this episode was pre-recorded as part of a live continuing education webinar on demand CEUs are still available for this presentation AllCEUs.com/Anxiety-CEU I'd like to welcome everybody to today's presentation on best practices for the treatment of Anxiety I am your host, Dr. Dawn Elise Snipes now not too long ago we did a presentation on strengths-based biopsychosocial approaches to addressing anxiety and while those are wonderful you know I thought maybe we ought to look at you know what's some of the current research so I went into PubMed which is I don't know it's playground for me it's where you find a lot of the journal articles and you can sort and I sorted by articles that were done and meta-analyses that were done within the past five years so that gives us an idea about current research I mean there's a lot of stuff that is still the same like some of the medications that were known to work ten years ago are still known to be you know good first-line treatments but there are also some newcomers that we'll talk about and there are also some changes that we're going to talk about so we're going to explore some common causes for anxiety symptoms in order to treat it we really need to and of course this does play into the biopsychosocial aspect we really need to understand kind of what causes it because anxiety that's caused by for example somebody having a racing heart may be different than anxiety that's caused for somebody who has abandonment issues so we're gonna treat the two things differently so we want to look at some of the common causes we're gonna look at some common triggers for anxiety you know what are some of these common themes that we see in practice and I will ask you to share some of the themes that you see that underline or underlie a lot of your clients anxiety and identify current best practices for anxiety management including counseling interventions medications physical interventions and supportive treatments so we care because anxiety can be debilitating and a lot of our clients have anxiety a lot of our clients have anxiety comorbid with depression and they're looking at us going how can I feel anxious and stressed out and like I can't sit still and depressed at the same time you know when you're depressed you're supposed to want to sleep well a lot of times people who are have both issues really want to sleep but they can't so I want to help clients understand that also sometimes anxiety when people are anxious for long enough the body starts kind of holding on to the cortisol the body actually recognizes at a certain point this is a losing battle I'm not going to put energy into this anymore so it starts with drawing some of its excitatory neurotransmitter so to speak and people will start to feel depressed basically the brain has already said this is hopeless this is you're you're helpless to change the situation so then people start feeling hopeless and helpless which is sort of the definition if you will of depression low-grade chronic stress and anxiety arose energy and people's ability to concentrate so if we're going to help them become their uber selves we need to help them figure out how to address anxiety not just generalized overwhelming debilitating anxiety but also panic social anxiety and those minor anxiety triggers that come along that may not meet the threshold for a diagnosis anxiety is a major trigger for addiction relapse if you have a client who is self medicated before or had an addiction for some reason anxiety is a major trigger increased physical pain when anxiety goes up people tend to tense their muscles when they tense their muscles they tend to feel more pain I mean think about when you're stressed you tend to have more pain like in your neck in your back and things that already hurt may hurt more why because serotonin which is one of our major anti-anxiety neurotransmitters is also one of our major pain modulators so when serotonin levels are too low because anxiety is high then our pain perception is going to be more acute and people can have sleep problems if you're stressed out your body thinks there's a threat you're not going to be able to get into that deep restful sleep you may have you may sleep you may sleep a lot but it's probably not quality sleep which means your neurotransmitters may get out of whack your hormones make it out of whack and your body is going to start perceiving your itself in a persistent state of stress when we're exhausted the body knows that we may be the weakest link in the herd so it continues to secrete cortisol to keep keep you on alert a little bit so you may again you may be resting kind of like when you have a new baby at home those first couple of months that my children were home from the hospital I slept but I didn't sleep well I mean the slightest little noise and I was awake and I was looking around and you know I felt it I felt exhausted and a lot of new parents do so triggers for anxiety abandonment and rejection and we're going to talk about ways we might want to deal with these things but some of the underlying themes that I've seen in a lot of clients and when I do the research what a lot of what themes that come out include low self-esteem if someone has low self-esteem they're looking to be externally validated oftentimes they're looking for somebody else to tell them you're lovable you're okay so that can lead to anxiety about not having people to tell them you're okay which makes their relationships tenuous and can make them dysfunctional irrational thoughts and cognitive distortions may lead people to believe that if I'm not perfect for example I am not lovable so we're going to look at some irrational thoughts and cognitive distortions unhealthy social supports and relationships when you're in a relationship it takes two to tango and even if your client is relatively mentally and physically healthy if they are in a dysfunctional relationship they can fear abandonment and rejection if that other person is always saying if you don't do X I'm going to leave you or if that other person is always cheating on them or whatever so relationships can trigger abandonment anxiety and ineffective interpersonal skills can lead to relationship turmoil and social exile if our clients are in relationships even if they're not completely dysfunctional if our clients are not able to ask for what they need and set appropriate boundaries and manage conflict effectively because conflict happens in every relationship then they may start to argue more which may lead to fearing may lead to relationships ending in the past and them going well every relationship I get into ends which means I must not be lovable so they start fearing abandonment and rejection so these are four areas that we can look at one more assessing clients another issue is the unknown and loss of control a lot of times negative self-talk and cognitive distortions can contribute to that if I don't have control of