Author: Leaman Ralph

Really sugar is shaky because it originates from a straight stick see the play is Granny yes Grandma plus new style luv MaryJane so listen (Granny Apple last years blue ribbon production winner AKA) I, I, I ain't on the right side of my house Jane something or the other is in my room: finally after an extermination Grannie speaks once more "let my (old man) Pacman step on it". See it is home on the range so solo as it be truity speaks got a problem it is your own. But alter scenario: Z/n time; narcotics I got that candy s.p.ee..d360 Bar itch its' and Mickey Mouse for the Sultan 7 1 4er well a hem a hem, it went early in the morning like a smack chanting sugar structure 7 -one 1 +eleven and 4 do an ate 'er 8 eight 'er? Well that aint nice. NARCO says do you know them numbers change (response) Yes it is a FiX they are MF's Ope yeah Ope Douglas is it. Surrounded by Alkaloid is both Mary and Grandma in an never ending circle of membership. French mandates declare put up their dukes... ZEN Pepsi can talk half Chocolate and your ole man Pacman down in Cuba posing as the worlds one and only Coffee Wizard "back 1:1" tis Coffee time... ||

Anxiety Meditation with Dr. Dawn-Elise Snipes

https://www.youtube.com/watch?v=FdlwMQ4GVWo
Hello everybody and welcome to this video anxiety  meditations i am your host dr dawn elise snipes anxiety often occurs when we feel unsafe or  powerless it increases your stress chemicals   kicks off that hpa axis or the fight or flight  response and you start to have tunnel vision  
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and become more reactive and impulsive so  anxiety can be a problem now remember anxiety   is a feeling it’s a normal feeling that tells  you that hey there might be something to be   aware of there might be a threat it doesn’t  mean there is a threat the anxiety is just  
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telling you to check and see if there’s a threat  meditation can help calm your stress response so   you can think more clearly about what to do to  improve the next moment so if you look around   and you decide you know what there’s really not  a threat or whatever it is that is threatening  
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i have no control over like you know a pandemic  or something then meditation can help you   calm or or tamp down that stress response  so you’re not burning up tons and tons of   energy and feeling anxious like you’re going  to crawl out of your skin all the time it’s  
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important before you begin any sort of meditation  to examine your surroundings and make sure you are   safe from interruptions you don’t want to  get into this nice relaxed state and all   of a sudden have your phone go off or the  dog bark get into a situation where you are
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protected from interruption where you feel  safe in your environment you have the door   shut you may have the blinds drawn whatever it  is that makes you feel the most safe and secure   if you’re not comfortable closing your eyes some  people have trauma histories and they are not  
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comfortable closing their eyes and that’s cool  if you’re not then pick a stationary object in   the room to focus on when i do meditations i love  focusing on the a candle flame just that’s always   been something that has um attracted my focus so  candle flames work for me you can pick a spot on  
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the wall you can pick a vase whatever it is you  want just make sure it’s not something that’s   going to move around that you’ve got a track  you want to make sure it stays right there the next thing you need to do once you feel  like you’re in a safe environment think of an  
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empowering mantra that you’re going to repeat to  yourself and depending on what is triggering your   anxiety you may have several different mantras  that you rotate through depending on the type of   anxiety if you are facing some sort of adversity  you can tell yourself i’ve got this or this too  
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shall pass you know maybe you are getting ready to  go take a your graduate entrance exams or you are   going on a job interview or you are experiencing  some something distressful maybe you and your best   friend got into a disagreement and there’s tension  right there so this too shall pass can work  
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another set if it has to do more with failure  you can remind yourself progress not perfection   nobody’s perfect and it’s important to strive for  progress not perfection to learn from our failures   or just i can succeed if you are afraid of failure  and you’re getting ready to do something just  
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telling yourself i can succeed i may not succeed  at everything but i can’t succeed now obviously   i’m elaborating on some of these you want to pick  something that is not more than a few words to   repeat to yourself if your  anxiety has to do with rejection  
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you may say to yourself something like it’s not  about me or i am enough if you have anxiety about   uncertainty you don’t know what’s going to happen  next you can tell yourself something like stay   open to options or i’m not alone and i’m not  alone really appeals to people who don’t like  
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uncertainty they like control but knowing that  they’re not alone knowing that they’ve got   support people to help them through something  that is uncertain can be very reassuring   now you can come up with your own mantras these  were just a few that i i pulled out for you  
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to give you an idea of think something  that you might want to say to yourself   look at the root of whatever’s causing your  anxiety pick a mantra make sure you’re in   a safe place with time and practice you’ll  be able to trigger the relaxation response  
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with your mantra and a deep breath or two so you  may not have to go through the entire meditation   which is really awesome so when if you get used  to it you may be able to approach adversity   and take a deep breath tell yourself i’ve got  this and exhale and do that a couple of more times  
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and feel relaxed it can help you get grounded  once your body’s recognized that okay when we   start saying this it’s time to relax you may think  that’s a little corny but think about other times   in your past when somebody has said something  that has just a word has triggered a response  
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when i used to teach at uf i would tell my class  okay clear your desk it’s time to take a pop quiz   and those words would strike fear in the majority  of the people in my class and that would trigger   their fight or flight response now obviously  we want to do the opposite here my point is  
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that something as simple as a word can trigger a  fight or flight response or a relaxation response   so i’m going to tell you what we’re going  to do and then we’re going to start doing it   you’re going to start by sitting comfortably  you know you’re in a safe environment you’ve  
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picked your mantra then you get comfortable  sitting ideally both feet on the ground you   know in a relaxed position begin by focusing  on your breath you’re gonna breathe in for four   hold for four and breathe out for four you’re  gonna do that twice and then you’re going to  
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continue to breathe in for four hold for four  and exhale for four but you’re when you do this   then you’re going to start noticing your belly  expand and deflate so the first thing you just   want to focus on your breath and then you want  to start focusing on your breath and your body  
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the next step is to notice the cool  refreshing air as it passes through your nose   feel it moving through your entire  body you’re going to do that twice   finally you’re going to as you breathe in you’re  going to repeat your mantra and sit with it while  
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you hold your breath for that four and as you  exhale you’re gonna feel the bad energy and worry   leaving your body you’re going to repeat this 10  times then just sit with this feeling for a few   minutes noticing how relaxed your body feels  it’s that simple you’re going to gradually  
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work up to ramp up to focusing on your on your  mantra and relaxing your anxiety but the first   thing you got to do is start with your breath  i’m going to walk you through this mantra and   it will take about 10 minutes so go  ahead and sit down and get comfortable
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begin by focusing on your  breath breathe in for four   three hold for four two three and exhale for four three four let’s do that again breathe in  for four two three four hold for four two  
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three and exhale for four now when you breathe in for  four notice your belly expand hold for four
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and exhale for four feeling your belly deflate again breathe in and notice your belly expand hold for 4. and exhale for four
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now as you breathe in for four notice the cool  refreshing air as it passes through your nose   feel it moving throughout  your entire body hold for four and exhale for four
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again inhale noticing the cool  air as it passes through your nose   and feel it moving through your entire body hold for four
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and exhale or four now as you breathe in repeat your mantra breathe in for four tell yourself  that it’s okay that you’ve got this
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hold for four as you exhale feel the bad energy  and worry leaving your body let’s breathe in again repeat  your mantra to yourself
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hold and exhale feeling the energy the bad  energy and worry leaving your body breathe in again repeat your mantra really  believing what you’re telling yourself
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and exhale feeling the worry and  the bad energy leaving your body breathe in repeat your mantra feel the positivity  and the strength feeling your body hold and exhale feeling the bad  energy and worry leaving
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breathe in again repeat your mantra notice  how you’re starting to feel more calm sit with this feeling of calmness as you   hold your breath and then exhale feeling  the bad energy worry leaving your body
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breathing again repeating your  mantra believing your mantra feeling that breath you took absorbing  all of the negative energy and exhale breathe in again repeat your mantra
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sit with this feeling of calm and strength   feeling the breath absorbing  all of the bad energy and exhale breathe in repeat your mantra
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really believe how strong and safe you are  feel that oxygen absorbing the bad energy   and exhale feeling the bad energy and worry  leaving your body breathe in repeat your mantra repeat your mantra again  
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sit with it while you hold your breath for a  minute let that air absorb all the bad energy   and as you exhale really feel your body relaxing  and melting into the chair that you’re sitting in one more time breathe in
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repeat your mantra notice a sense of hope and  energy but also calmness sit with this for a minute
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and exhale feeling the last little  bit of that worry leaving your body notice how relaxed your body feels now sit with  this feeling continue to repeat your mantra until you’re ready to start rejoining  your activities for the day there are  
Source : Youtube

9 Tips for Rewiring the Anxious Brain | Cognitive Behavioral Tools

https://www.youtube.com/watch?v=SHksvBpVSkk
Unlimited CEUs are available for $59 at AllCEUs.com/Anxiety-CEU hey there everybody and welcome to this  presentation on nine tips to rewire your   anxious brain i’m your host dr dawn elise snipes  in this presentation we’re going to start by  
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understanding a little bit more about what  anxiety is then we’ll talk about the influence   of experience and the stress response and we’ll  finish up by identifying those rewiring strategies anxiety is an emotional label we apply  to a particular set of physical reactions  
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like rapid breathing and increased heart rate  that can be triggered by a variety of things   phys physical stress like exercise can trigger  the hpa axis which is our stress response system   threat can also trigger the hpa axis  our cognitions or our thoughts can also  
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trigger this physiological reaction if we  tell ourselves there’s a impending danger   then it’s going to trigger that fight-or-flight  reaction relationship dynamics are another example   of something that can trigger a stress response  if someone starts interacting with you in a way  
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that reminds you of an unpleasant interaction in  the past it’ll trigger that memory and your brain   may respond with activating that stress response  system anxiety is an emotion it is there to help   protect us the fight-or-flight system the anger  and anxiety are designed to give us energy to  
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tell us that there might be a threat not that  there is a threat so this fight or flight system   is designed to help us survive it’s designed like  a fire alarm to alert us to the fact that there   might be a problem and i know i already said that  but it bears repeating anxiety is a feeling which  
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may or may not be based on accurate facts feelings  are not facts feelings tell us to check the facts when you experience something that causes anxiety  your brain encodes it as a threat so think about   if you are walking down the street and an  aggressive dog just runs up to the fence and  
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starts barking like crazy well if that’s your  first experience with a dog or if you felt too   threatened then your brain is going to encode  that and it’s going to make it really prominent   high winds are another example that i’ll use  throughout this presentation we live on a farm  
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and we’ve had occasions where the winds have  gotten so high that is not that it has knocked   down significant portions of our fence which not  only is inconvenient but it means the animals can   escape and it is not a cheap endeavor in order to  repair the fence so whenever we have high winds  
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there’s a part of me that may get a  little bit anxious that oh my gosh   i hope it doesn’t blow down the fence so we’ll  talk about how i’ve dealt with that over the years   it’s important to remember that in order to  protect us your brain gives more weight or  
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more prominently displays information about  threats so instead of remembering the 15   nice dogs that you’ve met in your life it’s  going to remind you of that one aggressive dog   or instead of remembering the 50 times that we had  a storm come through that there was no damage my  
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brain as soon as the wind starts picking up goes  to that one time well actually three times but   whatever those few times that the fence blew down  so probability is that nothing bad is going to   happen but my brain focuses on those distressful  events because it’s trying to keep me safe
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when your brain perceives a threat based on  prior experience or lack of experience so if   you’ve never encountered a situation  many times that’s going to trigger a   feeling of anxiety in you because your brain’s  like i’ve got no data i don’t know what to expect  
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so it could be bad it could be good but let’s just  err on the side of caution and be a little anxious   so it triggers the hpa axis which causes your  body to drop dump adrenaline we know that that’s   stimulating norepinephrine and glutamate those are  also stimulating and all of those things um work  
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together as well as uh your thyroid causing  blood sugar to be dumped into the system to   create that feeling of anxiety when we are anxious  when our fight-or-flight system has kicked off   i mentioned earlier our heart rate increases our  breathing increases our gi tract says you know  
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it’s not the time to rest and digest so let’s  clear out the system so a lot of times we get   stomach cramps or an uncomfortable feeling in  our belly all of that is just a normal reaction   to our body getting prepared in case we need  to fight or flee but we assume that since we’re  
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feeling that way then there must be a problem and  we’ll talk about emotional reasoning in a minute   when we have this physical  reaction we start feeling   anxious thoughts about our ability to keep  ourselves safe and to cope with the situation  
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can really affect whether it spirals and gets  worse into a panic attack or we’re able to cope   with it so if we start feeling anxious and we  believe that oh my gosh i’m feeling anxious this   is going to be out of control i’m going to feel  overwhelmed i’m powerless over these feelings  
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then we’re going to have increased anxiety which  is going to cause more adrenaline more glutamate   more blood sugar to be dumped because our our  body’s going ooh there must be a big problem   if our feel thoughts on the other hand are  that of safety curiosity and empowerment  
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i’m looking around i recognize that i’m pretty  safe and i think i can handle whatever life   throws at me okay so let me get curious i wonder  why i’m feeling pinky right now i wonder why i’m   feeling anxious right now so let me explore it  so i can figure out how to handle it that’s the  
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empowerment part well when we approach a situation  like that then it promotes functional responding   we can assess the situation accurately and  decide is this something i need to address   or can i turn on that rest and digest  and down regulate my stress response
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all right easier said than done so  when we talk about rewiring the brain   it’s important to start out with mindfulness and  i know we talk about mindfulness a lot but it’s so   important when you’re on autopilot then your brain  is just pulling from data that it already has  
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and not taking into account anything in the  present mindfulness encourages us to become   aware of things we become mindful of what  i call our pacer triggers for anxiety that   means our physical triggers for anxiety when  i feel a particular way for example if you’ve  
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got health anxiety then maybe if you have start  having pain that triggers anxiety in you okay   write it down what other physical sensations may  trigger anxiety in you maybe when your blood sugar   starts to get low you start to get really shaky  and you can’t necessarily differentiate that from  
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a panic attack so you assume that if you’re shaky  it must mean a panic attack so write down shaky   that’s a trigger for anxiety um some people  tend to be more anxious in certain situations   when they have certain feelings if they feel  angry that also may trigger their anxiety in other  
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videos we’ve talked about that as dirty discomfort  because we rarely have one isolated feeling   so if we get angry we may feel anxious that people  are going to get angry with us because we got   angry or if we feel depressed it may trigger our  anxiety that we’re never going to feel any better  
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so what feelings what affects trigger your anxiety  and then cognitive what thoughts trigger your   anxiety when you’re having an anxious moment  what are you telling yourself and sometimes   you may not be aware of these right now so the  first part of rewiring your brain is starting  
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to become mindful and become aware when i’m  feeling anxious what am i telling myself   when i’m feeling anxious what in the  environment might be triggering my anxiety   in the book the body keeps the score but um vessel  vander kulk talks about how a lot of times when  
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we’ve experienced trauma we may re-experience  it not as a thought so much as a reaction   so if there are stimuli in the environment  sites smart smells sounds in the environment   that remind you of a past trauma it may trigger  your anxiety and you may have that anxious  
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reaction and you don’t know where it’s coming from  it’s like oh i really don’t like how i’m feeling   and i don’t know why i’m feeling anxiety i’m  looking around and objectively everything’s fine   so it’ll be important to be aware of triggers  in your environment and start becoming aware of  
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things that trigger reactions from the past so you  can process that and recognize in the present are   you safe and and not even necessarily related to  trauma i remember one of the places i worked was   the walls were kind of this pukey blue green color  and it felt very institutional and it felt very  
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depressing and overly rigid and it  felt uncomfortable to be in there and   i couldn’t exactly tell you why and  to this day i can’t exactly tell you   why that color paint and the um environment  in that particular building triggered that  
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feeling but it did and i recognized that  when i started when i see that color   it triggers a emotional reaction in me it’s  not anxiety but people may have similar   reactions when they see particular colors  or environments and relationally what people  
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or interpersonal behaviors trigger anxiety in you  maybe particular people that you’ve interacted   with may trigger anxiety but also people that  look like those people can trigger anxiety in   you and it’s important to note that it could  be that they look physically like that person  
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or it could be that they are in a similar  role so maybe all doctors trigger your anxiety it’s important as you become more aware of  your triggers to also encourage yourself   to open your mind and become aware of  facts in context in the present moment  
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so i notice that when i’m in  this environment i feel icky facts in context in the present moment is  there something going on that is distressful   or is it triggering a reaction from the past you  know there are two completely different things
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another important step is what i call reducing  stress sensitivity if your body machine   is hyperactive hyper vigilant then you may tend to  respond with anxiety more easily or more strongly   than if it’s not so what can we do in order  to create a sense of safety and empowerment  
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well part of it is sleep when you are sleep  deprived your hpa axis becomes more active   which means and remember your hpa  axis is your stress response system   when that system is more active then you  are more likely to respond with more anxiety  
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think about it when you’re sleep deprived is  it just as easy to deal with life on life’s   terms or do things stress you out more easily  i mean i think most of us have the answer there   good quality sleep is important also with that  recognize some of your natural rhythms in the  
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morning there is the cortisol awakening response  and that is when your cortisol your stress hormone   and other uh hormones as well as your blood sugar  tend to be high your body is saying hey wake up   get ready for the day that is your body’s  um awakening response it’s not anxiety it’s  
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not designed to make you feel stressed out it’s  designed theoretically to make you feel excited   but sometimes we label it  differently sometimes our system is overly eager and it secretes too much cortisol  and it’s important to to take a look at that  
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so if you wake up in the morning and the first  thing is you feel anxious get curious examine   what thoughts am i having that  are contributing to this anxiety   what physical sensations did i not sleep well you  know what might be contributing to this besides  
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something that’s actually threatening so sleep  is important pain management is important when   we’re in pain that triggers that stress response  system to stay more active the primitive parts   of our brain say hey if we’re in pain that means  we’re vulnerable which means we are in more danger  
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from that hungry lion that might be chasing us  manage pain you may not be able to eliminate   it completely but be aware that pain may increase  your anxiety just because it triggers the hpa axis   pain may also trigger your anxiety because of  health anxiety and that’s a different video  
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but being aware of that and  managing your pain can be helpful   nutrition is important if you’re eating a  lot of simple sugars then your blood sugar   is doing this and that can contribute to feelings  of anxiety and jitteriness same thing with if  
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you drink a lot of coffee you can have surges  and crashes that can feel uh very anxiety like   getting enough protein throughout the  day to keep your blood sugar stable   can be really really helpful and paying attention  to insulin resistance is also important uh  
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when we become more insulin resistant  than our body has more difficulty   managing our blood sugar to grossly  oversimplify it some people have found that dietary changes can help with their anxiety  additionally making sure that you’re getting  
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a relatively healthy diet so your body can make  the neuro chemicals it needs to like gaba in order   to moderate your anxiety can be important and  then reducing minimizing eliminating if possible   stimulants if you’re already anxious then adding  stimulants is just turning up the volume of that  
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stress response system it’s giving it more energy  environmentally create safety in your environment   in your house in your car in your workspace so  you’re not hyper vigilant so you’re not on edge   a lot of the time turn down any unnecessary  sources of distress and develop a safety plan to  
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identify aspects within your control to respond to  common threats if x happens then i will so going   back to the aggressive dog if the aggressive dog  charges me i will respond with pepper spray you   know maybe i have pepper spray that keeps me  safe when i’m on my when when i’m on my runs  
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or if we get a bad storm and it does blow the  fence down then i will call my neighbor and i have   t posts that i can use in order to put the fence  back up so i have a plan that helps me feel   safer so i know that if this bad thing happens  i’m not saying that it will but if it happens  
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i can cope with it it’s not going  to have catastrophic consequences many people with anxiety get caught  in the emotional reasoning trap   i feel anxious therefore something bad must  be getting ready to happen emotional reasoning  
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causes you to seek out and focus on information  that confirms your feelings it’s not necessarily   confirming the facts it confirms your feelings  and it dismisses contradictory information if you   wake up and you’re having feeling anxious and you  say oh something bad’s going to happen today it’s  
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it’s going to be an awful day then you’re going  to pay attention and you’re going to notice the   bad things that happen and you’re not going to pay  attention or notice as as much of the good things another example i feel anxious about this test  therefore i am going to fail so the person starts  
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looking for confirmatory information they’re  taking the test and every time they get to a   question they don’t know they’re just like see  i knew i was going to fail and they can actually   create a confirmation bias they tell themselves  enough that they’re going to fail that they  
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actually do fail or i feel vulnerable and  anxious in this relationship therefore this   person must intend to abandon me so i feel anxious  maybe based on prior abandonment experiences therefore i’m going to look for any clue anything  this person may do that may indicate that they’re  
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getting ready to abandon me now i don’t know  for certain whether that’s what their behavior   actually means but i’m assuming based on other  people’s behaviors that that that’s what’s   going on here so there’s we’re not talking  about facts we’re talking about assumptions
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examine your relationship with anxiety  and i know that sounds really weird   but anxiety is there to protect you think  about how it has protected you in the past   and in what ways is this current anxiety maybe  
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dysfunctional but trying to protect you in  in the present you know it’s sort of that um   hyperactive or overprotective uh friend  that wants to make sure that you stay safe   how are you different now than you were in  the past what was dangerous or overwhelming or  
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whatever in the past uh things that caused you  anxiety in the past how are you different how can   you handle them differently how are you safer and  more empowered or how is the situation different   now in the past than in the past maybe in past  situations people that you dealt with were unkind  
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or caused you distress in some way how are these  people in the present different than those people sometimes that people find it helpful to treat  anxiety like a nervous friend think of piglet   from winnie the pooh and set good boundaries if  your nervous friend tells you that there might  
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be a problem and they’re really anxious about  something okay thank you for alerting me i’ll   check it out just because they feel anxious  doesn’t mean you need to take the information   thank them for letting you know and  then figure out for yourself what you  
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think and what your perception of the situation  is then be willing to explain to them why they   don’t need to be anxious in your perception or  why you don’t feel like you need to be anxious   so thank you for letting me know however these are  the actual facts in the situation as i see them  
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how are you safe and empowered if they persist if  your your anxious friend persists in saying no you   need to be anxious you need to be anxious you can  also set boundaries and tell them to go home you   know and that’s where those cognitive boundaries  come in if you treat anxiety as something separate  
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from you as a person or an entity separate from  you then you can more easily set boundaries it’s   hard to set boundaries with yourself sometimes  consider what are you afraid will happen   if you don’t dwell on anxiety all the time  if you’re not constantly scanning for the  
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next shoe to drop what are you afraid will happen  think back to times when you haven’t been anxious   moments hours even not necessarily days or weeks  but moments or hours when you haven’t been anxious   has something bad happened a lot of people  are afraid if they let go of their anxiety  
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then they’re going to be caught unawares by  something bad but think about it times when   you haven’t been hyper vigilant over anxious  when you’ve actually felt calm for a moment   did something bad happen and catch you unawares  a lot of times you’re going to be able to say no
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so rewiring the brain develop distress  tolerance tools for emotional regulation   when you are in your fight-or-flight  mode your cognition is impaired you’re   not going to be able to effectively  evaluate the situation and alter  
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your your brain’s shortcuts alter your brain’s  understanding of the situation when you’re in   fight or flight your brain is focused on just that  fight or flee not let’s check it out in order to   get into the place where you can effectively  evaluate what’s going on and potentially  
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rewire what’s going on you need to be able to  get into what linehan called your wise mind   using distress tolerance tools like  distress tolerant thoughts telling yourself   that you won’t be consumed by anxiety or  that you are able to handle this situation  
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activities like slow breathing breathe in for  four hold for four exhale for four hold for four   so that’s what we call square breathing or  engaging in relaxation activities or even exercise   i know that’s the opposite but sometimes when  your fight or flight system is revved and dumping  
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energy some people find that the best way to  manage that is to actually start moving their body   in sync with their heart so if their heart is  beating fast then they start moving and then when   they stop moving their heart naturally decreases  they kind of get it recalibrated or re-synced  
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between their their physiological  reaction and what their body is doing   guided imagery can be helpful as well as  sensations like sounds and smells and even   things that you feel like splashing cold water on  your face and i have lots of videos on distress  
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tolerance tools on the youtube channel so  i’m not going to go into that a lot here   but it’s important to find tools that work  for you so you can get into your wise mind   and engage in using some of the following tools
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when you’re confronted with a stressful  situation and you manually override your   stress response you use those distress  tolerance schools tools then your brain   actually says hmm wonder what’s going on here  i guess maybe i might not need to be nervous  
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about this i’m not sure you manually  override it you get into your wise mind   you can start adjusting the beliefs and  your brain also associates that anxiety   formerly anxiety provoking situation with  low amounts of physiological distress
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fcp is another technique that i really like   once you’re into your wise mind examine the  facts in the present context i feel anxious   okay that’s a fact i’m mindfully aware that i  feel anxious what thoughts are contributing to my  
00:28:19
feeling of anxiety what are the facts for  and against those thoughts in this context   at this time not when i was eight not last  week not three weeks from now but right now   in this context at this time what are the facts  for and against my belief that there is a threat  
00:28:42
what else might be contributing to my feeling  of anxiety did i have a little too much coffee   in the past few hours is my blood sugar  low am i under chronic stress so you know   i already was like that pressure cooker that  was at max capacity and this one thing that  
00:29:03
came at me normally wouldn’t bother me but  it’s just i don’t know how to deal with it   i don’t know that i have any more energy to deal  with it so i feel overwhelmed and i feel anxious   or as i mentioned earlier are there sensory  triggers around me right now that might be  
00:29:22
contributing to my feeling of anxiety there’s  no actual facts there’s no actual threat in the   environment but there’s sensory stimuli that are  triggering reactions based on prior experiences c stands for what’s within your control  we’ve already evaluated the facts we’ve  
00:29:47
identified what may be contributing to  what’s going on and if there’s a threat   what’s within your control what  can you do to address the situation   and if you do what’s within your control if  you do what you’re empowered to do what is the  
00:30:04
probability of the worst case scenario what is the  probability that catastrophe is going to happen   i have teenagers older children now and one  example can be letting them go out and drive   by themselves when they go out in the car by  themselves i feel anxious yes i do what thoughts  
00:30:28
are contributing to it they could get into a wreck  what are the facts for and against those thoughts   they have a license they are in a safe  vehicle so even if they do get into a wreck   it’s probably not going to be catastrophic  my daughter is a very good driver and
00:30:53
she’s been driving for years and never had an  accident so therefore um what are the facts   supporting my feeling my anxiety you know it do i  have information that says yeah it’s pretty likely   that she’s going to get into into an accident no  i don’t have that information so what is within  
00:31:19
my control with her driving with the exception  of taking away her keys not a lot therefore uh   i have to rely on her being smart and i cannot  control other drivers and i cannot control her   when she is out driving i did my best leading up  to this to make sure that she was a safe driver  
00:31:45
and and again what is the probability of  the worst case scenario the probability   of her getting into a catastrophic  car accident probably pretty small   she doesn’t drive on the interstates uh we  live in a very small town so there’s not a  
00:31:59
whole lot of traffic you know probability  of the worst case scenario is pretty slim another technique that can help in rewiring  is rewriting cognitions or your thoughts in   your core beliefs and i emphasize re-write and  rethinking about it is one thing but if you  
00:32:25
actually hand write it not type it hand write it  it solidifies the new memory or the restructured   memory in a different way than if you just  think it or even if you type it or talk about it when you start feeling anxious  write down what you’re thinking  
00:32:50
and then write down a restructured version or  a more accurate version of what you’re thinking   um all or nothing thinking this happens every time  every time there’s a storm the fence blows down   every time i get into a relationship i get  abandoned those are all or nothing thoughts  
00:33:16
so what are the exceptions write down the  exceptions to the rule um mental filtering   and that is when you focus only on the negative  so again you want to look for the positives   i’m always getting in trouble at work or at school  or my child is always getting in trouble at school  
00:33:40
look for the exceptions okay maybe they’ve  gotten in trouble a lot but not always so what’s   different during the times when they’re  not getting in trouble personalization   you know people don’t like me because i’m a  bad person or people are going to abandon me  
00:34:02
because i’m not lovable what are some alternate  explanations you know maybe it’s because they’ve   got stuff going on now that doesn’t necessarily  mean you’re not going to get abandoned   by a person but if you personalize it if you think  it’s about you then you expect that henceforth  
00:34:25
and forevermore everybody’s going to abandon  you because you’re the one that’s not lovable   if you look at the big picture find alternate  explanations why something may have happened   yes it’s unfortunate and you’ve got to  grieve that loss but you can also recognize
00:34:45
that that doesn’t always have to happen  magnification of the negative or minimization of   the positive look at the facts assuming or jumping  to conclusions without all of the information   or mind reading get the facts you don’t know  what somebody’s thinking if you’re anxious if  
00:35:07
you feel anxious that somebody’s angry with you  instead of assuming that you’re interpreting their   nonverbals correctly or their mood correctly  and it’s about you ask them get the facts   and availability is another thing that  contributes to anxiety we tend to remember and  
00:35:32
react based on the things that are either  most recent or most emotionally charged so   plane crashes for example we hear about plane  crashes on the news and those are devastating   those are very emotionally charged when we hear  about it we feel awful for those people and we  
00:35:54
may empathize and think how awful it would be to  be in that plane crash we don’t think about the   20 000 flights that took off that day that landed  successfully so it’s important to get the facts   if you start thinking flying is dangerous what  are the facts how many planes actually crash um  
00:36:17
driving you know how many cars actually crash how  many people you know actually have problems it’s   important to if there’s something that’s making  you anxious if there’s something you’re afraid of   get all of the facts about it snakes for example  you know when i was growing up a lot of people  
00:36:41
talked about how snakes were dangerous  and in my mind that’s all i heard   snakes are dangerous therefore all snakes  must be dangerous and that’s a false premise   when i started doing the research i learned  that yes there are six snakes in tennessee  
00:37:01
that are dangerous but there are literally  hundreds of other species that are not   so looking at the availability of  information i needed to broaden   my awareness of the whole picture not just  the sliver of information that i was presented
00:37:23
rewiring and retraining can also be done through  experience the first step is to be willing to   be open to the experience and challenge our  inaccurate beliefs which means i’ve got to be   able to look at the snake or whatever it is that’s  causing me anxiety use my distress tolerance  
00:37:42
skills to get into my wise mind and then examine  the accuracy of my facts in the current context   data collection can also be helpful write  it down again handwrite whenever possible   how often does this actually  happen how likely is it to happen  
00:38:06
does it happen literally every single  time so start keeping notes for the   storms i started keeping notes how frequently do  we have storms and how frequently during those   storms does my fence get blown down and the  preponderance of the time it didn’t happen uh  
00:38:32
so it’s important to get data to understand  how often does this happen versus how often   does it feel like it happens what are other  possible outcomes and how often do they happen   so let’s take relationships and abandonment  for example move away from the fence
00:38:54
how what are other possible  outcomes i get into a relationship   and it works out how often does that happen when how often does it happen that people get into  not necessarily just me that other people get into  
00:39:10
relationships that they get abandoned that other  people get into relationships and it works out   it’s important to recognize that how frequently you could expect something to  happen and how accurate are your expectations  
00:39:31
do you expect a gale-force wind and it’s only  a gentle breeze do you expect to fail a test   and okay you get a b minus what  were your expectations going into it   rewiring can also be done through guided imagery  envision yourself successfully navigating  
00:39:56
a concern that that you’re having going to  the doctor or asking somebody out on a date or   your kid going out driving and coming home safely  envision the positive scenario envision the   positive solution envision prior times when you’ve  experienced something similar and it’s gone okay  
00:40:20
remind yourself of other times when it’s gone  okay see that happening and repetition repeating   to yourself the distress tolerant thoughts  and those more accurate cognitions are really   helpful at reducing anxiety so instead of saying  everybody is dangerous or nobody is trustworthy  
00:40:45
repeating to yourself that some people are  untrustworthy and some people are trustworthy repetition repeating it to yourself over  and over again and stopping using the um   extreme or thoughts or the thoughts with the  cognitive distortions that trigger your anxiety  
00:41:12
can help you approach a situation and  feel more in control and empowered your brain learns from experience and uses  those experiences to help you predict the future   information from past experiences often only  provides part of the picture that is what happened  
00:41:33
in the past it doesn’t take into consideration  what’s going on right now when in fight or flight   cognition is impaired and prior information is  often unable to be modified to include new data   so if you expect something to be distressful and  you maintain your anxiety even if the situation  
00:41:54
ended up being no big deal your brain isn’t going  to process that because you were in that anxiety   haze if you will rewiring the brain requires  learning tools to calm the stress response   then identifying new information that may help  you feel safer more empowered that’s based in  
00:42:20
facts in the present context integrating that  new information training the brain to have new   expectations i’ve mentioned in other videos that  when i was very very little i had a bad experience   with a nurse giving me a shot and from then on  i was terrified of needles and i talked about  
00:42:47
it with my doctor one time when i was much much  older and she said i’m gonna give you the shot   trust me it’s not going to hurt and every  fiber of my being said oh she’s lying   but i did trust her and i was willing to be open  to a new experience and sure enough she gave  
00:43:11
me the shot and it didn’t hurt so now i go into  the doctor’s office different doctor now um and   i don’t automatically expect it to be painful  or distressful because i know that it i can get   shots without having it be be awful so i’ve  trained my brain to have new expectations  
00:43:37
now there are certain phlebotomists for  example that you may go to and you may   know from experience that they have difficulty  finding a vein so your anxiety may go up when you   see that particular phlebotomist whereas if you  see a different one who gets the vein every time  
00:44:01
you may not have any anxiety at all and in that  way you’ve trained your brain to be more selective   and not expect that every time you get your  blood drawn it’s going to be a painful situation   the brain’s desire for survival may cause  it to cling to the distressful expectations  
00:44:22
until it is proven wrong multiple  times you can’t just have this fear   and then have an experience that contradicts that  fear and your brain goes oh i was wrong never mind   your brain’s automatic response is to say maybe  that was just an exception let’s see if it happens  
00:44:44
again and so it may take several repetitions of  something several times experiencing something   or doing something like get public speaking  or asking somebody out on a date before it   doesn’t trigger the extreme anxiety response  so it takes practice what you want to look for  
00:45:07
is a reduction in the intensity of the anxiety  each time you repeat it now see if you feel   it feels a little bit easier each time i hope this  has given you a few tools to consider exploring in   rewiring your brain basically what you’re trying  to do is reprogram your brain by providing it  
Source : Youtube

