PACER Method & Trauma Informed Transdiagnostic Assessment | Continuing Education

Foreign. Welcome everybody, to today's presentation on the overview of the PACER method and transdiagnostic assessment. I'm your host, Dr. Donnelly Snipes. Now, transdiagnostic assessment sounds really complicated, but what it means is that there are a lot of different reasons you can have a particular symptom. And it's important not to just assume, for example, that because someone feels dull, depressed, that it's an emotional issue. So in this video, we're going to briefly define the PACER model and discuss why we really needed a new approach to treatment of behavioral health issues. We'll explore briefly how the PACER dimensions interact and examine the transdiagnostic assessment process. Now, in this series, there are going to be additional videos over the next 37 weeks. I believe that is, are going to go into depth on a lot of these issues. So I'm not going to go into an into depth on a lot of them. What I really want you to do today is help you understand the concept of the PACER method and why it's so important in order to help a whole lot more people achieve a state of what we will call mental health. 10% of Americans are on antidepressants for anxiety or depressive issues. Now think about that. That's 1 in 10. Put out your hands, you know, one of those fingers. Think about your family. One of those, one out of every 10 of those people may be on antidepressants. When you go to work, look around, one out of every ten of those people may be on antidepressants. And that number is actually climbing significantly over the past couple of years. Unfortunately, without medication, 20 to 40% of people with clinical depression noticed symptom improvement in six to eight weeks. So some people, their depression may have been caused by a situation like a divorce or a death or a move, or it may have been caused by something like the flu, for example, that just completely sapped their energy and made them feel kind of hopeless and helpless because it seemed like they just couldn't get their feet back under them with antidepressants. So of those people who do take antidepressants, 40 to 60% of people with clinical depression noticed symptom improvement in six to eight weeks. Okay, well, that's good. However, 40 to 60% of people, that is, you know, right around that halfway mark, which means as many as 60% of people are still struggling with significant symptoms after six to eight weeks. And those 40 to 60% of people were not saying that they were recovered. They noticed symptom improvement. They still weren't. A lot of them still weren't there where they wanted to be in order to feel happy and healthy and energized again. So it's important. And one of the things we'll talk about in future videos is the fact that in this case, depression can be caused by a variety of different neurotransmitter imbalances. And most antidepressants increase serotonin levels. But if serotonin isn't the thing that's out of balance for you, then guess what? An SSRI or a typical antidepressant probably isn't going to be super effective. You may need something that increases norepinephrine more or dopamine more. But we'll get into that in future videos. Another thing to point out is that research has shown that there is no high or moderate strength evidence for any intervention to effectively treat any phase of any type of bipolar disorder. Wow, that is startling. And the PACER method is not going to quote cure bipolar disorder or anything else for that matter. But we will talk over the next several months about how stress, physical stress, emotional stress, can exacerbate or make worse bipolar disorder and why it important to take a multi dimensional approach to treatment. So why a new approach? Well, research has shown that cognitive behavioral therapy appears to be effective in approximately 40, 47% of cases. Results are relatively mixed about whether cognitive behavioral therapy plus antidepressants can augment the treatment response. And remember, antidepressants, as I said, if you're on the right one and it is targeting the neurotransmitter that is deficient for you, then that might help. However, there are a lot of other factors to consider and therefore a lot of conclusions can't be effectively drawn from that. Cognitive behavioral interventions for depression and anxiety prevention showed a small effect for prevention of depression, but not anxiety, and no effect at 3 to 6 months and 12 month followup. So when the person's in therapy for CBT or with CBT, it is effective, it's helpful for them. But as soon as they quit therapy, you know, in short order, three to six months, their thinking has returned, their behaviors have returned, their problems have returned, and obviously at 12 months it hasn't gotten any better. So we need to look at why is that. And one of the reasons, in my humble opinion, is that a lot of times we don't address all of the issues and we don't teach people how to generalize. What is the skills that we're teaching them, like cognitive restructuring. If somebody comes to You. And they're sitting in a therapy session and they're talking about this always happens to me. And the therapist corrects them and says, okay, let's look at that extreme word always. Let's evaluate the evidence for and against that belief. Well, that's great. But if the person relies on the therapist to constantly point out cognitive distortions and tell them what tools to use, then they are not going to develop as effectively, if at all, the ability to use them on their own. There could be a lot of other reasons for relapse, but I think that is one area that we could