Anxiety Treatment & Therapy – Dr Elaine Ryan – Dublin

Understanding anxiety, why it affects your mind and body, and how CBT, exposure therapy and evidence-based psychological treatment can help. A guide to anxiety treatment, counselling and self-help in Dublin and throughout Ireland.

Anxiety can affect people in very different ways. For some, it is mainly physical: their heart races, they feel dizzy, their chest tightens or they have a frightening sense that something terrible is about to happen.

For others, anxiety is mostly in their thoughts. Their mind never seems to switch off. They worry about things that have happened, things that might happen and problems they cannot solve.

Some people become anxious in particular places or situations. Others seem anxious even when nothing obviously threatening is happening.

Whichever describes you, I want to help you understand what anxiety is, why you experience it and what psychological treatment can do.

Imagine arriving for your first anxiety appointment in Dublin

Imagine you’ve come to see me about anxiety. You’re downstairs in the waiting room. Perhaps you arrived early because you didn’t want to be late. You’re watching the clock, wondering what I’m going to ask. You might be worrying about whether you’ll be able to explain what’s happening. Your heart may already be beating faster than usual. Perhaps your stomach feels unsettled.

Then it’s time for your appointment. You walk through the door, come into my consulting room and sit down.

You may even feel a little more anxious. You’re in an unfamiliar situation, meeting somebody you don’t know, and you’re about to talk about something that has been troubling you.

You might be thinking: What am I supposed to say? Where do I begin? What if I can’t explain myself?

If you had come to see me, I wouldn’t begin by telling you to stop worrying or asking you to control your breathing. I would begin by explaining what we were going to do.

First, I would want to understand your difficulties. Then I would explain what anxiety actually is, why it occurs, why you experience particular symptoms and which psychological approaches we can use to treat it.

I would want you to understand the problem before we started trying to change it.

I find it much easier to make changes in my own life when I understand why something is happening. I think that understanding is valuable in psychological treatment too.

First, I would ask about your physical health

One of the first things I would establish is whether you had discussed your symptoms with your GP.

This is particularly important if you’re experiencing physical symptoms such as palpitations, dizziness, breathlessness or chest discomfort.

Anxiety can produce very real physical sensations, but some medical conditions can cause similar symptoms. Breathing difficulties may be associated with asthma or other respiratory problems. Palpitations have several possible causes. An overactive thyroid, anaemia and some medications can also produce symptoms resembling anxiety.

I wouldn’t want to assume that something was anxiety without an appropriate medical assessment. Your GP can decide whether examination, blood tests or other investigations are needed.

This doesn’t mean everyone with established anxiety needs repeated medical tests. It means possible physical causes should be considered appropriately, especially when symptoms are new, unexplained or have changed.

If you have sudden severe chest pain, serious breathing difficulty or symptoms suggesting an immediate medical emergency, seek urgent medical help rather than assuming they are anxiety.

Once the relevant physical concerns have been assessed, we can turn our attention to understanding the psychological processes.

Then I would explain anxiety to you

In psychology, we call this psychoeducation. It means helping you understand the difficulty you’re experiencing.

For anxiety, I would want you to understand:

• What anxiety actually is.
• Why you feel it in your body.
• Why it can occur when you aren’t in obvious danger.
• How your brain learns to associate situations, thoughts or sensations with fear.
• Why worrying, avoidance and understandable reactions can keep anxiety going.
• What psychological research tells us about treatments that help.
• How to begin applying that knowledge in your own life.

I wouldn’t expect you to learn everything immediately. But I would want you to begin seeing anxiety as something we can understand rather than a mysterious force controlling your life.

That’s where we’re going to begin.

What is anxiety?

Anxiety is part of our natural response to possible danger, uncertainty and threat. We need the ability to become anxious. Without a functioning threat-response system, we would be much less able to respond quickly to danger.

Sometimes anxiety is useful. You might feel anxious before an important exam, job interview or difficult conversation. That may help you prepare and pay attention.

The difficulty arises when anxiety becomes excessive, persistent or begins interfering with how you want to live.

For example, you might:

• Feel anxious most days without understanding why.
• Worry constantly about things that might happen.
• Become frightened by ordinary bodily sensations.
• Avoid places or situations because you fear becoming anxious.
• Need repeated reassurance that everything will be all right.
• Feel permanently tense, exhausted or on edge.
• Find that anxiety is influencing decisions, relationships and everyday activities.

Anxiety is not always an anxiety disorder. But when it becomes persistent, difficult to manage and significantly affects your life, a professional assessment may be useful.

Before looking at different disorders, I want to explain something that makes much of the rest of this page easier to understand: why does anxiety feel so physical?

Why anxiety feels so physical: imagine we’re on Baggot Street

One of the first questions people ask me about anxiety is why they experience such powerful physical symptoms. They may describe a racing heart, trembling, dizziness, feeling breathless or a sense that something terrible is about to happen.

Sometimes they are more frightened by the physical symptoms than by whatever triggered them. So let me explain what happens.

Imagine we’re walking along Baggot Street in Dublin

Suppose we’re walking together along Baggot Street. You’re just about to step off the kerb when a car comes speeding towards you.

What happens?

You don’t stand there thinking, Goodness, there’s a car coming. I wonder whether it would be a good idea to step back onto the pavement.

You move. You step back out of danger before you’ve had time to consciously reason through everything.

Your brain and nervous system have recognised a threat and organised a rapid response. Your heart beats faster. Your breathing changes. Your muscles prepare to move. Your attention becomes focused on what’s happening.

