Top 20 Cognitive Strategies to Reduce Anxiety

You. Hey there, everybody, and welcome to this video on 20 anxiety relief strategies. I'm your host, Dr. Donnellice Snipes. In this video, I'm going to walk you through the basic strategies that I use to address generalized anxiety in someone who comes into my office. Now, it's important to remember that every person is different and every person may display their anxiety slightly differently. So this just gives you a general idea of, of tools and techniques that I might use. We're gonna start out by looking at what I go over in the assessment or intake interview and how that relates to the symptoms of anxiety. Then we'll explore other things that I rule out or rule in that might be contributing to the person's symptoms. Then we summarize the typical interventions that I use when treating generalized anxiety disorder. And I finish up by listing 15 psychoeducational topics that I think are for everybody to have in a foundation treatment program. If you're not familiar with some of these tools or techniques that I'm using, that's okay. I've linked to longer videos that I've done on each one of them in the notes to this video. So just scroll down, look at some of those videos, and you'll be up to speed. So let's start out with the intake assessment or the diagnostic criteria. Remember, anxiety is a feeling. It's an emotion. So the first criteria for diagnosing generalized anxiety is excessive anxiety that's difficult to control on most days for at least six months. About a variety of things. It's not about one specific thing, it's about a variety of things. It's also important to recognize that just like you wouldn't wait to go to the doctor until you had pneumonia, you also are likely going to do better if you start addressing anxiety when you notice it. Instead of waiting until you're at a crisis point or until you accurately and completely fulfill diagnostic criteria. Just because you haven't had it for six months or more doesn't mean it doesn't need to be addressed. So we start out with this first symptom and I ask people about what triggers their anxiety. What causes them to feel anxious? What things do they think about when they're feel anxious? And I make a list of these things as we talk, and then we examine those triggers for themes. Are they related to things like loss or abandonment or rejection or failure or loss of control? And we start trying to group them together a little bit to help the person get a better understanding maybe of where their anxiety might be coming from. Then I asked them about their anxiety vulnerabilities. Now remember, vulnerabilities are different than triggers. Triggers are things that kick off the anxiety response. Vulnerabilities are things that make people more likely to be triggered when they encounter certain stimuli. So being over caffeinated, being unrested, being sick, being in a strange environment, all of those may be vulnerabilities for people's anxiety. And I go through each one very systematically. We look at physical vulnerabilities. So such as being over caffeinated or having low blood sugar, having poor sleep, being in pain. Then we move on to affective vulnerabilities. If the person's already feeling stressed out or overwhelmed about things, maybe they're just starting to feel burned out, then that may make them more vulnerable to react to things with anxiety. Then we look at cognitive vulnerabilities when they are in a particular mood, perceiving the world as either optimistic or pessimistic, does that make them more likely to feel anxiety? And then we'll look at environment. Are there particular environments that contribute to their anxiety? Like I mentioned earlier, being in a strange place or maybe being in an environment where there's lots of activity, like your kid's preschool classroom or a very busy restaurant, as opposed to your home or the library. And finally we'll look at relationship vulnerabilities, if you will. And that is people in the person's life that may make them more vulnerable to react with anxiety. Are there people that make the person feel on edge that may contribute to them being a little bit more hyper vigilant, so they're more likely to become anxious and notice, for example, micro expressions. After we go through the themes, the triggers and the vulnerabilities, then we go to effective coping strategies. What is the person doing right now that helps them either a little bit, kind of take the edge off their anxiety, or maybe it helps them relieve their anxiety, even if just for 5, 10 minutes, 30 minutes. Those are things that we can build on and that helps me understand the types of tools that might be effective for that person. The next characteristic or criteria for diagnosis of anxiety disorder is feeling restless, keyed up, or on edge. Now this is different than anxiety. This is having difficulty sitting still. And this is a common symptom of adhd. So the person may have anxiety, but they also may have concurrent ADHD or concurrent PTSD that is contributing to their sense of restlessness. So no matter how much of the anxiety that we treat, this particular symptom may continue to be present unless we also address it. So again, I asked them about what triggers your restlessness, what triggers your inability or difficulty sitting still? And are there any vulnerabilities that make it more likely that you will have difficulty sitting still or that you will feel more keyed up? A lot of these often overlap with the anxiety triggers, but it's still helpful to take a look at them. Then I asked them about their strengths and coping strategies for dealing with feeling