Impact of Anxiety and Mind Body Treatment Strategies to Improve Mental Health

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@Allce.com Counselortoolbox you I'd like to welcome everybody to today's presentation on the impact of anxiety on the person and interventions that we can use to help them. I am your host, Dr. Donnellice Snipes. We're going to review the symptoms of anxiety in adults and children. Now I know most of us can rattle off the top criteria for anxiety lickety split. However, it's important that we remember some of the lesser known or lesser remembered symptoms as well as recognizing that anxiety presents differently in children and adolescents and in some cases in adults who are who have significant intellectual disabilities. We want to explore the impact of anxiety and identify strategies for prevention and intervention. So why do we Care? Anxiety can be debilitating. In many cases, neurotransmitter imbalances, not the initial cause of it, are not the initial cause of anxiety, but a symptom. When something happens and you get stressed out, you know, you have your car breaks down or you know, whatever happens that causes you anxiety, you may have been going along yippee skippy, just fine and then that stressor happens, it activates the HPA axis and throws those neurotransmitters into fight or flight stage which can eventually, if it's sustained, cause some neurotransmitter imbalances which a lot of times we refer to as anxiety. Low grade chronic stress and anxiety erodes your energy and ability to concentrate. Anxiety is one of those words that honestly I don't think we use enough. We try to call things stress or worry or whatever. Basically those are all synonyms for anxiety. It's something that causes us to be revved up a little bit. Anxiety is a major trigger for addiction relapse. When people feel anxious, a lot of times they will self medicate. When people are stressed out about their ability to succeed, when they just feel generalized anxiety, when they have panic. There's a lot of different sources of anxiety that can cause people to either want to self medicate or just to numb it out. Depression can also be triggered by anxiety. When you are stressed out for too long. When you are anxious for too long. We've talked about the changes in the HPA axis where the body actually starts to shut down and become less sensitive to cortisol because your body says I can't run this hot all the time, I need to conserve my energy which is where we start Seeing depression. So we do have people who have a variant of depression that have concurrent anxiety and they may go back and forth between the two or three, or they may be depressed and worry all the time. We do want to be cognizant of the fact that not everybody who presents with depression has the same type of depression. There's increased physical pain with anxiety. Think about when you're anxious. One of the first things that I notice in myself when I'm anxious is my jaw starts to hurt because I grind my teeth. So increased physical pain can start happening because of neck tension, that causes headaches, can cause backaches. You can start feeling, you know, tightness in your upper back or even in your lower back. They found pain as serotonin levels go down, which happens when we're anxious because serotonin is one of our calming chemicals. Not time to calm, it's time to be alert when we're anxious. As serotonin goes down, pain tolerance goes down, which means any pain that we have is going to potentially feel more painful. And we are also going to potentially see a worsening of physical illnesses when we are anxious, we're burning a lot of energy. Our body has a hard time fending off other things. It's not worried about some of those things. So our immune system goes down. We which can make things problematic. We also can see autoimmune diseases flare up quite a bit when people are under a lot of stress or are significantly anxious. Chronic anxiety can also make people more vulnerable to ptsd. And I want us to really remember that because you could be going along okay in your life, but with a lot of chronic stress. Think about ER nurses, for example, and then something happens. If you wouldn't have had that chronic stress ahead of time that had caused hypocortisolism, had caused your body to become less sensitive to cortisol, then you would be better able to handle this crisis. That happens. But they found repeatedly in studies when people's cortisol levels are low, when they've started to adapt to chronic stress for some reason, that them more vulnerable to developing ptsd. Take home message from this. We really need to start working with people from the time that they are knee high to a grasshopper to help them control chronic stress. That way they are less vulnerable to PTSD when unfortunately trauma happens, because it does happen no matter who you are. I don't think people can go through their entire life without some kind of trauma. And they're going to be more resilient to it if they are not in a state of depletion. Remember that anxiety is half of the fight or flight response, and it's an excitatory response. The function is to protect you from danger. Your body's going, we need to get the hell out of here, because it's not a good place to be. Remember, anger is the fight part. Anxiety is the flee part. Well, we want to thank our brains for that. When we feel that way. Instead of saying, I shouldn't be anxious or getting upset because we're anxious. All right, let's thank that amygdala. It may be misguided, but ultimately it wants to help us survive. We just need to figure out how to calm it down a little bit. Anxiety can become a problem when it's overly intense or uncontrollable because of overgeneralization. Let's start with that one. And this is when we start to see what they call generalized anxiety disorder. You start with one thing that makes you anxious. Maybe when you were in school, speaking in front of your class made you anxious. And then it gradually became a bigger thing where you develop significant social anxiety in multiple situations. Overgeneralization can be a problem. Other examples, if one dog is not nice, and there are dogs out there that