Impact of Anxiety and Tools for Anxiety Relief

Foreign. I'd like to welcome everybody to today's presentation on the Quick Start guide to.

Understanding and addressing Anxiety. I am your host, Dr. Donnelly Snipes.

We are going to review the symptoms of anxiety in adults and children, remembering that children. Children's symptoms often are a little bit.

Different than what we see in adults. They're not quite as demonstrative and sometimes they have difficulty identifying what they're feeling. A lot of times when children are anxious, what we see is a lot of.

Irritability. It's important to remember that anxiety can be debilitating. In many cases, neurotransmitter imbalances are not.

The initial cause of the anxiety, but a symptom.

So we want to look at what caused that initial anxiety and we'll just.

Go with what's going on right now. With COVID and all of the disruption.

There were a lot of changes and.

Things that happened that made a lot of children feel out of control. If you remember to the last class when we talked about some of our basic fears, loss of control, fear, failure, rejection, isolation, there are a lot of feelings that are going on right now, especially as they pertain to isolation and loss of control. So things happened, schools shut down. You know, people got furloughed from work or started working from home. There were a lot of changes which added stress. Stress ramped up that HPA axis. Our threat response system increased our adrenaline, increased our norepinephrine levels, increased our cortisol levels.

All of those produce feelings that are.

Anxiety, like those are our fight or flee chemicals. When we can't resolve those threats, then we have long standing levels of those fight or flight chemicals which start impacting.

Our sleep, impacting our eating, which also.

Compound our HPA axis activation and contribute to maintaining high levels of those stress chemicals which come out as symptoms of anxiety.

Low grade chronic stress. And anxiety erodes people's energy and their ability to concentrate. Remember when we're under stress, when we're not sleeping well, our brain is not.

Clearing out all the adenosine at night.

So we're waking up in the morning.

And we're kind of foggy. We're not sleeping well, so our energy's going down. That adds to most of our stress. We feel fresh, frustrated, we start to feel, quote, depressed. We may feel out of it, or a little bit hopeless and helpless because we just can't seem to get on the ball, so to speak. That increases our stress, which increases our HPA axis activation, which increases the anxiety chemicals. So we see where we're going here.

Anxiety is a major trigger for addiction relapse depending on depression, increased physical pain.

And worsening of physical illnesses.

Now I want you to realize and remember that anxiety, as we've talked about.

Many times before, anxiety is a natural emotion. It is our body's alarm system telling us that there might be a threat. Remember, just like the faulty fire alarm, a lot of times our HPA axis.

Is a little bit faulty.

So it doesn't necessarily mean there is is a threat. We need to back it up with facts. We need to check and see. Is there something to be worried about right now?

What is the probability that the thoughts.

I'm having are going to result in catastrophe?

Regardless, when people have anxiety, they may.

Get to the point where they want to numb it. They don't feel like they can control it. They want to calm down. They, they're tired of feeling stressed out and revved up all the time. So they may be tempted to smoke or drink or engage in some sort of addictive behavior like gambling or watching pornography that distracts them from that anxiety.

Now remember, in Linehan's distress tolerance skills.

One of the first things is to engage in activities that help us change what we're thinking about. Another mantra in dialectical behavior therapy is distract, don't react well.

That's all well and good, but we want to make sure that the behaviors we're choosing to distract our short term.

Behaviors until we can get into our wise mind. They're not meant to make the problem go away. They're just meant to give us a chance to cool down.

And it's also important to recognize that.

Certain behaviors are going to prompt more of a dopamine rush and can lead to an addiction relapse.

So if somebody has a history of.

Addiction, regardless of what the addiction is, it's important that they be aware that they may resort to behaviors that cause that dopamine surge and help them feel excited or relaxed again.

Anxiety is a major trigger for depression because once we're revved up for so long, at a certain point we start running out of energy, we start getting foggy headed, start getting exhausted, we start.

Feeling hopeless and helpless, which is where that depression comes in.

So we're feeling anxious, but we're also.

Feeling trapped at the same time, which is why you can have depression and anxiety concurrently.

People have increased physical pain when they're anxious.

Most people have more muscle tension that contributes to pain.

A lot of people have difficulty getting.

Adequate skin sleep and they have difficulty getting comfortable, which can contribute to perception of Pain.

Additionally, when that HPA axis is activated.

Serotonin levels drop, which means that we may perceive more pain. Our pain tolerance goes down as our stress goes up.

It's important for people with chronic pain to develop really good distress tolerance and.

Anxiety management skills because if they are constantly revved up, if they are constantly anxious, they are going to probably feel more pain for a variety of reasons.

And the worsening of physical illnesses is another problem.

Whether it is an autoimmune issue, which we know is exacerbated by stress and anxiety, or diabetes, when we ramp up our HPA axis, what is one of the things our body does? It dumps blood glucose. It wants to prepare us to fight or flee.

When our body is just dumping glucose.

Then it sends that insulin balance all out of whack. So the more stressed or when somebody is stressed, they are going to have more difficulty balancing their insulin blood sugar levels.

Chronic anxiety can also make people more vulnerable to ptsd.

We have found that in, in the research and if you've not been to these classes before, you know, the Hyperlinks in the PowerPoint take you to a, the research studies on it in PubMed.