everything then it's all going to be a disaster negative others when clients hang out or when people hang out with negative people it kind of wears on you after a while you notice that people who are tend to be more negative pessimistic conspiracy minded tend to hang out with people who are also negative pessimistic and conspiracy minded so if you're hanging out with somebody who tends to be anxious then the anxiety can be palpable and it can kind of permeate physical complaints can lead people to be anxious because they don't know what's causing it like I said earlier sometimes if your heart starts to race if you don't know what's causing it you can start thinking I'm having a heart attack or I'm gonna die when people have panic attacks for example they truly think they're having a heart attack and it's I've had them they are very very unpleasant experiences but when people start having physical complaints and it can be you know they have a weird rash that they can't get to go away or it whatever but when they don't know what it is and they can't control it they can't make it go away they start thinking about all the worst-case scenarios and going online and getting on WebMD which usually gives you all the worst-case scenarios um so physical complaints are important we need to normalize the fact that nobody's pain-free all the time and you know the fact that you may have an ache or a pain or a lump or a bump or you know a cough most likely you know when we look at probability the probability of it being something significant is pretty small now do you want to get it checked out probably but you know the probability that is anything to be worried about is is relatively small and a sense of powerlessness can trigger fear of the unknown and loss of control for somebody who doesn't feel like they have any agency in their life if they have an external locus of control or if they felt victimized all of their life then they may fear not being in control they may be holding on and saying okay this is the one area of my life I can control when I grew up you know I grew up in a very chaotic environment I had no control I was bounced around in the foster system yadda yadda yadda now that I'm an adult you know I can control these things and I am going to hold on with white knuckles and if I can't control everything then that terrifies me death and loss are other triggers for anxiety and it can be people or pets and pets are important I don't want to minimize pets because you know they are little parts of a lot of our families so making sure we check that my daughter's dog for example is it's getting old she's getting older she's 14 now I think and you know she's in decent health we took her to the vet and the vet said yeah she's got a little heart murmur but that's expected for a 14 year old dog and but when she goes out if she doesn't come back when I call her I have this rush of anxiety for a second oh my gosh I hope this wasn't the day so anxiety around losing people and you know if she when she crosses the bridge she will and and you know I'm okay with that I'm I have a harder time dealing with my daughter's emotional turmoil when that happens and because she's grown up with this dog so you know those are the types of things that we want to talk about with our clients what things are weighing on you that you may not even be thinking about because I know in the back of my mind there's always that worry about one of our donkeys and her dog jobs and promotions can trigger anxiety if people are afraid they're gonna lose their job if they're always afraid that you know they're gonna walk in and get a pink slip or get fired you know we want to help them look at how realistic is that are you doing what you need to do in order to achieve and keep your job and sometimes it's not easy to answer I mean the first thought that a lot of us have is well you know if you're doing the right thing so just do it but there are those bosses out there and I've had some really amazing bosses a lot of them and I've had two really horrendous bosses and those two bosses I could never I never felt like I was able to do anything right and so going to those jobs there was always this anxiety about what I'm what am I going to get in trouble for today so you want to talk with people about does your job cause anxiety what can you do to moderate that anxiety the same thing with promotions people may get anxious about whether they're going to get promoted safety and security you know when you lose safety and security you can feel really anxious so if there's a break-in at the house next door or a shooting down the road or you start watching the news you can feel very unsafe and unsecure really quickly so we want to help people figure out how safe and secure are you really and a lot of it goes back to really looking at facts when people lose their dreams and hopes or fear that they're going to lose their dreams and hopes they can start to get anxious you know they have this dream that they're going to be a doctor or I just finished the presentation on helping high school students transition to college and a lot of high school students for example start college with these wide eyes and hopes to save the world and they want to be doctors and engineers and this and that and they get into it and they realize that it's a lot harder than they thought or they realize that you know what I really don't like this but I've already committed to it so what do I do or I want to help people but I can't I can't cut it doing this you know for me I figured out in my second year that I wasn't going to medical school because I wasn't going to pass calculus and that caused a lot of anxiety it was like okay what am I gonna do now you know what career should I choose so helping people figure out do you have dreams that have maybe kind of crashed and burned and you have to find new ones you know okay that one we've got to accept it figure out that it's not going to be and what can you do now people may also have dreams about relationships they get into relationships and they see themselves with this person forever and then this relationship ends and or starts to get rocky and they're like but that's my dream what happens if my that's got to happen because it's my dream I don't know how to function if that goes away we want to help people be able to rewrite their narrative and then sickness spiders and other phobias kind of goes in with death a lot of times when people get sick they start getting anxious that oh my gosh what if this is terminal oh my gosh what if this is you know incurable if I get bit by a spider it's gonna kill me and which is rare you know there are very few spiders that are actually that poisonous same thing with snakes going over bridges I've shared with you all that is not one of my irrational fears you know I am just terrified that you know something's going to happen and I'm going to get pushed off the side of the bridge which