do better client outcomes. So how a person does whether they achieve symptom, remission, or improvement is often determined by variables within the person, such as the chronicity and severity of their problem. And I call this the pacer ripple. And remember, pacer is what we're going to define in a minute, but basically it stands for physical, affective or emotional, cognitive, environmental, and relational. So when somebody has a chronic problem, it tends to erode their health and wellness in all of these other areas. So the longer they've had it, and the more chronically they've had it, and the more intensely they've had it, the more it's probably negatively impacting all of these other areas. It's important to look at that somebody who has had mild depression for two months is going to probably have a much different treatment trajectory and maybe even different treatment goals than someone who has had major depression on and off for the last three years. The complexity of symptoms also impacts what's going on. If you're dealing with somebody who has simple depression, which in my experience really rarely exists, but simple depression that is going to be treated very, in a very straightforward manner a lot of times. But unfortunately, a lot of times depression is actually a symptom of other things or a consequence of other things like chronic pain or sleep apnea or trauma. Trauma. And the more issues the person has, the more complex their case, because each of those issues interacts with every other one. So the more complex the case, the more difficult sometimes identifying an effective treatment plan can be. And the longer, let's face it, the longer the treatment probably will be. You're not going to take somebody who's been struggling with trauma and depression and abandonment anxiety for 20 years, work with them for eight weeks, and have them walk out the door and never come back, at least not happy. However, somebody who has what we call adjustment disorder or situational depression, they may be able to achieve significant relief within eight to 10 weeks if they don't have a whole lot of other underlying issues. Another issue that affects the outcome is the person's acceptance of responsibility for change. And that. I don't like the way that sounds, but what we're really looking at is their belief that they have the ability to actually make a difference, that they can actually do something to improve the situation and they're willing to do it. So they need to accept that the therapist can't fix them. The therapist can give them tools that they can use to fix themselves. The, the doctor generally can't fix mental health issues. They can prescribe medication, but a lot of times that's not going to do the whole job. So it's incumbent upon the person to accept responsibility to do their part to change. And their motivation level, if somebody's been in treatment before and it hasn't worked, then motivation may be pretty low. Or if they've never been in treatment and they don't think it's going to work, or they already feel helpless and hopeless and exhausted, then maintaining the motivation to do what is necessary to change is going to be a lot harder. So it's important for the therapist to work with the person to identify and increase and maintain motivation for the treatment process. Other things, it's not just the person in treatment that affects the outcomes. It's important that the therapist does their job. And that may look different for different therapists, but it is important, regardless of your approach, to effectively differentially diagnose what's going on. I've had people present with symptoms of, quote, depression before. And yeah, they had all of the criteria for depression in the Diagnostic and Statistical Manual, and they did have some low energy and sense of hopelessness and helplessness and frustration. Okay, yes, they did. But underlying all that, I had one patient who was critically anemic. I had another patient whose thyroid was really, really low. And anemia and hypothyroid can both significantly contribute to or cause depressive symptoms. No amount of talk therapy was going to increase the, the iron levels or increase the thyroid levels of these two patients. So it's important that we do an effective differential diagnosis. It's also important that we use appropriate treatment interventions and referrals. And when I start talking about trauma informed, I'm going to talk a little bit more about what that looks like. But just assuming that it is cognitive or interpersonal, and that is the extent of the problem is foolhardy. 90% of the time or more, there's going to be some components of their relationships, some components of their Physical health, their, maybe their nutrition, their sleep. So it's important that we really look at the person holistically. Counseled patients are significantly more likely to have recovered than non counseled patients. Well, okay, that makes sense. There are nearly always affective or emotional, cognitive or thought processes, and relational or relationship consequences to any physical and mental health issues, especially if they're ongoing. If they're lasting a day or two or a week, okay, maybe very little impairment. But if they are chronic or ongoing, then they often have significant impacts on all of the areas, all of the pacer areas of a person's life. Counseling itself helps people understand the physical, affective, cognitive, environmental and relationship consequences and causes of their problems. So they can start understanding how all of these things work together and in many cases start recognizing that it's not, quote, just all in their head and start