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