restless or keyed up. What do you do when you have to sit still and you feel restless? Maybe it's in a staff meeting or on an airplane or something else. What strategies can you use that help you cope with that sense of restlessness and edginess? Muscle tension, sleep disturbances and being easily fatigued are all additional symptoms and they can all be caused by a variety of things. Muscle tension can be caused by poor ergonomics and pain, for example, that is completely unrelated to anxiety. So again, we can treat the anxiety and we can address the stress related muscle tension. But if there's also muscle tension for other reasons, we need to pay attention to that too, because muscle tension is perceived by the body as a stressor and that is going to trigger the stress response which is going to make the person more vulnerable to anxiety. So I ask about different triggers for their muscle tension and what's an effective coping strategy. Whether it's progressive muscular relaxation or massage or heat or stretching, what is it that helps them reduce their muscle tension? In terms of sleep disturbances, Sleep can be disturbed for a lot of reasons. Your circadian rhythms can be out of whack, your hormones can be out of whack, you could be experiencing pain that is impacting your sleep. None of those are necessarily directly related to the anxiety, but they could be contributing to maintaining the symptoms. So I ask about what are triggers for sleep disturbances, for example, watching particular movies before going to sleep, or checking their email before going to sleep. And what vulnerabilities exist for sleep disturbance, what things make you more likely to have difficulty going to sleep, and what are some effective sleep strategies that the person currently uses? Sleep hygiene is a big focus of early treatment for, dare I say, just about every disorder that I treat. Because when a person is sleep deprived, when they're not getting good quality sleep, it contributes to a whole bunch of symptoms, physical symptoms, cognitive thinking symptoms, emotional symptoms, as well as emotional lability and difficulty regulating their emotions. So sleep strategies are important and I generally provide people in the initial intake a link to a video on sleep hygiene and a handout on sleep hygiene so they can evaluate their own sleep and then if they're easily fatigued, why is this? Is it because they're not getting good sleep? Okay, that could be it. Is it because their nutrition is poor? If you're not getting good B vitamins, or if you're stressed all the time so your body can't use the food that you are eating nearly as effectively, or if you're eating foods that don't provide all the nutrients for your body to make energy available, then nutrition may be a cause of fatigue or a contributor to your fatigue. Over and above fatigue caused by poor sleep and being anxious or stressed out all the time, tension can contribute to fatigue. Even though you may not notice that you're holding a lot of muscle tension, holding that tension, keeping those muscles clenched takes energy, and that contributes to fatigue. And finally, deconditioning. People who are anxious and people who are depressed often feel overwhelmed and exhausted because of life. So going to the gym, that's a pie in the sky thought they feel like they barely have the energy to get through the day. They can't imagine mustering the energy to work out. But even deconditioning, in terms of not being able to spend as much time cleaning the house or working on the yard, just doing regular activities of daily living may seem completely overwhelming. So they're not doing them. And after a period of time, the body loses its conditioning, it loses its stamina. The good thing is, stamina can be rebuilt, but it's not something that comes back overnight. It's something that has to be gradually rebuilt. And what helps the person improve their energy when they're feeling fatigued? You may not be able to go from feeling completely exhausted to ready to go to the gym. But if you're feeling fatigued, is there something that can put a little pep in your step Besides caffeine? And I ask people about music, are there particular songs or playlists they listen to that can give them a little boost? Music can actually help increase dopamine and norepinephrine, which make energy more available to us. So music's one, maybe deep breathing or just getting up and moving around or going outside into bright light. Those are all tools or techniques that help some people get a little bit of energy. Like I said, it's not going to be a panacea. But we want to look at any strategies that work for the person at least a little bit, and then we can build on those two more. Criteria for anxiety disorder include difficulty concentrating or your mind going blank and irritability when you're stressed. When you feel Anxious, you've got that fight or flight system going on. You've got your brain in rescue mode, if you will. So your brain is paying more attention to all the threats because it doesn't feel safe. It's paying attention to more things that are going on around you because it doesn't feel safe. Which means if you're in an environment where there's a lot of distractions, maybe in a busy restaurant or even at work, if you work in a open area with lots of other people moving around, it may be more difficult to maintain your train of thought. Because you're thinking and then all of a sudden your hypervigilance makes you go over here to pay attention to that person that just walked in or over there to pay attention to Sally who just dropped something on the floor. And then you