But basically when people are revved up.

For a long time, when their HPA axis is activated for a long time.

At a certain point the body says.

You know what, this is not winnable. We need to protect ourselves from this hyperactivation, from this excitotoxic environment as they call it. So we're not going to send out as much cortisol.

This leads to a state called hypocortisolism.

Which is, you know, not that uncommon.

However, they found that when people who.

Have hypocortisolism, people who've been exposed to extended periods of stress or lots of.

Extreme stressors, are exposed to a threat.

They become more vulnerable to actually developing full blown PTSD than someone who had normal cortisol levels who was exposed to the same threat.

It's just important to recognize that there are a lot of things that our body does to, to try to protect us. So think about the person who has chronic anxiety. Their cortisol levels are low, they're exposed to a threat. Their body just starts dumping all kinds.

Of cortisol and norepinephrine and stuff to try to protect them.

And then it's even more exhausted, if.

You want to think about it that way. It's even more exhausted afterwards and it.

Wants to protect itself from being threatened from, you know, future things in the environment.

It says, wow, I was already weak and Vulnerable and this happened and look what happened. So now I need to be hyper vigilant. Now I need to, you know, start having creating all those symptoms of PTSD to protect the person because they're extra super vulnerable right now. Which helps people understand why they may start developing certain symptoms.

It's important to help them understand their.

Symptoms from a biological survival perspective. The brain wants to help us survive.

Remember, anxiety is half of the fight or flight response and it's excitatory. Its function is to protect you from possible danger. One of the things I tell my clients to do, and I try to.

Remember to do is when they notice.

That they're feeling anxious is to thank their brain to say thank you self for trying to protect me. Now let's see if there's really a problem. If every time I felt anxious I.

Determined, I assumed that there was a threat. That's emotional reasoning and it's going to steer me wrong more than factual reasoning will.

So when I feel anxious, I thank my brain for trying to protect me and then I say okay, let's look at the that fact facts.

Is there really any threat right now and what's the probability that I'm actually in danger?

Anxiety can become a problem when it is overly intense or is over uncontrollable because of overgeneralization. For example, there are some people right.

Now, and my heart just breaks for.

Them who are still terrified to leave.

Their house because they have been watching way too much news and networks that are, you know, doing the whole chicken little thing and they are afraid to go anywhere or do anything. You know, it's not, well, you know, I need to be careful if I go out, I need to wash my.

Hands, you know, practice social distancing, yada yada. What they are thinking is it is.

Dangerous to leave my house to go anywhere or be next to anyone, anybody, because anybody might be a carrier. So they've over generalized the threat to everything everywhere. And they're basically prisoners in their, in their own home right now.

And so we're going to see unfortunately.

An increase in anxiety with related agoraphobia over the next, you know, several months. And that's expected. When you look at prior pandemics, we have seen some of those symptoms come out, especially in people who were exposed to the virus, like first responders. Interestingly enough, poor coping skills can also.

Cause anxiety to be a problem. If somebody starts to feel anxious and they don't have any tools to turn it down. Think about like a pressure cooker. Anxiety turns up the heat.

If they don't have any way to.

Turn down the heat, they're just sitting there going, praying that the top doesn't pop off, that the pressure cooker doesn't explode. We want to help them figure out tools that work for them, and we're.

Going to talk about those in a minute that work for them to help.

Them turn down the heat on the anxiety. It doesn't mean that everything's perfect, but we want to recognize on a scale.

Of 1 to 10, I don't like those really big scales, but sometimes you can use them, or 1 to 5.

What level the threat is.

Is it a 1 or a 2.

Or is it a 5? You know, so they can figure out.

What they need to do.

Emotional reasoning, as I said earlier, and.

Cognitive distortions also increase anxiety and can cause it to become uncontrollable.

If every time I feel a little.

Bit anxious in my tummy, I figure that there must be something to be.

Afraid of, then I am probably going.

To be controlled by the anxiety.

It's important to help people recognize the.

Difference between emotional reasoning based on just how I'm feeling and cognitive reasoning or fact based reasoning.

It's also important to help people identify.

Those old cognitive distortions. The all or nothing thinking, the over general realization, the mind reading, the jumping to conclusions without sufficient information. I have several videos on cognitive distortions on the All CEU's education channel on.

YouTube if you need a primer or.

A refresher on those cognitive distortions.

Biochemical issues can also cause anxiety to.

Kind of spiral out of control.

If people are not eating well, if they're not eating the foods that they.

Need to provide the body the building blocks to make the neurochemicals like serotonin and gaba, then they are going to.

Feel more anxious if they are overdoing.

It on the caffeine or the nicotine that is going to increase their HPA activation and their stress response.

So there are things in nutrition, interestingly enough, also dehydration and low blood sugar. When we get into a state where we're dehydrated or our blood sugar's low.

Our HPA axis actually does ramp up again. So people tend to feel jittery or, or anxious. We want to make sure that people.

Are mindful of whether their body's getting.

The fuel it needs, when it needs it.

Hormones can increase levels of anxiety when testosterone or estrogen are out of balance.

For that person, or when thyroid hormones.

Are too high, it can create a parallel condition that feels like anxiety There are a lot of physiological things that.

Can cause anxiety, like symptoms.

So it's important to make sure our.

