Case Study Addressing Anxiety with the PACER Mind Body Approach to Treatment

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@allceus.com Counselortoolbox you I'd like to welcome everybody to today's presentation. Today we're going to switch gears if you want to say that a little bit, and we're going to try a different approach to class. And this is an anxiety case study. What I want to encourage you to do is as we're going through this, ponder as if you were going through a client's assessment, what might be treatment plan goals, what might be causing this person's anxiety. And please feel free to share. But we're going to use that PACER assessment that we went over last week as a template for what we're going through today. The Case Sally is a 49 year old female with one child in college and a second child who's a senior in high school. She started having anxiety, difficulty sleeping and panic attacks over the last six months. Her doctor prescribed her Xanax to take as needed to prevent panic attacks and help her sleep. She says the rebound anxiety from that is terrible and just won't take it anymore. She cannot identify any particular precipitating factor that triggered her anxiety or her panic. She says the anxiety came on kind of gradually over the past few months and the panic attacks only started in the past few weeks. She reports that she was in counseling for about a month with someone else, but it wasn't helping very much and things are getting worse and her doctor doesn't really have many other options besides more medication. So Sally comes into your clinic and you know, this is kind of what you get on the phone or maybe a little less when you're making the appointment and Sally comes into your clinic and obviously you're going to have a few minutes to kind of get an overview of what's going on with Sally. But let's start talking about Sally's anxiety. So you start doing your assessment and for sleep we ask her on an average night, how much sleep does she get? And she says about two hours of REM sleep, about 0.5, half an hour of deep sleep, and about six hours of light sleep. Okay. Well that's, you know, eight and a half hours if that's accurate. On an average night, how many times do you wake up? Three to four times. Well, that's a lot of waking up after an average night's sleep. How do you feel? Tired. Okay. Or energetic. And Sally says tired. When you Wake up feeling refreshed. How much sleep do you get? And she says rem, three hours of sleep deep, at least two hours of sleep and light, you know, the remaining, but at least three. And that's what she says makes her feel best. And she has a fitness tracker, so that's what we're using to monitor it. She's not obviously not doing multi day sleep studies. She reports her sleep has worsened significantly in the last four months. Okay, so as a clinician, that makes me think what's, what happened four months ago that might be making her sleep worse and making it. And, and what does that mean? One of the things I'm going to have Sally do is do a sleep hygiene self assessment. And in the sleep hygiene self assessment, it talks about alcohol and caffeine and sleep routines and light and all those things in order to get an idea about what's going on in terms of Sally's circadian rhythms. Is she doing things to help maintain her circadian rhythms? The next thing I ask is using a free app like Spark people track your nutrition for a week. And hopefully she did this before she came in for her first appointment. Which nutrients do you get? Less than 75% of the full recommended daily allowance. Magnesium, zinc and iron is what she brought. The data she brought in. Okay, well that's important because magnesium, zinc and iron are all necessary for the production of serotonin. Iron is also necessary. Or iron deficiencies are also implicated in things that in conditions where there is not enough dopamine. So iron is somehow involved in the production of dopamine? Well, dopamine and serotonin are both linked to anxiety, anxiety reduction when they're in the right balances. So this is something good to know and we're going to file that in our little mental banks. When was the last time you had a full panel blood test to examine your kidney and liver function, thyroid and vitamin D levels? And she says 18 months ago. Well, that's not too terribly long ago. But she suddenly started having problems about six months ago that got significantly worse four months ago. It might be worth having a blood panel done again. This is your typical, you know, regular physical checkup blood panel. Why do we ask about these things? Kidney and liver functioning well, kidneys is where your adrenal glands are. If there's something going on with your kidneys, it's possible that you could have increased anxiety. Kidneys and liver. Your kidney and liver also filter out toxins. And if they're not working well, then it can cause backups in the system, so to speak. Thyroid hyperthyroid, if you remember, is associated with anxiety and hypothyroid is associated with depression. We want to make sure that, you know, her thyroid levels are normal. And what about her vitamin D levels? Vitamin D is typically associated with seasonal affective disorder, but heck, just throw that in there as long as we're drawing her blood anyway. Encourage her to describe her eating habits. And Sally says she eats pretty healthfully but tends to be a stress eater and has cut out all processed foods, including breads and cereals and red meat. That's a very valid choice. A lot of people have made that choice. However, we get a lot of our B vitamins, our folate and our B vitamins. Well, folate is a B vitamin from our grains. So if she has cut out all processed foods, including your breads and cereals, and cereals are often also vitamin enriched. If you look at the side of Wheaties or Raisin Bran or any of those foods, you're gonna see that this breads and cereals that we eat are almost all vitamin enriched. So by cutting all those out, she may not be getting the full array of vitamins that she needs. We already know that she's not getting enough magnesium, zinc and iron. And zinc is one of those micronutrients, if you will, that is actually kind of hard to get, especially if you're not eating, you know, wheat and or other foods. So let's just, you know, filter that in the back of our mind. She's not getting enough iron. Well, she cut out breads and cereals, which are usually iron enriched, and red meat, which is a good source of iron. Green leafy vegetables are a great source of iron too. We can tell she's probably not getting quite enough of those. We're not dieticians, we're not going to make dietary prescriptions, but we can see that there might be some issues in her diet that are contributing to her anxiety issues. It couldn't hurt to have it evaluated. It doesn't