completely lose your train of thought. So it's important for people to recognize when they're feeling anxious, what environments, what situations, what conditions make them more vulnerable to having episodes where they can't concentrate or their mind goes blank and what can help them. A lot of people find that in this particular situation, having noise canceling, headphones on, sitting in a quiet environment at work, maybe at a carrel or in a private office, can help them focus more effectively. And what effective coping strategies do they have to help them deal with this difficulty concentrating and their mind going blank? Making lists is a big one. If they have a bunch of stuff to do at work, but they've got a lot of anxiety, it may be hard to remember, okay, what is it that I've got to do next? But if they make lists, that can help them keep track and follow along with what they need to do. And irritability is that sense of being short tempered, if you will. And it's important for people to recognize what makes them irritable. Irritability is sort of. You can think of it as a mild form of anger. And anger, just like anxiety, is a response to a threat, when a person feels anxious, when a person feels exhausted, when a person feels vulnerable for some reason, then they're more likely to respond to any sort of outside input, especially stressful outside input. With irritability, it's like, I just can't take one more thing. Go away. It's important for people to recognize that and recognize what their triggers are for irritability when they're angry. I'm sorry, when they're anxious, what things tend to trigger their short fuse, if you will, and what makes them more likely to be triggered, for example, being too hyped up on caffeine or being exhausted or being in pain. Then I move on to ruling out. No matter how much work a person does on their anxiety and their thoughts and cognitions about their anxiety, if there are underlying physical issues or other mental health issues that aren't being addressed, there's only so much progress the person can make. It's important to recognize that people are not just a bunch of independent parts. Everything interacts. So if somebody's in pain, physical pain, that's going to trigger their stress response, which is going to make them more vulnerable to anxiety. In order to make them less vulnerable to anxiety. Helping them address anxiety is great, but we also have to address that pain. So the stress response system, the HPA axis, isn't always turned on. We want to rule out thyroid imbalance, hyper or hypothyroid estrogen fluctuations, Lyme disease, nutritional deficiencies, food sensitivities, excess caffeine or stimulants. And that can come from the form of energy drinks or diet pills or other herbs that somebody may be taking that have stimulatory effects. Medication side effects some medications have in their list of side effects can contribute to anxiety. It's important to recognize that when serotonin gets too high, for example, it can contribute to anxiety. Some people, when they start taking antidepressants, feel anxiety for the first couple of days because all of a sudden their body's being exposed to more serotonin than it prior to taking the medication. Now eventually it all balances out, but it's important to recognize that that is a potential side effect. Alcohol and benzodiazepine withdrawal also contribute to feelings of anxiety. Now alcohol related anxiety tends to be much shorter than benzodiazepine withdrawal. When you withdraw from alcohol, usually it's two or three days that the person experiences high blood pressure, increased anxiety, etc. And then things start to level out. I'm not going to say their anxiety goes away, but it levels out quite a bit with benzodiazepines or anti anxiety medications, it can take a lot longer for the anxiety to go away. A lot of people also experience experience rebound anxiety when their anti anxiety medication starts to leave their system. So if they're taking a short acting anti anxiety medication, it may start helping them feel better real quick. But then as it starts to leave their system, their anxiety rebounds and it feels like it's even stronger than it was before they took the pill in the first place. And it's important if that's occurring to talk with your doctor. About whether there are more longer acting options that would reduce the rebound anxiety or if there are other treatment options, which there are in, in lieu of benzodiazepines. Pain, as I mentioned, can also contribute to keeping that stress response, that HPA axis turned on, keeping the person hyper vigilant. When you're in pain, you tend to be kind of guarding because you don't want to hurt anymore, you don't want to get injured anymore. And it can make people more likely to respond with anger or anxiety. So we do need to address pain. Whether it's chronic pain like from fibromyalgia or intermittent pain, like from frequent migraines, we still need to address what's going on. For people who have intermittent pain, they can also experience anxiety because they dread having another episode. For people with chronic pain, they can have anxiety related to the chronic pain, worrying that it's going to get worse and worrying that it's going to keep them from having the life they want. Ptsd, Post Traumatic stress disorder has a lot of anxiety related symptoms. However, people can have both generalized anxiety as well as ptsd. PTSD symptoms are focused mainly around triggers, reminders of the trauma. Whereas generalized anxiety, the anxiety is about more things. But if a person has PTSD, they are going to likely be hypervigilant which is going