Author: Leaman Ralph

In this episode we’re going  to talk about your vagal tone.
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So in a previous episode we talked about  four self-regulatory techniques that   help trigger the parasympathetic  response in our nervous system.
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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.
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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.
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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.
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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.
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Messaging to the body to slow  down and calm down so you can   give that a try go try standing on your head.
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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

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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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
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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  
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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  
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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  
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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  
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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  
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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  

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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  
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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  
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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  
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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  
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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  
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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  
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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
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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  
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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  
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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  
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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  
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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  
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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
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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
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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  
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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  
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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  
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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  
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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  
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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
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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
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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  
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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  
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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  
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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  
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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  
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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  
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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

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

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