mean she has to add back in the bread, cereals and red meat. If she does, if she has reasons not to, there are ways around it. Like multivitamins. Not my favorite option, but that's for her and her physician and nutritionist to discuss. Do you eat due to stress or comfort when you're upset? She said yes. Okay, good to know. Do you drink at least 64 ounces of non caffeinated, non alcoholic beverages each day? She says yes. When we get dehydrated, we can feel sluggish. We can get confused, we can have difficulty concentrating and sometimes that can trigger anxiety in some people. We want to make sure that she is drinking those fluids that are going to help flesh out her kidneys and her liver, but also maintain her level of hydration. Our brain and our body, our nervous system communicates through those synapses. What happens when that neurotransmitter is released into the synapse. It's in this fluid filled junction. It's not just in space. If we don't have enough fluid in our body, we're going to have impaired transmission of signals for just about everything, not just mood. How much caffeine do you have on an average day? And I just kind of put this here for you guys to have a general idea. Eight ounces of regular coffee. And I use this in a general term. We're not talking about super espresso or some of your deluxe coffees that you can buy, but just regular gas station coffee or restaurant coffee is 100-150mg per 8oz. Now I will show you guys. This is my coffee cup. Now I drink decaf or something else anymore. However, a lot of people use bigger coffee cups. That cup is 24 ounces. That is three regular cups of coffee. So it is not hard to drink four of these over the course of a whole day. Which brings us to how much is she drinking? Well, she admits she drinks a whole pot of coffee every day. 12 cups of coffee. And a lot of people do. That's not something that's really all that shocking. They just put it in, you know, paper cups or, you know, they stretch it out, they make it look different. But let's just face it, a lot of people drink the equivalent of one pot of coffee a day and that's 1200 milligrams of caffeine. That's a lot of stinking caffeine. Like we talked about in one of the other classes last week, you can go online and look at the recommended daily allowance or daily limit for caffeine. And I believe it's right around 300 milligrams. So she's way up there. I start to ask myself why. Well, one, she's developed a tolerance to caffeine so she's able to drink more. If you've never had caffeine before and you drink a whole pot of coffee, even if it's stretched out over a day, you are going to be wired. We can see that she has, you know, obviously some level of tolerance to it. Why Else might she be drinking so much caffeine? And why do we all drink caffeine? A lot of times sometimes because you like the taste of it, but a lot of times because we're looking for a pick me up. We're fatigued, we're feeling sluggish. Okay, let's start taking a look at that. We asked her earlier about her sleep and she said, you know, she wakes up, she rarely feels rested. She wakes up multiple times a night. Maybe she has difficulty getting to sleep. All of those things contribute to poor quality sleep. She's in bed for eight or so hours, but she's not getting quality sleep. And she's substituting that. She's kind of pushing her body by adding caffeine. As the old saying goes, you can't squeeze blood from a turnip. At a certain point, her body is going to say, I got nothing left to give. You know, you've pushed every little ounce using caffeine. You've pushed every little ounce of norepinephrine and adrenaline that I've got to give you right now out. And again, that's oversimplified, but we do see people reach a point with caffeine ingestion, that some people will actually get more tired when they drink caffeine because their brain's like, no, been there before. I'm sensitized to that. We're not going to respond to the cat, to the caffeine stimulation. We also want to know about how much nicotine she uses on an average day. And Sally says, none. So that's one thing we don't have to worry about. Nicotine is another one of those things that can impair sleep. It is also a stimulant in some aspects and can increase anxiety, as can caffeine. Are you currently over or under fat? And I use the word fat as opposed to weight because people can have a lot of muscle and not be unhealthy. Why am I asking about weight? We know that there's a strong relationship between HPA axis dysregulation and emotional eating and grazing and people being overweight. Now, theoretically, we can look at Sally and say, you know, she's not, but I want to get her opinion on whether she's over or under fat. She says no. Have you recently had any problems with excessive thirst or hunger? No, that's my diabetes screening question. If people are having difficulty managing their blood glucose, they may have anxiety related symptoms or anxiety like symptoms symptoms. Do you have problems with hypoglycemia? You know, you're moving along, and then your blood sugar just kind of bottoms out if you haven't eaten in a while. And she says, yes, well, that's something to be aware of. Now, I don't want to freak her out and go, oh, that's a sign of prediabetes. It may not be. It may be a sign that she hadn't eaten since 5 in the morning and it's now 4 in the afternoon. It's important for her to recognize, though, that when we become hypoglycemic, our HPA axis, our threat response system, kicks off. When it does that, cortisol. Secreted cortisol causes blood sugar to be dumped into the system. Well, that's what a lot of times causes us to start feeling a little bit shaky. That adrenaline and norepinephrine and then the sudden rush of blood sugar can make us feel a little bit shaky. That's our body's way of saying, well, you're not providing me any fuel, so. So I'm going to pull it out of storage. Has your doctor tested your blood sugar lately? Through a fasting blood test that's not always done at every annual exam. She says no. She said no to the diabetes question. You know, it's just kind of one of those things to file away in our memory banks if we need to come back to it. Do you mainly gain weight around your belly? She says yes. All right, well, metabolic syndrome is a cluster of symptoms where people tend to gain weight around their belly. They tend to be insulin resistant and tend to have a higher risk of developing diabetes. Research has shown that when people's cortisol levels are higher, they tend to gain weight around their belly. I'm not sure why I haven't read anything in the research that can actually explain why we gain our weight there when we have high levels of cortisol. But it's true. This is telling me that her HPA axis, her threat response system, is activated quite a lot. She seems to be under a lot