People are getting a physical, to rule.

Out some of the biochemical issues, because.

No amount of talk therapy and lifestyle adjustment is going to do everything if they have some underlying physiological issue.

And sleep deprivation, when we are sleep deprived, when our circadian rhythms are out.

Of whack, our cortisol levels are going to be out of whack, which means our HPA axis is going to be more volatile.

Anxiety can be caused by excess serotonin, norepinephrine or glutamate, or too little gaba. It's important to remember that when we're looking at neurochemicals, it doesn't necessarily mean that the body's not producing enough. We might remember when neurotransmitters work, they're.

Excreted from one side. So enough needs to be made, enough.

Needs to be secreted, and enough needs.

To be basically absorbed on the other side. If there's a breakdown in any one.

Of those three places, if the body.

Can'T make enough, if for some reason it's not secreting enough, or if enough is not getting through to the other side, then we can have low levels of or high levels of different neurotransmitters.

Excess serotonin, norepinephrine, or glutamate means we've.

Got too much going through. You know, those. Those doors are not shutting to prevent us from getting flooded with these stimulatory neurotransmitters.

There's not a whole lot we can do about that. But it is important to recognize that.

Some people who are taking SSRIs may feel anxious because the SSRI increases their serotonin. Some SSRIs also increase norepinephrine.

It's important to recognize that when we start monkeying with one neurotransmitter, it affects.

All the neurotransmitters because they all interact with one another. There are different antidepressants out there. SSRIs, selective norepinephrine reuptake inhibitors, selective norepinephrine and dopamine reuptake inhibitors.

So it's important for people to recognize.

That if selective serotonin reuptake inhibitors don't work for them, and they are one of those people who feels like they need medication, there are other options.

It's also important to remember and to educate our clients that according to the research, these pharmaceuticals.

Like antidepressants, only work.

For about 30 to 40% of the.

Population, the other 60 to 70% have other issues that are going on. And it's not that they need more of a neurotransmitter, they need to identify a leak that's further down the system. If you want to think about it.

That way, we want to think about.

What'S causing the neurochemical imbalance in the person.

And one of the things that I tell people is that neurotransmitters, if you want to think of it like water pressure, when you have good water pressure, you know, you turn on your faucet, everything runs just as it's supposed to, you're happy. But if there is a leak in.

The pipe going from the water meter.

Into your house, you turn on the.

Faucet and there's low water pressure.

So if there's a breakdown in say.

For example, the serotonin system, then along the way, you know, your body can't make enough of it or something, then.

Enough serotonin won't get through in order.

To help you feel calm.

Now, just like the water, if you turn up the water pressure, then the water pressure in the house will improve.

You know, turn it up at the.

At the street, the water pressure in the house will improve temporarily. What happens though is if you haven't addressed the leak, if you haven't addressed.

The original problem causing the low water pressure, when you turn up the water.

Pressure at the street, all it's going.

To do over time is make that leak worse.

So eventually the water pressure in the.

House is going to go down again.

Which is why it is so important.

To figure out what is causing not enough serotonin to get through to the other side.

You know, other things that could cause problems in your water pressure would be a clog in the pipe.

You know, it may not even be.

A leak, it may be a clog.

And that would be akin to not enough receptors opening up.

So, you know, you can work with.

This metaphor a little bit, but it's.

My take home message for people is that when you take medication, it's like.

Turning up the water pressure at the street.

All you're doing is increasing the amount.

Of that neurotransmitter that's available. But you're not addressing why it was low in the first place.

Symptoms of generalized anxiety, they may vary from person to person. And I try not to get too.

Caught up in, do you meet the DSM criteria?

If somebody comes in and they say, doc, I'm anxious, okay, I'm not going.

To invalidate it and Go well, you know, you don't meet criteria. If they are experiencing unacceptable levels of anxiety, then totally we're going to talk about it.

So with adults we have persistent worrying or obsession about small or large concerns out of proportion to the impact of the event. People who are anxious over Covid, for example, if you look at, you know.

The potential fallout, if you look at.

Some of the things we're being told.

Or were being told as things change.

You know, a lot of people's anxiety was not a disorder. It was a reaction to an untenable situation. And it's important for us to normalize feelings.

You know, that doesn't make the anxiety.

Go away for people, but it's important for us to normalize that. A lot of people's anxiety right now.

Is very much in proportion to the impact of the event.

Some people are disproportionate, but it, you know, we do want to educate people.

And normalize what's going on.

People have an inability to set aside or let go of worry. You know, if you're thinking about whatever.

It is 24 hours a day then, or 20 hours a day, that can be debilitating.

If they have an inability to relax, restlessness and feeling keyed up or on edge, that's that HPA axis telling you you need to be aware, you need.

To be on your toes. So at a moment's notice you can.

Spring into action and fight or flee.

That is not conducive to health. Our body needs a chance where it can rest, relax and repair.

When people have difficulty concentrating or the feeling that their mind is going blank. Interestingly, when that HPA axis is activated, guess what goes our higher order thinking. It's not time for us to be.

Thinking about in depth problems.

When we are in that stress and anxiety fight or flea mode, our body is saying you don't need to think, you need to do, you need to.

Get the heck out of here.

Which means that we do have more difficulty concentrating, especially on things unrelated to the current threat.

