Evidence Based Practices for Anxiety Relief | Cognitive Behavioral Counseling Tools

Hey there everybody, and welcome to this presentation on evidence based practices for anxiety disorders. I'm your host, Dr. Donnelly Snipes. In this presentation, we're going to review the physical, affective, cognitive, environmental and relational or interpersonal evidence based practices for anxiety disorders. Now remember, the evidence based practices we're talking about here are practices that have a significant body of research that support their utility or effectiveness. For some people with anxiety disorders, no one treatment is probably going to be effective for every single person. Let's start out with the physical. There's actually a lot of physical interventions for anxiety and it kind of makes sense. And anxiety is a response that happens when our fight or flight system, our threat response system, HPA axis, whatever you want to call it, gets activated. And there's a lot of things that can activate our stress response system, not just things that we think or things that we see or environments that we're in, but it can also be triggered by too much caffeine, so sleep deprivation, inflammation, or insufficient vitamin D. So there are a lot of different avenues that we can explore to help people achieve greater amounts of symptom remission. So let's look at some of these exercise. And I know some people are groaning because they're like, oh, I don't like exercise. And you bring it up for every single one. Well, unfortunately or fortunately, however you want to look at it, exercise does seem to be helpful for a lot of different issues. Exercise can be helpful because when people get anxious, you know, they're sitting still and they start feeling anxious, their heart starts racing, there's a disconnect between what their body is doing and what their heart is doing. And the heart has, the brain has a hard time reconciling what's going on. When people start to exercise, then it basically sort of re syncs or can help re sync the heart rate with the body movement. So then when the body slows down, the heart rate slows down. So that's one hypothesis for why exercise might be helpful. And I could go into a long discussion about heart rate variability, but that's an entire other course. Another reason exercise might be helpful, especially low intensity exercise, is because it helps with reduce cortisol levels. They've shown that exercising at 40 to 50% of your target heart rate, which is what you might call fat burning zone or leisurely exercise, not something where you're huffing and puffing, actually does reduce cortisol, which is your stress hormone, which can lead to greater relaxation. So there are a variety of theories why exercise can help but there have been multiple studies and multiple meta analyses that have shown that it can be helpful. The key, when prescribing, if you will, exercise, obviously you want to make sure that the person is cleared by their doctor for exercise, but also to encourage them if they're going to try it, to do something they enjoy. If they hate it, they're probably not going to do it and it's probably going to cause more stress. So what is it that they want to do? Do they want to swim? Do they want to do yoga? Do they want to walk their dog? What is it that they might be willing to do? Playing Frisbee, Playing balloon toss with their kids? There are a lot of things that you can do that aren't what we would consider traditional exercise. That can be very helpful. We're going to talk, when we get down to the environment, about the benefits they found from being in natural settings. The common term for this right now is forest bathing. And that's a little bit misleading because you don't have to be in a forest. But being in an environment where there's lots of greenery, lots of plants that are photosynthesizing and producing oxygen has also been found to reduce stress. So if you combine exercise with being outdoors in a park or even indoors, maybe in a, in an arboretum, like in Nashville, we have the Grand Ole Opry resort and they have this indoor area that there are paths that you can walk in. There's actually a waterfall and a little kayak boat tour sort of thing. So it's really a neat place to be and you can be surrounded by lots of greenery and lots of pseudo nature even in the dead of winter. Okay, so enough with exercise. Nutrition inadequate protein, especially tryptophan, which is an amino acid. It's part of a, part of the things that make up proteins. And inadequate omega 3s have been associated with anxiety. Now tryptophan is broken down to make serotonin. So we can see that it would be important for having that. Tyrosine is another amino acid that gets broken down to help make neurotransmitters. A good healthy diet with adequate whole protein can help the person be getting, or complete proteins, I should say, can help the person be getting enough tryptophan. In an average diet, it's really not that hard to do omega 3s. Now that is a lot harder. Especially in the American diet. We don't tend to have eat near enough omega 3s, nearly enough fatty, fatty fish, or eat things like walnuts and other chia seeds. Other Things that are really high in omega 3s. Omega 3s are helpful for improving communication between neurons, which can be helpful. They are also strongly associated with being an anti inflammatory food. Another thing that they've noted in the literature is a lot of people with anxiety disorders excessively consume inflammatory