is completely irrational but we need to help people look at those and identify the thoughts that they're telling themself about those phobias and deal with that anxiety failure is another trigger for anxiety especially in this culture our culture American culture in in large part puts a high premium on success and perfectionism so when people realize that they're not perfect they may start to get anxious because they feel like if I'm not perfect then I'm a failure you know those cognitive distortions of all-or-nothing thinking and they start with that negative self-talk you know you can't do anything right so those are some of the issues that you know we often see in counseling sessions so what do we do you know somebody comes in and it like I can't live this way doc anxiety depression and substance disorders as well as a range of physical disorders are often comorbid so this is the first thing we need to realize we need to realize that we're very rarely dealing with a very simple diagnosis you know when somebody comes in we need to figure out you know if they come in and they're presenting with depression all right let's talk about that and then we start realizing that their depression started to occur after a long period of being really really anxious okay so we need to deal with that but we also need to help them with their sense of hopelessness and helplessness we need to develop that sense of empowerment and then substance disorders we know that substance use is often a way of self-medicating but we also know that it monkeys with the neuro chemicals in the brain and can contribute to anxiety and depression same thing with physical issues pain from physical disorders anxiety about having physical disorders medications you're taking for physical disorders can all contribute to anxiety so we need to look at the person as whole and go what are all the things that are contributing to the anxiety and what are all the things that the anxiety is contributing to so we have we start having this big list of stuff that needs to be addressed and then we can start figuring out okay where do we start so knowing that these things are comorbid helps researchers explore pathways to mental disorders so they can start figuring out you know what little string can we pull to unravel this blanket of anxiety so it doesn't suffocate somebody and for us as clinicians it provides us key opportunities to intervene you know sometimes clients will come in and they're start talking they start talking about their anxiety and their their physical issues you know maybe their anxieties about you know heart palpitations and because that's a common one we may want to encourage them to go see the doctor to get that ruled out you know rule out anything that has to do with hormone imbalances or you know heart conditions or anything else that might be contributing to it which can help them address it and if they do have physical disorders let's go with hormone imbalances that are contributing to the heart palpitations then they can start to treat that if they don't start to treat that then no amount of talk therapy we do is going to get them to the quality of life that they're looking for because they're still gonna feel those so we want to make sure that we're addressing them holistically anxiety disorders should be treated with psychological therapy pharmaco therapy or a combination of both and what they found and this is no surprise this is kind of old news is that counseling Plus pharmacotherapy tends to have the best outcomes but separating the two they have similar outcomes in many cases but that's just looking at and I hate to call it simple anxiety but we're just looking at anxiety symptoms here we're not looking at full quality of life and we want to make sure that we're also including any medical issues behavioral therapy is regarded as the psychotherapy with the highest level of evidence there are a variety of cognitive behavioral approaches ranging from acceptance and commitment therapy to dialectical behavior therapy to CBT to rebt you know any of those that deal with the thoughts and the cognitions fall in that realm and it has been found to be effective the current conceptualization of the etiology of anxiety disorders includes an interaction of psychosocial factors such as childhood adversity or stressful events and a genetic vulnerability so the psychosocial factors and these are other things when we do our assessment we want to pay attention to because our approach for treatment is going to be different for people for example who have trauma related brain changes maybe then for somebody who doesn't so we want to look at childhood adversity and stressful events that it may have caused basically what I what I tell clients is like rewiring of the brain there are trauma related brain changes in soldiers and especially in children or in people who've been exposed to extreme trauma that are designed to protect them but it also can cause complications kind of later on in dealing with anxiety coping skills that were learned that are ineffective you know sometimes people grow up in a household or an environment or a situation where they don't learn effective coping skills so we need to kind of help them unlearn those and learn new ones build on their strengths and trauma issues that may still need to be dealt with such as domestic violence you know if they grew up a lot around a lot of domestic violence they may think you know I'm out of that situation it's over I don't want to think about it it's not bothering me anymore or a parental absence and I put absence because it can be death it can be a parent that just packed up and left it could be a child that got put up for adoption whatever put the child in a position of feeling like they were rejected by a parent can be very traumatic and bullying among other things but there are a lot of trauma issues that people once they're out of that situation often say you know I'm out of it it's not a big deal I dealt with it let's move on and they don't realize the full ramifications and how that's contributing to their current anxiety and their current self talk and cognitions current stressors if somebody has a lot of current stressors that's also going to impact whether they develop generalized anxiety you know we're kind of stacking the deck here and the current availability of social support if they don't have effective current social support then they're gonna have difficulty bearing the weight of everything on their own shoulders so we want to look at all these psychosocial factors when we do our assessment now going back to trauma issues if you've taken the trauma courses at all CEUs you know that some people are not ready to acknowledge that the trauma is still bothering them or work on the trauma and that's okay we can educate them that it might be an issue and then let them choose how to address it but we want to bear in mind the fact that you know this