Parasympathetic Response: Train Your Nervous System to Turn off Stress: Anxiety Skills #11

https://www.youtube.com/watch?v=8FpKpW0EhYo
In this episode we’re going  to talk about your vagal tone.
00:00:02
So in a previous episode we talked about  four self-regulatory techniques that   help trigger the parasympathetic  response in our nervous system.
00:00:17
That’s the calming reaction that our nervous  system has to balance out the sympathetic response which is the alerting fight flight  or freeze response. In this episode we’re going to talk about a few more  things that we can do to calm our brain. One of the first things that comes  to mind is meditative breathing so long deep intentional breathing now This helps trigger that calming  reaction and people have been   doing it for thousands of  years for that very reason.
00:00:45
When you breathe out with a  long exhale you may notice an   increased production of Saliva in your mouth. Now That’s a parasympathetic response. A lot more  people are familiar with the sympathetic response Which is a dry mouth. So meditative  breathing long slow out-breath. Now on that note Mindfulness and meditation is also very helpful in triggering the parasympathetic nervous system And we’ll talk more about that  in upcoming episodes. Laughter   is another technique that helps  trigger the parasympathetic response So try and find a way to laugh every day even  if it’s watching dumb cat videos on YouTube. I’m going to put a link to my favorite  down in the description so check that out. Another way to foster your vagal tone Which is the strength of your vagus  nerve is to listen to your biorhythms.   So that means going to sleep when you’re tired, Waking up when you’re refreshed,  eating when you’re hungry,   stopping when you’re full.  These sort of biorhythms naturally help the body  restore its nervous system and function at its optimal level. We  all know how crappy we feel when   we don’t have enough sleep and how it affects our emotional reactions.
00:01:50
Multitasking is something our brains  are not very well developed to do So mono-tasking is a way that  helps calm the brain. Doing one Task at a time and doing it slowly so  doing one slow thing a day something that’s calming and slow and peaceful. For  example sitting down and petting a dog or or taking a slow walk, looking at the sunset or  doing some knitting or crocheting whatever it Is that you like to do.
00:02:17
But just do it slowly without rush. That helps   trigger that vagal response. Social  connection also helps trigger that parasympathetic response so hugging someone, interacting in a positive way,   reaching out and connecting. That all  helps soothe the mind and foster calmness. Anything we can do to take care  of our body also helps relieve   that sympathetic stressed-out,  stored up, pent-up energy, so stretching like just stretching  out your muscles is a Helpful way to release that tension  and trigger that calming reaction as   well as getting a massage or  any kind of physical activity really can be very helpful. Another weird thing  that triggers the parasympathetic response is Standing on your head Now this puts extra pressure on  the heart which causes the heart   to reacts differently and long story  short it triggers that vagal nerve.
00:03:08
Messaging to the body to slow  down and calm down so you can   give that a try go try standing on your head.
00:03:15
It’s important to remember that  none of these techniques are   going to solve your problems. The  purpose behind these techniques is Calming you down So that you can solve your problems if we use  these anxiety reducing techniques as a distraction from our problems or from our anxiety,   in the long run our anxiety is going to stay.  So it’s really important to find out the Function behind your emotions  what they’re trying to tell you   and then meet their needs. We’ll talk  more about this in upcoming videos. Make sure you’re not using these techniques as an   attempt to control or force  your emotions to change as That can often make things worse what we’re   really trying to do is foster the  calm part of your nervous system That’s already there. Hope this was  helpful. Thanks for watching and take care
Source : Youtube

5 Tips for Quick Anxiety Relief in Your Body and Brain | Cognitive Behavioral Therapy Tools

https://www.youtube.com/watch?v=kSloV5jCbBo
Hey there everybody and welcome  to today’s live presentation   five tips to calm your anxiety  i’m your host dr donnelly snipes five tips now there are a lot of different ways  to process your anxiety or calm your anxiety but  
00:00:19
let’s talk about a few that i find particularly  helpful number one recognize anxiety for what it   is anxiety is part of the fight-or-flight response  it’s your body’s way of identifying the fact that   there might be a threat i’ve made the analogy  before that it’s like your body’s smoke alarm  
00:00:41
smoke alarms are not always a hundred percent  accurate they can be set off by a steamy shower   or by a really strong wind or whatever you can  get a lot of false positives with smoke alarms   same thing is true with our anxiety and our  anger sometimes when we experience a situation  
00:01:02
similar to one we experienced in the past that was  threatening we may perceive it as threatening now   even though the situation is totally different  it’s similar but it’s not actually not a problem   now so it’s important to recognize that  it’s your body trying to tell you there  
00:01:23
might be a threat and give you the energy through  that activation of the hpa axis give you the   energy to actually get up off the couch and check  and see if there is a threat it doesn’t mean   that you have this energy and that you have to  run that you have to fight it means it’s just  
00:01:45
allowing you to have the the resources  you need just in case learn your anxiety   vulnerabilities and triggers vulnerabilities  are things that make you more likely to react   to a situation with a stronger than normal  reaction for you so vulnerabilities can be  
00:02:09
like being over tired being sick being in pain  being in a large crowded area or being in an   area where there’s a lot of hubbub going on  where you feel just completely overwhelmed   vulnerabilities can be physical like i said sleep  deprivation sickness pain etc low blood sugar it’s  
00:02:32
another one vulnerabilities can be affective if  you’re already anxious or angry or depressed or   overwhelmed then it’s you’re already primed to  react to stress with a more intense reaction   vulnerabilities can be cognitive if you are in a  negative frame of mind where you are interpreting  
00:02:59
most things as catastrophic then that can  put you in a place where you’re probably   going to be more likely to have a more intense  response vulnerabilities as i mentioned can be   environmental if you are one of those people  who doesn’t like to be in the middle of all the  
00:03:17
stuff and being uh in the middle of for example a  classroom of six-year-olds is overwhelming to you   then that might cause you stress because you’ve  got you know little ones running around everywhere   so you might be more likely to react with  a more intense irritability or reaction  
00:03:39
and finally relationship vulnerabilities  if you are feeling bad about yourself   your self-esteem slow or if you are feeling uh  unsupported or maybe you’re just around somebody   who gets on your very last nerve let’s just put it  out there then that may make you more vulnerable  
00:04:01
to respond to mild triggers with a more intense  reaction so vulnerabilities it’s important to   be aware of these because a lot of them you can  mitigate or you can prepare for so let’s take   the example of if you didn’t get enough sleep  and you’re not feeling your best you have got  
00:04:25
to volunteer in your kids kindergarten classroom  where there’s a bunch of little five-year-olds   running around everywhere and that’s not really  your thing to be you know managing 15 children   there are a lot of vulnerabilities there so  what can you do to prevent your vulnerabilities  
00:04:47
from resulting in a more intense reaction  breathing ahead of time maybe calling in   and saying you know what i can’t volunteer in  the classroom today sometimes you just gotta   tap out triggers are the things that activate your  anxiety or your anger so when you’re vulnerable  
00:05:12
triggers are more likely to prompt an anxiety  response but again your triggers can be physical   what physical things trigger your anxiety physical  sensations for example what affective things   trigger your anxiety maybe if you start feeling  depressed it might also trigger your anxiety  
00:05:34
because you start worrying that people are going  to judge you for being depressed triggers can   be cognitive if certain things that you think or  certain things that you learn trigger your anxiety   triggers a lot of triggers can be environmental  sights sounds smells and relationships can also  
00:05:56
be triggers again if you’re around somebody who  is stressful to be around that can be a trigger   for your anxiety or if you’re around somebody  and you have a fear of abandonment then certain   nonverbals that they have may trigger your anxiety  but being aware of those is important because as  
00:06:21
soon as you’re aware then you can take steps to  more effectively evaluate is this a threat in   this particular situation at this time number  three develop a relationship with your anxiety i   know that sounds really weird instead of trying  to get rid of it it’s there to protect you  
00:06:44
develop a relationship with it the first  example i’ll give you is piglet if you remember   uh from winnie the pooh piglet had some anxiety  let me tell you what and you know it could kind of   be stressful i think to be around piglet because  he was always worried about stuff however getting  
00:07:03
to know piglet and developing a relationship with  him allowed he and pooh to get along just fine   recognizing that pooh recognized that sometimes  piglet would get upset about stuff that   pooh didn’t really see as threatening your anxiety  is the same way sometimes your inner piglet is  
00:07:25
going to get upset and you look around and you  go you know what it’s it’s not such a big deal   mine is lenny and when i start having um high  levels of anxiety my chest starts to feel tight   and i’ve named it lenny i i literally call it my  name and i’m like you know lenny’s sitting on my  
00:07:47
chest today and by doing that it separates the  anxiety from me i don’t have to be that feeling   i recognize that lenny’s there and lenny’s not  doing anything but you know sitting on my chest   and lenny will go away but that’s you know kind  of how i uh personify it in order to unhook from  
00:08:12
those feelings when you start feeling anxious scat  and when i say scat i mean like scat scat get away   not scat what animals leave on the ground i  recognized after i did that mnemonic that it could   be taken either way but scat stands for check to  see if you’re safe get mindful look around go am i  
00:08:33
safe at this point in time is there any imminent  threat to me in this context am i safe okay   so once you recognize that you are safe then you  can start taking steps to address those triggers   that might be contributing to  your anxiety smoke alarm going off
00:08:58
calming your anxiety isn’t just about feeling  anxiety and starting to breathe and going okay   if i breathe for long enough i’m going to feel  relaxed and the anxiety is going to go away no   as long as that amygdala is you know fired up and  saying hey there might be a threat it’s going to  
00:09:18
be hard to tone down that anxiety so being aware  of your triggers developing a relationship with it   so you don’t feel like you have to react you know  just because pig was anxious doesn’t mean you have   to be anxious and then addressing those triggers  in the moment looking around and going okay  
00:09:39
that’s what’s triggering me  right now what can i do about it   and finally develop an anxiety response plan that  includes distress tolerance and square breathing   now remember square breathing inhale for four  hold for four exhale for four hold for four  
00:09:58
and repeat a couple of times and this doesn’t do  everything but it can help manually override the   stress response like i said in and of itself  that’s not going to do everything because if   you’re still feeling anxious if your brain is  still screaming at you hey there’s a problem  
00:10:20
then they’re gonna be in in competition distress  tolerance is are things like thoughts that you   can have that encourage yourself to recognize okay  this sucks and i can get through it i feel anxious   and it won’t consume me or i recognize that i feel  anxious i see no threat therefore i’m going to  
00:10:48
engage in some other distress tolerant  activity but those are five things that   you can do in order to handle in general handle  anxiety sort of sort of on the fly instead of   fearing anxiety instead of fearing fear recognize  its purpose get to know it and help your brain  
Source : Youtube

Evidence Based Practices for Health Anxiety and Somatic Symptom Disorders

https://www.youtube.com/watch?v=y6SMkw_LKws

00:00:02
Hey there everybody and welcome to this video  on practices for addressing health anxiety and   somatic symptoms i’m your host dr donnelly snipes  now obviously the title of this is evidence-based   practices however doing the research on pubmed  unfortunately there was a devastating lack of  
00:00:25
research on evidence-based practices for treating  these issues so we’ll talk about what i did find   and we’ll talk about what i have learned  over 20 some odd years of clinical practice unfortunately much of the literature  still refers to somatic symptom disorders  
00:00:47
as symptoms which have no physical  cause and that is not true anymore   and i mean this was even after the dsm 5 was  released that the research especially from   in medical journals was focused on symptoms  that have no identifiable medical cause  
00:01:11
the dsm-5 defines somatic symptom disorders though  as one or more physical symptoms that result in   clinically significant distress it says nothing  about whether there is or is not a physiological   cause and we need to really underscore that  doctors must get away from assuming that something  
00:01:36
is all in people’s heads when they cannot  identify a cause fibromyalgia for the longest time   pots hyperparathyroid and chronic fatigue syndrome  have all fallen into that category where for years   decades people were told that hey there’s  no underlying physiological cause for your  
00:01:59
complaints therefore nothing must be wrong and it  must be all in your head and now we know that hey   there actually is physiological um markers there  actually are physiological markers and something   is actually a miss in the body factory you just  didn’t know what to look for before um and it’s  
00:02:22
important for us as behavioral health clinicians  and social workers to also really guard against   invalidating people’s experiences we want to help  them improve their quality of life we don’t live   in their skin so invalidating  their experiences is not helpful
00:02:46
one of the analogies i make sometimes if you’ve  ever worked with somebody who has a psychotic   disorder when they are in a psychotic episode  no amount of telling them that their perception   of what’s going on is wrong is going  to do any good it’s actually going to  
00:03:06
break the relationship it’s important to join  them in their reality their perceptions now i   am by no means saying that people with somatic  symptoms are psychotic no i am not i’m saying   their symptoms their perceptions their feelings  the way they are experiencing life is very  
00:03:26
real and just because we don’t experience it  that way doesn’t mean it’s not real to them   we’ve learned over the years that there are a lot  of people with sensory integration and sensory   gaiting difficulties for example that experience  things very differently what you may experience  
00:03:48
as lukewarm they may experience as scalding the  temperature objectively is the exact same but   their nervous system their sensory  response is very very different and   by ignoring that we are causing trauma we are  causing them to feel invalidated hopeless and  
00:04:11
helpless and we’re promoting emotional  dysregulation think about people who well let me go on with this before i before i  make another analogy physical interventions for   somatic symptom disorders this person is having  physical symptoms it’s going to be difficult to  
00:04:37
address anything cognitively until we have  the facts so they’ve probably already had   a physical and blood work in order to  provide evidence of what is or is not   going on that we can measure at this  point in time so let’s get that data
00:04:59
this can help people rule out for example  catastrophic physical concerns if they’re   concerned that they’ve got cancer for example you  know let’s get the information that says we don’t   see any evidence of that right now doesn’t mean  you’re not having symptoms but let’s rule out  
00:05:18
anything that we can um relatively easily  i’m not talking about sending people to   you know 16 different specialists but that  can help us when we get to the cognitive   interventions because it gives us some foundation  to evaluate so for example if somebody is having  
00:05:39
pain in their back and i will use my example  my mother died of kidney cancer for months she   thought that she had pulled a  muscle in her back at the gym   turns out it was kidney cancer and that freaked  me out um so then when i started having pain  
00:06:02
in my back i got concerned and then i got some  blood work that was a little bit off i got even   more concerned but then i looked at the blood work  and i looked at all of the other tests of kidney   function and white blood cells and everything  else and they were all within normal parameters  
00:06:20
so what was the take home and we’re going  to talk more about occam’s razor in a minute   the take-home or the most um logical  explanation the simplest explanation was   hey it’s probably your scoliosis or you  probably pulled a muscle in your back which  
00:06:38
i do a lot you know working out on the farm  moving bales of hay and those sorts of things cognitive interventions now if  somebody is having somatic symptoms   we are not necessarily going to be able  to address those very much what we are  
00:06:56
going to need to look for is how can we improve  your quality of life emdr i have on the top of the   list why is that a lot of people not everybody  but a lot of people with somatic symptoms   have a history of trauma and vander kulk said it  best that a lot of times trauma is remembered as  
00:07:22
a sensation or a feeling as opposed to a thought  or a memory and emdr may be able to help untangle   or identify a connection between a  traumatic experience and a somatic   symptom so emdr can be very helpful people  can also develop health anxiety and after  
00:07:49
a traumatic experience where a loved one dies  of an illness or after they have a particular   physical health problem like a heart attack  then they may become hyper vigilant to   any sort of cardiac symptoms or any sort of  related symptoms so emdr can be really helpful at  
00:08:13
helping people integrate these memories in  a way that it doesn’t always trigger their   fight or flight response it doesn’t trigger  their anxiety at least not to the same extent   improving health literacy is very very helpful  and there was a little research on this the more  
00:08:32
people feel educated about a particular  illness or condition the more empowered   they feel to either protect themselves from  getting it or to deal with it if it happens   the key is where do you how do you improve  health literacy and it’s really difficult in  
00:08:54
today’s day and age of the internet where  not everything is a hundred percent accurate   and a lot of things are written so generally  that it can actually promote more anxiety   improving health literacy especially in people who  already have health anxiety or somatic symptoms  
00:09:17
in my opinion can best be done through  guidance from a case manager a social worker a counselor or a medical professional  who can gather the information that is   appropriate and accurate for that person without  providing them information that might trigger
00:09:44
unnecessary anxiety and we’ll talk about that a  little bit more in a minute cognitive processing   and this is where that physical comes in cognitive  processing encourages people to get away from   emotional reasoning emotion-based reasoning i  feel scared therefore something must be wrong  
00:10:06
and look at the facts what are  the facts for and against my   belief that i’m in danger of getting this  condition or that i have this condition   now cognitive processing doesn’t work as well with  somatic symptoms because the facts are the facts  
00:10:24
if the person is experiencing a symptom that’s  what they’re experiencing and even if there’s no   medical cause or if there is it doesn’t matter for  our purposes as behavioral health clinicians if   they’re experiencing a reduction in their quality  of life as a result of a physiological symptom  
00:10:49
then it is so what facts might we look at well  we’re going to talk about backward chaining in   a minute but we might look at facts such as  what makes it worse and what makes it better   control what aspects of this situation can you  control once you’ve identified what makes it worse  
00:11:08
and what makes it better then you can identify  ways to try to reduce the intensity of the   symptoms once you’ve identified the risk factors  for getting an illness then what aspects can you   control what can you do to keep from getting  it or if you have it what can you do to help  
00:11:33
yourself recover from it or live a high quality  of life with it and p stands for probability and   we need to recognize it and again it’s really  important not to invalidate people’s perceptions   but we also need to recognize if based  on the facts that i have and if i do the  
00:11:57
things that are within my control what is the  probability i can have a high quality of life cognitive behavioral interventions those come up a  lot i think it’s probably because it’s one of the   easiest things to do a study on quite honestly  but addressing distortions can be very helpful  
00:12:19
all or none thinking i’m either sick or i’m not  sick i can either have a horrible quality of life   or a good quality of life jumping to conclusions  like i said i have a back egg therefore it must be   catastrophic all right let’s look at the facts and  same thing for emotion-based reasoning looking at  
00:12:42
the facts and thinking you know what are three  other explanations for why my back might hurt   or why i might feel like you know my chest is  a little tight besides something catastrophic living in the and and heartiness are also  interventions that can be very helpful recognizing  
00:13:04
again that sometimes people have symptoms somatic  physical symptoms that met current medical   knowledge can’t fully explain or can’t explain the  intensity of the symptom however they’re having it   so how can they have their highest quality  of life and be experiencing this symptom  
00:13:29
people with chronic illnesses face this all the  time how can i have a rich and meaningful life and   cope with the symptoms of my particular condition   similar to living in the and is hardiness  and we’ve talked about this in other videos  
00:13:48
heartiness is comprised of commitment control  and challenge commitment means helping people   recognize all of the things in their life to which  they are committed all of the things in their life   that bring it meaning and richness and each one  of those things is like a bean in a jar or a  
00:14:09
slice of a pie however you want to think about  it recognizing that any one point in time   all of the pieces of your pie may not be going  perfect but focusing or at least acknowledging   those things that are going right that you’re  committed to can be helpful control what can you  
00:14:34
do to continue to experience good things and the  things that are going right and what things can   you do to maybe improve the things that are going  crappy right now and challenge you know sometimes   life just keeps throwing us curveballs or  lemons or whatever your life throws at you  
00:14:54
and yes it sucks we can view these things as  barriers that keep us from having the life we want   and just kind of sit down and go i give up or  we can view them as obstacles things that we   need to either get over around under or through in  order to get to that quality of life that we want
00:15:17
now take drawing from dialectical behavior  therapy we have backward chaining radical   acceptance and distress tolerance many people who  have somatic symptoms or who have health anxiety   have experienced invalidation from significant  others from health care providers even from  
00:15:38
mental health providers and therefore they  may feel very hopeless helpless demoralized   it’s important to give them a place where  they can say this is what i’m experiencing   and be heard and believed we’re not saying you’re  making it up we recognize we may not be able to  
00:16:01
explain why you’re feeling it but we recognize  you’re feeling it so let’s backward chain and see   what was it or what things may have added  together to trigger this flare up to trigger   this particular um symptom episode that you’re  having and this is something that lenahan  
00:16:25
really promotes with people who  have borderline personality disorder   and emotional dysregulation however it’s very  very helpful for people who also experience   what i’ll call somatic dysregular dysregulation  helping them identify what is causing this symptom  
00:16:46
for them at this point in time it provides an  immense amount of personal control to be able to   say okay i can see a couple of things that i  might be able to do to prevent this in the future   radical acceptance is recognizing that hey i  have this symptom maybe there is no medical  
00:17:12
explanation or maybe there is and i can’t  get rid of it for some reason like pots or   chronic fatigue syndrome radically accepting i’ve  got this so back up to living in the end how can   i have my highest quality of life possible and  also have this condition this symptom this fear
00:17:40
distress tolerance is another skill that can  be helpful when people start feeling a symptom not saying that it doesn’t exist okay  i’m not saying that it doesn’t exist   what i’m saying is when they start feeling the  symptom just like we do with anxiety sort of  
00:18:00
developing a relationship with it and saying all  right you’re back again well crap on a cracker once a person is able to tolerate the distress  they don’t have to like it but being able to   tolerate it can prevent rushes of anxiety  floods of adrenaline that can potentially  
00:18:23
exacerbate or make make their symptoms worse so  distress tolerance can be helpful when they’re   having a flare-up being distress tolerant for most  symptoms that people present with can be helpful   because when we get stressed it triggers  that stress response system and it can  
00:18:45
increase inflammation it can impair sleep it can  impair gi functioning it can cause all kinds of   symptoms that can make the original symptom even  worse so distress tolerance can be a helpful tool   again and i know i’ve said this like 16  times already i’m going to say it again  
00:19:08
this is not to say the person is not  experiencing xyz symptom it’s just help them   recognize okay i’m experiencing this symptom it is  what it is what can i do next instead of getting   angry and starting to fight with it and try to  get rid of it even though they know they can’t  
00:19:32
another technique that can be helpful for people  especially with health anxiety is to schedule in   worry what i call worry checking or research  time depending on their particular diagnosis   if they have health anxiety tabling their worry  tabling their focus on doing research to try to  
00:19:53
figure out what’s going on to a prescribed 30  minute period during the day can feel somewhat   liberating because then they don’t have to  think about it the rest of the day when they   start worrying about it they can jot it down  in their journal or on a little piece of paper  
00:20:15
and say okay i will worry about this this evening  right now i’m going to focus on these other things   checking during this time if they are  concerned about particular issues instead of   spending a whole lot of time checking  things scheduling time to do it or research  
00:20:38
and research again can be a little  bit dicey because people can find out   not so good or not so hopeful information  i am not encouraging people to ignore acute   intense symptoms if they’re  having them it is important to
00:21:01
find that happy medium environmental interventions turn off the tv turn  it off if you are hearing stuff on the tv that   is triggering your health anxiety triggering your  somatic symptoms then turn it off this was super  
00:21:21
true during the pandemic i almost didn’t watch tv  during the pandemic and even like um prime time tv   especially when they started integrating the  pandemic into the storyline i quit watching it i’m   like when i am watching tv i am trying to escape  i don’t want this continually thrown in my face  
00:21:44
i’ll do the same thing when i’m watching a show  and they insist on weaving in this theme of some   character in the store and in the show having  cancer there was a period there it seemed like   every single show i was watching somebody had  cancer i’m like this is not what i want to have  
00:22:03
to think about right now now obviously that was  shortly after my mother had passed from cancer   and i’m like no i don’t want to have to think  about that i don’t want to worry about that   so turn off the tv or find something  that you know is safe to watch  
00:22:22
a comedy a you know some other show  where that’s not going to be woven in avoid and yes there’s a term  for it now cyberchondria   many very benign as well as not so benign  conditions share similar symptoms like fatigue  
00:22:44
people may go on and and start searching for what  would be causing my persistent ongoing fatigue   and there is literally everything in the alphabet  that can cause fatigue but a person with health   anxiety is often going to hone in on the uh most  catastrophic explanation oh my gosh it could be  
00:23:16
this well okay how likely let’s go back to facts  control and probability what is the probability   out of the 37 things it could be what is the  probability it’s the one catastrophic thing   there’s a a theory i don’t know what to call it  called occam’s razor which says basically often  
00:23:40
the simplest explanation is the most accurate  explanation so think you know if you have a   backache if you have a neck ache if you have  um an itch what is the most likely cause of it   and then explore explore that and and that  can really help allay some of your anxiety  
00:24:09
and recognize click bait click bait is there  and this is true for the media too they’ll put   out these little teasers but click bait and  television teasers are there to motivate you   to go to their site to hear what they have  to say so they can get advertising revenue  
00:24:28
and it’s important to recognize that so  they are going to probably put some very   generic benign stuff out there that everybody  has or everybody can relate to because they’re   trying to trigger your anxiety people are more  motivated when they feel like there’s a problem  
00:24:48
if they’re saying oh watch this video  of this this happy dog running around   they’re not going to get as many people to  click on it as if they say watch this video   that may um help you identify five early warning  signs of this catastrophic something something  
00:25:06
um so do recognize click bait for what it is a  organization’s desire to increase their views and relational interventions  limit exposure to people who   dwell on their symptoms or people’s disorders
00:25:28
many of us know people who are very very  focused on these things and they want to talk   about these things constantly their friend’s xyz  disorder or their xyz symptom or the possibility   of getting xyz condition and when you  are immersed in that when it’s constantly  
00:25:50
bombarding you just like every time you turn on  the tv it can feel inescapable and you can feel   uh powerless and unsafe because you’re constantly  being presented with the worst case scenario   and rarely are you hearing okay well here  are all the other factors here are all the  
00:26:14
ways to prevent it here’s the probability  that it’s going to be an issue for you   so if you need to limit exposure to what  i call chicken littles the one the people   who want to focus on the sky falling that is a  healthy boundary to set find a trusted provider  
00:26:36
mental health social work medical ideally  medical that can help you get your get   answers to your questions somebody  who can point you in the direction of   accurate understandable  health literacy information  
00:26:53
communicate with your significant others how they  can best help you with your distress and this goes   back to some degree to those secure attachments  being responsive to you when you’re in distress   reminding you of distress tolerance skills maybe  helping you by turning off that tv you know what  
00:27:14
this seems to be triggering your anxiety so  let’s turn this off and go do something else   and not perseverating sometimes it’s important  to remind people in your life that hey that’s too   much for me to hear i don’t want to hear about  whatever it is validation of your perception  
00:27:35
it’s important for people to understand that your  reality is your reality they don’t have to agree   with it they don’t have to be experiencing it  themselves but your reality is your reality   when um we’re at my house my my body temperature  runs very different than everybody else in my  
00:27:58
household and i can be like sweating to death  and they’re all walking around in sweaters   does it mean that i’m not actually hot no clearly  i am i’m sweating but their perception is very   different they’re like i don’t know how you can  be hot or walking around in shorts in this weather  
00:28:20
i am it just is the way i am is how  i’m experiencing the world right now   so validating your perception and in our household  i validate that hey you know i can see your cold   by the fact that you’re wearing a sweater i’m  not going to be critical you do what you need  
00:28:38
to do i do what i need to do and empathy empathy  can be really helpful now that doesn’t mean um encouraging perseverating on the symptoms but  empathy about how frustrating and disempowering it   must feel sometimes not to have answers and i was  just having a discussion with one of my friends  
00:29:03
the other day about how liberating it can be  even if you are diagnosed with a chronic illness   how liberating it can be to finally have a  diagnosis that says this is what you’ve got and   even if there’s not a treatment for  it at least you know at least you have  
00:29:22
something to call it at least you have  you know an avenue that you can look for   clinical trials or something if  you feel like you need to do that   but it’s very liberating as well because a  lot of times unfortunately i know i’ve gone  
00:29:41
through this entire presentation and harped  on the fact that your reality is your reality   but a lot of our loved ones and providers  and other people don’t understand and if they   don’t have a diagnosis it’s hard for them to be  willing to empathize and the same thing is true  
00:30:02
in terms of getting reasonable accommodations  at work unless you have a diagnosis of some sort   a lot of times it’s really difficult to get  reasonable accommodations so there can be a additional reason why somebody may  be really wanting a diagnosis just  
00:30:26
tell me what’s wrong or tell  me what i’ve got that way i can   get what i need to get in order  to have my highest quality of life there is a disturbing lack of research into  the interventions to help improve the quality  
00:30:43
of life of people with somatic symptom  disorders and health anxiety the majority   of interventions discussed in this presentation  are those that i have used in clinical practice   and or used personally one of the  most important factors in addressing  
00:31:00
somatic symptom disorders and health  anxiety in my opinion is to balance   awareness of the current facts with the reality  of the presenting symptoms for that person   and focus on helping them do what they  can to improve their quality of life
Source : Youtube