are, you know, forgive me for saying psycho, and they probably had trauma in their hat in. In their past and yada yada, but they are dogs who will bite you. And, you know, I've. My husband used to work with canines on. In law enforcement, and some of the canines were not good pets. Let's just say that. So you have occasionally have these dogs that are aggressive. All right, for whatever reason they're aggressive, they too are experiencing an exaggerated fight or flight response and trying to protect themselves. Okay, let's. I get it. But if you take that and you start saying, okay, that German shepherd was aggressive, that that must mean that all German shepherds are scary. And then you hear another dog bark that looks like a German shepherd. It's a Malinois. So now I'm afraid of German shepherds and Malinois. Okay, let's add an Akita in there. Let's add a lab in there. As you start generalizing and identifying instead of narrowing it down and saying, okay, it's only these particular dogs in these particular situations. If you start to think, well, all dogs are dangerous, then that can cause you a significant amount of stress because you're going to see dogs out and about. And children tend to overgeneralize a lot because that's how they think they Think dichotomously. All dogs are good or all dogs are bad. There is no middle ground for a three year old. They can't process the fact that, okay, Fluffy over here is a good dog, but you know, whatever that dog's name is down the street, I need to stay away from it. You know, it's three year olds don't get that. So if they learned this lesson, if they learned to become afraid when they were three, then they may avoid all dogs henceforth and forevermore until they check and maybe modify that belief that they hold that schema that they have about dogs. Poor coping skills can also cause anxiety to become overly intense or uncontrollable. If you feel anxious and you start stewing in that anxiety and you don't know how to control it, and you feel like your body is betraying you, and you know, you feel like you're out of control, then you can start to become anxious about becoming anxious. And we see this a lot in people who experience panic attacks which can lead to that anxiety becoming more of a problem. Emotional reasoning and cognitive distortions also can cause anxiety to become more intense. If you. Emotional reasoning, remember, is like saying flying must be dangerous because I'm afraid of flying. That's emotional reasoning. We have no facts to support it. Up to support it. We're just saying I'm afraid of flying. Therefore if I'm afraid of it, that means it must be dangerous. Spiders must be dangerous because I'm afraid of them. Well, when you do the research, there's actually very few spiders that are actually poisonous and most of them are really good and helpful. So again, that's emotional reasoning. I have this fear. Maybe I learned it when I was young, maybe, maybe it's just an innate fear. Whatever it is, however, I have this fear. I don't know why I have this fear, but that means that whatever it is must be dangerous. We want to help people start checking that and saying, okay, what are the facts that I have that say that spiders are dangerous? What are the facts that I have that support my belief that flying is dangerous and what are the facts against both of those things? Then our good old friends, cognitive distortions, the all or nothing thinking, personalization, magnification, drawing conclusions without having all the facts, yada yada. And biochemical issues can also make anxiety become a problem. And this is one of those that we often leave out as mental health clinicians. We think of over generalization and the coping skills, distress tolerance and emotional reasoning and all that mental stuff. But a lot of times we forget the biochemical. If the person's not getting adequate nutrition and you've been in other classes before, you know that the body needs not only tryptophan, but calcium, iron, vitamin B6, magnesium, and a whole host of other vitamins and minerals in order to make serotonin. If the body can't make serotonin or gaba, the body needs other building blocks to make gaba. If the body doesn't have those building blocks from nutrition, then it's probably not going to be able to make those. Therefore, when the person wants to calm down, they may not be able to. Hormones can also cause anxiety or make anxiety worse. For example, when women start to go through menopause and they start to have the hot flashes. When you start to have a hot flash, your heart rate for some people can increase, you know, 12 to 20 beats a minute. That's not, you know, uncommon for some people. That freaks them out, you know, they start feeling hot and flushed and their heart starts pounding. They're like, okay, I'm going to die. We want to help people recognize that hormones can cause physiological symptoms that look like anxiety. But another thing that we've talked about before is that hormones, testosterone, progesterone, estrogen being the big ones, also regulate the availability of dopamine, our go get it chemical, norepinephrine, our excitatory motivation chemical. And serotonin are sort of calming. Supposedly moderating chemical. GABA is the real calming one. Serotonin can go either way. If you've got a serotonin imbalance, you can see people go either way. Some will have too much serotonin and get anxious, some will have too little serotonin and be anxious. So it depends on the person and the exact nature of the imbalance. What other things are imbalance, but the take home message from that, when even gonadal hormones are out of whack, it affects the availability of our mental health hormones, if you will, and sleep deprivation. A lot of times when people are sleep deprived, they tend to feel more vulnerable to, they tend to have harder time dealing with life on life's terms. They get stressed out easier. And this is what we're talking about with anxiety. Their anxiety goes up and they start feeling out of control. As I just said, anxiety can be caused by excess serotonin, norepinephrine or glutamate, or too little Gaba. It's estimated that about 80% of adults have some level of neurochemical