could be sort of an underlying force motivating some of the current cognitions and genetic vulnerability so you take any three people and you put them or 300 people and you put them through roughly the same psychosocial situations they're all probably going to react a little bit differently based on their prior experiences but also because of their genetic makeup there are certain permutations and they found four we'll talk about later that makes the brain more or less responsive to stress and more or less responsive to serotonin which is your calming chemical so brains that are less responsive to serotonin aren't going to you know send out as much or send out serotonin as easily so people can stay kind of tensed and wired that's really oversimplified explanation but that's all you really need for right now so genetic vulnerability impacts people's susceptibility to the effects and development of dependence on certain substances which can increase anxiety when people are detoxing from alcohol when they're detoxing from benzos when they're detoxing from opiates they can feel high levels of anxiety when they take opiates some people find that opiates have wonderful anti-anxiety properties not that I am advocating for the use of opiates I'm just client experiences have shown that that can be true so some people are going to be more susceptible to the anti-anxiety effects of certain substances and some people are going to be Cerrone to become dependent on substances where others may not and that part of that is genetic vulnerability and they estimates about 30% of the predictability of the development of anxiety disorders is genetic and genetics also impact which medications are effective if you have genetic makeup a then SSRIs might be helpful if you have genetic makeup be then atypical antipsychotics may be a more effective and SSRIs might not do anything which is why a lot of our clients get so frustrated because you know there's no way to figure out exactly I guess there is now that there's genetic testing out there but up until then it was harder to figure out which medications to start with and most physicians matter of fact I don't know of a single physician that actually starts out by saying well let's do a genetic profile to see what med to start you out with most we'll start out with events as with a SSRI or some other anti-anxiety medication some sort of a benzo that's been my experience so we may want to encourage clients to consider genetic testing if they're having difficulty finding a medication regime that works for them and they are feeling like they have to have medication genetic vulnerability also affects what's going to make somebody more vulnerable now of all of you in class today you know thinking about sleep you know sleep may not be a big deal for some of you I know people who can go days or weeks with four or five hours of sleep and they feel fine it's not a big deal not me I need eight or nine hours of sleep so genetically for whatever reason I am programmed to need a lot of sleep so when I don't get that much sleep I tend to be it tends to be harder for me to deal with life on life's terms and I know that that makes me more vulnerable to being irritable so genetic vulnerability affects who can become addicted affects what medications work best and affects what situations are going to tend to make somebody more vulnerable to anxiety so our medications and I know the type on here is small but we're going to go through it the first-line drugs are the SSRIs selective serotonin reuptake inhibitors and the SNR is selective norepinephrine reuptake inhibitors now the names are a little bit deceptive because selective norepinephrine reuptake inhibitors also increase available serotonin but the mechanism of action is different the mechanism of action for each SSRI is a little bit different as well which is why you can put somebody on Prozac and they have an awful experience and you can put them on zoloft and they have a much better experience like I said earlier a lot of the research pre five years ago had been done on medications and zoloft paxil luvox lexapro celexa and their generics have all been found to be effective at treating anxiety in certain people no one medication works for everybody in the last five years effexor has come on the radar and it has been a found effective according to the hamilton rating scale for anxiety so that's another one to consider if clients are not successful or getting the treatment effect that they need for on some of the other medications obviously none of us probably are prescribers but we do need to educate clients about why the first drug or even the third drug that the doc doc tries may not work so they don't start feeling helpless and hopeless like I said earlier there are at least four different genetic variations which are correlated with the development of generalized anxiety disorder and different medications are more or less effective depending on the genetic makeup of the person there's a high mortality rate moving on to two benzos the recommendation has actually switched to really back off from the use of benzos now for some doctors will prescribe an SSRI and for the first four weeks while the SSRI is building up in the system they will also prescribe a benzo to be taken as needed in order to moderate the anxiety and you know you could argue either side of that if somebody has a history of substance use or substance dependence benzos are really a bad idea because they do have a high rate of dependence but the other reasons that they are now cautioning against the use of benzodiazepines is that there's a higher mortality rate among benzo users compared with non-users there's an increased risk for dependence with use for more than six months and that's a long time to be using benzo and when we're talking about dependence and six months we're talking about somebody who uses it like every four hours or every eight hours depending on your benzo every single day not a PRN user if somebody's using it at night to help them go to sleep or you know three or four times a week when the anxiety gets really high the risk of dependence is relatively low but a lot of people with anxiety because if they find the right benzo it makes them feel so much better they may not want to be off of it and for a lot of people when that benzo reaches its half-life and starts getting out of the system even more their anxiety spikes you know they have rebound anxiety which they want to medicate with more benzos that's gonna be an issue for them to discuss with their doctor there's also an increased risk of dementia identified in long-term benzodiazepine users again this is for the people who use you know throughout the day every day for six months or relatively every day for six months or more and it doesn't matter if it's you know we're talking about somebody who's 65 or somebody who's 35 who's been using benzos for you know six months a year two