Health Anxiety, and Illness Related Psychological Distress | Somatic Symptom Disorders | DSM 5 TR

https://www.youtube.com/watch?v=hy46OtDsjpI
Hello everybody and welcome to this week’s ceu  class on health anxiety and illness related   psychological distress in the dsm this is  the category of somatic symptom disorders   i’m your host dr donnelly snipes in this  presentation you’re going to learn about  
00:00:18
the category of somatic symptom disorders in the  dsm-5tr we’ll explore the diagnostic criteria   for the disorders in this category as outlined  in the dsm-5tr and identify risk factors and   co-occurring issues as identified in the dsm-5-tr  as well as in clinical research i.e from pubmed
00:00:44
of the disorders in the somatic symptom disorder  section are focused mainly on somatic symptoms or   illness anxiety although in the dsm-5 they tried  to more effectively differentiate the disorders   there is still a great deal of overlap  and you’ll see that when we get in there  
00:01:03
interestingly the dsm notes that non-psychiatric  physicians and mental health clinicians   found the dsm-4 diagnostic criteria  difficult to apply which is why they   revised it in the dsm-5 by reducing the  number of disorders and sub-categories  
00:01:20
so in the dsm-4 it was even harder to  differentiate and differentially diagnose   it’s important to remember that many mental  disorders initially present with primarily   physical or somatic symptoms and in some cultures  that somatic presentation may always predominate  
00:01:43
previous criteria for somatic symptom disorders  over emphasized the importance of symptoms being   unexplained by a physiological exam it is noted  in the dsm 5tr that it is not appropriate to give   an individual a mental disorder diagnosis solely  because there is a lack of physiological findings  
00:02:07
that is an important note that we need to  remember when making these diagnoses risk   factors for somatic symptom disorders include  genetic and biological vulnerabilities that cause   differential pain perception well that makes  sense when somebody is more sensitive to pain  
00:02:30
or less reactive to pain it can present as  different symptoms neurological disorders or   chronic pain issues or somatic symptoms trauma is  also a risk factor for somatic symptom disorders   if you’ll remember from other presentations  vanderkulk has said repeatedly that a lot of times  
00:02:57
trauma is remembered in the body it’s remembered  as a somatic sensation not necessarily as a an   overt memory additionally people who are in  situations in which the sick role is reinforced   may be more likely to present with somatic  illnesses as well as situations in which  
00:03:21
there is not any reinforcement for mental  health presentations of distress again in   some cultures and even in some families mental  distress is ignored minimized pathologized and   somatic symptoms or physical symptoms are the  only thing that is recognized and considered  
00:03:43
a valid complaint so the presentation may  of mental illness or mental health issues   may vary based on culture and family acceptance  of mental health symptoms differences in   cultural expectations and explanations  for physical symptoms or somatic symptoms  
00:04:10
and the differences in the management of symptoms  may also be a risk factor or a differentiating   factor for diagnosis of somatic symptom disorder  so let’s talk about somatic symptom disorder and   it is obviously the primary disorder in this  category that is titled somatic symptom disorders  
00:04:38
in somatic symptom disorder the person has  to have one or more physical symptoms that   result in clinically significant  distress okay that’s pretty broad criteria number two they must exhibit  excessive thoughts feelings or behaviors  
00:04:58
related to the physical symptom now  excessive is what differentiates it from   quote normal or expected anxiety or behaviors  and there is no objective definition of excessive   the excessive thoughts or feelings or behaviors  can be characterized by one or more of the  
00:05:25
following a disproportionate persistent thought  about the seriousness of the illness so if   somebody has i have a strong history of cancer in  my family particularly melanoma so i’m regularly   checking my my freckles and my moles um now if i  were disproportionately obsessed with you know oh  
00:05:48
this mole looks a little strange and it suddenly  consumed what i was doing then that might qualify   persistently high level of anxiety about the  symptoms so if i had a lot of anxiety about   the fact that you know some of my moles  are slightly different colors or whatever  
00:06:09
that could also be a symptom but again it has  to be excessive and who defines excessive that’s   one of the things we’re going to talk about and  finally excessive time and energy is devoted to   these symptoms or concerns so let’s switch gears  you know cancer is something people worry about  
00:06:30
viruses or something people worry about but  menopause hot flashes okay that is a physical   symptom that can result in clinically significant  distress if you’ve ever had hot flashes you know   it can wake you up in the middle of  the night hot flashes can be really  
00:06:50
um disruptive to your life and they’re real  they they exist a lot of times when you have   hot flashes your heart is also racing a little bit  it can increase up to 20 beats a minute they say   a person may spend a lot of time and energy trying  to figure out what can i do to control these  
00:07:11
hot flashes so i can sleep through the freaking  night and they’re looking at different mattresses   and different solutions and they’re looking at  different herbs and consulting different doctors   is that excessive when the physical symptoms  are preventing them from being able to sleep  
00:07:30
i’m not saying one way or another however  i think it’s important for us to consider   what is the impact the symptom is having on the  person and how much is it the symptom itself   being um functionally disruptive for them and as  a result of that is the time and energy devoted to  
00:07:56
the concerned or alleviating the concerns  excessive it may not be we need to be really   really careful about pathologizing people’s  desire to have a reasonable quality of life   and finally for the diagnostic criteria although  any particular symptom may not be continuously  
00:08:18
present the person exhibits symptoms continuously  for at least six months so they may have   disproportionate or persistent thoughts about the  seriousness of a variety of different concerns or   persist persistently high levels of anxiety about  a variety of symptoms that they’re experiencing  
00:08:38
or they may spend excessive time and energy  devoted to a variety of different symptoms and   you know for those of you who are older you know  as you get older you seem to break a little bit   more and there is a and younger people who  are going through growth spurts may have  
00:08:59
um aches and pains and changes that uh vary  over the course of several months so we do   want to consider you know what’s going  on and is this excessive for the person somatic symptom disorder can be diagnosed  with or without a medical explanation and  
00:09:23
i’m going to spend most of the time in this  presentation on somatic symptom disorder since   it is the primary diagnosis and the one with  the most research behind it in this category but   so somatic symptom disorder can develop in  somebody after they’ve had a heart attack they may  
00:09:45
be hyper vigilant to signs of another heart attack  well that kind of makes sense now we want to look   at is there concern and is are there feelings  about this fear about having another heart attack   is it disruptive to their life and you know it’s  really this is where it kind of starts getting  
00:10:07
really dicey to differentially diagnose  between somatic symptom disorder and   anxiety um and illness related anxiety  but i digress superventricular tachycardia   is another one of those things it’s  kind of like when you take your car  
00:10:25
to the mechanic and there’s this sporadic squeak  or issue that you’re having the mechanic can’t   find it so they said there’s nothing wrong  it’s you know all in your head svt is one   of those that we’re going to talk about that is  really difficult a lot of times for doctors to  
00:10:45
catch because it occurs so sporadically you can  have multiple in a day and then go weeks or months   without having one supraventricular  tachycardia is when your heart rate goes from   normal for you to all of a sudden just jumping  up to you know 170 180 200 and it feels like it’s  
00:11:09
going to pound out of your chest and it hurts  so supraventricular tachycardia is one of those   that people may be more hyper vigilant about after  they’ve had an episode because it’s terrifying   but it’s also one that is often dismissed  by doctors that say well if it resets on  
00:11:30
its own it’s not a big deal well what  happens if it doesn’t reset on its own   if somebody has had a death of a loved one  from fill in the blank cancer heart attack   stroke whatever then they may become more  hyper vigilant when they have similar symptoms  
00:11:50
i already talked about menopause that can  be something that comes on and it comes on   at different ages for different people but it  can cause a variety of physiological symptoms   that may be disruptive to the person’s  life that they may spend a lot of time  
00:12:07
trying to figure out how to manage the virus and  i can’t say the c word because the youtube algos   would like completely lose their ever-loving mind  but getting sick with a virus can be uh can also   prompt somatic symptom disorder or health anxiety  or i’m sorry they call it illness anxiety um
00:12:33
in people when they start getting a sniffly nose  they start thinking oh my gosh i must have this   virus when they have a cough that’s sort of  quote unexplained they may worry about it   especially when that particular disorder whatever  it is is regularly presented to the people  
00:12:56
and there are a lot of diffuse  symptoms that can characterize it then it can become easier for people to  develop somatic symptom disorder and become   hyper vigilant to a lot of those symptoms oh do  i have a headache oh i wonder what that means  
00:13:14
fibromyalgia and pots fibromyalgia was actually  initially identified in 1904 but it wasn’t   recognized by the american college of rheumatology  until 1990 pots postural orthostatic tachycardia   syndrome was originally identified i believe in  1984 i had the reference later in the presentation  
00:13:40
but there are a lot of doctors that still don’t  believe that it truly exists now interestingly   enough fibromyalgia and pots both have clinically  identifiable symptoms in fibromyalgia it’s through   an mri and through blood tests and pots  there’s a variety of other tests that can  
00:14:04
identify whether somebody meets criteria but  despite that for the longest time fibromyalgia was   dismissed as being something that was not a  real diagnosis now that now we know it is and   you know potts is still trying to  establish itself despite there being  
00:14:30
clinical centers of excellence like the one  at vanderbilt that are actively studying it   chronic fatigue is another one of those syndromes  or issues that people can have that has long been   pathologized if you will and stigmatized  because it’s what they call a diagnosis of  
00:14:56
exclusion there is no test for chronic  fatigue it’s just a person who presents with   a certain set of symptoms that aren’t explained  by anything else must have chronic fatigue hyperparathyroid and this one um i bring  up specifically because i have known a  
00:15:18
couple of people who’ve had it and it has gone  they’ve gone years without it being diagnosed   but people with hyperparathyroid may experience  fatigue and depressive like symptoms as well as   quote according to the mayo clinic frequent  complaints of illness with no apparent cause  
00:15:38
so this is another one that often probably got  pushed off as a mental health issue when in   actuality there was a an actual dysfunction within  the hyperparathyroid gland oh my gosh and both of   these people once they had their hyperparathyroid  gland removed they were asymptomatic imagine that  
00:16:03
and then i did find another article that  was interesting that indicated that ptsd   uh often has a lot of somatic symptoms quote  somatic symptoms are ubiquitous especially are   a ubiquitous aspect of the clinical presentation  of ptsd therefore we need to recognize  
00:16:27
that people with ptsd often have somatic  symptoms now that’s not really highlighted a lot   in the diagnostic criteria so a lot of times  people with ptsd and concurrent somatic symptoms   or people with depression and concurrent somatic  symptoms are given somatic symptom disorder  
00:16:51
diagnosis in addition to the other uh in addition  to the other diagnosis because the mind-body   dualism is still not really well integrated in  the dsm 66 to 75 percent of people who previously   were diagnosed with hypochondriasis i know  that’s like dr dragging your fingernails down  
00:17:18
a blackboard to hear it are now diagnosed  with somatic symptom disorder the rest are   diagnosed with illness anxiety hypochondriasis is  no longer a diagnosis in the dsm-5 or the dsm-5tr a distinct characteristic of people with somatic  symptom disorder is not the somatic symptoms per  
00:17:41
se but instead the way they present or interpret  them they may have a symptom which is either   a normal bodily symptom or a what many people  would consider a minor pain or a minor symptom   and they are perceiving it as far more dangerous  and intense now that can be for a variety of  
00:18:07
reasons part of it could be because of perceptual  differences and i really didn’t find much on   the comorbidity of somatic symptom disorder  and other mental health issues that involve   sensory differences like autism spectrum  disorders or adhd but i would wonder if  
00:18:33
there’s a higher comorbidity there in those  especially in those that are hypersensitive   to sensory stimulation i’m just hypothesizing  however the fact that we even say that it’s not   the symptom that’s the problem it’s  the way that you’re interpreting it  
00:18:54
often causes invalidation of the person the  doctors often say it’s all in your head or   you’re overreacting well how invalidating is that  how hopeless and helpless do i feel if i’ve got   this chronic symptom that is impairing my  quality of life and my medical providers
00:19:16
talk to me like i’m an idiot you know  that’s very invalidating so a lot of people   who receive that reception from their physician  often go to the internet to try to self-diagnose   and self-treat their issues anybody who’s  gone on the internet to try to self-diagnose  
00:19:37
knows that the information out there  varies widely in credibility and it   very easily promotes catastrophic  perceptions you know you can go to just about   um like on mayo clinic or webmd and look up just  about any symptom and under each one of them  
00:20:01
it will say there’s a small chance that it  could be cancer okay so then the person that   has somatic symptom disorder or health related  anxiety now they have that in their head and   it becomes terrifying for them so a lot of  times ins by invalidating and dismissing  
00:20:23
patients doctors are actually increasing  the severity of their their anxiety and   their hyper vigilance towards symptoms well what  does this do aside from create more mental health   and dysphoria it keeps that hpa axis excessively  triggered and we know when that happens that
00:20:49
increased cortisol and persistently can lead  to increased inflammation and can start causing   dysfunction and other bodily  symptoms so not only is invalidating patients perceptions increasing their  their mental health issues it’s also  
00:21:12
probably increasing their physical health issues somatic symptom disorder that occurs with  other mental health issues often results   in more functional impairment  and more difficulty in treatment
00:21:29
the more symptoms that are there the more systems  that are probably involved and feeding off of each   other so as one symptom or one condition gets  worse it probably worsens the other conditions   likewise when one symptom starts getting better  hopefully it also improves the other symptoms  
00:21:52
the more category b symptoms  of somatic symptom disorder   that is the more they perseverate on the  seriousness of the disorder the more they   have anxiety about having the disorder  and the more time and energy they spend  
00:22:07
trying to address the disorder likely the  more severe the somatic symptom disorder is   people with somatic symptom disorder have  a high frequency of medical visits which   rarely alleviate their concerns and it even  states in the dsm that a lot of times doctors  
00:22:26
are very dismissive and invalidating  of people’s presentation additionally the people may get to a doctor that says okay  well we can try to treat you with this if the   treatment doesn’t work then the person feels  helpless and hopeless and sometimes the doctor  
00:22:47
says well if that was the problem that treatment  should have worked so that must not be the problem   ergo it must be all in your head and not all  doctors do this you know i do want to emphasize   the fact that there are good doctors out there  but unfortunately this happens my experience um  
00:23:10
and with personally and with friends and  family this happens more often than not   there was a 2015 article  that was relatively scathing   about the somatic symptom disorder and it  said the new dsm-5 this was before the tr  
00:23:27
somatic symptom disorder over psychologizes  chronic pain it has low sensitivity and   specificity and contributes to misdiagnosis and  stigma so think about people with fibromyalgia who up until recently were falling through  the cracks it was i believe in 2017
00:23:53
maybe a 2007. i can’t remember right offhand  but very very recently they recognized that a   lot of people with fibromyalgia were not  getting diagnosed because the criteria   were actually too restrictive so they changed  the criteria now all those people that quote fell  
00:24:13
through the cracks actually had fibromyalgia and  were denied treatment because it was considered   they were considered to have it as a somatic  symptom issue or something else who knows   so i think it’s really important that we take  people’s perceptions of their physical symptoms  
00:24:38
very very seriously we may not understand it we  may not see it but it’s important to recognize how   it impacts their quality of life and recognize  that we don’t know every disorder that exists   like i said pots just recently started being  diagnosed you know compared to other things um  
00:24:58
and are being identified back when i was in high  school you know to kind of put it into perspective associated features of somatic symptom disorder  catastrophic interpretation of normal bodily   sensations when somebody has a sensation they  think oh my gosh this is it this is the big one
00:25:22
my grandmother when after my grandfather died  now they had been married for 50 plus years and   they had a very traditional marriage where he took  care of things she took care of the house when he   passed on all of the stuff that he did fell onto  her and it wasn’t something that she was used to  
00:25:42
so she had high levels of anxiety and occasionally  would have a vasovagal response and fall out   and her interpretation of what was going on was  it was the good lord calling her up to heaven you   know that was her catastrophic interpretation  of the symptoms of the heart palpitations that  
00:26:06
were going on and it was important to examine  everything that was going on because this was   really more a grief and anxiety and anxiety  issue for her because she felt overwhelmed   with everything that was going on and was  perpetually stressed out not sleeping well  
00:26:27
but i digress associated features also include a  self-con concept of bodily weakness they perceive   themselves as more frail and more likely to  get sick intolerance of physical symptoms a lot of us i would venture to say that most  everyone has awakened at some point and they’ve  
00:26:52
had a kink in their neck from sleeping wrong  or they have back pain and they’re not really   sure where it came from they just wake up  and it’s there or they suddenly get this   ringing in their ears and instead of looking at  the most likely explanation did i lift something  
00:27:12
wrong did i sleep wrong they cannot  tolerate that symptom and they start   on this you know fast track of catastrophic  explanations for what’s going on negative affect   including a sense of hopelessness and helplessness  and quote demoralization straight from the dsm  
00:27:33
5tr the person feels hopeless and hopeless that’s  a primary description of a depressive symptom   and they may feel demoralized they may feel like  they’re not believed they may feel like nobody’s   there to help them unsupported because they are  regularly being invalidated typically people with  
00:28:01
somatic symptom disorders present in a medical  setting because they’re concerned about guess what   a physical symptom you don’t go to a psychologist  if you’ve got you know a physical symptom   reassurance by medical professionals and attempts  to refocus the person’s concerns proves futile  
00:28:21
and this is important but it is not remember it  is not a diagnostic feature it’s just associated   the reassurance you know the person may have  gone to other doctors before and been reassured   that hey it’s no big deal you don’t need to worry  about it but they can’t explain what’s causing it  
00:28:41
or the symptoms getting worse or the symptom is  causing them clinically significant impairment and   functioning yet they can’t get any um validation  from profession from their professionals to date   so going to the current professional  they may say well you know i only have  
00:29:03
a mild belief that this person can  be helpful but i’ll try again anyway and attempts to refocus the person’s concerns  prove futile when you’re being told that   okay yes you have this symptom but  it’s not that big of a deal you need to  
00:29:20
turn your attention to you know stop it stop  ruminating about it instead of focusing on what’s   causing it you need to focus on stop ruminating  that can feel extremely invalidating as well the prevalence according to the  dsm-5 tr is 7 to 17 percent now  
00:29:41
looking on line looking in pubmed  there were actually very few uh   research articles that i found that looked at the  prevalence in a in the general population there   were some that looked at the prevalence in medical  students some that looked at the prevalence in um
00:30:06
very very specific   subgroups but finding accurate data about  the prevalence in the general population was not there you know except for what is  stated in the dsm so i’m not sure where  
00:30:23
those numbers came from but those are the  numbers still 17 that’s almost one in five   so it’s important to recognize  that that’s a pretty high number   it says that somatic symptom disorders are higher  in women and you know i tend to take issue with  
00:30:40
that because of the stigma associated with it  what many women perceive when they hear that is   just like when they hear that prevalence  of anxiety disorders is higher in women   they hear that the perception is that  females may present in ways that are more  
00:31:06
to use the old term um hypochondriacal if  that’s even a correct conjugation of it   however there are some interesting things  that they don’t point out and there are some   interesting things to consider in today’s  day and age with p a lot of people that are  
00:31:25
undergoing gender reassignment procedures  testosterone seems to be unrelated to pain   perception okay so that’s interesting however  estrogens and progesterone significantly impact   not only pain perception but also serotonin levels  this is something that is really important for  
00:31:48
us to recognize for people who are biologically  female as well as for people who are transitioning   to female because the addition of  estrogens and progesterone may impact their   some of their physiological symptoms estrogens  also directly interact with cardiac function  
00:32:14
okay well so let’s think about this  when estrogen is high people tend to   have more quote anxiety symptoms heart  racing shallow breathing clammy hands   high levels of estrogens are associated more with  activation of that hpa axis and again that cardiac  
00:32:35
function heart heart beating a lot of people  with somatic symptom disorders have symptoms   that are related to either pain or heart function  so estrogen alterations may impact the symptoms   therefore i think it’s important that we make sure  that the person has had a uh physiological workup  
00:33:04
not only for estrogens but also to look for  imbalances and things like high thyroid um   to assess if there are any underlying thyroid  uh um any underlying hormone conditions that   may be contributing to the somatic symptoms that  aren’t readily apparent elevated cyclic estrogens  
00:33:26
are associated with somatic symptoms that are  common to many mental disorders there is evidence   that changes in estrogen levels may precipitate  certain symptoms and people who have   um irregular hormone cycles which can be  influenced by disrupted circadian rhythms  
00:33:50
may have seemingly unpredictable symptom onsets  but it would be interesting to correlate them with hormone levels both gonadal and testosterone  or i’m sorry gonadal and thyroid   additionally research indicates that our  distinct sex hormone actions between the sexes  
00:34:14
play a critical role in the cns functioning so  the people who are of different biological genders   um or or who have differential levels of  hormones and there wasn’t any research   that i found on people who are undergoing uh  gender reassignment so i’m i’m speculating here  
00:34:41
may have altered sensory perceptions may have  altered sensations of pain and cardiac rhythm   and things like that so it would be interesting  to explore whether it’s the way the body is   wired you know so those who are biologically  assigned female and biologically assigned male  
00:35:04
will always act differently or whether that  changes when hormone levels are rebalanced to the   identified gender so just  things things that i think about   children as young as five have evidence limiting  somatic complaints especially stomach ache  
00:35:26
headache fatigue and nausea now what do we what do  we know about this uh the research has indicated   that it’s highly comorbid with depression and  anxiety in adolescents okay so adolescents who   have high levels of anxiety or depression often  have stomach aches headaches fatigue and nausea  
00:35:48
well aren’t those kind of part and parcel  of depression and anxiety just a question   and in young children somatic symptoms were  highly correlated with parental accommodation   so the more the parents accommodated the  symptoms the more prevalent the symptoms became  
00:36:09
the more the parents focused on the symptoms  the more the child focused on the symptoms   the course of the illness is impacted by  age at onset level of impairment comorbidity   whether comorbidity with physical or mental  health issues harm avoidance if the person is um  
00:36:30
afraid that they’ve got a problem then that  harm avoidance that fear of having to face   uh a problem maybe make it more difficult to  treat and increase the severity rumination and   negative affect which are both associated with the  personality characteristic of quote neuroticism  
00:36:52
can also negatively impact the outcome the more  the person ruminates on it and stresses about   it the worse it can get the more that hpa axis  stays activated the more inflammation the more cis   systemic dysregulation the person’s going to  experience cooperativeness also obviously if  
00:37:15
they’re treatment compliant then um the course  is probably going to be different than if they’re   treatment non-compliant health literacy  also impacts the development if people are able to understand the multiplicity of causes  of different symptoms and not just focus on the  
00:37:37
one catastrophic thing that can actually help so  if they had a loved one for example who died of   a heart attack or of can’t cancer yes that could  be something that could happen but what else could   cause that symptom in you a healthy individual a  person who’s health literate is able to evaluate  
00:38:01
the options more effectively than somebody who  just says oh this symptom means this diagnosis   access to medical services also contributes to the  development in course if the person does not have   access to adequate helpful medical services  then they may have symptoms that are perpetual  
00:38:25
and they don’t know what’s causing them or how  to fix it and prior health care experiences if   they’ve been poor then the person is more likely  going to be distrustful of future providers somatic symptom disorder is under diagnosed in  older adults because the worry is often considered  
00:38:45
understandable well so maybe the worry is  understandable does it mean we need to be   diagnosing everybody who worries about  symptoms in a level that we perceive   as excessive is there an opportunity for  quality of life improvement even if their  
00:39:06
symptoms are perceived as understandable that’s  something that we really need to look at do we   need to wait until they meet dsm criteria  for something before we try to help people   improve their quality of life or manage  their symptoms cultural stigma related to  
00:39:25
mental health diagnosis partially explains  differences in somatic symptom reporting   some cultures have what they call idioms of  distress that are misunderstood by many providers   so they may be um downplayed and or ignored and  other times there are cultural explanations that
00:39:53
mean the person is is not going  to be reporting the same symptoms burnout for example is one of  those cultural explanations   punishment for doing something bad some cultures  believe that illnesses are are a result or a  
00:40:13
punishment for doing something bad other cultures  may believe that people’s presenting symptoms   are a result of imbalance between the hot and the  cold or the damp and the dry the yin and the yang so it’s important to recognize how people  explain things and understand what they’re  
00:40:36
trying to communicate somatic symptom disorder has  a higher level of suicidal ideation and attempts   due to comorbidity with mood disorders well  i don’t know about you but if i’ve had this   symptom that is disruptive to my life to my  sleep to my ability to do things and the medical  
00:41:00
providers keep telling me there’s nothing they  can do there’s no underlying cause for it it’s all   in my head or i’m exaggerating how bad it is then  yeah i’m gonna start to feel hopeless and helpless   and the impact of that symptom may be such and  the worry about that symptom may be such that it  
00:41:19
starts disrupting sleep which contributes  to fatigue and difficulty concentrating   and you can see how very easily someone  could also develop comorbid depression and   perception of the cause of the symptoms is  also linked to increased suicidal ideation  
00:41:43
if people think that oh my gosh this symptom  means that i’ve got this terminal illness   or i’ve got this illness that i refuse  to live with then they may be more likely   to take matters into their own hands so we do need  to understand people’s perception of what’s going  
00:42:03
on and how it’s going to impact their quality  of life and their sense of personal control now illness anxiety disorder we’re moving on  from somatic symptom disorder there are a couple   others in this chapter that are have very minimal  information on them illness anxiety disorder  
00:42:24
is diagnosed when the individual performs  excessive health-related behaviors   like frequent checking of you know moles  or heart rate or blood pressure or whatever   extreme lifestyle alterations or intensive ongoing  research about a particular symptom or disorder  
00:42:47
or exhibit maladaptive avoidance of  medical care so they may be either all   in and trying to figure out what it is or  they may be all out going yeah this might   be really bad so i don’t want to know and i  refuse to go seek medical a medical opinion  
00:43:06
illness anxiety is present for at least six  months but the specific illness may change   and it’s not better explained by another  mental disorder according to the dsm-5 tr preoccupation with having or acquiring  a serious illness is a mainstay  
00:43:27
of illness anxiety disorder and the  somatic symptoms are not present   or and this is where it starts to get dicey  if present they are only mild in intensity   if a medical condition is present or there’s a  high risk for developing a medical condition like  
00:43:46
a strong family history the preoccupation  is clearly excessive or disproportionate   thinking about somebody who’s had a family  member that died of cancer or heart disease   and they have a strong family history you know  it’s not just one person it’s like the whole  
00:44:04
family is there preoccupation or concern about the  issue excessive or disproportionate who’s to make   that decision and that’s really where we need to  work with the the patient if the patient considers   it disproportionate okay you know let’s work with  that however i think we get into very gray area  
00:44:31
ethically when we start telling people how how  valid it is their the intensity of their worry   there’s a high level of anxiety and  hyper vigilance about their health   so all of these things have  to be there they have to  
00:44:51
do the frequent checking they have to have  a preoccupation with having or acquiring an   illness they have to have it for at least six  months and it’s not explained by a another medical   condition and there has to be a high level  of anxiety and hyper vigilance about health
00:45:11
now not in the dsm so this isn’t part of the  diagnostic criteria but it’s also interesting to   consider health anxiety by proxy and this is when  a parent caregiver loved one becomes so focused   on the symptoms of their child or loved one  that they start having all of these other  
00:45:39
meeting all of these other criteria and  they want a doctor to diagnose their child   so there is the health anxiety by proxy this  is very different than munch houses by proxy   in which there is a clear issue that’s going  on a clear physiological problem but health  
00:45:57
anxiety by proxy is not in the dsm however it is  a something that does present more often than not um illness uh anxiety disorder the prevalence in  the dsm-5tr is between one and ten percent not   finding a lot of information in pubmed that gives  us any other reference for how prevalent it is  
00:46:30
the development in course there was  virtually no information although they   did mention it was rare in children the  risk factors include a history of abuse   serious illness in self or parent during childhood  if the child remember children think dichotomously  
00:46:49
all good all bad all healthy all sick and if  the loved one experienced a serious illness in   childhood then that child probably associated  that symptom with catastrophic consequences   so we can see that that schema that was  developed may be outdated but we can see  
00:47:13
how it develops and again the history of abuse may  be somaticized they may be having that traumatic   memory come out as a physiological reaction as  opposed to an overt visual or or verbal memory   culture related issues to um illness anxiety  disorder are unknown the functional consequences  
00:47:40
the only thing the dsm identifies is that it  interferes with relationships and work performance   i would argue that it interferes with a whole  lot more than that if people have a high level   of illness and anxiety and they’re seeing a lot  of doctors it’s going to impact them financially  
00:47:58
physically that anxiety is likely going to impact  their ability to get good quality sleep it’s going   to impact their energy levels it’s going to  impact their immunity as that hpa axis stays   activated as that anxiety level stays high  cortisol loses its ability as an anti-inflammatory  
00:48:22
and we start seeing pro-inflammatory cytokines  being secreted a lot more frequently so we’re   going to start seeing um increased problems  in various health functions if you will   affectively people with illness anxiety disorder  may have anger they may have guilt they may have  
00:48:47
grief they may have depression cognitively when  you’re not getting good sleep when you’re stressed   out all the time when your brain cells are bathed  in stress hormones it is really hard to think   clearly make decisions problem solve do all those  things that help us function throughout the day  
00:49:07
and interpersonally you know the dsm did note that  so i really emphasize and encourage you to think   about the person as a biopsychosocial being  and the impact that these conditions either   directly or indirectly may have on a person’s  quality of life functional neurological symptom  
00:49:33
disorder also known as conversion disorder one  or more symptoms of altered sensory function or   voluntary motor function there are no supporting  medical findings so the person may be mute   or may not be able to lift an arm or may  not be able to hear or see but there’s  
00:49:51
no neurological explanation for it the mri  comes back clear it’s not better explained   by another medical or mental disorder causes  clinically significant distress or impairment   it is important for clinicians mental health  clinicians to note that doctors will all often  
00:50:09
perform multiple exams to test the dysfunction  and look for what they call internal consistency   so one test for it shows that there is  a neurological problem but another test   of the same issue may show that there’s  not a neurological problem and the dsm  
00:50:32
goes through different examples of that that’s not  something we’re going to get into however again it   can feel very invalidating for the individual  that’s experiencing this neurological symptom subtypes need to be noted it’s  either with weakness or paralysis  
00:50:51
abnormal movement swallowing issues speech  issues and that it can even be mutism   seizures numbness or sensory loss sensory symptoms  or a mixed presentation it is acute if it lasts   less than six months and persistent if it lasts  more than six months and it’s important to specify  
00:51:13
with or without psychological stressors this one  is pretty straightforward it is often associated   with dissociative symptoms such as  depersonalization derealization and dissociative   amnesia however the prevalence is thought  to be less than one percent risk factors for
00:51:38
functional neurological symptom disorder  emotional dysregulation well we see emotional   dysregulation a lot in people with a history of  trauma therefore is it emotional dysregulation   or the trauma history a history of abuse  or neglect well there’s trauma right there  
00:51:59
or a presence of a neurological disease that  causes similar symptoms so they may have   for example epilepsy and they may also have  non-epileptic seizures instances resembling   functional neurological and dissociative symptoms  are common in certain culturally sanctioned  
00:52:18
rituals and would therefore not qualify for fnsd  speaking in tongues is one of those examples where   somebody’s speech gets becomes dysregulated a  lot of times they also may faint but that is   only within the context of the religious  ritual it is more common in women and  
00:52:41
people with functional neurological symptom  disorder have a higher rate of suicidality   than those with a recognized neurological disease  may be due to the perception of hopelessness and   helplessness if the doctors can’t seem to tell  you what’s wrong i don’t know just hypothesizing  
00:52:59
functional consequences according to the dsm are  simply physical disability however again and we   don’t have time to really go through it again in  this presentation but think about the physical   affective cognitive and relational impact that  having a functional neurological symptom disorder  
00:53:23
may have on people remember the fnsd does not have  an underlying neurological basis to it so how does   that impact how do people perceive that how does  that impact people’s perception of themselves   and psychological factors affecting medical  conditions a medical condition is present  
00:53:45
psychological factors or behaviors that  are well established as health risks   which adversely impact the medical condition  by causing exacerbation delayed recovery   treatment non-compliance or failure to  seek treatment so for example people with  
00:54:04
high levels of anxiety it may exacerbate their  asthma other times people may ignore a heart   attack because you know they’re they’re avoiding  the health system and that could cause them to die   if not go to the emergency room people who have  been diagnosed with diabetes may have a resistance  
00:54:28
to that diagnosis either anger about it or what  have you and they may engage in behaviors that are   contrary like eating a lot of sugar additionally  anxiety is and and high levels of stress are   associated with difficulty managing a1c levels  so there’s a lot of things that could go here  
00:54:49
it’s not better explained by another medical or  mental health disorder for example people who are   um qualify for alcohol use disorder may drink even  though they have hepatitis and that is actually   covered in the diagnostic criteria for addiction  continued engagement in behaviors that are
00:55:18
known to cause known to be exacer known to  exacerbate medical conditions prevalence   of is unknown the development of course is unclear  quote psychological factors affecting other   medical conditions must be differentiated  from culturally specific coping behaviors  
00:55:40
such as accessing faith spiritual or traditional  healers or other variations in illness management   that are acceptable within the cultural context  end quote so what they’re saying is if people   don’t choose to go through traditional western  medicine that doesn’t mean that they are having  
00:55:59
a psychological issue that’s complicating  their medical condition they are following a   culturally sanctioned treatment path differential  diagnosis factors that distinguish somatic symptom   and related disorders from medical conditions  alone include the ineffectiveness of medications  
00:56:18
a history of mental disorders thought that  was interesting unclear triggers or mitigators   so there’s no it’s difficult to identify what  causes um symptoms and or what makes them better   persistence over a period of several months  or more and excessive anxiety psychological  
00:56:38
factors affecting other medical conditions that  diagnosis it’s important to recognize that in this   disorder the psychological presentation  is not considered excessive necessarily   however it negatively impacts treatment or  worsens a presenting physical issue okay so
00:57:02
fictitious disorder or malingering we didn’t go  over but in in this one the individual presents   as sick with the intent to deceive they’re  faking it functional neurologic symptom disorder   what used to be called conversion disorder  we talked about in this one the presenting  
00:57:20
symptom is a loss of function not distress about  particular symptoms so there is no neurological   basis but they have a loss of function in illness  anxiety there are few or minimal somatic symptoms   and the anxiety is only about the illness  as opposed to other anxiety disorders  
00:57:45
in adjustment disorder a person’s anxiety is  clearly related to identified medical conditions   and does not cause clinically significant  impairment and lasts for less than six months panic disorder the physical symptoms or health  anxiety occur intermittently and surround the  
00:58:06
panic attack um and the episodic and neurological  symptoms are not the only symptoms during a   panic attack so you know you look through the  criteria for panic attacks you’ll see there’s   a host of symptoms um emotional cognitive and  physical that need to be present if the person has  
00:58:28
generalized anxiety generalized anxiety the worry  is about a variety of issues not just their health if the person has depression the focus  is on depressed mood and anhedonia not   the physical symptoms per se or if it  is focused on the physical symptoms  
00:58:50
this health and health health related stress  only occurs during a depressive episode   they did not specify anything about  um persistent depressive disorder   delusional disorder somatic type the intensity  of the conviction about the somatic symptoms  
00:59:12
is far greater than in people with somatic symptom  disorder so it’s just an intensity type diagnosis   however sometimes in delusional disorder  the delusions may be about something that is objectively not real like an organ is decaying  inside them body dysmorphic disorder the focus is  
00:59:40
of the distress is on a perceived flaw not getting  an illness but on a perceived flaw that they have   and it usually involves something  in the face or upper torso area   in ocd recurrent thoughts are more  intrusive and focused on preventing  
00:59:56
getting a disease in the future and  there’s a presence of compulsive behaviors   most of the time with somatic symptom  disorder there aren’t the compulsive behaviors   and the focus is on current symptoms  not preventing getting a disease  
01:00:13
in psychotic disorders the individual  is unable to acknowledge the possibility   that the feared disease may not be present or the  somatic delusions may be more desir more bizarre somatic symptom disorders are frequently  comorbid with mood disorders ptsd ocd  
01:00:35
sexual dysfunction in men  interestingly they were very specific   um our understanding of many physical disorders  is still evolving although known to exist since   1904 the american college of rheumatology didn’t  officially recognize fibromyalgia until 1990.  
01:00:53
likewise potts was first described in 1940  so i was wrong in my earlier guests it was   first described in 1940 yet even today many  doctors doubt the existence of the disorder   it is important for us as clinicians to recognize  the negative impact of psychological distress on  
01:01:13
medical disorders as well as the negative impact  of medical disorders on psychological health   we need to be very careful not to invalidate  patient perceptions of their distress   and instead help them identify strategies  to improve their quality of life
Source : Youtube