Your body is mobilising the resources you need to get out of danger quickly.

Then you stand safely on the pavement. Your heart is pounding. You might say, Oh, that was close!

Gradually, your heart rate settles, your breathing returns towards its usual pattern and your muscles relax. Your body is moving back towards its ordinary resting balance, a process involved in maintaining homeostasis.

That is a normal, useful stress response. It is exactly the sort of response you want when a car is coming towards you. It can protect your life.

Your nervous system works automatically

The physical changes are regulated largely by your autonomic nervous system. Autonomic means that much of its activity happens automatically, without conscious instruction.

You don’t have to decide to make your heart beat faster. You don’t have to remember to prepare your muscles. Your body responds.

Two important parts of this system are the sympathetic nervous system, which helps mobilise your body for action, and the parasympathetic nervous system, which contributes to rest, digestion, recovery and regulation.

You can think of them as involving an accelerator and a brake, although both systems are more complex and constantly interact.

In genuine danger, your body becomes more alert and ready to act. As the threat passes, recovery processes help it settle.

The autonomic nervous system and its role in the stress response.

How the stress response works and begins to settle.

Why does this happen when there’s no speeding car?

Now imagine you’re sitting at home worrying about money. Or you’re at work and think your boss is unhappy with you.

Perhaps you’ve received an email saying, Can you come and see me tomorrow? Immediately you start wondering what you’ve done wrong.

Am I in trouble? Have I made a mistake? What if I lose my job?

Your brain can interpret those possibilities as threatening, and your body may respond. Your heart beats faster. Your stomach becomes unsettled. Your muscles tighten.

But there is no car coming towards you. There may be no immediate physical danger at all. Instead, you are responding to a possible future problem.

And unlike the car on Baggot Street, this problem may not have a clear moment when it is over.

You worry about what your boss might say. Then you imagine losing your job. Then you think about your mortgage. Each worrying thought can reactivate the body’s threat response.

This is one way anxiety becomes persistent: your threat-response system keeps being activated by anticipated problems, worrying thoughts, memories and uncertainty.

Your body isn’t necessarily malfunctioning. It may be responding repeatedly to signals your brain interprets as threatening. That distinction matters because it gives us opportunities to change the pattern.

An old protective response in a modern world

You may have heard explanations involving our ancestors running away from sabre-toothed tigers. It’s a useful idea, but I prefer the Baggot Street example because it’s easier to imagine.

We still need rapid responses to immediate danger. But much of modern anxiety involves money worries, health concerns, work, relationships and things that haven’t happened yet.

Our ability to think about the future is useful, but can also make us anxious about events that are not happening now.

Someone may spend hours worrying about something that may never occur while experiencing very real physical symptoms in the present.

How an ancient stress response can be activated by modern worries.

Dr Ryan’s longer teaching video about the stress and relaxation responses.

Physical symptoms of anxiety: what is happening in your body?

For more on how tension can affect the body, see anxiety, muscle tension and trouble relaxing and anxiety and sleep.

I want to explain these symptoms carefully because understanding them can make them less mysterious.

The same physical sensation can have several causes. Once appropriate medical causes have been considered, these explanations may help you recognise how anxiety contributes.

Heart palpitations, a racing heart and chest discomfort

When your body prepares for action, your heart may beat faster or more forcefully. You can become very aware of your heartbeat. Muscle tension and changes in breathing can also contribute to discomfort.

New or concerning symptoms require appropriate medical assessment. When they’ve been assessed and are linked to anxiety, understanding the stress response can help you interpret them differently.

Breathlessness and feeling unable to get enough air

Anxiety may make you breathe faster, use your upper chest more or repeatedly take deep breaths. Changes in breathing can alter carbon dioxide levels and contribute to dizziness, tingling or a sensation of not getting a satisfying breath.

Some people call this air hunger. It can feel frightening. Not every breathing difficulty is caused by anxiety, however; asthma and other conditions must be considered where appropriate.

Dizziness, light-headedness and feeling faint

Changes in breathing, arousal and muscle tension can contribute to dizziness or light-headedness.

Once you’ve experienced frightening dizziness, you may begin monitoring yourself for it. You may worry, What if I faint in the supermarket? That thought increases anxiety, which makes you notice more sensations. Fear of the symptom becomes part of the cycle.

Muscle tension, shaking and headaches

Muscles prepare for action during a perceived threat. You may experience:

• Tight shoulders or a clenched jaw.
• Trembling hands or shaking.
• Neck pain.
• Tension headaches.

Some people carry tension for so long that they hardly notice it until they deliberately relax.

Stomach problems and bowel symptoms

Anxiety affects digestion. You may experience butterflies, nausea, cramps, urgent bowel movements or a change in bowel habits.

You may recognise this from the feeling before an exam or interview. Persistent problems still deserve appropriate medical attention.

Tingling, sweating and temperature changes

Anxiety may be associated with sweaty palms, hot flushes, feeling cold, pins and needles, tingling around the mouth or hands, and dry mouth.

These sensations can be unsettling when you don’t know what’s happening.

Feeling unreal, detached or unusually sensitive

Some people experience a sense of unreality or detachment when anxious. Others become unusually aware of lights, sounds, movement or physical sensations.

These experiences are not unique to anxiety, so unfamiliar or persistent symptoms should be assessed. They can, however, accompany significant anxiety and changes in attention.

Sleep, fatigue and being constantly on edge

When you’re worried or physically aroused it can be hard to settle. You may struggle to fall asleep, wake during the night and immediately worry, or feel exhausted yet physically tense.