imbalance. A lot of that is from our high stress lifestyles. Where we're not getting enough sleep, not getting enough exercise, not getting enough sunlight, which can contribute to a lot of things, and phytoestrogens and estrogen disruptors and lots of things that we do in our modern lifestyle. One of the things we want to look at with people with anxiety, we know that if they're feeling anxious, especially anxious a lot of the time, like generalized anxiety, or stressed out a lot of the time, especially if they can't put their finger on it, we want to figure out what's causing that neurochemical imbalance. And it's probably a combination of four or five or more of these things. The good news is if you start adjusting one thing, then you're going to help them feel better. Think about your water heater drawing a hot bath. You know, we need to figure out exactly how much excitatory and exactly how much calming we need for this person to feel calm. Not everybody has the same level of neurotransmitters. Generalized anxiety disorder symptoms can vary and may include persistent worrying or obsession about small or large concerns that are out of proportion to the impact of the event. And that last phrase is really important to remember that are out of proportion to the impact of the event. If you just got diagnosed with cancer or some sort of terminal disease and you are persistently worrying about it, and you're worrying about your family and you're worrying about your finances and how you're going to pay for the treatment, and you know, that is probably not out of proportion to the impact of the event. That is a big stinking deal. If a hurricane is coming, you know, there are things that you're going to worry about and a variety of things that you may persistently worry about until the spaghetti model finally figures out where the stupid thing is going to go. I've been through a fair number of hurricanes in my day that may be in proportion to the impact of the event. So we do want to look at the proportion. And if somebody is having a reaction that seems proportional to the event, we also want to validate that and go, you know, I can understand where you would feel like you're crawling out of your skin right now. Let's figure out what steps we can take to, you know, my favorite phrase, help you improve the next moment you have this anxiety. This anxiety is telling you that you need to fight or flee. You need to do something to change the situation. So what can we do to start attenuating this anxiety? People may have an inability to set aside or let go of worry and These are your high perseverating people. We need to help them develop skills like thought stopping and distress tolerance. They may have an inability to relax, restlessness and feeling keyed up or on edge. We want to look at what might be causing that. You know, it could be environmental. They're not in a relaxing environment. It could be some people when they get stressed out, they actually turn to things like drinking coffee and smoking cigarettes, both of which have stimulant effects. Not saying that we're going to tell somebody, well, when you're anxious, don't ever smoke, because we don't want to encourage them to go into nicotine withdrawals on top of everything else. That would be something for later down the road. But we do want to take into consideration what does your nutrition look like? What are you ingesting when you are anxious that may be causing you to feel keyed up, difficulty concentrating, or the feeling that their mind just goes blank. And I have those moments a lot where you walk into a room or you start to say something and you just forget what you're saying for a minute. That can be really frustrating to people. We want to help them figure out, all right, until you get all systems back online, you know, what can we do to help you feel less scattered if you're having difficulty concentrating? Well, let's start thinking about writing things down, you know, keeping notes and those sorts of things. The person may have distress about making decisions for fear of making the wrong decision. Well, we want to help them figure out how to deal with that. Whether that's getting consultation from a support person or weighing the pros and cons, whatever it is that they think will work to help them make decisions and help them examine their anxiety about the wrong decision. What's the worst that will happen if you make this decision? What's the worst that will happen and how can you deal with it? Is a way that some people can approach it, carrying every option in a situation all the way out to its possible negative conclusion. And this is one we don't really talk about a lot. But you do see it in a lot of people with anxiety. They just catastrophize and in the worst possible way. And it makes them feel anxious and on edge because instead of seeing what's likely to happen, they see the catastrophic scenario we want to help them evaluate. Okay, maybe that is a possibility. You know, if you don't get this job, you may not be able to make your house payment. You may get evicted in six months, you may become homeless. And when you're homeless, you may become a drug addict. I had one client who actually took it to that end and I said, okay, you know, is it possible that that chain of events could happen? Anything's possible. How likely is it that that's going to happen? And he didn't even really have to think for more than a half a second before he was like, yeah, it's pretty unlikely. I said, okay, so we have that over here and we don't want to go there. But what is more likely to happen? And you know, if you want to talk about this worst case scenario, what are your stopgaps, what can you do to prevent it from getting that far? And difficulty handling uncertainty or indecisiveness. A lot of times when we feel anxious, that fight or flee thing is kicking in. We want to try to control as much as we can. So if we don't know what's going to happen next, we start to feel on edge. Helping people develop some distress tolerance skills can be really helpful here because there are times when life's just uncertain. You know, the person who's diagnosed with a terminal illness or cancer, let's