Anxiety Disorders in the DSM 5 TR | Symptoms and Diagnosis

https://www.youtube.com/watch?v=D7qZ66inJQY

00:00:01
Hey there everybody and welcome to this  presentation on diagnosing anxiety and panic   in the dsm-5tr i’m your host dr donnelly snipes  in this presentation very briefly we’re going   to review the diagnostic criteria for anxiety  disorders or at least most of them in the dsm 5 tr
00:00:24
so let’s talk a little bit about anxiety  disorders in general when we’re talking about   anxiety disorders we need to remember that fear  and anxiety may be expressed as fighting agitation   tantrums fleeing freezing fawning clinging or  withdrawal or what i call the final f which is um  
00:00:46
politely forget about it because people just don’t  have any more energy left so they kind of withdraw   anxiety disorders differ from each other  regarding the types of objects or situations   that cause fear anxiety or avoidance  behaviors and the associated beliefs  
00:01:07
anxiety disorders represent a response that is  not developmentally culturally or i also add   contextually normative in terms of intensity or  duration so when we’re looking at what somebody is   anxious about we want to examine obviously culture  and development something that a five-year-old is  
00:01:29
afraid of is not necessarily going to be the  same thing that a 25 year old is afraid of   we also want to look at context though  something that uh you’re afraid of in one   context you may not be afraid of in another  like for children being around strangers  
00:01:50
may not be stressful for them when they are at  home or when they’re at school and somebody comes   in to do a presentation versus when they are  alone and they don’t have a caregiver around interestingly from august 2020 through december  2020 the percentage of adults reporting symptoms  
00:02:15
of an anxiety disorder rose from 31.4 to  36.9 now when you go through the dsm and   you start adding up the prevalence of these  anxiety disorders it is really hard to get to   a number anywhere close to 36.9 so the  numbers in the dsm and the numbers in the  
00:02:40
uh national health survey don’t seem to jive very  well we also have to remember that during 2020 we   were at the beginning of the pandemic so there  was obviously more anxiety you would expect that   but even the 31 percent that it was prior to 2020  seems to be higher than what is identified in the  
00:03:05
dsm so i think that’s interesting the anxiety  chapter in the dsm-5tr just like in the dsm-5   is arranged in order of diagnosis which appear  in children first so separation anxiety disorder   appears first and generalized anxiety disorder  is down a little ways whereas you might expect  
00:03:29
some of the quote more common disorders to be  first but that’s not how the dsm is arranged however in this presentation i did put  generalized anxiety first when we talk about   generalized anxiety we’re talking about excessive  anxiety most days for six or more months and the  
00:03:51
anxiety is about a variety of things it’s not  just about one particular thing like health or   an individual or a phobia it is about a variety  of things the worry in addition to being excessive   for the person’s developmental age culture  and context the worry is difficult to control  
00:04:18
the anxiety or the feeling of anxiety is  associated with three or more symptoms in adults   or one or more symptoms in children feeling  restless or feeling keyed up or on edge   easily fatigued difficulty concentrating or mind  going blank irritability muscle tension or sleep  
00:04:40
disturbance i want you to think about it anxiety  is part of the fight or flight response so we   would expect somebody experiencing anxiety would  it be experiencing symptoms of hpa axis activation   or activation of the threat threat response or  stress response whatever you want to call it  
00:05:00
so we would expect all of these symptoms  or any of these symptoms because when the   fight or flight system is engaged the body  is not focused on higher order processing or   memory or the concentration it’s focused on  self-preservation and protection the person  
00:05:22
becomes more vigilant because they are trying to  protect themselves from threats they’re not able   to relax enough to get good quality sleep because  guess what they are keyed up they’re scanning for   those threats muscle tension and i’ve mentioned  in other videos when i used to play tennis my  
00:05:41
coach always used to say don’t stand flat-footed  on the baseline because it takes more time and   it’s harder for you to run and spring into  action to where that ball is going to be   now that is not a threat per se but the same thing  is true for people with anxiety disorders when  
00:06:00
you are when you’ve got that muscle tension it’s  kind of like standing on your toes on the baseline   in tennis you are primed and ready to go and it  makes it easier to theoretically fight or flee   these symptoms have to cause clinically  significant distress people can have subclinical  
00:06:22
anxiety disorder where they have a lot of worry  about a variety of things but it is either not   excessive for what they’re worried about or it  doesn’t cause them clinically significant distress   overall they report a decent quality of life it  doesn’t interfere with functioning in major areas  
00:06:44
of their life and generalized anxiety disorder  as well as all of the disorders are not better   explained by a medical mental or substance use  disorder and we’re going to talk in the end about   differential diagnosis of the anxiety disorders  in general because there’s a lot of overlap  
00:07:09
between the symptoms as well as the  differential diagnosis and comorbidities for   anxiety disorders remember the difference is often  what the person experiences anxiety about and   the cognitions associated with that diagnostic  features of generalized anxiety disorder well  
00:07:34
this section as with most of the sections in the  anxiety chapter pretty much just recapitulated   the diagnostic criteria and it elaborated a  little bit one interesting feature is that   for generalized anxiety disorder they noted that  adults tend to worry about general life things  
00:07:57
like paying bills and getting a promotion or  what’s going to happen with this or that or what’s   going on in the world kids tend to worry about  their competence like performing at school or   their ability to be competent in relationships  sometimes they worry about disaster now with  
00:08:19
coming off of the pandemic  we can probably add that too   but other disasters like hurricanes and  fires and floods and those sorts of things   can prompt a lot of worry in  children and and punctuality  
00:08:34
interestingly enough some children become very  concerned about being punctual and so it’s   interesting to note that there is a difference  in what they worry about which makes sense   because adults have different responsibilities  than kids do and you notice that with the  
00:08:53
exception of disaster a lot of these worries  revolve around the primary life areas or functions   of the person you know kids aren’t worried  about paying bills or or maintaining   or parenting or some of the things that that  adults worry about associated symptoms well let  
00:09:18
me talk about disaster really quick i’m trying not  to go too far off the rails today because we’ve   got a lot to cover but it’s important to recognize  that children have a difficult time understanding   prevalence and likelihood of things so when there  is a disaster such as you know we’ve had several  
00:09:38
in middle tennessee over the past two years and a  child watching the news or hearing about the news   may not understand how close or far away that  disaster was or the likelihood of it recurring   adults are better able to understand you know  it’s a 100 year flood or there’s the chances  
00:10:03
of it happening again are you know whatever  the probability is depending on what you’re   talking about children don’t understand that  they see it on the news it feels like since   it’s on the news it’s kind of in their house  so it feels like it’s right in their space  
00:10:20
and it’s hard to know when it’s going to end  or when it’s going to happen again which can   prompt them to have a lot more worries about  disasters parents can help by explaining some   of the things to them and explaining to children  the probability of another disaster occurring and  
00:10:42
you know how that they’re safe right now and the  steps that they can take it won’t do everything   but it is important again to recognize children’s  different cognitive abilities compared to adults   associated symptoms with generalized anxiety  disorder other somatic symptoms that are not  
00:11:02
as intense as those seen in panic disorder so we  will also see potentially heart racing clammy skin   rapid breathing other things and an upset  stomach that aren’t specifically indicated   in diagnostic criteria but we know happen when  that fight or flight response is kicked off  
00:11:27
the prevalence remember i said if you start add  up the prevalence of all these anxiety disorders   you’re going to be hard-pressed to get anywhere  close to 31 percent and according to the dsm-5 tr   between one percent of adolescents and three  percent of adults in the u.s experience  
00:11:46
generalized anxiety disorder according to  the national center on health statistics   in 2019 now that was before the pandemic  15.6 of adults experienced symptoms of   generalized anxiety disorder in the prior  two weeks the development and course  
00:12:11
the mean onset is rarely before adolescence  and is i’m sorry the mean onset is 35   and rarely before adolescence so this is one  of the disorders that actually has a much   later onset than other disorders which i  did find that to be somewhat interesting
00:12:34
now we’ll move on to separation anxiety separation  anxiety is the first disorder in the chapter   because it tends to be the one that presents  earliest and it can be diagnosed as early as   preschool separation anxiety is characterized by  developmentally inappropriate excessive recurrent  
00:12:53
anxiety about separation from major attachment  figures in order to be diagnosed the person has to   have three or more symptoms it can be diagnosed  in childhood it can be diagnosed in adulthood   if it’s diagnosed in adulthood you do  not have to have a childhood onset of  
00:13:15
separation anxiety it actually can have an  adult onset so that is something to remember symptoms three or more distress due to or in in  anticipation of separation from home or from major   attachment figures anxiety about losing a major  attachment figure or about possible harm to them  
00:13:41
anxiety about something bad happening to the  person the patient which would cause them to be   separated from an anxiety from an attachment  figure so they have fears about something   happening to the attachment figure causing  separation and fears about them something  
00:13:59
bad happening to themselves causing separation a  reluctance a refusal to go out or away from home   because of fear of separation now generally  this is leaving home and separating from that   attachment figure but in some cases it can include  even being reluctant to leave the house be cut  
00:14:24
with the attachment figure because they’re afraid  that when they’re out there they may get separated   now think how this might occur if there was a  child who happened to be at a carnival and got   separated from their caregiver that might prompt  future fears of separation when in public places  
00:14:45
fear of or reluctance to being alone  or without major attachment figures   refusal to go to sleep without being near a major  attachment figure nightmares about separation   or physical complaints in reaction to or  in anticipation of separation so they have  
00:15:06
those physiological symptoms of anxiety  now note here they keep talking about   major attachment figures because remember this can  be diagnosed in adulthood we’re not talking about   the primary attachment from infancy we’re talking  about the person’s current major attachment figure  
00:15:26
whether that be their a significant other  their parent whomever that happens to be the fear anxiety or avoidance is persistent  lasting at least four weeks in children and   adolescents and typically six months or more  in adults and you’ll find that’s a common theme  
00:15:48
where a lot of these situations or conditions  have to last six months or more and be causing   clinically significant distress for six  months or more in order to rank a diagnosis   although the symptoms often develop in childhood  they can be expressed throughout adulthood it can  
00:16:12
be diagnosed in adults in the absence of a history  of childhood separation anxiety disorder and as   i said it causes clinically significant distress  or impairment in one or more areas of functioning the diagnostic features section repeats the  diagnostic criteria with some elaboration  
00:16:34
and examples it’s a pretty straightforward  diagnosis in terms of development and course   the onset of separation anxiety can be any time  from preschool through adulthood but generally   before the age of 30. so you can have diagnoses  of separation anxiety up in through the 20s  
00:16:58
there may be periods of exacerbation and remission  although most child onset cases do not experience   ongoing clinically significant impairment  i thought that was kind of interesting associated features now these are not diagnostic  criteria these are features that are associated  
00:17:19
with separation anxiety but didn’t rank in the  diagnostic criteria sadness or apathy well if   somebody is perpetually anxious that hpa axis is  going to down regulate some which may contribute   to apathy if they are perpetually anxious they  may also start feeling hopeless and hopeless  
00:17:43
which is associated with feelings of sadness and  depression they may have difficulty concentrating   well the mind is not focused on concentration  if it’s in a perpetual state of fight or flee   there may be social withdrawal just stepping  away from everything because they don’t have  
00:18:04
the energy to engage with others because the  anxiety is so pervasive in older children you   may see homesickness or pining when they are away  at camp or or something like that now obviously a   lot of children who don’t have separation  anxiety disorder experience homesickness  
00:18:25
when they’re away at camp for the first  time however this is also associated with   separation anxiety the child migs or the person  may exhibit anger or aggression towards separators   so anybody who’s causing a separation between the  patient and their major attachment figures may
00:18:48
provoke anxiety provoke anger perceptual  disturbances now these are not hallucinations   these are when a person is alone for example at  night and they feel like somebody’s watching them   or they think they see something moving in the  shadows it’s not really there and by turning  
00:19:11
on the light so there’s no more shadows you  know that goes away it’s not a persistent   uh hallucination that the person is experiencing  but perceptual disturbances are more common   in children than than they are in adults and  we want to make sure we don’t mislabel that as  
00:19:33
something related to a psychotic disorder children  with separation anxiety tend to be described as   demanding intrusive and in need of constant  attention according to the dsm now i would   argue when we get down a little further that this  may be true of all people with separation anxiety  
00:19:56
adults may appear dependent and are likely  to contact their major attachment figures   throughout the day and track their whereabouts  they are also often overprotective as parents   and pet owners interestingly enough the  dsm did mention pets where the person with  
00:20:16
separation anxiety may be excessively concerned  about knowing where their pet is at all times the prevalence of separation anxiety in  children is approximately four percent   and in adolescence and adults it ranges  from one to two percent in the culture  
00:20:38
section the dsm talked about the importance of  differentiating separation anxiety disorder from   the high value some cultural communities place  on strong interdependence among family members specific phobias is the next in the line of  disorders we’re going to talk about and a specific  
00:20:59
phobia is pretty straightforward there’s a marked  fear or anxiety about an object or a situation   about 75 percent of people that have one phobia  have more than one phobia and i think if you think   about it even if it doesn’t rise to the level  of being a diagnosable phobia you can think  
00:21:21
about if you have one what we’ll call irrational  fear you probably have a couple of others when i   started to think about it i’m like yeah i have  i have a couple in there the stimulus almost   always produces an immediate fear response and is  actively avoided the fear is disproportionate to  
00:21:41
the threat persist for guess what six months or  more and causes clinically significant distress   and i have this bold and and italicized because  it’s important to remember that having a fear   and i’ve talked in other videos about my fear of  bridges i also have a fear of enclosed spaces i  
00:22:02
hate you know those little water tubes and tunnels  and things that make me feel closed in does it   cause me clinically significant distress or caused  me to have to alter my life to get around it no so   it doesn’t rise to the level of specific phobia  a lot of people have fears that may not have a um  
00:22:28
basis or or the fear may be disproportionate  to the threat in reality we recognize it but   it doesn’t cause us clinically significant  distress so it would not be diagnosable as   a specific phobia and the specific phobia is  not better explained by another mental disorder  
00:22:49
and i’m thinking here more obsessive compulsive  disorder but in the differential diagnosis list   on the anxiety disorders there were a lot so we’re  just going to go through all of those at the end the diagnostic features again in for specific  phobias was pretty much a restatement of the  
00:23:11
diagnostic criteria associated features  interestingly enough for some people   are arousal well that makes sense when the hpa  axis kicks off a lot of people have a um increased   heart rate sort of a panic sort of feeling  about them not to the level of a panic attack  
00:23:36
necessarily but they have that aroused state in  preparation for fight or flee other people may   have what they call a vasovagal response in which  their heart rate decelerates their blood pressure   drops and they may faint my grandmother used  to do this oh my gosh and it wasn’t necessarily  
00:23:57
hers wasn’t phobia related but when she would get  startled or surprised she would fall out and for   the longest time the doctors couldn’t figure  out exactly what was going on but ultimately   my guess would be it re had something to do with  with anxiety or generalized anxiety the prevalence  
00:24:20
of phobias is between eight and twelve percent it  peaks in adolescence at sixteen percent so sixty   percent of adolescents have specific phobias the  development in course it usually develops prior   to age 10 or after a trauma and the presence  of phobias is a risk factor for neurocognitive  
00:24:46
disorders in older adults why is this we’ve  again we’ve talked in other videos about how hyperactivation of that stress response system  keeps levels of glutamate and norepinephrine and   stuff high in the brain which causes  neurodegeneration which can lead to  
00:25:08
neurocognitive disorders additionally because of  social withdrawal and avoidance and restructuring   of their daily lives to avoid the phobic stimulus  there tends to be less stimulation for the person   with specific phobias which may also lead to  a decline in what they call cognitive reserve
00:25:36
and social anxiety disorder in social  anxiety disorder there’s a marked fear   of social situations in when in which one might be  judged so you’ve got generalized anxiety which is   anxiety about a lot of things over the course of  at least six months we have specific phobia which  
00:25:57
is obviously something specific like enclosed  spaces or spiders or snakes um separation anxiety   which is anxiety or fear of being separated from  an attachment figure and then social anxiety which   is fear from being in situations in which one  might be judged with children the symptoms have  
00:26:22
to be present not only in relationships with  adults but in relationships with their peers   it’s natural for children to be somewhat  anxious if they’re interacting with adults   if they’re having the same anxiety when they’re  interacting with their peers then that’s really  
00:26:42
what we’re going to look for for a trigger the  person has an excessive fear of being embarrassed   rejected or offensive and the offensive  seems to be increasing in popularity   or not popularity in commonality um very  quickly with twitter and facebook and tick  
00:27:06
tock and all these other things and trying to be  politically correct a lot of people have developed   a level of social anxiety maybe not to the level  of being a disorder but definitely a level of   social anxiety because they fear not saying the  right thing because they fear being cancelled  
00:27:27
social situations almost always trigger  the anxiety and social anxiety disorder   social situations are actively  avoided or endured with intense fear   and the level of fear is disproportionate  to the potential consequences  
00:27:46
people may have a high level of fear and  anxiety uh before going out and giving a   performance in front of 10 000  people the level of anxiety for that   would probably be different than giving  a speech in front of six classmates  
00:28:12
you know you see the difference here but a person  with social anxiety disorder they would have that   same level of fear in front of six people they  knew as opposed to ten thousand that they didn’t   persistence again for six months or more  causes clinically significant distress  
00:28:29
and is not due to another medical mental  health or substance related condition   there is a note that social anxiety disorder can  be performance only and you do want to specify   that if it only has to do with giving speeches  performing sports music anything like that
00:28:55
the diagnostic criteria   features section gave further examples of the  symptoms that were identified in the diagnostic   criteria associated features with social anxiety  the person may be passive or shy they may want  
00:29:14
to kind of blend into the wall they may be  somewhat withdrawn because they don’t want to be   out there in the limelight they don’t want to  be in this position where they fear being judged   on the other end of the spectrum though there’s a  proportion of people with social anxiety disorder  
00:29:32
who are highly controlling of situations and  they may try to control the conversation and   control other people in the situation  in order to avoid feeling out of control use of substances substance use misuse or abuse is  often associated with people with social anxiety  
00:29:56
disorder and i have parenthetically hear liquid  courage that’s what we used to call it back in   the day i don’t know if it’s what they still call  it but using substances to help temporarily allay   anxiety interestingly as alcohol leaves the body  people tend to have an enhanced anxiety response  
00:30:19
so using alcohol prior to a social situation  may actually end up causing more problems   for some people but that’s that’s up to them  additionally you may see a worsening of physical   illness symptoms such as tachycardia or increased  tremor in people with social anxiety disorder so  
00:30:41
if they already have something that causes a  tremor or a tick that may get worse if they   already have something that causes tachycardia  that may get worse in situations in which   they fear being judged now i have here increased  pain question mark that’s not identified in the  
00:31:02
dsm-5t however we know that hyperactivation of the  hpa axis contributes to ultimately development of   systemic inflammation and worsening of autoimmune  disorders so i would be interested to see   what the actual numbers are for that and no i  could not find any research that actually compared  
00:31:30
the rates of increased pain with social anxiety  specifically prevalence seven percent of people   in the united states experience social anxiety  disorder now brace yourself this is not a typo 2.3   percent of people in europe can be diagnosed with  social anxiety disorder so what is that a third  
00:31:59
what’s different in the united states that is  contributing to significantly higher rates of   social anxiety and fear of being judged  and fear of offending people just saying   additionally social anxiety disorder does  tend to be highest in non-hispanic whites  
00:32:22
so what is unique about non-hispanic whites  in the us i’ll leave you to talk about that and panic disorder people with panic  disorder experience recurrent unexpected   surges of intense fear or discomfort that peaks  within minutes and has a and the accompanying  
00:32:46
four plus symptoms now i have bolded  and italicized unexpected here   there are expected panic attacks when you’re  in a situation in which you’ve had a panic   attack before when there is a known trigger for  the panic attack that’s a expected panic attack  
00:33:06
that doesn’t count towards our diagnosis here  which i don’t know seems a little strange but   okay the panic attacks have to be unexpected  that is they come from out of the clear blue and the panic attacks need to be characterized  by four or more of the following symptoms  
00:33:27
palpitations which is when it feels  like your heart is like fluttering   pounding heart or tachycardia which is  racing heart sweating trembling or shaking   a feeling of shortness of breath or smothering  you just can’t don’t feel like you can breathe  
00:33:45
feeling like you’re choking chest pain or  discomfort nausea or abdominal distress   feeling dizzy unsteady lightheaded or  faint chills or heat sensations numbness   or tingling derealization which things just don’t  feel real you feel like you’re kind of in a in a  
00:34:08
dream or depersonalization you don’t feel  like you’re part of your own body anymore   fear of losing control or going crazy and fear  of dying now i’ll mention even though it’s   pretty obvious these many of these symptoms are  also symptoms of a heart attack it is important  
00:34:29
if you are a clinician not to assume that  somebody who is experiencing a panic attack   it’s it’s just a panic attack and to dismiss  it it’s important to take every panic attack   seriously when somebody’s experiencing it and  work with their medical provider to help them  
00:34:52
differentiate between what’s a panic attack how  do i know when i’m having another panic attack   versus how do i know when i need to go to the  er and their doctor will work with them on that culture specific symptoms for panic may  include tinnitus or ringing in the ear  
00:35:13
neck soreness headache uncontrollable screaming  or crying interestingly even though these are   culture specific symptoms the dsm said those don’t  count toward the required four plus symptoms so additionally at least one of the attacks  unexpected attacks has been followed by one  
00:35:35
month or more of both of the following persistent  concern or worry about additional panic attacks or   their consequences and a significant maladaptive  change in behavior related to the attacks   avoidance of situations where you think  they might happen again or ritualized or  
00:35:56
superstitious behavior or extreme behavior like  changing your diet completely or doing something   extreme in order to try to prevent the attack  so the unexpected attack happens and then for   the next month or more both of those persistent  concern about it happening again and significant  
00:36:21
maladaptive changes in behavior are occurring  it has to cause clinically significant distress   and it’s not due to another mental  medical or substance use disorder interestingly for panic attack there were no  specifiers but in the diagnostic features it  
00:36:43
did note that panic attacks can be full means  four or more symptoms or limited symptom   so it doesn’t meet all of it doesn’t meet four  symptoms or more but the person’s clearly having   a panic response if the person has never had a  full-blown panic attack uh four or more symptoms  
00:37:04
then you would not diagnose panic disorder  frequency can be relatively regular like one   per week or it can come in bursts where they where  they have multiple really close together then they   go weeks months or even years without having them  and then they have another burst of panic attacks  
00:37:28
and there could also be instances where they just  have a panic attack and then they may go for a   couple of years or more before they have another  one it still qualifies as panic disorder there is   no code for remission of panic disorder and the  expectation is unfortunately that if somebody has  
00:37:51
had a panic disorder at some point they probably  will have another panic attack at another point   remember that expected to panic attacks occur with  known triggers and there are many culture related   diagnostic issues due to expected triggers  so if you read through the culture related  
00:38:13
diagnostic issues section of the dsm-5tr  you will find they talk about a lot of   culture bound triggers that can  cause a panic attack in people associated features people who  have panic attacks panic disorder  
00:38:36
may also have intermittent anxiety  about health or mental health   they tend to be more somatically sensitive that  means they’re more aware of what’s going on in   their body well that makes sense if you’ve  already had your body kind of go haywire on  
00:38:52
you once makes sense that you would be a little  bit more hypersensitive to it happening again   they may have increased anxiety about ability  to tolerate daily stress there a lot of times   this may stem from the fear of if they experience  too much stress it’ll trigger another panic attack  
00:39:12
and they may have more extreme  behaviors to control panic   the prevalence of panic disorder is about  the same two and two percent to three percent   in both the u.s in europe and europe the  only disorder that had a marked difference  
00:39:30
between the u.s and other countries  interestingly enough was social anxiety disorder   the development of panic disorder  the median age is 20 to 24 in the us   and 32 worldwide so that is a little bit  divergent you know the prevalence the the  
00:39:53
number of people that experience it worldwide  is pretty comparable but the median age for   panic disorder is much younger in the us than  other countries additionally they speculate that   older adults may attribute symptoms to medical  conditions so they may be under represented in the
00:40:19
prevalence rates because when they’re having  these panic symptoms they’re attributing   them to medication side effects or other  health conditions that they already have so let’s talk about some of the risk and  prognostic factors for anxiety disorders  
00:40:37
in general anxiety disorders often develop  after a life stress this could be a death a   severe illness a disaster a big move becoming a  parent or adverse childhood experiences or aces   that’s just to name a few obviously  that those aren’t all of the causes  
00:41:00
but i think it’s interesting that  becoming a parent was in there as a life stress that often triggers the development of  anxiety disorders i mean i’m a parent myself i can   see how that could happen but it’s not something  that i had really considered in the past as a
00:41:23
risk factor for the development  of anxiety disorders   people who’ve been bullied have an increased risk  of developing anxiety disorders heritability of   anxiety disorders ranges between 30 and 75 percent  i found that interesting but they didn’t explain  
00:41:44
in any of the diagnoses whether they were looking  at twins that were raised in the same household   or twins that were raised in different households  if they’re raised in different households   it gives more credence to a genetic component if  they’re raised in the same household then they’re  
00:42:05
experienced to the same psychosocial environmental  stressors both of them are so i i don’t know what   the actual data is on that people with negative  affectivity they tend to be more brooding more   depressed more irritable people who are more  self-conscious people who ruminate more also  
00:42:31
all of these kind of are combined often referred  to as neuroticism they are at higher risk for   the development of anxiety disorders attentional  bias to threat was noted in generalized anxiety   disorder as being an associated feature but  research actually shows that people with  
00:42:57
any anxiety disorder tend to have a stronger  attentional bias to threat which means they tend   to be more hyper vigilant they tend to be more  aware when there’s threats in the environment   anxiety disorders by and large tend to be  much more frequent in women than in men  
00:43:18
interesting not sure why again my assumption  is this is people who are biologically female   and it seems to be consistent across cultures  therefore i am wondering what the genetic   predisposition might be that may cause this  it seems like it’s less about environment and  
00:43:46
shaping and behavioral training and  more about a physiological response but   additionally and these last two were not in  the dsm but i did a pubmed search for risk   factors for anxiety disorders and those  who have a more external locus of control  
00:44:08
that means they believe that things happen in  the world by fate by chance there’s not a they   don’t have a whole lot of control or ability to  change what’s going on destiny is preordained etc   people with that outlook who have a more external  locus of control tend to have much higher rates  
00:44:29
of anxiety and depressive disorders and again not  in the dsm but in the in pubmed in the literature   people who have a lack of emotional  support also tend to be at greater risk   for developing anxiety disorders seems pretty  self-explanatory in terms of suicidal thoughts  
00:44:54
anxiety itself increases risk of suicidal  thoughts all of your anxiety disorders carry   with them an increased risk of suicidal  thoughts people with separation anxiety have that generalized anxiety-related  increased risk but people with specific  
00:45:15
phobias interestingly enough have an  increased transition from ideation to attempt   in a study that was cited in the ds well mentioned  in the dsm but they didn’t say what the study was   they looked at adults and they found  that up to 30 percent of people
00:45:38
who had their first suicide attempt it was  related they also had a specific phobia or it   was related to that specific phobia so that’s 30  percent is a big number uh when we’re especially   when we’re talking about suicide suicide attempts  and suicidal ideation if you have somebody with a  
00:45:58
specific phobia we often downplay that because we  think it’s just a fear of this or a fear of that   but that fear can feel very limiting and  oppressive to a lot of people and again   30 percent of them uh 30 percent of people who  have attempted suicide also had specific phobia
00:46:23
functional consequences now i could go on a  diatribe about the functional consequences   of anxiety disorders the dsm didn’t have much to  say about it so let’s talk about some of these   limited independent activities this is especially  true in agoraphobia and separation anxiety  
00:46:47
people who are afraid of leaving the house  for fear of being separated from their   significant other or for fear of being separated  from their safe place and people who have social   anxiety who fear being in social situations  may have a lot of restrictions on their life  
00:47:08
activities and limited activities that they  feel safe or comfortable doing by themselves   not in the dsm 5 tr but in the literature also the  functional consequences of impaired relationships   people with anxiety disorders may be because of  their restrictions on life activities and their  
00:47:34
um potential need to know where people  are and their separation anxiety etc   a lot of times people with anxiety disorders   struggle in their relationships because  it can feel overwhelming to the partners  
00:47:53
as i mentioned earlier people with anger anxiety  disorders have higher rates of autoimmune issues   continuous or excessive levels of stress hormones   contributes to systemic inflammation  which will trigger depression  
00:48:12
or is associated with triggering depression and  associated with worsening of autoimmune conditions   and obesity i thought this one was interesting  but it makes sense when you look at it people   with anxiety disorders who often are restricted  in their life activities may feel worn down and  
00:48:35
exhausted from being stressed out all the time  may not have a lot of energy to do other stuff   tend to be more prone to develop obesity so  that’s an interesting functional consequence now differential diagnosis i told you there was a  laundry list of them generalized anxiety disorder  
00:49:01
in gad excessive anxiety is about a variety of  things for at least six months separation anxiety   the worry or the anxiety is about  separation from the attachment figure   okay that’s pretty clear agoraphobia the  fear is about being trapped or helpless  
00:49:20
in situations in which escape is difficult the  fear surrounds being away from their safe place   not being away from a person they want  to be in a place where they feel safe   and it needs to be not specific to one setting  so being trapped or helpless in a situation
00:49:46
i give the example of an mri those  closed mris oh my gosh i can’t stand them   i’m terrified of them but that is specific to one  setting and i’m not afraid to leave the house for   fear of being trapped or helpless in a situation  social anxiety the anxiety is about being judged  
00:50:10
negatively and illness anxiety and this illness  anxiety actually falls under the somatic disorders   but illness anxiety the worry is about the  illness not separation judgment or being away   from your safe place so that’s differential  diagnosis of your basic anxiety disorders  
00:50:34
in terms of other disorders because there’s  that criteria not better explained by another   mental health or medical disorder psychotic  disorders people who have hallucinations and   delusions may also have anxiety but their worry  or fear surrounds hallucinations or delusions  
00:50:53
and is not reversed by context or the presence of  an attachment figure so a person with psychotic   disorders if their major attachment figure shows  up that doesn’t help them feel more comfortable   if they turn on the light to eliminate the shadows  that doesn’t make them feel more comfortable  
00:51:15
and the hallucinations are not due to the with  psychotic disorders the hallucinations are not   due to something that are actually present  eating disorders avoidance behavior is only   related to food and food-related cues according  to the dsm however one of the main criteria  
00:51:41
for your eating disorders is a excessive fear  about weight shape and size and it’s important   to recognize that because people with eating  disorders may avoid mirrors and scales and   food obviously certain foods and that could all be  related to their eating disorder body dysmorphic  
00:52:11
disorder the fears are only related to people  being offended by a particular perceived flaw   in obsessive-compulsive disorder the fear is an  object or situation as a result of obsessions so   if they start thinking about germs on their  hands and they keep thinking about it then  
00:52:33
they start developing a fear of getting germs  on their hands so the fear becomes the object   of their obsessions or their their obsessions turn  cause what they’re thinking about to become a fear   in autism spectrum the person lacks  sufficient age-appropriate relationships  
00:52:57
and social communication capacity in  anxiety disorders the person often has   sufficient age-appropriate relationships  and can communicate socially socially   understand others just fine what we’re  looking at in anxiety is fear of being judged
00:53:25
conduct disorder school avoidance is a  very common symptom of conduct disorder   but school avoidance is not due to worry or  fear in conduct disorder school avoidance   and conduct disorder is due to not wanting  to be told what to do thank you very much  
00:53:44
in oppositional defiant disorder the oppositional  behaviors occur in response to multiple situations   not just separation or situational anxiety  not just in response to an anxiety provoking   threat so if somebody has separation anxiety they  may become oppositional about leaving their major  
00:54:06
attachment figure if somebody has social phobia  they may become oppositional about engaging in   situations that would prompt that anxiety or if  they have a specific phobia maybe they’re afraid   of snakes they may become oppositional  about doing something like going hiking  
00:54:25
because they are actively  avoiding that phobic stimulus if they are actively avoiding a phobic  stimulus or an anxiety provoking stimulus   it’s probably not oppositional defiant now  you can have both you can have them co-occur  
00:54:45
but you do want to differentiate what is the cause  of the behavior prolonged grief is characterized   by intense longing and yearning for the deceased  not fear of separation from them now you can have   prolonged grief and separation anxiety  co-occur you can’t have somebody who develops  
00:55:11
a fear of separation from others after a  particularly particularly traumatic loss   that can happen but you do want to  differentiate and diagnose appropriately   and in depression and bipolar a lot of people  who are in a major depressive episode may have  
00:55:32
reluctance to leave home but this is due to lack  of motivation and energy to engage and apathy   it’s not due to fear of something out there they  just they don’t care or they don’t have the energy personality the person with dependent personality  relies too much on others it’s not that they fear  
00:55:55
uh their safety or loss of attachment figures and  avoidant personality disorder broader avoidance   patterns and a pervasive negative self-concept  differentiate avoidant personality disorder from   anxiety related disorders not in the dsm i’m  bringing up for differential diagnosis anxiety  
00:56:22
is related to apprehension and vigilance  of physiological sensations and may have   an onset after a concussion pots is a postural  orthostatic tachycardia and when people have it   when they stand up their heart rate will jump  30 or more beats just from when they move from  
00:56:46
sitting to standing and that can feel very scary  they can also get light-headed they can faint   hypoglycemia can also produce symptoms  of anxiety and sweating and agitation   in people so we want to differentially diagnose  i believe i read a study that more than 25  
00:57:07
of americans are pre-diabetic and don’t know it co-morbidity anxiety disorders are comorbid  with each other so if you have one you probably   have some of its buddies it’s also comorbid  with depression bipolar ptsd prolonged grief  
00:57:27
obsessive-compulsive disorder  obsessive-compulsive personality disorder   somatic symptom related disorders so  any of your physical symptom disorders   anti-social personality specifically social  anxiety common commonly may co-occur with  
00:57:49
anti-social oppositional defiant  disorder and substance use disorders physically autoimmune diseases may increase the  risk of psychiatric disorders partially due to   thyroid dysfunction when that hpa axis goes  offline it also affects the functioning of  
00:58:10
the thyroid cardiovascular issues  like supraventricular tachycardia   can also be misdiagnosed and is  often misdiagnosed for panic disorder   hormone level fluctuations especially extreme  hormone fluctuations can contribute to anxiety  
00:58:32
related symptoms high levels of estrogen or  testosterone nutrient deficiencies or toxicities   so too much or too little of certain vitamins  and minerals can also cause anxiety like symptoms   environmentally poverty is a high risk factor for  the development of anxiety disorders for obvious  
00:58:57
reasons and socially adverse childhood experiences  that include abuse neglect abandonment or mental   illness in the household are all risk factors for  the development of anxiety disorders later in life anxiety disorders represent an anxiety  response that is developmentally  
00:59:21
culturally and contextually excessive  it’s persistent or recurrent and causes   clinically significant distress so  that differentiates it from people’s   run-of-the-mill anxiety if you will  multiple anxiety disorders are common  
00:59:41
this presentation covered some of the more  common anxiety disorders but did not cover   selective mutism substance induced anxiety or  other specified and unspecified anxiety disorders   finally it is important to rule out or  diagnose comorbidly any physiological causes  
Source : Youtube