This is why treating anxiety involves more than simply telling someone to relax. We need to understand what repeatedly activates the response.

Where do you feel anxious?

When somebody came to see me about anxiety, I wouldn’t assume their experience matched everybody else’s.

Some mainly experience physical sensations. Others become anxious in certain situations. Others describe constant worry and an overactive mind. Many experience a mixture.

Think about which pattern you recognise in yourself.

Do you feel anxious for no obvious reason?

Read why you may feel anxious for no obvious reason.

You might suddenly notice your heart racing or a feeling of dread while watching television, lying in bed or doing something ordinary.

It feels unpredictable because you cannot identify an immediate trigger.

Sometimes a response is influenced by bodily sensations, accumulated stress or learned associations you aren’t consciously noticing. At other times, a medical explanation needs consideration. We would want to understand the pattern rather than assuming there is no explanation.

Do you become anxious in the same situations?

Perhaps you’re anxious when driving, shopping, giving a presentation, meeting people, using public transport or talking to someone in authority.

I would want to ask what you fear might happen, what you do to feel safer and how previous experiences might influence your response.

Is your anxiety mainly in thoughts and worries?

Some people describe their mind as never switching off.

They worry about the future, replay conversations, imagine worst-case scenarios and struggle to make decisions because they’re trying to work out everything that might go wrong.

We would pay attention to thinking patterns, uncertainty and the behaviours associated with worry.

You may recognise more than one category. These processes often interact.

Your three brain pathways: instinct, emotional memory and thought

I’ve often used the idea of the three brains to explain anxiety.

It provides a teaching metaphor for rapid automatic threat responses, emotional learning and memory, and conscious thinking, planning and worrying.

The original triune brain model calls these the reptilian, mammalian and thinking brains. Modern neuroscience shows the brain does not literally operate as three separate evolutionary layers. Brain systems are much more interconnected.

But as a teaching analogy, the model can help if we understand its limitations.

Your primitive survival response

Think again about Baggot Street. Your body can respond rapidly to danger without lengthy conscious analysis.

That is useful, but automatic responses can also occur when danger is uncertain or not immediately physical.

You might wake from a frightening dream with your heart pounding. Or you may watch a frightening film and feel your heart racing even though you know the story isn’t real.

Your physical fear response isn’t always dependent on consciously deciding something is dangerous.

Your emotional-learning system

My article about emotional memory and anxiety explains this connection in more detail.

The amygdala and other interconnected brain systems are involved in emotional learning and processing possible threats.

Suppose you once had a difficult experience giving a presentation to your boss. Perhaps you felt embarrassed, frightened or humiliated.

The next time you present, you become anxious before anything has happened. Your brain has learned an association between the situation and the earlier experience.

Simply thinking about the meeting may bring anxiety back. You don’t consciously decide to be frightened; the response feels automatic.

An example of a frightening workplace presentation.

The amygdala as a guard-dog analogy for threat processing.

The amygdala doesn’t act alone, but understanding emotional learning can help explain why fear can return quickly. Read my article on the amygdala and anxiety.

Your thinking brain

For further examples, see anticipatory anxiety and negative automatic thoughts in CBT.

We have a remarkable ability to imagine, remember, plan and anticipate. These abilities are essential, but can contribute to anxiety.

After the presentation, you may spend hours thinking: Why did I go blank? Did my boss think I was incompetent? What if it happens again?

For the difference between useful problem-solving and repeated mental reviewing, see rumination and anxiety.

You replay the past and predict the future. By the time another presentation approaches, you’re already expecting anxiety.

Your body responds, you remember previous fear, you worry about what will happen and the worry influences your body again.

You can begin learning to notice these thoughts rather than automatically treating them as instructions or facts.

Cognitive defusion: learning to relate differently to anxious thoughts.

How your brain learns anxiety — and how to teach it something different

Your brain is constantly learning from experience. Learning involves changes to connections and patterns of activity across brain networks.

Some things require enormous conscious effort at first, but become familiar and automatic through practice.

Think about learning to read

When you were a child, reading took effort. You learned letters, sounds, words and meanings.

Now you’re reading this page without consciously sounding out each word. Years of practice made reading much more automatic.

Remember the fire drills you did in school

When you were a child, you probably practised the school fire drill.

The bell rang. You learned where to go, which exit to use and where to assemble. You practised repeatedly.

Why? Because in a real fire nobody wants a room full of children stopping to debate what to do next.

The fire brigade and other emergency services rehearse procedures for the same reason: in an emergency there may not be time to work through every decision.

Practice helps useful responses become familiar and increasingly automatic.

Now think about anxiety. Perhaps you’ve repeatedly reacted with fear in a supermarket, on public transport or when giving a presentation.

Your brain can learn associations between those situations and fear. You begin expecting anxiety, watch for signs of it and find the response happens more readily.

You didn’t deliberately practise anxiety as you practised a fire drill. But repeated experiences, attention, predictions and behaviour can establish patterns.

The good news is that learning can work in another direction

If you learned to expect danger in certain situations, new learning can also take place.

That’s one reason CBT uses behavioural experiments and exposure. You gradually discover that some situations are safer, more manageable or more tolerable than expected.

You practise different responses. New experiences can change your predictions and strengthen different patterns.

The original fear memory doesn’t necessarily disappear, but it doesn’t have to keep determining how you live.

This is related to neuroplasticity: the brain’s ability to change through experience and learning.

What are you teaching your brain?

Imagine you’re late for work and stuck in traffic. You cannot make the cars move faster, but you begin thinking: I should have left earlier. My boss will be furious. I can’t believe this is happening.