getting curious and empowered to try something new instead of trying to do the same old, same old, which may not have worked for them in the, in the past. Counseling also helps people understand the interaction between behaviors, thoughts, feelings, and their environment. We'll talk about that actually next week. It helps people understand how to increase and maintain their motivation, effective strategies to address their problems. Remember I just said a person with depression, there are a lot of cognitive, behavioral and counseling type tools we can use to help them. But if they are nutritionally deficient, if they are have hypothyroid, if their sex hormones are low, if their iron levels are low, no amount of talk therapy is going to address those things. It is incumbent upon the therapist to say, you know what, let's make sure that we're addressing everything that's going on when it comes to physical stuff. Obviously we're not prescribers, we're not physicians, we're not, we refer out. But it is important, in my estimation, vital to make sure that the person assesses any physiological causes of their current s situation and problems. And counseling also helps people understand how to set and achieve effective goals. A lot of people, even a lot of counselors, really are not effective at setting realistic, achievable, time limited goals. And when we set goals and we fail to achieve them, then we start feeling defeated and hopeless and helpless. When we set goals and achieve them, then we feel empowered. So counseling really helps walk people through the process and assist them in achieving success. So let's talk really quickly about some, some examples of what may be going on and how this interaction works for somebody with chronic pain. And I know we started out by talking about counseling, but as a clinician, many Times I've had people come see me who are experiencing chronic pain. Physical. Let's look at the causes of chronic pain. Physical causes could be birth defects like scoliosis or ergonomic issues, or repetitive stress injuries, or, you know, the list goes on. There's a lot of physical causes of chronic pain. Physical consequences of chronic pain can include lack of sleep, you can't get comfortable, you can't go to sleep. It can include addictive behaviors, trying to numb it with overuse or misuse of prescription medication or alcohol or something else. It can impact your nutrition when you're under stress, when you're in pain, you're under stress. When you're under stress, the composition of your gut microbiome actually changes and it manufactures, if you will, different neurotransmitters and activates different systems than would be activated if you weren't under stress. So there are a lot of consequences of chronic pain. When all this is going on, a lot of times people start feeling fatigued and they have difficulty doing the things that they need to do as well as the things that they want to do when, which can contribute to them feeling hopeless and helpless, affectively, cognitively pessimistic, et cetera. Now, chronic pain, physical consequences, that kind of makes sense affectively. When people experience chronic pain, they often not only may struggle with issues like depression, they also may struggle with anxiety about whether it's getting worse, about whether people are going to reject them because they can't do the things they used to do, anger at the situation, grief at not being able to do the things that they had wanted to do. You know, loss of dreams, anger, anxiety, grief, jealousy, resentment, guilt. You know, there are a lot of emotions that can it come out when somebody is struggling with chronic pain. And I want you to think about a time that you were experiencing pain for an ongoing period of time, whether it was because you threw your back out or you had, you know, an in depth surgery that required a long recovery time. Cognitively, when we are stressed, when we are in pain, we are in fight orf flight mode. When you're in fight or flight mode, when that HPA axis or that stress response system is kicked off, it's more difficult to focus because your body is focused on fight or flee, not thinking about paying the bills or the spreadsheet or even focusing on what's on tv. So it's more difficult to concentrate when you're in chronic pain. It is more difficult to remember things when you're in chronic pain. And a lot of times your Attitude may become more pessimistic or more negative when you're in chronic pain. Environmentally, when you're in chronic pain, it may be more difficult to keep the environment clean and tidy. And when people are in a chaotic environment, it often contributes to feelings of distress and anxiety. When you're in chronic pain, you may have difficulty making it to work. So things like your basic needs, housing, security, safety may also be at risk. And relationally, it's often difficult for people who don't have chronic pain to truly empathize with those who do experience chronic pain. So it can put strain on relationships. So these are things that a therapist would assess and address using the PACER method. We would really look past just frustration over the chronic pain and we would want to look at in what ways is this chronic pain impacting all of the areas of your life. Likewise, educating people about how these other areas may increase their pain. When you are experiencing ongoing distress, it actually reduces your pain threshold. When you are expecting to be in pain, it generally plays out that way. When you're in an environment that is stressful, it reduces your pain tolerance. It can increase muscle tension, which increases pain. When you're in relationships