just stick with cancer because I know more about that one uncertainty. Will chemo work? Well, we don't know. And it's not like you get one treatment and then you can go have an MRI and say, oh yeah, that's, you know, we're on the right track. You have to go through it for whatever it is, 12 sessions, which can be like three months before you can have another MRI. So there's three months in there where the person is wondering and worrying and having this, all of these symptoms again, is it out of proportion to the impact of the event? In my opinion, no, probably not. If you know they were diagnosed with some form of aggressive cancer, does it do any good to worry? And that's when we go back to talking about when you worry, you're actually working against yourself. You are creating situations where you have more difficulty finding fun in the things that you used to enjoy. Appreciating the moment. You're probably going to get sick more, you're going to feel more fatigued. So it negatively impacts your present. When you're worried and worry, anxiety is energy tied up in something that hasn't happened yet. You know, it's in the future I am worried that I am anxious about. Well, that's stuff that's gonna, hasn't happened right now. Let's figure out, you know, how to help people appreciate the moment and plan for the eventualities. Potentially Generalized anxiety disorder may include physical signs and symptoms such as fatigue, irritability, muscle tension, trembling or feeling twitchy, being easily startled, trouble sleeping, sweating, nausea, diarrhea or irritable bowel syndrome or headaches. If you've ever been anxious, whether it rose to the level of a clinical diagnosis or you were just going through a period where you were anxious, you can probably check off multiple of these symptoms. Now think about how that impacts you at work. If you are tired and irritable and achy and easily startled and have a headache, how productive are you at work? How much fun are you to be around? How much do you really want to engage with your social supports or even your children? At that point, it's probably negatively impacting that. We do want to recognize that some of these symptoms may be what people prefer present with because they tend to somaticize culturally. Maybe it's more appropriate for them to present with physical symptoms than mental health oriented symptoms. Being Aware in kids, they may have excessive worry about performance at school or in sporting events. Whether they're going to get an A on a particular test, or they may have great anxiety, they may have worries about being punctual. If you don't get there 30 minutes ahead of time, they're gonna freak the freak out. Earthquakes, nuclear war, or other catastrophic events can also be a topic or area of worry for kids, especially kids who watch the news. If they see or hear about North Korea setting off a missile or whatever it is that they're seeing, they may not have the context to understand whether that's a threat to them or not. They may be watching the news and not have the ability to contextualize things. A child or teen with generalized anxiety disorder may feel overly anxious to fit in, be a perfectionist, lack confidence, strive for approval, or require a lot of reassurance about performance. I will put the caveat out there that most of these characteristics are pretty common for just about any child or teenager at some point. It's a matter of degree. Just like anything else, it's a matter of degree how much and how often is this anxiety happening and how much does it impact their life? Are they a perfectionist about one thing or are they a perfectionist about everything and it controls their life and they can't have any fun because they are just so worried about getting everything perfect. Physical Impacts of Anxiety HPA axis overstimulation leading to excess cortisol when we have excess cortisol cortisol and it causes excess glutamate to be released into the brain Creating, remember what we call a neurotoxic or excitotoxic environment. So we actually kill brain cells when we're stressed out. And sometimes when you put things in a particular way to somebody, they're like, oh, well, I don't like that. You know, maybe that's enough motivation for me to work on my anxiety. It can cause metabolic syndrome, which, if you remember, is a insulin resistance and gaining weight around the midsection and an increased risk of developing type 2 diabetes. Part of that is because of the cortisol. When we've got cortisol in our system, it's telling our body to release blood glucose. Release blood glucose because we need energy to fight or flee. When all that blood glucose is constantly there, just like our brain does. In response to too much cortisol for too long. In response to too much blood sugar for too long, our receptors become less sensitive to the blood glucose. High blood pressure, you know, that makes sense with anxiety. High blood sugar for the same reasons I just explained. GI disturbances and ulcers. When we are stressed out, when we are anxious, when we are in fight or flee. Our body's not worried about digesting food. It says, let's just clean out the system. Because we need to focus on fighting or fleeing, not digesting and resting. Which is why when we get stressed, our systems tend to run faster, which is why a lot of times you see people have stomach cramps or diarrhea. But we also see people start to develop ulcers. And when we're under stress, it upsets our gastric microbiome, which can lead to the proliferation of bad bacteria that can lead to stomach ulcers and potentially stomach cancer in certain situations. Sleep disturbances. When we're anxious, we don't sleep well. When you are ready to fight or flee, then you are not relaxing and getting that deep sleep. We talked about this last week. Increased aging. People's rate of aging speeds up as they are running faster and hotter than normal. Think about a car. Think about gas mileage, or not gas mileage, but car mileage at a certain point, you know, you get a car, you expect it to run for 100,000 miles. You know, just pick round numbers for me. Well, one person can drive like crazy, pedal to the metal for, you know, three