You know, so if people are stressed out about COVID then they may not have any problem concentrating on reading those articles, but they may have con difficulty concentrating on doing their work, which is not related to protecting from the perceived.

Threat, distress about making decisions or fear of making the wrong decision. Yeah, there are a lot of challenges when people are feeling anxious.

What is the right decision?

One of the things I go through.

With my clients is to have them make a list of all the available options that they have for decisions and.

Then think about you Know the probability.

Of which one is the most probably the right decision.

And you know, what's the likelihood that.

If they make this decision and it's the wrong one, they won't be able to make another decision. If you buy a house, you know.

You may buy this house, it looks gorgeous. You move into it, you're really happy.

And 18 months into it, you know, the house starts falling apart and it starts becoming a money pit and you're like, oh crap. Or the neighborhood starts suddenly plummeting and you're like, oh crap.

Well, yes, you may take some losses.

When you sell the house, but it is not like you are necessarily stuck there forever. You can sell the house. You do have options.

Rarely do you get into a place.

Where you are permanently, you know, that the decision you made is completely unchangeable.

People who are anxious carry every option in a situation all the way out.

To its possible negative conclusion. If I go out, I'm going to catch, you know, I'm going to contact a Covid germ, it's going to make me sick and I'm going to end up in the hospital on a ventilator and die. Okay, you know, that is the most negative possible conclusion. Now what is the likelihood for you, whoever you are, that that will actually happen? If you practice social distancing, if you wear a mask, if you do all.

Those things, and especially if you are.

Relatively healthy and under the age of.

65, what is the likelihood and difficulty handling uncertainty or indecisiveness? When people are anxious, they're already feeling.

A threat, they're already feeling a lack of control.

So when there's even more uncertain, it.

Just adds to their feeling of powerlessness and increases their HPA axis activation.

Generalized anxiety disorder symptoms include fatigue, irritability, muscle tension, aches, trembling, feeling twitchy, being easily startled, trouble sleeping, sweating, nausea, diarrhea, irritable bowel syndrome, or when we're stressed, when our cortisol levels are high, our.

Body is kind of on fast mode. So it's not, it says, you know, now's not the time to rest and digest. Which is why a lot of times when people get really stressed, they end up with diarrhea, for example, because their.

Body'S trying to clear that out so.

It can focus energy on fighting or fleeing.

People also may have headaches, be a lot of times because they're clenching their, clenching their teeth. But stress also increases our blood pressure, which can increase our propensity for, for headaches. Helping people recognize how the HPA axis.

Activation, how Stress how anxiety can cause.

These feelings and why, you know, irritability makes sense. If I feel like there's a threat, then I am on guard, then I am somewhat hyper vigilant, so I'm trying to protect myself. And anything that makes me feel more.

Out of control is going to make me react with more of an a fight or flee response, which looks like irritability.

In kids. They may have difficulty or excessive worry about performing at school or sporting events. They may be worried about being on time or focusing on earthquakes, nuclear war or other catastrophic events if they feel unsafe. Remember, anxiety is a symptom of feeling.

Unsafe, of feeling out of control, of feeling powerless. So what do we want to do? We want to help people feel safe, in control and empowered.

Kids may not be able to put a reason. They may feel anxious but may not understand why.

So they may kind of grasp at straws and say, you know, oh, well, I'm worried about an earthquake.

Or remember, kids have a. Especially young kids have difficulty separating what's.

Really going on right now from what the news is talking about 24 7, 365.

You know, we went through that right.

After 9, 11, as well as Hurricane Katrina where I lived, you know, my son had difficulty understanding, okay, you know, the Twin Towers is not falling down. That's not another set of buildings that's falling down. That's the same set of buildings. He was like 2 at the time. And you know, we ended up just turning off the TV because he just was having difficulty understanding that he was safe.

He also couldn't conceptualize New York from the middle of Florida.

You know, it wasn't downtown that this was happening. You know, it wasn't like this was something that was 30 miles away. You know, this was way far away. And my adult brain knows that, you know, Gainesville, Florida isn't much of a terror. You know, target hotspot. There's ain't much there.

So in my mind, I felt relatively.

Confident that we probably weren't going to have something similar right after the, right after the bombings.

But, you know, he didn't understand all that. He was two for goodness sake. So that is the long version of kids will often try to find a.

Reason to explain their anxiety if they don't, if they can't put their finger on it.

And it's important for us to, you.

Know, maybe dig a little bit and.

Obviously reassure them about whatever their articulating.

Is causing their anxiety, but also talk to them about how they're safe right now and how, you know, Parents or caregivers are going to help them stay safe.

A child or teen with generalized anxiety disorder may also feel overly anxious to fit in.

You know, remember those threats of rejection and isolation cause a lot of anxiety in people. So a child or teen, especially going through that stage Ericksonian development where they're trying to develop their identity, they may feel very anxious to fit in and very fearful of rejection and being a perfectionist, lacking confidence, striving for perf, for.

Approval, and requiring a lot of reassurance about performance. All of those go with those fears.

Of rejection, isolation and fear failure, which are so paramount in that developmental phase of, you know, identity development.

So we want to recognize that a lot of youth spheres are related to their growth and development and they're natural. Most kids are going to go through a little bit of a period where.