that are not supportive, you may feel stressed about abandonment. When you're in relationships that are are conflictual, it can actually increase your stress level, increase that HPA axis activation and consequently increase your pain. So there are a lot of parts of you that, as they go wonky, can actually worsen the physiological causes of chronic pain. Same sort of thing with anxiety. We think of anxiety as an emotional issue, but physically when we're anxious, we tend to not sleep as well. Our GI system, our stomach and our intestines tend to get quote upset. We have more difficulty digesting food, we may lose our appetite, we may crave high carbohydrate, high fat, low nutrient foods. I think I already said sleep energy probably goes down because when we're anxious, we keep our muscles tensed, we're not sleeping well, which both of those things drain energy. And until we're able to help re the person reset their HPA axis then and and get them out of fight or flight mode, then there's going to be a lot of drain on the particular system. Affectively, when people are anxious, it can also increase their irritability, their anger and over a long course depression. When you feel anxious and stressed and worried for long enough, at a certain point you get exhausted and may start feeling hopeless and helpless. Cognitively, we tend to pay attention to the things are in our environment and the thoughts that we have that are congruent with our feelings. So if we are feeling anxious, we tend to pay attention to threats. And when we pay attention to threats, it makes us feel like think generally falsely that the world is a much more negative and dangerous place. Environmentally. When we're anxious, it's really hard to feel safe. And that can contribute to a lot of distress and a lot of excess burned up energy. And relationally, when we're anxious and depending on what you're anxious about, it will affect relationships in different ways, but it can cause problems in relationships with people who don't understand where the anxiety is coming from. Or it can cause problems in relationships if the person who is anxious either is clingy or avoidant of others because they're afraid, they're anxious about abandonment or rejection. So anxiety can impact all of those areas and dysfunctional relationships. If you get into a relationship with somebody who has their own stuff that's not well managed, that can increase anxiety. For example, being in environments that are not your preferred environments, that can increase anxiety. For example, if you're an introvert, being in a really crowded environment like a concert or a mall on Saturday can be really stressful for you and increase your anxiety. So my point is it's important to recognize how the problem impacts area, every other, every area of life, and how every area of life can impact the problem. So let's talk about the current approaches and what's good and what's not so good. The humanistic approach, which is what most clinicians are trained in when they are in college. The types include person centered therapy, which is, you know, your standby existential gestalt, logotherapy and narrative therapy. All of these fall under the umbrella of humanistic approaches. The benefits of humanistic approaches is that they're great for developing a secure attachment. The person learns how to have a healthy relationship, becomes mindfully aware of their feelings and starts gaining a sense of meaning in life. So all of those things are wonderful. And I think all of these things are important in a therapeutic environment, in a therapeutic relationship. I'm not dissing humanistic, however, I'm saying by itself, oftentimes it doesn't do everything that's needed. Techniques in humanistic therapy, the person explores things that bring meaning to their life. They explore how people, how they interpret their experiences in the present. And they explore how they are different from their problems. They have depression, they are not depression, they have relationship difficulties, they are not relationship difficulties. So all of the these things are great and it's A wonderful launch pad. And it is so essential to in trauma informed counseling to make sure that the person feels safe in the relationship with the therapist and in the environment. So humanistic therapy or person centered approaches are super helpful for laying that foundation, laying that groundwork. Cognitive behavioral therapy is much more directive. Types of cognitive behavioral therapy include rational emotive behavior therapy or rebt, Cognitive behavioral therapy or cbt, Acceptance and commitment therapy or act, and dialectical behavior therapy or dbt. So some of these CBT and REBT were your first wave cognitive behavioral therapy approaches. And ACT and DBT and some others have sort of recently come on in new wave approaches where humanistic approaches focus on creating meaning, understanding feelings, and seeing self as separate from problems. Cognitive behavioral therapy, the way I view it, focuses on taking people to the next step, helping them recognize the connection between their thoughts, feelings and behaviors, identifying and restructuring thoughts that contribute to their distress. So techniques generally can kind of be summed up in restructuring cognitive distortions, understanding the connection between their thoughts, their cognitions, their behaviors, or their reactions and their feelings. So when I have a stressful thought, how does it make me feel? And what are my urges or the behaviors that I use? And relaxationing or strengthening vagal tone. And we're going to talk a lot about the vagus nerve over the next few