years and put on 100,000 miles. Another person, like me, you know, may put on 7 or 8,000 miles a year. And so my car is not going to wear down or wear out as fast. That's kind of the analogy that I use with people when we are anxious. It is similar to that person who is driving their car as hard as they can, pedal to the floor all day, every day. And eventually, you know, parts are going to start to wear out a lot sooner than with somebody who drives more gingerly. Headaches. We talked about infertility. When we get stressed, our body says, you know what? Now is not the time to procreate. We're fighting or fleeing. We don't need to bring a little organism into this world, which also contributes to sexual dysfunction. You know, if you're not interested in procreating, then sexual function is not super important in the big scheme of Darwinian evolution. Both of those tend to go down because our libido hormones, our gonadal hormones, are altered under stress. We have a weakened immune system. Fatigue, restlessness, hair loss. This is another one I hate. But you do see in men and women, when they are under a lot of stress, physical or emotional, they tend to lose hair. Women, when they are pregnant or give birth, you know, your hair grows really fast. But sometimes some women, especially ones that have challenging pregnancies, may lose a lot of hair during pregnancy or right after childbirth, and that's not uncommon. It grows back. But that hair loss is the body's way of saying, I need to devote the energy to survival, not creating luscious locks right now. So that's just gonna have to wait. And autoimmune issues, like we talked about, cognitive and emotional aspects of anxiety. When we're stressed out. And I want you to think about a time when you were stressed out and. Think about how easy or hard it was to take other people's perspective. You, you're at work, something's going wrong, you're stressed out, you have the solution. You know what needs to happen. We need to do it. Gosh darn it, let's do it now. How hard is it to listen to your peers or your colleagues who say, all right, let's slow your roll for a second and think about doing it this way. When we are stressed again, we don't like not being in control. And one of our reactions often is to try to take control. So we may have difficulty taking perspectives, difficulty concentrating. When we are anxious, again, fight or flee, think about being in this state of threat. We're going to be more attentive or have more difficulty filtering out stimuli because we are more alert to all of those threats that are out there. We're feeling vulnerable. We may become easily confused. Well, when you have difficulty concentrating and it's hard to sometimes keep your thoughts in order, we may have memory problems. If you're having difficulty concentrating and easily confused memory problems make sense. Your body is not worried about processing memories and filing them for later use. People when they are anxious often have a lot of negative self talk. A lot of times it's the I can't deal with this, what we call distress intolerant thoughts. In dbt they have a lot of self talk about you're so stupid, how could you have gotten yourself into this position? You know, how are you going to get out? Yada yada. They may have marked mood swings and that's that emotional dysregulation we've talked about in other classes. When we're exposed to chronic stress or chronic anxiety and we start to develop a level of glucocorticoid resistance or hypocortisolism, whatever you want to call it, we go into a state where it is either the flat or the furious. And that's my best analogy for it. When we are not feeling threatened, we are flat and we're kind of like Eeyore, just kind of going through life and it is what it is and I just don't have energy to really be concerned about much. But then when something does rise to the level of a stressor instead of being a little bothered by it, we have an exaggerated stress response and you go from flat to furious. Those marked mood swings seem to be coming from out of the blue. But if you understand that that's the body, it's holding onto its energy until it absolutely has to respond and and then it's going to push away that threat with all its might so it can go back into conservation stage. And people who are anxious find it hard to make decisions for the same reasons we talked about. They're worried about what if I make the wrong decision? What if, what if, what if? Social impact social withdrawal A lot of times when we're anxious we just don't have energy for other people. You know, it's I can't even muster the energy to text my best friend, let alone want to go out to a movie or something. Reduce support system because of social withdrawal. Again, that difficulty taking perspectives can make it challenging to engage with others in your household. If you're having difficulty understanding or empathizing with how other people in your household are feeling, it can cause conflict and a reduction in leisure activities because you don't have any stinking energy which removes some of those happiness promoting chemicals and happiness promoting activities. Biological interventions. Well, your body thinks there's a threat help it restore itself so it's ready to fight that proverbial lion. The amygdala is still in that primitive state where you are the weak link in the pride and you're the one that's going to be eaten by the hungry lion. So bolster your physical self so you can be ready for the lion. Create a sleep routine. This helps the body and brain rebalance and restores HPA axis functioning. Gets that cortisol back into the proper pattern by resetting our circadian rhythms. Really important, it improves energy level through the removal of adenosine and systemic repair when we actually finally get good sleep. Remember, we only really remove the adenosine buildup in our brain when we're in that deep sleep phase. People who are anxious may not be getting to that deep sleep phase. So they may sleep and awaken and not feel rested at all. Make sure they're practicing good nutrition, which provides the building blocks to make the neurotransmitters they need and the hormones they need in