of stress, and her body is constantly on guard and on alert, which might be contributing to this. Another one of those things I may not share with her, but I'm going to file away in my memory banks. What are we going to do about this? Well, referral to her primary care physician for a physical to include a nutritional evaluation, hormone evaluation. Remember, she's 49. And possible addition of multivitamin to address nutritional deficiencies. I want her to discuss with her primary care her sleep problems with the onset. And, well, we'll get to the rest of it in a minute. I jumped ahead of myself. Medications, what medications is she on? Well, we find out that she's taking Mirapex because about four months ago she was diagnosed with restless leg syndrome. Aha. That's about when she said her sleep problem started. Interesting to note as a side note, Mirapex is and other medications that increase dopamine are associated with insomnia. Not necessarily just a coincidence. She may want to look at that. Are there other options for her to take? Yes, there are other options she can consider if that is what's causing her problems. But that's why I want her to talk with her doctor about it because obviously I'm not qualified to say, oh, you need to get off of that. But if she's having difficulty sleeping, that's only going to make all of her other symptoms worse. She reports that she's taking diet pills and she very proudly reports that she's not taking diet pills with caffeine. Okay, well that's good because you're already getting way more than you should through the coffee. But she's taking diet pills that have hydroxycitric acid or garcinia cambogea. This is a very common herb that is promoted for appetite suppressant and weight loss, which, you know, that's fine if that's what people want to look at. However, it is associated with, guess what? Anxiety. And my little link went away here. There are. There it is. And bring this over here just for reference. And this link is obviously in your PowerPoint. There are a lot of different herbs and over the counter supplements that people take in order to control weight that are associated with headaches, anxiety, chest pain. Bitter orange is one that's associated with chest pain, anxiety, increased blood pressure and heart rate. Caffeine obviously is associated with nervousness, jitteriness. We know it can be also associated with anxiety and rapid heart rate. Let's see, where was another one anyhow? Garcinia, chamygia, headache, nausea, upper respiratory tract symptoms and mania and potentially liver damage. There are a lot of negative reports about the over the counter drug supplements. And Sally was taking over the counter drug supplements or weight loss supplements because her doctor didn't see any problem with her weight and she really wasn't overly concerned. But she was concerned that when she didn't, if she wasn't taking something that she would overeat, which in and of itself could become a therapeutic issue later. But she couldn't get prescription weight control medicines from her doctor encouraging her when she goes to her Doctor to talk to the doctor about the pills she is taking, the supplements she is taking in order to make sure that it's not contraindicated with the other medication she's taking. She also takes Zyrtec for her allergies, which is fine. Is another one of those drugs. Obviously all of these are fine if you they're over the counter. The doctor prescribed them. Whatever. Zyrtec is associated with fatigue. A lot of people, even though it says it's non drowsy, a lot of people say they feel kind of loopy and drowsy after they've taken Zyrtec, and that's not uncommon. But it could be fueling her desire to drink copious amounts of caffeine to stay awake. And Flexeril. She's taking Flexeril because of a back injury that she got about 18 months ago. She takes it PRN and as needed and doesn't really tend to take it a lot because she says she can't function when she's on it. That's fine. Being aware of that Flexeril probably isn't going to contribute to her anxiety at all. It's another one that can potentially contribute to her fatigue symptoms, which she is medicating, if you will, with or seems to be medicating with caffeine. We want to educate her about the anxiety effects of hydroxycitric acid, the sleep, the fatigue effects of Zyrtec and the insomnia. Potential insomnia side effects of Mirapex. Get her to start thinking about when did those sleep problems really start getting bad and is it associated with the Mirapex? If so, talk about it with your doctor. If not, you know, no harm, no foul pain. Do you have any chronic pain? She says yes. What causes it? The back injury that she's had for 18 months. What makes it worse? Bending and sitting. Well, that's stuff you do a lot. What makes it better? Heat, ice, muscle relaxers. Yet she says she can't take her muscle relaxer and function, so she doesn't take them very much. How has this pain impacted your mood? Relationships, energy, sleep, self esteem. She reports that it's really frustrating to be in pain and tired all the time and not able to do her gardening and play with her kids and do the things that she loves doing. So she's feeling stuck and helpless in some ways. We do want her to do an ergonomic self study and educate her about ergonomics. Maybe the way she's sitting can be altered a little bit in order to help her feel More comfortable. What is she doing at work? What is she doing when she's in the car? What is she doing when she's home watching tv? That might be aggravating it. And how can she improve her ergonomics in her sitting positions in those places? Likewise, what can she do, for example, to reduce or eliminate bending as much as possible right now until this injury gets healed? And, you know, back injuries take a while to heal because it's not like you can put them in a sling and immobilize them at all. Sedentariness and exercise. Sally says she exercises typically every day for at least 45 minutes. When she exercises after she's finished, her energy level, she reports, seems to be better. Well, that's good. That means, you know, when we get that serotonin going, that she tends to have a little bit more energy. Remember that serotonin, too little or too much can contribute to anxiety. And different types of serotonin are also implicated in anxiety. The type of serotonin that they believe is increased when you exercise is 5ht 1a, which is more associated with relaxation. Do you sleep better on days you exercise? Yes. Unfortunately, she hasn't been able to exercise as hard or as long as she wanted for quite a while now because every time she starts to do that, her back starts hurting. Does muscle soreness make it harder to sleep? Yes. When she does work out. Sometimes she works out and, you know, she lifts weights or something, and she