to make them more vulnerable to anxiety about a variety of things. Obsessive compulsive disorder has an anxiety component. People have these obsessions that they are, they can't get out of their head and they're worried that if they don't do, if they don't do X, if they don't engage in a compulsion, then it is going to end up causing bad things. Or they may just have this repetitive intrusive thought that they ruminate on that contributes to their anxiety and social anxiety. Remember I said generalized anxiety, the person is anxious about a multitude of things. In social anxiety, the anxiety is specifically about being negatively evaluated by people. Can you have both? Yes, potentially. But we do need, if somebody has a social anxiety component, we need to make sure that we're addressing that. In addition to the generalized anxiety, The general treatment flow that I go through with generalized anxiety, in this initial meeting we have talked about triggers, vulnerabilities and current effective strategies that the person uses. So I take all of those and I put them into a spreadsheet and, and we look for themes and I give them to the, give the spreadsheet to the person so they are more aware, they can start identifying vulnerabilities and Triggers that they want to address. I also refer people to their primary care to rule out physical causes and contributors like hormone imbalances, nutritional deficiencies, chronic pain if they need to be, or they want to be referred to a nutritionist or a sleep specialist. I also make a referral to those particular people at that point in time. I also have people start keeping a daily anxiety log in which they note the date, the time, the trigger or triggers for their anxiety, the intensity of their anxiety on a scale of one to four, one being, yeah, I noticed it, but it wasn't a big deal. Two is felt anxious, but I was able to get through just fine. Three is I felt really anxious, but I managed somehow to get through it and pushed through, but it was really, really hard. And four, the anxiety was overwhelming. I just, I couldn't, I was paralyzed. So date, time, triggers, intensity, duration, did it last five minutes or five hours? And what interventions, what things did they do that helped to either reduce their anxiety or help them recover? After the anxiety episode, and then henceforth each week we review their anxiety logs. That's like the first thing that I do with people after I ask them, you know, how's your week been? We look at the anxiety logs and I evaluate it for repeating triggers and repeating themes for their anxiety. Then we process at least three of their triggers for their anxiety. And I use the FCP method. What are the facts for and against your belief about this situation? What aspects did you have control of in this situation? And based on the facts and your ability to control the factors you had control of, what's the probability that this actually would have ended up being a catastrophe, would have actually ended up being a notable threat. That's where we start. A lot of times, helping people move away from emotional reasoning into factual reasoning gives them a sense of new perspective and a greater sense of mastery over the situation. They may not feel like they can control it yet, but they're feeling like they have a better understanding. Eventually, as we go through the treatment process, people will learn about cognitive restructuring, dialectics, living in the and purposeful action and hardiness, and will apply each one of those tools as they learn them or when we process their triggers. I also look at their anxiety logs for potential vulnerabilities and I identify mitigation strategies include setting and maintaining boundaries, assertiveness, and trigger management. So for example, if one of their common triggers was interacting with their boss or interacting with their sister in law, then I would say, okay, what mitigation strategies could we use? How can you effectively set and maintain healthy boundaries and manage this trigger in a meaningful way. May not be able to completely prevent the anxiety. But how can we help you move from a four, where you're completely paralyzed by your anxiety, to a three where you can start, you can get through it. It sucks, but you can get through it. And then eventually we'll get down to A1. We discuss what tools have been effective in the past week. It's really important in my mind to help people identify and build on their strengths and realize the power that they already have, realize the resources that they already have that they may be taking for granted. And then I provide a video, handout and worksheet on a particular psychoeducation topic. And it's important for a lot of people to have a video that kind of explains it and walks them through it, and then a handout or worksheet to apply it. Why do I do this for in between sessions? Because I feel that people's money is best spent when they're in session with me actually processing something stuff. The psychoeducation component, I think, is something in most cases is something that people can spend their time learning between sessions. I don't want to waste their money lecturing them when they could watch a video on it. I want to spend their time in session actually using what they've learned and applying the information. So the psychoeducation topics that I think are important for everybody to learn about the function of anxiety, its connection to the stress response, and the impact of fight or flight on perception and problem solving. And I mentioned that several times in this video that when we're in fight or flight mode, we