They may feel anxious, maybe not to the level of, you know, diagnosability. We need to respect that and not minimize.

So if they are experiencing fears of.

Rejection or they're being a perfectionist, we.

May need to talk to them about what it means to fail and reassure.

Them that we love them for who they are even if they fail, because they are going to fail at some things.

And yes, anxiety can also be caused.

By caregivers anxiety for even in infants.

Who are preverbal, they are very sensitive to our emotions. When we are stressed, they will be.

More colicky, more cranky, more irritable, whatever word you want to use with it.

They will also avert their gaze more.

And they will tend to yawn more. Those are all signs that a child is overstimulated or feeling stressed out, so to speak.

It is important to recognize that as, as Jennifer so rightly points out, that even if something's going on like Covid, that we as adults are stressed out.

About that, we need to model stress management skills and we need to effectively communicate with our, with our children, with our family about what's going on and the facts about it so they aren't wondering, you know, oh, mom's really stressed out. This must mean that, you know, the sky is falling. We want to let them know what's going on. Which does mean we have to practice and model good coping skills.

Physical impacts of anxiety. And we're just going to go through these really quickly so we can get to the interventions. HPA access, overstimulation and excess cortisol.

We already talked about that. That threat response system is turned way up.

Metabolic syndrome. And that is when we tend to start storing more fat around our Bell around our bellies. And that is an interesting side effect of excess cortisol. So people start to develop metabolic syndrome.

Which is also associated with increased risk for diabetes as well as heart disease.

High blood pressure, high blood sugar. When our stress response system is activated.

It'S dumping glucose for that fight or.

Flea, and it's dumping norepinephrine and adrenaline, which increase our blood pressure. When we are stressed out for too long, guess what we end up with.

Persistently high blood pressure and high blood sugar.

GI disturbances and ulcers. We already talked about how the body.

Doesn'T want to focus on digestion right now, wants to focus on fight or flee sleep disturbances.

When you perceive that there's a threat, your body is not going to let you completely relax. Kind of like a soldier in a foxhole. They may doze off here and there.

But they are probably never going to get into a good deep sleep because they're always on alert for when they need to spring into action.

Increased aging. The more anxious we are, the harder we're running that HPA axis, the quicker we wear down or age.

If you want to think of it that way.

Our body think about presidents when they.

Start and when they leave office. Most of them look dramatically different because the stress has taken a toll on them.

Think about a car. If you drive a car really, really hard and you just run the heck out of it, it's probably not going.

To get nearly as much time on.

It as somebody like me who drives.

Maybe 8,000 miles a year.

So, you know, think about your body.

And the effect that it's having, which.

Is another motivating fact for people to use interventions.

Most of us don't want to age any faster. We can recognize that stress is taking time away from us.

Headaches, infertility. When we are stressed, when that HPA axis is activated, our sex hormones, our godadal hormones, our in a different balance because our body is saying, you know what?

Now is not a good time to procreate because there's a threat out there.

Which also causes sexual dysfunction.

Now's not a time to procreate because.

There'S a threat out there. We have a weakened immune system. When we're stressed, our body is devoting.

Energy to fighting or fleeing and it.

Worries about rest and repair when the threat is gone. But if the threat doesn't go away.

The then we start to wear down our immune system.

Fatigue, restlessness. One of my least favorite hair loss.

A lot of people when they undergo.

Extreme stress will start losing hair.

The nice Thing is, when the stress abates a little bit, their hair generally grows back.

And this can be physical stress or emotional stress. And finally autoimmune issues when we are.

Stressed and that cortisol level is high.

They found that it also increases stress, increases inflammation throughout the body.

And that increased inflammation triggers more of an autoimmune response, more of a cytokine storm.

Affective and cognitively. And yes, Jessica, children and teens often do have the same or similar physique.

Physiological impacts of stress because the HPA axis really is dumb or primitive, if you want to say that. And it just responds to kind of in line with the amygdala.

It feels like there's a threat, it's concern that there's a threat, so it.

Is going to turn on. It doesn't have that higher order ability to say, oh, this isn't that big of a threat.

With children and teens, the difference we see is a lot of times they have fewer experiences and less knowledge to compare it to. So there are more things that cause.

Them stress, which means they may tend to have more stress.

They also, especially teens, have lots of.

Things going on with growth spurts and hormone changes which can contribute and exacerbate anxiety and depressive symptoms.

So they are very similar in their reactions. But for children and teens, the exact.

The reactions may be more dramatic, they may be more intense than what you might see in an adult.

Affectively and cognitively, people have difficulty taking perspectives and concentrating and they may become easily confused and have difficulty remembering things.

When they are stressed.

We're fighting or fleeing.

We're not studying for a test right now. What does that mean?

That means to help people who are experiencing a lot of stress, they need.

To write things down.

Make lists for the grocery store, make lists for what you have to do for the day. Write down anything you need to know. If as clinicians we need to write.

Down what people need to do between sessions and give it to them, not.

Assume that they're going to remember what.

We talked about 10 minutes after they walk out of our door.

Cognitively, people may have negative or self defeating self talk.

They may feel very powerless and be repeating mantras of distress intolerance.

They may have marked mood swings which.

We call emotional dysregulation.

When cortisol levels get low, we enter into this phase that I call the flat or the furious.