foods. So that increases the inflammation which can kick off or prime hyperactivate that HPA axis. We want to be aware of this. We are not dietitians or nutritionists, so as mental health counselors, marriage and family therapists, social workers, we're not going to prescribe a method of eating for anybody because that is outside of our scope of practice. However, it's important to educate people that this could be contributing and encourage them to learn more about it and talk with their doctor or a dietitian. Inflammatory foods are highly processed foods, trans fats and red meats, and foods that are highly processed, especially meats that are highly processed with nitrates and nitrites, like hot dogs and sandwich meat and bacon. People with anxiety tend to have a higher abundance of pro inflammatory bacteria in their microbiome. The research has indicated that there might be a benefit for this group of people to consume probiotics or probiotic rich foods. And a lot of those foods are like your fermented foods, like your yogurt and your kefir and your kombucha, all of those things. Sauerkraut, all of those things can help improve the balance of bacteria in the gut microbiome. So we see a lot of indications between inadequate omega 3s too much in the way of inflammatory foods and a higher abundance of bacteria in the gut that trigger the release of inflammatory cytokines. There's a strong relationship between anxiety and systemic inflammation. Another thing that came up in the nutrition literature, and this is probably not going to be a surprise, is L Theanine. L Theanine is the active ingredient, I guess, if you will, in green tea that helps produce a calming effect and has been shown to be associated with improved cognitive processing. In some countries they actually use it as a food additive. There's one type of gum that is actually made, chewing gum that is actually made and it's supplemented or it's enhanced with L Theanine that provides that boost throughout the day. So there has been some research on that as well. Always check with your doctor before trying to take any supplements. Repetitive transcranial magnetic stimulation, or RTMS, has also been found to be very effective with a lot of mental health and mood disorders, anxiety included. RTMS is not something you can do at Home. It's something you have to do in a clinic where someone's been specially trained for where to put the electrodes to stimulate the right areas of your brain. But it's non, invasive. They don't have to implant anything. They just put little electrodes on your head. That has been shown to be effective. And in most major cities there are clinics where you can receive RTMS treatments. It may be something that we refer out to a clinic for and we work in consultation with that clinic as the counselor and then they're the ones that provide that sort of treatment. But reach out to the RTMS clinics in your area if you're interested in this as a alternative treatment for your patients. Many of them are very open to, to having you come in and observe procedures, take a tour, learn more about it so you can better explain it to your patients. Now another one that is really interesting and can be done at home, although it should be medically supervised the first time, just in case the person has any unexpected side effects. What they call TVNs or transcutaneous, that means through the skin vagus nerve stimulation. And they found that by using special clips to attach a TENS unit. We've talked before a lot about TENS units. Using a special clip to attach the TENS unit to the tragus in the ear, it's possible to stimulate the vagus nerve and promote a relaxation response. They found that TVNS reduces spontaneous but not induced negative thought intrusions. What does that mean? A lot of people with anxiety have a lot of rumination and a lot of intrusive thoughts. Some of those thoughts I will call monkey mind. They're just, they're sitting on the bus on the way to work, whatever, and this intrusive thought pops in. That's a spontaneous intrusive thought. And TVNS has been found to be very effective at reducing these spontaneous intrusive thoughts. The induced negative intrusive thoughts are ones that are brought about by being presented with a stimulus. They are thinking about a meeting that they've got to go to or they see a picture that reminds them of something of the past that that triggers those negative thoughts. TVNS was not helpful with that. If it was triggered by something, then the brain is saying, hey, there's something to pay attention to. But the TVNS actually does slow down and or dampen at least the spontaneous negative thought intrusions. It kind of helps people learn to tame their monkey mind, if you will. TVNS has been shown to improve heart rate variability. And it's important to understand more about the VAGUS nerve more than we can go into in this presentation to really understand the connection between TVNs and heart rate variability. But basically, very simply, heart rate variability is what you want. You want your heart rate to be slower when you're relaxed and increase when you're stressed. Rest and then go back down when you're relaxed. That's good heart rate variability. If you are stressed, whether it's physically like being over trained or being sick or having anxiety or what have you, a lot of times your heart rate stays elevated. So instead of going from 60 beats a minute to 100 beats a minute and back down, it may be from 80 beats a minute to 100 beats a minute and