don't pay attention to the good stuff. We are actually more aware more of the threats in the environment because we are on high alert, so to speak, which means we tend to perceive the world as more dangerous. And because of all that, because of the glutamate and the norepinephrine and everything else in our brain, it makes it harder to think clearly. Our brain has tunnel vision, adrenaline haze, whatever you want to call it, that is geared towards helping us fight or flee, not think about all the possible options and problem solving. So until people can get into what Linehan called the wise mind, until people can get out of that high anxiety state, it's going to be difficult to problem solve. Then we talk about distress tolerance skills, which are the skills that people need when they feel anxious to help them remember that they can tolerate the distress so they don't feel feed into it by saying, oh my Gosh, this is going to overwhelm me. I'm not going to be able to handle it. These distress tolerance skills help people feel more empowered, even in the face of anxiety, and can help them get into their wise mind. We talk about circadian rhythms and sleep hygiene because it's so important for developing new skills, for learning new things, as well as for helping the HPA axis, the threat response system, recover that people are getting good quality sleep. Then I talk about nutrition and neurotransmitter support. What we eat is broken down to make neurotransmitters, to make hormones to repair the body. So if we're eating like crap, we're probably going to feel like crap. A lot of people want to get straight down to the nitty gritty of how can I improve my serotonin, my dopamine, my norepinephrine? And ultimately everything is in a fine balance. So if one goes up, one happy chemical goes up, the other ones are likely gonna go up too. But that requires a healthy diet, for example, making serotonin to break down tryptophan, we need to have vitamin B, we need to have calcium, we need to have zinc, we need to have iron, we need to have tryptophan itself. And then to break down, it goes from tryptophan to 5ht. Then to break that down even more, we need even more vitamins and minerals. So it's important that people understand the importance of a healthy diet, but also understand the regular foods that they can eat to support their body's ability to make those neurotransmitters like spinach and bananas and cocoa and tea and colorful vegetables. It's not anything that's really weird, wild, and radical. Next, we talk about mindfulness, the difference between focused mindfulness. So you're focusing on something like a candle flame or open awareness mindfulness, where you're walking through a park, for example, and you're not focusing on any one thing in particular, you're just noticing, quote, everything as you walk down the path. That open awareness encourages you to be mindful, be in the moment instead of thinking, instead of being in your own head. And then mindfulness in terms of the self scan, mindfully scanning your head, heart and gut, so to speak. How am I feeling, feeling emotionally? How am I feeling physically? What am I needing emotionally? What am I needing physically? Right now, the next lesson is on compassion and loving kindness. Developing compassion for yourself as well as other people. A lot of times, anxiety comes from fears of being rejected, fears of being criticized, fears of not being good enough. And sometimes that comes because your own inner critic is just harsh and hateful. So developing self compassion, recognizing that it's okay to be imperfect can be helpful to encourage people to move towards self acceptance as opposed to self abandonment and loving kindness. Meditation is helpful to inspire compassion for others, even others that are being kind of difficult. The next unit or topic is cognitive distortions, what they are, their function, and restructuring them. Cognitive distortions include things like all or none thinking, mind reading and catastrophizing, and over personalization. So we talk about how those thinking errors are likely thinking strategies that formed in childhood before you could think more critically, so to speak, and often remained unchecked. Then we talk about alternatives, such as looking for alternatives instead of thinking it always happens or it never happens. Looking for exceptions. You know, when has this happened? If I say it never happens, is that true? Or are there exceptions? If I'm taking things too personally instead of saying it's all about me or the person's mad at me or hates me, what are three other explanations for why they may have given you a dirty look besides you? Did they even see you? Or were they caught in their own thoughts? Then we move on to optimism, and I have in here tragic optimism. Because unbridled optimism can be just as unhealthy as unbridled. Tragic optimism includes an element of dialectics and living in the and in tragic optimism, we recognize what is, but we have hope that it can get better. We recognize the good and the bad in the present, and we have hope that we can make a difference to move towards a more rich and meaningful life. Unit 9 looks at schema Schema are our brain's cliff notes, our brain's shortcut to help us interpret what to happen. You have schema about everything, stop lights. I'm assuming everybody who's watching drives. And so you have a schema. When you see a stoplight that's on yellow, you have a schema that tells you how to react. If you think that yellow lights are really long and you've got plenty of time to get through, then you're going to keep on going, or maybe even floor it. If you