Releasing Anger Anxiety and Depression | Counselor Education Tools

https://www.youtube.com/watch?v=6mKFQbdKh_0

00:00:02
Good morning everybody and welcome to this  episode of integrative behavioral health   care i’m your host dr dawn elise snipes today  we are talking about one of the affective   aspects of integrative behavioral health we’re  talking about releasing anger in all its forms and  
00:00:20
anxiety and depression so what are we really  talking about well when i say anger in all of its   forms what i’m talking about is obviously anger  hatred irritation resentment guilt which is anger   at yourself for something jealousy which is anger  at somebody else for something that they have  
00:00:46
envy which is similar to jealousy just kind of a  different word and grief grief remember is also   going to be talked about over in depression  because when we go through the grieving process   we go through denial anger bargaining depression  and acceptance not necessarily in that order when  
00:01:06
i’m talking about anxiety i’m talking about  the various forms from just general stress   to worry fear panic and depression  is obviously you’ve got your   quote run-of-the-mill depression  your clinical depression and the  
00:01:23
depression that comes along with grief so we’re  talking about all of these dysphoric feelings when we hold on to dysphoria it keeps our hpa  axis revved it’s kind of like training with a   bungee cord you are trying to get away from it but  the the dysphoric feelings are like this little  
00:01:47
guy back here that is just holding you back it’s  taking your energy and you’re trying to get away   but you’re just kind of stuck physically when  that happens it drains our energy it can alter   our sleep quality because we are on high alert  it can increase inflammation it reduces immunity  
00:02:09
you know all of the things that we talk about  that happen when that hpa axis stays activated   for too long affectively when we’re dysphoric  a lot of times we don’t have just one simple   dysphoric emotion if we have depression we may  also have guilt and anger and resentment on top  
00:02:30
of it so affectively when we are feeling unhappy  there are often a lot of associated emotions in   acceptance and commitment therapy hayes talks  about that as dirty discomfort so if you want   to learn more about that you can watch one of  the videos on acceptance and commitment therapy  
00:02:50
i digress cognitively when we are in hpa axis  overdrive we are not going to think as clearly   or as flexibly because we are in fight-or-flight  mode we kind of have tunnel vision going on   so it’ll be easier once we release this dysphoria  to think you know more broadly to think more  
00:03:14
flexibly we’ll have more energy in our environment  and more energy to devote to our relationships   when we are not nurturing the unpleasant feelings  which will improve our relationships and hopefully   improve our environment so let’s talk about some  of these things anger remember is your fight  
00:03:37
part of the fight or flee anxiety is the flea  part of fight or flee and depression is the forget   about it part of fight or flee anxiety and anger  are responses to perceived threats remember when   you feel anxious when you feel angry it doesn’t  necessarily mean there is a threat in this context  
00:04:01
at this point in time it means there might be  and you need to use that energy that your body is   freed up for you to check it out to make sure that  you’re safe to make sure that there is no threat   depression indicates a state of helplessness  and hopelessness which can be a response to  
00:04:21
an ongoing threat with no hope of resolution  if you are exposed to something and you know   you just can’t seem to escape it it can you can  feel depressed you can feel hopeless and helpless   depression can also occur as a result of grief  over the loss of something or someone important  
00:04:43
you know that is again a sense of hopelessness and  helplessness you’re not going to be able to get   that person or thing back so you may go through  a grieving period of depression where you lament   not having that thing in your life but it also is  an opportunity to reflect on the things that are  
00:05:04
important in your life and redirect your  energy towards some of those things to be   to nurture them while they are still there so  sometimes depression can serve a motivating   focus to help you kind of get um some wind at  your back again it takes energy to stay angry  
00:05:28
anxious or depressed and to complain and to blame  so we want to figure out what’s a better way   to use that energy you have to make a choice  and you notice that is italicized bolded and   underlined you have to make a choice to use your  energy to improve the next moment and you may not  
00:05:51
have very much energy you may only have a sliver  of energy or an ounce or a drop or however you   want to categorize it but that energy that you  do have you have to make a choice how to use it   when i talk about dysphoria a lot  of times i use a dog poop analogy  
00:06:08
we have a lot of dogs in our house so it makes  sense to me but i can be sitting at the table   or sitting on the living room in the  living room and start smelling dog poop   and that is kind of like my hpa axis telling me  that there might be a threat because you know  
00:06:27
i get angry when i start to smell that i’m like  oh who did what where now it doesn’t necessarily   mean that there is dog poop somewhere in the  house one of my dogs could have just passed gas   and they do that very well thank you very  much but i have a choice at this point  
00:06:46
i can sit on the sofa and get angry about the fact  that a dog may have pooped somewhere in the house   and it’s stinking up my house and it’s making  me angry that it’s stinking up my house   and i can complain about it but is that  going to do anything to resolve the smell no  
00:07:05
a better use of my energy is probably  to get up and look around to see   is it dog poop or did somebody just pass  gas because that helps me figure out you   know whether there’s a problem or it’s  it’s something else that may be fleeting  
00:07:25
your choice when you feel distressed  you feel anxious you feel angry you feel   depressed for some reason all right notice that  acknowledge that accept it non-judgmentally that’s   your body telling you to do something it’s telling  you that something may not be right and you need  
00:07:44
to check it out all right so what do we do once  we figure out what’s going on we need to make sure   we’re safe you know look around make sure you’re  safe if not do what you need to do to get safe   but then choose your energy for  how to improve the next moment  
00:08:03
it could be to use your distress tolerance skills  it could be to take a shower and get dressed   when people are grieving or depressed sometimes  get taking a shower and getting dressed is a   monumental task but if you can at least do that  that day i remember when my kids were young  
00:08:25
and i had postpartum depression with  both of them but a lot worse with my son   just getting up and taking a shower and getting  depre getting dressed was seemed like a monumental   task some mornings but i felt a lot better after i  did it partly because i got up and got out of bed  
00:08:45
but partly because when i forced myself to do that  i was helping to reset those circadian rhythms   you may use your energy to make a doctor’s  appointment if you are feeling clinically   depressed or you just can’t seem to shake that  anxiety maybe what you need to do is see a doctor  
00:09:03
and get evaluated for any physiological causes  of what’s going on or you know maybe you want to   consider a short course of medicine that’s an a a  reasonable choice you may choose to call a friend   or to pray sometimes screaming into a pillow when  you’re angry can help and that may seem juvenile  
00:09:26
but let’s think about it we know that when we  breathe in hold and breathe out when we slow our   breathing down it actually triggers the relaxation  response well when you scream into a pillow what   are you doing you’re taking a big breath in you’re  holding it for a second and then you are exhaling  
00:09:47
and it’s really slow so yes you’re screaming but  you’re also slowing your breathing which can help   release some of that tension and  start triggering the rest and digest   you can also practice deep breathing and maybe  even add in a little aromatherapy take in that  
00:10:07
breath that soothing smell back when i was  very young there was a a commercial for calgon   bath bath beads or bubbles or whatever it was  and their their slogan was uh calgon take me away   and you could see this woman just soaking  down into her tub and taking this deep breath  
00:10:28
and letting all the stress go so aromatherapy can  have a place deep breathing we know has a place   but it’s up to you to figure out what  is the best way to use my energy now   you can ask yourself how is what i’m doing  right now helping me to improve the next moment  
00:10:51
and i would ask you right now how  is what you’re doing right now   helping to improve the next moment you know maybe  you’re learning by watching this you’re learning   about uh or hoping to learn about new skills that  you can use to help you de-stress when you get  
00:11:08
anxious or maybe you’re hoping to find something  that you can use right now i don’t know what can   you do as soon as this broadcast is over to  improve the next moment even if you’re having   a great day what can you do to make it even better  what can you do to continually use your energy to  
00:11:27
work towards that rich and meaningful life that’s  filled with happiness that you hope to have feeling threatened or hopeless  so angry anxious or depressed   represents a state of powerlessness we don’t  like to feel powerless because that makes us  
00:11:47
feel vulnerable it makes total sense and  even the primitive parts of our brain   back in that amygdala says says i don’t like  this i don’t want to keep feeling this way   all right that is reasonable what are your early  warning signs of anger anxiety and depression  
00:12:07
sometimes if we can catch these things early  before irritation turns into rage it’s easier to   check it out improve the next moment and reverse  course what can you do so when you notice these   signs you can de-escalate what helps you when you  start getting angry what helps you de-escalate  
00:12:31
is it going on a walk is it taking some deep  breaths what works for you keep a list of   these things because when you’re in that moment  when you’re in that zone you’re not going to be   thinking broadly about okay what are my options  you want the distress to stop so it’s nice to  
00:12:49
have a little list right there by your computer on  your mobile device wherever that can help you out along with this when you start feeling  angry anxious depressed what can others do   to accommodate or help you sometimes it just  means getting out of your way and leaving you  
00:13:10
alone so you can have a minute to yourself some  people really just need some me time other people   need a hug some people want someone to talk  to what is it that other people can do for you   when i worked in community mental health that  was one of the questions that we would ask  
00:13:29
everybody at admission when you are experiencing  distress what things are most helpful for us to do   and what things do you absolutely not  want us to do what things are most   not helpful um and and that gave people  the option or the ability to state  
00:13:50
when they were clear-headed and able to  think about the options um what would be   most helpful and give us a clue about what might  actually make the matters make matters worse   another thing that you can do before we release  it we’ve got to figure out what causes it and  
00:14:08
what to do about it so another thing that you can  do is identify what are your triggers in general   what things generally make you  angry you know i get irritable um   with people who are rude for example um and going  through and identifying the things that trigger  
00:14:27
your emotions you know i get depressed when  i see an animal or a person that’s suffering   so i know that’s one of my things once you  identify these situations that are general   triggers for you identify what aspects of  the situation you have power over what can  
00:14:47
you do to feel empowered in this situation  with animals you know i can’t rescue every   animal i’ve had to accept that but i can engage  in animal rescue i can engage in animal advocacy   so in terms of my depression about animals who are  suffering that’s something that i have power over  
00:15:10
i don’t have power over you know backyard  breeders and other things so thinking about   each of your general triggers identifying what  aspects you have power over will help you so   whenev whenever you encounter those situations  you don’t automatically feel powerless you know  
00:15:28
that okay there are some things that i can do in  this situation that can help me feel empowered in what ways is holding on to your anxiety anger  or depression helpful to you and yes it can be   helpful we hold on to it for a reason a  lot of people hold on to their anxiety  
00:15:50
because they’re afraid if they let it go then  they won’t be alert to threats that are going   on so examining you know what is motivating  you to hold on to these feelings and in what   ways is holding on to those dysphoric emotions  unhelpful now remember i said at the beginning  
00:16:09
ident feeling them identifying them accepting  them non-judgmentally that’s always helpful   that’s your brain trying to communicate  to you holding on to them and nurturing   them for hours on end without doing anything  about them that can sometimes be unhelpful  
00:16:30
what are you afraid will happen if you let  go of your anxiety anger and depression   is that belief accurate is the belief that  if i let go of my anger at this person   they will hurt me again is that belief accurate  well and and we talked about this you know a  
00:16:49
couple weeks ago when we talked about anger  not necessarily forgiveness just means letting   go of that anger just means you are choosing  not to give them a steady dose of your energy   all the time it doesn’t mean you’re forgetting  what they did it doesn’t mean you’re not learning  
00:17:09
from what they did it doesn’t mean that you’re  not protecting yourself from them it means that   you’re choosing not to invest that emotional  energy over there you’re choosing to save that   for your rich and meaningful life and  those relationships that are important
00:17:27
once you’ve identified what you’re afraid will   happen what can you do to address  those fears to keep yourself safe the next thing you can do is make three  lists identify you know one for anxious  
00:17:44
one for angry and one for depressed identify  what you currently are anxious about what you   currently are angry about what you currently are  depressed about once you have it down on paper   you can start dealing with it you know get it  out there so you can see it and then you can  
00:18:04
start crossing them off your list as you deal with  them for each one of those situations ask yourself   become mindfully aware what are the facts  about this issue in this context at this time   am i safe if not what can i do to get safe  safety is always the first priority how does  
00:18:28
this situation remind me of a past time when i  felt powerless and what is similar and different   in this situation you may be in a relationship  this it often comes up in relationships   you’ve been in bad relationships in the past  you’re in a relationship now and you start feeling  
00:18:47
abandonment anxiety you start feeling anxious well  okay am i safe from abandonment right now am i   safe in my person if not what can i control to  get safe you can’t control whether that other   person comes or goes but what can you do to  make sure that you’re safe from harm how does  
00:19:09
this remind me of that past relationship when  i felt powerless okay you know maybe that your   significant other is engaging in similar behaviors  all right so what’s similar and different in this   situation well one big thing is it’s a different  significant other so we do want to consider that  
00:19:29
and asking yourself you know do i know that for a  fact for a fact that this person’s behaviors and   the way they’re acting mean the same thing  that that other person’s behaviors meant   and the chances are probably not so it’s  important to look at that transference  
00:19:50
and not hold people and situations in the present  hostage for something that happened in the past   be informed by the past but judge the present on  its own merits what part of this situation do i   have control over what are my toward options so  let’s stay with abandonment anxiety for right now  
00:20:14
one of my tour options might be talking to my  significant other and telling them how i’m feeling   and why or asking them about what’s going on maybe  another toward option is to call my best friend   and run it by her see what her take is on it  because she’s more objective maybe going on a  
00:20:35
walk is a better tour option because sitting  there stewing over it isn’t doing me any good   you see where i’m going here figuring out what  part what parts of the situation do i have control   over how can i improve the next moment how can  i keep myself safe and improve the next moment  
00:20:54
and then finally what is the probability that  if i do what i can to improve the situation   that there will still be a terrible outcome you  know what’s the probability that if i talk to   my significant other that i am going to find  out that they are getting ready to abandon me  
00:21:15
what’s the probability that that’s going  to happen what’s the probability that   if i use my energy proactively that the  worst case scenario is going to play out   most of the time the probability of  the worst case scenario is pretty small
00:21:36
okay so you’ve figured out what you are  angry anxious or depressed about you’ve   started identifying ways you can improve the  next moment to deal with it once you have done   all that you can you have this residual feeling  of anxiety or dysphoria sometimes or tension  
00:21:55
sometimes a situation can can’t be completely  resolved right now you have to have patience and   during that time when you’re have quote having  patience stewing on or continuing to hold on to   that anxiety or anger or depression just in case  that’s not doing you any good because continuing  
00:22:18
to be anxious isn’t solving the problem so once  you’re safe you’ve done what you can to improve   the next moment it’s important to trigger that  relaxation response continuing to stay revved is   only going to impair your health your energy  your happiness and maybe your relationships  
00:22:38
so make a choice i’ve identified the problem i’ve  done what i can now i’m going to make a choice   to use my energy in a more positive way and you  can use the acronym cats if you want contributions   if you engage in contributory activities to help  others maybe you go help help your neighbor do  
00:23:03
yard work or go volunteer somewhere that may  get your mind off of it that also promotes   serotonin dopamine and oxytocin release  activities to distract yourself and increase   positive emotions that also is going to increase  your serotonin and your dopamine and when you’re  
00:23:25
proactively doing these activities that you enjoy  it’s going to down regulate that hpa axis because   you’re helping as serotonin and dopamine go up  cortisol is going to go down thought restructuring   embracing the good with the bad trying to focus  on the positives you know any of those cognitive  
00:23:47
behavioral tools that you want to try to use those  are things that you can do when those unpleasant   thoughts start to resurface again you can try  to restructure those thoughts so they are more   powerful so they were that sorry so they  reflect you having more power in that situation  
00:24:09
instead of reflecting a sense of hopelessness and  helplessness and s stands for sensation immersion   we’ve talked in other videos about how  aromatherapy massage just walking outside and   feeling the sun beat on your face for a minute not  for too terribly long can help release serotonin  
00:24:32
and dopamine and endorphins exercising can also  help release those so you start using your energy   to promote those positive neurotransmitters and  start feeling better start improving your energy   deep breathing and guided imagery can also  be helpful now these there are a lot of  
00:24:55
different techniques that you can use one that  i like is when i’m feeling uh anxiety or anger   when i inhale you know and it’s  the deep breathing inhale for eight   hold exhale for eight when i inhale i  envision the air coming into my body  
00:25:13
being this brilliant blue color i love blue  so blue and it’s calming and it’s cooling   i hold it for a second as as i exhale that blue  has turned to red it’s absorbed all of the anger   and anxiety and as i exhale i envision that  air coming out being red and taking all of the  
00:25:38
hot emotions with it when i’m depressed i do the  same thing but instead as i inhale i inhale yellow   yellow is cheerful to me sometimes it’s purple  but we’ll stick with yellow for this as i inhale   i inhale yellow and when i exhale i’m exhaling  all of the blackness all of the darkness that  
00:26:01
i’m feeling and you know you need to do it a few  times but it can be helpful it occupies your mind   and it also slows your breathing slows your  heart rate and triggers that rest and digest   when you’re inhaling remember feel the power  and positive energy pulsing through your body  
00:26:24
when i do it i inhale i feel that blue  coming in and almost like it’s joining   with my blood and going through all of my veins  and arteries and scouring for anger and anxiety   to absorb it um sort of thinking about it that  way but feeling it come in and energize your body  
00:26:44
you can use progressive muscular relaxation and  i have a video on that on the youtube channel   there are other people that have  progressive muscular relaxation videos   but the big thing to remember with progressive  muscular relaxation is to focus on two things  
00:27:04
noticing being able to actually relax your  muscles and feeling that tension and energy   move out of your body so i like to start from  the head and move down and every time i tense   and then i release i imagine the enter the  energy and the distress being pushed out  
00:27:26
being pushed further down kind of like  when i’m power washing the sidewalk   and then it goes out my fingertips  and out my toes eventually   so with progressive muscular relaxation you start  we’ll start at the top start at your head as you  
00:27:43
inhale you tense your scalp muscles you hold that  for a second you notice what it feels like tense   and then you actually relax and you feel those  muscles relax when you feel those muscles relax   what’s happening actually is the blood flow is  going back to that area but you can envision the  
00:28:04
blood coming in and grabbing the tension and  moving it out of your scalp and you do that   for every muscle group all the way down to your  toes when you tense hold your breath notice what   that tension feels like as you exhale say in your  head relax and feel the tension moving out of your
00:28:26
body can also try to release some of this the  distress with what i call positive power mantras   breathe in hold it for a second and  then as you exhale say your mantra   a few i am strong i am courageous i can get  through this or i am loved i have people who  
00:28:52
will help me god loves me i am safe loved and  protected or i choose to be calm and at peace   you can write your own positive power  mantra but basically you are trying to   reassure and nurture yourself just like a  loving parent would have done to help you  
00:29:12
feel calmer and relaxed even if the  adversity is not completely resolved   you can try turning your focus instead of focusing  on the problem turning your attention saying okay   the problem exists but i’m going to shelve it  you know sitting here focusing on the fact that  
00:29:34
my arm’s broken isn’t going to make it heal any  faster so okay my arm’s broken got it i’m gonna   focus on these other things over here that  are that i’m grateful for you can also do   a mindfulness activity and really focus on the  present moment and when you start feeling that  
00:29:53
anxiety or depression creeping back in again  check make sure you’re safe as long as you’re   safe and you’ve done everything you can identify  the positive things that you notice right now with guided imagery you can go to your happy  place and i have a couple different guided imagery  
00:30:16
meditations on the youtube channel but it just  helps you to sort of transport yourself in your   mind to a place where you can completely relax you  can also visualize yourself becoming happy in the   moment imagine okay i’m not feeling great right  now i’m going to visualize what’s the next thing  
00:30:38
i’m going to do to start feeling happier visualize  you know the next 10 15 minutes and see yourself   doing things or see yourself getting happier  some people like to journal about it get it out   on paper and then give it to the universe you  know once it’s there you don’t have to worry  
00:30:58
about forgetting about it you write it down and  you can give it to the universe some people prefer   to give it to god their higher power whomever but  once you get it out then you can put it in a box   and choose to revisit it then you have a choice  about all right i’m going to leave that there  
00:31:20
some people like they feel they need to revisit  it periodically other people once they put it in   that box it’s like okay i’ve done all i can do  i’m going to put it on the shelf for right now   try doing exercise or something cathartic to  redirect that energy and promote the release  
00:31:40
of endorse endorphins cathartic means  using that energy in a way that helps you feel a little bit better for example going out  and taking a ball if you’re angry going out and   taking a ball and throwing it as hard as you can  against the wall playing um a handball basically  
00:32:00
for a little while um exercising can be good  push-ups something is something else that you   can do pretty easily without a lot of equipment  the last suggestion i have is what i call fake   it till you make it and i don’t mean ignore your  feelings completely i don’t mean fail to take care  
00:32:23
of yourself acknowledge accept unconditionally  make sure you’re safe and then choose   remind yourself that as distressful  thoughts arise that you’re safe you know   maybe you’re waiting on test results from the  doctor okay you know you’ve done everything you  
00:32:45
can you went to the doctor you got the test  done now it’s a waiting game and stressing   over those test results is just gonna make you  irritable drain your energy impair your sleep   so okay i’ve done everything i can to deal with  this situation right now when distressful thoughts  
00:33:02
arise i’m gonna remind myself i already done it  i’ve i have already done everything i can i’m safe   and i am going to choose to commit my energy  to other things that are important in my life   in dialectical behavior therapy marsha linehan  talks about um turned up smile and open hands  
00:33:26
just trying to be present in the moment when  we adjust our non-verbals even if we’re all by   ourself when we adjust our non-verbals  it actually can help improve our mood   dysphoric emotions serve a purpose  to motivate you to do something  
00:33:46
to ensure that you’re safe and appreciate  what you have in the present moment   once you’re safe and you’ve done what you can to  improve the next moment to address the situation   actively triggering the relaxation response  can help down regulate your hpa axis  
00:34:04
which can help improve your mood increase  your energy and improve your health all right in terms of questions i’m  looking at what we have going on right here   it’s important to remember when you’re  engaging in towards behaviors if one of  
00:34:39
those is seeking emotional support for someone  from someone you know you want to make sure that   what you’re engaging in is helpful and moving  you toward your goal of a rich and meaningful   life if all you’re doing is commiserating  uh then that’s probably an away behavior  
00:35:01
we can engage with others who are going  to as we say in addiction cosign on our bs   and that’s not helpful so it is important to make  sure that your relationships are pro pro social   and proactive and promoting you  towards your rich and meaningful life  
00:35:23
uh providing support providing validation  providing empathy um and providing   encouragement to take that next step  forward toward what you think is important in terms of sharing this information with  other people not everybody is ready willing  
00:35:51
or able to hear it people have to be at a level  of readiness for change and i have several videos   on the youtube channel that talk about stages of  readiness for change and increasing motivation but   until someone is motivated to start using their  energy nothing that you say to them is probably  
00:36:16
going to land because they don’t want to hear  it they’re not ready or open to any new ideas   and there are a lot of reasons people may be in  what we call the pre-contemplation stage of change   and it’s important to be sensitive to that a lot  of times people are in pre-contemplation either  
00:36:36
because they don’t realize there’s a problem  or because they feel hopeless and powerless   and it’s important to be sensitive to  that that you know maybe they’ve tried   to recover before whether it’s depression  or anxiety or you know pain and it hasn’t  
00:36:57
stuck maybe it helped for a little while but  it didn’t stick and they relapsed and that   can cause people to be hesitant to start trying to  change again so we do want to be sensitive to that   and in that case it may be helpful to enlist  you know a counselor or a spiritual guide to  
00:37:23
help you figure out what direction might be  useful it’s not there’s nothing that i can do   from you know just talking in generalities that  can really help in any individual situation to get somebody to change people are  going to change when they decide  
00:37:44
they’re ready to change all we can do  is hope to bolster their motivation with   motivational interviewing techniques  or motivational enhancement techniques are there any other questions
00:38:06
i really appreciate everybody taking time   out to be with me i know for a lot of you you’re  still on your holiday break so i appreciate you   being here and enjoy having you guys um present  this is part of that ongoing uh six weeks to a  
00:38:24
happier healthier use series so tomorrow  we will be talking about cognitive tools in response to your question about avoiding  people who are going through similar situations   no support systems can be super important but  it is whether you are engaging with people  
00:38:52
who are empathetic and encouraging and supportive  of proactive positive forward movement or you are in the quagmire of a group of people who  are who just want to sit around and complain   uh is you know the non-tactful way to say it  support groups are not created equally but  
00:39:19
some support groups are very helpful and i do  encourage people to find support groups that   do have helpful people in them and not  everybody in a support group may may be helpful   there may be certain people that are more  proactive than others but ultimately it  
00:39:41
comes down to when you interact with this  person do you feel understood validated   supported and empowered or does it just reinforce  your sense of helplessness and powerlessness have a great day everybody and i’ll  see you tomorrow same time same station
Source : Youtube