weeks. But cognitive behavioral therapy, especially the newer wave cognitive behavioral therapies, recognize the importance of getting out of fight or flight and into what Linehan and DBT called the wise mind, or getting into that executive functioning area of our brain instead of emotional reasoning. But that still doesn't do everything. And cognitive behavioral therapy in the research has been the gold standard, if you will, for the majority of mental health issues for the past 50 years or so. But as I mentioned, it's helpful, but it's often not enduring. So what else do we need? Well, behavior therapy is another approach, and behavior modification is the technique, if you will. Humanistic approaches focus on those feelings and relationships. CBT cognitive behavioral therapy focuses on thoughts and schema. Behavior modification shines in its focus on understanding the triggers for behaviors and increasing and maintaining motivation to make that change. And in traditional behavioral interventions, the focus is exclusively on observable things, observable triggers, observable reinforcers. In using it in clinical practice, a lot of times we talk some about motivation and things that are more feeling focused. That's, that's not truly sticking with the behavior modification or, or behavioral therapy theory, but, you know, it is what it is. Techniques that are used trigger awareness and identification and behavior Modification. We call these, quote, discriminative stimuli. And those are things in the environment that trigger a behavior, that trigger a reaction. Reinforcers and punishment. Becoming aware of what reinforces or increases the likelihood of behaviors and what punishes or decreases the likelihood of behaviors, and modifying those in order to maintain motivation and prompt you to do certain behaviors. And then chaining. Chaining looks at behaviors in terms of an ongoing sequence of events. The way, the way somebody ends up behaving is not always directly related to something that just happened. It may have been a buildup of things. So chaining can be backwards, where after an event you look back and said, what led up to this? Or forwards, in which you say, okay, I'm here and I want to get to here. So what needs to happen? What do I need to do? And finally, trauma informed Trauma informed counseling is not an approach per se, but sort of an overlay, if you will. In each of the aforementioned approaches. Trauma informed care recognizes the symptoms and impact of trauma and helps the person create a greater sense of safety and empowerment. Many people, most people that are presenting with mental health issues have experienced trauma, either trauma that caused the mental health issue or trauma as a result of the mental health issue. And we need to recognize all of the different ways that trauma has impacted that person's life, leading them to feel unsafe and disempowered. So trauma informed care recognizes the many different types of trauma and their impacts on the individual as well as their family or social support system, and seeks to actively resist retraumatizing people and responding by ensuring the person feels empowered, safe and secure in the therapeutic relationship and in life. You know, we're going to have people explore things in the therapeutic relationship in session, if you will. And we want to make sure we don't say, okay, here's this technique. Run wild with it. If there's a chance that they are going to get into a situation where they feel unsafe and disempowered. We want to make sure that we don't throw them into the deep end, as my boss used to say. So the PACER method uses a trauma informed trans diagnostic and trans theoretical approach to recovery to assist people in optimizing their quality of life. So basically, we recognize that people can have all of the symptoms of depression, but all of those symptoms can be also caused by a variety of other things, from autoimmune issues to nutritional deficiencies, to hormone imbalances, etc. So we need to rule out all of the other issues or rule them in and address them and Then trans theoretical means there's many ways to address this same symptom. And not everybody is willing to use the same technique to address a particular symptom. So we need to empower the person to identify what works for them and what are they willing to do. Interventions as well as problems are available or present in all of the PACER dimensions. Physical, affective, cognitive, environmental and relationships. And the PACER method is consistently looking at the bi or multi directional interactions. So when you do X, how does it affect all of the different dimensions of your life? And as those things are affected, let's say improved, how does it improve? How do they improve each other? And how does it improve your presenting issue? And we end up seeing a reciprocal interaction. When one thing starts improving, it often has imp. It improves every other area of life a little bit. It the goals of the PACE PACER method include developing a secure attachment and a safe place for the person to explore feelings, thoughts and behaviors. And I emphasized safety. And what is safe for a particular person depends on them and their history and their experiences. So just because we feel like we're safe, we feel like the setting is safe, doesn't mean the person that we're working with does. So it's important to have an open conversation with them about what helps them feel safe and empowered and accepted. We want to empower them to define their rich and meaningful life and use their energy to move toward that. So a lot of times in session with clients who are struggling with anger, for example, we