years the risk of later life dementia is greatly increased according to the research benzodiazepines also don't treat depression okay so if you've got somebody who has concurrent anxiety and depression there's a much higher suicide risk if they're on benzodiazepines so being aware and generally that suicide risk comes from overdosing on the benzodiazepines but not always other treatment options you know if the benzos aren't something that people want to touch you know they scare the living daylights out of me and SSRIs and SNRIs don't seem to be working then tricyclic antidepressants can be tried those your older generation antidepressants seroquel is used a lot and there are some there's some research that shows it can be really effective with anxiety like some of the antidepressants and depending on the person the benzos seroquel can make people very very very sleepy so you know it may not the side effects of the seroquel the weight gain and the fatigue and you know sleepiness may be unacceptable side effects for some clients and boosts perón is the third option boost barone works more like an anti-depressive serotonin reuptake inhibitor and that it takes you know four weeks or so to kind of build up in the system studies have shown that there's really no long-term benefit to taking it but six months to eighteen months of use it has been shown to be effective in talking with clients a lot of clients report that boost bar when they take it it doesn't necessarily help them stop being anxious like a benzodiazepine does but it helps them not go from zero to 200 in 2.3 seconds it kind of you know keeps them from having this gush of a freak out reaction every time something goes wrong which a lot of clients report helps because they feel more stable throughout the day after remission medication should be continued for six to twelve months and during that last six months first six months keep it as is last six months you know they say that tapering is best it's best not to stop somebody cold turkey on any of these but it's definitely important for people once they're in remission to not just suddenly go okay I feel better I don't need any of this anymore they need to work into it and make sure they've developed the skills and tools that they need in order to deal with some of the anxiety that is going to happen in life so physical signs and symptoms of anxiety may include fatigue irritability muscle tension or muscle aches try laying feeling twitchy being easily startled trouble sleeping nausea diarrhea irritable bowel syndrome headaches so the first thing we want to do with clients when we're talking to them well second thing first thing is say get a physical lets rule out physiological causes of this but we can also help clients look at you know what might be causing these things that you can do to mitigate it what might be contributing to your fatigue what might be contributing to your irritability and your muscle tension or your muscle aches I mean let's look at economics did you recently get a new bed or do you need to get a new bed what about your desk chair I know you know I get more muscle tension and muscle achy when I do a lot of mousing because I have deplorable posture being becoming aware of that helps and then I'm like okay well I know it caused it it's unfortunate it's unpleasant but it's not a big deal trembling or feeling twitchy you know that can be caused by low blood sugar that can be caused by anxiety that can also be caused by early onset Parkinson's symptoms you know there's you know it can be worst case scenario or it can be something really benign so we want to have people figure out you know when you start trembling or feeling twitchy is there something that it's related to you know I know when my son gets really excited he's he just sits there and you can see him almost shake because he's so excited about something so we want to have people prevent misidentification we don't want them to jump to that worst-case scenario we don't want them to go onto WebMD and go oh my gosh I've got cancer I've got this debilitating disease and I'm going to die in six months probabilistic Lee speaking it's not gonna happen yes get a doctor's opinion I'm certainly not going to tell them it's all in your head I definitely want them to get an evaluation but I do want to in the meantime help them really think about how likely is this and other things for headaches and this is one another one of those that can be frustrating as we get older our eyesight starts to go and you know there was a period there I did fine and then after I hit 45 my eyesight just started to like steadily and kind of rapidly in my mind decline so I have to get my eye glass prescription changed every couple of years and that can cause headaches so instead of starting starting to worry about oh my gosh I've got a headache all the time maybe I've got a brain tumor you know I know that it's it's probably my glasses or I'm grinding my teeth so other biological interventions that have been evaluated there's something called the floatation rest system reduced environmental stimulation therapy it reduces sensory input into the nervous system through the act of floating supine which is on your back in a pool of water saturated with Epsom salt you know I'm looking at this going that sounds really good and you can't quite get the same experience in a bathtub because you're not floating you've got pressure points and you're still hearing stuff clients can sort of simulate it with you know earplugs or whatever but it's if they can access this it's been shown to be really effective the float experience is calibrated so that sensory signals from visual auditory olfactory gustatory thermal tactile or tactile vestibular gravitational and preceptive channels are minimized that means you don't see here taste touch smell feel nothing as is most movement and speech so you want people to lay just like completely motionless and not talk which can be hard for some people with anxiety in the study the study that I looked at fifty participants reported significant reductions in stress muscle tension pain depression and negative effect and it was accompanied by significant improvement in mood characterized by increases in relaxation happiness and well-being I read the study I'm like where can I sign up you know it sounds in looking at some of the research this was actually more effective for addressing anxiety than something like a massage Tai Chi also produced significant reductions in anxiety there was approximately a 20% treatment effect 25% treatment effect in patients with anxiety and fibromyalgia who practiced twice a week for a year now you know we want to look at the con founding things here is it the Tai Chi itself or is it learning to control the muscles and becoming more in tune with your body and learning to control your breathing that helps people reduce their anxiety either way you know Tai Chi helps people do that and it