Your thoughts may intensify your anxiety. The consequences of being late may be real, but the way you respond can still make the experience harder.

You could instead think: I’m late. I can’t change the traffic, but I can let work know and decide what to do when I arrive.

The situation hasn’t changed. Your response has.

You give yourself opportunities to develop different habits by practising more helpful interpretations and actions.

You were born with the capacity for fear, not every anxious habit you have now

I’ve often used the phrase you were not born anxious to explain learned anxiety. I’d express that more precisely here.

We are born with the capacity for fear and responding to threat; we need that. But many particular situations, interpretations and coping habits associated with your anxiety develop through experience and learning.

What has been learned can sometimes be changed through new learning.

This is why treatment involves practice, not simply understanding.

Is there one root cause of anxiety?

People often look for one event that caused their anxiety. Sometimes there is a clear frightening experience, illness, bereavement or stressful period.

But anxiety doesn’t always have one identifiable root cause. Temperament, genetics, learning, life events, health and ongoing stress may all contribute.

I would want to understand how your anxiety began. But I’d also ask: what is keeping it going now? Those maintaining factors often give us useful targets for change.

Your original teaching video: What Causes Anxiety?

Different pathways to anxiety

Anxiety may start with bodily sensations, learned associations with situations or the thoughts and predictions you make.

For many people, these pathways interact. The important part is working out which processes are strongest for you so we can choose the appropriate skills.

Different Pathways to Anxiety — Dr Elaine Ryan.

What keeps anxiety going?

For more on this cycle, see why anxiety keeps coming back after you calm down.

Often it isn’t the original event that keeps anxiety going. It’s the pattern of thoughts, sensations and responses that develops around it.

Imagine you’re standing in a supermarket queue. You notice your heart beating faster and think: What if I have a panic attack?

Your fear increases. You become more aware of your heartbeat. You think you need to escape and leave the queue.

You feel relief, but your brain may learn that the queue was dangerous and leaving kept you safe. The next time you approach a supermarket, anxiety may begin before you’ve even joined the queue.

Trigger ? Threat interpretation ? Physical anxiety ? Protective behaviour ? Temporary relief ? Stronger expectation of future danger.

Not everybody experiences the cycle in this order. A physical sensation or a thought may come first. Understanding the pattern gives us something to work with.

Avoidance in anxiety

Avoidance is an important maintaining process in many anxiety disorders.

Leaving the supermarket or cancelling a presentation can bring immediate relief. But it may prevent you discovering that you could have managed the situation.

Over time, you may avoid more places and your world becomes smaller.

That’s why exposure-based techniques are important for many anxiety problems: they create opportunities for new learning.

Safety behaviours: what you do ‘just in case’

Safety behaviours are things you do to prevent a feared outcome or make a situation feel manageable:

• Sitting near an exit.
• Repeatedly checking your pulse.
• Constantly researching symptoms.
• Repeatedly asking others for reassurance.
• Rehearsing every sentence before speaking.
• Always needing somebody with you when leaving home.

Some precautions are sensible or medically necessary. The question is whether a particular behaviour is genuinely useful or keeping an exaggerated fear going.

Somebody with social anxiety may believe they only got through a conversation because they rehearsed every word. They may never discover they could cope without extensive rehearsal.

Reassurance, checking and persistent worry

Read about why reassurance only helps anxiety briefly and how to stop worrying.

If you’re worried about your health, reassurance may make you feel better briefly. But soon another doubt appears, and you check again.

With persistent worry, you may think that imagining every possible problem will prepare you. Instead, you can spend hours worrying about events you cannot solve.

Treatment helps you distinguish useful problem-solving from repetitive mental activity that keeps you engaged with threat.

For health anxiety, the goal is to reduce unnecessary checking while still responding appropriately to genuine medical concerns.

Let’s begin understanding your particular anxiety

If you were sitting opposite me, I would ask about a particular anxious moment. Let’s try a short exercise.

Choose an ordinary example, not your most frightening experience.

1. What happened? Where were you?
2. What did you notice first? A thought, sensation, memory or situation?
3. What did you think might happen?
4. What did you feel in your body?
5. What did you do? Avoid, leave, check, seek reassurance?
6. What happened afterwards? Did relief teach you anything about the pattern?

You can begin to see connections between the trigger, interpretation, physical sensations and behaviour.

A worked example: Saoirse speaks in meetings

Saoirse is anxious about speaking in meetings. She thinks: I’ll make a fool of myself, and everyone will think I’m incompetent.

Her heart races and stomach tightens. She stays quiet. Afterwards she feels relieved, but disappointed that she didn’t contribute.

The next meeting approaches, and she feels anxious again.

Situation: Work meeting.

Prediction: I’ll say something stupid.

Physical response: Racing heart and tense stomach.

Behaviour: Stay quiet.

Short-term result: Relief.

Longer-term result: She doesn’t discover whether her prediction is accurate.

Now we can work with a specific pattern instead of merely telling her to be more confident.

What would you like life to look like if anxiety were less dominant?

Would you like to drive without fearing panic, speak up at work, stop checking symptoms, sleep without hours of worry or enjoy activities without continually monitoring yourself?

These are meaningful treatment goals. The aim isn’t necessarily to guarantee you’ll never feel anxious again, but to help you do more of the things that matter.

Anxiety treatment: why CBT is so important

Psychologists don’t simply make up techniques. We draw on professional training, psychological research and treatment guidelines.