talk about what's triggering their anger and how that's a response or a reaction to a potential threat and what are the options to address that anger, to use their energy to move toward their rich and meaningful life instead of just burning it up, stewing over something that maybe they can't change. We educate the person about PACER issues which create or maintain imbalances in the nervous system and cause unnecessary distress, and explore and build off techniques, tools and triggers that have helped the person in the past. Don't start from where you want to start. Start with their strengths. Start with what works for them. So physical assessment. We want to rule out or rule in physical causes of mental illness. And that starts by ruling out organic dysfunction in the system. There are over 30 hormones and the body must construct there are over 30 hormones the body must construct to regulate the over 100 neurotransmitters. I know you thought there were only six. There's over a hundred neurotransmitters that regulate attention, memory, sleep, feeding heart rate, respiration energy, motivation, mood, pain, and more. If the body cannot make or balance the neurotransmitters due to health or behavioral issues, then those issues have to be addressed. So if the person is not eating healthfully, if the person is not giving their body the building blocks it needs to make the neurotransmitters, that's going to have to be addressed because you can't get blood out of a turnip. You can't make neurotransmitters if the building blocks aren't there. Up to 95% of some neurotransmitters and hormones are actually made in the gut. And I will talk a lot about the gut microbiome. Some people refer to the gut as the second brain. Yeah, it's that important. The gut microbes, or the bacteria in the gut that break down your food and make these neurotransmitters and hormones, they require vitamins, minerals, and amino acids in order to do their job, and they get that from the food you eat. The products that are produced from the food you eat vary depending on your stress level. So if you're distressed, then the stress team gets called in and they recruit and, and make the neurotransmitters necessary for fight or flee. If you're relaxed, then the relaxation crew gets called in and they do what they do best and they help you make those neurotransmitters in that balance. Now, in all this, the vagus nerve connects the gut to the brain and helps regulate the stress response. So think of the vagus nerve kind of like the floor manager that lets the, the brain know what's going on on the floor. If there's something amiss down there, and takes messages from the CEO from the brain to the floor and tells the floor what they need to produce. If the body can't produce or effectively regulate hormones and neurotransmitters, people are going to have symptoms I mentioned earlier. Serotonin, for example, controls heart rate, it controls mood, it controls pain, perception, it controls a lot of things, attention. When people's HPA axis or their stress response system is out of whack or dysfunctional, as we say, and they're exposed to stress, it intensifies this problem, which can make them more at risk for developing addictions. At a certain point, they're going to want to give the workers a day off, they're going to want to take a break, they're going to want to get some relief. And that's where the risk of addiction may come in. Some hormones and Neurotransmitters increase the levels of certain hormones and neurotransmitters while simultaneously decreasing levels of others. Under stress, cortisol increases norepinephrine, adrenaline, glutamate, estrogen and ghrelin and inhibits the availability of serotonin to certain receptors and the creation of T3. During relaxation, DHEA, GABA and serotonin levels often increase which help reduce cortisol and norepinephrine, adrenaline, glutamate, estrogen and ghrelin. So you see as some things go up, other things go down and then when the situation flips, so when you go from stress to relaxation, then the balance goes back the other way, kind of like a teeter totter. We want to do a physical assessment that looks at a lot of different things. Sleep. If people are not adults are not getting seven to nine hours of quality sleep, that is going to impact their mental health as well as their ability to think clearly, solve problems, etc. Nutrition. If they're not getting the building blocks they need, they can't keep the body factory running effectively. And people can monitor their nutrition through phone apps that where they keep a daily diary or a daily log of what they eat and they can go to their doctor and get a blood test that can assess for things like thyroid, vitamin D etc. Weight is another issue that we want to look at. Now you know there are people of varying weights. I'm not saying you need to be a certain weight, but we do know that as adipose tissue or fat fat increases, estrogen tends to go up and inflammation tends to go up. As inflammation goes up, depression tends to go up. So that's important to look at. On the other end of the spectrum, anorexia. Whether it is anorexia, the eating disorder, or just not having an appetite, not wanting to eat because of stress or grief, if the person has dropped a bunch of weight, it can be an indication that they're not getting enough nutrients. And a multivitamin does not substitute for healthy nutrition. Bariatric surgery can also cause mental health issues because the gut microbiome is sometimes altered and then the way the food bypasses can also prevent absorption of a lot of different nutrients. So if people are not following their bariatric regiment to the