21 Tips to Beat Anxiety with Dr. Dawn Elise Snipes

https://www.youtube.com/watch?v=kcZXl0Yr-QU

00:00:01
Hi everybody and welcome to happiness and brain  surgery with dr dawn elise snipes practical tools to improve   your mood and quality of life today we’re going to  be talking about 21 practical tips to beat anxiety   this is based on a book that i’ve got  coming out in two months it’s in the  
00:00:17
in press right now happiness isn’t brain surgery  100 plus practical tips to beat anxiety so look   for that to be released in june of 2018 so not  too long now we’re going to go over 21 of the tips   that are in that book right now to give you an  idea of some things that you can start doing now  
00:00:39
instead of having to wait till june to deal with  your anxiety so the first one and i’ve talked   about this in different situations is learning the  difference between emotional and factual reasoning   just because you may feel anxious doesn’t mean  that it’s necessarily a threatening or dangerous  
00:00:57
situation when i get ready to go to a social  function i get a little bit butterfly in my   stomach i get a little bit of anxiety i’m not one  to do mixers so i get a little bit of anxiety but   emotional reasoning would mean that i’m thinking  about all the reasons that i need to be scared  
00:01:20
before i go into that situation  factual reasoning is backing up and   thinking factually about the situation i’m going  to this mixer there’s a lot of other people there   many of them probably feel like me um and you  know this is what i’m going to do the facts of  
00:01:37
the matter are that it doesn’t have to be scary  nobody at the mixer is going to try to embarrass   me or humiliate me um any potential perceived  threats are pretty much all in my own head   so it’s important to separate emotional from  factual learn to differentiate what’s actually  
00:01:56
happening happening from what you’re currently  thinking about sometimes you can be going in   and doing something and thinking about the worst  possible scenario thinking that the sky is going   to fall for example and in reality it’s not that  bad when we have a storm come through for example  
00:02:18
last year we had a significant portion of our  fence blown down in a storm that came through   which is kind of a big deal when you’ve got you  know equines and chickens and ducks and everybody   to keep contained and it kind of freaked me out a  little bit so now when we have a storm i can get a  
00:02:38
little bit anxious at first and i need to remember  you know what’s actually happening right now is   it’s a storm it’s no big deal we’ve had hundreds  of them factual and what’s happening now not   what i’m currently thinking about which is what  happened last year so i need to get my head out of  
00:02:54
the past because the past is the past and there’s  no nothing saying that it has to ever occur again   so focusing on what is actually happening now if  you’ve been in a car accident before for example   then you might get stressed out when you’re in  heavy traffic again what is actually happening  
00:03:15
now yes traffic is heavy but you’re safe you’ve  got good distance between you and the people in   front of you you know if you feel the need to  you can get all the way over into the right   lane so you have an exit strategy should you feel  like it’s getting too you know claustrophobic or  
00:03:32
something but that’s what’s happening now you’re  not currently in danger you’re just going with the   flow the third thing you can do is try to prove  yourself wrong show yourself that your thoughts   have no basis in truth so if you’re worried about  you know a rash you’ve got go to the doctor and  
00:03:50
confirm that you aren’t dying of some incurable  disease which is what you may be thinking about   or ask someone how they feel about you if you  don’t know so if you’re wondering if so-and-so   hates you instead of stressing about it ask them  you know prove yourself wrong or right but at  
00:04:08
least you’ll have an answer you’ll have a factual  answer not just an emotion based answer don’t live   in the gray area when answers are available  to you sometimes there aren’t any answers   sometimes you have a gray area but if there are  answers available get them so you can let go of  
00:04:25
that anxiety or deal with it and move on number  four is stop trying to navigate the path while the   hallway is dark you know that old saying that when  one door closes another door opens and the follow   on to that is but those hallways are a [ __ ]  yeah um it’s dark before that other door opens and  
00:04:45
the first one is closed you’re in a dark hallway  that’s okay you know don’t try to make decisions   when the hallway is dark when you can’t see what’s  going on and this is what happens when you’re   upset you kind of get tunnel vision when you get  a lot of adrenaline going through your system you  
00:05:01
get tunnel vision and that can make things dark it  can make it harder to see all of your options so   wait until you’re less upset get in your wise mind  before you make any life-altering decisions you   know you may decide when you’re upset something  bad happens at work you’re anxious about something  
00:05:21
you may decide that you need to go on a walk okay  that’s fine but when you’re anxious and upset   and right in the midst of it it’s not the time  to say well i’m going to quit my job no no the   hallway’s dark you need to be able to look at what  are at least three options that you can consider  
00:05:41
when you are trying to figure out what to do  number five is to unhook from your emotions   instead of saying i am terrified say i am having  the thought that i’m terrified and you may think   to yourself you know whatever you know that’s  just semantics but think about it this way  
00:06:01
if you are a smoker for example or you like  chocolate cake if you think to yourself i have   to have a piece of chocolate cake or i have to  have a cigarette it feels like it has to be done   you know there’s just no question if you say to  yourself i’m having the thought that i have to  
00:06:20
have a piece of chocolate cake or a cigarette  then that thought you can choose to act on   or not act on so it’s separating it and making  it so it’s something that you can put away fire can burn your house down or it can cook your  dinner each night and keep you warm in the winter  
00:06:41
which means it can be bad or it can be good your  mind is the same way will you let it burn you out   and cause you to feel helpless and hopeless  just spinning around with anxiety and what ifs   and oh my goodnesses or will it help you  turn into macgyver and whenever you face  
00:07:00
a challenge or something that makes you anxious  it will help you view that as a challenge and   find creative solutions your mind can  do either one it can keep you spinning   you know i don’t know if you know the younger  people listening may remember sitting spins  
00:07:18
we had those when i was little you sat on this  little disc and you turned and you just spun   around in it in the same place until you got  dizzy and that’s all it did and that’s what   happens when we get stuck with our emotions  we’re on our own little personal sit and spin  
00:07:33
it’s not going to do any any good  except for make us sick to our stomach   now if we take that energy and instead of sitting  and spinning we use it to address the challenge   and view it as a problem that can be solved then  we’re going to make some more forward progress
00:07:54
number seven realize that thoughts can be merely  illusions think about all the things that you’ve   thought about and worried about that have turned  out to be nothing at all you know you got yourself   all in a tizzy over nothing think of all the time  you wasted preparing for outcomes that would never  
00:08:13
happen the what ifs i mean i’m i’ll admit i’m bad  i’m one of those people who usually has not only   a plan b but also a plan c but i stop at plan  c i know people who have planned d e and f and   you know that takes a lot of time and energy to  have all those backup plans so in the future when  
00:08:33
you start to worry ask yourself if what you’re  worried about is factual and probable so if   you’re getting ready to go take an exam um you  know you can worry that you’re going to fail it   but you know that’s a lot of worry and you  can start figuring out what you’re going to  
00:08:51
do if you fail that test which means you’re  probably going to fail the class which means   you can work yourself up into this whole  catastrophic situation or you can say is   it factual is it probable that i’m going to fail  this exam well if you’ve done what you needed to  
00:09:08
probably not when you when people go in to have  their hiv test done there’s typically a lot of   anxiety going in to do that and so people can  get really worried and start coming up with   all these plans of how they’re gonna tell people  and what they’re gonna do if they’re positive and  
00:09:27
what they’re gonna how life will change and all  this kind of stuff and they get their results   back in their negative and they expended amazing  amounts of energy planning for the worst case   scenario so sometimes especially if there’s  an answer to it you know you’re not living  
00:09:44
in the gray area you’re getting ready to get the  answer sometimes you have to be patient and just   have faith that you will be able to handle  whatever the answer is otherwise you could be   going in the completely wrong direction with with  your plans follow it to the end is number eight  
00:10:05
think about whatever you’re worried about then  imagine realistically what will happen and follow   it to its conclusion your boss leaves a message on  your desk that he needs to talk to you on monday   at 9am be in his office well that can be a  little bit intimidating no matter who you are  
00:10:24
if your boss is doing that and then  you’ve got all weekend to worry about it   so imagine realistically what’s going to happen  so think about you know have you been doing your   job have you been a decent employee all right are  things does the business seem to be going well or  
00:10:39
are they laying people off realistically is he  going to call you in individually if he’s going   to do layoffs no so going through all those  things in the in your head you can figure out   with reasonable accuracy what is likely going to  happen um and at least whether the worst thing  
00:11:01
is likely going to happen if you go through those  things and you say yeah i’ve been being a good   employee i’ve been on time i’ve done all these  things the business is doing well you know i   don’t think there’s anything that i could  be in trouble for so i don’t know what he  
00:11:17
wants wish i did but i don’t and then you can  distract yourself for the rest of the weekend   because you follow it to its conclusion if there’s  nothing major that you’ve done wrong then likely   you’re not going to lose your job likely you’re  not going to get demoted none of those awful  
00:11:36
things are going to happen likely you will meet  with him and he’ll say whatever he has to say   and then you’ll go on about your business if you  stick with fact-based probable scenarios you will   often find that the outcome is not that scary you  know if you look over it and you go yeah i’ve been  
00:11:56
late six days out of the last 15 and i haven’t  gotten my work done in a month well then yeah you   probably need to make some plans but at this point  there’s nothing much that you can do to change it   change what whatever he’s got to say so being  aware of what is likely and probable to happen  
00:12:22
remember the average person has over 50 000  thoughts every day heck i had four thoughts   before i even got out of bed this morning i woke  up and i’ve got a foster kitty staying in my room   and my first thought was where’s vicki and then  she was up on my bed and my second thought was  
00:12:39
that’s different she’s you know sitting  on my feet instead of on her pillow   and my third thought was i don’t really want  to get out of bed this morning and you know   just kept going on fifty thousand thoughts  some are happy some are sad some are fearful  
00:12:57
if you were asked how many of your fifty  thousand thoughts you remember today   it’s likely going to be less than a hundred  you know you can remember that you thought   about what to eat for breakfast you can remember  that you decided whether or not to go to the gym  
00:13:11
you know those are thoughts that you can probably  think back and remember but if you really had   to start thinking you know i bet you would be  hard-pressed to come up with more than a hundred so you’re going to have some scary thoughts  that’s okay let them go thoughts are just  
00:13:30
illusions they come in and they go out it’s kind  of like think about clouds if you’ve ever made   cloud pictures cloud pictures um you know you’re  laying on your back you’re watching the clouds and   they morph into something and it’s a dinosaur  or a whale or something and that’s awesome  
00:13:47
and it’s it it’s exciting and then it turns into  something else our thoughts are the same way   you know they don’t have to stay stuck in anxiety   ride the wave is number 10. and we’ve talked  about this one before feelings come peak in  
00:14:04
about 20 minutes and subside just like waves come  in and crest and and go out unless you feed them   if you’re anxious and you start thinking about  all the reasons you need to be anxious and you   start thinking about all the possible worst case  scenarios that could happen or what if in yourself  
00:14:24
you’re going to stay stuck you’re feeding that  anxiety you know imagine if you’ve ever played um   don’t cut the rope the little green monster on  that he’s so cute but imagine feeding him imagine   that to your anxiety monster and every time you  have a catastrophic thought you’re just feeding  
00:14:42
him and giving him energy if you ride the wave  acknowledge that you’re anxious you know but if   your boss leaves that note on your desk you may be  anxious so all weekend periodically you may have   that thought i wonder what my boss wants to talk  to me about you know that’s kind of intimidating  
00:15:00
acknowledge it say that’s that’s  stressful i’m anxious about that   but there’s nothing i can do about it right now  and what can you do to improve the next moment   and focusing on that and dwelling on it  is not going to improve the next moment  
00:15:15
so ride the wave let your feelings come in  acknowledge them go do something distract   yourself you’ll check in a few minutes later  and you’ll go what you’ll probably say you   know what i don’t feel as stressed out right now  you know it’s that feeling’s starting to go away  
00:15:33
now some feelings like grief can linger for a  while you know i’m not saying that all feelings   are going to come in and go out but anxiety  is one of those that if we start looking at   the positive if we start looking at the facts  if we start really evaluating the situation  
00:15:51
instead of using emotion-based reasoning and  worst case scenarios our anxiety can go away don’t swat the bee and this is another one that  i’ve talked about in some of the other podcasts   our urges are what happen when we have a feeling  and we want it to go away when you have that  
00:16:13
feeling of anxiety you want to make it stop it’s  unpleasant it’s like when a bee lands on your arm   you want it to go away because you’re afraid  it’s gonna sting you and that’s gonna hurt   so you wanna your urge is to swat at it to  get it to get off of you well if you swat  
00:16:30
at it you’re increasing the likelihood that it’s  going to sting you most of the time it won’t so   just like you let the bee fly off on his own and  everybody’s happy when you have anxiety don’t act   impulsively don’t do the first thing that comes  to mind to make the anxiety stop because a lot  
00:16:52
of times that’s not going to be your best choice  let yourself get rid of some of the adrenaline   get into your wise mind think of three options  for how to handle this situation and then choose   from there by the time you do all that stuff the  adrenaline is gone down but until you can think of  
00:17:11
three potential options or scenarios  then you’re still in that adrenaline haze   embrace the dialectics as number 12. try to figure  out how two seemingly contradictory things can   be true such as this relationship i’m in may end  you know it can’t some people get really anxious  
00:17:33
that they’re going to be abandoned or that  a relationship’s going to end and it may   end but you can also be okay you know and both of  those things can be true it’s hard to imagine but   both of them can be true somebody could be  anxious that they’re going to lose their job  
00:17:51
and you know because there are a bunch of  layoffs happening at the company so they   could start having a lot of stress about that  but remembering that they could still lose their   job but it doesn’t mean they’ll lose their family  they’ll still have their family they’ll still have  
00:18:05
other things that are important to them so  remembering and embracing the dialectics   there are going to be some bad things but those  bad things will be balanced by good things and   can even create opportunities if you lose your job  maybe you’ll be in a better one that’s more secure  
00:18:26
look for opportunity in the angst worry tells you  that something might need to change if you’re in a   relationship and you’re worried that it’s going to  end that tells me that there’s something going on   either it’s an unhealthy relationship or the  communication is poor or you’ve got some stuff  
00:18:45
that you need to deal with something is going  on that’s making you feel either unlovable or   feel like the relationship is going to end so  that’s what worry tells you okay well that’s fine   thank you for alerting me to the fact that  something might need to change mr worry monster  
00:19:04
now what’s the opportunity how can i embrace this  and say what can i do to improve this situation   opportunities make up the majority of the iceberg  that is in in the reality you don’t yet know and   can’t yet see so if you’re in this relationship  and it ends you know that’s the tip of the iceberg  
00:19:26
and that’s the thing you don’t really want to  know about and you don’t really want to see and   that’s the awful thing the elephant in the middle  of the room so to speak but underneath the water   the bottom of that iceberg is much much bigger  and it’s all the opportunities that wait for you  
00:19:42
now that you’re not in that relationship so  how can this be an opportunity for you to grow   to meet someone new to explore something to  maybe get a job somewhere else and move to   a different state start over again who knows what  are the opportunities number 14 is to change your  
00:20:03
objective the goal shouldn’t be to feel good all  the time nobody’s going to feel good all the time   the goal is to be able to express a healthy range  of emotion without suppressing it or suffering   you know if you don’t have any days when  you’re sad that mean likely means you don’t  
00:20:22
have anything that’s important to you that you’ve  lost and you know things that are important to us   we occasionally lose we lose pets we lose you  know whatever relationships we lose people   people die we lose jobs we lose hopes we lose  dreams we lose things and when we lose those  
00:20:44
things we’re going to feel sad that’s your  brain’s way of saying that was important   we’re gonna miss that okay you know so acknowledge  it experience it and improve the next moment   you don’t have to feel good all the time matter  of fact if you felt good all the time it wouldn’t  
00:21:01
be that rewarding you’d just be like yeah this  is normal now if you have occasional sad days   and occasionally get a little bit irritable then  when you feel happy you’re like oh i like this   we’ll we’ll do this for quite a while so you feel  a difference and you feel that depth of emotion  
00:21:20
remember yin and yang and if you look at it  you have the circle and then the little you   know apostrophe looking things that are together  but in each one there’s a little bit of the other   in yin there’s a little bit of yang and in  yang there’s a little bit of yin you can’t have  
00:21:37
pure happiness you know there’s always going to  be a little bit of stuff that’s not going quite   right or not exactly the way you want but it  doesn’t mean you can’t be the majority of happy   when there’s unpleasantness and it  can feel like there’s a lot of it  
00:21:53
but if you look in that unpleasantness  there’s going to be a little bit of happiness   a little bit of opportunity a little  bit of something to be grateful for   so it’s embracing the depth and quality of those  emotions recognizing that okay anxiety is is on  
00:22:12
kind of on the dark side how can we turn this  into an opportunity to learn and to grow and   express the full range of emotions develop  hardiness commitment control and challenge   heartiness means that you understand that there  are dozens of things that make your life rich and  
00:22:32
meaningful and you’re committed to those things  now occasionally one of those is going to go wonky   and you’re gonna have to deal with it but  while you’re dealing with that wonky thing   the other 11 things or more in your life that make  it rich and meaningful and that you’re committed  
00:22:50
to they’re still going well so for example if  work starts to go a little bit haywire and you’re   unhappy at your job all right you got to deal with  that but it’s allowing you to put a roof over your   head and you you like your house it’s allowing  you to put food on the table and feed your family  
00:23:09
you’ll love your family they’re really important  so your commitment to all those things makes life   worth living even though this thing over  here not going so well right now control   is the second part of it once you’re looking  at all those things that you’re committed to  
00:23:27
most of them you don’t have a hundred percent  control over that’s just life so focusing only   on the things that you have control over if you  try to change things you don’t have control over   you’re going to make yourself depressed  anxious upset irritable so don’t do it  
00:23:46
ask yourself is this something i actually  can control we can’t control other people we   can’t control other people’s reactions we can  control what we do you know the person who is   worried that he’s going to get laid off or  fired you know they he can’t control whether  
00:24:04
the business is doing well he can’t control what  his colleagues are doing all he can control is   whether he goes to work gets there on time  and does his job that part is in his control um irrational thoughts it’s important  to think about irrational thoughts as  
00:24:27
something your brain is telling you that’s kind  of extreme like i must be loved by everybody all   the time or the world is going to end oftentimes  irrational thoughts are products of traumas that   you’ve yet to fully acknowledge or deal with  so if you grew up in a chaotic home environment  
00:24:48
and you have a lot of anxiety about  relationships ending and people abandoning you   you may have some irrational thoughts that  are telling you that you’re not lovable or   you’re going to be abandoned that stem from that  childhood trauma so when you start getting anxious  
00:25:06
you need to ask yourself what am i  afraid of and why am i afraid of it   what is this really a threat right now so what  am i afraid of this relationship ending why   am i afraid of it because i don’t want to be  abandoned um is this really a threat right now  
00:25:27
when you’re six fearing that a parent is going  to abandon you is threatening when you are 26   fearing that a relationship is going to end  you know it’s unpleasant but you can still   feed yourself you can meet new people you can  go go on about your life so it’s likely not as
00:25:48
imperative that you maintain that relationship  so you know think about when you start getting   anxious is this a reaction caused by something  in my past or is this a reaction to something   that’s going on now except the fact that everyone  everywhere has weird incorrect disturbing thoughts  
00:26:13
that have no bearing on reality we all have  catastrophic thoughts sometimes you’re not a freak   you’re probably not sick you just have to  learn to not be intimidated by your own mind   your mind takes in information but ironically  it’s really not that smart so we have to help  
00:26:33
it interpret that information if i hear a loud  noise outside you know it may sound like a gunshot   but it could be a car back firing so initially  i’ll have a startle reaction because it was a   loud noise and i think oh my gosh you know  there’s a gunshot and then reality sets in  
00:26:52
and i go no i’m in downtown you know there’s  parking lot outside it was probably a car back   firing so making sure that you check yourself and  check your thoughts to make sure that you’re not   just making a catastrophe when you  completely misinterpret this situation  
00:27:15
stop gauging how bad things are by how much you  panic the more you panic the more you panic so   if you get nervous about going to the doctor  and think oh this must be really bad because   i’m really stressed out then you’re going to get  yourself even more stressed out because your heart  
00:27:32
rate’s going to go up and your breathing is going  to go faster which is going to cause your body to   release more stress chemicals so you’re going to  feel worse so don’t assume that because you feel   really bad really anxious that it’s really that  bad you could have got talked yourself into it  
00:27:53
so instead of gauging how bad  things are by how much you panic   remember to gauge things how bad things are based  on facts for it being a catastrophe and against it   being a catastrophe what are the actual facts  in the situation identify your comfort zones  
00:28:12
and step back into them now and again you  didn’t think i’d ever say that did you   a lot of times i’m saying step out of your  comfort zone well it can be anxiety provoking   moving past the place that you’re comfortable  with out of your comfort zone is a gradual process  
00:28:28
going too quickly is a recipe for stress so when  we take students and i just did a class today on   helping students transition from high school to  college that is a huge jump from one comfort zone   to a discomfort zone so to speak because students  just aren’t used to living on their own and have  
00:28:48
being away from mom and dad and all those  different things so it causes a lot of stress   in college freshmen but the same thing is  true if it’s a new job or whatever it is   go in slowly you know dip your toe in see  how it feels just like when you’re getting  
00:29:07
into a cold pool well at least me i don’t do  a cannonball into the pool i put my toe in   let my feet get used to it then let my calves  get used to it and i ease myself in so it isn’t   quite as much of a shock to my system and  it doesn’t cause me as as much discomfort  
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but you can practice and this is  number 20 practice healthy discomfort   this means lean into your stress don’t resist it  acknowledge that you’re anxious and go okay this   means i’m getting outside my comfort zone  which means i’m growing and that’s awesome  
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means this is a challenge and that’s a little  intimidating but it’s also exciting accept how   you feel and remember you can tolerate it  think back to times in the past when you’ve   been anxious and you’ve worked through a  situation it wasn’t the end of the world  
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think about times in the past when you’ve  been anxious and ways you’ve coped with it   you know i’m not asking you to lean into it and  do it all by yourself you know call on those past   strengths and tools that you’ve used to deal  with the anxiety instead of running from it  
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finally practice radical acceptance learn  to acknowledge the parts of your story you’d   rather ignore forget or not admit so choose  to love your home your body and your work   instead of saying you know i am fat ugly and  useless and being upset or saying everybody’s  
00:30:36
going to abandon me because i’m not lovable um you  know let’s practice radical acceptance you are who   you are and you can choose to hate yourself or you  can choose to love yourself you can choose to hate   where you live and be miserable about it and go  around like oscar the grouch or you can choose to  
00:30:57
love where you live and make it a home and  decide to change whatever you think needs to be   changed choose to build your life from a place of  gratitude and vision you know maybe you don’t love   everything about yourself right now that’s okay  that means you’ve got room for growth so embrace  
00:31:15
yourself love yourself as a human being and  say okay now there are things i need to work on   and use that vision to figure out where you want  to go from here because you’ve got a long way to   go on your life journey life’s journey when  you build your life from gratitude and vision  
00:31:35
then you’re using your energy to grow and move  forward instead of run from your own fears so remember anxiety is your body’s response to  what it thinks might be a threat it’s like that   faulty fire alarm that goes off it’s trying to  warn you but in reality there’s nothing to be  
00:31:57
warned about there are many ways to address  your anxiety including getting good nutrition   avoiding too many stimulants getting plenty of  sleep so you’re not exhausted and over tired   exercise which releases serotonin get social  support you know reach out to those friends  
00:32:15
and change your perspective so instead  of looking at the worst possible scenario   you’re saying what’s the best thing that could  happen or how have i handled similar situations   before because i can do this and add some  happiness to your life you know you really  
00:32:33
can’t just eliminate anxiety or just  eliminate depression if you eliminate   it then there’s nothing you need to  add some happiness to take its place   and that will help you start addressing your  anxiety if you like this podcast please subscribe
Source : Youtube