Cognitive Behavioural Therapy (CBT) is one of the best-supported and most recommended psychological treatments for anxiety disorders. Exposure-based approaches are also central for many fears and phobias, often as part of CBT.

The approach should be matched to the particular problem: generalised anxiety, panic, social anxiety and health anxiety share processes but aren’t identical.

What is Cognitive Behavioural Therapy?

CBT examines the relationship between:

• Thoughts: how you interpret situations and what you predict.
• Emotions and physical sensations: fear, tension, dread or palpitations.
• Behaviour: what you do, including avoidance, checking and reassurance seeking.

These influence one another, giving us several opportunities to change the pattern.

CBT isn’t simply positive thinking. It’s examining how accurately and usefully you interpret situations and learning responses that help rather than maintain anxiety.

1. Understanding and challenging anxious thoughts

Imagine an important presentation. You think, I’m definitely going to fail.

CBT encourages you to ask: Is failure certain? Have I presented successfully before? What evidence supports or contradicts my prediction?

A more balanced response might be: I may feel nervous, but I’ve prepared. I can still contribute even if I’m not perfect.

The aim isn’t to guarantee a wonderful outcome. It’s to avoid treating a frightening prediction as fact.

A CBT thought record

A thought record helps you write down a situation, emotional response, automatic thought, evidence for and against it, and a balanced interpretation.

Imagine Aisling has made a small mistake at work. Her thought is: If I don’t get everything perfect, I’ll fail.

She considers whether it’s realistic never to make mistakes and recalls times she corrected problems.

Her more balanced response is: One mistake doesn’t mean I’m incapable. I can correct it and learn.

Practice can help develop a different way of interpreting setbacks.

Example CBT Thought Record worksheet.

Download the CBT Thought Record worksheet

Read more about catastrophic thinking and cognitive restructuring.

2. Behavioural experiments: testing your predictions

One of the most useful parts of CBT is testing anxious predictions. You become a little like a scientist rather than assuming your fear is correct.

Saoirse believes everyone will think she’s foolish if she speaks. She agrees to make one brief contribution in a relatively ordinary meeting.

Beforehand she records her prediction. Afterwards she asks what actually happened. Did everyone criticise her? Did she manage to contribute despite feeling anxious? What did she learn?

The aim isn’t to force calmness before acting. It’s to gather evidence and learn through experience.

Read my guide to behavioural experiments for anxiety.

3. Exposure therapy: learning to approach what you fear

Exposure is an important component of evidence-based treatment for many anxiety difficulties.

If you avoid what frightens you, you may never discover that you can cope. Appropriate exposure involves approaching feared situations in a planned, structured way after considering your health, risks, anxiety pattern and treatment goals.

For example, Conor is frightened of flying. Depending on assessment, exercises may include looking at flight-related material, visiting an airport and eventually taking a flight.

The aim isn’t simply to remain in a situation until anxiety disappears. It is to create new learning about safety, uncertainty and what you can tolerate.

Exposure should not involve forcing somebody into genuinely unsafe situations.

4. Changing safety behaviours

You may only speak in meetings after extensive rehearsal or avoid every activity that increases your heart rate.

CBT examines what these behaviours teach you and, where appropriate and safe, gradually tests different responses.

Exercises involving bodily sensations must take medical history into account.

5. Learning to tolerate uncertainty

For a more detailed exercise, read CBT for intolerance of uncertainty.

Much anxiety involves seeking complete certainty about the future: health, money, relationships or what other people think.

But life rarely provides absolute guarantees. CBT helps you distinguish a problem you can act on now from a possible future event you cannot resolve by repeatedly worrying.

When useful action is possible, make a plan. When it’s hypothetical, practise allowing some uncertainty without constant checking.

6. Relating differently to anxious thoughts

Sometimes arguing with every thought can become exhausting.

Cognitive defusion, associated with Acceptance and Commitment Therapy, helps you notice thoughts as mental events rather than facts you must obey.

I’m having the thought that something terrible will happen is different from something terrible will happen.

You may not need to prove every thought wrong. You can notice it and decide what to do next.

7. Practising outside therapy

Understanding CBT in an article or appointment helps. But change usually involves practising in daily life:

• Record anxious predictions.
• Try an appropriate behavioural experiment.
• Practise a planned exposure step.
• Reduce an unnecessary safety behaviour.
• Respond differently to a worrying thought.
• Review what actually happened.

Small repeated exercises can help build new patterns. As with learning to read or practising fire drills, repetition matters.

You can also watch my original video explaining CBT for anxiety.

What psychological treatment for anxiety would involve

Let’s return to your imaginary appointment in Dublin. We’ve discussed your symptoms and physical health. I’ve explained the nervous system. Now we’d work out how anxiety operates in your particular life.

The first stage: assessment

We’d explore when anxiety began, your symptoms, triggers, worries, what you avoid, how it affects your life, what you’ve tried, and your goals.

I would consider whether your symptoms fit a particular anxiety disorder or combination of difficulties. Sometimes questionnaires help us understand the pattern and measure progress.

The aim isn’t just to give you a label. It’s to understand what may help.

The second stage: making sense of the pattern

In CBT, a formulation links your experiences, beliefs, triggers, sensations and behaviours.

For example, you notice your heart racing, predict you’re about to collapse and become more frightened. You leave the situation and feel relief, but don’t discover whether you could have tolerated the sensations safely.

Once you see the pattern, it becomes easier to understand why specific techniques are proposed.

The third stage: agreeing goals

What would you like to do that anxiety currently prevents? Drive, return to work, attend social events, reduce unnecessary checking, sleep better?