letter, then they may be experiencing nutritional problems as well as increased inflammation, stress, etc. Pain. We already talked about pain and how it can impact sleep and nutrition and just general muscle tension, exercise or sedentariness. Well, they say sitting is the new smoking. Well, okay, whatever. Exercise means moving the body. It doesn't necessarily mean having to get your heart all the way up into target heart rate training zone. But we do need to see how much movement a person is doing because lack of movement may be an in indication of depression. It also may be may contribute to low levels of oxygenation, which can contribute to brain fog and fatigue. Energy levels just people's general energy. If they have low energy, there can be a variety of causes for that, including thyroid imbalances, poor sleep, low oxygenation. So we want to be curious, be detectives and figure out what is causing this instead of assuming, oh, you've got depression. So energy. As your depression gets better, your energy will improve. That may not happen. Libido and sex hormones when you're stressed or when you're depressed, the body says, hey, probably not the time to procreate right now. Not a good situation out there. So if people's libido and sex hormones are low, it could indicate depression or anxiety. Additionally, sex hormones, your gonadal hormones like estrogen and testosterone and impact the availability of neurotransmitters like serotonin and norepinephrine. So if sex hormones are low as they are want to do as we get older, by nature, people may start experiencing mood symptoms because their neurotransmitter levels also go down. Blood sugar levels or hypoglycemia can also contribute to especially feelings of anxiety and agitation. When your blood sugar gets low, it trips the stress response system or the HPA axis in order to release blood glucose into the system. So a lot of people feel anxious or shaky when their blood sugar gets low. Traumatic brain injury can have a variety of different impacts on the individual depending on what parts of the brain were injured. But it's important to identify that and factor that into the treatment plan. Hyper vigilance. If people are have an excessive startle response or they are constantly scanning because they don't feel safe, that is freaking exhausting. And it keeps that HPA axis engaged a lot of the time, which drains energy and it throws the system out of whack because like at a factory, the workers really need to take a break. They want to go home for a little while. And when you're hyper vigilant, you're not letting the workers go home and get a break. Autoimmune issues and inflammation, including rheumatoid arthritis, irritable bowel syndrome, diabetes, type 1 psoriasis, Crohn's disease, the list goes on. As immunity autoimmune issues go up, as inflammation goes up, depression and anxiety Often go up as well. Some of it may be biochemical, some of it may also surround the pacer. Consequences of that autoimmune issue. Headaches, including stress headaches, migraine headaches, or headaches caused by blood pressure that's too high can impair a person's energy. Their ability to focus, focus and contribute to, especially if they're chronic, contribute to things like anxiety and depression. Medications like beta blockers, proton pup inhibitors, you know, for stomach issues, corticosteroids, Parkinson's and antipsychotic medications, hormone replacement therapy, stimulants, antic convulsants, statins like you take for cholesterol, opioids like you would take for pain or ben, benzodiazepines, anti anxiety medications. All of these have their own set of consequences or impacts on people's mood. So it's not just alcohol, it's not just illicit drugs. We need to really get a full, full picture of all the different medications somebody's on in order to identify, you know, might something in there be contributing to their symptoms? Especially if they can say, yeah, I noticed my symptoms started a week after or two weeks after I started taking this medication. Well, aha, let's talk to your doctor about that. And we want to assess for substance use and potentially addictive behaviors like sex and pornography, gambling or video games. These behaviors increase dopamine to unsustainable levels. And when that dopamine system gets out of whack, it negatively impacts everything else. Serotonin, norepinephrine, etc. Affective causes of mental and physical illness. We want to start by talking with the person about different emotions and what they look like for them and how often they have them. This helps us get an understanding of their stress response functioning and their triggers. Do they dysregulate when they get upset? Do they go from 0 to 250 and it takes them a long time to get back to baseline? If so, that indicates a problem with what we call their vagal tone. That vagus nerve isn't communicating with the brain very effectively, and there are things we can do to help them strengthen that. But they also may not be aware. They may have low emotional intelligence. They may not be aware of their feelings, what those feelings look like, what the early warning signs are, what triggers them for them. So we want to start looking at that to help people become more aware and mindful of their situation. Dysphoric emotions typically impair sleep quality, excite the stress response system, reduce pain tolerance, prompt cravings for high carbohydrate high fat foods. So questions we can ask include in an average week how much time is spent on each emotion? That's a good curiosity. Exercise. What does each emotion look like for you? Physically? You know, what are your physical symptoms? Affectively, cognitively, how