Assisting the Person without Enabling

https://www.youtube.com/watch?v=r8PUYdEa5PE

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This episode was pre-recorded as part of a live continuing education webinar on demand CEUs are still available for this presentation through all CEUs register at all CEUs comm slash counselor toolbox
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all righty I’d like to welcome everybody to today’s presentation on supporting the person without enabling now you notice I said person not patient and hopefully I’ll remember to say that throughout because enabling isn’t just
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something that people who are in a relationship with someone who is addicted to something can do I mean we can eight we can enable our children we can enable our friends so we’re gonna look at enabling broadly and in this
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presentation we’ll explore how a person becomes an enabler defined enabling examine the consequences of enabling learn about the connection between enabling and codependency defined characteristics of
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codependency and how they may develop from being in an enabling relationship and examine practical strategies to provide support and encouragement to the loved one without enabling so what makes an enabler a person that you love is in
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trouble or experiencing pain and this can be an addicted person you know that’s typically what we think of when we think of enabling it can be a person with a mental health issue so if somebody is clinically depressed or has
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severe generalized anxiety disorder and enabler may step in and try to care take that person and we’ll talk about you know where you cross the line there a person with chronic pain can also be enabled if their chronic pain they don’t
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want to get up they don’t want to move they you know and people start start doing things for them that they could do for themselves and we can also enable our children and we’re going to look at different examples of that as we go
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through in addition to having someone you love experiencing pain the person has to also experience a sense of responsibility for the problem generally if I would have been more aware that his drinking has gotten so bad if I would
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have been more aware that the depression was coming on or if I had made John go to the doctor for the depression got this bad if I wouldn’t have been driving when we got into that car accident all of those
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things the ifs and the when’s the person feels a certain amount of responsibility whether they were around when the thing was initially triggered or they feel like they should have intervened sooner to do something before it became a
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crisis there’s also a denial that there’s a problem requiring professional help initially because once you’ve helped it’s hard to stop so once you’ve bailed John out of jail the first time it’s hard to stop once
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you have been doing things for somebody that they can do for themselves it’s hard to say okay I’m not doing that anymore you got to do it on your own I’ve got teenagers at home and one of my children is just amazingly structured
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and I’m structured so that works really well with me the my other child is much more on the perceiving and he’s much more loosey-goosey and it’s hard for me to kind of let him do his thing so he learns to be responsible so when
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he was growing up I tended to enable him a little bit more than I should have by doing things for him and always reminding him and being on him where you know once he became an older teenager he started having to take
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responsibility and it’s painful sometimes to sit back and watch him fall on his face but it has to happen sometimes for people to learn from the natural consequences enabling behavior protects the person from the natural
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consequences of their behavior whether it’s you know alcoholism if they are in pain for example and they’re not willing to or they’re not thinking they’re able to get up and do anything go to work
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follow through with their physical therapy those sorts of things they may get used to people waiting on them and doing things for them enabler keeps secrets about the person’s behavior from others in order to make
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peace this is more true in addiction but I mean think about it if you’ve worked with families before where you have one parent who’s been enabling the child and doing everything for them and kind of staying on top of it and you have
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another parent who’s kind of oblivious you know the the first parent says okay now don’t tell your mom or your dad whoever the other parent is that I keep reminding you of this but you’ve got to start taking responsibility that threat
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kind of falls on on deaf ears because there’s no follow-through to it the person makes excuses the enabler makes excuses for the person’s behavior with teachers friends legal authorities employers and even other family members
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why they didn’t why the person didn’t get things done bales the person out of trouble such as paying debts fixing tickets hiring lawyers and providing jobs you know at a certain point there are certain things that we can do to
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assist people in their recovery process but generally and when I’m saying providing jobs I’ve had occasions where somebody’s called me and they’ve tried to make a an interview for their significant other and I’m like no you
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know that person if they want the job they need to call so and I’ve seen this in other situations it’s important that we look at when we’re looking at enabling we’re looking at having the person who is
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struggling do the things they can do for themselves otherwise we are enabling them we’re teaching them that they’re powerless that they need help we’re creating a dependency the enabler sees the problem as the result of something
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else they’ll make excuses the person is too shy the person is a teenager they’re just they’re going to be irresponsible the person’s drinking because they’re lonely they come from a broken home
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they have ADHD they have some other illness so a lot of times the enabler in making excuses will find other reasons for the problem and they truly believe that that’s the reason they don’t want to believe that this person is just
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taking advantage of the system so to speak it avoids the person in order to keep peace so out of sight out of mind so if you’re the enabler may avoid the troubled person because you know if we get in the same room then we’re going to
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get into an argument so I’m just going to avoid it and do what I need to do I’ll send text messages when he needs to do something and so you’re still enabling but you’re keeping distance so it’s not as stressful and may give help
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that is undeserved unearned or unappreciated you know there are times when we want to reach out and help somebody you know help them get something done and that’s cool I remember with my staff
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there were times where they would just kind of get overloaded with paperwork this was usually towards the end of the fiscal year when our census went through the roof and so I would step in and I would assist them and getting getting
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some things done I mean that help was definitely deserved earned and appreciated now during Christmas holidays for example our census would usually plummet so it was a fifth of what it should be
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so there should be no reason for people not getting their work done so if I’m stepping in and doing things for my clinicians then you know that that help is undeserved because they are perfectly able of doing
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their their groups as well as their paperwork enabling behavior attempts to control the other person by planning activities choosing their friends getting them jobs making their doctor’s appointments a lot of you have probably
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had similar experiences where someone has called up and they’ve tried to make an appointment for their loved one now it’s one thing if their loved one is like 12 but it’s another thing if it’s another adult and I have found I used to
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let that happen I don’t even let it happen anymore but when I used to let it happen my no-show rates for that person we’re usually somewhere between 85 and 90 percent because that person didn’t even have the wherewithal to call and
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make the appointment let alone show up for it so that kind of shows levels of motivation as well the person who’s an enabler makes threats that had no follow-through or consistency if I tell my teenager you have got to be more
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responsible the answer the question that comes after that is if I’m not what’s gonna happen what are the consequences so the person needs to know that there are consequences when people are in drug court for example they know that if they
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use they’re going to likely have to do some time in jail when you go to a job you know that if you don’t show up you’re likely going to lose your job so there are consequences to what we do the enabler shields the struggling person
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from any of those consequences so they start to develop the idea that you know there are really no consequences for their actions whatever they do you know the enabler will clean it up it’s not a big deal the enabler may care take the
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person by doing what that person is expected to do for him or herself they may ignore the person’s negative negative and potentially dangerous behavior thinking that okay if I just do these things then the
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person will stop hurting themself they have difficulty expressing emotions especially if there are negative repercussions for doing so and when people get into these relationships it can be conflictual because you have
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somebody that you’ve been doing stuff for and you’ve been basically waiting on if you will and then all of a sudden you set boundaries and you say no you’ve got to do it for yourself what’s the first reaction likely going to be you’re awful
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that’s mean why are you doing this and a lot of times there are much stronger words that are used but you kind of get the idea the person rebels and tries to say no you need to keep doing this so there can be negative and unpleasant
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emotions the person who’s being able or doesn’t love what’s going on so they may often feel taken advantage of neglected resentful yada yada and if they express those emotions to the person who is struggling a lot of times again that
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will not be met with empathy it will be met with resistance enables prioritize the needs of the person with the problem or the addiction before their own they make sure that that person is up in the morning they make sure that that person
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is dressed for work they make sure that person you know has money to buy lunch or or whatever the case may be before they start worrying about themselves they may act out of fear since addiction can cause frightening events the enabler
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will do whatever it takes to avoid such actions that’s one example now if we talk about a teenager for example and you know I’ll use my kids my son is getting ready to go to college and for the scholarships that he’s gotten there
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are certain things that he has to do if he doesn’t do them he loses his scholarship and that’s a big deal so it’s important to for him to make sure that he’s doing these things but part of me wants to do it for him because I’m
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afraid he’s going to forget and then he’s going to have these huge student loans well if he does guess what he does that’s you know people have got I had student loans I’m sure you did
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so and and it hasn’t ever killed anybody but it’s important to make sure that he knows what the consequences are if he doesn’t follow through with these things and to let him experience consequences and the person who’s an enabler may
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resent the person with the problem whether it’s addiction pain just learning to adult things that you may hear and enable or say he’s so irresponsible with money he could never make it on his own if I kicked him out
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he would be homeless so what else can I do I let him continue to stay here and this can be true of somebody who’s a problem gambler or just someone who’s awful with
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money every time I’ve tried to talk to her about her addiction she’s gone on even a worse binge and I’m afraid she’ll overdose now think about you know the reactivity of what’s going on think about kind of
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borderline ish behavior if you do this then look at what you made me do not saying that all of these people are borderline by any means but you know that is one of those reactive behaviors that we often see when somebody tries to
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withdraw enabling behavior I know I shouldn’t have paid for his lawyer after the third DUI but if he went to jail he would Lewis lose his job and as a family we rely on his income okay you can see this person’s concern you can see how
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they’re acting out of fear because their significant other contributes significantly financially to the family every time she and her boyfriend fight she crashes here I let her because I know it can be violent and I don’t want
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her to be hurt again enabling her to stay in that relationship which evidently is not healthy because that person is afraid that the the woman will be hurt it’s my fault she’s in pain so I must do whatever she wants if I
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change what he did at least I can limit the damage if I can’t change the fact that he totaled the car for example I can limit the damage that it may cause I can make sure that I Drive him to work from now on I can make sure that I make
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sure he gets to his appointments maybe he will wake up and just come to his senses he’ll wake up and suddenly start doing everything for himself that he can do for himself but that’s not going to
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happen I mean it 99.9% of the cases do you wake up in the morning and go hmm you know I could let somebody else do all this stuff for me but today I think I’ll do it all myself a lot of most of the time it doesn’t happen think about
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if you had a full-time maid living living with you wouldn’t that be great that full-time maid you wake up in the morning and you go you know this person cleans and makes the meals and stuff all the time
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but you know what today I’m gonna do it all myself for no particular reason and I’m gonna do it henceforth and forevermore probably not going to happen because that person has gotten used to having the maid consequences of enabling
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enablers detest the behaviors of the enabled but fear the consequences of those behaviors even more so if I don’t bail him out of jail if I don’t do this if I do kick this person out what are the consequences gonna be not only to
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that person but also to me and potentially my family they’re locked in a lose-lose position in the family setting boundaries feels like punishment or abandonment of the person they love it’s hard to say you know what no you’ve
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got to do it on your own because when you do that the person starts rebelling if you will they get their feelings hurt they may not understand why it changed they may be resentful of why it changed so it creates chaos there’s a certain
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amount of homeostasis and a family when you’re doing what you’re doing you know there’s no that family is functioning like it’s supposed to and then when you stop doing that when you withdraw some of that
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support it upsets the balance in the family then all of a sudden people have got to start choosing their roles again enabler SHM a struggle with the guilt they would feel if the person they’re enabling were hurt by the real
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consequences of their actions whether it be losing a job or getting physically hurt or going to jail whatever the case may be enabler czar also protecting themselves and/or their children from those
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consequences an enabling basically means someone else the enabler will always fix solve or make the consequences for problems go away enabled persons come to expect that their behaviors have no consequences or negative outcomes I mean
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they can see what happens but they know somebody’s going to fix it so it’s not going to harm them now remember one of the basic principles of behavior modification we do things that are rewarding and we don’t do things that
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are punishing well if you take the punishment away then the behavior is at least neutral if not rewarding so you’re continuing to reinforce that behavior enablers may become emotional hostages as the person learns to manipulate them
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in order to ensure that the help and support keep coming back to that look what you made me do if you would have followed up with me to make sure that I got up in the morning then I wouldn’t have missed the bus and not gotten to
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school today if you would have done this then I wouldn’t have experienced this consequence it’s your fault the enabler is desperate to prevent the enormous crisis but winds up experiencing a constant state of stress they don’t want
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to enable the person anymore they want to set boundaries but the tension that occurs when they try to set boundaries and the guilt the other person can make them feel or try to make them feel is can be oppressive so one of the things
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we’re going to talk about in a little while is how to deal with some of that guilt and recognize how to set boundaries the enabled person and be enabler become stuck in a role in which they both feel
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incompetent being the enabled person has been having somebody do everything for them so there they may start thinking to themselves well maybe I can’t do it maybe I need her to do it for me and the enabler doesn’t see this person’s
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behavior changing they want this person to stand up and start doing what they’re supposed to do what they’re not so the enabler also starts to feel incompetent and incapable because they’re not changing that other person so they both
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get in this lose-lose situation and they may gradually accept a self-concept that includes these negative traits destroying self-esteem and leading to codependency so what is codependency and there are whole classes on that we’re
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just kind of hit the highlights here the person had someone they loved and either failed to fix them the loved one chose another behavior over the relationship impacting self-esteem self-efficacy and abandonment anxiety so
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the codependent person we get there because at some point in the past they tried to fix somebody and may have failed to fix them so they’re gonna keep trying to fix the other person because their self-worth is tied up in being
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able to fix that person or they got abandoned the person chose the addiction or chose someone else over them so now they’re struggling with feeling good enough and by attaching to someone who needs to be rescued it gives them a
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mission it gives them a purpose it gives something them something to try to feel good about there’s an exaggerated sense of responsibility for the actions of others and a tendency to confuse love and pity with a tendency to love people
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they can pity and rescue they love people that they can make dependent upon them a willingness to do anything to hold on to a relationship and to avoid the feeling of abandonment most people who are codependent are terrified that
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they’re going to be abandoned they’re terrified that if they let the natural course happen and this person experiences consequences that they will be rejected an extreme need for approval and recognition a sense of guilt when
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asserting themselves and setting boundaries and a tendency to do more than their share and become hurt when people don’t recognize their efforts they also tend to have a compelling need to control others a lack of trust in
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themselves and other people which makes sense I mean if they got into this relationship and most people you know when they get into their first enabling relationship they don’t get into it as an enabling relationship they often get
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into it you know as a normal healthy relationship which goes awry unless they came from an addicted family but anyway so they for whatever reason they start feeling this need to control other people in order to feel safe in order to
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prevent an abandonment and feel okay about themselves they need to make themselves indispensable and they don’t trust themselves to be good enough as they are and they don’t trust their own judgements so they’re always
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second-guessing themselves about what should they have done what shouldn’t they have done they have difficulty identifying feelings because you know think back to a couple slides ago we said they have difficulty talking about
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their feelings well they shoved them down because talking about unpleasant feelings often meets with problems and and difficulties so they shove those down but when you have all this animosity and resentment
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and exhaustion and anxiety and everything else kind of churning around inside you there’s not a whole lot of room for happiness and the other things so they may start having difficulty kind of knowing how they feel they just feel
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icky all the time and they’re trying not to focus on it too much because then they have to face some hard realities they may be rigid and have difficulty adjusting to change and problems with intimacy and boundaries they
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be chronically angry lie and be dishonest remember they’re lying and covering up for their significant other but they’re also probably lying and covering up for how they feel you know saying everything’s fine you know I’m
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going to put on this picture that we have got the perfect family they may have poor communications and difficulty making decisions in the addicted family there’s a mantra if you will called don’t talk don’t dress don’t trust and
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don’t feel in any sort of relationship where there’s an enabling situation going on this is really true most of the time we don’t want to talk about setting boundaries we don’t want to talk about how I feel about the fact that you’re
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not taking responsibility I can’t trust you to follow through with things so I can’t trust you to do anything that’s going on and I can’t feel because if I feel then it hurts and I can’t understand why I’m staying with the hurt
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and so I don’t want to feel anything and I need to make sure that you know if you’re happy I can be happy okay so I’m not gonna have my own feelings because if you’re happy that means you’re not gonna leave if you’re not gonna leave
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that means I’m happy that abandonment anxiety can be tabled for a little while so what do we do first have the client learn about addiction or whatever issue the person may have let’s learn about it if we’re dealing with a
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teenager who is having difficulty getting as feet under himself to adult okay maybe the person needs to learn about parenting parenting skills and how to set boundaries and that kind of thing if we’re talking about somebody in a
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domestically violent relationship let’s learn about that addiction depression anxiety chronic pain whatever it is that is causing the loved one to struggle the enabler needs to learn about it figure out you know what’s causing this what
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makes it worse what makes it better what options are there for this person you know kind of do your research so you have an idea get help and support from others reach out to communities that is that are similar to what you’re dealing
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with calmly let the loved one know that you’re aware of their problems that you won’t tolerate that continued behavior and that you’re willing and able to support them on the road to
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recovery so not tolerating is kind of a rough phrase and this will often be met with a lot of resistance which is one of the reasons I encourage my clients to do have this discussion either in in
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session or in some sort of mediated maybe with their their spiritual leader or whatever so there’s a arbitrary third party that can keep things from getting too antagonistic the person needs to I encourage the
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enabler to write these things down so it doesn’t get emotional and it’s not all over the place it’s like okay these are the 10 things that need just happen and generally when we have these discussions I work with the enabler
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ahead of time and we remove we review the list to make sure everything’s on there that is of utmost importance to them and the list should include explaining what you’re going to withdraw I’m not doing this for you anymore and
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this is why if you choose to not do what you can do for yourself or if you choose to refuse help these are going to be the consequences and making it very clear not aggressive not angry just this is very matter-of-fact if you continue to
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drink then I can’t continue to bail you out or I won’t continue to bail you out from jail you know you’re going to have to deal with those consequences healthy help involves providing information encouragement and coaching
00:28:34
to the person so we learned all about it because the person who’s struggling may be too mired in their own unhappiness and emotional or physical pain to really think clearly so we may need to take take it to them and say okay this is all
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the information I found and I know you can do this I know you can get through it and I am going to be here to cheer you on give the person contact information for doctors counselors lawyers rehab
00:29:03
programs whatever resources the person needs without the feeling without feeling the need to force him or her to accept this help and that’s the hard part it’s easy to say okay here’s all the stuff but if they take the stuff and
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they set it down they go okay I’ll get to it later the person who’s enabling can be like no no no you need to do it now what we need to do is you know present the case you know this is what needs to change this is why it needs to
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change this is what’s going to happen if it doesn’t change these are the resources for that you can access to help this change process and the balls in your court it’s important to discuss with the person what the possible
00:29:53
consequences of actions might be without feelings if you must make sure they make the choice you want them to make they may leave you know if you tell somebody you can’t be I can’t have you spending every dime of your paycheck every month