finds that she gets sore and then it wakes her up when she rolls over at night. So we want to discuss methods for reducing muscle soreness to improve sleep. She can talk about this with her doctor. This is one of those things, if you've got minimal training in fitness, you know, you can probably talk about with her in terms of massage, stretching, and again, ergonomics. But a lot of it comes down to massage and stretching. And they have the. What's the word? The rollers, the foam rollers that you can use now that are really awesome. If you don't have somebody who can, you know, massage it for you, that you can get a real good deep tissue massage. I like to use them before bed because it just kind of pushes all that lactic acid out. Her energy on an average day, what's her energy like? She says, well, I can get through the day. Well, yeah, she can get through the day with a whole pot of coffee. Her energy level is not good. Has she had her thyroid level tested lately? No, that was back 18 or so months ago. Something that we might look at now because she has anxiety, but she's also got a lot of fatigue. You know, the jury's out. I'm not thinking that there's probably a thyroid issue going on here, but, you know, it can't hurt to look at that system. Her resting heart rate is 65, which is not bad for a 49 year old woman. Her O2 saturation is 98. So we're not thinking that she's not getting enough oxygen and that's triggering stress in any sort of way. She does report having high blood pressure. That's managed with diet. Okay, that's good. So she's not supposed to eat as much, eat much sodium and that's, that's her primary thing is she's not supposed to eat much sodium and she's supposed to, you know, get enough fluid. Dr. Probably wouldn't be happy if he knew how much caffeine she was taking in. She has no other heart conditions. Heart conditions and any cardiovascular problems often can be associated with anxiety symptoms. So you do want to rule those out. How is her sex drive? She says non existent, but that's not an option here, so we go with low. Has there been a change? Yes. When and what caused it? She didn't remember. If you're over 45, have you had your sex hormone levels tested in the past year? She says no. We know that women can start experiencing significant changes in their hormonal profile in their mid-40s beginning in their mid-40s, and men also can experience significant declines in DHEA and testosterone beginning in their 40s. If you've got a client who seems to have a mood issue, it's always good to have that tested. It's not hard. It's done as part of that blood panel. Not hard to do. How often do you have sex? And she says less than once a week. She's like, I can't remember. Well, that's something else to think about and whether that is a change, which she says it is from what was going on before and how is that impacting or that's something that we can talk about in counseling. Do you tend to feel on edge and startle easily? She says no. Do you have a history of trauma? She says no. Do you have any autoimmune issues? No. Okay. All of these things are good. Have you ever had a concussion or other traumatic brain injury? No. Okay, great. How often do you get. Do you often get headaches? She says yes. Stress usually triggers them and either a neck massage or ice or heat helps them go away. Well, this is good. She knows different ways to get them to go away. Basically relaxing her neck muscles, which tells me that she's carrying a lot of stress. And she probably has her shoulders up to her ears. Sometimes she may be grinding her teeth. And I want to look at those ergonomics again. That can also be contributing to stress. A lot of times when we get stressed, we start to hunch over. Do you ever see spots or floaties when you get a headache? She said, yes, that's a little concerning to me because that often can indicate blood pressure is going up. That is contributing to the headache. Doesn't always mean that it's important to know. Do you get migraines? She says no. How often do you drink alcohol? She says daily. She drinks wine in the evenings, about two to three glasses a night, which averages out to about 14 to 21 drinks per week. Most people grossly underestimate how much they drink. So if she's saying two to three tonight per night to relax, I'm thinking it's probably closer to three to five. But we're just going to go with what she says because even two to three per night is still in the moderate to heavy range for drinking. Why is this a problem? Well, if she's drinking them right before bed, it's helping her relax. That's true. But when the depressant effects of alcohol wear off, guess what happens? Then the stimulant effects kick in because the body hasn't responded by secreting enough GABA yet, which is why people tend to start feeling anxious as they start sobering up. They found that people who drink before bed do fall asleep faster. And the first part of their sleep may be a little bit more restful. But. But as soon as that stimulatory effect of alcohol kicks in, they tend to have much more disrupted sleep, wake up a lot more, have more anxiety. Do you gamble or play the lottery? No. Great. Okay. So we don't have to worry about that. Oops. All of those things we just kind of want to filter in the back of our mind. Obviously, the physical stuff the doctor is probably going to handle, but we do start to recognize that there's more going on here than just cognitive distortions. Affective part. For each of the following feelings, identify how often you feel it each week, what triggers it, and what makes it better. Well, she says she feels happy about three days a week. That's good. You know, I'm glad she feels happy three days a week. And we're going to talk in a few minutes about the things that make her happy. Well, actually, I have it right here. Her kids, her dogs, shopping, watching funny movies and hiking. Those are what make her happy. Those are pretty. Except for the shopping. Those are pretty easy things to incorporate most every day, depending on how much money you have. Shopping may or may. Not. Exceptions when sad. I have fatigue a lot, but I really don't feel all that depressed right now. Well, that's good. She feels stressed or overwhelmed four or five days a week. Okay, now we're getting back into that anxiety. What triggers it? Work, finances. Not being able to work out like I want and just too much to do around the house and not enough hours in the day. She feels just completely overwhelmed and overburdened sometimes. What helps you feel better? Focusing on her kids and cooking. So we've added yet another thing to that list of activities and things she can do that help her feel better. Does it solve the problems? No, but it's good for helping her distract. And until she can come back to baseline and get into her wise mind, she