back down. And a lot of us who exercise and pay attention to our training recognize that if our heart rate, if our resting heart rate is staying too high, that's our body's way of saying it's still under stress and we shouldn't do an all out, you know, intensive workout in the the next day. We want to wait until our resting heart rate is back down to where it should be. So we have a greater amount of heart rate variability when we're putting in our effort. It's up here, but when we're relaxing, it can come back down anyhow. Low heart rate variability or lack of heart rate variability indicates that there's an underlying level of persistent stress. TVNs helps reduce that underlying level of persistent stress. So you have increased heart rate variability. It's really cool when you stop to think about it. And because of the ability of TVNs to stimulate the vagus nerve, which stimulates the relaxation response, it also helps heal, if you will recalibrate whatever word you want to use, the HPA axis. So there's fewer stress hormones coursing through the body, less amount of time, which contributes to reduced inflammation, which is another thing that causes stress on the body. So TBNS is really cool. And it, like I said, it can be done at home with a relatively inexpensive TENS unit and an ear clip. However, since it does stimulate the vagus nerve and it is associated with heart rate and everything else, I always recommend that it be done under supervision the first time and definitely under medical supervision with somebody who has any sort of heart problems or has a pacemaker or anything like that, they definitely need to work with their doctor or their cardiologist before they start doing any of that. Massage. Massage has been found to be very helpful both with and and without aromatherapy. Not everybody's down with aromatherapy, but massage itself has been found to be helpful Interestingly, acupoint massage or specific body reflex area massage shows a larger effect than general massage. Well, I can see where that might work because I hold tension in specific areas and when I work the knots out of those particular areas, it helps a lot. I am a firm believer in acupressure and acupuncture, so I can see how by addressing those particular acupoints that it might produce a greater sensation of relaxation than just an overall body massage, which may feel great, but it may not have all of the same physiological effects. Another one, a free one that people can do. Laughter. And yes, you're like, excuse me, but laughter has actually been found to decrease cortisol and trigger the vagus nerve. You have a nerve called the trigeminal nerve, and I'm going to talk about that in an upcoming presentation, hopefully early next week. But your trigeminal nerve goes, is a nerve that is kind of back here and then it has little fingers that kind of reach out around your eyes, your mouth, your chin, and it registers what's going on. So when you smile, different muscles are triggered and different areas of the trigeminal nerve gets the sense that, hey, you're smiling. Smiling is associated with good things. It sends that message to the vagus nerve. The vagus nerve takes that information to the brain and says, hey, we're smiling. Must be okay to relax. So they have found that there actually is a decrease in blood cortisol levels when people laugh. And they believe that part of that is because laughter and smiling can help trigger the vagus nerve. Now, a physical section would not be complete without at least mentioning pharmacology. Our SSRIs, selective serotonin reuptake inhibitors, and our SNRIs, selective norepinephrine reuptake inhibitors are still the first line treatment for anxiety. Unfortunately, SSRIs and SNRIs have a pretty hefty panel of side effects that a lot of people don't want to deal with. The next in line is often what they call the GABA analog medications like gabapentin. Gabapentin is usually used for neuropathic pain or nerve pain, but it has also been shown to be somewhat effective for anxiety. And it has a much lower abuse potential than your benzodiazepines. The third in line is often atypical antipsychotics like Seroquel and some of those others. They reduce dopamine levels, but they also can be somewhat sedating and as such may reduce the fight or flight response, may reduce the neurochemicals that are contributing to feeling keyed up and on edge. Benzodiazepines. Because they have been shown in some studies to contribute to the development of neurocognitive problems in some people with regular use when they get older, benzodiazepines are sort of losing favor. Additionally, they are highly addictive. Highly, highly addictive. And it's very easy for them to be misused. So they have lost favor. As the first line treatment for a lot of people with anxiety disorders. Cognitive behavioral mindfulness has been shown to be super effective for anxiety. Why might that be? Well, if you start feeling anxious, a lot of times people start feeling anxious and they don't know why. Mindfulness is awareness, non judgmental awareness of the present moment. It helps people get grounded. And when people become mindful of what's going on around them and become mindful of the present moment, they are not attending to those intrusive memories or whatever. And they are also recognizing, hey, at this moment, in this context, I'm actually safe, I feel okay. They start becoming more aware of what they are able to address and what they are not able to address. Mindfulness can contribute to a