Clear goals help decide what to work on and how to measure progress.

The fourth stage: learning and practising

We would select appropriate CBT thought records, behavioural experiments, planned exposure, worry-management techniques or work on safety behaviours.

You would practise suitable exercises in everyday life, review the experience and adjust the plan.

The fifth stage: using the skills independently

This is the part I especially value. Therapy isn’t intended to make you dependent indefinitely.

I used to say, “The aim of therapy is to make me redundant.”

You learn enough about your difficulties and build enough confidence to use the skills yourself. You may still feel anxious occasionally, as everybody does, but it no longer needs to dictate so many decisions.

Different types of anxiety disorders

During assessment I’d consider what kind of anxiety difficulty you are experiencing. Different disorders share features but don’t work in exactly the same way, and treatment should reflect those differences.

Generalised Anxiety Disorder (GAD)

GAD involves persistent, difficult-to-control worry across areas such as health, work, finances and relationships.

One worry ends and another begins. You may feel mentally exhausted yet restless — tired but wired.

CBT often involves working with worry, uncertainty, beliefs and problem-solving.

Read my guide to Generalised Anxiety Disorder.

Panic disorder

A panic attack involves an intense surge of fear or discomfort with physical sensations such as a racing heart, breathlessness, dizziness, trembling or feeling you are losing control.

Panic disorder involves recurrent unexpected attacks and ongoing concern or behaviour changes relating to further attacks.

Somebody may avoid driving because they fear another attack behind the wheel.

CBT for panic involves understanding sensations, changing catastrophic interpretations and addressing avoidance.

Read about panic attacks and panic attacks versus anxiety attacks.

Social anxiety disorder

Social anxiety involves significant fear of negative evaluation or judgement. Someone may avoid speaking up, eating in public, meeting people or answering the telephone.

Afterwards they might replay conversations and criticise themselves. CBT often addresses predictions, self-focused attention, safety behaviours and experiments.

Read my guide to social anxiety.

Agoraphobia

Agoraphobia involves fear of situations where escape might seem difficult or help unavailable, such as crowds, transport, shops or being away from home.

Some people fear panic symptoms or not being able to cope. Suitable CBT and exposure-based treatment can address the associated avoidance.

Read my guide to agoraphobia.

Specific phobias

Specific phobias involve marked fear of a particular object or situation, such as flying, animals, heights or medical procedures.

The fear is more than simply disliking something. Someone might go to considerable lengths to avoid the object, affecting everyday life.

Exposure-based approaches are often especially important in treatment.

Health anxiety

Health anxiety involves excessive worry about having or developing a serious illness. A person may check symptoms repeatedly, seek reassurance, search online or avoid medical information.

Treatment looks at interpretations, attention, checking and reassurance while still responding appropriately to genuine medical needs.

Read my guide to health anxiety.

Separation anxiety

Separation anxiety can affect adults as well as children. It involves excessive fear or anxiety about being separated from important attachment figures.

Someone may experience intense worry when their partner travels away.

Selective mutism

Selective mutism is an anxiety-related difficulty usually noticed in childhood, where a person can speak in some circumstances but finds themselves unable to speak in specific social situations.

For example, a child may speak freely at home but be unable to speak at school. Appropriate developmental and clinical assessment matters.

The HSE provides information on selective mutism.

Other conditions associated with anxiety

Anxiety can also occur alongside depression, ADHD, trauma-related problems and OCD. OCD is classified separately from anxiety disorders, although anxiety is often part of the experience.

Anxiety may be caused or influenced by medications, substances, withdrawal or another medical condition. This is another reason not to treat everybody identically.

What causes anxiety?

There isn’t always one cause. Anxiety can involve a combination of factors.

Biological vulnerability

Some people are more prone to anxiety because of inherited characteristics, temperament or differences in responses to stress. Brain networks involved in learning, attention, emotion and threat all contribute.

Anxiety isn’t adequately explained by the simple claim of a single chemical imbalance.

Learning and life experiences

Frightening or stressful experiences can lead to associations between situations and fear. Repeated criticism may shape beliefs about yourself; traumatic events may affect responses to reminders of danger.

Thinking patterns and behaviour

Catastrophic predictions, self-criticism, threat monitoring and intolerance of uncertainty can all contribute.

Avoidance, checking and repeated reassurance can then maintain a cycle by preventing different learning.

Read about anxiety triggers and cognitive distortions.

Current circumstances, health and lifestyle

Financial worries, caring responsibilities, work stress, relationships, bereavement, poor sleep, pain, medication, caffeine, alcohol and other substances can all contribute.

Not every worry is irrational. Sometimes there are real problems to address. Treatment helps distinguish useful action from patterns that make things harder.

Anxiety treatment and counselling in Dublin and Ireland

People searching for anxiety therapy in Dublin, counselling in Ireland or CBT treatment want to know their options. You may consider psychological treatment, guided self-help, medication or a suitable online programme.

The right approach depends on the problem, its severity, your circumstances and preferences.

CBT and psychological therapy

For the detailed treatment model, see my Cognitive Behavioural Therapy guide.

CBT is a well-supported approach for several anxiety disorders, but particular problems require different emphases.

A suitably trained psychologist or CBT therapist can assess your difficulties, develop a formulation and agree an appropriate plan.

Anxiety counselling

Counselling may provide space to discuss difficulties. Some counsellors have specialist CBT or other anxiety-treatment qualifications.

Ask about training, experience with your particular anxiety problem and the approaches used. Not every method is equally suited to every disorder.

What is a stepped-care approach?