feels anxious or worried seven days a week. She said every single day of the week. She ends up feeling. Worrying about something or some things she worries about her kids, happiness, whether she was a good parent, finances, her health. She said her. She has a family history of cancer and. And her dad died when he was her age. Okay. Well, that's, you know, one of those crucial things that might be triggering some very, you know, understandable anxiety. She hasn't figured out what helps make her feel better. When she gets anxious, though, she gets on this worry wagon and she can't seem to put on the brakes. That's something we're going to want to talk about early in the therapeutic process. She says she really doesn't feel angry or resentful. She's not one of those, you know, irritable people. So that's good. Even though she has a lot of anxiety, she doesn't seem to be irritable and angry. She does say that three out of three days a week. Ish. She also has feelings of guilt. So when we're putting these together, yes, she has happiness several days a week, but she also has stress, anxiety, and guilt quite a few days a week. So there's a lot of dysphoria. And it's not. I don't get the feeling that it's balancing out what triggers her guilt. She regrets not doing more with her kids when they were younger and feels bad for not being as good of a friend as she thinks she should. And this is another Thing that we're going to probably talk about later. What helps you feel better when you start feeling guilty, it's another one of those she just doesn't know. She says she starts feeling guilty and kind of goes down into this pity pot. In the past year, she has experienced the following losses that caused her to feel grief. Her dog died, her mother died, her grandmother died. Her oldest child moved out and started college. And her best friend barely has time to talk to her anymore. And I put parenthetically in here, she didn't identify that as one of the losses that occurred in the past year because it hasn't occurred yet. But her youngest child is a senior and preparing to leave for college, which means she'll have an empty nest at the end of this school year. So there's some anticipatory, potentially some anticipatory grief. What stressors are currently present. She said so much misery and hate in the world trying to save for retirement. Work regularly has layoffs and she's never certain that she's going to have a job. She has her back injury that's been plaguing her and worrying about her kids, choosing a path that will help them be successful and happy in life. Well, she's kind of bearing the weight of the world on her shoulders. Okay. What's different when you're happy? She's spending time with her family and animals. She has the time and energy to exercise and go hiking and she's 15 pounds lighter and the house is clean. Okay. Obviously I'm not judging her goals. They are her goals and they are the things that make her happy. We can talk about why those things make her happy, but it makes her happy. And as long as it's not necessarily harmful to her, like, you know, as long as losing 15 pounds is not going to put her in that anorexic range, you know, more power to her. Some people feel better when they are leaner. How long does it take for you to calm down after you get upset? Plus or minus an hour. Well, that's a long time, especially if you're feeling guilt, anxiety and stress all on the same day. That's probably four or five hours just in dysphoric emotions. What helps you calm down? Distracting myself or solving the problem. Okay. We know from that that she's a problem or a solution focused problem solver. We do want to educate her about hpa, axis activation, biofeedback and relaxation techniques. Help her understand the biomechanics, if you will, of emotional dysregulation when she Gets upset, what's going on. You know, that ACTH is released, cortisol's released, norepinephrine's released. You know, preparing her to fight or flee. Relaxation techniques like belly breathing that can help her trigger the rest and relax system and down regulate the HPA axis and ways to potentially use biofeedback. We already know that she's got a fitness tracker that she likes using. She uses it to track her sleep and wears it religiously. That's something that she can use to start helping herself learn how to reregulate after she's gotten upset instead of feeling dysphoric for an hour or more. So have her use her fitness tracker to practice a variety of relaxation techniques when she starts to feel stressed and or starts getting a stress headache to reduce her heart rate by five or more beats per minute. That's not really hard to do. You could probably do that right now without any interventions. If you just sat still as opposed to moving around. It starts giving her. And I choose five beats or more per minute because I've never had anybody not be able to slow their heart rate by five beats a minute. And it gives them a sense of personal control over that nervous system and over that anxiety that seems completely uncontrollable. They're like, okay, I can slow my heart down. I can do this. I can control, you know, to an extent what's going on and we will, you know, all of those things that she listed in the affective part of the assessment are obviously issues to discuss in counseling and we'll talk more about that when we get to setting the treatment plan. Negative self talk. Do you frequently judge or criticize yourself? She says yes. She's well aware she does that she does not hold herself to a higher standard than other people, which is good. Do you think she thinks she's lovable regardless of whether she's perfect? And she does understand that she got her negative self talk from her family and from teen media that she was exposed to when she was growing up. The messages that came through in the magazines she read and the, you know, websites she went to encourage her to pay attention to her thoughts for a week and have her place a check by the thinking errors which are most common and and contribute to her unhappiness for her all or non thinking, assuming and jumping to conclusions, focusing on only a small aspect of the problem or the situation instead of the bigger picture. Taking things too personally, expecting people to be able to read her mind and assuming she knows what others are thinking. Are the ones that came up most frequently for her. That's a lot, but it's not in the big scheme of things. It's really not a lot compared to most people. I think most people have, you know, at least five or six of these that unless they're consciously working to address them, periodically come up. So we talk about finding exceptions for all or none, thinking, you know, it's rarely. Are things always or never? When has this happened the opposite way? If you say this always happens, give