Overcoming anxiety for the holidays

From Thanksgiving to the New Year, a bustling stream of family gatherings, office parties and high expectations fill most hearts with joy. But for some people—and maybe more people than you think—the holidays bring untold levels of anxiety. An introverted personality, an inability to say no to relatives or colleagues, age-old family conflicts: All can heighten anxiety in normally healthy people while making life miserable for people with clinical anxiety disorders.

"Holiday anxiety is similar to holiday depression," says Cal Adler, MD, professor of psychiatry and behavioral neuroscience at the University of Cincinnati and co-director of the Mood Disorders Center at the UC Neuroscience Institute, one of four institutes of the UC College of Medicine and UC Health. "There's an expectation that you're going to have a great time and that you're going to conform to these idealized holiday patterns. Like any stressful event, this brings out our frailties, our vulnerabilities, those spots in our personalities where we sometimes need to be shored up."

Adler and his colleague Scott Ries, LISW, associate professor of clinical psychiatry at UC and a member of the Mood Disorders Center team, offer a variety of coping techniques for those whose anxiety shows up like an unwelcomed guest during the holiday season.

All forms of anxiety, Ries explains, boil down to one emotion: fear. "Anxiety is a physiological response that is evolutionarily designed to keep us safe," he says. "When the brain is like that, it's doing you a favor. It's trying to help you survive. The brain receives the same signal if a bear is after you or if you're in a meeting with your boss."

Holiday anxiety can be triggered by a variety of circumstances:

• Underlying social anxiety, which is a fear of being humiliated in public.
• Introversion or shyness, which can go hand-in-hand with social anxiety.
• Feelings of being overwhelmed by expectations to act a certain way.
• Feelings of being overwhelmed by obligations and events.
• A history of unhappy relationships with immediate or extended family members.

Ries frequently discusses coping methods with his patients as the holidays approach, and he helps them draw on the tools of cognitive behavioral therapy, or CBT. The process involves identifying the individual's dysfunctional thought process or behavior and working toward an action-oriented solution. Ries helps his patients think through a troublesome scenario to its potential conclusions and helps them recognize that (1) the worst feared outcome probably will not happen and (2) if it does happen, this is how it can be handled.

"I don't try to talk people out of the possibility that bad things will happen," Ries says. "I help them de-catastrophize the thoughts."

A typical scenario might involve telling family members that you won't be joining them because of unhappy past experiences with another relative. "If you have really unpleasant memories you might want to create your own tradition," Ries says. "Now, based on the assumption that your family will be mad at you, let's assume that they do get upset with you. Then what? What will the outcome be? Do you fear that they'll never speak to you again? In reality, that's not likely to happen. It is unlikely that your family would cut you off. And if they did, you probably don't have much of a relationship with them anyway."

In a second scenario involving the use of cognitive therapy, Ries helps an anxious, introverted person rehearse the potential outcomes of attending a company holiday party. The person fears, first, that he will walk in and no one will pay any attention to him. His second fear is that if he is invited into a conversation, he will say something stupid and be humiliated.

Acting out the scenario, Ries asks: "Well, how would someone know that you're feeling stupid? Do you have a sign that goes up that says 'stupid'? And what if you do say something stupid? Give me all the stupid things you can imagine saying. Now, let's assume the worst: you not only say something stupid, but you also simultaneously spill something on yourself. Then what do you imagine happening? Our belief is that everyone stops and stares and laughs at you. We're replaying all those terrible classroom experiences. And I say, well, would you do that to someone else? Of course, you wouldn't. And probably your co-workers wouldn't either. Because in reality that's not what happens at parties."

Ries encourages introverts to scan the crowd for other introverts, who make up half the world. That shy person hovering in the background, he notes, is a "soul mate." He also reminds anxious patients that "you've already said lots of dumb things in your lifetime, and yet you have friends; you have a job." And he notes that, "Because I'm an extrovert, I've said even more dumb things than most people. And yet people seem to think I'm competent."

Decision-making, Adler says, also can contribute significantly to holiday anxiety.

"A recent study about decision-making before and after lunch showed that people take routes of least resistance when they're tired or making a lot of decisions," Adler says. "You kind of run out of mental energy. And holidays are all about running out of mental energy. You're deciding what to do, maybe deciding between competing demands and family members. You make a decision what to buy, what to spend, how much to spend.

"And then other things pop up, like all the 'Giving Tuesday' emails, requests for help from all sorts of spheres. And if you're hosting or traveling, you have even more layers of obligation."

One of the ironies of holiday parties, Adler says, is that December is probably the worst time of year to have them because people have so many things to do. For that very reason, Adler adds, the UC Department of Psychiatry and Behavioral Neuroscience Division of Bipolar Disorder Research moved its holiday party to February a few years ago.

Adler's advice for people who are coping with too many responsibilities is to try to manage expectations. "That's easier said than done, because you are definitely swimming upstream," he says. "To the degree that one can, we should use that cognitive behavioral approach and say, 'What am I expecting and why? And is this even what I want?' And, to the degree that one can, you can simplify the holiday, limit how much you have to do. Say no in a gentle way. If you have three different parties on the same night, tell someone you can't make it. Go to one and have fun, instead of spending the evening worrying about how you're going to run from one to the other and not offend anybody. Don't have 30 relatives over to your place for dinner if you can't manage that right now. Some people might love that, but most of us probably don't. Try to limit what you're going to do."

One of the best things about anxiety is that it is not a permanent state. Physiologically, one cannot maintain a state of anxiety indefinitely, Ries says. "If you confront an anxiety-provoking situation and stick with it, your anxiety will decrease," he says. "This fact enables us to desensitize people to a phobia, such as snakes. You can start by looking at photos of snakes until it no longer provokes anxiety, then move on to seeing live snakes at the zoo until it no longer provokes anxiety, and then continue step by step until you can handle snakes comfortably. It is also the idea behind Toastmasters, which is a great way to help people overcome their fear of public speaking."

Ultimately, the best way to approach social anxiety, Ries believes, is to meet it head-on.

"The important thing about any kind of anxiety—the anxiety about confronting family members, the anxiety about why you don't want to come for Thanksgiving or Christmas, the anxiety of going to social events that make you anxious—is that there is no substitute for doing it," Ries says. "You can go to a therapist for years and talk about your social anxiety, or you can actually start socializing. Doing that will take care of your social anxiety much faster than years of therapy."