does it affect the way you think and problem solve when you're feeling curious and anxious, depressed, etc. Environmentally, how does it impact your environment and the way you perceive your environment when you're in that mood and relationally when you're in that mood, how does it impact your relationships and how do you how does it impact how you want to be in your relationships? What triggers each emotion? What stressors are currently present? What stressors have been present in the past 12 months? What's different when they're happy and how long does it take for them to calm down after they get upset? Cognitive causes of mood and physical illness include dopamine, norepinephrine, serotonin, oxytocin or estrogen or even testosterone imbalances which can all contribute to con concentration problems, brain fog, memory problems and difficulty with problem solving thoughts or cognitions can cause biological, emotional and behavioral changes which throw hormones and neurotransmitters out of balance and impact the mind, body, relationships and the environment. So think about somebody you know who's negative Ned versus positive Pete. You know, how does, how are they in terms of their immune system, their health, their wellness, their problem solving, their ability to interact with others? We want to assess people's cognitive functioning by looking at their attention and their concentration, their memory and their problem solving ability. We want to assess their cognitive HPA axis triggers, the thoughts that trigger their stress response, including negative attitudes and perceptions, their hardiness or lack thereof, their commitment, their control and challenge or their sense of hopelessness and helplessness. You know, it's they're hardy or they're hopeless and helpless. They're typically tend to be two ends of the spectrum, their locus of control. How much control do they believe they have over their situation, over their feelings, their cognitive distortions, their negative self talk and their time management and organizational skills Environmentally. Now some of these things in the environment simply just increase stress and when that stress is increased, it predisposes or make people more vulnerable to other issues. But sometimes they actually are directly correlated to increases in anxiety and depression. So environmentally do they feel safe in their environments? If not, why not? Noise. Is there a lot of chronic noise that keeps them from getting good sleep or stresses them out? They've even found that wind turbines that hum from the wind turbines contributes to increases in anxiety and depression in people who live by wind farms light. Are people destroying their circadian rhythms or, or upsetting their circadian rhythms by being exposed to too much blue light or being in the darkness too much. And we see this a lot with the advent of computers and video games. Smells can also be noxious or triggering, you know, overwhelming to people or sometimes they can be assistive. So we want to look at different smells that might help people with insomnia, sleep, anxiety, pain, depression or reducing cortisol. And I do do a video on essential oils and terpenes that might be informative on that. Air pollution, including carbon dioxide, carbon monoxide, nitrous oxides, volatile organic compounds and tobacco smoke all reduce the air quality, which reduce oxygenation, which can contribute to fatigue and health problems and contribute to a sense of anxiety or depression. And temperature, if you're not at the right temperature, it can trigger that stress response system. The body wants to maintain that. 98.6 so if you're too hot or too cold it actually does increase the the stress in your body, the cortisol levels. And finally, relationships and their impact on mental health. We want to evaluate the person's sense of self esteem, how do they feel about themselves and their competence or their self efficacy. We want to evaluate their attachment style because attachment or insecure attachment is actually associated with disruption of neurotransmitters and hormones including oxytocin, serotonin, dopamine and even endogenous or natural opioids. Boundaries. Is the person able to set and maintain healthy emotional, physical and cognitive boundaries with other people? If not, then they may feel unsafe a lot of the time because people are trampling all over their boundaries. Communication skills can they effectively identify and assertively communicate their feelings and thoughts in order to get their needs met? Their social support system. Is it accessible and functional and able to do what is necessary in their life? Not just supporting them in times of trouble, but also helping them feel loved, helping them explore the things that interest them, helping them do things that make them happy. And finally, animals and pets, what is their relationship with their support animals? If they've got an older pet for example, then they may have some underlying anxiety a lot of the time that that pet is going to cross the rainbow bridge and that stress can contribute to mental health issues that can contribute to anxiety and sleep problems which can exacerbate mental health issues. Our current uni or bi dimensional approach to treatment does not work for the majority of people. There are a myriad of underlying causes of distress, and most people have multiple contributing factors. A transdiagnostic approach works to identify all of the causes of the symptoms, understand their interrelationship and causes, and develop a treatment plan or an action plan based on what the person is most motivated to address in a manner that works for them.