me an example. When it wasn't occurring. If you say this never happens, give me an example when it did. You know, you come home and you tell your roommate you never changed the litter box, and turns out that two weeks ago on Sunday, they changed the litter box. Assuming or jumping to conclusions without all the facts encourage people to not use emotional reasoning and to get the facts. And when they start focusing on a small aspect of the situation, like they are driving to work and they get a flat tire and they come home at the end of the day and they're like, oh, my day was just a disaster. What about your day was a disaster? I got a flat tire. Okay, what else? They're discounting the whole rest of the day. That flat tire was the focus of their entire day. Yes, it is truly unpleasant. However, encouraging them to look at the bigger picture of their day and other things that may have actually gone well. Taking things too personally, you know, consider alternate explanations for why things might happen besides having to do with you. Expecting people to be able to reach your mind. Talk with her about evaluating how she communicated what she wanted, and work with her on practicing assertive communication. And these will be things that you're going to work on session after session after session. And assuming you know what others are thinking, Encourage her to evaluate the evidence and get the facts. She may tend to think she knows what her kid is going to say in response to her or her partner or whatever, Encouraging her to really stop trying to read other people's minds. One of the first sessions that we would go through with Sally would be to educate her about cognitive distortions and the interventions that we just talked about and provide her worksheets to keep a log of her cognitive distortions throughout the week in session. When I work with people who have cognitive distortions, I often will jot next to on a piece of paper each time they make a cognitive distortion. You know, it's just a little hashtag so I'm not making any, like, sudden moves. And then we start talking about how many times they made a cognitive distortion and corrected themselves versus how many times they made a cognitive distortion and didn't early on. I will tend to try to redirect and refocus people right after it happens. Instead of waiting till the end of the session and go, you know, well, you made nine cognitive distortions. That's not super helpful unless you're recording the session and you can go back and evaluate those with the client. Cognitive hardiness goes into cognitive focusing on, you know, everything in your life that's truly important to a rich and meaningful life. What parts of those things can she can control her relationship with her children. She can control the time and quality, the amount and quality of time that she spends with them and remember to praise the positive instead of just nitpicking with her spouse or partner. Again, she can control how much time and the quality of the time she spends with them and choose to pick her battles instead of nitpicking. She says she's not real irritable, but she does tend to identify as focusing on the negative with friends. She can also focus on the quality and quantity of time she spends with them and how she reacts to certain characteristics they bring into the relationship. One friend tends to have a lot of drama and she needs to figure out how to set boundaries there and another friend tends to the one who doesn't have time to talk anymore. She needs to figure out how she is going to deal with the one sidedness of the relationship, set realistic goals for her job and do things at her job that you know she doesn't like but she has to do and then focus the rest of the day on doing the things that she does like in order to make the job and each day go by and be more fun or rewarding or whatever word you want to use for your job. And since she's worried about losing her job because of layoffs, finding ways to increase her job security. Maybe that means getting additional training or getting a promotion or transferring to a different different unit around the house. The house is important to her, how it looks and how it smells and all that stuff. Have her family help with the cleaning and keep holiday decorating simple. She wants to decorate but she already feels overwhelmed and overburdened so how can she have both? How can she have a clean house decorated for the holidays but not add yet another thing that is going to suck three days of her week in trying to make it happen? Her pets make an effort to spend time with them and work on their obedience so they don't bark as much and Drive her crazy money, develop a realistic budget. Volunteering is important to her. One of the things she can do that is sort of a twofer is to get her friends to volunteer with her. And these are all things that she brainstormed as ways of working towards that life that she views as rich and meaningful. And her health is obviously important to her. So she's going to work on exercising and stretching each day, eating a reasonable diet, getting enough sleep and not smoking. She already doesn't smoke, so that's sort of a non issue. For this section. I would educate her about psychological flexibility and discuss how, how much and how often she intends on doing each one of these things. And encourage her to make a schedule or checklist for one week to remind her to do them. And then next week she can make another schedule or checklist and then eventually she'll find a routine that works for her. So she remembers to do each one of these things at least once a week. She says her time management is great if she gives up sleep. So time management is not so good. She tends to take on too much and feel overwhelmed. And although she's not a perfectionist, she does tend to procrastinate. We're talking already back in the hardiness section about creating a schedule and determining and trying to save time and manage time a little bit better. Time management may need to be another treatment goal later down the line if she's finding that that's one of those things that's really contributing to her anxiety. Encourage her to develop a schedule that includes the must do's These are the things I gotta get done this week and delegates and simplifies when possible. Yes, I've got to get grocery shopping done this week, but I don't necessarily have to be the one to go grocery shopping. I can make a list, give it to my partner. So encourage Sally to think about her must do's and which of those things that she can delegate to free up more time so she can do things besides just go to work, come home, go to sleep and repeat environmentally asking her where she feels safe most of the time. And that's at home. She feels great there. What helps her feel safe? Her dogs. Loves