People are either flat and kind of blah and have difficulty getting going. They're foggy headed and confused.

But when they get stressed they go.

From 0 to 250 in no time flat.

So I call that the flat or.

The furious, which is, you know, the, the mood swings people may experience and.

They find it hard to make decisions.

We already kind of talked about that.

When you're foggy headed, when you are.

Worried about fighting or fleeing, and those higher order cognitive processes are kind of.

Dampene, then yeah, it's harder to think.

It'S harder to make decisions.

Makes sense. When the stress passes, you will be.

Able to do those things again.

But until then, it's important to help.

People make a plan for how they're going to deal with life with the resources that they have right now.

Relational impacts Sometimes people withdraw socially because.

They just can't take anything else.

Other times they may go the opposite.

Way and become excessively clingy. They need constant reassurance, constant reinforcement because they're terrified of rejection or they're terrified of the threat. So they want to cling to somebody that they feel is safe.

There's a reduced support system if they withdraw. But if they are clinging to somebody, that may push those people even further away.

They, the support system may get overwhelmed or exhausted by the person's high levels of anxiety and clinginess.

Since we have difficulty taking perspectives when we're anxious, it makes it more difficult.

For us to be empathetic and responsive to our friends. When we get into those relationships, it tends to be the person with the anxiety tends to be more of the take, take, take because they're needing that reinforcement so much.

Not all the time. And there's often a reduction in leisure activities. When you're stressed out, it's hard to.

Get motivated to do fun things.

So what do we do about it? Now's the fun part. Your body thinks there's a threat. Help it restore itself so it is.

Ready to fight that threat. Like the angry lion that is chasing you, you know, from primitive times.

Which means create a sleep routine. When we have a sleep routine, doing.

Three some, some, three things every night.

That helps trigger our body that hey.

It'S time to start making melatonin and.

Getting ready for bed. That helps our brain and body rebalance.

And restore the HPA axis functioning. When we get our circadian rhythms in whack in rhythm, we are going to be more prepared, more energized to deal with life on life's terms.

Think about dealing with threats like something that drains your battery or when you are taking care of yourself, you are.

Charging your internal battery.

Creating a sleep routine is like planning.

On charging your phone. You figure out what you're when you're going to charge your phone so it's ready the next day when you need to use it.

Creating a sleep routine improves energy level.

Through the removal of adenosine and allowing the body to systemically repair itself.

It is so important that people start.

Trying to get good quality sleep again.

There are lots of videos on the.

All CEU's education channel about create sleep hygiene and things that people need to do to improve their sleep.

Good nutrition is also important and there are more videos that are specifically on nutrition. Nutrition is important because it provides the building blocks for your body to make.

The serotonin and the GABA and the norepinephrine and the dopamine and the endogenous opioids and all those things.

Nutrition provides us the energy to do what we need to do. It provides us those glucose stores to fight or flee. If you don't have glucose stores, you don't have en.

Well, you don't have as much energy. You're reliant on body fat.

And nutrition also, interestingly enough, helps set our circadian rhythms when we are sleeping.

When our circadian rhythms are, you know.

Regulated it they secrete our hunger and.

Satiation hormones at particular times.

So if our circadian rhythms are out of whack, our hunger and satiation hormones are also usually out of whack.

So we tend to be either not hungry or hungry at weird times or all the time.

Encourage people to think about if they need medication. Like I said earlier, only 35 to 40% of people will benefit from benecation. But you know, that is still a little over a third.

So we don't want to rule it out.

SSRIs, SNRIs, SNDRIs are all different types.

Of antidepressants which can be helpful. Buspirone is kind of in its own.

Category and it actually acts on a.

Different serotonin receptor than most of the antidepressants. Buspirone helps people not go from flat to furious. It helps kind of dampen that HPA axis response, the emotional dysregulation. A lot of my clients have reported that it helps them a lot. Some of my clients have reported that when they take it, they just don't care about anything. So it really, you know, clients need to be able to advocate for themselves and talk with their prescribing physician.

Exercising at a low intensity, 40 to 50% of your target heart rate zone.

Which is like an easy walk, has.

Been shown to reduce cortisol. When we work out in our target.

Heart rate Training zones, and we're breathing.

Heavy and everything that actually does increase.

Cortisol, but it also increases serotonin.

So, you know, both of them have their place. But if you've had a really stressful.

Day, one of the best things that.

You can do for yourself is, is.

To spend 30 or 40 minutes, you know, doing an easy walk.

Yoga and mindfulness can help us trigger that rest and digest response because it.

Increases deep breathing, and deep breathing slows our heart rate and triggers relaxation and the secretion of GABA and, you know, all that kind of stuff.

And it tells our body that we're.

Overriding it, that there is no threat right now, that we can relax.

As far as medications for children, that changes with regularity. So that's something that the child would.

Really need to, or the family would really need to discuss with a primary care or physician or a child psychiatrist.

Sunlight is also important. So important right now for so many of our clients.

I have been fussing at all of mine and because literally none of them are getting out enough and getting enough sunlight. So their circadian rhythms are all out of whack. Their vitamin D levels are low. We know that low levels of vitamin D contribute to the development of seasonal affective disorder, which is has symptoms of depression.