This approach is also described in the NICE guideline on generalised anxiety and panic disorder.

When I worked in the NHS, stepped-care principles helped match the level of intervention to someone’s needs.

For some people, psychoeducation or structured self-help can be useful. Others benefit from guided self-help, individual CBT, medication or specialist treatment.

Stepped care doesn’t mean everybody must try self-help first. It means choosing suitable help based on assessment.

The HSE also describes psychological therapy and guided self-help as possible options for GAD.

HSE anxiety support in Ireland

The HSE also has guidance on self-help for generalised anxiety disorder.

Your GP can advise on suitable services. The HSE provides information about anxiety, treatment and Primary Care Psychology.

Read HSE guidance on GAD treatment.

How to choose an anxiety therapist in Dublin

See the HSE’s information on private talk therapy and the Psychological Society of Ireland directory when considering a practitioner.

If you are looking for a psychologist, counsellor or CBT therapist, consider asking:

• What professional qualifications do you have?
• Do you have specialist CBT or other established anxiety-treatment training?
• Do you regularly work with my particular anxiety difficulty?
• How do you assess the problem?
• Will we agree on goals and practise between sessions?
• How will progress be measured?
• What happens if the approach isn’t helping?

Directories such as the Psychological Society of Ireland and recognised counselling associations can help locate practitioners, but a directory listing alone doesn’t establish expertise with your specific anxiety disorder.

You can also read my guide to finding anxiety help in Ireland.

Can online CBT help?

Evidence-based CBT can be delivered through appropriate online formats for some anxiety problems.

Therapist-supported online CBT and a self-paced educational course are not identical. Therapist-supported treatment includes clinical assessment and professional involvement. A self-paced programme lets you work through teaching and exercises independently.

Both may have a place, depending on your needs. Structured self-help may be useful alone, while waiting for therapy or alongside it.

How long does anxiety therapy take?

There’s no universal number of sessions. Duration depends on the disorder, severity, treatment approach, other difficulties and progress.

Useful signs of progress include doing previously avoided things, spending less time caught in worry, needing less reassurance, interpreting sensations less catastrophically and feeling more confident.

I especially like this measure: your life starts becoming bigger again.

What about medication for anxiety?

Medication is an established treatment option for some anxiety disorders. In Ireland prescribing decisions are made by doctors, such as GPs and psychiatrists. Psychologists do not prescribe medication.

For generalised anxiety disorder, the HSE discusses CBT, guided self-help and medicines such as selective serotonin reuptake inhibitors (SSRIs).

Your GP considers symptoms, medical history, other medications, preferences and potential side effects.

Some people benefit from therapy without medication; others use medication and CBT together. If you’re taking medication, discuss changes with the prescribing doctor rather than stopping it because of an article.

Psychological work can still help while you’re taking medication. The aim is to build practical skills rather than assume one approach suits everybody.

What can you do about anxiety right now?

I’ve explained a great deal of psychology. Now let’s bring it back to something practical.

If you’re anxious as you read this, a brief calming exercise may help. But managing anxiety in the moment and changing the patterns that maintain it over time are different things. Both can be useful.

Controlled breathing

When you’re anxious, your breathing pattern may change. Some people find gently slowing breathing helps reduce arousal.

Breathe comfortably without forcing large breaths or holding your breath in a way that feels unpleasant. If you have a medical condition affecting breathing or the heart, use techniques appropriate to your health.

Controlled breathing — Dr Elaine Ryan.

7–11 breathing

I’ve also recorded a short explanation of 7–11 breathing. Some people find a longer, gentle out-breath useful.

Don’t force a particular count if it causes discomfort or dizziness. The aim is an easy, comfortable rhythm.

7–11 breathing exercise — Dr Elaine Ryan.

Ground yourself in the present

If you’re caught up in worries about the future, gently return attention to what’s happening now.

Notice what you can see and hear. Feel your feet on the floor. You aren’t trying to prove anxiety has vanished; you’re practising moving attention away from endless threat monitoring.

Don’t turn calming into another safety behaviour

If you believe you can only go shopping once every physical sensation has disappeared, calming techniques themselves can become a rule you depend on.

For some anxiety problems, treatment helps you learn that you can tolerate anxiety and continue with appropriate activities without eliminating every sensation first.

Use calming skills thoughtfully. They aren’t the entire treatment.

Begin your own anxiety-management plan

I want you to leave with something practical. You understand the stress response, how anxiety can become learned and why CBT focuses on thoughts and behaviour.

Step 1: Understand your pattern

For one week, briefly note the situation, what you noticed first, the prediction, the bodily sensations, what you did and what happened afterwards. A few lines are enough.

Step 2: Choose one specific goal

Instead of I want to stop being anxious, try I want to go into the supermarket without leaving every time I notice anxiety or I want to contribute at meetings even when I worry about judgement.

Your goal should describe something meaningful you want to do.

Step 3: Identify what’s maintaining the fear

Ask whether you are avoiding, seeking reassurance, assuming the worst, monitoring bodily sensations, trying to eliminate uncertainty or treating an anxious thought as fact.

Step 4: Choose one suitable skill

Depending on the problem, try an appropriate CBT thought record, balanced-thinking exercise, safe behavioural experiment, planned exposure, reduced reassurance or worry-management technique.

If you’re dealing with trauma, serious risk or complex symptoms, independent exercises may not be the right starting point.

Step 5: Review what you learned

Ask: What did I predict would happen? What actually happened? What did I learn? What could I try differently?

You’re learning something new, not simply trying to get rid of an uncomfortable feeling.