her dogs and she feels comfortable in her neighborhood. Are you able to have peace and quiet when you want it and when you sleep? She said yep, not a problem during the day. Are you able to access natural light or at least a really bright working area? She says yes. Okay, that's great for helping set those circadian rhythms. So that's probably not contributing to her sleep problems. When you sleep, are you able to make your room totally dark or block out the light? Yes. Another great thing. And do you eliminate blue light from television and electronic devices at least two hours before bed? And she says yes, that's one thing she's already started doing. Those questions will come up again on her sleep hygiene survey, so she will be asked to look at those and consider those things again. But I've already taken a look at those in the assessment and identified some of the biggies that I think might be disrupting sleep. And she doesn't seem to have any notable things that are disrupting sleep. What smells are you regularly exposed to that are noxious, unpleasant and irritating? She says dog poop and burned food. Well, we need to work on the dog poop thing. And you know, how can you, how can you work with eliminating those smells? What triggering smells? Things that remind her of something unpleasant. She had this uncle that she used to go visit. There was no abuse or anything. She just didn't like him. And his house always smelled really musty. And whenever she goes to the old buildings it reminds her of that. Well, let's avoid those smells then. Or if she has to be in a place where there's musty smells, what can she do? Can she bring a hanky that has essential oils on it that she sniffs every once in a while? When my husband was in law enforcement and they used to have to go to certain types of calls, they would put Vicks VapoRub underneath their nose to avoid having to smell the stench of what they were going out for. Happy, relaxing and energizing smells she identified as rosemary, basil, roses, caramel, and just various wax tarts that suit her fancy. She loves her wax tarts, encouraging her to put those in her environment everywhere. You know, any, any way she can figure out how to get those smells, whether she's growing them or the rosemary and basil. Obviously you can't grow caramel or using the wax tarts or using some sort of aromatherapy. Mr. Anything that can help trigger those happy memories and happy feelings is going to be helpful. Are you able to keep your environment at a temperature that you find comfortable? She says yes, except during the hot flashes. This is another big clue that her hormones might be out of whack and partly, you know, just age related thing. When women have hot flashes, it's not uncommon for them to also have heart palpitations where their heart rate goes up, you know, 10, 20 beats a minute over what it normally is. And that can really Freak some women out and they think, oh my gosh, I'm having a heart attack. And they can work themselves up into a full scale panic attack. We do want to educate her about, you know, potential signs of early premenopausal sort of things going on and normalize the. If she's having heart palpitations during those hot flashes, that that's not necessarily all that uncommon. And refer her to an appropriate peer reviewed website. And finally, relationships. Do you feel you're capable of love? You are capable, lovable and deserving? She said, yeah. Great, that's awesome. She says she has overall healthy relationships with her family, doesn't often fear abandonment. Okay, that's awesome. We can take that off the table or at least table it a little bit. We still have that whole empty nest thing, but they're two different things. You can have empty nest where you grieve not being, you know, a daily parent anymore and not worry about being abandoned at the same time. Can you effectively identify and communicate feelings and thoughts to get your needs met? She says yeah, she does that pretty well. So awesome. She does report though that while she has a social support system that's great with providing practical assistance, they can pick up her dry cleaning or give her a ride somewhere whenever she needs it. They're not super great on emotional support, something we may want to look at enhancing. So her initial treatment plan goals, we're wrapping it up here. Referral to her primary care for nutritional and hormone evaluation, medication side effects, her headaches and her chronic pain. Hopefully she can get a physical therapy referral from her doctor. I really want her to at least have the appointment made. If not have gone to the appointment or before she comes back for her first official week of counseling. And ideally bring me some feedback from the physician, her sleep duration and quality. I want to give her a sleep hygiene assessment. I have that as a printed handout and I also want her to bring that back for the first official counseling appointment. And then we'll make a sleep hygiene enhancement plan based on the data that she brings back and we'll review that every single week for the first eight weeks. Once eight weeks have gone by, that's pretty much covered everything. Emotional dysregulation and biofeedback. She's going to work on that from today, which I call week zero, to through week eight. Week one, she's just going to work on. I'm going to teach her about belly breathing and object focus when she comes back so she can start learning different ways to start slowing her heart rate. She'll keep a log of when she does it and gets the best results. We'll repeat this educational component every week with a different relaxation exercise or distress tolerance activity. Her pain frequency, intensity, impact and interventions. We're going to look at the ergonomic assessment. We're going to give that to her. That's due back on the second week of counseling. And we really want to find out what's going on with her. Her cognitive distortions, she's going to start working on that now. But really, week two through week eight, we're going to focus in counseling as we talk on identifying some of those extreme ways of viewing things and her hardiness enhancement with psychological flexibility. That chart that we looked at that she was going to create a checklist so she did something for each one of the things that's important in her life every single week. We're going to work on that. Weeks three through eight, every single week we're going to review her checklist, see what she did, see how she's feeling about it, see what modifications she may need to make specific worries. We're going to talk about her kids happiness, whether she was a good parent, finances, her personal health and anxiety related to her family history of cancer and the possibility of current pain being permanent. You know, this back