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in order to buy your toys and do those things because I need it in order to pay the bills around here so if you continue to spend every time you make then you may need to move out or whatever the case may be but it’s important to set
00:30:30
those consequences because remember again what is more rewarding is going to be what the person chooses so then the person is going to have to say well do I want to buy a bunch toys and not be responsible for anything
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or is this relationship more important because only once you’ve tipped that decisional balance will that person be willing to consider change they have to be one wanting to change we can’t make them change no amount of fussing and
00:30:58
carrying on is probably going to work we want to foster hope both for you and for the enabler and the person sometimes people refuse to get help only to turn around and ask for help a short time later it’s not uncommon a lot of times
00:31:15
especially with addictions the person that you’re working with who’s struggling is wanting to maintain control and they feel like you took away their control when you started setting limits and telling them what they had to
00:31:30
do so they may rebel against that initially and go no I’m not doing it you know I didn’t need you before I don’t need you now and walk out doesn’t mean they won’t come back the key is to plant that seed let them know what options are
00:31:46
available and say okay you know well if you decide that you want help I am here to help you along the way it’s really hard to watch the person walk out the door whether you’re a clinician having a conversation with somebody who you know
00:32:01
needs to be in treatment or you’re a loved one having this conversation with somebody who you know needs to take some steps and just to watch them kind of thumb their nose at you and walk away it’s painful it’s hard it’s it’s a
00:32:17
struggle because you’re like oh my gosh that’s this person is just headed down the wrong road but they have to be willing to change and if we keep the door open for them then they can come back and they can come back a week later
00:32:32
or two weeks later and feel like they’re in more control because they’re presenting and going I’m ready for help okay cool now let’s see where we go from here we also want to make sure that the person refuses to tolerate or enable the
00:32:52
addiction related behavior or whatever the behavior is whatever the behavior is that you’re trying to get the person to change you can’t be wishy-washy on it the enabler has to set a hard line in the sand and say I will
00:33:06
not tolerate this not I won’t tolerate it very often or I won’t tolerate it but one or two more times no I will not tolerate this anymore because as soon as you give in then that that line moves practical strategies
00:33:24
people who are enablers are exhausted people who are being enabled are also probably exhausted so these practical strategies you know fit for both both types of people in order to be a support person for someone
00:33:41
in recovery or for someone trying to make a change and in order to make a change people have to be optimally functioning they have to be as healthy as possible so they need to practice good sleep
00:33:54
habits they need to eat well they need to get some exercise you know get out get that body moving they need to take care of their emotions which means increasing the happy emotions not just dispelling the bad ones but bringing
00:34:09
some happy emotions in so you’ve got that yin-yang balance social relationships and activities need to happen for both parties you know they need to engage with other people and not just be completely wound up in
00:34:24
themselves and both parties need to be aware of what is truly important to them you know have them make a list of the people places things activities that are truly important for them to have in their life to have a rich and meaningful
00:34:40
life I mean this kind of goes to that acceptance and commitment therapy trend if you will but both of them need to figure that out so if the person who is being enabled puts down on their list that this
00:34:56
relationship is important to them to have a rich and meaningful life well then they’re going to have to make some changes you know they may have to choose between their behavior and the relay ship and they’re going to have to decide
00:35:09
which one of those is more important when you’re together it’s important that enablers remember not to helicopter not to constantly micromanage the person to see what they’re doing how they’re doing how they’re feeling you know if they’ve
00:35:23
taken their meds whatever the case may be and encourage the person the enabler to try not to obsess or worry about the other person you know you’ve given them the tools they are adults you know obviously there are certain caveats and
00:35:40
exceptions here if somebody is cognitively impaired for some reason you’re gonna have to do a little bit more but most of the time the person is able to do the next step they just have to be willing and willing is something
00:35:56
that they they choose to do so it’s important to encourage the the enabler to try not to worry to recognize that this person may fall on some hard times they have to experience some unpleasantness some pain before they’re
00:36:11
probably going to be motivated to change prepare them for it example thoughts that people with who are enablers may may have I have to do this or he will have this consequence or if I truly loved her then I would do this for her
00:36:32
or if she chooses that behavior it means I’m a failure and unlovable and this is when I see more in addictions where if somebody and especially with children you know children don’t understand and when their parent in their mind chooses
00:36:53
drugs and alcohol over being home with them so we want to help the children realize that they are lovable and the same thing with the other the other parent that is or the other caretaker it’s important that everybody
00:37:07
understands how they feel handling thoughts so when enabler start to have these thoughts that I have to protect this person or if I don’t do this it means that I’m an awful person or I’m
00:37:22
unlovable have them unhook from the thoughts instead of saying I have to they need to have say to themselves I am having the thought that I have to and use the challenging questions what is the evidence for and against this you
00:37:39
know I have to pay her rent or she will be homeless all right well that may be true so there could be great evidence for that what are the consequences of her being homeless you know are there places she can stay you know play it out
00:37:58
to the end if she’s homeless then what’s going to happen and then what’s going to happen what parts of this are my responsibility continue to play it through to the end you know if I withdraw my support what parts of this
00:38:13
are my responsibilities which important things does this help me move toward so if I withdraw my support and I don’t pay her rent for example which important things in my life does that help me move toward maybe that helps me pay off my
00:38:28
own house or pay my own bills or whatever the case may be maybe it reduces friction a lot of times we see this in parents that have kids in college where one parent is sliding money under the table to the kid and the
00:38:41
other parent doesn’t think the child should be getting additional money so there’s a lot of friction so if the parent says well if I if I don’t pay her rent now if I make her actually get a job and pay her own rent then not only
00:38:55
will I save money and be able to pay my own bills but it’ll reduce stress in my marriage which is another thing that is truly important to me we all said we can’t look at toward without looking at away from what important things does
00:39:12
this move me away from well you know we’ll stick with the college kid for right now if we have a college person and you say you know what I’m not gonna pay your rent anymore you have to get a job and start adulting the college
00:39:29
student may say some pretty hurtful things and may be very angry for a while which is difficult for a parent I mean there’s no doubt it’s hard for a parent to go that’s okay you can be angry you can say
00:39:44
you’ll never speak to me again it’s hard to ride through that so it’s important to understand that there are consequences when we do things you know just like there are consequences when the when the struggling person does
00:39:58
things and which values does doing this support so my value to be loyal honest trustworthy compassionate caring you know where does that fall in if I withdraw my support from my child and I say no you’ve got to get your own job
00:40:17
how do I feel about myself and that goes with that guilt that the person the enabler needs to work through and and yes finding that line between enabling and supporting is often a gray area and a lot of the times I ask clients to
00:40:37
really think you know the first question is is this something that my loved one could do for themselves and if so okay now how do we move there a lot of times it’s it can be a gradual thing you know if the person is using drugs for example
00:41:00
or well we’ll stick with that one for a minute if you say okay you need to get help you need to get into treatment you know that’s the first step is getting the person into treatment and it’s not
00:41:15
saying you have to quit using be clean and sober and never ever use again and go to treatment and get fixed all at once you know the first step can be I need you to commit to going to treatment in order to get better or whatever with
00:41:32
the student you know parents can say ahead of time okay beginning next semester you need to pay for your own housing you
00:41:59
so yes it is a negotiation process that sometimes can take place it doesn’t have to be a hundred percent line in the sand right starting right now but the person who’s being enabled needs to know where we’re going you know this
00:42:16
is what I need to happen so the first step I need you to take is blah blah and then we’ll reassess and yes the person does need to step back and say what is in my best interest
00:42:40
assuming we’re dealing with adults here as the person who was struggling you know adults have the ability to make choices and do things on their own most of the time there are those times where it’s not possible what if it’s somebody
00:42:59
who is really struggling with chronic pain because of a terminal illness you know you got to look at where you need to what’s in in everybody’s best interest how do you want this situation to resolve itself and what do you feel
00:43:17
resentful about talking about the enabler you know if you resent having to do this that in the other it’s important to identify why you resent it and maybe what are some options that could happen maybe the person who is well we’ll go on
00:43:39
later don’t judge the person who’s struggling and that is so hard for both parties not to judge one another it is what it is and recognize that at this point the person who is is being enabled is choosing the more rewarding option so
00:44:00
if we remove that yeah they may change but it there has to be teeth to it because if they know if they know that you’re gonna make empty threats then they’re not going to change their behavior and both parties have to accept
00:44:15
it is what it is you know you may not like what I’m doing but it’s my choice don’t have expectations of others instead meet expectations of yourself and this is one I really ask clients to really hold on to what are your
00:44:31
expectations of yourself in terms of the things that are important in your rich and meaningful life in terms of your family your job your other things you know have those expectations what are your expectations
00:44:45
of yourself in terms of this relationship and have them set goals for what they need to do in order to take care of themselves remind them that they didn’t cause the other person’s behavior and they’re only responsible for theirs
00:45:04
you know even if they have been enabling for you know three years or whatever that person made choices along the way now obviously again this is adults if we’re talking about a budding adolescent then it’s a little bit different we may
00:45:22
need to help nurture and mentor and guide that person along the way but that’s where the coaching comes in we’re not doing it for them we’re not calling the admissions office and finding out when applications are due we’re saying
00:45:36
okay what do you need to do in order to get into this college go do it and then helping them learn how to set goals and things we can’t change or fix anybody else they have to want to do it and before engaging in enabling behavior
00:45:54
weigh your options for short and long term pain and this is kind of what I think Margaret was saying about doing what’s in my best interest having clients say okay either way this is gonna be uncomfortable either way
00:46:10
this is gonna hurt so do I continue doing this in order to avoid the short-term pain of arguments and what have you and knowing that there’s going to be long term pain anger resentment
00:46:26
duh-duh-duh or do I say you know what I’m just going to endure this short-term pain of watching my loved one struggle for a bit knowing that hopefully it’ll come out on the other end they will choose to seek help and then I can be
00:46:44
there for them again encourage people to write about their feelings in a journal when enablers are trying to break this if you will it’s important they jot down how they’re feeling so they can identify it and deal with it so they can take
00:47:00
care of themselves deal with the guilt deal with the anger at the other person deal with the anger at themself and encourage them to pursue their own interests and have fun it’s really hard when you are being a blur and the other
00:47:16
person is struggling to say you know what you brought this on yourself you’re gonna do okay and I’m here to help you when you’re ready to start making a change but until then I’m gonna go live my life I remember when my when my
00:47:31
cousin was in jail my aunt had the hardest time going out and living her life and being happy she was just devastated that and and wanted to go in and wanted to fix it and wanted to bail her out and felt so guilty anytime she
00:47:46
had fun because she knew that my cousin was in jail again practice setting boundaries part of both parties recovery is getting very clear about what their boundaries are what do you expect from your partner and and be realistic about
00:48:04
it and this can be a negotiation to a certain extent what behaviors are acceptable and what will you no longer tolerate and I encourage them to also talk about you know what happens if there’s a relapse this is again
00:48:18
especially true with addictions because a lot of times people do relapse and what happens does that mean all bets are off bye-bye I’m washing my hands of you what are the consequences what needs to happen in addicted relationships
00:48:35
sometimes the thought is you need to go to treatment you need to go to outpatient or whatever it is and you need to stay clean and sober if you relapse then you have to agree to go to residential you know so there’s an
00:48:49
upping of the ante of what you need to do what does the enabler need to feel safe and secure so they can let go of those abandonment fears better social supports you know there’s going to be a lot and we need to make sure that all of
00:49:06
their answers to this question don’t center around the person being enabled because we can’t know that that person is gonna make the next right choice for the enabler so we need to say alright what do you need you know what
00:49:21
happens if this person chooses to continue with these behaviors how can you feel safe and secure if this person tries to do the right thing what do you need to feel safe and secure and a lot of times in in these kinds of
00:49:38
relationships the person who was the enabler needs constant reassurance that the person who’s being enabled is doing the next right thing and the person who was being enabled who’s trying to do the right thing now starts feeling like
00:49:53
they’re being henpecked which goes back to that hovering thing so it’s really important to have an open discussion about what each party needs to have to feel safe and secure and it’s also really good for enablers to get involved
00:50:12
in support groups al-anon Alateen any of the 12-step programs if the person has an addiction codependents anonymous is another good one in order for people to start expressing and reaching out to others who have similar experiences and
00:50:32
saying you know I’ve heard this phrase before I feel like I’m going crazy because you know every time he comes home I’m looking for or I’m looking at how do you handle that or you know they’ll run behaviors by each other and
00:50:47
go this is what I’ve started seeing lately is this person headed towards a relapse you know nobody can say that for sure but people who’ve been down that road before can say either no that’s a normal part of this early recovery
00:51:02
process or yeah it looks like that person’s getting into dangerous waters help clients learn how to say no and to mean it how to set that boundary and say no I’m not going to do it this time despite whatever you throw at me
00:51:18
verbally of course I I will not give in to this and it’s hard just like when you have a child and in the candy aisle I remember one time we’re getting ready to check out it was like four and my son was hungry but we
00:51:36
were getting ready to go home and make dinner and we were at the checkout aisle and he wanted candy and I said no and he was like really I want candy please you know like kids do he begged for it he could Joel for it whatever and I said a
00:51:51
hard line and I said no we’re gonna go home and we’re gonna make dinner and then you can have dessert afterwards if you eat your dinner no volume control whatsoever he cited the motto to the store he’s like well so much for Publix
00:52:04
where shopping is a pleasure oh my gosh I was so ready to get out of that store um but I didn’t give in I said no and I meant it and he never did that again thankfully and we need to have our enablers learn how to ask for help and
00:52:22
to get it because too lot for too long they’ve been trying to control everything they’ve been the puppeteer moving around those marionettes and now we have to say you know what somebody has to help you out too you’re not meant
00:52:34
to do it all by yourself so what do you need help with it doesn’t mean you’re weak it doesn’t mean you’re giving in or giving up encourage them to take time out when they get emotional and practice distress tolerance to get into their
00:52:49
wise mind there are going to be days that are harder than others and encouraging clients to just recognize this is important and develop those distress tolerance skills remember accepts and improves are the two
00:53:01
acronyms that we use in DBT have the person identify each day three things they did well or they liked about their themselves and write them in their awesomeness journal you can call it whatever you want mmm but I want people
00:53:17
to remember how good they are and that they are deserving of love and they do deserve to be treated how they expect to be treated encourage them to take the labels off good bad and should you know everything is
00:53:34
kind of gray when we’re dealing with enabling how you feel is how you feel what you do is what you do you either choose to or you choose not to should doesn’t belong in there when it comes to expectations assumptions and excuses
00:53:51
encourage the person to ask themselves how they would treat the other person if it wasn’t their loved one so you know if it wasn’t your child would you be going out of your way to do this for somebody or are you just doing it because it’s
00:54:08
your kid so that helps people get some distance on is am i doing something for this person that they really could do for themselves or and that is fair for me and but in my best interest again that question doesn’t work 100% of the
00:54:24
time but it does help get some perspective sometimes when you’re tempted to think or worry about somebody else turn the attention back to you so when enabler start to get worried about the person they’re enabling they need to
00:54:40
turn that back around and go okay what is it that I need because I can control how I feel I can control what I do and if you know I have to be here and healthy if I want to be of any help to that person so I need to take care of me
00:54:56
encourage the enabler to pay attention to how they talk and treat themselves silencing the inner critic and being compassionate that means quieting those shoulds and not listening to that inner critic that they’ve probably
00:55:08
internalized from the from the person they’ve been been enabling that says you really suck if you don’t do this or how could you do this you are the worst person in the world they need to quiet that down and remember why they’re doing
00:55:26
it and remember that they’re a good person encourage them to have fun pursuing hobbies and interests oh my gosh for however long their life has revolved around taking care of this person and cleaning up messes and
00:55:41
holding things together just kind of by the skin of their teeth well now it’s time to start taking care of you and having some fun get some fun back in your life spend time alone with themselves where
00:55:54
they can just be if they want to sit in their pajamas and watch television if they want to go hiking whatever it is but encourage them to give themselves permission to be alone with themselves because a lot of times people within
00:56:07
Bandhan menthe anxiety also have really low self-esteem and if they’re alone with themselves then they start getting scared they start because they draw goodness they feel like they need other people to validate them so if they start
00:56:23
spending time alone with themselves they’re gonna learn to start self validating and they’re not gonna feel so anxious that oh my gosh if this person leaves I’m gonna be alone they’re gonna think if this person leaves I’m gonna be
00:56:35
alone oh well start looking for the positive in your life and add to the gratitude list each day encourage them to stand up for themselves if someone criticizes undermines or tries to control them
00:56:47
because they’ve gotten that from the person they’ve been enabling for a while and so it’s easy unfortunately to let other people also do it if you’re used to having it from a loved one encourage them to practice mindfulness and radical
00:57:04
acceptance to deal with worry letting go of the control and the need to manage other people remembering the saying live-and-let-live hard to do and you know and I tell people this is what we want to do this is the goal we’re
00:57:19
working towards it is hard to do so I don’t want them to think that I’m being nonchalant about it and help people figure out how can you do this how can you accept yourself and realize that you know what you don’t have to be perfect
00:57:33
to be a lovable human being encourage them to get in touch with their feelings and and not judge their feelings feelings are what they are and if they struggle with them then they’re gonna get stuck in them like quicksand if they
00:57:50
feel sad they feel sad and encourage them to ride the wave and let that feeling come in and go out there are other activities if you use a more cognitive approach that can do but give people tools to deal
00:58:04
with their feelings so they can improve the next moment and not just be stuck with I’m devastated I don’t know what to do with this encourage them to express themselves honestly with everyone what tact of course encourage them to say
00:58:18
what they think and feel and ask for what they need a lot of assertiveness skills and communication skills training is often helpful when working with people who are enablers because they’ve been biting their tongue for so long
00:58:33
that it either comes out as passive or aggressive and there’s nothing in the middle encourage people to reach out for help when they feel bad and not fall into the trap of thinking they should be able to
00:58:44
manage alone because that’s a symptom of codependency too we need help we need other people that we can rely on encourage support and activities support and recovery activities avoiding the dry drunk and this we want people to
00:59:03
continue to do what they need to do to get happy and healthy if it’s pain if it’s addiction whatever remembering you can’t be your partner’s only support if you’re a parent you know you can’t have a 35 year old child or yeah I guess
00:59:21
they’re still your child at 35 that you’re calling every morning going did you get out of bed did you pack your lunch did you do this that’s just not practical you know that person needs to learn to do for themselves what they can
00:59:33
and they need to have other people who are there to support them you can’t be their whole world encourage and support by helping to arrange time in the family schedule and budget and providing emotional support or transportation so
00:59:48
if the loved one needs help doing the recovery activity is going to physical therapy going to treatment whatever it is you know okay you know let’s figure out how to make that happen if you’re willing to do it I am willing to go the
01:00:01
extra mile to help you get there but you have to be willing to do the work have them remember that encouraging doesn’t mean forcing manipulating making ultimatums or nagging and this one gets a little bit
01:00:13
sticky because when you set boundaries you know that’s kind of like an ultimatum if you do this then these are the consequences and a lot of it has to do with delivery just putting out very flatly when this happens this is the
01:00:30
consequence to me or this is why I can’t handle this happening anymore so if it continues to happen then I am going to have to you know that’s not saying you have to do something or I will it’s saying if this continues then from my
01:00:45
own safety sanity and well-being I must do these sorts of things and encourage the person to engage the enabler to engage in their own recovery activities reaching out to other healthy happy in people in their life have them restore
01:01:03
balance stop making excuses minimizing or avoiding problems and simply doing things for that person they can do for themselves even the little things like their laundry or grocery shopping if you have somebody who is addicted a lot of
01:01:18
times parents will or friends will go over to their house and they’ll see this person doesn’t have anything in the refrigerator but beer or maybe not even so they may go out and and grow shopping for the person they can do that for
01:01:31
themselves we need to maybe you need to drive them there but they need to get up and do their own shopping and take responsibility that will help them feel empowered to start making changes in their life leaving the person to clean
01:01:45
up messes she makes well engaging in the destructive behavior whatever that is don’t allow the person to put you in situations that may endanger yourself or others if you’re living with somebody who’s bad with money you know don’t
01:02:00
allow them to have open access you know maybe to the bank account if you’re afraid that they’re going to gamble or spend it all and you won’t be able to pay your bills follow through with plans even if the person refuses to
01:02:13
participate a lot of times people especially if they’re being they feel like they’re being forced to change may kind of dig their heels in and go no I don’t want to go you know I don’t want to do it unless it’s what I want to do
01:02:26
that’s okay you know we made plans to go do this as a family we would love to have you but if you don’t want to go that is your decision we’re not going to continue to cajole you oops
01:02:40
enabling behaviors can occur with anyone not just people who are addicted most of the time people don’t start out enabling they often feel responsible in some way for whatever predicament the person has gotten into and are trying to make
01:02:54
things better supporting without enabling means getting clear boundaries about your wants and needs as the enabler setting those boundaries both emotional boundaries it’s okay for me to be happy even if you’re angry physical
01:03:10
boundaries you know what’s safe what’s not safe can this person live in this household can they not live in this household whatever and financial boundaries learning how to say no when the person asks for assistance which
01:03:24
also goes along with setting boundaries and being willing to encourage and support healthy behaviors that’s the supporting part you know we’re willing to be there and help you take that step we’re willing to be there and help you
01:03:39
figure out what the next right step is as long as you’re willing to take the step and yes depending on the person encouraging the enabler to set boundaries is often relatively easy because a lot of times they’re coming in
01:04:07
going I’m at my wit’s end I I’m miserable I’m stuck I don’t feel like I can know what to do anymore and then we start talking about from a behavioral as well I start talking about from a behavioral standpoint helping them
01:04:21
understand motivation and helping them understand reinforcement and punishment and really look at the chaining if you want to use and dialectical behavior therapy has wonderful chaining worksheets that you can help the enable
01:04:34
or see how their behavior leads to X Y Z consequence how they might be able to do something differently in order to break that chain and lead to a different consequence and it’s a slow process a lot of times the
01:04:51
first thing in a blurs say when you say you gotta start setting boundaries is I can’t okay let’s talk about that you can’t or you’re afraid to or you’d feel guilty and we go down those so generally it’s
01:05:05
not a one session and done sort of thing where person comes in you say set boundaries they say cool I’m going to do that and move out there’s a building up process to getting the courage to do it and dealing with their own stuff and
01:05:17
figuring out okay what do I need to do and how can I do it in a way that is most helpful and meaningful to me and my family are there any questions any other questions
01:05:57
all righty everybody have an awesome weekend and I will see you next week if you enjoy this podcast please like and subscribe either in your podcast player or on YouTube you can attend and participate in our live webinars with
01:06:12
doctor Snipes by subscribing at all CEUs comm slash counselor toolbox this episode has been brought to you in part by all CEUs calm providing 24/7 multimedia continuing education and pre certification training to counselors
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