sense of safety and personal empowerment. A lot of times, mindfulness also, especially the grounding exercises like five, four, three, two, one, five things you see, four things you hear, three things you smell, two things you feel, and one thing you taste, that can help divert people's attention to, you know, what's going on around me right now. Instead of thinking about whatever that stressful issue is, and it can help them down regulate that stress response, get into their wise mind so that they can more objectively return to thinking about that problem and figure out, okay, all right, my initial stress response is done. What can I do about this situation? Another cognitive behavioral technique. It's an oldie but a goodie. Systematic desensitization or exposure and response prevention. In systematic desensitization, people gradually are exposed to their threatened situation. Whether it's public speaking or being around dogs or snakes or spiders or whatever. They're gradually exposed to it, and they learn how to trigger the relaxation response. So they start by thinking about being in your office where it's safe and thinking about a feared situation. They rank their anxiety, which usually it ramps up, and then they practice relaxation techniques until they can think about that situation and not get a strong stress reaction. They can think about that situation and it's like, okay, that doesn't feel so scary. Then they grat. Remember, I emphasize gradually. Then you start saying, okay, you can think about that situation. Now, what about being in the presence of that situation? Maybe going to the auditorium while it's empty, while nobody's there, going to the auditorium where you're going to give your speech, you know, so there are gradual steps that the person takes. Each step, they stay there until they can be in that situation without having an extreme stress response. They feel like they are. They've mastered their emotional reaction to that situation. You work all the way up to actually doing or experiencing that feared stimulus, but it takes a while. This is not something that happens in a day, two sessions. A lot of times it's multiple sessions that the person. That it takes the person in order to develop that mastery. And it's much, much better to go slowly so they don't feel anxious going into the activity or the exercise. Now, there is another type of exposure and response prevention that's called flooding. And I didn't find a lot of current articles on using flooding for anxiety situations. What flooding is is basically taking the person and putting them in that situation that they're. That they fear and staying with them until that they can de. Escalate. That's always been somewhat controversial. Systematic desensitization is a much kinder, gentler, empowering method of doing the same thing. But with systematic desensitization, you're still preventing the response. They're there, you know, the first session. They're thinking about being in that situation. They're not in it. They're nowhere around it. They're thinking about being in that situation. And normally they may try to stop thinking about it because it's stressful. The response prevention comes in when you. They're encouraged to continue to think about that situation and identify how they're safe and how they're in control. Guided imagery is another one that I was thrilled to find a fair amount of research on for addressing anxiety disorders. The two most common and most effective strategies with guided imagery are using guided imagery to rescript aversive memories. If the person is afraid of dogs, it's probably associated with experience, a bad experience with a dog. So going back and rescripting that aversive memory, looking at it and saying, you know, what else might have been going on? When they're in the moment, all they see is this dog lunging at them. But what else might have been going on? And breaking that generalization, because that situation was translated in that person's mind from this dog is psycho crazy to all dogs are dangerous. And rescripting helps them identify, okay, what was different about this dog than other dogs and create a more functional cognition, a more functional schema about dogs. Positive imagery is obviously will stay with dogs. Using guided imagery to, to associate with something positive and thinking about nice dogs and seeing dogs play with children and seeing dogs do things that make you happy. And this would be something that you would use for somebody who loves dogs, you know, encouraging them to envision, you know, puppy dogs and kitty cats, you know, that imagery, envisioning that thing that makes them happy can down regulate the stress response and reduce cortisol levels. Meditation can also be helpful. And one of the principles of meditation is starting with focusing on your breath. So it makes sense that meditation would be in there as a really effective intervention, because what happens when you slow your breathing, it triggers the relaxation response. They just go together. That's the way it happens. So when people start practicing meditation, they slow their breathing. That helps trigger that relaxation response. Then meditation also encourages people to focus on something. There's open awareness meditation, there's focused meditation, but people are doing something that is intentional instead of focusing on those negative or problematic thoughts. Aromatherapy can be used either as herbs where they're taken orally under doctor supervision, Because