order to have that body system, that body machine, running effectively. Good nutrition also provides sufficient energy. Sometimes when people get anxious, their stomach gets upset and they just don't want to eat at all. Well, not only are they not getting the building blocks, but they're not getting the sugars and everything else they need to fuel the body. And believe it or not, eating, eating for nutritional sake at proper times also helps set our circadian rhythms. Your body starts to predict when it's supposed to eat breakfast, lunch, dinner, snack, whatever it is that you eat. And it regulates your hunger and satiation hormones partly based on that. So nutrition can help serve as an anchor point throughout the day for your circadian rhythms. Medication is a biological intervention. It doesn't work for everybody, only works for about 30% of people, but it does work for about 30% of people. So your SSRIs, your typical antidepressants that you know, Zoloft, Paxil, Prozac, Lexapro, those things. Your SNRIs are serotonin, norepinephrine, reuptake inhibitors are, you know, both considered your first line antidepressants these days. Buspirone works on the 5ht system, the serotonin system, but is not considered an SSRI or snri. It's kind of out there in a class by itself. Buspirone is often prescribed for people who have anxiety, but because it tends to help people who go from flat to furious modulate their reactions so they don't go from 0 to 200 lickety split. But that is just kind of anecdotal. Clients really need to feel out for themselves whether that, whether buspirone is helpful. I've had some clients that said when they were on it, they just didn't feel anything and they didn't care about anything and it was just, it was just blah and they hated that feeling. I had have worked with others who swear by it. So you know, depends on the person. Exercise exercising at a low intensity. Remember 40 to 50% of your target heart rate zone. So for me that would be like 96 to 104 beats a minute. Not hard at all. Has been shown to reduce cortisol. Exercising at a higher intensity than that increases cortisol in the short term. So going on a gentle walk, walking the dog, gardening, anything like that can actually reduce cortisol. Yoga and mindfulness have also both been shown to help calm the HPA axis and reduce cortisol levels. Vitamin D deficiency has been implicated in some mood issues and some issues related to serotonin system imbalances, including anxiety. Sunlight prompts the skin to tell the brain to produce neurotransmitters. It sets circadian rhythms which impact the release of serotonin, melatonin and gaba. Psychological Interventions Mindfulness and acceptance is where I generally start. Help people figure out how to identify a rich and meaningful life. What is it that you want in life? What is important to you? All right, let's focus on those things instead of 100 million different things going in six different directions and help them live in the and recognizing that there are going to be things that cause you stress, that make you anxious and and you can still have a rich and meaningful life. You can be anxious about something at work and enjoy your kids play that you go to or dance recital or whatever it is. Help people practice observation, acceptance, labeling and letting go. Observing what it is and accepting it is what it is. Being that fly on the wall, labeling it for what it is. This is what's going on. This is how I feel about it, okay? It is what it is. Instead of trying to get caught up in that, help them identify trigger thoughts. What triggers your anxiety? What types of self talk do you have that trigger your anxiety and encourage them to differentiate between expectations and current reality? When when maybe you're working with a young person who is anxious about asking somebody out on the date. Differentiate between expectations. What do you expect is going to happen versus reality? What you know and they may expect to get rejected and laughed at or whatever and you know, be very anxious about that which of course you would be. But what is the reality? Do you know that anything like that is going to happen? What is actually happening on the right hand side of the PowerPoint? I have accepts and improve. They are mnemonics designed by Marsha Linehan for dialectical behavior therapy. But I really like their handiness. I love mnemonics. These are interventions that we can use to help people deal with distress. Sometimes you can't change what's going on for the person who has a cancer diagnosis, for example, well, you may not be able to change that right now. You can go to chemotherapy, you can do all the things that you're supposed to do, but until that chemo runs its cycle, you may not have any answers. So what can you do in the meantime other than perseverating and worrying, which is where activities, contributing, comparisons, thought stopping, using cognitive distractions and sensations can come in handy. In response to your question, Danielle, yes, too much sleep for some people can cause more anxiety because it does mess with sleep cycles. The more we sleep, the worse quality sleep we get, surprisingly, or maybe not, because our melatonin and our circadian rhythms get out of whack. Our cortisol gets out of whack. So we're not. Any sleep we're getting is not good sleep. So you may be sleeping a lot, but it's not good sleep. So when you wake up, you're still technically sleep deprived and more vulnerable to distress. Distress tolerance. When we're working with people with anxiety, it's not always about controlling the anxiety and acceptance. Commitment therapy would say that's one of the worst things that you can do is try to control it. Distress tolerance means working with it in harmony. Distract, don't react, ride the wave. Recognize that anxiety comes in, crests and goes out usually within about 15 minutes or so. If you don't feed it, if you keep feeding it, then you may build up more energy and create a tidal wave. Otherwise it's just going to be one of those nice little cascading waves. Use distancing techniques. I'm having the thought that for the person who is anxious about asking somebody out on a date, having the