was shown that after a year after the first six months there was a significant treatment effect but after a year you know it kept growing and after a year it was about 25% so Tai Chi can be really effective an acupuncture at the HT 7 median Meridian can attenuate anxiety-like behavior induced by withdrawal from chronic morphine treatment through the meditation of the GABA a receptor system what does that mean that means if you if the acupuncture is done in very certain places places the anxiety behavior the the GABA a receptor system GABA is your main calming relaxation neurochemical that is triggered and it causes your body to sort of flood that receptor system and this research was done on people who were detoxing from morphine treatment but we can look at generalizing the results and I would be interested to see further studies on it pain other things we need to do to help people with anxiety when people are in chronic pain they often have anxiety that oh my gosh this is getting worse or it's never gonna get better or I just can't take this pain anymore or they may get anxious that they're going to be rejected because they can't do some of the things they used to do because they're in so much pain so there's a lot of guilt and anxiety that can kind of revolve around pain what can we do to help clients guided imagery is generally very helpful if we can help them imagine you know if that pain in their shoulder imagine the pain is like the color red and flowing out of their arm or other focus mindfulness so you know when you think about something you know when I get a shot if I don't think about it it doesn't hurt near as much is if the nurse says okay now one two three and you know she's counting down and I'm getting prepared and I'm really focused on it I had another nurse one time who she was just talking to me and you know put the alcohol on my arm and just kept on talking didn't tell me she was getting ready to give me a shot and before I knew it she had given me a shot and she was like okay we're done I'm like you didn't give me a shot yet she said yes I did it's like oh so not focusing on it and next time you have an itch for example if you've ever been driving on the interstate and you can each on your on your foot I get those on the bottom of my foot sometimes and I'm like okay I'm not going to pull over to each my foot if you focus on something besides the itch eventually it goes away I'm not saying pain is gonna completely go away but the more people focus on it the more it hurts physical therapy can help so encourage them to get a referral and encourage them to do a self-evaluation if nothing else of ergonomics in their car at work where they watch TV and spend most of their time at home and they're sleeping so those are the four places that they spend most of their time what do their ergonomics look like and that can help for a lot of people mitigate a lot of pain hormones are another thing that we need to look at imbalances of estrogen and testosterone can contribute to anxiety symptoms heart palpitations fatigue irritability having people get a physical we can't as clinicians do anything about it but doctors can rapid heart weight rate sweating palpitations are not uncommon in women in perimenopause or menopause so a lot of women start feeling like they're developing generalized anxiety and/or something's going wrong when they start reaching that mid 40s to mid 50s area and they start having some of these symptoms again we're not going to diagnose it but we do want them to recognize that it may not be anything you know catastrophic this is something that a lot of women experience and help them figure out how to deal with that supportive care biologically now you know this isn't gonna treat anything but we can help them minimize their vulnerabilities help them create a sleep routine so their brain and body can rebalance this can help repair any adrenal issues that may be going on and improve energy level people with anxiety don't sleep well so helping them figure out how to get some quality sleep is important nutrition minimizing caffeine and other stimulants is going to be a big help because those make people feel anxious encourage them to work with a nutritionist to try to prevent spikes and drops in blood sugar which can trigger the stress response when your blood sugar goes way up or way down you can start getting kind of shaky and feel weird and that can cause people anxiety because they might think oh my gosh I'm having a stroke or a heart attack or you know I don't know what these tremors are so it's important that they don't miss identify symptoms and encourage them to drink enough water dehydration can lead to toxic Ardea which is increased heart rate sunlight vitamin D deficiency is implicated in both depression and anxiety mood issues vitamin D has been found in those main areas where serotonin receptors are found vitamin D receptors are found so we know the serotonin and vitamin D have something going on sunlight prompts the skin to tell the brain to produce neurotransmitters and set circadian rhythms which impact the release of serotonin your calming neuro chemical melatonin which is made from breaking down serotonin and it helps you sleep and gaba so sunlight actually helps increase the release of gaba when it's time to start calming down and going to sleep exercise studies have shown that exercise can have a relaxing effect encourage clients to start slowly there's not a whole lot of new research on exercise and anxiety aromatherapy has been used a lot in especially in other countries in the treatment of people with anxiety people with hospital anxiety people women who are giving birth and they have some birth anxiety there they've been found to be really effective in a lot of those studies essential oils for anxiety include lavender rose Bedevere ylang ylang bergamot chamomile frankincense and Clary sage encourage clients to just go to a health food store and you know sniff some of these see if it makes them feel happy and calm and content the aromatherapy molecules enter the nasal membranes and they will start triggering neuro chemical reactions and so you don't need to apply it you don't need to ingest it all you need to do is so encourage clients if they're open to it to think about this because aromatherapy can be integrated into their bedroom for example with an atomizer or a mr.
