. It is important to make a distinction between responsible behaviour and the search for absolute certainty. Remember this example: responsible behaviour involves a regular check-up at the doctor, not rushing for reassurance every time a disturbing symptom appears. 3 Taking action is an excellent way to change your habits. In fact, you can increase your tolerance of uncertainty by taking concrete actions as though you were already tolerant of uncertainty. To increase your tolerance of uncertainty, you need to take concrete steps designed to help you accept and deal with uncertainty in various areas of your life. As with all new activities (biking, driving, cooking, etc.), practice makes perfect.

 

Identify your typical reactions to uncertainty.

Once you have identified your reactions, you will be ready to practice tolerating uncertainty by taking action. You can choose to perform certain actions that will help you to gradually increase your tolerance of uncertainty. This is called exposure to uncertainty. It makes sense to begin with actions that are not too difficult for you to perform. You should act as though you are already tolerant of uncertainty or as someone you know would act. You may feel slightly uneasy during the exercise as you are not yet used to tolerating uncertainty. It will be easy for you to return to your old ways. You should be aware, however, that it is normal to feel anxious when starting a new behaviour and that this anxiety will gradually disappear. Moreover, motivation generally follows action: the more you act, the more you are motivated to continue acting in the same way.

Your turn! Exposure to uncertainty

First choose one of the manifestations of intolerance of uncertainty and describe the action you have chosen to fight it with. From this moment on, this action will be your new behaviour in response to this reaction of intolerance of uncertainty. Next, identify the discomfort and thoughts during and after the action. You will find that the discomfort decreases as you practice the new behaviour. Choose a new action each week. The ultimate goal is to become a detective skilled at identifying your reactions to uncertainty and to choose to act as though you were already tolerant of uncertainty. This exercise will help you reduce your worrying.

Anxiety is a part of life but the steps above can help you to manage your anxiety a lot better.

Mandy X