thought that she is going to reject me. Well, a thought is a thought and it can come and go. It is not fact. So I can check that against facts. Instead of saying I'm, you know, I'm thinking, I know she's going to reject me. I don't know anything. I'm having the thought that she's going to reject me. Or you can just distance by taking a mental vacation, you can check out mentally for a few minutes and go to your happy place. And I know that sounds weird to say or condescending or whatever. I have a happy place that I like to go to. And everybody needs a place where they can just let their hair down, so to speak. Practice thought stopping and guided imagery. Imagery can be really helpful when you're working with clients where they can imagine doing whatever it is and succeeding at it. They can imagine being somewhere else. There's a lot of things our brain can help us do. Basic fears. When you're working with clients who have anxiety, recognize that a lot of us have fears of failure. And part of that is just ingrained. We've been taught to succeed, to, you know, compete all of our lives. So we want to explore the dialectics. We're going to fail when we fail, okay, it's unpleasant. We don't like the way it makes us feel. What's the positive out of it? You know, there's. There's yin and yang. We learned how not to do it again. We grew. We, you know, what is the positive that can came out of that failure? Instead of seeing it as a crushing blow, how can you look at it? And there was a commercial or whatever you want to say, infomercial on YouTube at one point with several different Michael Jordan talking about his failures and how he grew from those. Instead of looking at them as devastations. We can help people provide themselves with encouragement. Sometimes you need to be your own best cheerleader. A lot of us fear rejection or isolation. We want to help people depersonalize when that happens. When you don't get a job, when somebody doesn't agree to go out with you, when you break up, when you get a divorce, when you have a falling out with your best friend, you're not going to be everybody's everything all the time. It's just not the way it is. So depersonalizing that and helping them look at what part they may have had in it, but what part the other person had in it. Maybe, you know, in terms of a job, there was a team that you were going to join and you just weren't the right fit. It's not because you are incompetent or incapable. It's just they were looking for a different dynamic. Again, help people explore the dialectics of rejection. What are the benefits? Okay, I didn't get that job means there's another one out there that's going to be even better waiting for me because I really don't want to be in a place where I'm having to be a chameleon and try to be inauthentic in order to fit in. Loss of control and the unknown. Focus on one thing in the moment and think of prior experiences. When we're feeling out of control, focusing on just one thing right then can keep you from getting anxious. Whether it's taking a test or moving or getting a lot of us, you know, that wedding day could be really overwhelming. Focusing on one thing in the moment, what do I have to do right now? And thinking of prior experiences where you felt out of control and you emerged unscathed or victorious or whatever you want to say. Relaxation skills. Well, help people figure out what relaxation is, what does it look like for them? And that means mental and physical relaxation, calming the mind and the body. One of the easiest things is combat breathing. Breathing. In for four, hold for four, out for four. We can do this just about anywhere. Too often when I hear people talk about taking, you know, 10 deep breaths, I see them doing it like in rapid succession. And all that does is make you dizzy. For most people, encouraging people to breathe in, hold and breathe out, it starts triggering that rest and digest system. And your heart rate actually responds to your breathing rate. They're connected. So when you start breathing more slowly and your body goes, oh, guess the heart doesn't need to beat quite this fast. Heart rate will start to slow down. And then you've got two of those symptoms of anxiety that are starting to remit, the shallow breathing and the rapid heart rate. Meditation is another thing that can help people with diaphragmatic breathing, because a lot of meditation approaches begin with focusing on the breath and cued progressive muscular relaxation. Way too much to go into here, but it is a excellent tool, especially for people who have a lot of anxiety, who have difficulty going to sleep. They go from top to bottom or bottom to top and notice the difference between tensing a muscle and what it feels like relax. And they go muscle group to muscle group through the body, focusing obviously their attention on the body so they're not thinking about hither and yon. A lot of times that helps people start relaxing and so they can get to sleep. Self esteem. A lot of anxiety is underscored by a lack of self esteem and self efficacy. So help people work on their self esteem. Who, who is it that they want to be? Encourage them to develop compassionate self talk instead of rejecting themselves and criticizing themselves. You know, silence that and be compassionate instead of being that angry person that is watching and supervising and criticizing Be the nurturing parent that is saying, all right, well you didn't succeed at that, but you can do this or you know, you haven't failed yet, you can do this. And practice silencing that inner critic. And a lot of that just comes to thought stopping when you start hearing yourself say something like there is no way I can do this or I am going to fail this exam. Just telling yourself, no, I am not going to do that right now. And then repeating something positive in response. And encouraging people to spotlight their strengths, whether it's in a scrapbook or a collage or a list, whatever, it works for them. And accept their imperfections because that makes them who they are. None of us is perfect at everything. Cognitive restructuring Help people address their cognitive distortions. And we've got other videos on our YouTube