Vitamin D prompts the skin to tell the brain to produce neurotransmitters. When we get enough sunlight, our brain is saying, hey, it's time to wake up. Let's, you know, secrete some of those.

Get up and go and the dopamine to keep us going through the day.

Sunlight sets circadian rhythms, which impacts the release of serotonin, melatonin, and gaba. Sunlight's important. You know, it doesn't mean we have.

To get a ton of it.

They say 15 minutes a day is plenty to help set our circadian rhythms.

But we need to get out and let our brain know that, hey, it's morning, it's time to be awake, and then at night, we need to avoid those bright, harsh blue lights.

Mindfulness and acceptance. Encourage people to identify what a rich.

And meaningful life looks like to them right now.

Not six months from now, not three years from now.

What needs to happen right now so they can enjoy a rich and meaningful life.

And, you know, some things are out.

Of their control, but what can they nurture in order to, you know, have a. A good life right now?

Encourage people to practice observation, acceptance, labeling and letting go. Observing how they feel, accepting without judgment, how they feel.

I'm angry, I'm happy, I'm Feel guilty, whatever.

Okay, it is what it is. Label how you feel and then let it go. Say, okay, it is what it is.

Now what can I do to improve the next moment?

Have people identify trigger thoughts that are contributing to their anxiety.

When they start feeling anxious, have them.

Think backwards and think, what am I.

Telling myself right now? And is it accurate?

Have people differentiate between expectations and the current reality. You know, if I'm getting ready to go make a certain speech in front.

Of 500 people, you know, if I have the expectation that I'm going to flub and I'm going to drop my notes or whatever, then that may cause me a lot of anxiety.

What's the reality? I don't know what I'm going to.

Do five minutes from now.

So encourage people to look between expectations.

And differentiate between what they're assuming is going to happen and what they know is happening.

Distress tolerance is not always about controlling your anxiety. What we want people to do is distract, not react.

We don't want them to impulsively react to what's going on. We want them to be able to get in their wise mind and think, what is the best choice for me right now based on what I want in life? You know, if I have a puppy right now who has no manners at.

All and we're working on it, and when she, you know, gets excited, she can be somewhat overwhelming. And my first response, you know, I just want to pin her to the.

Ground and be like, or put her out in the garage and that's not going to be helpful. That's a reaction and that takes care.

Of the problem in the immediate right now.

But it doesn't do anything to fix.

The long term problem. Encourage people to practice riding the wave, you know, recognizing that urges and fears come in and they recede as long.

As we're not feeding them.

If you're continuing to sit there and think about it, then you're going to feel more distress. So encourage them to just accept that. All right, I feel this way.

It sucks, but I know in 10 or 15 minutes that I won't feel as stressed if I do something else, if I don't sit here and dwell on it.

Have people use distancing techniques, saying things like, I'm having the thought that if.

I go into public I am going to get sick and die, as opposed to, if I go into public I'm going to get sick and die.

Because we can look at thoughts and.

Determine whether they are accurate or not.

Have people just take a mental vacation if they're stressed out, you know, have them go to a party place that.

Makes them feel calm and happy.

Encourage them to identify five things that.

They see, four things that they hear.

Three things that they smell. Encourage them to really use their senses.

To make it dimensional so they're there and they can start relaxing for a moment. Because then when they come back from that little vacation, their HPA axis is probably going to be dampened a little bit and they can get into their wise mind.

Teach thought stopping and how to use guided imagery. Encourage them to use imagery that helps them see succeeding, helps them becoming safe.

Helps them feel empowered. Depending on the situation, this imagery will be a little bit different.

But remember, addressing anxiety means helping people.

Feel safe and empowered.

Remember the basic fears we talked about last week? We'll go through them really quickly. People feel fear, failure. Have them explore the dialectics.

What happens if you do fail? What's the good and the bad that can happen when you fail?

Encourage them, help them recognize that failure is a part of life. Encourage them to recognize themselves as lovable human beings and separate from what they do.

I may fail at something, but I am not a failure.

Rejection and isolation. Encourage them to depersonalize things. You know, maybe Sally was in a poochie mood today because she didn't sleep well. Maybe it had nothing to do with you. Encourage them to identify three reasons why.

Besides them that whatever happened, happened.

You know, depersonalize it.

What are some other reasons this might have happened that didn't have to do with me?

And again, explore the dialectics.

What is the good and the bad that's going on right now?

Loss of control and the unknown. Have people focus on one thing in the moment. With COVID there's a lot of things.

That are out of control. The news is changing constantly.

So we need to recognize what, what is different and, and we need to focus on what's going on right now.

What is the news? What is the information we have right now? What can we control right now? Next week there may be more things we can control. But what can I control right now?

And have them identify prior experiences where.

They felt out of control and survived.

Have them practice relaxation skills including diaphragmatic breathing, which is breathing in for four.

Holding for four, exhaling for four.

Exploring different types of medica meditation.

There are, you know, dozens of different types of meditation that people can use, including but not limited to cued progressive muscular relaxation.

Have people work on their self esteem if their anxiety is related to things.

Like rejection or isolation.

Explore their real versus ideal.

Deal Self.

Encourage them to notice how they talk to themselves and develop compassionate self talk.

Including not allowing themselves to be self rejecting. When they say something hateful to themselves.