a lot of herbs, you know, even though they're just herbs, plants, spices, whatever you want to call them, they can alter serotonin levels, they can alter cytochrome P450 and affect levels of other medications the person is taking. So I always strongly encourage people to make sure their doctor knows what herbs they're taking. Essential oils don't have near the effect effect on cytochrome P450 because you're not ingesting it. They may increase neurotransmitter levels in the body somewhat. But I have seen no evidence, I've seen no studies or reports of inhalation of essential oils. You know, just smelling them, negatively interacting with any medications. Now you don't want to ingest essential oils. You don't need to put them on you. Some people have a bad reaction when they put them on them. But simple inhalation, whether it's sniffing the bottle or using an atomizer, German chamomile, valerian, lavender, magnolia bark, lemon balm, ginkgo, saffron, kava and passionflower have all been found to be useful for reducing anxiety. I mentioned earlier forest bathing, and it again, it's somewhat misleading. The I believe it's Japanese, and I'm sorry, I can't remember the particular origin of this treatment, but that term translates very loosely in English to forest bathing. So that's what it's called in the research. But being in natural settings where people can inhale the additional oxygen, which is hopeful, that is produced by the photosynthesizing plants as well as the terpenes, those parts of the plant, I guess you want to say, that produce aromas, those scent particles. Terpenes have been associated, just like in aromatherapy, with producing healing effects and calming effects in people. And they found that terpenes from live plants are effective at helping reduce pain and anxiety not only in the average population, but in hospital bound populations. And music therapy. I have three different references for music therapy here. Music therapy was found to be extremely effective for helping reduce anxiety, especially generalized anxiety. However, none of the studies. Go figure. None of the studies really talked about the actual methodology. Were they listening to classical? Were they listening to hard rock? Were they listening to anything they wanted to? What were they listening to for the music therapy in order to produce the desired outcome? I've talked before about how on my mobile device I have multiple playlists that I listen to when I feel in different moods that can that sort of jibe with whatever mood that is. I have one that's more ruckus for when I'm feeling frustrated and angry. I have one that's happier for for when I'm just in this giddy mood. And it really depends on my mood, what I want to listen to. So I would be interested in exploring music therapy a little bit more to see exactly what qualities of the music therapy are effective. It could be that just like some of these other interventions, listening to something that you like to listen to that actually focuses your attention away from the anxiety provoking stimulus is what you need. So whatever it is that's going to capture your attention is what you should listen to. I don't know that to be true. And I would be interested if any of you have experiences with listening to music to help yourself calm down or cope with feelings. You know, what is it about the music that helps you feel better? I'd be interested to know that if you want to drop that in the comments. And finally, relational virtual reality has been shown to be valid for the acquisition of social skills and improving the symptoms of social anxiety disorder. Virtual reality is awesome because it's one of those sort of intermediary steps between being in a group of people and being all by yourself. So virtual reality can be an excellent tool to use for that. Virtual reality has also been used for exposure and response prevention. Maybe somebody's afraid of snakes and you don't happen to have snakes handy that you can bring in for systematic desensitization. Virtual reality can be used to in that stepwise process to help people get more comfortable to be about being around snakes. With snakes, for example, understanding how to look at a snake and tell with reasonable certainty whether it's poisonous or not. In most places there's very few poisonous snakes. There are a few places where there's a bunch of them, but in most places there are very few. In Tennessee, I think there's five. Knowing what those five look like is a good start. Knowing how to look at the head shape to get an idea. Is this one of the poison venomous ones or non venomous ones that can be helpful so people can actually increase their comfort and awareness of snakes in virtual reality so they feel more competent identifying a venomous versus a non venomous snake before they actually have to encounter one. So there are a lot of different ways that we can use virtual reality and we're just now beginning to sort of scratch that surface. Anxiety disorders have many different origins. Often one single treatment will be insufficient for full symptom remission. Current evidence based practices recognize the involvement of the vagus nerve, the microbiome, nutrition and maintaining in maintain that in maintaining anxiety disorders. Massage, aromatherapy, environmental interventions, cognitive therapy and virtual reality can all be considered as treatments in addition to or instead of if somebody doesn't want to use medication to enhance traditional approaches to anxiety treatment.