channel on cognitive distortions. Reframe challenges in terms of current strengths, not past weaknesses. So if somebody is facing a challenge, how is that helping them grow and enhance their current strengths as opposed to playing on their weaknesses? Encourage people to create an attitude of gratitude and optimism. If they start seeing that glass is half full, then it's maybe going to permeate into other areas of their life. You can help them explore acceptance and commitment Therapy Identifying what is truly important in your life. What does a rich and meaningful life look like? What are you thinking and what thoughts can help you move toward what's important? If you're having these self defeating thoughts, is that helping you move toward being happy and a good friend and productive at work? Probably not. Let's think about what the person is doing and encouraging them to act purposefully when they use their energy for thoughts or actions or even emotions. Is this helping me get closer to what's important? Have the person identify what they're experiencing. What are they seeing, hearing, feeling, smelling? And what can they do or say or stop listening to or saying that can help them move closer to what's important again? Behaviors. Thoughts. What are they doing? How are they using their energy? We can get anxious and we can fight with that anxiety and we can perseverate on that anxiety. Does that do any good? No, that's like sitting at a stoplight and just revving that engine in the car. Not doing anything. You're not moving forward, not moving backwards. You're just wasting a bunch of gas. Recreation. Yes, this is a weird one. But there's always going to be stuff that you can do. There's always going to be stuff that you can fret about. Sometimes a break is what you need to Get a breakthrough. Taking time off. And if you've ever had a word on the tip of your tongue and you're just like or something that you wanted to say and you couldn't think of it, as soon as you took a break from trying to think of it and you did something different, a lot of times it will pop into your head. Same sort of thing here. Sometimes we need to recharge to clear out the cobwebs and get everything oiled and running smoothly again. Have people make a list of fun things that they want to do, activities. What things do they enjoy doing for recreation? Is it, you know, playing foosball? Is it gaming? Is it reading? Is it gardening? What works for them? They can include things that they do to contribute. Maybe they enjoy volunteering or what kinds of sensations help them relax. For me it's a hot tub. I love a good hot tub, but that can help me relax mentally and physically. Encouraging people to figure out what it is that helps them relax and recreate and how they can incorporate that into their life. When they're feeling anxious to allow themselves to get a breath and or get the break to have the breakthrough. Socially, have people improve their relationship with themselves. That goes back to self esteem. Have them practice mindfulness to identify their needs and wants and become their own best friend when they're anxious. What would they want a best friend to tell them? Well, they need to tell themselves that for right now they need to examine how much of their validation is internal versus external. We have a lot of anxiety if we rely on external validation. If we are able to look in the mirror and say I'm good enough and I'm smart enough and. And gosh darn it, people like me. Thank you, Stuart Smalley. Then we have less anxiety about rejection and we need to improve our relationship with ourselves by being compassionate instead of being critical and hateful and making ourselves feel bad, building ourselves up, being that nurturing parental figure to ourselves. We also need to develop healthy, supportive relationships. Most of us are not meant to be hermits living by ourselves in a cave. But to do that we need to understand about boundaries and develop assertiveness skills. We need to be able to describe what an ideal healthy, supportive relationship looks like for us and separate the ideals from the reals. Would I like to have a Wharton June Cleaver family and relationship? Well, maybe. But that's not real. That's just not how life goes. Life can be messy at times. Understanding that and not getting hung up on the Hallmark versions of what life is supposed to be like once they've figured that out, figured out what these relationships look like, develop those skills, then figuring out who they know that fits into that category or maybe where they need to meet people. Anxiety is a natural emotion that serves a survival function. Excess anxiety can develop from lack of sleep, nutritional problems, neurochemical imbalances, failure to develop adequate coping skills, cognitive distortions, low self esteem, and a need for external validation. Recovery involves reducing physical and psychological vulnerabilities by improving health behaviors like sleep and nutrition, identifying and building on current coping strategies, addressing cognitive distortions, and developing healthy, supportive relationships with oneself and others. And Deborah I have read the same book, the Anxiety and Phobia Workbook by Edmond J. Bourne and that was really good. I really like a lot of the resources by Matthew McKay and I tend to gravitate toward ACT and DBT in my approaches. So things that are written by Stephen Hayes or Marsha Linehan I tend to like. But that's me because that's my approach. There are lots of other approaches that are out there actually. Matthew McKay writes on on Emotion Focused Therapy and Compassion Focused Therapy. He has a book on each one that is available. If you're interested in looking at that, you can also go to, you know my favorite site, PubMed, and find articles that describe those two approaches. All righty everybody, have a wonderful afternoon and I will see you on Thursday. Between writing notes, filing insurance claims and scheduling with clients, it can be hard to stay organized. That's why I recommend TherapyNotes. Their easy to use platform lets you manage your practice securely and efficiently. 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