Step 6: Repeat and build on the learning

One exercise may not change a longstanding pattern. Remember reading and fire drills: practice makes different responses more familiar.

The point isn’t to force yourself indiscriminately into frightening situations. It’s to develop understanding and use appropriate techniques repeatedly.

Step 7: Prepare for setbacks

Some days anxiety may be worse. Poor sleep or stress may contribute, or an old response may return. That doesn’t mean you’ve forgotten everything. Examine what happened, adjust your plan and continue.

Progress means greater flexibility and confidence, not necessarily never feeling anxious again.

If you would like to work through anxiety management with me

If you’re comparing different self-help options, read which anxiety course is right for me.

I hope this guide has helped you understand why anxiety feels the way it does. If you prefer structured teaching, my online programme Retrain Your Brain brings together psychological explanations, CBT skills, exercises and worksheets.

It covers:

• The different pathways into anxiety.
• Physical sensations and the stress response.
• Automatic learning and emotional memory.
• Anxious thoughts and core beliefs.
• Thought records and cognitive restructuring.
• Behavioural experiments and changing unhelpful responses.
• Skills you can use independently.

You can follow the lessons at your own pace, revisit sections and practise. The free information on this website remains available whether or not you choose the course.

Dr Elaine Ryan teaching Retrain Your Brain.

Frequently asked questions about anxiety treatment

How do I know whether my symptoms are anxiety or a physical illness?

Anxiety can cause palpitations, dizziness, breathlessness, stomach symptoms and muscle tension. Some medical conditions produce similar symptoms. If symptoms are new, unexplained, changing or concerning, speak with your GP for appropriate assessment.

Do I need to see my GP before seeking anxiety treatment?

A GP review is particularly important for significant unexplained physical symptoms. You don’t always need a referral to contact a private professional, but medical assessment may still be appropriate.

What is the best therapy for anxiety?

CBT is among the best-supported treatments for several anxiety disorders. Exposure-based approaches are important for many phobias and fears. The specific treatment depends on the problem and individual assessment.

What if I’ve tried counselling before and it didn’t help?

That doesn’t mean no psychological treatment will help. Previous treatment may not have involved an anxiety-specific assessment, a suitable evidence-based approach, clear goals or practical work between appointments. A qualified professional can help review options.

Will I have to do things that terrify me during CBT?

Appropriate exposure is planned and structured around the particular anxiety problem and your health. It isn’t intended to overwhelm or force someone into unsafe situations. The goal is new learning and increased confidence.

Can CBT help if I’m already taking medication?

Yes. CBT and medication are sometimes used together. Medication decisions belong with your GP or psychiatrist; psychological skills can be useful regardless of whether you’re taking medication.

Is online CBT as effective as face-to-face therapy?

Appropriately delivered online CBT can be effective for several anxiety problems. Therapist-supported online CBT and a self-paced educational course are different services and may be suitable in different circumstances.

Can self-help help me become less anxious?

For some people, structured CBT-based self-help is useful. Psychoeducation, thought records, behavioural experiments and work on avoidance can provide a starting point. More severe or complex problems may need professional support.

Why do I feel anxious when nothing is wrong?

Anxiety may be triggered by bodily sensations, learned associations, memories or automatic predictions that aren’t obvious. Accumulated stress may also play a role. Unexplained symptoms should be assessed medically when appropriate.

Why does anxiety make me so tired?

Persistent worry, tension, heightened alertness and disturbed sleep can be exhausting. Fatigue also has other possible medical causes and shouldn’t automatically be attributed to anxiety.

How long does CBT take to work?

There is no universal timetable. Progress depends on the anxiety problem, its severity, the treatment used and practice. Reduced avoidance, improved daily functioning and greater confidence are useful measures.

Where can I find anxiety therapy or counselling in Dublin?

Ask your GP about suitable services or use recognised directories to find qualified psychologists, CBT therapists and counsellors. Ask about experience with your particular anxiety problem and how treatment works.

Can anxiety go away completely?

Some people recover substantially and have long periods with little difficulty. Others still experience anxiety occasionally but learn to manage it more effectively. Feeling anxious sometimes is normal; the goal is for anxiety not to dominate your life.

What if I’ve had anxiety for years?

Longstanding anxiety can involve well-established thought and behaviour patterns. That doesn’t make change impossible. Appropriate assessment, evidence-based treatment and repeated practice can help.

A final word from me

I want to take you back to the beginning of this page.

Imagine you’re sitting downstairs in the waiting room before that first appointment in Dublin. You’re nervous. Perhaps your heart is beating faster. You don’t quite know what to expect.

Then you come into the room, we begin talking and I start explaining anxiety.

I explain the nervous system, why your body can respond so powerfully, how worrying, emotional learning and avoidance can keep anxiety going, and how established psychological treatments can help.

Perhaps some things begin to make sense. Maybe you recognise parts of your own experience.

That understanding matters. But it’s only the beginning. The next part is learning skills and practising them in your own life.

When I worked with people in therapy, I wanted them to understand enough about their difficulties to increasingly manage them themselves. I didn’t want them to remain dependent on me.

I want to help you become your own therapist.

Not because you have to manage everything alone, but because understanding anxiety and learning to use psychological skills can give you more choice over how you live.

You don’t have to organise your life around avoiding every uncomfortable feeling. You can learn to understand anxiety, respond differently and begin doing more of the things that matter.

That, for me, is the purpose of psychological treatment.

Dr Elaine Ryan, PsychD — Doctor of Psychology, Chartered Psychologist (BPS).