It can be incorporated in a lot of different places again where they're not applying it or ingesting it in any way all they're doing is smelling it they've used it in defusing aromatherapy in hospital emergency rooms and they found that it reduces stress and irritability of the people in emergency rooms and I've been to enough emergency rooms over the course of the years to know that people who are in ers typically are not in the best mood so if it can help those people then it's probably going to have some sort of an effect so psychologically helping clients realize that their body thinks there's a threat for some reason that's why it triggered the threat response system which is what they call anxiety so they need to figure out why is there really a threat you know sometimes it's like the fire alarm going off in my house it just means that the windows are open and there's a strong breeze there is no fire there is no problem there's just a malfunction it's a false alarm a lot of times for clients they get this threat reaction they get this stress reaction and it's not a big deal right now so they can start modifying what their brain responds to and again those basic fears that a lot of people worry about failure rejection loss of control the unknown and death and loss distress tolerance is one of those cognitive interventions that has taken center stage in the anxiety research and it isn't about controlling your anxiety you know helping people recognize their anxiety acknowledge it and say okay I'm anxious it is what it is how can I improve the next moment instead of saying I'm anxious I shouldn't be anxious I hate being anxious and slang with that anxiety let it go just accept it is what it is have the client learn to start saying I am feeling anxious okay so distract don't react because and I explain to them the whole notion feelings come in crest and go out in about 20 minutes it's like a wave so once they acknowledge their feeling if they can distract themselves for twenty or thirty minutes you know obviously they figured out there's no real threat they if they can distract themselves for twenty or thirty minutes those emotions can go down and then they can deal with it in their wise mind encourage them to use distancing techniques instead of saying I am anxious or I am terrified or whatever have them say I am having the thought that this is the worst thing in the world I am having the thought that I cannot handle this because thoughts come and go and that comes from acceptance and commitment therapy functional analysis makes it possible to specify where when with what frequency with what intensity and under what circumstances the anxious response is triggered so it's important that we help clients develop the ability to do functional analyses on their own so when they start feeling anxious they can stop and say okay where am I what's going on how intense is it what are the circumstances and they start really trying to figure out what causes this for them so they can identify any common themes from their psychoeducation about cognitive distortions and techniques to prevent those circumstances or mitigate them can be provided so if the client knows that they get anxious before they go into a meeting with their boss and it's usually a high intensity of anxiety okay so we can educate them help them identify what fears that may be related to techniques to slow their breathing and calm their stress reaction and help them figure out times in the past when they've handled going in and talking to their boss and it really wasn't the end of the world you know there's lots of different things we can do there for them there but the first key and it gives them a lot of a huge sense of empowerment to start becoming detectives in their own life and going okay now under what situations does this happen positive writing this was another really cool study each day for 30 days the experimental group and this was high school-aged youth in China but you know the experimental group engaged in 20 minutes of writing about positive emotions they felt that day so they're writing about anything positive that make them happy that made them enthusiastic that gave them hope whatever long-term expressive writing a positive emotions so after 30 days it appeared to help reduce test anxiety by helping them develop insight and use positive emotion words so it got them out of the habit of using the destruction and doom words and encouraged them to get in the habit of looking at the positive things and being more optimistic it's a really cool activity that clients can try it's not gonna hurt anything if you have them journal each day for 30 days mindfulness was also came up in the research and was shown to be really effective in a meta-analysis six articles about mindfulness based stress reduction four about mindfulness based cognitive therapy and three about fear of negative appraisal and emotion regulation were reviewed all of these showed that mindfulness was an effective strategy for the treatment of mood and anxiety disorders and is an effective in therapy protocols with different structures including virtual modalities so you know if you're doing it via teleconference mindfulness can still be helpful mindfulness helps people start learning how to observe what's going on and become aware of what's going on more aware of those circumstances which will help them complete their functional analysis but it also helps them become aware of vulnerabilities and head off things at the past and if they're taking better care of themselves that they're living more mindfully then they may not experience as many situations that trigger their anxiety mindfulness also encourages clients to learn acceptance that radical acceptance of it is what it is I'm not gonna fight it I'm angry right now I am anxious right now however I'm feeling right now is how I feel and that's okay and it's hard for clients to get to that but once they get a hold of that and they truly believe it and they can say all right it's fine I'm not gonna feel this way forever I'm gonna do something else until the feeling passes it helps and that's where the labeling and letting go comes in mindfulness can also help them identify trigger thoughts what thought were you having right before you started feeling anxious if people are mindful or let's start back when people are not mindful they often notice or don't notice that they're getting anxious until they're like super super anxious when people are mindful they become more aware of subtle cues address unhelpful thoughts when they say or believe it's a dire necessity for adults to be loved by significant others for almost everything they do always running gonna happen why is it a necessity what we can encourage them to do is concentrate on their own self-respect on winning approval for practical purposes you know for promotions or whatever but it's not about me being lovable it's about me getting a promotion and making more money and focusing on loving rather than being loved because when we give love we generally get love back unhelpful thought number two people feel they aren't able to stand it if things are not the way they want them to be or are not in their control so encourage clients to focus on the parts that are in their control and other things in life which are going well and to which they're committed number three misery is invariably externally caused and is forced on us by outside people and events just reading that makes me feel disempowered so encouraging