injury, you know, what's going on there. Her guilt for not being the parent she thinks she should have been and the friends she thinks she should be. You know how I love that word should. Grief over empty nest and the deaths in her family. Those are all things we're going to explore in greater depth when she comes in. Those are, you know, the talk therapy aspects. So reassessment after eight weeks, you know, reassessment. Her primary care physician provided the physical therapy referral which seemed to be reducing pain. Her hormone levels indicated early stages of menopause. The doctor also normalized heart palpitations which were associated with her hot flashes. Her blood pressure, remember, she did have high blood pressure. It's stable, still stable, which is good. She did start taking a multivitamin and eating more grains, not processed foods, but grains and leafy vegetables to improve her nutritional profile. She discontinued, with the doctor's advice, the Mirapex and started taking iron and magnesium supplements which seem to make the restless leg syndrome symptoms go away. She reports sleeping somewhat better and is still waking up occasionally but getting more deep sleep. She reports that her energy does seem to be improving. Now. There's a lot of things that could be going into that, but I'm just glad that she's feeling like she's headed in the right direction. She's still drinking a full pot of coffee each day, but it's down to half cafe and she is stopping caffeine after 3pm she's working toward no caffeine after noon, but that's hard and she admits she's not going to give up her morning coffee. She's cut back on alcohol at night but still drinks occasionally and started taking, per her doctor, one milligram of melatonin at night to help her get sleepy so that helps her get relaxed and drift off instead of having to have the alcohol. Biofeedback seems to be helping. She actually got a new fitness tracker that monitors her heart rate variability and prompts her to use belly breathing when it detects she is stressed. Her stress episodes have decreased from an average of five times per day to three and a half times per day when you average it over a week. So these little fitness trackers can be good. I know mine has that feature and I turned it off because it was going off all the time. Pain is improving with physical therapy. She got a stability ball to sit on at her desk to prevent leaning and poor posture and got a knee pillow to help keep her back in better alignment when she sleeps. She's becoming more aware of her cognitive distortions which she credits with reducing her stress episodes and in session she quickly corrects herself when she makes a distorted statement and is effectively identifying 85% of the distorted statements that she makes. Her hardiness enhancement activity has been her favorite. She reports that she feels she's making much better use of her time instead of just feeling stuck and confused all the time in terms of her specific worries. She reports realizing in terms of her kids happiness she can't make anyone else happy and is focusing now on helping her children start to use the psychological flexibility tools she learned in counseling. Regarding whether she was a good parent. She has stopped focusing on what she should have done to be a good parent and is more objectively looking at her kids overall success and mood compared to other other adolescents. She wanted to raise happy, healthy kids and she's realizing that she did a good job of that. She recognizes that most of her stress about finances comes from cognitive distortions of catastrophizing and has made an objective budget and set savings goals which she is adhering to. She's also consulted with a financial planner to get reassurance that she will have enough money to retire and won't have to work until she's 80. Personal health anxiety related to her family history of cancer and the possibility of her current pain being permanent. She assessed her lifestyle and risk factors for cancer and came to the conclusion that while it's possible her main risk factors for cancer are alcohol use and stress, both of which she is working to reduce. Regarding her pain, the physical therapist assured her that it's muscular and not nerve or spine related, so she should recover fully in three to six months. She also recognized that catastrophizing was increasing her stress about her injury. Guilt for not being the parent she thinks she should have, should be, or should have been. She's still working on radically accepting that she cannot change the past and is not happy about some of her choices, but she can start making choices more congruent with her values now. It's not been a year since her mother's death and less than two years since her grandmother's, and they were the last family she had besides her kids and spouse. She's still working through the bereavement process for those losses and has recognized that her daughter getting ready to go to college is triggering a lot of feelings of isolation and loss. So she still has a way to go, but at least at the time of this writing, if you will, but she's making a lot of really awesome progress. By understanding that anxiety is an excitatory response brought on by activation of the HPA axis, we were better able to understand the impact of medications, alcohol use, nutritional deficiencies, grief, and chronic stress on HPA axis functioning and resultant anxiety. Anxiety is the result of stimulation of the HPA axis, and panic attacks may be the result of HPA axis dysregulation due to chronic stress, especially since it's been going on for over a year. Restless leg syndrome medications typically increase dopamine, which can cause insomnia, and insomnia leads to fatigue, hypocortisolism, and excessive caffeine consumption in a lot of people. Addressing the problem from the standpoint of identifying and addressing the causes of the HPA axis dysfunction instead of simply addressing the cognitions can prove much more beneficial in the long term, Though. I have the text version of that assessment in your classroom if you want to take a look at it. Obviously, I cut and pasted it here into the PowerPoint. You can get an idea about other things because there are other things that I didn't even mention on here that could be triggering anxiety or could be interventions, but those are. That's definitely a way to approach it. And Brooke, yes, this is the standard assessment that I use in my intake. Are there any questions? I know we went through a ton of stuff just kind of wrapping up a lot of the stuff we've been talking about over the past six months or so. Between writing notes, filing insurance claims and scheduling with clients, it can be hard to stay organized. That's why I recommend TherapyNotes. 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