They need to apologize and and say something different.

They need to work on silencing that inner critic, remembering, you know, or asking.

Themselves, would I say this to something.

Else, to somebody else? Would I say what I'm saying to myself, to my best friend? Most of the time it's like, no.

That would be rude. Well then why the heck are you saying it to yourself? Have them spotlight their strengths and accept their imperfections. Have them address cognitive distortions like all or nothing thinking. Reframe challenges in terms of current strengths. You know, this lockdown, isolation, quarantine was a challenge. So how is it building on my current strengths?

How is it making me stronger? What tools do I have that can help me get through it? Instead of looking at past weaknesses, create.

An attitude of gratitude and optimism, focusing.

On what I do have in the moment instead of what I don't have yet or what I've lost.

What do I still have?

What do I have that I am grateful for?

Have them identify what is truly important.

To them right now and thoughts and.

Behaviors that can help them move closer.

To those things and realize those things that are truly important to them right now, like family, good health, you know, happiness.

There is always going to be stuff.

That we can do.

There's always going to be stuff in our inbox. Sometimes a break is what we need.

To get a breakthrough.

Take that time. Just like when you have something on the tip of your tongue and you're.

Trying to think of it and you can't think of the word and you.

Just step away from it, start thinking about something else, then all of a.

Sudden the word appears.

Same sort of thing with cognitive thinking. Sometimes when we think too hard and.

We can't come up with the answer, we get frustrated.

That frustration is that HPA axis ramping up, which means our concentration is going.

To start to, you know, dwiddle away.

And it's going to be more difficult.

For us to get to the breakthrough.

So we need to allow ourselves to get to a point place, take a.

Break so we can get into our wise mind. Dampen down that HPA axis for us to be able to engage more of that higher order thinking and get that breakthrough.

Have people make a list of fun things to do opposite emotions. You can be anxious and have fun at the same time. If you're anxious about, you know, test.

Results that are coming in, you can.

Be anxious about that and and still.

Do do things over the week while you're waiting that are enjoyable.

Have people add triggers for relaxation, sights, sounds and smells that can help them remember to relax, that can make them happy and have them eliminate stress triggers.

Sights and sounds specifically like, you know, noise. Maybe they get a white noise maker or sites like watching the news constantly or something that they're going to see that's going to stress them out.

Have them try to create at least a place in their environment that is.

Promoting of relaxation and does not contain stress triggers.

Relationally, have people improve their relationship with their self, identify their needs and wants, be their own best friend and work on providing internal validation, telling themselves that they are good enough and be compassionate with themselves, recognizing that they don't have to be perfect. Also have them develop healthy, supportive relationships.

That include good boundaries and assertiveness skills.

Have them identify or describe the ideal healthy, supportive relationship and encourage them to separate the ideals from the reals. Sometimes we want this ideal relationship that.

Is just way too Disney. So help people get more realistic in.

Their expectations and then identify who that is that they currently know or where.

They might find somebody who meets that.

Anxiety is a natural emotion that serves a survival function. Excess anxiety can develop from lack of sleep, nutritional problems, neurochemical imbalances, poor coping skills, cognitive distortions, or even low self esteem. Recovery involves reducing physical and psychological vulnerabilities.

Through improving health behaviors, identifying and building.

On current coping strategies, addressing cognitive distortions, and developing a healthy, supportive relationship with yourself as well as others. And a question comes in about clients who don't feel like they had anxiety before they had a panic attack and.

Now they have more panic.

And when we look at panic disorder, this is really very common because having a panic attack, people feel so completely out of control. And if the panic attack feels like.

It, quote, came from out of nowhere, then they may feel like they don't know when to expect it again, which.

Makes them more hypervigilant. I know when I was pregnant with.

My daughter, well actually also my son, I had a heart condition called supraventricular tachycardia.

And one of the symptoms of it was when I would sit still for a long period of time, the blood.

Would pool in my feet and all.

Of a sudden my heart would start to race to try to get the.

Blood back up and I would get tunnel vision, things would go black and.

Spidery and it was really freaking scary. But that made me more anxious until.

I realized what it was and until I knew how to address made me.

More anxious because it would the first.

One hit when I was in the car one time and the next one hit when I was in the office.

And, and I didn't know what was causing it. So I was always worried that I.

Was going to have another one, which.

Caused me to start being more anxious.

And to start over.

Generalizing so in a way, your, your patient may be right. I wouldn't say it rewired his brain necessarily.

I would say it altered the neurotransmitter levels because he has this right now, he may have this persistent underlying level of anxiety that he's going to have another panic attack.

So, you know, that's, that's where I.

Would kind of look at it.

Rewiring sounds very permanent. Neurotransmitter imbalances sound a little less permanent.

They sound more fixable.

So I would encourage him to look.

At, you know, leading up to what types of self talk may be prompting his anxiety right now and how might those be related to the uncontrollability and to the lack of safety that he felt during that initial panic attack?

Between writing notes, filing insurance claims, and scheduling with clients, it can be hard to stay organized. That's why I recommend Therapy Notes.

Their easy to use platform lets you.

Manage your practice securely and efficiently. Visit therapynotes.com to get two free months of Therapy Notes by just using the promo code CEU when you sign up for a free trial at therapynotes.com.

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