think that yellow lights tend to change really quickly and you don't want to run the red light, then you're probably going to stop. So based on your past experiences with yellow lights, you're going to react in the current moment, probably without thinking about it. You're not going to sit there and go, okay, well the last three times I came to this light it changed really fast. It's just sort of an automatic process. That's the beauty of schema. It helps us do some of our things in default mode or on autopilot. Unfortunately, if somebody's been exposed to trauma or has been anxious for a long time, then their schema may have been altered to expect that the world is going to always be a dangerous, disempowering, unpleasant place. So it's going to be important to evaluate their schema back then. That may have been true in the current context at the current time. Is this schema still accurate? If so, okay, how do we deal with it? If not, how can you adjust your schema? Relationships are the same way. If you've been in multiple bad relationships, you may expect that people aren't trustworthy, but that really sets everybody else up to be at a loss because you're just expecting they're going to behave badly. If you adjust your schema and you say, okay, in this context at this time with this person, are my beliefs about what's going on? Are my expectations true? Or am I just assuming based on other people's behaviors and past experiences? Number 10 is creating a rich and meaningful life vision board helping people visualize what things are important in their rich and meaningful life. What things do they currently have that are important in their rich and meaningful life? And instead of using their energy just holding on to anxiety and tossing it around in their hands like a hot potato, how can they instead use that energy to nurture the things that are important in their life? And what kind of a difference would that make? Number 11 is acceptance, purposeful action, and hardiness. Helping people recognize that sometimes life just sucks. It is what it is, so to speak. But using their energy purposefully instead of using their energy to be angry about it and stew on it and pout. Using their energy and saying, okay, can't change this situation, but what can I change? What can I use this energy for that would help me move closer to a rich and meaningful life? Number 12 moves into relationships and interpersonal behaviors. And I start out with setting and maintaining boundaries. A lot of times people feel anxious because they have never been taught how to set boundaries and maintain them. They have other people have encroached on their boundaries and told them what to think or what to feel, or criticized them for how they think or how they feel. And so learning how to set and maintain boundaries is really important to helping people feel empowered and safe. Any relationship in section 13, we talk about secure attachment, positive self talk, and the inner child so there's a lot there. Hopefully by this point in treatment, people's triggers and anxiety experiences are a lot less intense and a lot less frequent, so they have more time to spend on developing additional skills. But in order to feel safe, in order to feel loved, people typically need to have some secure attachments, including a secure attachment with self feeling like you can be there to respond to your own needs. So we talk about what secure attachment looks like, how secure attachment is developed, how to use positive self talk to enhance your secure attachment with yourself, and to help heal your inner child that may have been wounded because of past things. In unit 14, we talk talk more about the inner critic, because the inner critic is huge and contributes to a lot of people's anxiety. The inner critic may bring up past stuff. Remember back then you failed, you're going to fail again, which can trigger anxiety. Or the inner critic can bring up anticipatory things. You think you're going to be able to do this, you're going to fail, and then this is what's going to happen and the sky is going to fall. So getting that inner critic under control is really important. In 15, we talk about listening without defensiveness, because defensiveness is a anxiety, anger, threat reaction. When people feel like they're being criticized or when people feel like others don't necessarily agree with them. The automatic reaction for a lot of people is to feel threatened and to get defensive. So we talk about how to hear other people's opinions, maintain your own boundaries and not get defensive. You don't have to agree with them, but it's important to be able to listen. And then finally, in unit 16, we talk about assertiveness in order to feel safe and empowered, which is what you need to do to feel not threatened, to feel less anxious. It's important to be able to assertively communicate your thoughts, wants and needs. So we talk about any barriers to assertiveness and how to assertively communicate what you need to others while still respecting their boundaries and maintaining yours. That gives you a general overview of the types of things that I go through in a 12 to 16 week treatment program with somebody who presents with generalized anxiety. Now remember, every individual is different. So I may add things like a unit on abandonment anxiety or a unit on grief and loss for people based on what their the themes of their anxiety triggers are. But the skills that I have already gone over, the skills that I've highlighted in this presentation think are essential foundational skills for anybody to prevent anxiety and to deal with it when it does happen.