clients to focus on the fact that reactions such as misery or happiness are largely caused by the view that people take of the conditions so if you see it as a tragedy and devastating then it's probably going to produce misery if you see it as an opportunity and a challenge it's probably going to produce a different emotional reaction if something is or may be dangerous or fearsome people should be terribly upset and endlessly upset about obsess about it a lot of people with anxiety gets stuck on this you know if I feel like its fearsome I need to worry about it getting on a plane for example if I fear that that's dangerous that I need to think about it and worry about it that's not going to do any good so encourage clients to figure out how to face it and render it harmless if possible and when that's not possible accept the inevitable so looking at airplanes you know facing it means doing the research to figure out how dangerous is it really and realizing that it's really not that dangerous so that helps render it a little bit harmless in their own mind it proves to them that it's not as dangerous as it could be and when it's not possible accepting the inevitable you know you got a fly so getting on there figuring out how you're gonna get through it hurricanes are the same way people especially in places like Texas Louisiana Florida may obsess as soon as it starts coming to hurricane season or if a hurricane is spotted out in the Atlantic somewhere they start checking the weather every hour or more wondering what the path is going to be and you know what there's you can't change the path of the hurricane so all you can do is board up your house evacuate if necessary and deal with the fallout child driving is just another example I'll give you know my children are learning how to drive and that's kind of scary and fearsome you know what's gonna happen when they're out there you know you see crashes all the time well render it harmless by making sure they've got good training on how to drive make sure they're good drivers and then accepting that some things are just not within my control it's easier to avoid than face life difficulties and responsibilities well running from fear is usually much harder in the long run so encourage clients to look back at times that they've avoided difficulties and responsibilities and the eventual outcome you know what happened there people believe they should be thoroughly competent in achieving in all possible respects or they will be isolated rejected and failures we need to encourage clients to accept themselves as imperfect with human limitations and flaws and focus on what makes them a loveable human being what qualities like courage and intelligence and creativity and those things that can't be taken away what inherent qualities do they have that make them awesome people because something once strongly affected people's lives they should indefinitely fear it if you got lost you know when little kids get lost it's terrifying when you're grown up if you get lost you turn on the GPS and you figure out your way but some people still you know freaked out about getting lost if they got lost once so we want to help people look back at past episodes that may be contributing to the current anxiety and compare the situation's you know are you the same person or is this not a big deal now that you're older wiser stronger encourage them to learn from past experiences but not be overly attached to or prejudiced by them yeah you could have maybe got lost in the past and it was a horrible experience well you were six I can see where that would be terrifying and a horrible experience but it doesn't have to continue to impact you that way now when you're you know 26 getting lost you know could be an opportunity to try a new restaurant or something people must have complete control over things well this doesn't happen so encourage clients to remember that the past and the future are uncontrollable we can't change the past it is what it is we can learn from it so it doesn't repeat but we can't change it and the future is largely uncontrollable I mean there's a lot of things I can do to stay moving toward a rich and meaningful life but life is going to throw me curveballs sometimes and there's nothing I can do to plan for or control that we can control our actions in the present to stay on our preferred path and general develop general skills to deal with adversity should it arise so we want to help clients develop those general problem-solving skills and the general support system so when they are thrown a curveball you know it doesn't knock them upside the head people have virtually no control over their emotions and cannot help feeling disturbed by things well encourage them to think about the fact that they have real control over destructive emotions if they choose to work at improving the next moment and changing inaccurate thoughts then they're not going to experience the destructive emotions as intensely or as frequently when you feel an emotion you feel how you feel but again you don't have to wrestle with it fight it and nurture it you can say this is how I feel how do i improve the next moment when it comes to cognitive distortions encourage them to find alternatives when they start to personalize things if somebody laughs when you walk out of the room then the and the person starts getting anxious thinking oh they were making fun of me I wonder what they thought I wonder if I had something stuck to the back of my dress and they start getting all panicked about it that doesn't do any good encouraging them to think you know what our three alternate explanations that hadn't but had nothing to do with you for why they laughed magnification of the worst thing you know taking something and saying if this happens then it's going to be a catastrophe and minimisation going along with that a lot of times when people magnify and see a catastrophe they minimize not only their own strengths and resources but all the other stuff that they've got going for them all they're seeing is this catastrophe so encouraging them to focus on the facts what is actually happening and what is the high probability event and and encourage them to get information and look at the broader picture you know yes you got into a car crash and your car is totaled and that is unfortunate you know it really sucks but you know that is not going to cause you to lose your job and then become homeless and penniless and yadda-yadda it might cause your insurance to go up but okay so you don't have a car but what are the resources that you have who can who do you work with that might be able to give you a ride to work you know let's look at the resources you have and work around so problem-solving helps with magnification and also focusing on you know let's be grateful for what didn't happen you know you could have been killed but you weren't the car was totaled it's replaceable all or nothing thin